key: cord-300311-eah49b3g authors: bueving, herman j.; van der wouden, johannes c. title: what is the role of virus vaccination in patients with asthma? date: 2007-05-30 journal: curr allergy asthma rep doi: 10.1007/s11882-007-0033-z sha: doc_id: 300311 cord_uid: eah49b3g it is estimated that viruses play a role in 30% to 80% of asthma exacerbations. thus, virus vaccination in patients with asthma could play an important role in preventing asthma exacerbations and other complications. influenza is the only agent for which a routine vaccine is currently available. this article discusses whether influenza vaccination in patients with asthma, based on the available evidence, is justified. cost-effectiveness of (influenza) vaccination for patients with asthma is questionable. for the other major viruses involved, the present state of affairs is described. although progress is being made, a vaccine may be available in the near future only for respiratory syncytial virus (rsv). meanwhile, clinicians and patients should aim for an optimal treatment with the currently available asthma medication. worldwide, asthma is one of the major chronic diseases and there is evidence its incidence and prevalence is still growing [1] . today asthma is regarded as a chronic inflammatory disease of the airways instead of solely a reversible airway obstruction. the use of rescue and anti-inflammatory medication has altered the prospects of asthma patients and has improved their quality of life. thus, most asthma patients can lead a normal life without restrictions. the degree of asthma control achieved by patients is an important predictor of the likelihood of complications of the disease [2•] . however, upper and lower respiratory infections can trigger exacerbations of acute asthma. most infections have a viral origin. they play an important role in clinical complications of asthma such as dyspnea, pneumonia, and respiratory insufficiency, which result in loss of quality of life, absenteeism, use of rescue medication, use of antibiotics, physician consultation, emergency department visits, hospitalization, and sometimes death. the best way to prevent exacerbations caused by infection is vaccination. this review summarizes the current evidence on the role of viral vaccination in the protection of asthma patients. we searched medline and google scholar for relevant articles and reports published between 1999 and july 2006 on the current status of vaccination in patients with asthma. viral infections have long been associated with asthma exacerbations. studies in children report varying incidences, suggesting that between 30% and 80% of exacerbations are due to a virus [3] [4] [5] [6] . for adults data on this issue are scarcer, but adults are believed to have as many asthma exacerbations linked with viral infections as children [7, 8] . the spectrum of viruses found consists of rhinovirus, coronavirus, respiratory syncytial virus (rsv), influenza virus, and an assortment of other viruses. of these, rsv and influenza affect primarily the lower respiratory tract, whereas rhinovirus and coronavirus replicate in the upper respiratory tract. the mechanism by which these viruses cause asthma exacerbations is not yet known precisely. postulations vary from direct infection to indirect induction of inflammatory responses [9] . in case of complications in patients with asthma, laboratory proof for the presence of virus should preferably coincide with symptomatic disease. however, evidence for the rate of complications mostly comes from large observational studies. in these reports on the impact of viruses, laboratory proof is often lacking. instead, extrapolated, partly population-based, incidence rates of influenza or influenza-like illness and the occurrence of complications are used as a proxy. in these studies, hard confirmation of the responsible agent on the individual level is not possible [10] [11] [12] [13] . other studies are often based on selected populations with existing symptoms or complications, reflecting only the worst of the spectrum of disease caused by acute respiratory infections [9, [14] [15] [16] [17] ] and thus disregarding their often self-limiting nature. although asthma control achieved by asthmatics is an important predictor of the likelihood of complications of the disease [2•], asthma exacerbations do not respond to inhaled steroids nor can they substantially be prevented in this way [18, 19] . only the use of oral corticosteroids seems to be unmistakably effective [20, 21] . the availability of effective vaccines against the key viruses involved in asthma exacerbations thus could play an important role in its prevention. below, we will discuss the vaccines that are available or may become available in the near future [22] . this species consists of about 100 serotypes and is responsible for the majority of "common colds." in asthmatics human rhinoviruses are responsible for the majority of asthma exacerbations and complications of asthma [23] . prevalent serotypes change from year to year. when prevalent, the relative predominance from any serotype is not higher than 40%. due to these circumstances and the large number of serotypes, an effective vaccine is not expected in the near future [22,24•]. coronaviruses have recently been highlighted because of a disease outbreak caused by the so-called severe acute respiratory syndrome (sars) coronavirus. in adults with asthma, coronaviruses are the second most important cause of virally induced exacerbations [7, 8] . animal vaccines are being tested. despite this a vaccine for human use will probably not be available in the near future [22]. rsv is especially predominant in young childhood and causes wheezing in children. in elderly people with asthma, rsv also may play an important role [25] . a connection has been suggested between bronchiolitis caused by rsv infection in childhood and the development of asthma [26] . against this background, a vaccine for rsv may not only prevent exacerbations but may also prevent the development of asthma later on. however, in the 1960s an experimental vaccine unfortunately had serious adverse effects by increasing the clinical symptoms of naturally acquired rsv infections. several other vaccines are being tested [27] , and despite the initial problems it is believed that a vaccine for routine immunization may be available within the next decade [22] . the influenza viruses are classified in three genera, labeled a, b, and c. only types a and b cause considerable epidemics. every year influenza viruses change their genome partially, which is called an antigenic drift. because of different subtypes and antigenic drift, formerly built-up natural immunity or vaccine-initiated immunity will not provide protection throughout successive seasons. there are three types of influenza a virus known to have infected humans and to have transmitted from human to human: h1n1, h2n2, and h3n2. however, water birds carry and are infected with about 15 different h-types. infections can spread from these birds to poultry, swine, and other animals living more closely to humans. by mixing infections, new subtypes can develop (antigenic shift). if a new subtype has the ability to infect humans and disseminate, a pandemic could occur. this is an often expressed fear in the case of the h5n1 influenza virus. influenza is the only lower respiratory tract infection in humans for which a vaccine has existed for decades. inactivated vaccines, delivered by subcutaneous or intramuscular injection, are widely used for the prevention of influenza. the guidelines of most western countries advise to vaccinate patients with asthma [28] . influenza is one of the common respiratory tract infections in humans [29] and according to the world health organization a yearly public health problem [30] . every year, influenza centers worldwide report influenza activity and the occurrence of influenza-like illnesses (ili) as well as data on subsequent health care use. but, many viruses can cause ili and thus a direct relation between influenza virus and symptomatic disease is difficult to determine. in published articles isolated serologic incidence rates, rates of ili, and the occurrence of complications are often used as proxy measures for influenza-related clinical illness. confirmation of influenza at an individual level is not provided in these large observational studies [11, 12, 31, 32] . however, when influenza infection is confirmed by laboratory tests as in trials or smaller observational studies, the clinical impact of influenza seems to be limited [4,6,33,34•,35] . incidence of influenza varies from place to place and from season to season. national and international influenza centers and organizations worldwide report incidence figures. usually, these figures are measured in an indirect way and relate to excess hospitalizations or mortality due to pneumonia and influenza or excess health care use. seasonal incidence figures for ili of 20% to 30% are not uncommon. however, symptomatic disease should preferably be corroborated by a positive laboratory test [36] . only in children do such figures seem to be available for a considerable number of years [37] . based on these data, the average incidence, depending on age category, is between 5% and 9.5%. the clinical picture is usually described as mild [37] . regarding the fluctuating incidence of ili reported, it is likely that in adults, the average incidence does not exceed these figures. comparable figures on the incidence in asthmatics are even scarcer. the proportion of asthma exacerbations due to influenza reported in asthmatic children were 18% and 5% [4,34•] . no severe complications (eg, hospitalizations) were found in these two studies. the effect of influenza vaccination in preventing clinical symptoms is a much-debated item. a number of reviews indicate that (inactivated) vaccines can have an efficacy of 70% in reducing serologically confirmed cases of influenza. however, when using symptom-based outcomes the vaccines showed an efficacy of only about 25% [38] [39] [40] . moreover, in case of a mismatch between the vaccine composition and the natural virus, efficacy will be much lower or absent. over the past years, live attenuated vaccines have been developed, tested, and used for intranasal administration. the less invasive route, of course, is a benefit in administering the vaccine. besides, the extra local immune response that is activated is a potential benefit. yet, even then there still remains a striking difference between efficacy and clinical effectiveness [39] . currently, animal research is being done into the development of vaccines that induce broad-spectrum and long-lasting immune response, which, if successful, would alter the prospects of the current influenza vaccination programs. in asthmatics, observational studies report varying and sometimes even contradictory outcomes [41] [42] [43] . but clinical efficacy has not been established yet at the highest level of evidence. uncertainty still remains about the degree of protection vaccination affords against influenzarelated symptoms such as asthma exacerbations [44••] . in a recent study in children with asthma, no positive effect of vaccination was found [34• ]. however, a distinct effect on quality of life in influenza-related episodes in asthmatic children was reported [6] . as for side effects and complications, the evidence that influenza vaccination is safe and well tolerated is extensive [44••] . several studies have addressed the cost-effectiveness of influenza vaccination. we also identified one costeffectiveness study that addressed a hypothetical rsv vaccine in elderly people [45] . all cost-effectiveness studies are based on a population-wide use of the vaccines, for example, in preschool children or elderly persons. in all of these studies, the cost-effectiveness of influenza vaccination is based on several premises. often the incidence of influenza is approximated by that of ili in epidemic seasons. these figures certainly exceed the average incidence of influenza when taking into account the seasons with low or no influenza activity. other biases may be the target populations and the definition used for influenza [46] . in the elderly cost-effectiveness is globally accepted [47] . in either case, population-wide cost-effectiveness preventive options against influenza for healthy adults 14 to 60 years old do not seem to be easily achieved, and therefore some authors have suggested that the most cost-effective option is not to take any action [48] . for high-risk patients with chronic respiratory conditions, again, in the elderly cost-effectiveness was achieved; however, this was not the case for the 18 to 65 years age category [49, 50] . in children with high-risk conditions the use of influenza vaccination was calculated to be cost-effective. however, this study assumed a much higher incidence and a far more favorable effectiveness of influenza vaccination than described above [50] . the role of virus vaccination in patients with asthma at this moment and in the near future seems to be limited (table 1) . currently, vaccines are available for routine use only for influenza. however, because of a lack of clinical effectiveness, the natural antigenic variations of the influenza virus, and the low average incidence of influenza, cost-effectiveness in children and adults with asthma will not be easily achieved if vaccination has to be delivered annually. as for the other viruses that play an important role in the complications of patients with asthma, many hurdles remain to be overcome. for rsv, the first experiences with vaccines were a major disappointment. in the case of coronaviruses, attention is understandably focused on a vaccine for the prevention of sars. as for rhinoviruses, the major cause of asthma exacerbations, because of the amount of subspecies a vaccine will not be available in the near future. of course other therapies, such as antiviral medication or immunoglobulin, are used and are sometimes effective in reducing complications. but, the therapeutic use of these treatments is limited because they are often expensive and should be used only when there is proof of the agent that is causing the patient's symptoms. for prophylactic use their cost is a major problem. yet, the role of the clinician in patients with asthma experiencing the threat of an exacerbation with its complications is clear. an oral corticosteroid can be provided and kept on hand by the patient. this permits initiation of more prompt and effective treatment than is likely to occur when a patient must first go to a physician's office or emergency department, because it can be taken as soon as the response to bronchodilator therapy is incomplete [21] . moreover, patients with asthma should be treated according to national and international standards. access to and compliance with inhaled corticosteroid treatment is an important predictor of the likelihood of asthma exacerbations occurring, including those that occur during respiratory viral infections [2•]. papers of particular interest, published recently, have been highlighted as: • of importance •• of major importance incidence and prevalence of asthma and allergic rhinitis: a cohort study of finnish adolescents this review describes the epidemiology of asthma exacerbations based on multiple sources viruses as precipitants of asthmatic attacks in children community study of role of viral infections in exacerbations of asthma in 9-11 year old children asthma exacerbations in children associated with rhinovirus but not human metapneumovirus infection influenza vaccination in asthmatic children: effects on quality of life and symptoms respiratory viruses and exacerbations of asthma in adults respiratory tract viral infections in inner-city asthmatic adults viruses in asthma exacerbations the relationship between upper respiratory infections and hospital admissions for asthma: a time-trend analysis influenza and the rates of hospitalization for respiratory disease among infants and young children the burden of influenza illness in children with asthma and other chronic medical conditions respiratory infections and the autumn increase in asthma morbidity the incidence of respiratory tract infection in adults requiring hospitalization for asthma spectrum of clinical illness in hospitalized patients with "common cold" virus infections epidemiology of respiratory viruses in patients hospitalized with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease population-based surveillance for hospitalizations associated with respiratory syncytial virus, influenza virus, and parainfluenza viruses among young children inhaled steroids for episodic viral wheeze of childhood early use of inhaled corticosteroids in the emergency department treatment of acute asthma early emergency department treatment of acute asthma with systemic corticosteroids treatment strategies for viral respiratory infection-induced asthma epidemiology of human rhinoviruses this interesting thesis describes the difficulties met and the progress made in rhinovirus research respiratory syncytial virus infection in elderly and high-risk adults clinical patterns and natural history of asthma progress in the development of respiratory syncytial virus and parainfluenza virus vaccines influenza vaccination in 2000: recommendations and vaccine use in 50 developed and rapidly developing countries respiratory viral infections in adults who 2003: influenza factsheet populationbased study on incidence, risk factors, clinical complications and drug utilisation associated with influenza in the united kingdom the underrecognized burden of influenza in young children the efficacy of influenza vaccination in elderly individuals. a randomized double-blind placebo-controlled trial influenza vaccination in children with asthma: randomized double-blind placebo-controlled trial until now, the only rct investigating the clinical effectiveness of influenza vaccination in children burden of influenza in children in the community invited commentary: use of selective viral cultures to adjust nonvirologic endpoints in studies of influenza vaccine efficacy incidence of influenza and associated illness in children aged 0-19 years: a systematic review vaccines for preventing influenza in healthy adults assessment of the efficacy and effectiveness of influenza vaccines in healthy children: systematic review methodological quality of studies and patient age as major sources of variation in efficacy estimates of influenza vaccination in healthy adults: a meta-analysis clinical effectiveness of conventional influenza vaccination in asthmatic children effectiveness of influenza vaccine for the prevention of asthma exacerbations influenza vaccination in patients with asthma: effect on the frequency of upper respiratory tract infections and exacerbations vaccines for preventing influenza in people with asthma. cochrane database syst rev 2004:cd000364. systematic review gathering all available evidence from randomized controlled trials into the effects and adverse events of influenza vaccination the cost-effectiveness of a hypothetical respiratory syncytial virus vaccine in the elderly systematic review and economic decision modelling for the prevention and treatment of influenza a and b influence of clinical outcome and outcome period definitions on estimates of absolute clinical and economic benefits of influenza vaccination in community dwelling elderly persons prevention and early treatment of influenza in healthy adults is immunizing all patients with chronic lung disease in the community against influenza cost effective? evidence from a general practice based clinical prospective cohort study in utrecht, the netherlands cost-effectiveness of influenza vaccination in high-risk children in argentina key: cord-339578-eg19rfvi authors: garcia-garcia, maria luz; calvo, cristina; ruiz, sara; pozo, francisco; del pozo, victoria; remedios, laura; exposito, nadia; tellez, ana; casas, inmaculada title: role of viral coinfections in asthma development date: 2017-12-05 journal: plos one doi: 10.1371/journal.pone.0189083 sha: doc_id: 339578 cord_uid: eg19rfvi background: viral respiratory infections, especially acute bronchiolitis, play a key role in the development of asthma in childhood. however, most studies have focused on respiratory syncytial virus or rhinovirus infections and none of them have compared the long-term evolution of single versus double or multiple viral infections. objective: our aim was to compare the frequency of asthma development at 6–8 years in children with previous admission for bronchiolitis associated with single versus double or multiple viral infection. patients & methods: a cross-sectional study was performed in 244 children currently aged 6–8 years, previously admitted due to bronchiolitis between september 2008 and december 2011. a structured clinical interview and the isaac questionnaire for asthma symptoms for 6-7-year-old children, were answered by parents by telephone. specimens of nasopharyngeal aspirate for virological study (polymerase chain reaction) and clinical data were prospectively taken during admission for bronchiolitis. results: median current age at follow-up was 7.3 years (iqr: 6.7–8.1). the rate of recurrent wheezing was 82.7% in the coinfection group and 69.7% in the single-infection group, p = 0.06. the number of wheezing-related admissions was twice as high in coinfections than in single infections, p = 0.004. regarding the isaac questionnaire, 30.8% of coinfections versus 15% of single infections, p = 0.01, presented “wheezing in the last 12 months”, data that strongly correlate with current prevalence of asthma. “dry cough at night” was also reported more frequently in coinfections than in single infections, p = 0.02. the strongest independent risk factors for asthma at 6–8 years of age were: age > 9 months at admission for bronchiolitis (or: 3.484; ci95%: 1.459–8.317, p:0.005), allergic rhinitis (or: 5.910; 95%ci: 2.622–13.318, p<0.001), and viral coinfection-bronchiolitis (or: 3.374; ci95%: 1.542–7.386, p:0.01). conclusions: asthma at 6–8 years is more frequent and severe in those children previously hospitalized with viral coinfection-bronchiolitis compared with those with single infection. allergic rhinitis and older age at admission seem also to be strong independent risk factors for asthma development in children previously hospitalised because of bronchiolitis. a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 more frequently in coinfections than in single infections, p = 0.02. the strongest independent risk factors for asthma at 6-8 years of age were: age > 9 months at admission for bronchiolitis (or: 3.484; ci95%: 1.459-8.317, p:0.005), allergic rhinitis (or: 5.910; 95%ci: 2.622-13.318, p<0.001), and viral coinfection-bronchiolitis (or: 3.374; ci95%: 1.542-7.386, p:0.01). there is strong evidence that respiratory viruses play a key role in the development of asthma in children. classic studies by sigurs et al. showed that respiratory syncytial virus (rsv) bronchiolitis, severe enough to require hospitalization, is a risk factor for asthma at the age of 7, 13 and 18 [1, 2, 3] . ng asthma at 6 years being more than four-fold higher compared with hrvnegative cases [4, 5] . other studies have reported that early human metapneumovirus (hmpv) infection during infancy is also an independent risk factor for the development of preschool asthma [6] ]. however, most studies have focused on rsv or hrv infections and only one of thm has evaluated the long-term evolution of viral coinfections, although focused exclusively on human bocavirus (hbov) and hrv coinfections in 3 to 35 month-old children with their first or second wheezing episode [7] . our main objective was to compare the frequency of asthma and other respiratory symptoms, at 6-8 years of age, in children with previous admission with bronchiolitis associated with viral co-infection versus simple viral infection. this is a substudy of an ongoing prospective investigation of respiratory tract infections in children, approved by the medical ethics committee. inclusion criteria were children 6-8 years of current age, with a previous hospitalization with bronchiolitis at 0-24 months of age, between september 2008 and december 2011. during the hospital stay a physician filled out a study-questionnaire with the following variables: age, sex, month of admission, clinical diagnosis, history of prematurity, need for oxygen therapy-evaluated via transcutaneous oxygen saturation -, axillary temperature (! 38˚c), presence of infiltrates and/or atelectasis in chest x-rays, administration of antibiotic therapy, length of hospital stay, total white blood cell (wbc) count, c-reactive protein (crp) serum levels and blood culture results (for those cases where such tests were performed) and results of the virological study. parents were contacted by phone between october 2016 and january 2017, and were invited to take part in the study. a telephone interview based on a structured questionnaire was performed, to obtain information on wheezing episodes, related hospital admissions, physician-diagnosed atopic dermatitis, allergic rhinitis, food allergy, use of bronchodilators and maintenance medication for asthma. information on pet contacts, parental smoking habits, presence of allergy, eczema and asthma in first order family members (mother, father or siblings) that had been diagnosed by a medical doctor was also recorded. furthermore, the present investigation used the isaac questionnaire for asthma symptoms for 6-7-year-old children, previously validated and translated to spanish [8] , which was answered by parents over the phone. the researchers were blinded to the status of the child when the interviews were performed. informed consent was obtained from parents or legal guardians. exclusion criteria were refusal to participate. specimens consisted of nasopharyngeal aspirates (npa) that were taken from each patient at admission. each specimen was sent for virological investigation to the respiratory virus and influenza unit at the national microbiology center (isciii, madrid, spain). npas were processed within 24 hours after collection. upon receipt, three aliquots were prepared and stored at -70˚c. both the reception and the npa sample processing areas were separate from those defined as working areas. polymerase chain reactions (pcr) methods for detection of sixteen respiratory viruses. three reverse transcription (rt)-nested pcr assays were performed to detect a total of sixteen respiratory viruses. in these assays, the reverse transcription and first amplification round were carried out in a single tube using the qiagen onestep rt-pcr kit (qiagen). influenza a, b and c viruses were detected by using primer sets only to amplify influenza viruses in a multiplex pcr assay as previously described [9] . a second multiplex pcr was used to detect parainfluenza viruses 1 to 4 (piv), human coronaviruses (cov) 229e and oc43, enteroviruses (ev) and hrv [10] . presence of rsv a and b types, hmpv, hbov and adenoviruses (adv) were investigated by a third multiplex rt-nested pcr-brq method [11] (s1 table) . bronchiolitis. all the classic criteria, present in an initial episode of acute onset expiratory dyspnea with previous signs of viral respiratory infection-whether or not this was associated to respiratory distress or pneumonia-were applied in diagnosing bronchiolitis [12] . the term recurrent wheezing was used to imply more than one episode of wheezing verified by a physician. the children who answered affirmatively to question 2 of the isaac questionnaire, "wheezing in the last 12 months", being the one that in the validation studies has shown a better correlation with the current prevalence of asthma, were considered to have asthma [13] . allergic rhinitis. was defined as rhinitis appearing at least twice after exposure to a particular allergen and unrelated to infection. viral coinfection. was defined as the detection of more than one viral pathogen in the same sample. continuous variables were described using mean and standard deviation. categorical variables were described using absolute and relative frequencies. clinical characteristics of patients with simple infections were compared with those associated with coinfections. to compare qualitative variables, chi 2 test or fisher's exact test was used if there were 5 items of data in a cell. for quantitative variables, as all of them followed a normal distribution, the means were compared using the students´s t to compare two groups. a two-sided value of p < 0.05 was considered statistically significant. multivariate stepwise logistic regression analysis was used to calculate the adjusted odds ratios (or) with 95% confidence intervals for estimating the association between different factors and asthma. all analyses were performed using the statistical package for the social sciences (spss), version 21.0. of the 351 children previously admitted with bronchiolitis, with positive viral detection and current age between 6 and 8 years, 244 (52 coinfections and 192 single infections) could be located and agreed to participate in the study. clinical characteristics during admission for bronchiolitis are presented in table 1 . no significant clinical differences could be detected between both groups, coinfections and single infections, in terms of age at admission, gender, prematurity, fever, hypoxia or length of hospital stay. the most frequently identified viruses in single infections were: rsv (100, 52%), hrv (29, 15%), hmpv (15, 8%), adv (5, 2.6%) and hbov (3, 1.6%). the most frequent coinfections were rsv + hrv (15, 29%) and rsv + hbov (12, 23%). with respect to comparability between both groups, no differences were found between coinfections and single infections regarding allergic rhinitis, atopic dermatitis or food allergy ( table 2) . several possible hereditary and environmental factors for the development of recurrent wheezing or asthma were also evaluated. no differences were observed in the family history of asthma or atopy. nearly one-third of children were exposed to tobacco smoke, with similar percentages in both groups ( table 2) . median current age at follow-up contact was 7.3 years (iqr: 6.7-8.1), with a slight predominance of females (52.5%). the rate of recurrent wheezing was 82.7% in the coinfection group and 69.7% in the single-infection group, p = 0.06, needing rehospitalization for wheezing 21% and 29% respectively, p = 0.251. the number of wheezing-related admissions was twice as high in coinfections than in single infections, p = 0.004. a similar percentage of children were prescribed inhaled corticosteroids in both groups. however, montelukast was used more frequently in coinfections than in simple infections, p = 0.01 (table 3) . regarding the isaac questionnaire answers, nearly 70% had "ever wheezed", without significant differences between both groups. however, 30.8% of coinfections versus 15% of single infections, p = 0.01, presented "wheezing in the last 12 months", data that strongly correlate with current prevalence of asthma. "dry cough at night" was also reported more frequently in coinfections than in single infections, p = 0.02. the questions: "wheezing during exercise?" and "ever had asthma?" were affirmatively answered with similar frequency in both groups. (table 4 ). in the combined coinfection and single infection group, several possible hereditary and environmental risk factors for asthma at the age of 6-8 were evaluated using a univariate analysis ( table 5 ). the risk of asthma was increased in children previously hospitalized for bronchiolitis with viral coinfection (or = 2.498; 95% ci: 1.229-5.077), in those who were older at the table 5 with a p-value < 0.10 were entered in a stepwise logistic regression analysis to estimate which factors were independently related to the development of asthma at 6-8 years. age > 12 months at admission for bronchiolitis (or: 7.389; 95%ci: 2.683-20.352, p<0.001), age > 9 months at admission for bronchiolitis (or: 3.484; ci95%: 1.459-8.317, p:0.005), allergic rhinitis (or: 5.910; 95%ci: 2.622-13.318, p<0.001), and viral coinfection-bronchiolitis (or: 3.374; ci95%: 1.542-7.386, p:0.01) were the strongest independent risk factors for asthma at 6-8 years of age. our current study shows for the first time to our knowledge, that there is a strong and independent association between severe bronchiolitis associated with viral coinfection and the development of asthma at 6-8 years old. viral coinfections are usually detected in up to 30% of children with an acute respiratory tract infection [14] . our group, in previous studies, found viral coinfections in 22.8% of 318 infants less than 2 years old admitted with bronchiolitis [11] and in 35% of 2,993 children less than 14 years old admitted with lower respiratory tract infection [15] . our current results confirm that the most frequently identified viral coinfections are dual rsv-hrv and rsv-hbov infections. results from cohort studies evaluating the severity of acute respiratory viral coinfections are conflicting. our group previously found that clinical severity was associated mainly with rsv infections, either alone or in combination with other viruses [15] . however, asner et al. [16] in a recent systematic review and meta-analysis found no differences in clinical disease severity between viral coinfections and simple infections, although an increased risk of mortality was observed amongst preschool children with coinfections. they conclude that large, prospective, well designed studies with objective outcomes are needed to better understand the clinical significance of viral respiratory coinfections. regarding the role of early viral respiratory coinfections in the development of wheezing or asthma, so far, no study evaluating this possible association has been published. our results confirm that recurrent wheezing and asthma are very common in the first years of life after a severe bronchiolitis. but the likelihood of developing asthma was 2.5 times higher if bronchiolitis was associated with viral coinfection compared to single infections. in addition, the number of rehospitalizations for asthma was also significantly higher in coinfections than in single infections, suggesting that coinfections are associated not only with more frequency of asthma but also with greater severity. the mechanism by which respiratory infections are associated with subsequent asthma is not fully understood but the different inflammatory responses released after viral infections seem to play a relevant role. the induction of a prevalent th2-type response, with the production of il-4, il-5, and il-13, results in a less robust and less efficient reaction to the infection, clinically presenting as increased disease severity and risk for future recurrent wheezing [17, 18] . several reports showed that thymic stromal lymphopoietin (tslp) is a key initiator of allergic airway responses [19] and significant negative correlation has been described between tslp levels in induced sputum and fev-1 in asthmatic children [20] . tslp is secreted by rsv-infected airway epithelial cells (aecs) to promote the activation of dendritic cells (dcs) [21, 22] . the activated dcs can then induce a th2 cell polarization response in the lung, which could contribute the development of asthma in rsv-infected individuals, as well as induction of exacerbations in asthmatic rsv-infected patients. it has been suggested that the ability of rsv to induce tslp expression by aecs is responsible for the subsequent th2 aspects of the immune response [23] . other recent studies performed in young children with hrv infection, have also found higher levels of nasal tslp [24, 25] . on the other hand, various genetic studies in humans have identified both il-33 and its receptor st2, as being key regulators in the development of asthma [26] and to have a strong th2-promoting ability in animal models of asthma [27] . il-33 is responsible for the immunopathophysiological response observed following neonatal rsv infection in mice. its presence in nasal aspirates of human infants with severe rsv, together with the finding that by blocking the receptor of interleukin 33 in vivo [28] , th2 responses are greatly reduced, suggest it has a role in disease severity and asthma [29] . our findings, in a recent study conducted in hospitalized infants with bronchiolitis and in healthy controls, showed that nasal tslp and il-33 are detected more frequently in viral coinfections than in single infections. in addition, infants with dual rsv+hrv infection were 9 times more likely to have detectable nasal tslp and this association was independent of other factors such as age or illness severity [30] . it is worth noting that no patient with bronchiolitis but with negative viral detection had detectable levels of nasal tslp or il-33, suggesting that the release of these proteins may be mediated by respiratory viruses. it can be hypothesized that this stronger tslp response after viral coinfection bronchiolitis, could stimulate a vigorous production of th2-associated effector cytokines, such as il-4, il-5, il-13, as was reported in asthmatic adults by ying et al, that could be associated with higher frequency of wheezing and asthma development later on [31] . as far as we know, only lukkarinen et al [7] have compared the systemic th1-type, th2-type and proinflammatory cytokine profiles in young children with simple versus viral coinfection, being hrv and hbov1 the viruses involved. they included hospitalized children less than 35 months of age with their first or second wheezing episode. they observed that wheezing children with hrv had higher proinflammatory responses than did those with hbov1 or those with coinfection hrv+hbov1, suggesting that hbov1 may interfere with hrv-induced immune responses. furthermore, this immunological response was accompanied by the clinical finding that children with hrv+hbov1 wheeze tended to develop recurrent wheezing later and less often than did those with hrv wheeze. our previous and current results suggest that an interaction may also occur in rsv and hrv coinfections, but in an opposite way, towards a predominant th2 response that could increase the development of recurrent wheezing/asthma. the risk of asthma in our study, like in other cohort studies on hospitalized children with lower respiratory symptoms, was directly dependent on age [4, 32] : the adjusted or was 3.4 for asthma in children with bronchiolitis aged > 9 months and 7.3 for asthma in school age in bronchiolitis children aged > 12 months. however, lukkarinen et al [33] , in a 7-year followup found asthma inversely dependent on age, probably because they studied infants with wheezing only, vs. bronchiolitis, with or without wheezing, in other studies as in ours. this different inclusion criteria may bias the kind of patients included in the studies. rhinitis is a known risk factor for asthma in children [34] . our results suggest that rhinitis is an independent risk factor for asthma persistence in school-age children with previous severe bronchiolitis. lauhkonen et al [35] in a prospective follow-up study, in 102 children hospitalised for bronchiolitis, also found that current asthma was associated with prolonged rhinitis and a positive skin prick test at five to seven years. on the other hand, recent reports have demonstrated that the severity of rhinitis and asthma are closely related in children [36] . thus, as other authors have stated [37] , all these results highlight the convenience to assess nasal symptoms in infants and children with recurrent wheezing and asthma. in conclusion, asthma at the age of 6-8 is more frequent and severe in those children previously hospitalized with viral coinfection bronchiolitis compared with those with single infection. moreover, viral coinfection, allergic rhinitis and older age at admission seem also to be strong independent risk factors for asthma development in children previously hospitalised because of bronchiolitis. however, given the complexity of the immunological mechanisms involved, more studies are needed to confirm this association and better understand its physiopathological mechanism. supporting information s1 respiratory syncytial virus bronchiolitis in infancy is an important risk factor for asthma and allergy at age 7 severe respiratory syncytial virus bronchiolitis in infancy and asthma and allergy at age 13 asthma and allergy patterns over 18 years after severe rsv bronchiolitis in the first year of life rhinovirusinduced wheezing in infancy-the first sign of childhood asthma? infantile respiratory syncytial virus and human rinovirus infections: respective role in inception and persistence of wheezing human metapneumovirus bronchiolitis in infancy is an important risk factor for asthma at age 5 human bocavirus 1 may suppress rhinovirus-associated immune response in wheezing children validation of the spanish versión of the phase iii isaac questionnaire on asthma simultaneous detection of influenza a, b, and c viruses, respiratory syncytial virus, and adenoviruses in clinical samples by multiplex reverse transcription nested-pcr assay simultaneous detection of fourteen respiratory viruses in clinical specimens by two multiplex reverse transcription nested-pcr assays detection of new respiratory virus in bronchiolitis: 3-year study what's in the name? validation of questionnaire and bronchial hyperresponsiveness against respiratory physician assessment in the diagnosis of asthma two-year prospective study of single infections and co-infections by respiratory syncytial virus and viruses identified recently in infants with acute respiratory disease respiratory syncytial virus coinfections with rhinovirus and human bocavirus in hospitalized children clinical disease severity of respiratory viral co-infection versus single viral infection: a systematic review and meta-analysis host response to respiratory syncytial virus infection respiratory syncytial virus-host interaction in the pathogenesis of bronchiolitis and its impact on respiratory. morbidity in later life stromal lymphopoietin as a key initiator of allergic airway inflammation in mice increased expression of thymic stromal lymphopoietin in induced sputum from asthmatic children tslp-activated dendritic cells induce an inflammatory t helper type 2 cell response through ox40 ligand tslp-activated dendritic cells induce human t follicular helper cell differentiation through ox40-ligand thymic stromal lymphopoietin is induced by respiratory syncytial virus-infected airway epithelial cells and promotes a type 2 response to infection rhinovirus infection in young children is associated with elevated airway tslp levels rhinovirus-induced airway cytokines and respiratory morbidity in severely premature children defining the contribution of snps identified in asthma gwas to clinical variables in asthmatic children il-33 is more potent than il-25 in provoking il-13-producing nuocytes (type 2 innate lymphoid cells) and airway contraction role of interleukin 33 in respiratory allergy and asthma respiratory syncytial virus disease is mediated by age-variable il-33 thymic stromal lymphopoietin, il-33, and periostin in hospitalized infants with viral bronchiolitis thymic stromal lymphopoietin expression is increased in asthmatic airways and correlates with expression of th2-attracting chemokines and disease severity wheezing rhinovirus illnesses in early life predict asthma development in high-risk children prednisolone reduces recurrent wheezing after first rhinovirus wheeze: a 7-year follow-up allergic rhinitis as a predictor for wheezing onset in school-aged children following up infant bronchiolitis patients provided new evidence for and against the united airway disease hypothesis severity of rhinitis and wheezing is strongly associated in preschoolers: a population-based study preschool-age wheezing phenotypes and asthma persistence in adolescents key: cord-351129-lzzyn570 authors: lee, jae-hyun; lee, youngsoo; lee, suh-young; van bever, hugo; lou, hongfei; zhang, luo; park, hae-sim title: management of allergic patients during the covid-19 pandemic in asia date: 2020-06-15 journal: allergy asthma immunol res doi: 10.4168/aair.2020.12.5.783 sha: doc_id: 351129 cord_uid: lzzyn570 although a viral infection is a major triggering factor of asthma and allergic diseases, asthma is suggested to be not a predisposing condition for coronavirus disease 2019 (covid-19) infection. however, patients with severe asthma/allergic disease requiring systemic corticosteroids or immunosuppressive agents may be at higher risk of more severe clinical course of this infectious disease. for allergic patients who have been followed up at an allergy clinic in our region, it is recommended that they (patients with asthma, rhinitis, atopic dermatitis or chronic urticaria) continue to receive maintenance therapy and be in a well-controlled status. patients who have used biologics (currently available for targeting type 2 inflammation) and allergen immunotherapy should continue the treatment while minimizing hospital and face-to-face visits. it is essential to wear protective equipment for the protection of health care workers as well as patients. we report this consensus to support allergists and clinical immunologists to make optimal decisions under the urgent situation in asia. the coronavirus disease 2019 (covid-19) outbreak has started from wuhan in china in late december 2019; the world health organization (who) named this new coronavirus severe acute respiratory syndrome coronavirus 2 (sars-cov-2). the first case of person-to-person transmission was confirmed in january 2020, and the first wave of the pandemic has started across the globe, including in asian countries. 1 the case-fatality rate among infected patients varies in our region: 5.5% in china, 2.2% in korea, 2.5% in japan and 0.1% in singapore, which is lower than in the us and european countries. 2 higher mortality rates (8%-15%) were reported in elderly patients and patients with comorbid conditions such as hypertension and metabolic diseases. 1, 3 in addition, an important issue is the spreading of this infection to healthcare workers (hcws). in china, 3.8% of the cases were found in hcws (14.8% among disclosure there are no financial or other issues that might lead to conflict of interest them were severe or critical) with a mortality of 0.3%; moreover, 63% of the affected hcws were reported in wuhan. 4 the prevalence of allergic diseases, including asthma and allergic rhinitis (ar), is increasing in asian countries, especially in the elderly, 5, 6 in which viral infections are major triggering factors. although the initial starting point for covid-19 appears to have been successful in controlling epidemics to the appropriate initial response in this region, there is constantly the possibility that a new virus subtype outbreak will begin. 7,8 therefore, we report our consensus on how to manage allergic patients during this pandemic as well as how to protect hcws. to prevent the spread of this viral infection, the specified preventive measures have been applied to the general public and hcws. the who recommended basic protective measures, including frequent hand washing, maintaining a social distance of 2 m and practicing respiratory hygiene for the public. 9 during the covid-19 pandemic, hospital authorities in korea have restricted entrance to the hospital through strict screening of people by checking recent travel history, clinical symptoms and body temperature. furthermore, all the patients have been asked to wear a disposable facial mask with careful monitoring of symptoms and temperatures during their stay in the hospital. the american centers for disease control and prevention (cdc) recommended appropriate personal protective equipment for healthcare providers, including gowns, gloves, n95 respirators and goggles. 1,10 although a respiratory viral infection is a major contributing factor to asthma exacerbation as well as a triggering factor, information about the influence of sars-cov-2 on asthma and allergic diseases is limited. it was reported that none of the 140 patients who were hospitalized due to confirmed covid-19 in wuhan, china had asthma or other allergic diseases such as ar, atopic dermatitis (ad) and food allergy. 11 drug hypersensitivity and urticaria were found in 11.4% and 1.4% of the patients, respectively, in that study; their relationships to covid-19 remain unclear. another report from wuhan observed a markedly lower prevalence of asthma (5 asthmatics among 548 patients with confirmed covid-19, 0.9%) compared to the prevalence of adult asthma in wuhan (6.4%). 12 in another recent study of the 1,099 patients with covid-19 admitted, no asthmatics were found among the study subjects. 13 korean data demonstrated that none of the 22 patients who died of covid-19 were suffering from asthma or other allergic diseases. 3 however, the possibility of under-diagnosis or under-reporting exists in those studies. although it has not been determined whether allergy or asthma may predispose patients to covid-19, non-pandemic coronavirus infections have aggravated asthma both in adults and children. [14] [15] [16] thus, the probability of the aggravation of asthma and other allergic diseases by covid-19 should be considered. furthermore, as pediatric patients with asthma are at higher risk of respiratory viral infections, most experts advise extreme caution in such cases. 17 immunosuppressive agents are frequently used to achieve a well-controlled status in patients with asthma or severe allergic diseases. systemic corticosteroid, one of the most widely used rescue medications in allergic diseases, is known to increase the risk for systemic infections, and so do other immunosuppressive agents such as methotrexate and cyclosporin. 18 fortunately, the advent of biologic agents, such as anti-immunoglobulin e (ige), anti-interleukin (il)-5 and anti-il-4 antibodies, has improved treatment outcomes with reduction in medications including systemic corticosteroids. as it is not clear whether biologics may increase the susceptibility to serious infections, further studies are needed to draw conclusions. taken together, we should consider the possibility of bidirectional influences between covid-19 and asthma/allergic diseases, which can be influenced by patients' clinical characteristics such as age, comorbid illnesses, and profiles of the medications. allergen-specific immunotherapy (ait), including subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit), is widely applied to patients with asthma or ar in asia. [19] [20] [21] [22] ait, especially scit, requires long-term regular contacts between hcws and patients (>3 years). during the covid-19 pandemic, home isolation strategy is necessary to control this highly contagious disease, and frequent hospital visits may increase the risk of exposure to the virus. to prevent the risk of infection and to provide safe medical services, the following control measures have been suggested to patients undergoing scit in each allergy center. 23 whenever the patients visit the hospital, they should be asked to take strict screening of covid-19 at the entrance and exit. only patients with a normal temperature are allowed to enter the outpatient clinic. they should wear a disposable surgical mask during their stay in the hospital. any confirmed cases of covid-19 should stop ait until this infection completely resolves and the viral test result becomes negative. 23 a good piece of advice is for hcws, including physicians, nurses and the administrative staff contacting with patients, to wear appropriate personal protective equipment such as n94/95 protective masks and latex gloves in korea, while additional protective equipment, including waterproof medical caps, anti-fog protective goggles and protective face shields, is required in allergy centers in beijing. injections for scit should be modified after case-by-case assessment. at the up-dose phase, discontinuation of scit is recommended if regular visits to the allergy center are difficult. re-initiation can be planned until continuous visits are available. in patients who are at the maintenance phase of scit, the injection protocol can be adjusted later, and the next dose can be administered again as recalculated according to the authoritative guidelines. slit can be continued without interruption. 23 online consultation and medicine delivery services are recommended to reduce the need for patients to visit or stay in an allergy center during the covid-19 pandemic. it is well known that common coronaviruses are associated with the worsening of asthma symptoms. 14, 15 recent reports have suggested that asthma does not increase the risk of covid-19 infection or related complications. 3, 11, 13 however, these data have been obtained from hospitalized patients with covid-19; therefore, the actual risk has not yet been accurately determined. the who recommends avoiding systemic steroid use in patients with covid-19 (not limited to asthmatic patients), except in some situations such as septic shock and acute respiratory distress syndrome. 11, [24] [25] [26] all asthmatic patients should be treated with inhaled corticosteroids (icss) with/without long-acting beta 2 -agonists as controllers according to the global initiative for asthma (gina) guidelines. 27 it would be better to use a metered-dose inhaler or dry-powder inhaler rather than a nebulizer in order to prevent the risk of the spread of the virus via the device. 28 if patients with mild-to-moderate asthma are well controlled and have sufficient maintenance medications, it would be better to postpone faceto-face visits along with online consultations. 29 considerable efforts should be made to reduce the prescribed dose of systemic corticosteroids in order to avoid an immuno-compromised status in the management of severe asthma. elderly patients with asthma or comorbid conditions should be more strictly monitored. additionally, it is recommended that regular ig replacement treatment be maintained in asthmatic patients with igg subclass deficiency suffering from frequent asthma exacerbations. 30 such patients should receive igg replacement treatment during the pandemic, even though they have the risk of exposure to the virus during their visits in order to prevent asthma exacerbation. 31 taken together, it is important to maintain each patient in an optimal controlled status, and it is not recommended to stepdown controller medications that are maintained. 29, 32 if patients have asthma exacerbations, they should be managed according to the gina guidelines. when conducting lung function tests to monitor control status, the clinical necessity and potential risk of droplet infection are compared carefully based on the judgment of the clinician. it is recommended to perform spirometry only when its results can draw an immediate treatment descision. 33 no specific documents are available for the management of ar during the covid-19 pandemic; therefore, stepwise treatment should be performed according to symptom severity. however, given the benefits of controlling ar in patients who also have asthma, ar should also be treated more actively. 34 in cases of mild/intermittent ar or seasonal rhinitis, face-to-face consultation should be postponed, and instead non-face-to-face consultation (online consultation) is advisable. from the data available, it is currently clear that children are far less affected by covid-19 than adults and that clinical symptoms are usually milder in children than in adults. 35 moreover, according to data from the american cdc, it is found that the prevalence of asthma in children (n = 345) with covid-19 is about 11.5%, which is lower than that in the general population (20%). however, these data must be interpreted with caution because the total number of children included in the study was relatively small, and there was a considerable amount of missing data. 36 although specific studies on the effect of covid-19 in asthmatic children have not been published yet, covid-19 may not be an asthmogenic virus in children. in a review article, it is suggested that pediatric allergists should treat patients with asthma, ar or other allergic conditions according to the usual guidelines. in addition, there is no evidence that currently available asthma and allergy medications, including antihistamines, icss and bronchodilators, increase the risk of disease exacerbation by covid-19. it is also not advisable to stop oral steroids in the management of asthma if the patient is already taking these medications or to avoid oral steroids for the treatment of an acute asthma attack even if it is due to covid-19. 31 although additional studies are needed in patients with pediatric asthma, it seems that covid-19 is not a risk for asthma exacerbation in healthy or asthmatic children. during the current pandemic, asthmatic children should continue to receive preventive treatment in order to be under good control. there have been no studies on the effect of covid-19 on ar in children yet. the allergic rhinitis and its impact on asthma (aria)-european academy of allergology and clinical immunology (eaaci) mentioned that patients with common allergic conditions do not develop additional distinct symptoms or seem to be at increased risk of severe disease when infected with covid-19. 37 ad is a chronic inflammatory skin disease characterized by recurrent eczematous skin lesions and pruritus. not only is ad associated with airway diseases such as asthma and ar, but patients with severe ad are also likely to be vulnerable to respiratory infections because of their systemic immunosuppressive treatment. 38 however, discontinuation of immunosuppressive agents should not be applied in all ad cases, since it can lead to the aggravation of ad and even to disseminated viral skin diseases such as eczema herpeticum. 39 maintenance of skin hygiene and the use of moisturizers and topical immunosuppressive agents would be preferable options in the treatment of ad. however, systemic immunosuppressant or immune-modulating agents, such as dupilumab, seem unlikely to elevate the risk of covid-19. a recent italian study reported that only 2 (0.82%) of 245 ad patients treated with dupilumab developed covid-19, and they successfully recovered from covid-19 while maintaining dupilumab therapy. 40 taken together, to maintain optimal skincare, topical immunosuppressant and immune-modulating therapies should not be deferred or stopped if needed on the basis of physicians' judgment to prevent flares of ad. cu is defined as urticaria that has been present for at least 6 weeks and required long-term maintenance therapy because symptoms can last for years in many cases. 41 in healthy subjects without any underlying diseases, cu symptoms are not usually life-threatening, and visiting healthcare facilities needs to be delayed and rescheduled (a few weeks to a few months) during the covid-19 pandemic. to avoid this highly contagious disease, it is necessary to reduce unnecessary visits to hospitals and to be isolated at home. in particular, older patients with comorbidities, such as hypertension, diabetes, cardiovascular disease and chronic respiratory disease, are vulnerable to infections and are more cautious in visiting hospitals. 42, 43 however, visiting healthcare facilities would be of some benefit in patients experiencing significant deterioration in the quality of life without regular medication. when patients develop severe symptoms, such as anaphylaxis, angioedema, bronchospasm, dizziness, and hypotension accompanying urticaria, they should visit the emergency department to treat symptoms. patients are required to follow all the policies for infection control. physicians should delay the evaluation of the causes of cu and reschedule patient outpatient visits until the pandemic is over. drug allergy can be managed according to similar basic principles. drug allergy should be immediately treated especially in the presence of symptoms, such as generalized urticaria, angioedema, bronchospasm and hypotension. epinephrine injection is contemplated in cases of suspected anaphylaxis. diagnostic procedures, such as drug challenge and drug skin tests, are required to be delayed until the pandemic is over. drug desensitization is actively considered in patients who need immediate administration of hypersensitivity drugs. in principle, desensitization needs to be performed in the hospital according to the infection control procedure. 44 regular administration of biologics, such as anti-il-5, anti-il-4 and anti-ige antibodies, has become a common treatment option for severe asthma as well as for uncontrolled cases of cu and ad. it is critical to control disease activity through the prevention of exacerbations. 45 in addition, there have been no studies showing that biological agents may induce immune suppression and increase the risk of covid-19. for these reasons, there is no need to stop or reduce the dosage of biologics scheduled. 29 however, most of the biologics require periodic parenteral/subcutaneous administration, for which such patients have to visit an allergy clinic to receive medications according to a treatment protocol. in these patients, it is advisable to provide required protective equipment to both hcws and patients and to administer the medication with minimal contact. 9, 10 in allergic children, biologics are mainly used in patients with severe eczema or severe asthma. there have been no studies or guidelines on the usage of biologics in allergic children during the covid-19 pandemic. a case report suggested that immunosuppressive therapy with biologics might be effective in covid-19 patients with an overactive immune response, cytokine storm; however, there have been no systematic studies on this. 46 when children under treatment with biologics are infected with covid-19 and present with only mild symptoms, the treatment can be continued. however, when either adults or children who develop severe covid-19 symptoms, the treatment should be delayed until they completely recover. it is still uncertain whether covid-19 increases the risk of aggravating asthma or allergic diseases. detailed monitoring and optimal treatment with ait, ics and biologics need to be continued in all patients suffering from asthma and allergic diseases. this can be achieved in a safe condition using optimal protective measures. patients at high risk (older age and comorbid conditions) should be monitored more strictly. we applaud all the allergy/ immunology specialists who strive to stay up for optimal health protection by focusing on patient management during the covid-19 pandemic. covid-19-new insight on a rapidly changing epidemic world health organization. who covid-19 dashboard korean society of infectious diseases; korean society of pediatric infectious diseases report on the epidemiological feature of coronavirus disease 2019 (covid-19) outbreak in the republic of korea from high prevalence of asthma in elderly women: findings from a korean national health database and adult asthma cohort increasing prevalence of allergic rhinitis in china beware of the second wave of covid-19 phylogenetic network analysis of sars-cov-2 genomes world health organization. who coronavirus disease (covid-19) advice for the public geneva: who covid-19) situation summary clinical characteristics of 140 patients infected with sars-cov-2 in wuhan risk factors 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covid-19 rhinitis therapy and the prevention of hospital care for asthma: a case-control study sars-cov-2 infection in children cdc covid-19 response team. coronavirus disease 2019 in children -united states intranasal corticosteroids in allergic rhinitis in covid-19 infected patients: an aria-eaaci statement atopic dermatitis: collegium internationale allergologicum (cia) update 2019 recurrent eczema herpeticum -a retrospective european multicenter study evaluating the clinical characteristics of eczema herpeticum cases in atopic dermatitis patients safety of dupilumab in severe atopic dermatitis and infection of covid-19: two case reports the diagnosis and management of acute and chronic urticaria: 2014 update clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study risk factors of critical & mortal covid-19 cases: a systematic literature review and meta-analysis inpatient care of patients with covid-19: a guide for hospitalists the use of biologics for immune modulation in allergic disease covid-19 in a ms patient treated with ocrelizumab: does immunosuppression have a protective role key: cord-340583-kjrxrk50 authors: castro‐rodriguez, jose a.; forno, erick title: asthma and covid‐19 in children – a systematic review and call for data date: 2020-06-18 journal: pediatr pulmonol doi: 10.1002/ppul.24909 sha: doc_id: 340583 cord_uid: kjrxrk50 rationale: whether asthma constitutes a risk factor for covid‐19 is unclear. here we aimed to assess whether asthma, the most common chronic disease in children, is associated with higher covid‐19 risk or severity in pediatric populations. methods: we performed a systematic literature search in three stages: first, we reviewed pubmed, embase and cinahl for systematic reviews of sars‐cov‐2 and covid‐19 in pediatric populations, and reviewed their primary articles; second, we searched pubmed for studies on covid‐19 or sars‐cov‐2 and asthma/wheeze, and evaluated whether the resulting studies included pediatric populations; third, we repeated the second search in biorxiv.org and medrxiv.org to find pre‐prints that may have information on pediatric asthma. results: in the first search, eight systematic reviews were found, of which five were done in pediatric populations; none of the 67 primary studies included data on pediatric asthma as a comorbidity for covid‐19. in the second search, we found 34 results in pubmed, of which five reported asthma in adults, but none included data on children. in the third search, 25 pre‐prints in medrxiv included data on asthma, but none on children. we found one report by the u.s. cdc stating that 40/345 (~11.5%) children with data on chronic conditions had “chronic lung diseases including asthma”, and one from a tertiary hospital in new york that reported asthma in 11/46 (~23.9%) children hospitalized for covid‐19. conclusion: there is scarcely any data on whether childhood asthma (or other pediatric respiratory diseases) constitute risk factors for sars‐cov‐2 infection or covid‐19 severity. studies are needed that go beyond counting the number of cases in the pediatric age range. this article is protected by copyright. all rights reserved. the current outbreak of coronavirus disease 2019 , caused by the severe acute respiratory syndrome coronavirus-2 (sars-cov-2), started in or around december, 2019, in wuhan (1) . on january 30 th , 2020 the world health organization (who) declared covid-19 a pandemic health emergency (2) . since then, covid-19 has continued to spread quickly and has now become the most dangerous pandemic in over 100 years. an interactive real-time covid-19 reporting system set up by the center for systemic science and engineering at johns hopkins university (3) shows, as of the time of this writing, more than 5.8 million confirmed cases and over 361,000 deaths worldwide (led by the u.s., with ~30% of all cases and ~28% of all deaths). globally, this corresponds to a ~6% case fatality rate, although rates vary widely among countries and subpopulations and it is difficult to ascertain both the true numerator (active unresolved cases may eventually become deaths) and the true denominator (many true cases may go untested or undetected). the first pediatric case in the literature was reported on january 2020 in 10-yearold boy from shenzhen, china, whose family had visited wuhan (4) . all epidemiological evidence to date suggests that sars-cov-2 infection is less severe in children than in adults. in the latest and largest study in the uk, including 16,749 patients hospitalized for covid-19, only 239 (2%) were <18 years of age (including 139 who were <5 years this article is protected by copyright. all rights reserved. supplementary table 1) . none of the primary studies reviewed reported asthma or recurrent wheezing as a comorbidity or risk factor for covid-19. instead, some of those studies reported young age (especially children <1 year of age) as a group with more severe covid-19. one large chinese study (16) reported non-respiratory chronic conditions (hydronephrosis, leukemia receiving chemotherapy, and intussusception) among three children who required icu support and mechanical ventilation. among them, one death occurred in a10-month old child with intussusception. another study reported a patient who developed shock with metabolic acidosis requiring icu (17) . yet another report from china (18) described one patient aged 10-19 years who died, without other clinical information; that death probably represents the same 14-year-old boy described by dong and colleagues (19) . unfortunately, the two larger studies in chinese pediatric patients, dong et al. (19) (2,413 children) and wu and macgoogan (20) (965 children) did not report enough clinical data to identify comorbidities or risk factors for covid-19 severity. in the german survey of 33 hospitalized children, 4 out of 22 (18%) children with clinical information had "respiratory comorbidities" without further details (15) . our second search yielded 34 results in pubmed. of those, five were primary studies that reported on asthma in adults (21) (22) (23) (24) (25) ; one other was a guidance statement (26) that referenced a primary report that also included information on asthma in adults (27) . no studies from that search included information on asthma in children, although one case series reported two young children (ages 2 and 3 years) with history of atopic dermatitis and allergic rhinitis, who were hospitalized with covid-19; both patients recovered (28) . this article is protected by copyright. all rights reserved. our third search yielded 26 pre-prints in biorxiv and 137 in medrxiv. none of the biorxiv posts were relevant to our topic. of the 137 pre-prints in medrxiv, 23 nonduplicate studies included information on asthma , but none of them included specific information in children. weekly report (mmwr) (52) , published by the cdc, that included information from 2,572 u.s. children aged < 18 years. of those cases, 345 had data on clinical and underlying conditions, and 80 of those children (23%) had at least one underlying condition. the most common underlying conditions were "chronic lung diseases (including asthma)" in 40 children, cardiovascular disease in 25, and immunosuppression in 10; separate information on asthma was not provided. among the 295 cases for which data on both hospitalization status and underlying medical conditions was available, 28/37 (77%) hospitalized patients had one or more underlying medical condition (including all six patients admitted to an icu); compared to 30/258 (12%) patients who were not hospitalized (52) . a recently published italian study, including100 children seen in 17 emergency departments, reported that 27% had comorbidities without more specifications, and no deaths occurred (53) . and most recently, a study of 46 children this article is protected by copyright. all rights reserved. in a systematic review of the literature, we only found two reports that described asthma or recurrent wheezing as potential risk factors for covid-19 in children. importantly, none of the largest epidemiological studies including children with covid-19 reported clinical findings or underlying characteristics to help assess whether asthma -or other chronic lung diseases-constitutes a risk factor for sars-cov-2 infection or covid-19 severity. covid-19 affects primarily the lungs, and accordingly several international guidelines have designated some respiratory conditions as a potential risk factor for severe disease. chinese guidelines (54) state that "children with a history of contact with severe 2019-ncov infected cases, or with underlying conditions (such as congenital heart disease, bronchial pulmonary hypoplasia, respiratory tract anomaly, with abnormal hemoglobin level, severe malnutrition), or with immune deficiency or immunocompromised status… may become severe cases". a recent statement from the eaaci section on pediatrics (26) declared that "patients with asthma (particularly severe or uncontrolled asthma) and immunodeficiency have also been classified to be at increased risk of developing severe covid-19, based more on common sense rather than mounting evidence". the global initiative for asthma (gina) recommends avoiding the use of nebulizers due to the increased risk of disseminating covid-19 to other patients and healthcare staff; they thus recommend the use of pressurized metered dose inhalers (pmdi) as the preferred delivery system during asthma attacks (55) . a recent randomized controlled trial (rct) (56) showed that even in children with severe asthma exacerbations, administration of albuterol/salbutamol and ipratropium by mdi with valved-holding chamber and mask along with oxygen by nasal cannula was more effective than this article is protected by copyright. all rights reserved. accepted article nebulized administration. gina (55) and the british thoracic society (57) do not recommend stopping oral steroids in the patients already taking them for asthma management, and they do not recommend avoiding them for acute asthma attacks even if due to covid-19. the u.s. cdc, the canadian pediatric society, and other professional associations have issued guidance for patients with asthma and/or allergies (58) (59) (60) . other professional organizations, such as the american academy of pediatrics and the american thoracic society, have published interim guidelines that do not specifically address asthma, likely given a paucity of evidence (61, 62) . rather than a risk factor, a recent review of data in adults reported that both asthma and copd appear to be under-represented in the comorbidities reported for patients with covid-19, compared with global estimates of prevalence for these conditions in the general population (63) . this is consistent with individual studies we found during our search, which have shown lower-than-expected prevalence of asthma among cases of covid-19 (21) (22) (23) (24) 27) , and in contrast to the prevalence of other chronic diseases such as diabetes, which occurred with higher frequency among patients with covid-19 than the estimated national prevalence (63) . if asthma is indeed "protective", this could be due to several factors, including changes in the immune response or decreased risk secondary to chronic medications such as inhaled corticosteroids (ics). invitro models have shown that ics may suppress both coronavirus replication and cytokine production (64, 65) . analysis of induced sputum samples in a well-characterized cohort of adults with severe asthma found reduced ace2 (angiotensin-converting enzyme 2) and tmprss2 (transmembrane protease serine 2) gene expression among patients taking ics, and especially among those on higher doses (66) ; ace2 and tmprss2 mediate this article is protected by copyright. all rights reserved. patients with asthma and respiratory allergies had reduced ace2 gene expression in airway cells, suggesting a potential mechanism of reduced covid-19 risk (67) . this is particularly noteworthy considering that one of the potential explanations for children being generally less affected than adults is the hypothesis that children have lower ace2 receptor expression in alveolar type 2 cells (68) . however, the lower prevalence of asthma among covid-19 cases could also stem from bias due to underdiagnosis and underreporting, or because patients with chronic lung diseases may be especially cautious in practicing physical distancing and other measures to avoid infection. finally, it is also conceivable that some milder cases of covid-19 might be confused with exacerbations of respiratory disease, and/or that these patients may be reluctant to seek medical care even when sick and are thus never counted. it is important to note that our understanding of the role of asthma -even in adults-is still incipient. in the largest and most recent analysis to date, uk investigators analyzed data from 17 million adults, including 5,683 deaths due to covid-19, and reported that both asthma (adjusted hazard ratio, ahr: 1.11 [95% confidence interval: 1.02-1.20]) and severe asthma (ahr: 1.25 [1.08-1.44]) were risk factors for covid-19 mortality (51) . this study compared covid-19 deaths to the general population (regardless of being sars-cov-2 positive or not), so the estimates combine both risk of infection and risk of death once infected. these results highlight how incomplete our understanding still is. as with most other studies, this large analysis did not include a pediatric population. this article is protected by copyright. all rights reserved. after an extensive review of the current literature, only two reports included information on asthma as a potential risk factor for covid-19 infection -but not severity or mortality-in children. however, the largest studies to date have been limited to a description of the number of cases by age group, and so it remains unclear whether childhood asthma -or other pediatric respiratory diseases-are associated with covid-19 risk or severity. we hereby ask the public health community to move beyond confirming what's already known -that the disease affects children and young adults less frequently and severely than older groups-and to study affected pediatric populations in more detail. does asthma constitute a risk factor for covid-19 in children? do asthma severity or control modify the course of the disease? are asthma medications (particularly ics and systemic steroids) or their doses protective or detrimental? given the limited numbers of pediatric cases in any one given center/country, collaborative international efforts may be the only way to shed light on the topic. initiatives such as the pediatric asthma in real life (pearl) group (69) or a pediatric version of the international severe asthma registry (70) , or efforts coordinated by large professional societies, may be best suited for the task. this will be true not just for childhood asthma but for pediatric diseases in general. this article is protected by copyright. all rights reserved. china medical treatment expert group for c. clinical characteristics of coronavirus disease 2019 in china who director-general's opening remarks at the media briefing on covid-19 an interactive web-based dashboard to track covid-19 in real time a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster features of 16,749 hospitalised uk patients with covid-19 using the isaric who clinical characterisation protocol case-fatality rate and characteristics of patients dying in relation to covid-19 in italy preferred reporting items for systematic review and metaanalysis protocols (prisma-p) 2015: elaboration and explanation outcome of coronavirus spectrum infections (sars, mers, covid 1 -19) during pregnancy: a systematic review and meta-analysis school closure and management practices during coronavirus outbreaks including covid-19: a rapid systematic review systematic review of important viral diseases in africa in light of the 'one health severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection in children and adolescents: a systematic review epidemiology and clinical features of coronavirus disease 2019 in children clinical characteristics and diagnostic challenges of pediatric covid-19: a systematic review and meta-analysis systematic review of covid-19 in children shows milder cases and a better prognosis than adults epub 2020/04/23 chinese pediatric novel coronavirus study t. sars-cov-2 infection in children novel coronavirus pneumonia emergency response epidemiology t characteristics of and important lessons from the covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention clinical characteristics of 140 patients infected with sars-cov-2 in wuhan distinct characteristics of covid-19 patients with initial rrt-pcr-positive and rrt-pcrnegative results for sars-cov-2. allergy. 2020 risk factors for severity and mortality in adult covid-19 inpatients in wuhan postmortem lung findings in an asthmatic with coronavirus disease managing childhood allergies and immunodeficiencies during respiratory virus epidemics -the 2020 covid-19 pandemic hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 -covid-net, 14 states eleven faces of coronavirus disease 2019 covid-19 in iran, a comprehensive investigation from exposure to treatment outcomes icu and ventilator mortality among critically ill adults with covid-19 prevalence of sars-cov-2 infection in previously undiagnosed health care workers at the onset of the u.s. covid-19 epidemic predicting mortality due to sars-cov-2: a mechanistic score relating and diabetes to covid-19 outcomes in mexico an international characterisation of patients hospitalised with covid-19 and a comparison with those previously hospitalised with influenza how many are at increased risk of severe covid-19 disease? rapid global, regional and national estimates for 2020 epidemiology, clinical course, and outcomes of critically ill adults with covid-19 in new york city: a prospective cohort study key predictors of attending hospital with covid19: an association study from the covid symptom tracker app in 2,618,948 individuals clinical characteristics of hospitalized covid-19 patients between-centre differences for covid-19 icu mortality from early data in england machine learning to predict mortality and critical events in covid-19 positive test performance evaluation of sars-cov-2 serological assays potential factors for prediction of disease severity of covid-19 patients development and validation of a diagnostic nomogram to predict covid-19 pneumonia clinical characteristics associated with covid-19 severity in california covid-19 testing, hospital admission, and intensive care among 2,026,227 united states veterans aged 54-75 years factors associated with hospitalization and critical illness among 4,103 patients with covid-19 disease in new york city early short course corticosteroids in hospitalized patients with pre-existing characteristics associated with covid-19 illness severity supplementing the national early warning score (news2) for anticipating early deterioration among patients with covid-19 infection sars-cov-2 comorbidity network and outcome in hospitalized patients in updated estimates of comorbidities associated with risk for covid-19 complications based on us data opensafely: factors associated with covid-19-related hospital death in the linked electronic health records of 17 million adult nhs patients coronavirus infection in pediatric emergency departments research g. children with covid-19 in pediatric emergency departments in italy accepted article china medicine education association committee on p, chinese research hospital association committee on p, chinese non-government medical institutions association committee on p, china association of traditional chinese medicine cocsh, medicine r, china news of drug information association cocssm, global pediatric pulmonology a. diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: randomized clinical trial people who are at higher risk -people with asthma 2020 paediatric asthma and covid-19 2020 covid-19: pandemic contingency planning for the allergy and immunology clinic. the journal of allergy and clinical immunology in practice covid-19: interim guidance on management pending empirical evidence. from an american thoracic society-led international task force accepted article 62 do chronic respiratory diseases or their treatment affect the risk of sars-cov-2 infection? the lancet respiratory medicine inhibitory effects of glycopyrronium, formoterol, and budesonide on coronavirus hcov-229e replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells the inhaled corticosteroid ciclesonide blocks coronavirus rna replication by targeting viral nsp15 national heart l, blood institute severe asthma research program i. covid-19 related genes in sputum cells in asthma: relationship to demographic features and corticosteroids association of respiratory allergy, asthma and expression of the sars-cov-2 receptor, ace2 immune responses in covid-19 and potential vaccines: lessons learned from sars and mers epidemic accepted article papadopoulos ng. research priorities in pediatric asthma: results of a global survey of multiple stakeholder groups by the pediatric asthma in real life (pearl) think tank. the journal of allergy and clinical immunology in practice development of the international severe asthma registry (isar): a modified delphi study. the journal of allergy and clinical immunology in practice key: cord-000285-7p3b6tyf authors: hartert, tina v.; carroll, kecia; gebretsadik, tebeb; woodward, kimberly; minton, patricia title: the tennessee children's respiratory initiative: objectives, design and recruitment results of a prospective cohort study investigating infant viral respiratory illness and the development of asthma and allergic diseases date: 2010-04-08 journal: respirology doi: 10.1111/j.1440-1843.2010.01743.x sha: doc_id: 285 cord_uid: 7p3b6tyf background and objective: the ‘attack rate’ of asthma following viral lower respiratory tract infections (lrti) is about 3–4 fold higher than that of the general population; however, the majority of children who develop viral lrti during infancy do not develop asthma, and asthma incidence has been observed to continuously decrease with age. thus, we do not understand how viral lrti either predispose or serve as a marker of children to develop asthma. the tennessee children's respiratory initiative has been established as a longitudinal prospective investigation of infants and their biological mothers. the primary goals are to investigate both the acute and the long‐term health consequences of varying severity and aetiology of clinically significant viral respiratory tract infections on early childhood outcomes. methods: over four respiratory viral seasons, 2004–2008, term, non‐low birth weight previously healthy infants and their biological mothers were enrolled during an infant's acute viral respiratory illness. longitudinal follow up to age 6 years is ongoing. results: this report describes the study objectives, design and recruitment results of the over 650 families enrolled in this longitudinal investigation. the tennessee children's respiratory initiative is additionally unique because it is designed in parallel with a large retrospective birth cohort of over 95 000 mother–infant dyads with similar objectives to investigate the role of respiratory viral infection severity and aetiology in the development of asthma. conclusions: future reports from this cohort will help to clarify the complex relationship between infant respiratory viral infection severity, aetiology, atopic predisposition and the subsequent development of early childhood asthma and atopic diseases. the tennessee children's respiratory initiative (tcri) has been established as a longitudinal prospective investigation of term, non-low birth weight otherwise healthy infants and their biological mothers. the primary goals of the study are: (i) to investigate both the acute and the long-term health consequences of varying severity and aetiology of clinically significant viral respiratory tract infections on the outcomes of allergic rhinitis (ar) and early childhood asthma; and (ii) to identify the potentially modifiable factors that define children who are at greatest risk of developing asthma following infant respiratory viral infection. this study is unique, in that it was designed in parallel with our tennessee asthma bronchiolitis study (tabs), which is a retrospective birth cohort study of over 95 000 infants and their biological mothers similarly designed to elucidate the factors predisposing to childhood asthma and allergic this report describes the study objectives, design and recruitment results of the tennessee children's respiratory initiative, designed to investigate the role of respiratory viral infection severity and etiology in asthma development. future reports will address the complex relationship between infant respiratory viral infection and asthma and atopic diseases. diseases, but lacking biospecimens. thus, we designed the prospective tcri to establish a base for the evaluation of both the risks and benefits of documented significant infant viral respiratory infection of varying severity and aetiology and other environmental exposures on childhood atopy outcomes and to establish a biospecimen repository for analyses including biomarker testing and genotyping. the prospective cohort has the longitudinal design properties that may overcome potential limitations intrinsic to retrospective studies, such as our tabs cohort. [1] [2] [3] [4] [5] it is our eventual goal that the findings from these investigations, in conjunction with other investigations that have helped to elucidate genetic and environmental factors associated with asthma development, will help in the identification of primary and secondary prevention strategies for asthma. this report describes the study objectives, design and recruitment results of this study cohort. the tcri is a prospective cohort of mother-infant dyads enrolled in a longitudinal investigation of the relationship of infant viral respiratory infection severity and aetiology and the interaction of other risk factors on the development of childhood asthma and allergic diseases. the study was approved by the vanderbilt institutional review board, and parents provided written informed consent for both their and their child's study participation. term, non-low birth weight, otherwise healthy infants were enrolled along with their biological mothers, at a single academic institution, vanderbilt children's hospital, at the time of an acute visit (hospitalization, emergency department or unscheduled outpatient visit) for presumed viral bronchiolitis or upper respiratory tract infection (uri) during respiratory viral seasons september through may 2004-2008. inclusion and exclusion criteria are outlined in table 1 . because of the grant funding start date, the first study season did not begin until november 2004. recruitment was solely hospital-and clinic-based, and was performed 7 days/week during the first 2 years of cohort accrual, and 5 days per week for the two subsequent years. screening and recruitment were done by experienced congenital or acquired chronic heart or lung disease, prior requirement for mechanical ventilation for cardiac or pulmonary disease, immunodeficiency, neurologic disease with possible aspiration, significant gastroesophageal reflux disease felt to contribute to pulmonary disease, tracheomalacia ever received one or more doses of rsv-ivig or palivizumab prior study inclusion fever and neutropenia children whose parents or guardians were not able to understand the consent process, or a language barrier † research nurses using computerized medical charts to screen infants with presumed respiratory viral illness. the components and time line of the subject visits are outlined in table 2 mothers underwent prick skin testing to eight common aeroallergens and a blood specimen was obtained by venepuncture for serum immunoglobulin e (ige) and dna. a structured abstraction form was used to obtain information from the medical record regarding the index enrolment visit: current infant weight, confirmation of birth weight, room air pulse oximetry, requirement for supplemental oxygen, medication administration, prior wheezing episodes and detailed information on the current illness and hospital course. following discharge from the hospital or outpatient setting, the final discharge diagnosis and results of culture data were obtained through chart review. there are three phases of cohort follow up. first, mothers and children undergo an in-person wellchild follow-up visit during the child's second year of life conducted in the vanderbilt clinical research center, or during a home visit. second, families are re-contacted every 12-18 months by phone and/or mailings for purposes of cohort retention, and to provide reminders about the remaining study components. third, mothers, or the current guardians, undergo a phone interview during the fourth and sixth years of life to identify children with asthma, transient wheezing, ar and eczema. the 2-year in-person well-child visit is conducted in the vanderbilt clinical research center, or during a home visit offered to those unable to return to the study institution. during the visit, the isaac questionnaire is administered, blood samples are obtained from children and mothers (if not previously collected) and a buccal swab is collected for dna if blood cannot be obtained. a structured telephone questionnaire is administered to the mother/parent when their child is 4 and again at 6 years. trained interviewers employed in the vanderbilt survey research shared resource use a web-based computer system to conduct structured telephone interviews, which capture detailed information on asthma and atopy diagnoses and symptoms, extensive environmental exposure history, physical activity, and comorbidities. asthma, ar and atopic dermatitis outcomes are determined using the isaac questionnaire. for children with report of asthma and/or asthma symptoms in the previous 12 months, the asthma therapy assessment questionnaire is administered, and information on asthma medications, and asthma-related health-care visits are sought. 12, 13 biospecimen collection and laboratory analyses table 3 outlines the details of cohort biospecimen collection, repository and testing, which includes infant nasopharyngeal, urine, blood and nasal epithelial cell sample collection, and maternal prick skin testing and blood samples. the discharge diagnosis and supporting clinical parameters of the infant acute respiratory illness visit were reviewed to confirm whether each child had lower respiratory tract infections (lrti) or uri (n = 628) or another diagnosis (n = 46). lrti and uri were defined using both the physician discharge diagnosis, as well as post-discharge chart review, and those cases that were not clearly identified as either lrti or uri were reviewed by a panel of paediatricians who determined whether the illness represented an lrti, uri, croup or other, which included those that could not be categorized with the available clinical information. acute respiratory illness severity was determined using the ordinal bronchiolitis score that incorporates admission information on respiratory rate, flaring or retractions, room air oxygen saturation and wheezing, into a score ranging from 0 to 12 (12 being most severe). 27, 28 highly sensitive and specific qrt-pcr assays for many common respiratory viruses, including hmpv, hcov, rsv, influenza a and b, parainfluenzaviruses 1-3 and rhinovirus. real-time rt-pcr is performed using the cepheid smart cycler ii. all specimens are first tested for gapdh to confirm integrity of rna and monitor for potential pcr inhibitors. negative and positive controls are included with each run, including rna runoff transcripts to generate a quantitation curve. [14] [15] [16] [17] [18] [19] [20] [21] if rapid antigen and/or culture for rsv or influenza were performed at the discretion of the admitting physicians during the index visit, these results are also captured and entered in the database. the cells are collected using mid turbinate peds nylon flocked swabs (microrheologics, brescia, italy), and placed into collection and digestion media, followed by processing and plating onto collagen iv coated tissue culture and grown at 37°c in a 5% co2 incubator. to develop techniques for isolation, short-term culture, and in vivo modelling of epithelial and stromal cells, a xenograph model has been developed. following short-term growth in culture, cells are transferred to denuded rat tracheas and implanted subcutaneously in nude mice. follow-up well-child visit mother and child dna is collected from both the mother and child during the blood collection, or using a buccal swab if blood can not be obtained. dna is extracted by the vanderbilt center for human genetics research core laboratory and stored following extraction for future studies. enrolment infant urine is collected from hospitalized infants during the acute infant illness at study enrolment, and from a convenience sample of outpatient subjects. urinary measurements including, leukotrienes c4/d4/e4 (ltc4/d4/e4), and urinary metabolite of the isoprostane, 15-f2t-isop (8-iso-pgf2a) will be measured by a gas chromatographic, and other biomarkers and the remainder of the urinary biospecimens will be maintained in the repository. 25, 26 ige, immunoglobulin e; lrti, lower respiratory tract infections; uri, upper respiratory tract infection. the family history of atopy was obtained using a family tree. maternal atopy will be categorized as evidence of atopy by skin testing or specific ige, and/or clinical symptoms of an atopic disease as assessed by the isaac questionnaire. atopic status of the child will be determined by laboratory evidence of specific ige during the second year of life, and by clinical evidence based on the above definitions. the diagnosis of asthma will be determined at age 6 years based on responses to the isaac questionnaire. [6] [7] [8] the following criteria will define asthma during the sixth year of life: (i) 12-month prevalence of symptoms of asthma (current wheeze) or the presence of exercise-induced wheeze or dry cough at night not due to a cold or chest infection; and (ii) physician diagnosis as determined by the isaac questionnaire using either parental reported physician diagnosis of asthma or chronic use/ prescription of asthma-specific medications. probable asthma will be defined as physician diagnosis only and analysed separately. transient early wheezing will be defined as wheezing episodes present in the first 4 years of life, but not meeting the definition for childhood asthma at age 4 and 6 years. 29 allergic rhinitis will be determined through the isaac core questions on ar. 7, 8 children will be considered to have definite ar if each of three conditions is present between age 5 and 6 years: (i) a history of nasal congestion, runny nose, itchy watery eyes, sinus pain or pressure or headaches, sneezing, blocked nose, loss of sense of smell; (ii) substantial variability in symptoms over time or seasonality; and (iii) diagnosed as having allergic rhinitis by a physician or on medications for ar. probable allergic rhinitis will be defined as meeting two of the three criteria, or only criteria 3. atopic dermatitis will be determined through the isaac core questions on atopic dermatitis, which are based on a list of major and minor criteria widely applied in clinical studies. 8, 30, 31 as eczema is probably more readily confirmed by objective tests than either asthma or rhinitis, patients will be considered to have definite atopic dermatitis if between age 5 and 6 years they report ever having an itchy rash that comes and goes for at least 6 months, and being diagnosed with eczema by a physician. 30, 31 probable atopic dermatitis will be defined as one of the two above criteria. in order to standardize and monitor the quality of data collection and processing, all study personnel received training and were certified for all the study procedures. information is recorded on paper case report forms, data are entered and then checked by a second reviewer. logical data checks are programmed and additionally performed by our systems analyst, investigators and again by our biostatisticians. for laboratory analyses, blind qualitycontrol samples are included in each biospecimen run. telephone interviewers complete classroom training, orientation to the study population, computer modules, role play interviewing and training on study-specific protocols, and are formally evaluated at the end of training. a verbatim-recording of the interviewer and participant responses, and 10% participant re-contact allows quality-control staff to verify responses. the outcome variables of interest are the incidence of asthma and allergic rhinitis. the primary exposure variables of interest are the severity and aetiology of the infant viral illness and maternal and familial atopic status and other environmental exposures. cumulative asthma incidence over time, taking into account loss to follow up, will be used for illustrating incidence data. incidence of asthma and allergic diseases among the enrolled infant population with viral respiratory illness will be calculated by dividing the number of incident asthma cases by the person time of follow up. a kaplan-meier plot of cumulative incidence over time, taking into account loss to follow up, will be used for illustrating incidence data. incidence rates will be calculated by dividing the patient population into quartiles/quintiles of bronchiolitis severity scores. the adjusted risk of asthma and allergic rhinitis with bronchiolitis severity will be evaluated using the cox proportional hazard regression model. to assess the relationship between biomarker concentrations and increased risk of infant bronchiolitis, and early childhood asthma outcomes, we will conduct a nested case-control study. geometric means of urinary biomarker concentrations for those who develop and do not develop asthma will be calculated separately and compared using the paired t-test. the association between these biomarkers and the risk of asthma and allergic rhinitis will be assessed using odds ratios and their corresponding 95% confidence intervals from adjusted logistic regression models. the potential confounders that will be considered in multivariable analyses will include demographic and exposure characteristics. subject recruitment for the tcri study occurred over 4 years, and was completed in may 2008. overall, 9329 visits were screened, representing 7632 unique infants, and 2986 of these infants met study eligibility requirements. from the 2986 eligible infants, 674 infants and their biological mothers were enrolled (fig. 1) . among the 2312 subjects who were available during the recruitment periods, the major reasons for non-response were refusal (22%), insufficient time/ unwilling to stay for the visit (outpatients) (39%), conflict with or already enrolled in another study (20%), and other (18%) (includes language barrier, mother/ guardian not present, previously enrolled and other miscellaneous). in 99.9% of the cohort, the nasal/ throat swab was obtained, and in 79% of the hospitalized infants one spot urine sample was obtained at hospital admission. weekly enrolment into the cohort is depicted in figure 2 . the tcri is a large and comprehensive prospective epidemiologic study of mothers and their biologic children enrolled during infancy with a clinically significant lrti or uri who are being followed through early childhood. this study will provide important information about the role of infant respiratory viral infection severity, aetiology, biomarkers and predictors important in the development of early childhood asthma and allergic rhinitis. the tcri is additionally unique because it is designed in parallel with a large retrospective birth cohort of over 95 000 mother-infant dyads with similar objectives to investigate the role of respiratory viral infection severity and aetiology in the development of asthma. as evidence suggests that the development of asthma may result in part from respiratory viral infection during infancy, which has a predilection for infecting, destroying and/or in some way biologically altering lower airway epithelium, this study will help to delineate whether the severity of that infection and other early-life events impact the risk of asthma and allergic disease development in later childhood. 3 despite a high attack rate of developing asthma following viral bronchiolitis, the majority of children who have infant bronchiolitis do not develop childhood asthma. thus while viral respiratory infections may alter lung physiology and target the inflammatory response to the lower airway, this may only occur during a vulnerable time period during development of the immune system or lung, or in the presence of other risk factors. this developmental component may further reflect important gene-environment interactions that regulate both short-and long-term airway physiological alterations that manifest themselves clinically as childhood asthma. efforts to determine and define the role of these factors, including disease severity, maternal atopy and other environmental exposures, such as second-hand smoke, to asthma pathogenesis are the focus and goal of the tcri. several limitations of this study should be noted. first, the study sample was not randomly selected from the general population, but instead was recruited from a single hospital and clinic-based setting, the vanderbilt children's hospital. while vanderbilt hospitalizations represent greater than 90% of davidson county/nashville infant hospitalizations, it represents a smaller proportion of emergency department visits (51%), and likely even fewer paediatric acute care visits. 2 the relatively low participation rate among eligible subjects is multifactorial and the result of the long-term nature of the study, the lack of study personnel to enrol all eligible subjects, as well as lower willingness among outpatients to extend their visit in order to participate in the study. while this impacts the demographics and exposures of the study population, and thus generalizibility of our study results, it should not impact the findings of the role of infant viral infection on the outcomes of interest. next, while airway hyperreactivity is not assessed in making the diagnosis of childhood asthma, the identification of incident asthma cases will take into consideration the positive response to a validated written questionnaire that has been compared with bronchial provocation testing. 6, 8 while such an ascertainment strategy might result in the underdiagnosis of asthma, it is unlikely to result in false positive diagnoses during the sixth year of life. finally, as with many studies, where all eligible participants were approached for participation, difficulty was encountered in follow up of those currently age-eligible for follow up. strategies to address this include study personnel doing a significant number of follow-up visits at the subject's home, and shipping follow-up materials and requests to paediatricians of subjects who have moved from the region. future reports from this cohort will help to clarify the complex relationship between infant respiratory viral infection severity, aetiology, atopic predisposition, and the development of early childhood asthma and other atopic diseases. ultimately, this study, along with the companion tabs cohort, has the potential to provide new approaches to identify infants at high risk of developing early childhood asthma and allergic diseases, as well as provide important information that may contribute to the development of prevention strategies. increasing burden and risk factors for bronchiolitis-related medical visits in infants enrolled in a state health care 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culture, reverse transcription-pcr, and the quickvue influenza a+b test for rapid diagnosis of influenza a diverse group of previously unrecognized human rhinoviruses are common causes of respiratory illnesses in infants in vitro assays for the diagnosis of ige-mediated disorders clinical laboratory assessment of ige-dependent hypersensitivity elevations of local leukotriene c4 levels during viral upper respiratory tract infections quantification of the major urinary metabolite of 15-f2t-isoprostane (8-iso-pgf2alpha) by a stable isotope dilution mass spectrometric assay prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis dexamethasone and salbutamol in the treatment of acute wheezing in infants asthma and wheezing in the first six years of life. the group health medical associates diagnostic features of atopic dermatitis evaluation and relevance of atopic basic and minor features in patients with atopic dermatitis and in the general population we would like to thank the many families, paediatricians and their office staff, who have participated in this study, as without them, this work would not have been possible. key: cord-284313-rg3krh7d authors: wood, lisa g.; powell, heather; grissell, terry; nguyen, thuy t.d.; shafren, darren; hensley, michael; gibson, peter g. title: persistent airway obstruction after virus infection is not associated with airway inflammation date: 2007-02-28 journal: chest doi: 10.1378/chest.06-1062 sha: doc_id: 284313 cord_uid: rg3krh7d abstract background:this study examined the contribution of airway inflammation to the delayed lung function recovery that occurs in some people following virus-induced asthma exacerbations. methods:subjects (n = 40) were recruited at hospital admission for acute asthma exacerbation. respiratory virus infection was diagnosed by viral nucleic acid detection and/or cell culture, using induced sputum, nasal, or throat swabs. data collected included lung function, answers to common cold and asthma control questionnaires, and induced sputum cellular profiles. subjects were reexamined 4 to 6 weeks postexacerbation and were compared with stable asthmatic subjects (n = 26) who had been recruited from ambulatory care clinics. results:persistent airway obstruction, defined as lung function improvement at follow-up (ie, change in fev1percent predicted [δ%fev1]) of <15%, was observed in 10 subjects (25%). airway recovery (δ%fev1, ≥ 15%) was observed in the remaining subjects (30 subjects; 75%). during the acute episode, the airway-recovery group had increased total cell count (p = 0.019), increased number of neutrophils (p = 0.005), and increased percentage of neutrophils (p = 0.0043) compared to the group of stable subjects with asthma. postexacerbation, the airway-recovery group had reduced numbers of neutrophils and an increased percentage of eosinophils. in contrast, during exacerbation, subjects with persistent airway obstruction showed no differences in inflammatory cell counts compared to stable subjects with asthma, nor did cell counts change postexacerbation. symptoms improved in both groups postexacerbation. however, in the persistent-airway-obstruction group, asthma remained uncontrolled. conclusion:persistent airway obstruction and uncontrolled asthma are observed in some people after viral asthma exacerbations. these abnormalities are not associated with inflammatory cell influx into the airway lining fluid during the exacerbation and may reflect the involvement of noncellular elements. further work should explore other mechanisms leading to incomplete airway recovery. s evere exacerbations of asthma are responsible for a large burden of illness in australia and throughout the world. viral infection is the main cause of asthma exacerbation requiring hospitalization, 1 with respiratory viruses being isolated from 81% of patients with asthma exacerbations requiring hospitalization in adults and children. 2 the mechanisms driving viral asthma exacerbations are clearly differ-ent from the well-characterized pathogenesis of allergen-induced asthma, which is driven by an interleukin (il)-5-mediated eosinophil infiltrate. [3] [4] [5] viral asthma exacerbations involve a marked neutrophil infiltration together with eosinophil degranulation. 2,6 -10 the chemokine rantes (or regulated on activation, normal t cell expressed and secreted), which promotes eosinophil degranulation, and the cytokine il-10, which suppresses eosinophil cellular infiltration, may be important in this inflammatory response, as the gene expression of these mediators is up-regulated in patients with virus-induced asthma. 11 despite optimal medical therapy, incomplete recovery of airway function occurs in a relatively high proportion of people after an acute asthma exacerbation. corne et al 12 observed that in people with asthma who were infected with human rhinovirus (rv), lower respiratory tract symptoms were experienced more often, were more severe, and were of longer duration than in nonasthmatic people. persistent lower respiratory symptoms in people with asthma extended up to 35 days, which is well beyond the 7-day expected duration of common cold symptoms. chang et al 13 described a group with prolonged episodes of persistent asthma that lasted months to years and was triggered by symptoms of viral infection in 89% of cases. incomplete recovery of peak expiratory flow (pef) has also been reported after acute episodes of asthma. 14 in another study, 15 there was a trend for asthmatic subjects with human rv infection to have lower pef measurements during convalescence. delayed recovery of lung function has also been reported following copd exacerbations, with 25% of subjects not recovering to baseline pef levels after 5 weeks. 16, 17 thus, persistent airway abnormality after respiratory exacerbation is a well-documented clinical problem, occurring both in patients with asthma and with copd. in addition to the delayed recovery of lung function after acute asthma episodes, the inflammatory response has been shown to persist. pizzichini et al 10 studied adults who had experienced asthma exacerbations triggered by viral infection (n ϭ 6) vs those triggered by nonviral causes (n ϭ 2). they observed a persistent reduction in fev 1 (73% vs 93% predicted, respectively) and persistent sputum neutrophilia (53% vs 20% of cells, respectively) at follow-up in the virus-infected group. el-radhi et al 18 reported the persistent elevation of serum il-5, soluble cd25, and eosinophilic cationic protein (ecp) after oral corticosteroid treatment for acute asthma in children. we hypothesize that the delayed recovery of lung function after acute asthma episodes may be due to an altered inflammatory response. the aim of this study was to elucidate the role of airway inflammation in the persistence of airway obstruction that occurs in some people following virus-induced asthma exacerbations. we have carefully characterized subjects whose condition does not improve following a virus-induced asthma exacerbation, comparing their airway inflammatory profile to that of subjects who do improve postexacerbation. patients admitted to john hunter hospital (newcastle, nsw, australia) who were experiencing an acute exacerbation of asthma were recruited into the study between february 2001 and may 2005; a subset of these patients has previously been described. 11 induced sputum samples were collected after ultrasonic nebulization of isotonic saline solution, as previously described. 9, 19, 20 the selection criteria were the presence of acute asthma with positive viral infection, age ͼ 7 years, fev 1 ͼ 40% predicted, and completion of a follow-up visit. the subjects were studied again 4 to 6 weeks postexacerbation. participants provided nasal/throat swabs, and underwent skin allergen testing and spirometry. participants also completed the common cold questionnaire (ccq) 21 and the asthma control questionnaire (acq). 22 the acq is a seven-item questionnaire that has been validated to measure the goals of asthma management (ie, minimization of daytime and nighttime symptoms, activity limitation, ␤ 2 -agonist use, and bronchoconstriction). analysis of asthma status using this scoring system has determined that well-controlled asthma has an optimal cut point of ͻ 0.75, while a score of ͼ 1.50 indicates inadequately controlled asthma. 22 at follow-up, subjects were categorized into one of the following two groups: the persistent-airway-obstruction group, defined as subjects with an improvement in lung function (ie, change in fev 1 percent predicted [⌬%fev 1 ]) ͻ15%; and the airwayrecovery group, defined as a ⌬%fev 1 of ն 15%. stable subjects with asthma who were recruited within the same study period were included as a comparison group. they met american thoracic society criteria 23 for asthma diagnosis, had experienced no change in asthma activity or respiratory infections in the last 4 weeks, and were recruited from john hunter hospital ambulatory care clinics. written informed consent was obtained from all participants for this study, which was approved by the hunter area health service and university of newcastle human research ethics committees. selected portions of induced sputum samples were allocated to (1) a lytic solution (buffer rlt; qiagen; hilden, germany) for rna extraction and subsequent messenger rna expression analysis and virus polymerase chain reaction (pcr), (2) in vitro culture in virus-permissive human epithelial cell lines (hel and hep-2) for outgrowth of respiratory viruses, and (3) sequential dithiothreitol and phosphate-buffered saline solutions for cellular dispersion and profiling. this involved selecting sputum samples from saliva, processing it in a dithiothreitol solution, then filtering the dispersed suspension and performing a total cell count of leukocytes. cytospins were also prepared and stained (may-grü nwald giemsa stain), and a differential cell count was obtained from 400 nonsquamous cells. 24, 25 nasal swabs and throat swabs were also immersed in the lytic solution (buffer rlt; qiagen), and extraction and purification of the sputum sample, clarification of the in vitro culture supernatant, and swab rna were performed using a standard commercially available kit (rneasy kit; qiagen) per the instructions of the manufacturer. rna was then reverse-transcribed to total complementary dna using random primers and a standard commercially available kit (superscript ii rt kit; invitrogen; carlsbad, ca). patient samples were assayed for the presence of rv, enterovirus (ev), influenza virus types a and b, respiratory syncytial virus (rsv) types a and b, non-severe acute respiratory syndrome coronavirus, and metapneumovirus (mpv) virus rna transcripts. 11 due to the application of advances in real-time pcr technology, the initial gel-based pcr assays for rv, ev, rsv, and mpv were replaced with real-time pcr assays (taq-man probe; applied biosystems; foster city, ca) [rv, 26 ev, 27 rsv types a and b, 28 human mpv, 29 and coronavirus 30 ] during the later stages of this study, and real-time pcr also was used to confirm prior gel-based viral detection results. all pcr assays (taqman; applied biosystems) proceeded using 12.5% of the complementary dna product and a commercially available kit (realmastermix probe rox kit; eppendorf ag; hamburg, germany), all with the same cycling parameters, namely, 2 min at 95°c to activate the pcr assay (hotmaster taq dna pcr; eppendorf ag) and 40 cycles of 95°c for 15 s followed by 1 min at 60°c (abi 7500 cycler; applied biosystems; foster city, ca). subjects were considered to be positive for virus if the presence of a virus was determined by either direct molecular detection (ie, gel pcr or real-time pcr) in sputum, swab (nasal or throat), or saliva specimens or by post-cell culture molecular detection (gel pcr or real-time pcr) in sputum or saliva specimens. subjects with virus-positive acute asthma at visit 1 were classified at visit 2 according to their improvement in fev 1 (in liters) [ͻ 15% or ն 15%] as having persistent airway obstruction or airway recovery, respectively. analysis was performed using a statistical software package (stata, version 7; stata corporation; college station, tx), with results presented as the median (interquartile range [iqr]) or no. (%). significance (p ͻ 0.05) was determined from a nonparametric kruskal-wallis test or fisher exact test and 2 test. post hoc analysis was applied to all significant variables using the kruskal-wallis test (kruskal-wal-lis2 test; stata corporation). paired analyses for the change from visit 1 to visit 2 were conducted using the wilcoxon signed rank test. viruses were detected in 40 subjects during acute exacerbations. these viruses included the following: rv, 30 subjects (75%); ev, 17 subjects (42.5%); influenza virus type a, 4 subjects (10%); influenza virus type b, 1 subject (2.5%); and rsv, 1 subject (2.5%). eleven subjects had dual viruses, and 1 subject tested positive for three viruses. following the acute exacerbation, persistent-airway-obstruction was observed in 10 subjects (25%) and airway recovery was observed in 30 subjects (75%). characteristics of these groups are described in table 1 . there was no significant difference in atopy between groups. however, the persistent-airway-obstruction group used a significantly higher maintenance dose of inhaled corticosteroid (ics) preexacerbation and had a longer duration of asthma. details of the acute asthma episode for the persistent-airway-obstruction group compared with those for the airway-recovery group are described in table 2 . on examination in the emergency departfig 1) . in the airway-recovery group, there was a highly significant ⌬%fev 1 , resulting in values at recovery that were similar to those for stable subjects with asthma. in the persistent-airway-obstruction group, however, fev 1 percent predicted did not improve. in the airway-recovery group, both the ccq and the acq scores showed highly significant improvements, with visit 2 values similar to those for stable subjects with asthma. for the persistent-airway-obstruction group, there was improvement in the ccq and the acq scores; however, asthma continued to be uncontrolled postexacerbation. at visit 1, subjects in the persistent-airway-obstruction group had a similar inflammatory cell profile to that in stable subjects with asthma. in contrast, the airway-recovery group had an increase in total cell count (fig 2, top, a) and neutrophil count (fig 2, bottom, b ) compared to those in stable subjects with asthma. on recovery, neutrophil counts in the airway-recovery group decreased significantly (table 4 ). in contrast, subjects in the persistentairway-obstruction group showed no significant decreases in inflammatory cell counts postexacerbation. persistent airway obstruction following acute asthma exacerbation is a significant clinical problem. approximately one in four people recovering from a severe asthma exacerbation with virus infection experience minimal improvement in lung function. they continue to experience persistent airway obstruction and poor asthma control. this study is the first to examine the role of lower airway inflammation in this phenomenon. we have determined that subjects with persistent airway obstruction following virus exacerbation had, at the time of the exacerbation, levels of total inflammatory cells, eosinophils, macrophages, and lymphocytes in the airway that were similar to those in stable subjects with asthma. furthermore, the inflammatory cell profile in the lower airways of these individuals did not change postexacerbation, despite some improvement in symptoms. this is a clinically important group, as, despite the absence of inflammatory cell influx into the airways during exacerbation, their asthma symptoms were uncontrolled during the exacerbation, and, although symptoms improved 4 to 6 weeks postexacerbation, they continued to be uncontrolled. while both the airway-recovery and persistentairway-obstruction groups experienced acute asthma exacerbations of apparently similar severity (table 2) , the two groups were clinically very different at follow-up. table 3 indicates that during the exacerbation the ccq was elevated in both the airwayrecovery and the persistent-airway-obstruction groups; then, at 4 to 6 weeks postexacerbation, a similar improvement in virus symptoms was seen in both groups (percentage change in ccq) [fig 1] . table 3 also describes inadequate asthma control during exacerbations in both the airway-recovery and persistent-airway-obstruction groups, as indicated by an asthma control score of ͼ 1.5. 31 however, while there was a highly significant improvement in acq score in the airway-recovery group, who demonstrated well-controlled asthma (acq score, ͻ 0.75) at visit 2, a more modest improvement was seen in persons in the persistent-airway-obstruction group, who continued to have inadequately controlled asthma (acq score, ͼ 1.5) 31 postexacerbation. the poor lung function (percent predicted fev 1 ) observed during the acute episode significantly improved in the airway-recovery group, with values returning to levels of stable asthma patients postexacerbation. however, there was no significant *values are given as the median (iqr), unless otherwise indicated. †p ͻ 0.05 compared to stable subjects with asthma. ‡stable subjects with asthma, n ϭ www.chestjournal.org chest / 131 / 2 / february, 2007 improvement in %fev 1 in the persistent-airwayobstruction group (fig 1, table 3 ). thus, while the two groups were clinically similar during exacerbations, they were distinctly different at recovery. this may reflect differences in the groups before or as a result of viral infection. due to the design of this study, preexacerbation data are not available. however, the higher dose of maintenance icss used in the persistent-airway-obstruction group suggests that this group had more severe illness before the exacerbation, and it is possible that they may have had preexisting airflow obstruction. incomplete clinical recovery from exacerbations has been reported 16 previously in copd patients, with 25% of patients experiencing exacerbations not recovering to baseline lung function at 5 weeks. seemungal et al 16 related exacerbation length to the magnitude of acute deterioration. while the extent of acute deterioration cannot be assessed by our study design, the data in table 2 suggest that acute episodes were of similar severity in the two groups. another longitudinal study 17 in copd patients found that, over time, clinical recovery to baseline levels (fev 1 and symptoms) after an exacerbation took longer. the mechanisms by which recovery rate slows over time are unclear, but it has been suggested that this may be associated with postviral increases in airway and systemic inflammation. 17 our data indicated that subjects in the persistent-airwayobstruction group had a longer duration of asthma. if this group had been followed up for a longer time, a return to baseline fev 1 may eventually have been observed. an alternate study design, which allowed the assessment of airflow obstruction preexacerbation, would be required to test this hypothesis. during asthma exacerbation, the airway-recovery group showed elevated total inflammatory cell counts, which were driven by increased numbers of neutrophils (fig 2) that decreased postexacerbation (table 4 ). this is consistent with the known effects of viral infection in the airway. 11 conversely, patients in the persistent-airway-obstruction group showed a lower airway inflammatory profile during exacerbations similar to those with stable asthma (fig 2) , and this did not change significantly postexacerbation (table 4 ). this is surprising, considering the wellestablished role of the neutrophil in driving an innate immune response to viral infection. however, the apparent insensitivity of lower airway inflammation to the presence of virus suggests that there is a suppression of the innate immune response in these subjects. the persistent-airway-obstruction group had been using a higher maintenance dose of icss than the airway-recovery group (table 1 ). it is possible that high doses of icss may be inhibiting the generation of inflammatory mediators 32 such as tumor necrosis factor-␣, il-1, and il-6, thereby preventing the infiltration of inflammatory cells into the airways. 33 there are a number of mechanisms associated with viral infection that may lead to the persistence of abnormal lung function and poor asthma control postexacerbation that are not dependent on inflammatory cell influx. virus-induced eosinophil activation may increase the release of mediators such as ecp 34 and leukotriene c4, 35, 36 which may worsen asthma symptoms. activated eosinophils may also drive neurogenic inflammation by releasing eosinophil major basic protein, which is an endogenous antagonist for m2 muscarinic receptors. these receptors normally inhibit the release of acetylcholine, but when blocked by major basic protein, acetylcholine is released, resulting in airway muscle hyperresponsiveness. 37 viral induction of vascular leakage has also been reported, with mediators such as il-8 and ecp 38 being exuded into the airway lumen, which may sustain and perpetuate the inflammatory process. 39 viral activation of mast cells, leading to increases in histamine release, may also contribute to worsened asthma. 40 mucus hypersecretion has also been linked to viral infection. 41, 42 thus, there are a range of different virus-induced mechanisms, which may exacerbate a variety of the physiologic features that characterize asthma but do not involve infiltration of the lower airways with inflammatory cells. finally, it is possible that the exacerbations in the persistent-airway-obstruction group are driven by upper rather than lower airway inflammation. this is supported by the data in table 3 , which indicate minimal changes in asthma symptoms at visit 2. this is further supported by the observation that throat symptoms were one of the domains that showed the greatest improvement postexacerbation. in conclusion, we have observed that approximately one in four people with asthma continue to have persistent airway obstruction and uncontrolled asthma symptoms at 4 to 6 weeks post-viral asthma exacerbation. we have thoroughly described the phenomenon and have determined that it does not involve the influx of inflammatory cells into the lower airways. other mechanisms, such as the activation of resident airway cells and enhanced upper airway inflammation should be further explored. the number of people who experience persistent airway obstruction postexacerbation represent a significant proportion of asthmatic patients (25%), and these people should be followed up postexacerbation as the continuation of uncontrolled asthma will lead to a significant loss of quality of life. acknowledgment: assistance with the collection of samples and clinical data were received from naomi timmins and table 4 asthma exacerbations: 3. pathogenesis neutrophil degranulation and cell lysis is associated with clinical severity in virus-induced asthma bronchoalveolar eosinophilia during allergen-induced late asthmatic reactions airway inflammation in thunderstorm asthma kinetics of allergen-induced airway eosinophilic cytokine production and airway inflammation the role of viral infections in intrinsic asthma: activation of neutrophil inflammation role of nasal interleukin-8 in neutrophil recruitment and activation in children with virus-induced asthma interleukin-8 secretion and neutrophil recruitment accompanies induced sputum eosinophil activation in children with acute asthma assessment of airway inflammation in children with acute asthma using induced sputum asthma and natural colds: inflammatory indices in induced sputum: a feasibility study interleukin-10 gene expression in acute virus-induced asthma frequency, severity and duration of rhinovirus infections in asthmatic and non-asthmatic individuals: a longitudinal cohort study prolonged episodes of persistent asthma: a distinct clinical pattern with characteristic clinical features predictors of short-term clinical response to acute asthma care in adults rhinovirus is associated with severe asthma exacerbations and raised nasal interleukin-12 time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease longitudinal changes in the nature, severity and frequency of copd exacerbations effect of oral glucocorticoid treatment on serum inflammatory markers in acute asthma epidemiological association of airway inflammation with asthma symptoms and airway hyperresponsiveness in childhood safety of sputum induction with isotonic saline in adults with acute severe asthma respiratory viruses and exacerbations of asthma in adults development and validation of a questionnaire to measure asthma control standardization of spirometry: 1987 update safety of sputum induction with isotonic saline in adults with acute severe asthma persistence of sputum eosinophilia in children with controlled asthma when compared with healthy children amplicon sequencing and improved detection of human rhinovirus in respiratory samples rapid and sensitive routine detection of all members of the genus enterovirus in different clinical specimens by real-time pcr applicability of a real-time quantitative pcr assay for diagnosis of respiratory syncytial virus infection in immunocompromised adults real-time reverse transcriptase pcr assay for detection of human metapneumoviruses from all known genetic lineages frequent detection of human coronaviruses in clinical specimens from patients with respiratory tract infection by use of a novel real-time reverse-transcriptase polymerase chain reaction identifying "wellcontrolled" and "not well-controlled" asthma using the asthma control questionnaire the effect of fluticasone propionate on respiratory syncytial virus-induced chemokine release by a human bronchial epithelial cell line innate immune responses and chronic obstructuve pulmonary disease eosinophil activation and cysteinyl leukotriene production in infants with respiratory syncytial virus bronchiolitis activation of human eosinophils in vitro by respiratory syncytial virus elevations of local leukotriene c4 levels during viral upper respiratory tract infections eosinophil recruitment to the airway nerves allergen challangeinduced acute exudation of il-8, ecp and ␣ 2 -macroglobulin in human rhinovirus-induced common colds airway microvascular extravasation and luminol entry of plasma urinary histamine metabolite elevations during experimental influenza infection viral dsrna activates mucin transcription in airway epithelial cells respiratory syncytial virus in allergic lung inflammation increases muc5ac and gob-5 key: cord-303606-ypkia5x1 authors: lee, so-lun; chiu, shui-seng susan; malik, peiris joseph s.; chan, kwok-hung; wong, hing-sang wilfred; lau, yu-lung title: is respiratory viral infection really an important trigger of asthma exacerbations in children? date: 2011-03-30 journal: eur j pediatr doi: 10.1007/s00431-011-1446-1 sha: doc_id: 303606 cord_uid: ypkia5x1 we performed a prospective cohort study from september 2003 to december 2004 to delineate attributing the effect of different respiratory viral infections including newly discovered ones to asthma exacerbations in children in hong kong. one hundred and fourteen children aged 6–14 years with chronic stable asthma and on regular inhaled steroid were monitored for respiratory symptoms over a full calendar year from recruitment. they would attend the study clinic if peak expiratory flow rate decreased to below 80% of their baselines, if they met a predefined symptom score, or if parents subjectively felt them developing a cold. virological diagnosis using virus culture, antigen detection, and polymerase chain reaction methods on nasal swab specimens would be attempted for all these visits irrespective of triggers. physician diagnosed outcome of each episode was documented. three hundred and five episodes of respiratory illnesses were captured in the cohort. nasal specimens were available in 166 episodes, 92 of which were diagnosed as asthma exacerbations, and 74 non-asthma related episodes. respiratory viruses were detected in 61 of 166 episodes (36.7%). there was no significant difference in virus detection rate between asthma exacerbations (32 out of 97 episodes, 34.8%) and non-asthma respiratory illnesses (29 out of 79 episodes, 39.2%). although newly discovered respiratory viruses were identified in these episodes, rhinovirus was the commonest organism associated with both asthma exacerbations and non-asthma related episodes. plausible explanations for much lower virus detection rate than previously reported include improved personal hygiene and precautionary measures taken during respiratory tract infections in the immediate post-severe acute respiratory syndrome period together with a significant contribution of other adverse factors like environmental air pollution. we conclude that not all viral infections in children with asthma lead to an asthma exacerbation and the attributing effect of different triggers of asthma exacerbations in children vary across different time periods and across different localities. episode was documented. three hundred and five episodes of respiratory illnesses were captured in the cohort. nasal specimens were available in 166 episodes, 92 of which were diagnosed as asthma exacerbations, and 74 nonasthma related episodes. respiratory viruses were detected in 61 of 166 episodes (36.7%). there was no significant difference in virus detection rate between asthma exacerbations (32 out of 97 episodes, 34.8%) and non-asthma respiratory illnesses (29 out of 79 episodes, 39.2%). although newly discovered respiratory viruses were identified in these episodes, rhinovirus was the commonest organism associated with both asthma exacerbations and non-asthma related episodes. plausible explanations for much lower virus detection rate than previously reported include improved personal hygiene and precautionary measures taken during respiratory tract infections in the immediate post-severe acute respiratory syndrome period together with a significant contribution of other adverse factors like environmental air pollution. we conclude that not all viral infections in children with asthma lead to an asthma exacerbation and the attributing effect of different triggers of asthma exacerbations in children vary across different time periods and across different localities. viral respiratory tract infection, with rhinovirus accounted for two thirds, was found to be associated with greater than 80% of asthma exacerbations in children in studies in the 1990s [14] . however, the prevalence of respiratory viral infection varies greatly across different places; for example, influenza is associated with more hospitalization among children in hong kong compared with temperate region [7] . recent observational studies have shown that influenza infection can be associated with asthma exacerbations. nevertheless, a metaanalysis failed to support the protective effect of influenza vaccination in asthma exacerbations [3] . newly discovered respiratory viruses such as human metapneumovirus may also play a role [20] . triggers other than respiratory tract infection, like air pollutions may become more prevalent over time and supersede respiratory tract infections as a major trigger. thus, we carried out a prospective study to delineate the current role of different viral respiratory tract infections including newly discovered respiratory viruses in asthma exacerbation in children in our locality. children aged 6-14 years who attended regular follow-up at the asthma clinic were invited to participate. children with physician-diagnosed asthma, symptoms of asthma in the preceding year, no hospital admission for exacerbation, and on regular inhaled steroid equivalent to beclomethasone ≤400 μg daily for at least 3 months prior to enrolment were recruited. exclusion criteria were those with other known chronic respiratory disease and oral steroid therapy given within 4 weeks of enrolment. the participants were followed up to cover a full calendar year to reduce potential biases associated with temporal and age-related differences in respiratory tract infections. patient's demographic data, treatment at enrolment, family history of atopy and asthma, and exposure to environmental tobacco smoke were recorded at the time of recruitment. measurement of lung function using vitalograph model 2120 was obtained according to american thoracic society recommendations in children who were able to perform spirometry [1] . skin prick test was done according to the standardized international study of asthma and allergies in childhood phase 2 protocol [12] . ten aeroallergens including dermatophagoides pteronyssinus, dermatophagoides farinae, cat, alternaria tenuis, mixed tree pollen, mixed grass pollen, dog, cockroach (american and german), and mixed moulds were tested. a wheal diameter of 3 mm greater than the diameter of the negative control was defined as positive response. children with ≥1 positive responses were defined as atopic. each child was given an asthma diary chart and a peak flow meter (mini-wright afs low range peak flow meter) during the run-in period. parents and children were taught on data entry, use of peak flow meter, and record twice daily peak expiratory flow rate (pefr) and any upper and lower respiratory symptoms for 2 weeks as baseline. [14] (appendix). the diary chart was then reviewed and the child's calculated 80% baseline pefr was recorded on a new log sheet. parents were instructed to start to record pefr twice daily and respiratory symptoms in a new log sheet when the symptoms scored >3. they were to call the research nurse if pefr fell to below 80% of the child's baseline, if total upper or lower respiratory symptom score totalled ≥4, or if parents subjectively felt the child was developing a cold even though pefr fell by <20% of baseline. an unscheduled clinic visit would be arranged within 48 h. during the unscheduled visit, upper and lower respiratory symptoms and physical signs were recorded. an asthma exacerbation was defined as a fall in morning pefr to below 80% of baseline in the absence of expiratory wheeze for ≥2 two consecutive days. the presence of wheeze detected by the attending paediatrician at the time of visit (lee sl/chiu ss), or an increase in the use of shortacting beta 2 agonists on at least two occasions per day for ≥2 consecutive days. diagnoses other than asthma exacerbation were also captured. chest radiograph were ordered if clinically indicated. respiratory secretions from children were obtained using nasal swabs. the cotton-tipped swab was inserted into the nostril for 2 to 3 cm and rotated three times against the respiratory epithelial surface of the nasal cavity. once collected, the specimen was put in a virus transport medium and immediately transported to the microbiology laboratory for processing. the child was treated as appropriate. the parents and child continued to record daily pefr and symptoms in the subsequent 2 weeks or longer until symptoms subsided completely. follow-up visits would be arranged. all participants also attended scheduled clinic visit every 3 months. at each scheduled visit, all respiratory symptoms at follow-up or any respiratory problems in between visits that were not reported would be recorded. part of the aliquot was used for routine detection of viral antigen using immunofluorescence (if) detection of viral antigens for five respiratory viruses, viz. influenza viruses types a & b, respiratory syncytial virus (rsv), parainfluenza virus, and adenovirus. it was also cultured for virus isolation. the remaining aliquot was used for polymerase chain reaction (pcr) detection of rhinovirus, human metapneumonvirus, human coronavirus nl 63, oc43, 229e, hku1, and bocavirus. [6, 8, 19, 21] ethical approval the study was approved by the institutional review board of the university of hong kong/hospital authority hong kong west cluster. the study was conducted in accordance with the declaration of helsinki. verbal consent was obtained from the participants and written consent was obtained from their parents or legal guardians. previous studies showed virus identification rate ranged from 32% to 85% of asthma exacerbation in children [14, 19] . the conservative estimation of virus detection rate of 50% would give the largest sample size estimate of 96 exacerbations with level of confidence at 95% and precision of detection rate of 10%. as the number of urgent visits due to asthma was 1.2 per person-year in children on regular inhaled steroids in another study, the number of subjects required would be around 80 [22] . we performed simple descriptive analyses of demographic data. the frequencies of presenting symptoms and physician diagnoses of unscheduled visits, virus detection rate and the distribution of different types of viruses were described. student t test (+− mann-whitney u test) was used to compare continuous variables; for example, age and pearson's chi-square test (with yates'correction/fisher's exact test) was used to compare categorical variables; for example, sex (female or male), atopic status (yes or no) between children with and without unscheduled visits. a p value less than 0.05 was considered to be statistically significant. all statistical analyses were carried out by the spss 11.0 software (spss inc., chicago, il). there were totally 122 participants recruited from the end of september to the end of december 2003 and were followed up until the end of december 2004. eight of these participants withdrew early as their parents found it inconvenient to attend unscheduled visit. one hundred and fourteen children aged 6 to 13 years completed the study. they were followed up for 12 to 15 months. their baseline characteristics were tabulated in table 1 . among these 114 children, 16 children (14.0 %) did not report any exacerbations or respiratory illnesses. children with respiratory illnesses were younger than children without respiratory illnesses (p<0.05) and there was greater proportion with normal pulmonary lung function test at the time of recruitment (p=0.02). fifteen children had reported 20 episodes of mild respiratory illness with symptoms with remaining 83 children had experienced ≥1 episode of respiratory illnesses with symptoms score >3 and the maximum number of episodes per children was seven in two children. there were a total of 211 episodes with a symptom score >3. nasal swab specimens were obtained in 166 and the interval between onset of respiratory symptoms and nasal swab collection ranged from 0.5 to 6 days. nasal swab specimens were not available in the remaining 45 episodes as the children attended general practitioner (gp) instead. there were 74 episodes of mild respiratory illnesses with symptom score ≤3 reported in these 83 children that were also managed by gp. the distribution of these episodes of respiratory illnesses among the children was illustrated in fig. 1 . thus, there were a total of 305 episodes of respiratory illnesses including asthma and non-asthma related episodes in our study cohort over the 14-month study period. the mean number of asthma exacerbations, other respiratory illnesses, and all episodes as diagnosed at unscheduled visits were 0.69, 1.6, and 2.29 per person-year, respectively. the presenting symptoms of 166 episodes of unscheduled visits with nasal swab specimens obtained are tabulated in table 2 . ninety-two episodes were diagnosed as asthma exacerbations and 74 non-asthma related. among 92 episodes of asthma exacerbations, physician also made a diagnosis of concomitant respiratory tract infection in 69 (59 with upper respiratory tract infection, 5 with lower respiratory tract infection, and 5 with sinusitis) of these episodes based on history and physical findings. respiratory viruses were detected in 61 of these 166 episodes (36.7 %) ( table 3 ). there was no significant difference in virus detection rate between asthma (32 out of 97 episodes, 34.8 %) and non-asthma related episodes (29 out of 74 episodes, 39.2 %). rhinovirus was detected in 41 episodes, influenza in 7, coronavirus in 6, parainfluenza virus in 2, rsv in 1, and mixed viruses in the remaining 4. the patterns of distribution of respiratory viruses were quite similar in asthma exacerbations and non-asthma related episodes. (table 4 ) a community study carried out in southampton, uk over a decade ago found viral infections in >80% of asthma exacerbations in 9-11-year-old children [14] . our virus detection rate was only 36.7 % of all unscheduled sick visit in children aged 6 to 14 years old and the rate was not significantly different between asthma exacerbations (34.8 %) and that of other diagnoses (39.2 %). this low detection rate was not due to inadequate power based on a priori sample size calculation. neither was it due to virus detection method as we included pcr detection of more scores ≤3 that did not warrant unscheduled visits. the recently discovered respiratory viruses including human metapneumonvirus, human coronavirus nl 63, oc43, 229e, hku1, and bocavirus in addition to the virus detection method adopted in the southampton study, i.e., using if detection of viral antigens and culture for five respiratory viruses, viz. influenza viruses types a & b, rsv, parainfluenza virus, and adenovirus and pcr for detection of rhinovirus. our previous study using pcr method in detecting rhinovirus was shown to be comparable to the global literature [5] . our result was comparable to a clinic-based prospective study [19] and more closely matched to the canadian case-control study conducted in september 2001 before the epidemics of severe acute respiratory syndrome (sars) in which 62% of asthma children attending emergency department for exacerbations had respiratory viruses isolated [13] . we offered several explanations for our findings. firstly, our study was carried out in the immediate post-sars period when the population was still highly cautious about infection control and practising good personal hygiene [15] . this could greatly reduce common viral infection. the low average number of unscheduled sick visits per person-year compared to previous epidemiology studies [18] inferred excellent general health status in our children population over the study period. the beneficial effect of improved community hygienic measures was also supported by a local study which showed significantly lower respiratory virus circulation in the community in the immediate post-sars period [17] . secondly, we used three criteria so as to capture as many as possible asthma exacerbations. the use of a symptom score that included both upper and lower airway symptoms and that parents could attend the study clinic if they subjectively felt that the child develop a cold were less stringent than the first criteria of a fall of 80% of baseline pefr. thus, 74 of 166 unscheduled visits were not asthma exacerbations. we might have overdiagnosed respiratory tract infection as a trigger in [16] . one other possibility is that all of our participants had better control of asthma symptoms that was reflected in the lower overall number of episodes of unscheduled sick visits per person time year compared to the southampton cohort. we speculated that the use of regular inhaled steroids might also have some effect. while most clinical or experimental studies failed to document the efficacy of inhaled steroids in preventing intermittent virus-induced asthma exacerbations [9, 10] , the aforementioned canadian case-control study [5] showed that children attending emergency department for asthma exacerbations were more likely to have respiratory viruses isolated but less likely to have prescription of anti-inflammatory medications. as in previous studies, rhinovirus was also the most frequent organism detected, accounting for followed by influenza among those asthma exacerbations with virus isolated in our cohort. we must address our limitations. firstly, nasal swab were not collected in 45 out of 211 of episodes that met the criteria for unscheduled visits. for the extreme case scenario whereby all these 45 episodes were asthma exacerbations with viruses isolated, the virus detection rate would have been 56.2 % but this is still much lower than southampton study. for the remaining 94 episodes of mild respiratory illnesses that did not meet the criteria for unscheduled visit, it was difficult to ascertain whether the subjects actually had very mild asthma exacerbations, leading to a possible underestimation. the second limitation was that nasal swab instead of nasopharyngeal aspirate was used for infection control reasons as the study was carried out in the immediate post-sars period. a recent study also showed that the sensitivity of nasal swabs was comparable to that of nasopharyngeal aspirates for the detection of all major respiratory viruses except rsv [11] . yet, rsv virus is not a common trigger of asthma exacerbations in school-aged children. the use of a flocked nasopharyngeal swab, which was not available at time of the study, can certainly lead to a better yield should similar study to be conducted in the future [4] . we found that viral infections accounted for about 35% of asthma exacerbations and 39% of non-asthma associated respiratory illnesses in children with stable asthma control during the immediate post-sars period. we did not negate the well-established causal relationship between respiratory viral infections and asthma exacerbations. rather, our study suggested that the improved personal hygiene and precautionary measures taken during respiratory tract infections may help to reduce the potential adverse effect at high risk groups, like children with asthma. in addition, factors like environmental air pollution may also contribute significantly to morbidity of children with asthma in locality where the problem is particularly adverse. we conclude that not all viral infections in children with asthma lead to an asthma exacerbation and the attributing effect of different triggers of asthma exacerbations in children varies across different time periods and across different localities. updated local data whenever available are preferred when planning for health care policies. standardization of spirometry, 1994 update global strategy for asthma management and prevention: gina executive summary vaccines for preventing influenza in people with asthma comparison of nasopharyngeal flocked swabs and aspirates for rapid diagnosis of respiratory viruses in children rhinovirus infection in hospitalized children in hong kong: a prospective study human coronavirus nl63 infection and other coronavirus infections in children hospitalized with acute respiratory disease in hong kong influenza-related hospitalizations among children in hong kong the association of newly identified respiratory viruses with lower respiratory tract infections in korean children effect of inhaled corticosteroids on episodes of wheezing associated with viral infection in school age children: randomised double blind placebo controlled trial rhinovirus-induced airway inflammation in asthma: effect of treatment with inhaled corticosteroids before and during experimental infection nasal swab versus nasopharyngeal aspirate for isolation of respiratory viruses phase ii modules of the international study of asthma and allergies in childhood (isaac) the september epidemic of asthma exacerbations in children: a search for etiology community study of role of viral infections in exacerbations of asthma in 9-11 year old children impacts of sars on health-seeking behaviors in general population in hong kong association between air pollution and asthma admission among children in hong kong respiratory infections during sars outbreak epidemiology of viral respiratory infections viruses as precipitants of asthma symptoms children with respiratory disease associated with metapneumovirus in hong kong early detection of acute rhinovirus infections by a rapid reverse transcription-pcr assay the childhood asthma management program research group (2000) long-term effects of budesonide or nedocromil in children with asthma acknowledgment lee sl and chiu ss participated in study design, conduct study, data analysis, and report writing. peiris js provided advice on identification of viruses in addition to study design and report writing. chan kh provided laboratory support in identification of viruses and report writing. wong whs provided statistical support. lau yl participated in study design, data analysis, and report writing. we thank our research assistants miss winnie lau and miss eunice chan, and we are also grateful to our study subjects and their parents for their support. conflict of interests all authors declare that they have no conflicts to declare.open access this article is distributed under the terms of the creative commons attribution noncommercial license which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. what is already known on this topic viral respiratory tract infection is an important trigger of asthma exacerbations in children.rhinovirus is the most common identified virus associated with asthma exacerbations. prevalence of triggers of asthma exacerbations in children varies with geographic locations and time period.with improved vigilance in personal hygiene after the sars period, viral respiratory tract infection became less prevalent as a trigger of asthma exacerbation in children in a polluted city like hong kong.yet, rhinovirus is still the most common identified virus associated with asthma exacerbations despite the emergence of different newly discovered respiratory viruses. key: cord-267835-ic0oqqln authors: jones, k.; gruffydd-jones, k. title: management of acute asthma attacks associated with respiratory tract infection: a postal survey of general practitioners in the u.k. date: 1996-08-31 journal: respiratory medicine doi: 10.1016/s0954-6111(96)90116-x sha: doc_id: 267835 cord_uid: ic0oqqln abstract asthma attacks in general practice are frequently associated with respiratory tract infection. the aim of this study was to examine how u.k. general practitioners (gps) might use oral steroids and antibiotics in such situations. the timing of follow-up and use of self-management plans were also examined. a postal questionnaire was sent to all 205 gp principals in bath health district, u.k. in february and march 1993. respondents were asked questions regarding the management of an adult and a child presenting with acute asthma associated with respiratory tract infection. replies were received from 185 of 205 (90%) doctors approached. antibiotics would have been prescribed by 119 of 179 (66%) doctors for the adult and 98 of 169 (58%) doctors for the child. the modal initial dosage of oral prednisolone was 40 mg for the adult and 30 mg for the child, and modal duration of oral steroid dosage was 5 days for both adult and child. planned follow-up was mainly doctor initiated within 24 h of initial consultation. there was low reported use of self-management plans (49% for adults and 33% in children over 7 years of age). antibiotic prescription appears to be common practice by gps when faced with an acute asthma attack associated with respiratory tract infection. there may also be inadequate duration of oral steroid courses in adults. there is a need to examine further the proper role, if any, of antibiotics in such situations, to determine the optimum dose and course length of oral steroid therapy, and to continue validating the use of self-management plans in acute asthma management. general practitioners (gps) are commonly faced with patients suffering from acute asthma attacks associated with respiratory tract infection. in schoolage children, 80-85% of such attacks have been shown to be associated with viral infections, notably rhinoviruses (1) . similar results, implicating both rhinoviruses and coronaviruses, have been found in adults (2) . guidelines regarding the management of acute asthma in general practice were drawn up by the british thoracic society (bts) and other agencies in the u. k. in 1990 (3) , and were revised in 1993 (4) . clear recommendations are given regarding the need for oral steroids in such situations, together with a condemnation of the use of antibiotics 'in the absence of bacterial infection'. however, advice regarding the best dosage, length of course and method of stopping the oral steroids is less clear. in spite of such recommendations, preliminary discussions with gp colleagues suggested a widespread use of antibiotics in asthma attacks associated with respiratory tract infection, and a wide diversity about the management of acute asthma attacks in general. research among gps, general and respiratory physicians, and paediatricians in the north of england which predated the bts guidelines reinforces this suggestion (5) . the general practitioners in asthma group (gpiag) audit of acute asthma attacks in general practice 199 l-l 992 (6) examined general characteristics and mainly initial management of such attacks. one hundred and three of the 218 gps participating in the audit were from the gpiag and the rest were self-selected from a group of 2000 gps who received invitations. hence, their audit tended to be biased towards gps interested in asthma. factors determining subsequent management in general practice were not examined. thus, there is a need to examine further gps' ideas regarding current management of acute asthma attacks in general practice, with particular reference to those associated with respiratory tract infection. this study aimed to examine the reported usage of oral steroids and antibiotics in asthma attacks associated with respiratory tract infection managed in general practice, and the timing of follow-up consultations using a postal scenario-based questionnaire sent to all gp principals in one health district. a questionnaire was devised by the investigators concerning the management of two fictitious case histories: (1) of a 45year-old adult, and (2) of a 9-year-old child; presenting with acute asthma associated with respiratory tract infection (see appendix 1) . the case histories were constructed so that, according to the british thoracic society guidelines, the patients could be completely managed in a general practice setting. questions were asked concerning the methods of usage of antibiotics and oral steroids in the clinical situations outlined, and about the timing of follow-up after the initial consultation. the questionnaires were checked for face validity with clinical colleagues, and were distributed by post to all 205 gp principals in the bath health district in order to avoid self-selection by doctors interested in asthma. initial distributions of questionnaires were carried out in february 1993, and reminders were sent to non-responders by post 4 weeks later. data were entered on an ibm compatible personal computer and analysed using the spss-pc+ (version 3.0) software package (7) . descriptive statistics are reported, plus comparisons between adult and child responses using mcnemar's test for paired data where appropriate. chi-square and p values with and without correction for continuity are quoted. replies were received from 185 of the 205 gps approached (90% response rate). of 185 respondents, 86 (4.7%) came from a postgraduate training practice, 154 (83%) stated that there was an asthma clinic in their practice, and 68 (37%) gps stated that they had a special interest in asthma. only six of 185 (4%) gps stated that they would admit the adult into hospjtal, and 14 of 185 (8%) gps would admit the child to hospital. this difference was statistically significant (~'~5.4, pzo.02; corrected 4.3 and 0.04). (7) 15 (9) values in parentheses are percentages. one hundred and sixty-seven of 179 (93%) gps and 148 of 169 (88%) gps stated that they would use oral steroids for the adult and the child, respectively k2=3.5, p~0.06; corrected 2.8 and 0.10) (see table 1 ). 'other' treatment was mainly 'use of the nebulizer', but it was unclear whether the respondents meant additional use of the nebulizer or had missed the point that a nebulizer had been used already. there was a high purported use of oral antibiotics with 119 of 179 (66%) gps and 98 of 169 (58%) gps stating they would use them for the adult and the child, respectively or'= 3.7, p=o.o6; corrected 3.0 and 0.08). there was a large degree of agreement about the initial dose of prednisolone to be used, with 139 of 167 (82%) gps stating that they would give 30 mg or 40 mg (mode 40 mg) of prednisolone for the adult and 115 of 148 (78%) gps prescribing 20 mg or 30 mg (mode 30 mg) for the child (see fig. 1 ). one gp preferred the use of dexamethasone and two doctors (1%) stated one dose of 1 mg kg-i prednisolone for the child. one hundred and sixty-four answers were received for the adult and 148 answers for the child concerning the duration of initial dosage of prednisolone. there was a modal duration of response of 5 days for both adult and child (see fig. 2 ). three doctors stated that they would continue the dose 'until peak flow returns to normal', and one doctor stated that the prednisolone would be continued 'until peak flow returns to normal and then same again'. eighteen (12%) and 15 gps (10%) would tail off the course of prednisolone if it lasted 5 days or less for the adult and the child, respectively. if the course lasted 5-14 days, 78 (47%) and 62 (42%) respondents would tail off the course for the adult and child, respectively, and 132 (79%) and 112 (76%) respondents, respectively, for initial courses of more than 14 days. there were no statistically significant differences in these responses. most doctors replied that they would initiate review, with only 20 of 179 (11%) and seven of 169 (4%) replying that the patient or parents/child, respectively, should determine the timing of review (see table 2 ). one hundred and ten (61%) gps stated that they would review the adult within 48 h and 130 (77%) would review the child within the same length of time k*=18.3, p<o.oool). the criteria by which a doctor would advise a patient to contact him/her for an unscheduled visit were also explored. forty-eight of 179 (27%) and 57 of 169 (34%) respondents answered that worsening symptoms alone were the main determinants in the adult and child cases, respectively. no respondents were using peak flow readings alone in the adult and only two of 169 (1%) gps were doing so in the child. (11) 42 (25) 90 (50) 88 (52) 33 (18) 20 (12) 3 (2) 2 (1) 20 (11) 7 (4) 12 (7) 10 (6) values in parentheses are percentages. twenty-seven of 179 (15%) doctors in the adult case and 25 of 169 (15%) in the child case stated that they would use a pre-existing self-management plan, but a large number [97 of 179 (54%) for the adult and 79 of 169 (47%) for the child] would use worsening symptoms and peak flow rate as factors for urgent re-assessment. two gps stated that the factors depended on the ability of the patient. ninety-one of 185 (49%) (gps) responding to the questionnaire stated that they issued selfmanagement plans to adult asthmatics rotitinely, with four of 185 (2%) stating they did 'sometimes' (six answers were missing). only 61 of 185 (33%) admitted to routine use in the over 7-year-olds and 46 of 185 (25%) (13 missing) in the under 7-year-olds. where there was an asthma clinic in the practice, 86 of 154 (56%) gps stated that they issued plans to the adults routinely, compared with 59 of 148 (six missing) (38%) gps to the over 7's and 44 of 148 (six missing) (29%) to the under 7's. the results show that most gps would prescribe oral steroids when faced with an acute asthma attack associated with respiratory tract infection and managed within a general practice setting. however, there is greater diversity of opinion about the initial dosage, length of course and means of stopping the course of treatment. contrary to the british thoracic society guidelines, there is a high reported usage of oral antibiotics in such situations. the 90% response rate suggested that the results are likely to be representative of all gps in the bath health district. although the characteristics of the 10% non-responders were not examined, 63% of respondents claimed not to have a special interest in asthma, tending to minimize the bias towards asthma-interested doctors noted in the gpiag survey (6) . however, the results cannot necessarily be extrapolated to the country as a whole. in addition, whilst use of case histories assesses how gps would respond to a standard situation, it does give rise to the criticism that respondents are more likely to give answers on the basis of what they 'think ought to be done' rather than on what they 'actually do'. the gpiag study (6) gave the present authors an opportunity to compare this survey of gps' reported treatments with those actually given in similar circumstances, and thus to validate the present observations against clinical practice. the gpiag data revealed a lower usage of steroids (56%) compared with 93% for adults and 88% for children in this study. while the reported usage of oral steroids may thus represent an overestimate of what the gps would actually do, the same is unlikely to be true for antibiotic prescribing. indeed, the reverse may apply since gps responding may have been aware of the bts guidelines. the gpiag data revealed that gps used antibiotics in 32% of acute attacks treated, whereas the present figures were considerably higher. this might reflect the present authors' quota sampling rather than the self-selection bias implicit in the gpiag study. figures similar to the present data were also shown by a hospital-based audit of therapy for acute attacks (8). the perception from the authors' preliminary discussions that antibiotics are commonly used in asthma attacks associated with respiratory tract infection is confirmed by the present data. recommendations to the contrary by the bts are based on good recent evidence that respiratory tract infections which trigger asthma are mainly viral (l), and on older research which shows that antibiotic therapy confers no additional benefit in acute asthma management where bacterial infection is absent (9). general practitioners have to initiate treatment empirically when faced with an acute asthma episode, without the benefit of radiological or laboratory investigations. studies are needed in a general practice setting to determine the proper role, if any, of antibiotics in this respect, since this appears to be a major resource usage issue. since some data from italy has shown the presence of chlamydia pneumoniae infection in seven out of 14 adults with exacerbations of asthma (lo), treatment with macrolides or tetracyclines, rather than penicillins, might have a role in some patients with acute asthma. the 'setting up' of inhaled steroids is recommended by the bts guidelines at the initial consultation during an acute asthma attack. disappointingly, only 35% and 31% of gps in this study said that they would increase the dose of inhaled steroids at the initial consultation with the adult and the child, respectively. however, there appears to be no scientific validation of this advice to date. the initial dose of oral prednisolone recommended by the bts in acute asthma in adults is 30-60 mg (3). this would have been used by 93% of respondents. there is a relative paucity of dose-response studies in such situations, but a study by webb in 1986 suggests a positive dose-response curve up to about 0.6 mg kg-' oral prednisolone and an optimal dose of 40mg (11). he also reported that there is an increasing response of mean peak flow rate, with duration of course of treatment up to a io-1cday plateau. this suggests that a lo-14-day course of treatment should be advised. in this study, just over two-thirds of gps would use a course of 5 days or less or oral steroids in the adult case, with only 5% of gps using a dose of 10 days or more. this suggests undertreatment. however, webb's study did not involve increasing (or indeed stabilizing) inhaled steroid dosage which may minimize the duration of oral steroid course required to regain optimal lung function. in children, the bts recommends an initial dosage of 1-2mgkgg' prednisolone. in this study, only 2% of respondents specifically mentioned this dosage recommendation as their choice of dose. however, for a 9-year-old child, 10-90th centile weight limits are 21-39 kg giving a possible dose range of 20-80 mg! the recommendations on 'best dose' in children do, therefore, seem imprecise and there is a need for dose-response studies in children. storr et al. suggested that a single high dose (60 mg) of oral prednisolone might be sufficient (12), but 30% of children in their study required further doses of treatment, suggesting that a single dose may not be satisfactory. in this study, tapering off of the oral steroid dose was widely accepted as being unnecessary for initial courses of prednisolone of 5 days or less (89% and 90% of respondents for the adult and child, respectively). forty-seven percent and 42% of gps would tail off the course of steroids if it lasted s-14 days in the adult and the child, respectively. the bts guidelines are unhelpful in this respect and suggest 'the drug may then be stopped or the dose tapered'. a study by o'driscoll et al. suggested that tapering of dosage is probably unnecessary in courses of treatment up to 10 days, providing that inhaled steroids are continued (13). the detail given in the authors' clinical vignettes was not sufficient for any conclusions regarding the variation in duration of reported prescribed steroids to be drawn. however, further evidence-based guidance on dosages, duration and tapering would clearly be helpful for gps who treat up to 90% of all episodes of acute asthma (6, 14) . most gps would instigate a follow-up of a patient within 24 h of the initial consultation. not surprisingly, more gps (77%) would follow-up the child within 24 h compared to the adult (61%). only 11% of gps said that they would ask the patient to initiate review in the adult case and only 4% in the child's case. most gps (69% for the adult and 64% for the child) would advise consideration of peak flow readings and worsening symptoms for urgent review. however, only 15% of gps would use a pre-existing self-management plan. this was reflected by the admission that only 49% of gps issued plans routinely to patients with figures of 33% and 25% for children over 7 years of age and under 7 years of age, respectively. these disappointing figures were still reported by doctors where there was an asthma clinic in the practice, with 56% of doctors issuing plans to adult patients, 38% to the over 7's and 29% to the under 7's. although the questionnaire did not specify exactly what type of self-management plan was being used, the study was conducted at a time in the u.k. when written home-peak-flow-based plans, as originally described by beasley (15) , were being strongly advocated. the usefulness of self-management plans in chronic asthma has been documented in improving lung function and reducing morbidity (15,16), although the levels of symptoms and peak flow at which various stepped interventions should be commenced have not been validated. increased use of self-management plans may allow follow-up after an acute attack managed in general practice to be more 'patient-led' rather than 'doctor led', although more caution is being expressed in the u.k. about the effectiveness of such plans for all patients with asthma (17,18). in summary, there appears to be widespread usage of both oral antibiotics and oral steroids in acute asthma attacks associated with respiratory tract infection treated in general practice. the most commonly reported duration of oral steroid course is 5 days, which may be sub-optimal in adults. there is probable over-practice of 'tapering off of oral steroids at course length over 5 days. follow-up after the initial consultation is mainly doctor initiated with low use of patient-initiated review using self-management plans. despite the shortcomings of the use of clinical vignettes, this research has raised important questions which need to be addressed. there is a need for more research to examine the role of antibiotics in acute asthma attacks associated with respiratory tract infection in general practice. particularly, historical or investigative indicators for appropriate antibiotic prescribing should be developed. the optimum dose, duration or oral prednisolone therapy and a need to examine the validity of 'stepping up' inhaled steroid therapy after an acute attack should be examined. finally, there is a need to validate the use of self-management plans in acute as well as chronic asthma and to promote their use as appropriate. community study of role of viral infections in exacerbations of asthma in 9-11 year old children respiratory viruses and exacerbations of asthma in adults guidelines for the management of asthma in adults. 2. acute asthma guidelines on the management of asthma infection in exacerbations of asthma: views of different groups of practitioners for general practitioners in asthma group. national asthma attack audit 1991-1992 the spss guide to data analysis for spss/pc+. chicago: statistical package for the social sciences use of a guideline based questionnaire to audit hospital care of acute asthma routine antibiotics in hospital management of asthma acute exacerbations of asthma in adults: role of chlamydiupneumoniue infection dose response of patients to oral corticosteroid treatment during exacerbations of asthma effect of a single oral dose of prednisolone in acute childhood asthma double-blind trial of steroid tapering in acute asthma the care of children with asthma in general practice: signs of progress? a self-management plan in the treatment of adult asthma evaluation of peak flow and symptoms only selfmanagement plans for control of acute asthma in general practice asthma: guided self management peak flow based asthma self-management: a randomised controlled study in general practice the authors wish to express their grateful thanks to the medical department of allen and hanburys for their educational grant and support in producing the questionnaire, to joan dunleavey, aldermoor health centre, southampton for collation of the results and to jenny coombs and caroline townley for their help with distribution and typing of the questionnaires and reports. finally, thanks to the gps of bath health district for finding time to fill in 'yet another questionnaire'. a 45year-old asthmatic man is usually well controlled on twice daily beclomethasone via a metered dose inhaler (total 4oopg day-i) and inhaled salbutamol qds pm. his maximum attainable peak flow rate (pefr) = 600 1 m-i.in the preceding 2 days, he has developed a respiratory tract infection with sore throat, cough with yellow sputum and runny nose. he has been waking at night and using his salbutamol six times in the last 24 h.on examination (in surgery at 10 am) he is: talking in unbroken sentences; pulse rate= 110 regular; respiratory rate = 30 min -i; and pefr=210 1 min-'. ausculation of his chest reveals scattered wheezes only. his pharynx is red. you give him nebulized salbutamol. he feels much better and pefr improves to 280 1 min -' after 20 min. a 9-year-old asthmatic girl (height 4ft 4ins) is usually well controlled on twice daily inhaled beclomethasone rotacaps (total dose 400,~g day-') and salbutamol rotacaps 2oopg pm qds. her maximum attainable peak flow rate (pefr) = 260 1 m -i. she is brought into the surgery by parents having developed a respiratory tract infection in the last 24 h, with a cough, productive of yellow sputum, runny nose and sore throat. she has become more wheezy and breathless and was awake during the night with wheeze.on examination (in surgery at 10 am): she speaks in short sentences; pulse rate=llomin-'; respiratory rate= 30 min -' (no intercostal recession); and pefr=1201min-'. you give her nebulized salbutamol and she symptomatically improves with pefr = 160 1 min -i . key: cord-333175-klnxnxwm authors: hussein, mohammad h.; toraih, eman a.; attia, abdallah s.; burley, nicholas; zhang, allen d.; roos, jackson; houghton, august; aniemeka, nedum; omar, mahmoud; aboueisha, mohamed; shama, mohamed a.; duchesne, juan; kandil, emad title: asthma in covid-19 patients: an extra chain fitting around the neck? date: 2020-11-11 journal: respir med doi: 10.1016/j.rmed.2020.106205 sha: doc_id: 333175 cord_uid: klnxnxwm introduction: the novel coronavirus disease 2019 (covid-19) has rapidly spread across the globe. pre-existing comorbidities have been found to have a dramatic effect on the disease course. we sought to analyze the effect of asthma on the disease progression and outcomes of covid-19 patients. methods: we conducted a multi-center retrospective study of positively confirmed covid-19 patients. the primary outcome of interest was in-hospital mortality. secondary outcomes were the intensive care unit (icu) admission, intubation, mechanical ventilation, and length of hospital stay. results: a total of 502 covid-19 adult patients (72 asthma and 430 non-asthma cohorts) with mean age of 60.7 years were included in the study. the frequency of asthma in hospitalized cohorts was 14.3%. univariate analysis revealed that asthma patients were more likely to be obese (75% versus 54.2%, p = 0.001), with a higher frequency of intubation (40.3% versus 27.8%, p = 0.036), and required a longer duration of hospitalization (15.1 ± 12.5 versus 11.5 ± 10.6, p = 0.015). after adjustment, multivariable analysis showed that asthmatic patients were not associated with higher risk of icu admission (or = 1.81, 95%ci = 0.98–3.09, p = 0.06), endotracheal intubation (or = 1.77, 95%ci = 0.99–3.04, p = 0.06) or complications (or = 1.37, 95%ci = 0.82–2.31, p = 0.23). asthmatic patients were not associated with higher odds of prolonged hospital length of stay (or = 1.48, 95%ci = 0.82–2.66, p = 0.20) or with icu stay (or = 0.76, 95%ci = 0.28–2.02, p = 0.58). kaplan-meier curve showed no significant difference in the overall survival of the two groups (p = 0.65). conclusion: despite the increased prevalence of hospitalization in elder asthmatic covid-19 patients, after adjustment for other variables, it was neither associated with increased severity nor worse outcomes. since its initial description in late 2019, the novel coronavirus (covid19) has become a global pandemic, overwhelming our healthcare systems and depleting resource stockpiles [1] . in some pandemic hotspots, physicians have had to make difficult decisions regarding lifesaving interventions due to a lack of supplies such as ventilators [2] . further complicating management of this disease, covid-19 has a broad clinical presentation. patients can be asymptomatic carriers or have mild non-respiratory and respiratory symptoms. on the other hand, the virus can also present with severe pneumonia or lethal respiratory failure. because of these severe outcomes, gaining an understanding of covid-19's disease course is essential to guiding treatment approaches and optimizing individual patient outcomes. preexisting comorbidities can have a dramatic impact on the course of a covid-19 infection. it is, therefore, crucial to identify which comorbidities most contribute to severe infections, which may influence individual patient care plans [3] . to better understand these relationships, the centers for disease control and prevention (cdc) is actively incorporating new and emerging data to update their treatment recommendations for patients with varying comorbid conditions. currently, the cdc reports that asthma is present in about 17% of hospitalized covid-19 patients, making it the fourth most prevalent comorbidity behind hypertension, obesity, and diabetes [4] . obese and diabetic patients have been categorized as high-risk, but there is still limited data regarding the impact of bronchial asthma on covid-19 outcomes [5] . because asthma is a chronic lung disease, it follows that asthmatics are at a greater risk for negative outcomes with a respiratory virus. however, there is a debate over the expected outcomes in covid-19 infected patients with asthma. some members of the coronaviridiae family that are associated with the common cold have been linked to asthma exacerbations [6] . in j o u r n a l p r e -p r o o f contrast, jackson et al. reported an observed protective relationship for asthma and atopic conditions in covid-19 patients [7] . in efforts to explain this phenomenon, it was proposed that patients with asthma and ectopic diseases may exhibit a lower concentration of respiratory tract angiotensin-converting enzyme (ace) receptors in patients. as has been widely reported, ace receptors and specifically, ace2, are known to be the host receptor site for sars-cov-2 [7, 8] . considering that more than 19 million adults in the united states have asthma [9] , it is crucial to characterize asthma in the setting of covid-19. therefore, we retrospectively evaluated hospitalized patients with laboratory-confirmed sars-cov-2, focusing on the differing outcomes between asthmatic and non-asthmatic patients. this study aimed to help further understand asthma's impact on covid-19 outcomes, hopefully enabling physicians to tailor management and resource allocation in response to the ongoing pandemic. following institutional review board (irb) approval, data of hospitalized patients with laboratory-confirmed sars-cov-2 infection was gathered and entered into the web-based data collection platform, redcap. patients included in the study presented to either university medical center new orleans (umcno), tulane medical center (tmc), saint francis medical center monroe (sfmc), or our lady of the lake regional medical center (olol) during the period between march 15 to june 9, 2020. a broad range of data was recorded, including but not limited to, the following: demographics, medical history, comorbidities, clinical presentation, daily laboratory values, complications, and j o u r n a l p r e -p r o o f outcomes. patients were excluded if they were below 18 years of age or did not have recorded outcome data. obesity was defined as body mass index (bmi) ≥30 kg/m 2 [10] . for severity assessment, the curb-65 score was estimated based on confusion status, respiratory rate≥30, blood pressure (systolic <90 mmhg or diastolic ≤60 mmhg), age ≥65 years, and blood urea nitrogen level >19 mg/dl (>7 mmol/l), and ranged from 0 to 5 [11] . quick sequential organ failure assessment (qsofa) score was calculated using glasgow coma score <15, respiratory rate ≥22, and systolic blood pressure ≤100, and was set to be a positive indicator for the poor outcome if ≥2 [12] . horowitz index (pao 2 / fio 2 ratio) was calculated as the ratio of arterial oxygen partial pressure (pao 2 in mmhg) to fractional inspired oxygen to determine a patient's respiratory efficiency [13] . the neutrophil-lymphocyte ratio (nlr), an indicator for poor outcome, was also estimated [14] . a comparison between the asthmatic and non-asthmatic cohorts was performed. the primary outcome of interest was in-hospital mortality. secondary outcomes were risk of intensive care unit (icu) admission, risk of endotracheal intubation, duration of mechanical ventilation, and length of hospital stay. clinical diagnosis of complications was made using standard definitions such as the risk, injury, failure, loss of kidney function, and end-stage kidney disease (rifle) score for renal injury [15] . berlin criteria were also utilized to identify cases of acute respiratory distress syndrome (ards) [16] statistical analysis interquartile ranges, while categorical data were presented as frequencies and percentages. chisquare or fisher's exact tests were used for categorical variables. student's t and mann-whitney u tests were applied for quantitative variables to examine the difference between asthmatic and non-asthmatics groups. shapiro-wilk test was used to test the normality of the continuous variables. kaplan-meier survival analysis and the log rank test was used to compare the inhospital mortality in the two groups. binary logistic regression analysis was used to assess the role of asthma comorbidity in the outcomes of covid-19 disease. age, gender, and obesity were adjusted in the model. hosmer-lemeshow test was used to assess goodness-of-fit. results were reported as odds ratio (or), and 95% confidence interval (ci) and two-sided p values below 0.05 were set as significant. a total of 502 confirmed positive covid-19 patients were identified from multiple hospitals in louisiana, including 72 bronchial asthma patients and 430 non-asthmatic controls. their mean age was 60.6 ± 13.9 years and 60.8 ± 15.7 years, respectively (p = 0.89). there was no observed age or gender difference. females accounted for 54.2% (39 patients) in the asthma group versus 52.0% (222 patients) in the non-asthma group (p = 0.79). the frequency of obesity among asthmatic patients (75%) was significantly higher than those without current asthma (54.2%), p = 0.001. on admission, asthma cohorts presented with greater respiratory rate (24.14 ± 7.03 vs 21.77 ± 7.20 breaths per minute, p = 0.015) and lower bicarbonate level (21.73 ± 5.41 vs 24.67 ± 3.57 meq/l, p = 0.022). no other significant differences were found regarding clinical and laboratory features ( table 1) . univariate analysis of covid-19 outcomes revealed that asthma was significantly associated with higher rate of endotracheal intubation (40.3% vs 27.8%, p = 0.036), mechanical ventilation (both invasive and non-invasive) (70.7% vs 52.2%, p = 0.039), and longer hospital length of stay (15.14 ± 12.48 days vs 11.51 ± 10.58 days, p = 0.015). asthma was not associated with a higher rate of intensive care unit (icu) admission (22.2% vs 14.9%, p = 0.12), acute respiratory distress syndrome (37.5% vs 30.9%, p = 0.27), or death (9.7% vs 13.5%, p = 0.45) among covid-19 patients. no other clinical and laboratory findings were different between patients with and without asthma ( table 2) . comparison stratified by obesity showed both asthmatic and non-asthmatic patients had overall similar demographic features, presenting manifestations and comorbidities in each subgroup. however, clinical courses differed significantly between some groups. on comparison to nonasthmatic obese patients, obese asthmatic patients were more likely to develop sepsis (25.9% vs 14.2%, p = 0.042), had higher risk of icu admission (48.1% vs 33.2%, p = 0.042), and required prolonged intubation (2.73 ± 3.63 days vs 1.38 ± 2.07, p = 0.032). using multivariate regression analysis, bronchial asthma was not associated with higher risk of as the covid-19 pandemic evolves, countries consider policies to protect those at increased risk of severe disease. to the best of our knowledge, this is the first study evaluating the relationship between asthma and covid-19 outcomes in hospitalized patients in louisiana. in the 502 patients included, the prevalence of asthma was 14.3%. this rate is higher than the national prevalence of asthma reported by the cdc (7.7%), but in line with cdc reports on the prevalence of asthma in covid-19 patients [17] . this increased prevalence of asthma in covid-19 patients may be attributable to increased disease awareness and concern to increased severity of the disease course among asthmatics. our initial univariate analysis of asthmatic patients showed significantly higher rates of endotracheal intubation and mechanical ventilation, and increased duration of hospital stay. patients with asthma were also more likely to be obese, a finding consistent with prior studies [18, 19] . as has been well-documented and widely reported, obesity alone has been associated with poor clinical outcomes in hospitalized covid-19 patients [4] . fittingly, in initial univariate analysis of obese asthmatic, there were significantly elevated rates of sepsis, icu admission, and prolonged intubation. however, after multivariate adjustment, asthma comorbidity did not drive poor outcomes for our primary and secondary endpoints of interest -icu admission, intubation, mechanical ventilation, ards, and case fatality rate. although these results may not be expected, there is a plausible mechanism, the downregulation of ace2 receptors, that could hypothetically account for these observations [20] . early data published by jackson et al. suggested that patients with allergic asthma have decreased ace2 expression in nasal and bronchial epithelial cells [7] . the possible explanation for this observation is two-fold. first, it has been postulated that that type ii immune modulation j o u r n a l p r e -p r o o f decreases the expression of the receptor for cellular entry of covid-19 -ace2 [22] . second, individuals with chronic respiratory conditions often use inhaled corticosteroids (ics). the severe asthma research program (sarp) demonstrated that ics use in asthmatic patients leads to decreased expression of ace2 and tmprss2 -a host serine protease which primes host cells for entry via the spike protein [23] . additional in vitro studies have demonstrated that treatment with ciclesonide, an ics used for suppressing asthma attacks, demonstrated viral suppression of sars-cov-2 [24] . it must be remembered that these experimental studies occurred in non-covid-19 patients; nonetheless, the results suggest further investigation is necessary to understand the possible protective role of type 2 inflammation in asthma and covid-19. based on these studies, it may be possible that ics treatment is protective via viral suppression or ace2/tmprss2 reduction. these protective effects may explain the lack of significant difference in outcomes among asthmatic and non-asthmatic patients. the potential limitations of this study include self-reporting of asthma history and the inability to identify the severity of asthma. to prevent false reporting, each patient's home medications were reviewed to confirm the diagnosis. asthma severity may be assessed retrospectively based on symptoms or via risk assessment requiring measurement of airflow limitation using spirometry or peak flow meter. however, these aerosol generating procedures (agps) may put healthcare workers at an increased risk of coronavirus exposure. the results of the current study show that while pre-existing asthma is more prevalent in our covid-19 cohort than in the general population, after adjustment for other covariates, it was neither associated with disease severity nor negative outcomes. therefore, although a seemingly poor prognosis, asthma does not imply a worse outcome than non-asthmatics. this information can help physicians and researchers identify people with other underlying medical conditions at j o u r n a l p r e -p r o o f risk for more severe covid-19 disease. the authors declare the absence of conflict of interest. none of the authors have any funding regarding this publication. we thank numerous doctors, nurses, government, and civilians working together to fight against the sars-cov-2. novel coronavirus disease (covid-19): a pandemic (epidemiology, pathogenesis and potential therapeutics) duty to plan: health care, crisis standards of care, and novel coronavirus sars-cov-2. nam perspectives. discussion paper. national academy of medicine comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease covid-19): are you at higher risk for severe illness? atlanta, ga: us department of health and human services, cdc regional, age and respiratory-secretion-specific prevalence of respiratory viruses associated with asthma exacerbation: a literature review association of respiratory allergy, asthma, and expression of the sars-cov-2 receptor ace2 sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor tables a-2b, a-2c bmi classification percentile and cut off points. statpearls external validation of the qsofa score in emergency department patients with pneumonia comparison of crb-65 and quick sepsis-related organ failure assessment for predicting the need for intensive respiratory or vasopressor support in patients with covid-19 sequential oxygenation index and organ dysfunction assessment within the first 3 days of mechanical ventilation predict the outcome of adult patients with severe acute respiratory failure the diagnostic and predictive role of nlr, d-nlr and plr in covid-19 patients importance of rifle (risk, injury, failure, loss, and end-stage renal failure) and akin (acute kidney injury network) in hemodialysis initiation and intensive care unit mortality acute respiratory distress syndrome: the berlin definition a review of obesity and asthma across the life spac obesity and asthma inhaled corticosteroids downregulate the sars-cov-2 receptor ace2 in copd through suppression of type i interferon. biorxiv preprint prevalence and characterization of asthma in hospitalized and non-hospitalized patients with covid-19 angiotensin-converting enzyme 2 is a functional receptor for the sars coronavirus covid-19-related genes in sputum cells in asthma. relationship to demographic features and corticosteroids the inhaled corticosterois ciclesonide blocks coronavirus rna replication by targeting viral nsp15 key: cord-263556-y8vx4ie2 authors: koistinen, annamari; lukkarinen, minna; turunen, riitta; vuorinen, tytti; vahlberg, tero; camargo, carlos a.; gern, james; ruuskanen, olli; jartti, tuomas title: prednisolone for the first rhinovirus‐induced wheezing and 4‐year asthma risk: a randomized trial date: 2017-08-06 journal: pediatr allergy immunol doi: 10.1111/pai.12749 sha: doc_id: 263556 cord_uid: y8vx4ie2 background: previous findings show that corticosteroid treatment during the first acute wheezing episode may reduce recurrent wheezing in children with high rhinovirus genome load at 12‐month follow‐up. longer‐term effects have not been investigated prospectively. methods: after pcr confirmation of rhinovirus from nasopharyngeal aspirate, 79 children with the first acute wheezing episode were randomized to receive orally prednisolone or placebo for 3 days. the initiation of asthma control medication before the age of 5 years was confirmed from medical record and/or from parental interview. the outcome was the time to initiation of regular asthma control medication. interaction analysis examined rhinovirus genome load. results: fifty‐nine (75%) children completed the follow‐up. asthma control medication was initiated in 40 (68%) children at the median age of 20 months. overall, prednisolone did not affect the time to initiation of asthma control medication when compared to placebo (p=.99). rhinovirus load modified the effect of prednisolone regarding the time to initiation of asthma control medication (p‐value for interaction=.04). in children with high rhinovirus load (>7000 copies/ml; n=23), the risk for initiation of medication was lower in the prednisolone group compared to the placebo group (p=.05). in the placebo group, asthma medication was initiated to all children with high rhinovirus load (n=9) during the 14 months after the first wheezing episode. conclusions: overall, prednisolone did not affect the time to initiation of asthma control medication when compared to placebo. however, prednisolone may be beneficial in first‐time wheezing children whose episode was severe and associated with high rhinovirus load. (clinicaltrials.gov, nct00731575). systemic corticosteroid treatment has not been found effective for acute treatment or secondary prevention of asthma in young wheezing children overall. [1] [2] [3] [4] the limitation of prior studies has been the lack of subgroup analyses that might identify responsive children. 5 rhinovirus-induced wheezing is strongly associated with recurrent wheezing and asthma up to age 13 years. 6, 7 we have previously shown in two randomized controlled trials (rcts) in first-time wheezing children (using both post hoc 8 and prospective designs 9 ) that a 3-day course of oral corticosteroid (ocs) may reduce the risk of recurrent wheezing, especially in children with high rhinovirus genome load. previously, using a design of rct, the effect of ocs treatment on the wheezing recurrence in rhinovirus-affected first-time wheezing children has only been investigated up to 12 months. 9 in the current analysis, our aim was to investigate the need for initiation of regular asthma control medication in the 4-year follow-up. based on our previous findings, 8, 9 we hypothesized that in children with high rhinovirus genome load, the effect of ocs is likely to last beyond 12 months by reducing the need for initiation of long-term asthma control medication. vinku2, a randomized, placebo-controlled trial ("vinku" means wheeze in finnish) prospectively investigated the long-term effectiveness of short course of oral prednisolone (prednisolon ® , leiras takeda, helsinki, finland; during the first rhinovirus-induced wheezing episode, first dose 2 mg/kg, then 2 mg/kg/d in 2 doses for 3 days, maximum 60 mg/d, given as minced 5 mg tablets) until the age of five. 9 inclusion criteria were age 3-23 months, delivery at ≥36 gestational weeks, first acute wheezing episode (parental report and confirmed from medical records), and nasopharyngeal aspirate positive for rhinovirus by pcr. exclusion criteria were a chronic non-atopic illness, previous systemic or inhaled corticosteroid treatment (ics), or a need for intensive care unit treatment. 9 the study was approved by the ethics committee of the turku university hospital and was commenced only after obtaining written informed consent from the guardians. at study entry, patients were examined by study physician and blood samples and nasopharyngeal aspirate were taken. children were reexamined by study physician 2 weeks, 2 months, 12 months, and 4 years after the first wheezing episode. parents were interviewed by study physician using standardized questionnaire at study entry and 12-month and 4-year follow-ups. the electronic patient charts were reviewed regarding asthma medications, therapy adherence, and asthma symptoms for the full follow-up period. the randomization protocol was described earlier. 9 the trial was double-blinded until the 12-month follow-up (clinicaltrials.gov, nct00731575). the primary outcome was the time to initiation of asthma control medication until the age of 5 years. the initiation of the medication was based on the 2007 national asthma education and prevention program (naepp) guidelines for the diagnosis of asthma in children aged <5 years. 10 the need for asthma control medication was defined as ≥4 wheezing episodes (≥1 diagnosed by a physician) within a year that lasted >1 day and affected sleep, in addition to one major risk factor (physician diagnosed atopic eczema, aeroallergen sensitization, or parental history of asthma) or two minor risk factors (wheezing apart from colds, blood eosinophil count (b-eos) ≥0.40×10 9 /l or food sensitization) and/or prolonged symptoms lasting >4 weeks and requiring symptomatic treatment >2 days per week, and/or two exacerbations requiring systemic corticosteroids within 6 months. 10 in some children, asthma control medication was started after the third acute wheezing episode according to the finnish guidelines. 11 the interaction analysis included the effect of rhinovirus genome load (ie, copy number) on the effectiveness of prednisolone vs placebo on the main outcome. an in-house pcr test was used for detecting rhinovirus species a, b, and c, enteroviruses, and respiratory syncytial virus (rsv) a and b from nasopharyngeal aspirate. 12 12 both an in-house and a commercial pcr tests were used, because according to our experience, the sensitivity of the tests, especially concerning on detection of rhinovirus, differs. rhinovirus or rsv detected by either in-house or multiplex pcr was defined as positive. human bocavirus was analyzed using pcr and serology. 13 b-eos and total and allergen-specific serum immunoglobulin e (ige) levels were analyzed using the routine diagnostic procedures of the the original power analysis was performed for 12-month, not 4-year, follow-up. 9 baseline differences in patient characteristics between treatment groups were analyzed using t test (age), mann-whitney u test (b-eos, total ige, 25(oh)d, rhinovirus genome load, duration of breast feeding, and delay in starting the study drug), chi-square test (sex, any sensitization, eczema, parental allergic rhinitis, paternal smoking, pet ownership, and coinfection), or fisher exact test (counts <5; admission to the ward, atopic eczema, parental asthma, maternal smoking, and virus etiology). the cox model was used for risk of the primary outcome. it included the main effects of dichotomized rhinovirus genome load and intervention group and the interaction effect of rhinovirus genome load by intervention group. the cox model included no covariates, as no significant differences in patient characteristics were found. survival times were censored at the age of 5 years if the event did not occur earlier. the cutoff level for rhinovirus genome load was identified by testing different copy number levels. the threshold was selected by considering significant p-value for rhinovirus load vs group interaction effect similar to our previous report. 9 ibm spss version 22 (spss inc, chicago, ill, usa) was used for statistics. a total of 79 children were randomized to receive prednisolone or placebo during their first acute wheezing episode. during the follow-up period, 10 children were excluded from the analysis due to insufficient follow-up time (dropouts), nine due to insufficient data about rhinovirus genome load, and one due to initiation of ics for another reason (figure 1 ). finally, 59 (75%) children were analyzed (inpatient:outpatient, 80%:20%). the excluded patients did not differ from the included patients according to age, sex, atopic characteristics, viral etiology, or any other asthma-related factors listed in table 1 (table s1). at study entry, the mean age of the 59 patients was 13 months (standard deviation [sd] 6 months), 18 (31%) were sensitized, and 23 (39%) had eczema (table 1) . twenty children (34%) had at least two viruses detected in their airways. rhinovirus genome load varied across patients, with a median of 4300 copies/ml (interquartile range [iqr] 79-16 000); 23 (39%) of the patients had a rhinovirus genome load level >7000 copies/ml ( table 2 ). median delay in starting the study drug was 45 hours (iqr: 41-71). the treatment groups did not differ in any patient characteristics shown in table 1 and table s2 . in the prednisolone group 22 (76%) children and in the placebo group 22 (73%) of the children received at least one ocs course during the follow-up. different cutoff levels for rhinovirus genome load was tested, and three different levels were noticed statistically significant ( table 2) . as the differences in final results did not differ significantly depending on the cutoff (data not shown), the same level with the earlier report was used. 9 10 in five children, asthma control medication was started after the third acute wheezing episode. 11 overall, prednisolone did not affect the time to initiation of asthma control medication when compared to placebo (p=.99; figure 2) . however, the level of rhinovirus genome load at study entry modified the effect of prednisolone in terms of the time to initiation of asthma control medication (rhinovirus load x study drug interaction, p=.04, figure 3 ). in children with a rhinovirus genome load of >7000 copies/ ml, the risk for initiation of asthma control medication was lower in the prednisolone group (n=14) compared to the placebo group (n=9; hazard ratio [hr] 0.38; 95% confidence interval [ci] 0.14-1.01, p=.05, figure 3 ). the asthma control medication was exclusively started to all placebo-treated children with high rhinovirus load within the subsequent 14 months after the first wheezing episode (figure 3 ). median age of the children at the time of the initiation of asthma medication was 16 months (iqr: 9-22 months). in children with a rhinovirus genome load of ≤7000 copies/ml, no differences were found between the prednisolone (n=15) and placebo groups (n=21; hr: 1.4, 95% ci: 0.58-3.2, p=.46, figure 3 ). no clinically significant adverse events were reported during the acute phase. this is the first randomized placebo-controlled trial to investigate the effect of ocs treatment until preschool age in carefully characterized young children suffering from their first acute rhinovirus-induced wheezing episode. we had three main findings: first, ocs was not found to be effective overall when regarding the time to initiation of asthma control medication. second, in the placebo group, asthma risk was high: regular asthma control medication was initiated to all children with high rhinovirus genome load during the subsequent 14 months after the first acute rhinovirus-induced wheezing episode. third, short course of prednisolone decreased the risk of asthma control medication in children with the first severe wheezing episode caused by high rhinovirus genome load. all of these findings are in line with previous data on the increased asthma risk associated with early rhinovirus-induced wheezing. [6] [7] [8] probable explanation for the association between rhinovirus infection and risk of asthma may be that pre-existing airway inflammation in asthma-prone children predisposes to rhinovirus infection. 15 moreover, high rhinovirus genome load has been associated with more severe airway inflammation. [16] [17] [18] [19] in asthma-prone patients, interferon responses can be deficient, thus increasing virus replication and promoting type 2 t-cell responses in respiratory epithelial cells. 20, 21 moreover, rhinovirus infection may further intensify the inflammation by increasing the expression of eotaxin and interleukins 4 and 13, as well as by stimulating the immigration of eosinophils, macrophages, and neutrophils. 22 our placebo group finding of an exceptionally high risk for initiating regular asthma control medication in children with high rhinovirus genome load is consistent with these earlier findings. nevertheless, we were surprised by the speed of asthma progression in these children. clinically, ocs treatment is recommended for asthma exacerbations in children, but effectiveness of ocs for the secondary prevention of asthma has not been confirmed in overall analysis of rcts our study population, especially those with high rhinovirus load, most likely represent the cluster a. most 9,16-19 but not all 25, 26 previous studies have shown the higher rhinovirus genome load to be associated with more severe and/or longer duration of acute lower respiratory illness. there are no previous data concerning the long-term outcomes beyond 12 months. 9 we used f i g u r e 2 the time to initiation of asthma control medication in children randomized to receive prednisolone or placebo for the first rhinovirus-induced wheezing episode. no difference was found in overall analysis f i g u r e 3 the time to initiation of asthma control medication in children randomized to receive prednisolone or placebo for the first rhinovirus-induced wheezing episode. data are represented according to the rhinovirus genome load. children with a rhinovirus genome load of >7000 copies/ml had longer time to initiation of asthma control medication in prednisolone group when compared with the placebo group. in the placebo group, asthma medication was initiated to all children with high rhinovirus genome load (n=9) during the 14 mo after the first wheezing episode more sensitive pcr (real-time pcr) compared to our previous study (conventional pcr and liquid hybridization), 8 which also allows quantification of rhinovirus genome load. here, we also used highly concentrated samples, while previous studies that did not find a relationship between viral shedding and outcomes 25, 26 used nasal wash samples to estimate genome load. these differences in methodology may explain apparent discrepancies between our results and those earlier studies. the strengths of the study include careful characterization of the patients and rct design although blinding was opened (as planned) for the 12-month report. 9 however, our study has some limitations. the sample size was small but large enough to generate statistically significant results consistent with our previous studies. 8, 9 most patients were hospitalized which raises questions about the generalizability of our results to outpatients or mild wheezing illness. 27 rhinovirus diagnostics caused a delay in administration of the study drug which could have contributed to the lack of effectiveness of prednisolone in overall rhinovirus analysis (in addition to more sensitive pcr). in our earlier post hoc analysis with no delay in initiation of study drug and no quantitative rhinovirus detection, prednisolone was found effective in all children with rhinovirus and/or eczema. 8, 28 the inflammatory profiling of t helper 1 and t helper 2 mediators in different subgroups would increase the interest of our findings but we did not do the profiling. moreover, there were many cutoff levels of rhinovirus genome load with significant p-value. in this study, we made a decision to be in line with the earlier follow-up. 9 in summary, early systemic short-course prednisolone treatment may be beneficial in reducing the risk for asthma control medication during the first 5 years in first-time wheezing preschool children whose episode was severe and associated with high rhinovirus genome load. the results call attention to different phenotypes of bronchiolitis and early wheezing, 5 which are likely to respond differently to different therapies. the natural course of asthma inception may be modifiable when high-risk children are identified early, even at the time of the first wheezing episode, and targeted with an effective intervention strategy. systemic glucocorticoids in childhood expiratory wheezing: relation between age and viral etiology with efficacy efficacy of a short course of parentinitiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial oral prednisolone for preschool children with acute virus-induced wheezing corticosteroids in respiratory diseases in children a clustering approach to identify severe bronchiolitis profiles in children recurrent wheezing 36 months after bronchiolitis is associated with rhinovirus infections and blood eosinophilia early life rhinovirus wheezing, allergic sensitization, and asthma risk at adolescence prednisolone reduces recurrent wheezing after first rhinovirus wheeze: a 7-year follow-up short-and long-term efficacy of prednisolone for first acute rhinovirus-induced wheezing episode expert panel report 3: guidelines for the diagnosis and management of asthma -full report working group set up by the finnish medical society duodecim and the finnish cardiac society, helsinki. current care guidelines: asthma; 2012. www.kaypahoito.fi the first wheezing episode: respiratory virus etiology, atopic characteristics, and illness severity clinical assessment and improved diagnosis of bocavirus-induced wheezing in children bronchiolitis: age and previous wheezing episodes are linked to viral etiology and atopic characteristics basal cells of differentiated bronchial epithelium are more susceptible to rhinovirus infection rhinovirus load and disease severity in children with lower respiratory tract infections impact of rhinovirus nasopharyngeal viral load and viremia on severity of respiratory infections in children impact of human rhinovirus types and viral load on the severity of illness in hospitalized children with lower respiratory tract infections clinical, virological and epidemiological characteristics of rhinovirus infections in early childhood: a comparison between non-hospitalised and hospitalised children deficient antiviral immune responses in childhood: distinct roles of atopy and asthma th2 cytokines impair innate immune responses to rhinovirus in respiratory epithelial cells understanding the association of human rhinovirus with asthma glucocorticoid actions on airway epithelial responses in immunity: functional outcomes and molecular targets comparison of viral load in individuals with and without asthma during infections with rhinovirus a mechanistic role for type iii ifn-λ1 in asthma exacerbations mediated by human rhinoviruses rhinovirus-induced bronchiolitis: lack of association between virus genomic load and short-term outcomes association between respiratory infections in early life and later asthma is independent of virus type sensitization at the first wheezing episode increases risk for longterm asthma therapy we thank biomedical laboratory scientist heidi jokinen from additional supporting information may be found online in the supporting information tab for this article. key: cord-328918-nc0a77r6 authors: kuczia, pawel; zuk, joanna; iwaniec, teresa; soja, jerzy; dropinski, jerzy; malesa-wlodzik, marta; zareba, lech; bazan, jan g.; undas, anetta; bazan-socha, stanislawa title: citrullinated histone h3, a marker of extracellular trap formation, is increased in blood of stable asthma patients date: 2020-07-13 journal: clin transl allergy doi: 10.1186/s13601-020-00337-8 sha: doc_id: 328918 cord_uid: nc0a77r6 background: emerging data indicates that extracellular traps (ets), structures formed by various immune cell types, may contribute to the pathology of noninfectious inflammatory diseases. histone hypercitrullination is an important step in ets formation and citrullinated histone h3 (h3cit) is considered a novel and specific biomarker of that process. in the present study we have evaluated circulating h3cit in stable asthmatics and investigated its relationship with asthma severity, pulmonary function and selected blood and bronchoalveolar lavage (bal) biomarkers. methods: in 60 white adult stable asthmatics and 50 well-matched controls we measured serum levels of h3cit. in asthmatics we also performed bronchoscopy with bal. we analyzed blood and bal biomarkers, including interleukin (il)-4, il-5, il-6, il-10, il-12p70, il-17a and interferon γ. for statistical analysis, mann–whitney u-test, χ(2) test, one-way ancova, roc curve analysis and univariate linear regression were applied. independent determinants of h3cit were established in a multiple linear regression model. results: asthma was characterized by elevated circulating h3cit (17.49 [11.25–22.58] vs. 13.66 [8.66–18.87] ng/ml, p = 0.03). in asthmatics positive associations were demonstrated between serum h3cit and lung function variables, including total lung capacity (tlc) (β = 0.37 [95% ci 0.24–0.50]) and residual volume (β = 0.38 [95% ci 0.25–0.51]). h3cit was increased in asthma patients receiving systemic steroids (p = 0.02), as well as in subjects with bal eosinophilia above 144 cells/ml (p = 0.02). in asthmatics, but not in controls, circulating h3cit correlated well with number of neutrophils (β = 0.31 [95% ci 0.19–0.44]) and monocytes (β = 0.42 [95% ci 0.29–0.55]) in peripheral blood. furthermore, bal macrophages, bal neutrophils, tlc, high-sensitivity c-reactive protein, il-12p70 and bronchial obstruction degree were independent determinants of h3cit in a multivariate linear regression model. conclusions: asthma is characterized by increased circulating h3cit likely related to the enhanced lung ets formation. inhibition of ets might be a therapeutic option in selected asthma phenotypes, such as neutrophilic asthma. asthma is a common chronic inflammatory disease of the airways with a complex pathomechanism involving diverse immune processes [1, 2] accompanied by a low-grade persistent systemic inflammation [3] . emerging data indicate that extracellular traps (ets) may contribute to the pathology of noninfectious inflammatory diseases [4] [5] [6] . ets are web-like structures coated with histones, granular and cytosolic proteins, formed by various immune cells, including neutrophils, eosinophils, and macrophages [7] . neutrophil ets (nets) were first discovered as being mainly implicated in the innate immune response in host defense, enabling neutrophils to immobilize and kill invading bacteria, fungi or even viruses [6, 8] . the impact and presence of ets formation in asthma have not been extensively studied yet, however, previous studies suggest that nets [9, 10] and eosinophil extracellular traps (eets) [4, 11] may contribute to the persistent airway inflammation in asthma. moreover, toussaint et al. [12] have shown that rhinovirus respiratory tract infection, the most common cause of asthma exacerbation in humans, induces host-derived double strand dna release in nasal lavage samples of patients with mildmoderate asthma. there is also a growing body of evidence that ets may be entangled in clotting of the blood. we have recently reported evidence of a prothrombotic state in asthma which is characterized by enhanced plasma thrombin formation, impaired clot lysis and platelet activation [13] , all of them related to the low-grade systemic inflammation [3] , endothelial injury [14] , elevated exacerbation rate [15] , and likely increased atherosclerotic risk [16, 17] . higher risk of thromboembolic events in asthmatics has been also demonstrated in epidemiological studies [18] [19] [20] [21] [22] . the mechanisms functionally underlying this phenomenon are currently under investigation; however, ets contribution may be of importance. one of the key steps in ets formation is citrullination of histones performed by the histone-specific enzyme peptidylarginine deiminase 4 (pad4) [8] . emerging data indicates that citrullinated histone h3 (h3cit), a key component of ets, may be recognized as a specific marker of ets formation both in tissue samples [23] [24] [25] and in peripheral blood [26] [27] [28] [29] . taking into account low-grade systemic inflammation demonstrated in asthma and important role of ets formation in human pathology, we sought to evaluate serum h3cit, a specific biomarker of ets formation, in asthma. we also studied its relation to asthma severity, lung function abnormalities, and selected blood and bronchoalveolar lavage asthma biomarkers. the study was conducted in the department of internal medicine, jagiellonian university medical college, krakow, poland, from june 2015 to january 2018. we enrolled 60 white adult patients with clinically stable asthma according to the global initiative for asthma (gina) guidelines [30] and 50 well-matched controls. the study participants were 18-65 years old. diagnosis of asthma was established based on a history of recurrent respiratory symptoms (wheeze, cough, shortness of breath, and chest tightness) together with current and/or historically documented postbronchodilator increase in forced expiratory volume in one second (fev 1 ) of 12% and at least 200 ml from the baseline [30] . atopic status was confirmed by a positive skin prick testing for at least one inhaled allergen (allergopharma, reinbeck, germany). all asthma medications, except for biological therapy, were permitted, including oral corticosteroids at a daily dose equivalent to ≤ 10 mg of prednisolone, only if the dose was unchanged for 3 consecutive months. asthma patients were eligible if they had no exacerbation during the preceding 6 months. severity of asthma was categorized according to the gina guidelines [30] . "mild" asthma was defined as a mild persistent disease, treated with short acting β 2 -agonist on demand, with or without low daily dose of inhaled corticosteroids (ics) (< 250 μg of fluticasone propionate [fp] [dry powder inhaler] or equivalent). "moderate" asthma was defined as a mild persistent disease treated with a low (combined with long-acting β 2 -agonists) or medium dose of ics (250-500 μg of fp or equivalent). "severe" asthma was defined as severe persistent disease despite using high daily dose of ics (> 500 μg of fp or equivalent). asthma symptom control was assessed based on result of asthma control test (act). scores 20-25 were classified as "well-controlled asthma", 16-19 as "not well-controlled", while 5-15 as "very poorly controlled asthma". spirometry and bronchial reversibility test with 400 μg of albuterol as well as postbronchodilator body plethysmography with assessment of residual volume (rv) and total lung capacity (tlc) were measured in all enrolled asthma patients according to the american thoracic society (ats) standards [31] , using a jaeger masterlab spirometer (jaeger-toennies gmbh; hochberg, germany). in asthma patients we also performed bronchoscopy with bronchoalveolar lavage (bal). exclusion criteria comprised any acute illness, congestive heart failure, atrial fibrillation, coronary heart disease, hyper-or hypothyroidism, liver injury, chronic kidney disease (stage 3 or more), autoimmune disease, malignant neoplasm or medical history of thromboembolism. in turn, arterial hypertension, diabetes mellitus, or hypercholesterolemia were allowed as comorbidities in subjects studied. arterial hypertension was defined based on a history of hypertension (blood pressure > 140/90 mmhg), or present antihypertensive treatment. diabetes mellitus was defined as the current use of insulin, or oral hypoglycemic medications, or fasting serum glucose > 7.0 mmol/l. hypercholesterolemia was defined as serum total cholesterol > 5.2 mmol/l or previous diagnosis along with lipid-lowering treatment. ex-smokers were eligible for enrolment if they had stopped smoking at least 5 years before inclusion. control subjects were enrolled from the hospital personnel and its relatives. they were matched with patients according to age, sex, bmi, smoking status and internal medicine comorbidities. subjects with history of allergic diseases or bronchial obstruction were excluded. each control was individually matched with two patients considering the closest values of the matching criteria. bronchofiberoscopy was performed in asthma subjects according to the ats guidelines [32] using the bf 1t180 bronchoscope (olympus, usa) with local anesthesia (2% lidocaine) and mild sedation (0.05-0.1 mg fentanyl and 2.5-5 mg midazolam, both intravenously). bal was performed with 200 ml of normal saline applied into the right middle lobe bronchus. first 10 ml aliquot of obtained bal fluid was discarded, while the next sample was used for investigation. the cytospin preparations (thermo scientific, walthman, ma) were made from bal fluid samples and stained with the may-grunwald giemsa dye. percentages of inflammatory cells among 1000 cells in each preparation were counted (with exception of epithelial cells). remaining bal fluid was centrifuged 2000×g for 20 min at room temperature, supernatant was frozen in aliquots and stored at − 70 °c until analysis. fasting blood samples were drawn from the antecubital vein between 8:00 and 11:00 a.m, using minimal stasis. lipid profile, glucose, creatinine, urea, alanine aminotransferase, as well as complete blood cell and platelet count were assayed by routine laboratory techniques. fibrinogen was determined with the clauss method. high-sensitivity c-reactive protein (hscrp) and immunoglobulin e (ige) were measured by latex nephelometry (siemens, marburg, germany). blood samples were drawn into serum separation tube, centrifuged 2000×g for 20 min, at room temperature. the supernatant was frozen in aliquots and stored at − 70 °c until analysis. high sensitivity immunoenzymatic assays were used to measure levels of interleukin(il)-4, il-5, il-6, il-10, il-12p70, il-17a, and interferon (inf)γ (ebiosciencea, vienna, austria, all) in serum and bal fluid of asthmatics and in serum of 25 (50%) controls. concentration of h3cit in serum was measured using elisa kit developed by cayman chemicals (ann arbor, mi, usa). this assay employed a monoclonal antibody specific for histone h3 citrullinated at r2, r8, and r17 (clone 11d3). the lower limit detection of the assay was 0.1 ng/ml, the upper 31 ng/ml. analyses were carried out using statistica software package version 12.5 (tibco inc). the shapiro-wilk test has shown that continuous variables were non-normally distributed. they were reported here as median and interquartile range and compared using the mann-whitney u-test. categorical variables were given as percentages and compared by χ 2 test with yates' correction, if applicable. age, sex, and body mass index (bmi) were considered as potential confounders for laboratory investigations. therefore, the box-cox normality transformation was used and a one way covariance analysis (ancova) was performed to adjust for confounding factors. to test for associations between two continuous variables univariate linear regression model was applied with adjustment for sex, age, and bmi. independent determinants of h3cit were established in a multiple linear regression model, built by a forward stepwise selection procedure, verified by f snedecor's statistics, with f > 1. the r2 was used as a measure of the variance. cut-off points of bal and blood biomarkers in relation to circulating h3cit levels were calculated in asthmatics based on receiver operating characteristic (roc) curves. moreover, to compare biomarkers between h3cit-high and h3cit-low asthma subjects the 75 th percentile value of the circulating h3cit in asthma individuals has been taken into account. in each case of multiple comparisons bonferroni correction has been applied and the nominal level of significance has been reduced proportional to the total number of all tests performed in multiple comparisons procedure. results were considered significant when the p value was less than 0.05. clinical and laboratory characteristics of subjects studied are given in tables 1 and 2, respectively. among asthmatics 41 (68.3%) subjects had atopy, while 30 (50%) were characterized by severe disease according to gina [30] . severe asthma was an indication for the use of systemic corticosteroids in 17 patients (28.3%). asthma individuals were characterized by increased serum levels of il-6, il-10 (fig. 1b, c) , alanine aminotransferase activity, as well as elevated monocyte, eosinophil, lymphocyte, and total white blood cell (wbc) counts as compared to controls ( table 1) . results of laboratory bal investigations are presented in table 3 . as it has been demonstrated, il-6 and il-12p70 were above the detection threshold in the majority of asthma patients. in turn, concentrations of il-4, il-5, il-17a, and ifnγ in bal and blood, as well as il-10 in bal were below the detection threshold in the majority of subjects (additional file 1: tables s1 and s2). as expected, in asthma concentration of il-6 in bal was associated with bal and blood neutrophilia (β = 0.51 [95% ci 0.41-0.6] and β = 0.41 [95% ci 0.31-0.51], respectively). circulating h3cit was significantly elevated in asthmatics in comparison to control group (17.49 [11.25-22 .58] vs. 13.66 [8.66-18 .87] ng/ml, p = 0.03), also after adjustment for potential confounders (p = 0.02) (fig. 1a) [11.11-19 .90] ng/ ml, p = 0.04). administration of other drugs, as well as comorbidities had no impact on that parameter. in asthma, but not in controls, circulating h3cit remained in positive associations with number of monocytes (β = 0.42 [95% ci 0.29-0.55]) and neutrophils [11.29-29 .83] ng/ml vs. 15.12 [9.48-19.53 ] ng/ml, p = 0.03), as well as with bal il-6 levels higher than 0.76 pg/ml (19.53 [11.29-32 .00] ng/ ml vs. 15.98 [10.96-18 .06] ng/ml, p = 0.04) (additional file 2: fig. s1 ). interestingly, in controls h3cit was directly associated with serum il-6 (β = 0.33 [95% ci 0.1-0.56]). in asthmatics, serum h3cit was strongly related to the results of lung function tests, including tlc (β = 0.37 [95% ci 0.24-0.50]) and rv (β = 0.38 [95% ci 0.25 to 0.51]), also after adjustment for potential confounders. asthma patients with higher h3cit, defined as values above 22.58 ng/ml (75th percentile as the cut-off point) had higher tlc in comparison to the remainders (6.42 [5.82-7.33] vs. 5.55 [5.11-6.14] ; p = 0.007) (additional file 3: fig. s2c ). moreover, a weak negative relationship independent determinants of circulating h3cit in asthmatics were identified using forward stepwise selection procedure. the number of macrophages and neutrophils in bal, hscrp, tlc, and the degree of prebronchodilator airway obstruction were demonstrated as positive predictors of h3cit level in peripheral blood. in turn, surprisingly, il-12 (p70) had a negative impact on circulating h3cit in that analysis. all aforementioned variables explained 57% of h3cit variability (table 4 ). in the present study we have demonstrated that serum h3cit, a novel biomarker of ets formation, is increased in stable asthma subjects. although serum h3cit was not related to the asthma severity according to the gina guidelines, a weak negative correlation with fev 1 /vc suggests that enhanced bronchial obstruction, characteristic for more severe asthma subtype, might be associated with ets release. the same applies to the tendency towards elevated circulating h3cit in those on systemic steroids or even anti-leukotriene medications. to our knowledge there is no evidence for upregulation of ets formation by steroids [33] or leukotriene antagonists, however we cannot exclude such a relationship. previously, dworski et al. [11] have found evidence for lung eets and nets formation in endobronchial biopsy specimens of mild and well-controlled asthma patients. in our study, the positive correlations demonstrated for tlc or rv and circulating h3cit suggest that indeed, lungs might be the site of ongoing ets formation with subsequent h3cit release into the peripheral blood of stable asthmatics. it might be assumed that in asthma higher lung volume and capacity, thus larger inflammatory site area, might result in the increase of local ets generation. interestingly, in asthma serum h3cit was related to the number of monocytes and neutrophils in peripheral blood, as well as macrophages in bal. it is an intriguing result, as the issue of extracellular trap formation by macrophages remains a subject of ongoing research and debate [34] . on the other hand, we found no direct association between serum h3cit and number of neutrophils in bal. that finding might be to some extent explained by the relatively low percentage of patients with neutrophilic bal in our cohort, as other studies demonstrated increased nets in neutrophilic asthma sputum [10] . however, we found increased h3cit among asthmatics with higher bal eosinophilia. previously, choi et al. [4] have demonstrated likely impact of eosinophils' derived eets on airway inflammation. our results stay in line with their finding, although bal composition does not necessarily reflect lung tissue inflammation [11] . associations between circulating h3cit and blood monocytes or neutrophils were not directly documented in the multivariate linear regression model, as hscrp, a biomarker closely related to monocyte and neutrophil counts in our study (data not shown), was a more precise determinant of serum h3cit. moreover, in that model bal macrophages and bal neutrophils remained independent h3cit determinants, suggesting the role of h3cit as a potential biomarker of neutrophilic asthma even despite the lack of a direct correlation between bal neutrophils and h3cit. interestingly, in our asthma cohort higher concentrations of bal il-6 was associated with increased circulating h3cit. in turn, elevated serum il-6 in asthmatics stays in line with the previous reports of persistent low-grade systemic inflammation in asthma. links between nets and cytokine release have already been documented, e.g. nets may induce the transcription of il-6 and pro-il-1β genes in macrophages in early atherosclerosis [8] . surprisingly, in our study asthma patients were characterized by il-10 elevation as compared to controls. il-10 is rather known for its anti-inflammatory properties including inhibition of nets release [8] . moreover, borish et al. have found diminished il-10 bal fluid concentrations in asthmatics [35] . however, the observed increase in serum il-10 in our study together with the negative correlation between bmi and h3cit in asthma subjects make further research of interactions between cytokines, adiponectin and ets release of interest. interestingly, serum h3cit was negatively determined by serum il-12(p70), a major player in the initiation and maintenance of t helper 1 cells response [36] . il-12 is known to inhibit airway inflammation and bronchial obstruction in murine models of allergic asthma [37] . an interventional study with recombinant il-12 in human asthmatics showed a decrease in peripheral blood and sputum eosinophilia with no impact on bronchial reactivity [38] . another function of il-12 is the inhibition of pathological angiogenesis [39] . it has been demonstrated that abnormal neovascularization is an important feature of airway remodeling in asthma patients [40, 41] . we cannot exclude, that in asthmatics with enhanced ets formation decrease of il-12 might contribute to the unfavorable airway remodeling and bronchial neovascularization. notably, increased h3cit in peripheral blood of asthma subjects is particularly important, since there is a growing body of evidence that enhanced ets formation might contribute to the development of various systemic sequelae, including thrombotic complications or autoimmunity [6] [51] . in particular, the presence of autoantibodies against citrullinated peptides in rheumatoid arthritis, another noninfectious inflammatory disease, is likely related to the pad4 activity enabling ets release [6, 42] . in turn, severe asthma patients present more frequently with autoimmune diseases [52] . thus, production of ets with subsequent release of related products into the circulation may provide the initial stimulus for autoimmunity, explaining the increased rate of autoimmune diseases in asthmatics. moreover, it has been demonstrated that histones might directly contribute to inflammatory injury by a host tissue damage [43] [44] [45] [46] , including microvascular endothelial barrier disruption and subsequent cell inflow into the inflammatory site [43, 47, 48] . experimental approach with specific h3cit inhibition led to improved outcomes in mouse sepsis models [29, 49] . although this is only a hypothesis, we believe that even relatively low concentrations of h3cit and other citrullinated histone types may contribute to the endothelium damage in asthmatics. the availability of pharmacologic histone inhibitors makes it a particularly intriguing issue, as their use might be of benefit at least in some asthma phenotypes. furthermore, the potential contribution of ets formation to the prothrombotic phenomenon in asthma also deserves a comment. fuchs et al. [50] has reported that nets trigger the blood clotting through activation of platelets, recruitment of red blood cells and stimulation of fibrin deposition, being a potential link between immune response and thrombosis. in particular, ammollo et al. [51] revealed that extracellular histones increase plasma thrombin generation by impairing thrombomodulin-dependent protein c activation. recently, zuo et al. [52] documented increased h3cit and myeloperoxidase-dna (mpo-dna) in sera of subjects with coronavirus disease 2019 (covid-19), illness accompanied by clotting impairment and microvascular thrombosis. thus, we speculate that elevated circulating h3cit may, at least to some extent, explain prothrombotic blood alterations and increased risk of thromboembolic complications demonstrated even in well-controlled asthma patients [13, [18] [19] [20] . the limitations of our study include relatively small sample size. particularly, subgroup analysis should be interpreted with caution. we determined each variable at a single time point, thus we cannot exclude changes of the variables during time. we did not analyze ets formation in a functional assay. however, the laboratory techniques for directly determining the ets formation are difficult and very demanding from the technical point of view. applied here h3cit elisa assay is simple, but relatively novel, thus might require further validation before being established as a reliable test for the extensive use in practice. we analyzed h3cit in blood and not in airways, which are the main loci of asthma inflammatory response. we did not measure other cytokines potentially relevant for the lung and systemic inflammatory response, including il-1β and il-18, released after nlrp3 stimulation by nets [53] . statistical associations reported here might not necessarily indicate cause-effect relationships. finally, a clinical relevance of increased serum h3cit in relation to asthma course, disease progression, exacerbation risk, or vascular outcomes remains to be established. asthma is characterized by increased circulating h3cit likely related to the enhanced lung ets formation. although large experimental and observational studies are needed to verify this hypothesis, it seems that ets release is involved in asthma pathogenesis. thus inhibition of ets might be a therapeutic option in selected asthma phenotypes, such as neutrophilic 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extracellular traps in covid-19 the three cytokines il-1β, il-18, and il-1α share related but distinct secretory routes publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. supplementary information accompanies this paper at https ://doi. org/10.1186/s1360 1-020-00337 -8.additional file 1. table s1 . cytokine concentrations in peripheral blood of asthma and control subjects (all tested cytokines). table s2 . bal cytokine concentrations in asthmatics (all tested cytokines).additional file 2. figure s1 . comparisons of asthma patient subgroups distinguished on the basis of roc curve analysis.additional file 3. figure s2 . comparisons of h3cit-low vs. h3cit-high asthma patients. asthma patients were subdivided into h3cit-high and h3cit-low groups using blood h3cit value of the 75th percentile as the cut-off point (22. 58 ng/ml). key: cord-332053-df44guu7 authors: malka, jonathan; covar, ronina; faino, anna; fish, jennifer; pickering, paige; ramamoorthy, preveen; gleason, melanie; spahn, joseph d. title: the effect of viral infection on exhaled nitric oxide in children with acute asthma exacerbations date: 2015-07-26 journal: j allergy clin immunol pract doi: 10.1016/j.jaip.2015.05.029 sha: doc_id: 332053 cord_uid: df44guu7 background: fraction of exhaled nitric oxide (feno) level is used as an aid in the diagnosis and management of chronic asthma. its role in acute asthma remains to be studied. objective: to determine whether feno levels are elevated in children with asthma exacerbations compared with baseline, and whether there is a difference in feno levels based on pcr positive (+) (respiratory virus isolated by pcr analysis) versus pcr negative (−) (respiratory virus not isolated by pcr analysis) status. methods: children with a previous feno level measurement while stable and who presented to an urgent care facility with an asthma exacerbation were enrolled. feno levels, spirometry, and nasal swabs for viral pcr were obtained at the time of the exacerbation and following a course of prednisone. data were available on 66 children. linear mixed models were used to regress the outcomes of interest (fev(1), fev(1)/forced vital capacity, forced expiratory flow at 25% to 75% of forced vital capacity, and natural log feno) on detected virus (yes/no), visit (baseline, exacerbation, follow-up), and the interaction between the detected virus and visit. results: compared with baseline, higher feno values and lower lung function were found at the time of an exacerbation. a respiratory virus was detected in 59% of the exacerbations. the interaction between pcr (+) and pcr (−) groups and visit on log feno was marginally significant (p = .07). there was no difference in log feno between the pcr (+) and pcr (−) groups at baseline, while higher log feno was found in the pcr (−) group at the time of exacerbation and following prednisone (p = .05 and .001, respectively). conclusions: higher feno concentration in pcr (−) exacerbations suggests an eosinophilic predominance in nonviral compared with viral exacerbations. the effect of viral infection on exhaled nitric oxide in children with acute asthma exacerbations jonathan malka, md a,b , ronina covar, md c,d , anna faino, ms e , jennifer fish, cpnp f , paige pickering, bs g , preveen ramamoorthy, md g , melanie gleason, pac b,h , and joseph d. spahn, md b,h aventura, fla; denver and aurora, colo what is already known about this topic? fraction of exhaled nitric oxide (feno) is a tool that can be used to diagnose asthma and to predict a positive response to inhaled steroid therapy, and can help measure adherence with inhaled steroid therapy in patients with chronic asthma. unfortunately, its utility in the management of acute asthma has not been widely studied. what does this article add to our knowledge? this study found that in children with an acute asthma exacerbation, feno levels are elevated compared with baseline levels. in addition, feno levels rise to a greater extent in children who do not have a viral-induced asthma exacerbation, suggesting that eosinophilic inflammation plays more of a role in noneviralinduced asthma exacerbations. last, prednisone was effective in reducing feno levels to their baseline state, with the biggest reduction seen in those with viral infections. how does this study impact current management guidelines? this study suggests that feno is a useful marker of inflammation during an acute asthma exacerbation and that prednisone therapy improves lung function and normalizes feno levels in children with acute asthma regardless of the underlying cause of their exacerbation. background: fraction of exhaled nitric oxide (feno) level is used as an aid in the diagnosis and management of chronic asthma. its role in acute asthma remains to be studied. objective: to determine whether feno levels are elevated in children with asthma exacerbations compared with baseline, and whether there is a difference in feno levels based on pcr positive (d) (respiratory virus isolated by pcr analysis) versus pcr negative (l) (respiratory virus not isolated by pcr analysis) status. methods: children with a previous feno level measurement while stable and who presented to an urgent care facility with an asthma exacerbation were enrolled. feno levels, spirometry, and nasal swabs for viral pcr were obtained at the time of the exacerbation and following a course of prednisone. data were available on 66 children. linear mixed models were used to regress the outcomes of interest (fev 1 , fev 1 /forced vital capacity, forced expiratory flow at 25% to 75% of forced vital capacity, and natural log feno) on detected virus (yes/no), visit (baseline, exacerbation, follow-up), and the interaction between the detected virus and visit. results: compared with baseline, higher feno values and lower lung function were found at the time of an exacerbation. a respiratory virus was detected in 59% of the exacerbations. the interaction between pcr (d) and pcr (l) groups and visit on log feno was marginally significant (p [ .07). there was no difference in log feno between the pcr (d) and pcr (l) groups at baseline, while higher log feno was found in the pcr (l) group at the time of exacerbation and following prednisone (p [ .05 and .001, respectively). conclusions: higher feno concentration in pcr (l) exacerbations suggests an eosinophilic predominance in nonviral compared with viral exacerbations. ó 2015 american academy of allergy, asthma & immunology (j allergy clin immunol pract 2015;3:913-9) key words: childhood asthma; fraction of exhaled nitric oxide (feno); asthma exacerbations abbreviations used ed-emergency department fef 25-75 -forced expiratory flow at 25% to 75% of forced vital capacity feno-fraction of exhaled nitric oxide fvc-forced vital capacity gc-glucocorticoid pcr (þ)-respiratory virus isolated by pcr analysis pcr (à)-respiratory virus not isolated by pcr analysis asthma is a chronic inflammatory disorder most commonly associated with eosinophilic infiltration into the airways and the release of several inflammatory mediators, 1 although other phenotypes of asthma are described, that is, neutrophilic and paucigraniolocytic. fractional exhaled nitric oxide (feno) has been accepted as a noninvasive measure of airway inflammation that can be used in both the diagnosis and the management of asthma. 2, 3 studies have shown feno to be as effective as beta-agonist reversibility and methacholine responsiveness in diagnosing asthma in both children and adults. 4-6 feno levels are positively correlated with bronchial wall inflammation, 7 induced-sputum eosinophilia, [8] [9] [10] and airway hyperresponsiveness. [11] [12] [13] increases in feno are associated with deterioration in asthma control with poor inhaled glucocorticoid (gc) adherence, 2,11 whereas feno levels fall in a dose-dependent manner with inhaled gc treatment. 11, 12 despite enhanced knowledge of feno in chronic asthma, little is known regarding its role in acute asthma. in 1 of 2 recently published studies, feno was not found to be useful in acute asthma because it could be measured only in 68% of the children presenting to the emergency department (ed) with acute asthma, 14 while in the second study, feno failed to distinguish children requiring hospitalization from those who were discharged to home. 15 in neither study were feno levels available at baseline, nor an attempt was made to determine what role viral infections played in feno levels. the aims of this study were 2-fold: to determine whether the feno level is elevated during an acute asthma exacerbation compared with baseline in children with persistent asthma and to determine the influence of viral infections on feno levels in children presenting with an acute asthma exacerbation requiring prednisone therapy. in this prospective cross-sectional study, informed consent was obtained from the parent or guardian and assent was obtained from the child when appropriate. the study was reviewed and approved by the national jewish health institutional review board. the study was performed at the national jewish health urgent care clinic from june 2010 to may 2011. a total of 70 participants aged 7 to 18 years were enrolled. we chose this age group because children of this age can perform adequate spirometry and exhaled nitric oxide measurements. all patients who presented to the urgent care clinic at national jewish health for an acute asthma exacerbation and who had undergone spirometry and feno measurements within the last 6 months when clinically stable (visit 1) were approached to participate in the study (figure 1 ). patients who could not perform either spirometry or feno measurements at the time of the exacerbation were ineligible as were patients who were on or had been treated with prednisone within 1 week before the urgent care visit. children with a history of lung disease other than asthma and patients with a history of vocal cord dysfunction were also excluded from participating in the study. once consent and assent were obtained, participants completed a clinical questionnaire, spirometry, and feno measurement and had a nasal swab obtained for viral pcr (visit 2). urgent care physicians independently directed treatment and determined the participants' dispositions. the treating physicians were not study investigators and the decision to treat with prednisone was at the discretion of the treating physician using treatment algorithms based on the national asthma education and prevention program guidelines. 16 participants who were discharged home were instructed to continue usual controller medications, to take albuterol at a frequency directed by the urgent care physician, and to complete a 5-to 7-day course of oral prednisone (2 mg/kg/d; maximum daily dose 60 mg). all discharged participants were also scheduled for follow-up 1 week later (visit 3). at the follow-up visit, all participants underwent spirometry and had feno levels measured. all participants underwent spirometry with at least 3 acceptable maneuvers. the three highest forced vital capacity (fvc) and fev 1 values were recorded according to the american thoracic society guidelines 17 using a jaeger masterscreen pneumo running jlab 5.20 software (erich jaeger, inc, wurzburg, germany). the data for fev 1 , fvc, and forced expiratory flow at 25% to 75% of forced vital capacity (fef ) were expressed as % predicted using the nhanes iii reference values. 18 the feno level was obtained after spirometry, and before the administration of short-acting beta-agonist therapy. the feno level was measured using the online technique recommended by the american thoracic society with the niox mino system (aerocrine ab, stockholm, sweden). 19 this technique uses a resistive device that provides a constant low expiratory flow rate and vellum closure. the combination of vellum closure and low flow rate ensures accurate measurement of pulmonary-derived exhaled no levels and excludes contamination from nasal no. participants exhale to their residual volume, insert the mouthpiece, inhale to total lung capacity, and then exhale for 10 seconds at a steady rate of 50 ml/s. visual incentives provide feedback for flow rate compliance. the end point of measurement occurred when a plateau for 4 seconds was observed. only 1 measurement was obtained because the repeatability of feno obtained with the niox mino is very high. 20 comparisons between pcr (þ) (respiratory virus isolated by pcr analysis) and pcr (à) (respiratory virus not isolated by pcr analysis) groups at baseline and at the time of an exacerbation were evaluated using independent sample t tests (for normally distributed continuous variables), or wilcoxon rank-sum tests (for variables that were not normally distributed), and using either c 2 tests or the fisher exact test (for small expected numbers) for categorical variables. linear mixed models were used to regress the outcomes of interest (fev 1 , fev 1 /fvc, fef 25/75 , and natural log feno) on detected virus (yes/no), visit (baseline, exacerbation, follow-up), and the interaction between the detected virus and visit. the interaction was the main predictor of interest in the models, and was kept in the model even if it was not statistically significant to allow for model flexibility. covariates of interest for adjusted models were season (winter, spring, summer, and fall) and inhaled gc therapy (yes/no), and also sex, weight, height, and race (hispanic, african american, or caucasian) for the adjusted feno model. backwards selection using a p-value cutoff of .15 was used to remove insignificant covariates. final adjusted models included season as a covariate. in addition, the adjusted feno model contained age and race (hispanic, african american, or caucasian) as covariates. all models contained a random intercept. to account for repeated measures and unequal times between visits across subjects, a spatial power covariance structure based on days from exacerbation was used. all analyses were done in sas version 9.4. plots were generated in r version 3.1.0. between june 2010 and may 2011, 70 participants were enrolled (table i) . five subjects did not return for visit 3 and were not included in the analysis. the mean age was 11 ae 3.2 years, 67% were male, 88% were atopic (presence of !1 positive skin test result to an aeroallergen), and 31% were obese. fortythree percent of the enrolled children were caucasian, 38% were hispanic, and 18% were african american. fourteen percent carried the diagnosis of mild-persistent, 67% moderatepersistent, and 18% severe-persistent asthma. seventy-five percent of the subjects were on inhaled gc therapy (15% on inhaled gc monotherapy and 60% on combination inhaled gc/long-acting beta-agonist therapy). more than 40% reported having an ed visit for acute asthma in the past year, requiring systemic steroids in the last 6 months, and having a history of hospital admissions for acute asthma. review of medication use at baseline (visit 1) compared with the time of exacerbation (visit 2) found no significant difference in the percentage of study participants on inhaled gc therapy alone or in combination with a long-acting beta-agonist, nor were significant differences found in the inhaled gc dose at visit 1 compared with visit 2. in addition, both feno level and lung function were in the normal range at visit 1 (geometric mean feno level ¼ 20.7 ppb; four of the 70 subjects were missing recorded calendar dates for their visits and were excluded from the mixed models (total of 66 subjects for fev 1 , fev 1 /fvc, and fef 25-75 models). in addition, 2 subjects were missing both baseline and follow-up feno measurements and 1 subject was missing race information (total of 63 subjects for feno models). at visit 2, the subjects had median daytime symptoms of 3 d/wk, nighttime symptoms 3 times a month, and required rescue albuterol for 1-day duration. compared with baseline, a significant increase in log exhaled no (þ0.76), and decrease in lung function (fev 1 % predicted, à24; fev 1 /fvc, à12%;, and fef 25-75 % predicted, à34), was noted at the time of exacerbation (all p values <.001) (tables ii and iii) . at visit 3, a significant decrease in log exhaled no (à0.76) and improvement in lung function parameters (fev 1 % predicted, þ21; fev 1 /fvc, þ9%; and fef 25-75 % predicted, þ29, respectively) (p < .001) were found from the time of exacerbation measurement and after the initiation of prednisone (table iii) . there were no differences between log feno (p ¼ .99), fev 1 % predicted (p ¼ .1), fev 1 /fvc (p ¼ .07), and fef 25-75 % predicted (p ¼ .2) after the initiation of prednisone treatment and baseline measurements. fifty-six percent of the children had evidence for a pcr (þ) exacerbation, with 1 or more respiratory viruses identified by pcr. no differences in patients' demographic characteristics were noted at baseline between children with pcr (þ) versus pcr (à) asthma exacerbations (table i) . the most commonly identified virus was rhinovirus, occurring in 62% of the participants followed by corona virus in 13%, influenza or metapneumovirus in 10%, and parainfluenza in 5%. of the 39 children with positive viral pcr, 11 had more than 1 virus identified at the time of the exacerbation. using unadjusted and adjusted models, changes in the following outcomes (log feno, fev 1 , fev 1 /fvc, and fef were evaluated between pcr (þ) and pcr (à) groups. in the unadjusted log feno model, the interaction between pcr (þ) and pcr (à) groups and visit was marginally significant (p ¼ .06; figure 2 , a). a trend was also found using adjusted analysis (p ¼ .07; figure 2 , b). in both the unadjusted and adjusted models, there was no difference in log feno between the 2 exacerbation groups by pcr viral detection at baseline (or steady state), but higher log feno was found in pcr (à) than in pcr (þ) children at the time of exacerbation and after the initiation of a prednisone course (p ¼ .05 and .001, respectively, from adjusted analysis). no differences were found between pcr (à) and pcr (þ) groups in the measures of lung function studied across visits. in this study of children with asthma, we sought to determine whether feno levels were elevated during acute asthma exacerbations. we also sought to determine the role pcr (þ) exacerbations had on feno levels and, last, we sought to determine the effect of prednisone on feno levels and whether there were differences in response to prednisone based on whether the exacerbation was pcr (þ). we found feno levels to rise significantly during an acute exacerbation of asthma, with the biggest increase noted in pcr (à)-associated exacerbations. following a short course of prednisone therapy, feno levels fell to near baseline levels, with the greatest reduction in pcr (þ) exacerbations. few studies have sought to evaluate feno levels in acute asthma. lanz et al 21 found feno levels to be elevated in children with acute asthma compared with levels in atopic children without asthma and normal control children and following a course of prednisone, feno levels fell to those of controls without asthma. limitations of this study included the small number of children studied and the lack of preexacerbation feno levels. kwok et al, 14 using a tidal breathing technique to assess feno levels in children presenting to the ed with an asthma exacerbation, found that only 68% of the children were able to successfully perform the maneuver. of those who were able to provide an adequate sample, no differences were found in feno levels among those with mild, moderate, and severe exacerbations. this study was limited by the technique used to measure feno levels and the lack of baseline feno levels. nelson et al 15 sought to determine whether feno levels at the time of an ed visit could predict children requiring hospitalization for acute asthma and found that feno levels could not distinguish children requiring hospitalization from those who were discharged to home. this study was limited by the small number of children who required hospitalization compared with those who were discharged to home. our study is novel in that we collected baseline, exacerbation, and postprednisone feno levels in addition to attempting to determine the etiology of the acute asthma exacerbation. we found feno levels to be the highest in children with acute asthma exacerbations that were not associated with viral infections [pcr(à)]. in this group of children, the exacerbation was likely allergen-driven. in this situation, the offending allergen triggers both immediate and late-phase allergic responses, leading to bronchoconstriction and airway edema as a consequence of figure 2. a, exhaled nitric oxide levels at baseline, during an exacerbation, and following a course of prednisone in unadjusted models. plotted values are mean estimates (ae standard errors) from unadjusted linear mixed models. black circles and dotted lines correspond to the pcr (à) group; gray squares and solid lines correspond to the pcr (þ) group. b, change in exhaled nitric oxide levels from baseline, during an exacerbation, and following a course of prednisone in adjusted models. plotted values are mean estimates (ae standard errors) from adjusted linear mixed models. all models have been adjusted for season (fall); feno model also adjusted for age and race. plotted mean estimates for feno correspond to white subjects of mean age 10.9 years. black circles and dotted lines correspond to the pcr (à) group; gray squares and solid lines correspond to the pcr (þ) group. ppb, parts per billion. preformed mediators of inflammation and the influx of eosinophils. because feno levels serve as a surrogate for eosinophilic inflammation, 6-9 elevated feno levels likely represent an influx of eosinophils and eosinophil-derived airway epithelial damage. feno levels were also increased (albeit to a lesser extent than pcr(à)-driven exacerbations) in pcr (þ) exacerbations of asthma, with this increase coming largely from children infected with rhinovirus. viral-induced asthma exacerbations are often associated with the influx of neutrophils into the airways. 22, 23 in adults with asthma in whom sputum induction was performed at the time of an acute exacerbation, neutrophilic inflammation was noted in 68% of the cases. 24 this may not come as much of a surprise because up to 80% of acute asthma exacerbations are caused by respiratory viruses. [25] [26] [27] past studies in adults with asthma have demonstrated that neutrophil-driven inflammation is not associated with elevated feno levels. 28 the mechanisms by which viral infections contribute to changes in airway inflammation and altered physiology that result in asthma exacerbations remain incompletely understood. 29 message et al 30 addressed this issue by inoculating those with asthma and healthy controls with human rhinovirus. both groups developed respiratory symptoms, but those with asthma had lung function impairment and heightened bronchial responsiveness and developed eosinophilic inflammation. unlike respiratory syncytial virus and influenza virus, rhinovirus is unique in that infection in those with asthma results in increased feno levels 31-33 by way of increased inducible nitric oxide synthase expression in airway epithelial cells. 34 indeed, when children with viral-associated exacerbations caused by rhinovirus were excluded from those with other respiratory viruses, feno levels were not elevated. both viral infections and allergic inflammation can damage the airway epithelium, which results in asthma worsening. viralinduced damage to the airway epithelium can lead to enhanced absorption of allergens, resulting in worsening airway inflammation. likewise, damage of the airway epithelium from allergic inflammation may promote viral replication and more severe clinical illness. 29 thus, in our children with pcr (þ) asthma exacerbations, there is likely to be a mixture of both eosinophilic and neutrophilic inflammation, which results in the moderate elevation in feno levels we noted. in contrast, the inflammation underlying pcr (à) exacerbations is more likely to be a purely eosinophil-driven process and as a result, feno levels would be expected to be higher. our study has a number of limitations. first, from a methodological standpoint, it would have been preferable to perform feno measurements before spirometry because spirometry can result in a transient reduction in feno levels. past studies have shown the reduction to be modest (2 ppb or <10%) 35 and unlikely to have significantly altered our results. second, we did not inquire as to whether our patients had recently ingested foods containing high levels of nitrates, or whether they were exposed to household cigarette smoke or were currently smoking cigarettes. ingestion of foods containing high levels of nitrates can cause the feno level to be elevated for up to 15 hours, 36 while current cigarette smoking can reduce the feno levels by 60%. 37 in addition, we reported the fev 1 /fvc ratio as a percentage, as opposed to the fev 1 /fvc percent predicted. because the ratio varies with age and sex, using percentage only misses this information and can give a false sense of abnormalities. another limitation is that we were unable to identify the triggering agent(s) involved in the acute exacerbation in the pcr (à) group. it is possible that these subjects were reacting to inhaled seasonal allergens or newly acquired perennial allergens such as cat or dog dander. alternatively, some of our patients may have had a falsely negative pcr result. last, although we speculate that pcr (à) exacerbations were likely eosinophil driven, we did not perform sputum induction or collect peripheral blood to assess for eosinophilia. in conclusion, feno levels are elevated in acute childhood asthma, with higher levels seen in children with pcr (à) exacerbations. a short course of prednisone resulted in significant reductions in feno levels. future studies are needed to better understand the underlying pathophysiologic differences between pcr (þ) and pcr (à) asthma exacerbations. this is of potential importance because therapy may be altered on the basis of the underlying inflammatory process. by providing optimal therapy at the time of an exacerbation, attenuation of airway remodeling and loss of lung function as a result of the exacerbation may be achieved. mucosal inflammation in asthma asthma end points and outcomes: what have we learned? exhaled nitric oxide reflects asthma severity and control prospective evaluation of the validity of exhaled nitric oxide for the diagnosis of asthma diagnosing asthma: comparison between exhaled nitric oxide measurements and conventional tests elevated exhaled nitric oxide in newborns of atopic mothers precedes respiratory symptoms relationship between exhaled nitric oxide and mucosal eosinophilic inflammation in children with difficult asthma, after treatment with oral prednisolone correlation between exhaled nitric oxide, sputum eosinophils, and methacholine responsiveness in participants with mild asthma safety and application of induced sputum analysis in childhood asthma the predictive value of exhaled nitric oxide measurements in assessing changes in asthma control dose dependent onset and cessation of action of inhaled budesonide on exhaled nitric oxide and symptoms in mild asthma exhaled no and assessment of anti-inflammatory effects of inhaled steroid: dose response relationship airway hyperresponsiveness to mannitol and methacholine and exhaled nitric oxide: a random-sample population study the role of exhaled nitric oxide in evaluation of acute asthma in a pediatric emergency department exhaled nitric oxide levels during treatment of pediatric acute asthma exacerbations and association with the need for hospitalization expert panel report 3: guidelines for the diagnosis and management of asthma. bethesda, md: national institutes of health, national heart, lung, and blood institute standardization of spirometry, 1994 update spirometric reference values from a sample of the general population recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide in adults and children-1999 performance of a new hand-held device for exhaled nitric oxide measurement in adults and children comparison of exhaled nitric oxide, serum eosinophilic cationic protein, and soluble interleukin-2 receptor in exacerbations of pediatric asthma neutrophil degranulation and cell lysis is associated with clinical severity in virus-induced asthma asthma and natural colds: inflammatory indices in induced sputum. a feasibility study determining asthma treatment by monitoring sputum cell counts: effect on exacerbations interleukin-10 gene expression in acute-virus-induced asthma respiratory tract viral infections in inner-city asthmatic adults community study of role of viral infections in exacerbations of asthma in 9-11 year old children exhaled nitric oxide identifies the persistent eosinophilic phenotype in severe refractory asthma role of viral respiratory infections in asthma and asthma exacerbations rhinovirus-induced lower respiratory illness is increased in asthma and related to virus load and th1/th2 cytokine and il-10 production respiratory nitric oxide levels in experimental human influenza relationship between exhaled nitric oxide and airway hyperresponsiveness following experimental rhinovirus infection in asthmatic participants experimental rhinovirus challenges in adults with mild asthma: response to infection in relation to ige rhinovirus infection induces expression of type 2 nitric oxide synthase in human respiratory epithelial cells in vitro and in vivo the effect of spirometry and exercise on exhaled nitric oxide in asthmatic children increased nitric oxide in exhaled air after intake of a nitrate-rich meal acute and chronic effects of cigarette smoking on exhaled nitric oxide conflict of interest: j. malka has received the device and the sensors used in the study from aerocrine; received the reagents used in the study from copan diagnostics, inc; has received consultancy and lecture fees as well as travel support from aerocrine; and has received lecture fees and travel support from thermofisher. r. covar has received research support from the national heart, lung, and blood institute, glaxosmithkline, and boehringer ingelheim. m. gleason has received grant support from the colorado department of public health and environment for school-centered asthma program. j. d. spahn has received the device and sensor used in the study from aerocrine. the rest of the authors declare that they have no relevant conflicts of interest. we acknowledge aerocrine for providing the niox mino and the sensors to perform the nitric oxide measurements. we also acknowledge quiagen, inc, for providing the respiratory viral nucleic kits for the respiratory samples. last, we thank national jewish nursing staff for their unconditional help, as well as dr searing and dr byrne for their efforts in the recruitment of patients. key: cord-254766-585iu5ey authors: tauro, sharyn; su, yung-chang; thomas, sandra; schwarze, jürgen; matthaei, klaus i.; townsend, dijana; simson, ljubov; tripp, ralph a.; mahalingam, suresh title: molecular and cellular mechanisms in the viral exacerbation of asthma date: 2008-08-13 journal: microbes infect doi: 10.1016/j.micinf.2008.07.037 sha: doc_id: 254766 cord_uid: 585iu5ey the aetiology of asthma associated with viral infection is complex. the dynamics that contribute to disease pathogenesis are multifactorial and involve overlapping molecular and cellular mechanisms, particularly the immune response to respiratory virus infection or allergen sensitization. this review summarizes the evidence associated with factors that may contribute to the development or exacerbation of asthma including age, host factors, genetic polymorphisms, altered immune responses, and aspects of viral antigen expression. this review also provides an important perspective of key events linked to the development of asthmatic disease and related pulmonary inflammation from human and animal studies, and discusses their relationship as targets for disease intervention strategies. asthma is a chronic, reversible inflammatory disorder of the airways characterized by laboured breathing due to variable and reversible airway flow limitation. asthmatics have sensitive airways that react to stimuli with inflammation, swelling of the airway lining, muscle tightening and mucus production; all of which make breathing more difficult. the symptoms can be one or more of the following: wheezing, coughing, tightness in the chest and shortness of breath. the prevalence or disease burden of asthma varies from country to country. it is estimated that there are approximately 300 million affected individuals worldwide [1] . annual worldwide deaths from asthma have been estimated at 250,000. the highest prevalence of asthma is in the uk, australia, new zealand and ireland [1] . in australia, 12% of children and young adults aged 0e24 years have asthma [2] and expenditure on asthma in 2000 was estimated at aus$693 million [3] . in the usa, 20 million people are affected by asthma and the total direct and indirect costs of asthma exceeded us$11.3 billion in 1998 [4] . the underlying causes of asthma are not well understood but many factors are recognized as contributing to the disease, including an atopic (allergic) disposition (often a family history of allergies and asthma), certain genetic mutations, exertion, irritants (including smoking, indoor and outdoor air pollutants), both inhaled and food allergens (e.g. house dust mites, mould spores, pollens, peanuts, egg), and viral infections [3] . in people with underlying asthma, respiratory viruses frequently trigger exacerbation of the disease, with 80e90% of exacerbations in children associated with respiratory infections [5] and up to two thirds of cases in adults [5] . respiratory viruses are also thought to have a role in people becoming sensitive to allergens and developing asthma [9, 10] . asthma is a multifactorial disease, with the genetics of the host interacting with a variety of environmental triggers. viral infections are one of the environmental triggers, having been implicated both in the induction of the disease and, more frequently, in its exacerbation. a number of viruses are associated with the exacerbation of asthma in children and adults. the most common viruses detected in connection with the symptoms of asthma are rhinoviruses (rv); however, human respiratory syncytial virus (rsv), human metapneumovirus (hmpv), parainfluenza and influenza viruses, adenoviruses and coronaviruses are also thought to contribute to the exacerbation of asthma [5, 6] . the characteristics of the main viruses are listed in table 1 . for some of these viruses, there is evidence from both epidemiological and experimental studies to confirm the role of a viral infection in exacerbating asthma, while for other viruses the evidence is less clear. the immune responses triggered by viral infections and allergens are well established (fig. 1 ). this review focuses on the association between viruses and the exacerbation of asthma and outlines current understanding of the molecular and cellular mechanisms involved. the inflammatory cascade associated with asthma involves mast cells, dc, t cells, eosinophils, macrophages, fibroblasts and neutrophils (table 2) . when the inflammation intensifies, the airways become very sensitive to provoking stimuli and airway hyper-responsiveness (ahr) develops. the mast cells degranulate and they, and other cells, release chemical mediators into the lower respiratory tract that prolong the response and cause contraction of the bronchial smooth muscles (table 2) . these actions, and airway swelling, mucus secretion and inflammation, contribute to the bronchoconstriction and airway obstruction seen in asthma attacks. a number of factors are known to affect the likelihood of asthma being exacerbated in response to a viral infection (fig. 2 ). these factors include the age at which the first viral infection occurs, the gender, genetic makeup of the host, the ability of the virus to persistently infect or to become latent in the host and viral antigens. viral infections that occur early in life appear to have an important role in shaping immunological development. if initial infection occurs early in life, the t helper 1 (th1) response may be weak, allowing the development of stronger th2 responses to challenges later in life. mice initially infected with rsv as neonates were more likely to have a th2 type response upon secondary infection, whereas those first infected when older were more likely to have a th1 type response [7] . one interpretation of these findings is that rsv infection in neonates suppresses the development of the th1 immune response and a th2 response occurs. in contrast, if the initial infection is delayed for several weeks, a th1 immune response is mounted which lacks the pathogenic th2 component associated with asthma. there is some evidence that infection at one stage in life may lead to a reduction in atopy while, at another stage, it toll like receptor tnf-a tumour necrosis factor-alpha may potentiate the emergence of allergies [8] and that early severe rsv infections in infancy leads to allergic asthma later in life [9, 10] . however, this issue is controversial. boys are more likely to have severe asthma than girls; however at puberty (about age 13e14) the ratios reverse and many more adult women are admitted to hospital for asthma than adult men [11] . the reasons for this switch in susceptibility are not known but this observation suggests a potential role for sex hormones in the development of asthma. a predisposition towards developing asthma runs in families, indicating a genetic component to the disease that has been confirmed by studies in twins [12] . specific genes have been associated with asthma in nearly 200 studies, with 64 different genes associated with asthma or atopy identified in one study [13] . some of these genes have repeatedly been found to be associated with asthma, including the th2 cytokines il-4 and il-13, human leukocyte antigen drb1 (hla-drb1), tnf-a, lymphotoxin-alpha (la-a), high-affinity ige receptor (fc3r1a) and the il-4 receptor (il-4r). the gene b2 adrenergic receptor (adrb2) has been associated with asthma severity [13] . other genes associated with atopy and asthma include, for atopy, pattern recognition receptor cd14 (receptor for endotoxins such as lipopolysaccharide (lps)) and granulocytemacrophage colony stimulating factor (gmcsf); for asthma, clara cell secretory protein (cc16), cd14, acyloxyacyl hydroxylase (aoah), tnf-a, leukotriene c4 (ltc 4 ) synthase, il-10 and il-8; and, for asthma severity, adrb2 [14, 15] . host genetics is also thought to affect the severity of viral infections and the type of immune response to the infection. for example, specific alleles of pulmonary surfactant genes have been associated with more severe rsv infections in infants [16] . surfactant proteins line the alveolar surface of the lungs and are essential for normal respiratory function. other genetic variations have been shown to affect the expression of cytokines in response to viral infections. a variation causing an increase in il-8 transcription was found to lead to enhanced susceptibility to rsv induced bronchiolitis [17] and a variant affecting transcription of il-4 was found to be associated with severe rsv disease and elevated levels of ige [18] . similarly, variations in genes for il-10 have been identified, with those people heterozygous for the gene found to be less likely to develop rsv bronchiolitis [19] , and two distinct mutations in the gene for toll like receptor 4 (tlr-4) have been found to be associated with severe rsv bronchiolitis [20] . an association between differences in il-13 genes and severe rsv infection has also been found [21] . environmental factors, such as viral infections, may impact on genetically predisposed individuals to affect the development of asthma and the viral exacerbation of asthma. a number of respiratory viruses have been found to persist in the host, despite the host mounting an immune response. for example, hmpv can persist in the lungs of mice for up to 60 days, despite the presence of neutralizing antibody [22] . in mice, rsv was found to persist in the lungs for more than 100 days, despite normal cytotoxic t-cell responses and normal rsv specific antibodies [23] and viral proteins have been found in guinea pigs 6 weeks after rsv infection, despite the presence of neutralizing antibodies [24] . the evidence about respiratory viral persistence in humans is less clear, with several recent studies finding directly opposing results. a study by wilkinson et al. found that rsv persisted in patients with chronic obstructive pulmonary disease (copd) [25] , while falsey et al. found no rsv persistence associated with copd [26] . studies on viral persistence with the other main virus associated with the exacerbation of asthma, rv, have also produced opposing results. in one study, 95% of adults with an exacerbation of asthma were found to be clear of rv 6 weeks after the exacerbation [27] , whereas a study in children found that more than 40% still had detectable rv after 6 weeks and this viral persistence was associated with more severe acute exacerbations of asthma [28] . a possible mechanism for immune evasion is persistence at a site that avoids immune system surveillance. with respiratory viruses, such a site may be the pulmonary neurons and rsv infection of nerve cells has recently been demonstrated [29] . in addition, a role for cytokine in viral persistence was demonstrated in mice by alvarez and tripp. they showed that the persistent presence of hmpv is associated with increased il-10 expression and weak ctl activity [30] . it is currently not clear whether respiratory viruses persist in the host, despite a functional immune response. further characterization is required to understand the possible relationships between respiratory viral latency, the host's immune responses and the exacerbation of asthma. it is well established that rsv g protein can influence the immune response in murine models. the g protein seems to elicit pre-dominantly a th2 driven response characterized by lung eosinophilia and local production of il-4 and il-5 [31] . prior sensitization with a recombinant vaccinia virus expressing rsv g protein leads to a th2 driven augmented disease, contrasting with the usual th1 response seen in primary viral infections [31] . studies have also shown that the non-structural proteins of rsv and influenza virus are capable of modulating the immune response through their ability to inhibit ifn responses in the infected host [31] . released mediators derived from neural signalling pathways contribute to the bronchoconstriction associated with asthma. studies in humans and animals have shown that an intact nervous system contributes to virus-induced ahr. in a guinea pig model, cutting the vagus nerve reduced airway responsiveness to histamines in animals previously infected with parainfluenza virus [32] . in humans, virus induced ahr was also vagally mediated [33] . in guinea pigs, rats and cats, the efferent, parasympathetic bronchoconstrictor limb of the ). the production of il-12 and the binding of antigen-mhc molecules commit the differentiation of na€ ıve t cells to the th1 cell subset that secretes th1 cytokines including ifn-g. the cytokine contributes to the activation of macrophage (make more il-12), b cells (make igg2a) and cytotoxic t cell (kill infected cells). an ifn-g dominated microenvironment inhibits the development of a th2 cell subset. together, these responses result in the resolution of the infection in the airways. (b) in the early phase of allergen exposure, cross linking of antigen-specific ige on the surface of mast cells results in the activation and release of mediators that cause bronchoconstriction and inflammation. activated mast cells also produce il-4 that commits na€ ıve t cells to the th2 subset as well as b cell isotype class switching to ige production. in addition, antigenic peptide is presented to na€ ıve t cells by apcs in the context of mhc class ii and co-stimulatory signals. in an il-4 dominated microenvironment, this triggers the differentiation of na€ ıve t cells to th2 cell subset that generates th2 cytokines (il-4, il-5, il-10 and il-13). these cytokines are responsible for orchestrating the late phase of the allergic response. il-4 and il-13 contribute to mast cell activation and the synthesis of ige. il-5 is implicated in eosinophilia and is known to stimulate these cells, resulting in degranulation and release of toxic basic proteins (e.g. ecp, mbp). il-10 inhibits apcs, therefore preventing il-12 from initiating a th1 immune response. cough and bronchoconstriction reflexes was enhanced during acute viral illness [32, 34] . acetylcholine is released from the nerve fibres that innervate smooth muscle in the airways and binds to m 3 muscarinic receptors on the smooth muscle and causes bronchoconstriction. this is normally limited because acetylcholine also binds to m 2 muscarinic receptors on neurons that inhibit further release of acetylcholine [35] . dysfunction of these m 2 receptors is thought to contribute to ahr during viral infections [34, 36] . a number of factors are thought to cause this receptor dysfunction including viral neuraminidase [37] , endogenous tachykinins [35] , induced inflammatory cell products, such as eosinophil cationic proteins (ecp) [37] , eosinophil major basic protein (mbp) [38] , ifns from macrophages or macrophage-stimulated t cells or nitric oxide (no) released from virus-activated macrophages [39] . the effects on the m 2 receptor function are transient and normal functions are restored several weeks after resolution of the acute infection [34] . stimulation of the nerve fibres during viral infection augments the release of neuropeptides, including somatostatin, calcitonin gene-related peptide (cgrp) and the tachykinins substance p and neurokinin a. a number of these neuropeptides are associated with symptoms of the exacerbation of asthma. for example, cgrp can cause eosinophilia in rat lungs [40] , substance p and neurokinin a are associated with an increase in eosinophil numbers in the airways [41] , and substance p activates eosinophils and mast cells and enhances the degranulation of eosinophils and the release of histamines from mast cells [42] . cgrp also inhibits the production of th1 cytokines, therefore unbalancing the th1/th2 equation in favour of a th2 response [43] . a role for the neurotrophin nerve growth factor (ngf) in viral induced asthma is suggested by results finding that ngf is increased in rsv infected rats, compared to control animals [44] . ngf up-regulates the expression of the high affinity receptor for substance p (the nk1 receptor) and substance p contributes to the neurogenic inflammation seen in rsvinfected airways [45] . ngf expression in the lungs normally declines as animals age but rsv infection interferes with this decline [44] . ngf may lead to short-and long-term changes in the distribution and development of nerves and changes in the reactivity of sensory nerves in the respiratory tract [44] and may also contribute to ahr, inflammation and the activation of recruited eosinophils and mast cells [46] . in understanding the mechanisms underlying viral exacerbation of asthma, it is helpful to observe models of primary virus infection. respiratory viruses including parainfluenza, influenza and rsv have been shown to induce airway inflammation and lung function changes in rodent models. in rsv infection in mice, airway inflammation and the development of ahr are dependent on the presence of the th2 cytokines il-5 [47] and il-13 [48] and not on ifn-g, the most abundant cytokine produced during rsv infection. in addition, inflammation and lung function changes in this model depend on cd8 þ t cells [49] . taken together this suggests that type 2 cytokine producing cd8 þ t cells may drive virus induced reactive airway disease. further, respiratory viral infections lead to a marked expansion of mature dc in the lung [50] . these mature lung dc have a strong capacity to activate both na€ ıve and memory t cells and to induce their proliferation. in a model of influenza infection, maturation of lung dc resulted in strong immunogenicity of an otherwise non-immunogenic antigen [50] . increases in numbers of lung dc, which arise from local precursors in the lung, outlast the resolution of disease in rsv infection [51] . importantly, pulmonary dc can stimulate t-cell responses in the lung in situ without migration to the regional lymph nodes, favouring th2 and tc2 responses [52] . these observations suggest that respiratory viral infections lead to a prolonged period of increased antigen presentation in the airways resulting in de novo and memory t-cell responses not only to the virus but also to unrelated antigens including allergens. in addition to studies of primary infections, models studying the interactions between respiratory viral infections and allergen sensitization are essential in understanding the mechanisms of virus induced asthma exacerbations. many small animal models were designed to reveal the pathogenic mechanisms behind the enhancement of allergic sensitization by respiratory virus infections; the increased airway inflammation and responsiveness resulting from allergic airway sensitization following respiratory viral infection and, in those with established allergic airway sensitization, the increased airway inflammation and responsiveness due to respiratory viral infections. these studies show that the immune responses to allergen sensitization and respiratory viral infections interact to cause persistent inflammation and ahr, symptomatic of the asthmatic response (fig. 2) [53] . many studies have been done in animals sensitized to different allergens and then infected with respiratory viruses, a model that mimics viral exacerbation of asthma in sensitized individuals. in one study, guinea pigs were sensitized with ovalbumin (ova) and challenged with rsv and those that underwent both treatments were found to have more severe symptoms of ahr and inflammation (fig. 3) [53] . similar results were also found in mice sensitized to ova and then infected with rsv [54] , mice sensitized to ova and challenged with murine cytomegalovirus [55] , and mice sensitized to the house dust mite dermatophagoides farinae then infected with rsv [56] . experiments have been performed to determine the contribution of released inflammatory mediators on ahr following viral infection. il-4 is important in the exacerbation of asthma but the response is not solely dependent on il-4 and il-5 has been observed to increase in virally infected sensitized mice and has been directly associated with the viral exacerbation of asthma [57] . il-10 is thought to be necessary for the development of allergic ahr [58] , however, its role in viral exacerbation of ahr is less certain. the role of il-10 is complex, inhibiting il-5 production, eosinophilic inflammation and chemotaxis but potentially inducing a decrease in th1 cytokine production [59] . mice deficient in il-10 that were both sensitized (to ova) and infected with rsv did develop ahr including eosinophilic inflammation, th2 cytokine production and goblet cell hyperplasia. inhibition of il-13 has been shown to significantly reduce ahr in sensitized and infected mice, to the level of that seen in mice only infected or only sensitized [60] . these factors all appear to contribute in varying extents to the viral exacerbation of asthma. the cysteinyl leukotrienes (cyslts) such as ltc 4 , ltd 4 and lte 4 are products of activated eosinophils, basophils, mast cells and macrophages. these potent inflammatory mediators have a diverse range of biological activities, including the ability to exacerbate asthma by inducing the contraction of bronchial smooth muscle [61] . ltc 4 has been found at elevated levels in the nasopharyngeal secretions of children during the acute phase of rsv infection, with higher levels in patients with lower respiratory tract involvement than in those with upper respiratory illness alone [62] . lte 4 has been found to be elevated in urine samples collected from patients with asthma exacerbations [63] . cyslt levels have also been found to be increased in the lower airways during rsv bronchiolitis, although their concentrations are lower than those in acute asthma [64] . in mice, rsv infection has been found to produce a marked increase in cyslts in the balf and lung tissue, resulting in the recruitment of neutrophils and lymphocytes into the airways and ahr [65] . cyslts have been found to have multiple effects in animals, including the induction of th2 responses in the lungs through effects on dcs and cytokine generation, the recruitment and activation of cells such as eosinophils and mast cells, and inflammation [63] . interestingly, an lt synthesis blocker prevents the development of rsv induced lung function changes in mice [66] and montelukast, a cyslt antagonist, seems to reduce post-bronchiolitis wheeze in small children [67] . bronchial reactivity to stimulation by histamine has been found to be increased in asthmatic patients following infection with influenza a virus [68] . human rv infection in adults with mild asthma often has little effect on the lower respiratory tract or lung function [69] ; however, when infection in asthmatics is followed by allergen challenge, ahr and eosinophilia in balf have been observed for up to a month following challenge [70] . deliberate infection with rv has found that asthmatic symptoms tended to peak later during infection and were more pronounced and persistent during the later stages of infection [71] . although nasal and upper respiratory symptoms were similar between asthmatics with high ige levels, asthmatics with low ige levels and control subjects before infection, asthmatics with higher ige levels had more symptoms of lower respiratory inflammation before and during infection. asthmatics with high ige levels also had lower lung function results before infection, while the results for the asthmatics with low ige levels were similar to the controls. however, the lung function tests results did not vary significantly during the course of rv infection [71] . a similar study of people with allergic rhinitis (hay fever) found that rv infection increased ahr and the inflammatory reaction to allergen challenge. before rv infection, most subjects developed only short-term responses to the allergen; however, during rv infection nearly all subjects developed late asthmatic reactions [70] . these late asthmatic reactions were independent of changes in airway reactivity or the size of the immediate response to allergen challenge, and the propensity to develop them persisted for up to 4 weeks after virus infection [70] . a similar study found that the allergic response changed from nearly all subjects having only an immediate response before infection to a majority of subjects having both an immediate and late asthmatic reaction during or following rv infection [72] . changes associated with rv infection and subsequent allergen challenge include an immediate increase in the release of histamine and the recruitment of eosinophils into the airways within a 48 h period [73] . a study of peripheral blood mononuclear cells from patients with atopic asthma and normal controls found that exposure to rv induced the production of ifn-g, il-12, il-10 and il-13 in both groups, with significantly lower levels of ifn-g and il-12 and higher levels of il-10 in the cells from asthmatics than the cells from normal subjects. il-4 was induced only in the asthmatic group and the ifn-g/il-4 ratio was more than three times lower in this group. this suggests that the normal type 1 immune response to rv infection is defective in atopic asthmatic individuals, with infection inducing a th2-immune response similar to their response to allergens [74] . vaccines and therapeutics have the potential for eliminating or reducing the synergy between viral infections and asthma, as well as decreasing unrecognized but associated disease burden and health care costs. vaccination is the mainstay of prophylaxis for respiratory viruses; however, for some viruses such as rsv and rv, developing safe and effective vaccines has been difficult. despite the need for anti-viral drugs as an adjunct to vaccines, few are available that are effective. therefore, novel and new approaches are highly desirable. recently, mahalingam and tindle have demonstrated the efficacy of an hmpv ctl epitope vaccine that triggers a strong th1 immune response which was associated with accelerated viral clearance in a murine model [75] . in addition, rna interference (rnai), a naturally occurring process for controlling gene expression that occurs through a process mediated by short interfering rna (sirna) molecules, has been shown to have the remarkable ability to silence rsv replication both in vitro and in vivo (tripp et al., unpublished data). these approaches can be used to target host cell genes to silence aspects of the inflammatory pathway that include th1 or th2 cytokines, chemokines or proteins that regulate their expression. thus, disease intervention strategies that target the virus and/or host response are rational approaches for breaking the link between the synergy of virus infection and asthma. wright and nhmrc peter doherty fellowships respectively. s.m. acknowledges support from the nhmrc for research on respiratory viral infections (project grant #399701). k.m. acknowledges support from nhmrc programme grant #224207. r.a.t. acknowledges the georgia research alliance for their continued support. j.s. acknowledges support from the wellcome trust (senior fellowship grant #067454). we thank mr timothy lewis for excellent editorial assistance. the international study of asthma and allergies in childhood (isaac) steering committee, worldwide variation in prevalence of symptoms of asthma, allergic rhino conjunctivitis and atopic eczema national health survey: summary of results australian centre for asthma monitoring, in: asthma series 2, woolcock institute of medical research/australian institute of health and welfare data fact sheet: asthma statistics, national institutes of health: national heart, lung, and blood institute community study of role of viral infections in exacerbations of asthma in 9e11 year old children respiratory viral infections as promoters of allergic 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respiratory syncytial virus diseasesusceptibility a common haplotype of interleukin 4 gene il-4 is associated with severe respiratory syncytial virus disease in korean children influence of promoter variants of il-10, il-9 and tumour necrosis factor-alpha genes on respiratory syncytial virus bronchiolitis association between common toll-like receptor 4 mutations and severe respiratory syncytial virus disease association between severe respiratory syncytial virus infection and il-13/il-4 haplotypes human metapneumovirus persists in balb/c mice despite the presence of neutralizing antibodies latency and persistence of respiratory syncytial virus despite t cell immunity persistence of airway hyperresponsiveness and viral antigen following respiratory syncytial virus bronchiolitis in young guinea pigs respiratory syncytial virus, airway inflammation, and fev1 decline in patients with chronic obstructive pulmonary disease detection of respiratory syncytial virus in adults with chronic obstructive pulmonary disease rhinovirus is associated with severe asthma exacerbations and raised nasal interleukin-12 respiration persistence of rhinovirus rna after asthma exacerbation in children respiratory syncytial virus infects neuronal cells and processes that innervate the lung by a process involving rsv g protein the immune response to human metapneumovirus is associated with aberrant immunity and impaired virus clearance in balb/c mice perspective on the host response to human metapneumovirus infection: what can we learn from respiratory syncytial virus infections? in vivo and in vitro studies on the use of the guinea pig as a model for virus-provoked airway hyperreactivity mechanisms of bronchial hyperreactivity in normal subjects following upper respiratory tract infection virus-induced airway obstruction and parasympathetic hyperresponsiveness in adult rats virus-induced asthma attacks parainfluenza virus infection damages inhibitory m2 muscarinic receptors on pulmonary parasympathetic nerves in the guinea pig function of pulmonary m2 muscarinic receptors in antigen-challenged guinea pigs is restored by heparin and poly-lglutamate pretreatment with antibody to eosinophil major basic protein prevents hyperresponsiveness by protecting neuronal ms muscarinic receptor function role of macrophages in virus-induced airway hyperresponsiveness and neuronal m2 muscarinic receptor dysfunction the effect of human calcitonin gene-related peptide on eosinophil chemotaxis in the rat airway clinical and inflammatory responses to exogenous tachykinins in allergic rhinitis substance, p induces histamine release from human pulmonary mast cells differential effects of neuropeptides on cytokine production by mouse helper t cell subsets nerve growth factor and nerve growth factor receptors in respiratory syncytial virus-infected lungs respiratory syncytial virus upregulates expression of the substance p receptor in rat lungs nerve growth factor: the central hub in the development of allergic asthma? il-5 and eosinophils are essential for the development of airway hyperresponsiveness following acute respiratory syncytial virus infection il-13-induced airway hyperreactivity during respiratory syncytial virus infection is stat6 dependent cd8 t cells are essential in the development of respiratory syncytial virus-induced lung eosinophilia and airway hyperresponsiveness influenza virusinduced dendritic cell maturation is associated with the induction of strong t cell immunity to a coadministered, normally nonimmunogenic protein local cd11cþ mhc ii precursors give rise to pulmonary myeloid dendritic cells and are depleted in the process after rsv infection resident lung antigen-presenting cells have the capacity to promote th2 t cell differentiation in situ allergic sensitization increases airway reactivity in guinea pigs with respiratory syncytial virus bronchiolitis prior airway exposure to allergen increases virus-induced airway hyperresponsiveness murine cytomegalovirus infection alters th1/th2 cytokine expression, decreases airway eosinophilia and enhances mucus production in allergic airway disease recurrent respiratory syncytial virus infections in allergen sensitized mice lead to persistent airway inflammation and hyperresponsiveness timing of infection and prior immunization with respiratory syncytial virus in rsv-enhanced allergic inflammation il-10 is necessary for the expression of airway hyperresponsiveness but not pulmonary inflammation after allergic sensitization the failure of il-10 deficient mice to develop airway hyperresponsiveness is overcome by respiratory syncytial virus infection in allergen sensitized/challenged mice respiratory syncytial virus induced airway hyperresponsiveness is independent of il-13 compared with that induced by allergen cysteinyl leukotrienes and their receptors: cellular distribution and function in immune and inflammatory responses the release of leukotrienes in the respiratory tract during infection with respiratory syncytial virus: role in obstructive airway disease recovery of leukotriene e4 from the urine of patients with airway obstruction increased levels of bal cysteinyl leukotrienes in acute rsv bronchiolitis role of cysteinyl leukotrienes in airway inflammation and responsiveness following rsv infection in balb/c mice zileuton reduces respiratory illness and lung inflammation, during respiratory syncytial virus infection, in mice study group on montelukast and respiratory syncytial virus. a randomized trial of montelukast in respiratory syncytial virus postbronchiolitis bronchial reactivity following uncomplicated influenza a infection in healthy subjects and in asthmatic patients rhinovirus-16 colds in healthy and in asthmatic subjects. similar changes in upper and lower airways rhinovirus upper respiratory infection increases airway hyperreactivity and late asthmatic reactions experimental rhinovirus challenges in adults with mild asthma: response to infection in relation to ige experimental rhinovirus 16 infection potentiates histamine release after antigen bronchoprovocation in allergic subjects a common cold virus, rhinovirus 16, potentiates airway inflammation after segmental antigen bronchoprovocation in allergic subjects a defective type 1 response to rhinovirus in atopic asthma cytotoxic t-lymphocyte epitope vaccination protects against human metapneumovirus infection and disease in mice key: cord-260472-xvvfguht authors: papadopoulos, nikolaos g.; konstantinou, george n. title: antimicrobial strategies: an option to treat allergy? date: 2007-01-31 journal: biomedicine & pharmacotherapy doi: 10.1016/j.biopha.2006.10.004 sha: doc_id: 260472 cord_uid: xvvfguht abstract respiratory infections by bacteria and viruses often trigger symptoms of asthma in both adults and children. this observation and subsequent mechanistic studies have demonstrated important interactions among allergens, microbes and the atopic host. the mechanisms responsible for microbe-induced asthma exacerbations are only incompletely understood. a focal point of current research is the inflammatory response of the host following an encounter with a pathogenic microbe, including variations in chemokine and cytokine production and resulting in changes in bronchial hyper-responsiveness and lung function. direct bronchial infection, exposure of nerves with resulting neurogenic inflammation and a deviated host immune response are among the mechanisms underlying these functional disorders. lately, suboptimal innate immune responses, expressed as defective interferon production, have gained attention as they might be amenable to intervention. this review describes the suggested mechanisms involved in the complex interactions between ‘asthmagenic’ microbes, the immune system and atopy, based on in-vitro and in-vivo experimental models and epidemiological evidence. in addition, it provides a synopsis of potential therapeutic strategies either directly against the microorganisms or in respect to the associated inflammation. the prevalence of allergies and asthma has been increasing, especially in children, for the last several decades. modern lifestyle and various environmental factors significantly influence the onset of these complex, chronic disorders. considerable research effort has focused on the potential effects of exposure to pollutants, aeroallergens and infectious agents that could adversely affect lung development or function but also precipitate asthma exacerbations [1] . it is widely recognized that respiratory viral infections are among the most important triggers of asthma exacerbations, both in children and adults [2e4] . the association between upper respiratory viral infections and asthma exacerbations in children was demonstrated almost three decades ago using virus cultures and serological techniques [5] . these findings were subsequently confirmed and expanded using more sensitive techniques for virus detection, such as reverse transcription polymerase chain reaction (rtepcr) assays in well-designed longitudinal studies [6e9]. after implementation of these techniques more than 80% of reported episodes of wheeze or drop in lung function could be attributed to respiratory viral infections [7] , rhinovirus (rv) being the most prevalent virus. similar studies in adults implicate respiratory pathogens in almost half of the exacerbations, rhinovirus being once again the prevailing virus [8, 10, 11] . abbreviations: rtepcr, reverse transcriptionepolymerase chain reaction; rv, rhinovirus; piv, parainfluenza virus; rsv, respiratory syncytial virus; mpv, human metapneumovirus; icam-1, intracellular adhesion molecule-1; ifn-b, interferon-beta; ngf, nerve growth factor; sp, substance p; nk1, neurokinin 1 receptor; mbl, mannose-binding lectin; laba, long-acting b 2 agonists. in addition, there is the evidence for an association between 'atypical' bacterial respiratory pathogens and the pathogenesis of asthma, with mycoplasma pneumoniae and chlamydophila pneumoniae most commonly implicated. however, many studies investigating such a link have been uncontrolled and have provided controversial evidence, mainly reflecting the difficulty in accurately diagnosing infection with these pathogens [12, 13] . taking into account these strong associations, it is conceivable that antimicrobial agents and/or strategies may have the potential to reduce the burden of asthma-associated morbidity. the majority of viruses implicated in the pathogenesis of asthma exacerbations are single-stranded rna viruses, including rv, influenza and parainfluenza (piv) viruses, respiratory syncytial virus (rsv) [3, 7, 14] , coronaviruses [15] and the newly described human metapneumovirus (mpv) [16] and bocavirus [17e19]. among the double-stranded dna viruses adenoviruses have also been involved [20] . in the human respiratory tract, all the above agents are able to produce a spectrum of clinical acute infection phenotypes, ranging from the common cold, croup and acute bronchiolitis, to pneumonia, although each virus has increased propensity for a particular clinical disease (e.g. parainfluenza for croup, rsv for severe bronchiolitis, influenza for pneumonia) [21, 22] . there is some evidence that adenovirus can also cause a latent infection in the human lung [23] . the spectrum of viral-triggered asthma exacerbations and reported viral prevalence may vary according to various factors. the age of the subjects is important [24] , since, overall, the frequency of viral respiratory illness is highest in children up to 4 years of age, gradually declines in teenagers, rises again in young parents exposed to children, re-declines in older adults, while the elderly are again more susceptible [25] . in addition respiratory viral infections have strong seasonal patterns although sporadic cases or nosocomial outbreaks can occur [6,26e30] . the presence or absence of a lipid-containing envelope affects viral survival in the environment [31, 32] . in temperate areas, the enveloped viruses, (e.g. influenza virus, rsv and coronavirus), are, characteristically, prevalent during middle-winter periods, whereas nonenveloped ones, such as rvs, are found most often in spring and fall. rv characteristically produces epidemics soon after children return to school. september epidemics of asthma exacerbations coincide with such increase in the rate of respiratory track infections [28, 29] . there is evidence that different infectious agents may induced asthma exacerbations of varying severity, however, stronger evidence is needed in this respect [6,33e35] . finally, the type of diagnostic test used to identify infection may considerably affect epidemiological results [7, 36] . although rsv remains the agent associated with the majority of cases of bronchiolitis requiring hospitalization, recent evidence suggests that in the community rv is the most prevalent virus at all ages [35] . furthermore, with a few exceptions, studies assessing virus-induced exacerbations of asthma have shown that rvs are the prevalent agents, attributing for 50e80% of virus-confirmed cases or around half of all exacerbations studied [7, 8] . there is also evidence that rv may be more 'asthmagenic' than other viruses (papadopoulos et al, unpublished) . rvs belong to picornaviridae family and probably represent the most abundant pathogenic microorganisms universally. these viruses have small rna genomes are nonenveloped and are capable of surviving on surfaces for several hours under ambient conditions [37] . more than 100 serotypes of rvs are identified and numbered. they are divided into major (90%) and minor (10%) groups depending on their receptor specificity. major rvs attach to the intracellular adhesion molecule-1 (icam-1) while minor group rv binds the low-density lipoprotein receptor. in vitro and in vivo, rv infects the bronchial epithelium and upregulates a range of pro-inflammatory cytokines, chemokines, adhesion molecules, mucins and growth factors, all of which are thought to contribute to lower airway inflammation and consequent effects on lung function [38, 39] . a large number of these mediators are upregulated partly or solely through the transcription factor nf-kb [40e42]. several mechanisms have been suggested as part of the complicated pathways leading from a viral infection to an acute asthma exacerbation. these include direct infection of the lower respiratory tract [43, 44] , induction of local inflammation [38, 41, 45] , increase in bronchial reactivity [43, 44, 46, 47] and induction of bronchial obstruction [48] . local inflammation produced after bronchial epithelial cell infection, neurogenic inflammation induced directly or indirectly through the epithelium, and the immune response of the host are probably the most important. there is increasing evidence that the epithelium of the lower airway does not simply act as a physical barrier. not only it has important regulatory role on the immune response inasmuch it may act as an antigen presenting structure [49] but also contributes to the inflammatory response following a viral infection through the production of cytokines and chemokines (e.g. il-6, il-8, il-11, tnf-a, rantes, gm-scf, eotaxin 1 and eotaxin 2) that attract inflammatory cells involved in asthma exacerbations [50, 51] . the epithelial cells' structure and function is altered after the infiltration with inflammatory cell and the oedema of the airway wall. it has been recently suggested that epithelial cells from asthmatic subjects may have an abnormal innate response to infection by rvs, resulting in increased virus replication and cell lysis compared with cells from healthy normal controls. cells from asthmatic individuals did not produce enough interferon-beta (ifn-b) in response to infection, leading to a reduced apoptosis rate, a consequent increase in viral replication within the cells and finally increased cytotoxicity because of the increased viral load [52] . another proposed mechanism by which acute infections might enhance airway narrowing and hyper-responsiveness is the stimulation of the airway neural network which may lead to neurogenic inflammation [39, 44, 53, 54] . virus-mediated damage to the epithelial layer can expose the dense subepithelial nerve endings, increasing stimulation of sensory nerves by inhaled particles or pro-inflammatory mediators. sensory nerves can directly release neuropeptides which may trigger reflex bronchoconstriction. among the mediators of neurogenic inflammation, nerve growth factor (ngf) may have an important role in the pathogenesis of hyper-responsiveness induced by respiratory viruses. it has been documented that ngf induces a selective up-regulation of the high-affinity neurokinin 1 receptor (nk1) for the tachykinin substance p (sp) [55] . sp is a neuropeptide released from sensory nerves with both bronchoconstrictive effects and immunomodulatory properties which regulates the functions of all white blood cells by affecting their migration and response to various mitogens and allergens [56] . one recent study [57] focused on neural development in the lungs during early life and has proposed that this process is under the control of ngf and its corresponding receptor trka. these factors control the branching of nerves into the developing lungs and are downregulated with age. ngf is strongly upregulated during rsv infections, especially in infants and such overexpression may result in prolonged viral clearance from the infected epithelial cells. finally, another interesting pathway attributes to protracted inflammation, associated with an imbalance in t h 1/t h 2 immune responses. in the lower airways of atopic asthmatic individuals a t h 2 environment predominates. although ifng, and il-12 (t h1 1 cytokines) are produced both in normal and atopic asthmatic subjects, the ratio between ifn/il-4 is considerably reduced in asthmatics compared with normal subjects [58] . furthermore, atopic individuals may have impaired antiviral responses concerning ifn-a [59, 60] or/ and ifn-b [52] or/and ifn-g [50, 61, 62] reduced secretion, something that may result in prolonged bronchial inflammation and increased asthma severity. it has been also demonstrated that this impairment is extended to cell recruitment, since in asthmatic patients there seems to be an increased number of eosinophils, compared with normal individuals which also indicates a difference in the immune response to viral infections [54, 63] . in the natural history of asthma exacerbations, interactions between viral infections and other environmental stimuli are often noted. in several occasions synergistic effects have been shown. this is important as it implies that therapeutic results may occur with treatment of only one of such factors. an association between upper respiratory tract infection and air pollution, especially no 2 , and tobacco smoke exposure, has been observed in children [64e66]. there are several potential mechanisms by which pollutants can exacerbate asthma interacting with respiratory viral infections. direct effects of the pollutant on the airways include epithelial damage and an acquired ciliary dyskinesia; release of pro-inflammatory mediators and increases in ige concentration may follow. indirectly no 2 can also impair local antiviral immunity in the airways [67e69]. recent studies have suggested that viruses and allergens may have a synergistic effect on individuals with asthma [43, 70] . this has been shown for both clinical outcomes [71] (symptoms severity) and in experimental models, where there is evidence that viral infections enhance allergen induced inflammatory responses, eosinophil recruitment, histamine release and late phase airway response [72] . although there is increasing evidence from controlled studies to support an association between atypical bacterial infection and both chronic stable asthma and acute exacerbations of asthma, it is still unclear whether such association is causal or patients with asthma are just more susceptible to colonization and/or infection with atypical bacteria. nevertheless, case reports, but also controlled trials during several decades have suggested that postinfectious wheezing may respond to antibiotic therapy, in particular to macrolides [73, 74] . problems with diagnostic techniques for acute and chronic infections with mycoplasma pneumoniae and chlamydophila pneumoniae have made difficult to conduct and interpret epidemiologic studies of the potential relation between these microorganisms and asthma. to add to this complexity, macrolides and ketolides have been shown to have anti-inflammatory properties [75, 76] , making it difficult to assess the true role of infection. in asthmatic patients, exacerbations can be associated with an increase in antibody titres to chlamydophila pneumoniae or mycoplasma pneumoniae [13, 74, 77, 78] . it has recently been proposed that c. pneumoniae might modulate epithelial cell apoptosis by upregulating both pro-apoptosis and anti-apoptosis genes. it has been suggested that c. pneumoniae-induced inhibition of apoptosis increases the longevity of the host cell, enhancing the survival of c. pneumoniae in patients with chronic asthma [79] . consequently, bronchial infection with atypical bacteria is likely to be associated with increased airway inflammation and thus possibly increasing asthma severity and airway remodelling. although, these organisms are common causes of infection, not all infected patients develop or exacerbate their asthma. this suggests that certain individuals may be genetically predisposed to the chronic effects of atypical bacteria, or be genetically susceptible to infection [52] , rendering them more likely to be persistently infected. only a few studies have investigated the possibility of such susceptibility. in one of them [80] , isotype-specific serologic tests have been performed for c. pneumoniae, and the results have been compared with variations in mannose-binding lectin (mbl), a complement component that is important in clearance of respiratory pathogens. the presence of variant alleles in mbl was associated with increased susceptibility to other types of respiratory infections, significantly increasing the risk of asthma development among children infected with c. pneumoniae. on the other hand, a recent study, detailed below, showed improved outcomes when a ketolide was used in patients with asthma exacerbations [81] . although there has been much progress in understanding the mechanisms of microbe-induced asthma exacerbations, there is a need for the development of new therapeutic agents as well as preventive strategies. both antimicrobial and immune modulators could have therapeutic benefits in this respect. rhinovirus is the key virus accounting for the majority of exacerbations both in children and adults and thus the effective treatment or prevention of that infection would be a major asset in asthma therapy. unfortunately, there is currently no available antiviral therapy of clinical value and vaccination seems to be far away because of the large number of rvs' serotypes (more than 100). although this genetic diversity has hampered vaccine development, modern vaccination strategies (such as recombinant proteins, reverse genetics, replication defective particles and other techniques) may make it feasible to induce cross-reactive neutralizing antibodies to the majority of serotypes and produce an effective vaccine [82] . in contrast to rv, rsv has gained more attention because of its association with severe bronchiolitis in infancy. ribavirin, although initially promising, did not find a place in majority of cases, although still included among possible choices for severe bronchiolitis. passive immunoprophylaxis by monthly administration of anti-f monoclonal antibody (palivizumab) reduces the risk of lower respiratory tract rsv disease and hospitalization in high-risk infants and children [83] . however, it cannot be used widely or in an outpatient basis. no vaccine against rsv is available yet, but studies of intranasal live-attenuated vaccine in children and injected subunit vaccine in elderly persons are ongoing [84] . influenza viruses a and b cause annual outbreaks of illness worldwide. a variety of antiviral agents are available for treatment of influenza. the previous generation of agents, amantadine and rimantadine, have demonstrated clinical efficacy, however, potential side effects and most importantly resistance considerably reduced its usefulness [85e87]. the more recent neuraminidase inhibitors, zanamivir and oseltamivir, are active against both a and b viruses, including the avian influenza a/h5n1 strain [87, 88] , and are promising as important tools against a pandemic. more possibilities for anti-influenza agents are being explored [89] . influenza vaccination is available in two forms: an intramuscular preparation containing formalin-inactivated virus and purified surface antigen and an intranasal spray containing live attenuated viruses [90] . the efficacy of these vaccines is approximately 70e90% in young adults, especially when the vaccine antigen and the circulating strain are closely matched. immunization in healthy working adults is associated with fewer upper respiratory illnesses and fewer visits to physicians' offices [90e93]. however, the use of influenza vaccines in reducing virus-induced exacerbations remain controversial [94, 95] . concerning the other asthmagenic viruses (coronaviruses, adenoviruses, human metapneumovirus, bocavirus), clinically available therapeutic or prophylactic agents are still awaited. as mentioned above, a causal link between deficient interferon-impaired apoptosis and increased virus replication has been demonstrated, suggesting that type i interferons might be useful in the treatment or prevention of virus-induced asthma exacerbations. type i ifns include the numerous ifn-as, ifn-b and the newly identified ifn-ls [96] . in the past, ifn-a2 was shown to be effective when given prior to experimental rv infection [97e99], or as a prophylactic therapy [100, 101] , in a context of natural rv infections, however cost and side-effects have prevented its exploitation in the common cold and/or asthma exacerbation fields. ifn-b has not been very effective in preventing experimental or natural rv colds [52,102e104] , but its effects on asthma exacerbations have not been investigated. promising data have been recently published about ifn-ls [105] . it should be noted that in addition to the antiviral approach, combinations of ifn-a with intranasal ipratropium, or oral naproxen, or chlorpheniramine, or ibuprofen have been tested with promising results, but these were also not commercialized [106, 107] . although quite active in vitro [108] , glucocorticosteroids (gcs) so far have been disappointing in their ability to control symptoms in models of experimental rv challenge of asthmatics [109, 110] and high-dose steroids remain only partially effective at controlling virus-induced exacerbations of asthma [111, 112] . a synergistic effect of gcs with long-acting b 2 agonists (laba) has been shown both in in vitro studies and clinically. labas act via a g protein coupled receptor, activate adenylate cyclase and through the second messenger camp, induce intracellular signalling events affecting a broad range of physiological processes, providing by this way an extra potentiality to enhance the anti-inflammatory properties of gcs when acting together in a combination therapy [113] . studies have confirmed clinical benefit in exacerbations, although the viral origin of these events has not been confirmed [114, 115] . evidence suggests that leukotrienes play a key role in viralinduced respiratory illness [116, 117] . the leukotriene receptor antagonist, montelukast, has proven efficacy in the control of asthma exacerbations in adults [118] , but also in preschool and school children with persistent [119, 120] and intermittent asthma [121] . in addition, montelukast significantly reduced symptoms and exacerbations from respiratory syncytial virus postbronchiolitis in infants without asthma [122] . other agents, including antihistamines [123] and antioxidants [124] can block pro-inflammatory mechanisms induced by virus infections in airway epithelial cells, although in vitro evidence has not been paralleled by convincing clinical data. although viral infections are of major interest, the potential role of antibacterial therapy should also be discussed. a number of different antibacterial agents, namely tetracyclines, macrolides, quinolones, azalides and the ketolide telithromycin have in vitro and in vivo activity against the common atypical bacteria c. pneumoniae and m. pneumoniae [125e128]. clarithromycin, roxithromycin, azithromycin [73, 74, 129, 130] and recently telithromycin [81] , have shown some clinical benefit in patients with chronic stable asthma or acute exacerbations. in the most recently published double-blind, randomized, placebo-controlled study [81] telithromycin (at a daily dose of 800 mg for 10 days) provided improvement in symptoms and lung function among adult patients with acute exacerbations of asthma. the study design did not incorporate an analysis of the mechanism by which telithromycin was associated with improvement, but the data imply a benefit not solely attributable to an antimicrobial effect. it should be noted that resistance need also to be considered before initiation of long term therapy in order to control or to prevent probable bacteria-induced asthma attacks. although promising, many questions should be answered before antibacterial therapies can be proposed for the treatment or prevention of asthma exacerbations. certainly, a combination of the antimicrobial with anti-inflammatory approaches seems reasonable. there is evidence suggesting that a window of opportunity exists between appearance of a viral infection and the initiation of an exacerbation [131] . on the other hand, more controlled studies with macrolides, especially in children, are urgently needed as management of exacerbations is an important unmet need in this age group. global initiative for asthma (gina) and its objectives virusinduced asthma rhinovirus respiratory infections and asthma viruses as precipitants of asthmatic attacks in children the relationship between upper respiratory infections and hospital admissions for asthma: a timetrend analysis community study of role of viral infections in exacerbations of asthma in 9-11 year old children respiratory viruses and exacerbations of asthma in adults rhinovirus and respiratory syncytial virus in wheezing children requiring emergency care. ige and eosinophil analyses the incidence of respiratory tract infection in adults requiring 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in 6-to 14-year-old children: a randomized, double-blind trial. pediatric montelukast study group montelukast reduces asthma exacerbations in 2-to 5-year-old children with intermittent asthma a randomized trial of montelukast in respiratory syncytial virus postbronchiolitis effect of desloratadine and loratadine on rhinovirusinduced intercellular adhesion molecule 1 upregulation and promoter activation in respiratory epithelial cells oxidants in asthma and in chronic obstructive pulmonary disease (copd) activity of gemifloxacin and other new quinolones against chlamydia pneumoniae: a review effects of respiratory mycoplasma pneumoniae infection on allergen-induced bronchial hyperresponsiveness and lung inflammation in mice activity of telithromycin, a new ketolide antibacterial, against atypical and intracellular respiratory tract pathogens review of macrolides and ketolides: focus on respiratory tract infections macrolides for chronic asthma macrolides for chronic asthma effect of inhaled formoterol and budesonide on exacerbations of asthma. formoterol and corticosteroids establishing therapy (facet) international study group key: cord-252012-hdjbxah8 authors: mcerlean, peter; greiman, alyssa; favoreto, silvio; avila, pedro c. title: viral diversity in asthma: immunology and allergy clinics of north america: asthma and infectious disease date: 2010-11-01 journal: immunology and allergy clinics of north america doi: 10.1016/j.iac.2010.08.001 sha: doc_id: 252012 cord_uid: hdjbxah8 asthma exacerbations are precipitated primarily by respiratory virus infection and frequently require immediate medical intervention. studies of childhood and adult asthma have implicated a wide variety of respiratory viruses in exacerbations. by focusing on both rna and dna respiratory viruses and some newly identified viruses, this review illustrates the diversity and highlights some of the uncertainties that exist in our understanding of virus-related asthma exacerbations. peter mcerlean, phd a, *, alyssa greiman, bsc a , silvio favoreto jr, phd, dds b , pedro c. avila, md c asthma is a heterogeneous inflammatory disease of the airways characterized by reversible airway obstruction, airway hyperresponsiveness, inflammatory cell infiltration, thickening of the lamina reticularis, and the accompanying symptoms of chest tightness, wheezing, coughing, and shortness of breath. 1, 2 asthma now affects an estimated 16.4 million adults and 7.0 million children (7.3% and 9.4% of the population, respectively) within the united states 3,4 and is additionally indicated as a "contributing factor" in nearly 7000 deaths each year. 5 whereas chronic asthma results from the daily inhalation and response to allergen (eg, dust, pollen, animal dander) and is by and large successfully managed by the individual, acute asthma attacks or exacerbations are precipitated primarily by respiratory viral infections and frequently require immediate medical intervention. in the united states alone, severe asthma exacerbations lead to over 400,000 hospitalizations each year, at a cost of one-third of the total $11.5 billion in annual asthma-related health care expenditures. 6 although the exact mechanism(s) by which respiratory viral infection causes asthma exacerbation remains to be determined, the respiratory viruses implicated in exacerbations have themselves been largely identified and well characterized ( table 1) . traditionally associated with acute respiratory illness (ari) or symptoms of the "common cold," the respiratory viruses implicated in asthma exacerbations predominantly possess rna genomes with a distinct genome organization (positive [1] or negative [à] sense), virus particle (virion) morphology (enveloped or nonenveloped), host cell receptor interaction, and well-defined annual or seasonal prevalence. the full extent of respiratory virus involvement in exacerbation has recently been revealed in asthma studies with the implementation of molecular methods of viral detection, specifically the reverse transcriptase polymerase chain reaction (rt-pcr). 7, 8 molecular methods of viral detection have superior sensitivity and specificity compared with cell culture-based methods and additionally allow for the improved identification of multiple viruses (and other pathogens), revealing the role dual or multiple infections play in asthma exacerbations. indeed, molecular methods have also been invaluable in identifying new respiratory viruses, the majority of which were described after the emergence of the severe acute respiratory syndrome-associated coronavirus (sars-cov) that prompted research into the etiology of ari. these "newly identified viruses" (nivs) including human metapneumovirus (hmpv; described pre-sars), the human rhinovirus (hrv) species c (hrv-cs), human coronaviruses (hcovs)-nl63 and -hku1, human bocavirus (hbov), and the ki and wu polyomaviruses (kipyv and wupyv) are now the focus of intense research, and their involvement in asthma exacerbations is slowly beginning to be determined. because those respiratory viruses most associated with exacerbations-the hrvs, respiratory syncytial virus (rsv), and hmpv-are reviewed elsewhere in this issue by miller and colleagues, this review discusses some of the other respiratory viruses implicated in childhood and adult asthma exacerbations, including additional rna viruses and those with dna genomes. by also encompassing some of the recently described nivs, this article illustrates the diversity that exists in virus-related asthma exacerbations. influenza viruses (ifvs) are probably the best known of all the respiratory viruses, due to their ability to cause annual epidemics and potential pandemics of serious respiratory disease. 9 ifvs pose the greatest risk of morbidity and mortality to young children and the elderly, and as such have been the focus of repeated public health and vaccination campaigns. however, despite their potential to cause serious respiratory illness in otherwise healthy individuals, most asthma studies describe relatively low levels of ifvs in exacerbations, accounting for approximately 1% to 9% of all virus-related asthma exacerbations (see table 1 ). 7, [10] [11] [12] [13] [14] [15] [16] ifvs constitute the family orthomyxoviridae and are segmented àsingle stranded (ss) rna viruses. the ifv virion has a pleomorphic envelope derived from host cell membranes and incorporates 3 viral encoded surface proteins: hemagglutinin (ha), neuraminidase (na), and matrix protein 2 (m2). under the envelope and encased within the matrix protein (m1), the core of the ifv virion contains the ribonucleoprotein complex, consisting of the viral rna segments, polymerase proteins (pb1, pb2, and pa), and the nucleoprotein (np). 17 there are 3 types of ifvs, -a (ifav), -b (ifbv), and -c (ifcv), which are divided further in subtypes and strains based on the combination of ha and na proteins (eg, h1n1, h3n2). ifav and ifcv have subtypes known to infect both animals (eg, birds, pigs) and humans, whereas ifbv is predominately a human virus. although all types of ifvs can cause ari in humans, ifav and ifbv subtypes and strains are of the most prominent in the annual epidemics or "flu season" that occurs during the winter months. ifvs initiate infection via the ha protein attaching to sialic acid (sa) linked to galactose (gal) sugars on the terminal ends of host cell surface glycans. it has been determined that the ha interaction is dependent on the sialic acid-galactose linkages, with ha from subtypes that infect humans recognizing a2,6 linkages (saa2,6gal), whereas ha from subtypes infecting other animals mostly recognize a2,3 linkages (saa2,3gal). 17, 18 although ifvs are implicated in 1.9% to 6.6% of wheezing illnesses in children 7,10,12,13 and have been detected in 9.8% of asthmatic adults during emergency department (ed) visits, 15 uncertainty remains as to whether ifvs are specifically responsible for the production of asthma exacerbations. 19, 20 the main contention arises from the role that vaccination has played in preventing exacerbations. because, unlike other respiratory viruses, vaccines against ifv subtypes and strains are available and asthmatics frequently have increased vaccination rates due to their at-risk status during flu season, ifv-related exacerbations should be reduced or indeed eliminated among asthmatic children and adults. 21, 22 however, some studies have shown that despite their three-to fourfold greater odds of having an influenza vaccination (as reported by parents), asthmatic children have higher rates of ifv-related hospital visits 23 and that vaccination does not affect the number, duration, or severity of ifvrelated asthma exacerbations compared with placebo. 24 other similar studies have shown that influenza vaccination also fails to reduce severe and fatal complications in adults with asthma and chronic obstructive pulmonary disease (copd). 20 the association of ifvs with exacerbations in vaccinated asthmatics questions the efficacy of seasonal influenza vaccines in this group and also suggests a role for other respiratory viruses in ifv-related exacerbations. if influenza vaccinations are effective, then it is likely that ifv-related exacerbations are caused by infection with another respiratory virus, such as those that peak in prevalence during the same time as ifvs (eg, rsv and hmpv). however, if influenza vaccination of asthmatics fails to reduce ifv-proven exacerbations (ie, by rt-pcr during symptomatic illness) then alternative vaccination strategies may be required to increase efficacy. ensuring that comprehensive respiratory virus testing is employed during both influenza vaccination and asthma studies and that vaccination rates among asthmatics remain high, the contention over vaccination and ifv-related exacerbations will be better clarified. some recent studies focusing on ari suggest that infection with other respiratory viruses, particularly hrvs, may actually provide "protection" against ifv infection. 25, 26 although such claims remain to be fully substantiated, viral competition may be a contributing factor in the relatively low rates of ifv-related asthma exacerbations being reported. it remains to be determined whether the asthmatic phenotype preferentially facilitates infection with respiratory viruses other than ifvs or whether, owing to vaccination in the wider community, the overall prevalence of ifvs is reduced making infection with another "uncontrolled" respiratory virus more likely. the association of ifvs with asthma exacerbation is complicated by the emergence of more virulent pandemic strains, such as the novel 2009 swine-origin ifav h1n1 (s-oiv), which may pose a greater risk to asthmatics than seasonal strains. 27 although the full impact of s-oiv remains to be determined, initial studies have indicated that among both children and adults hospitalized with rt-pcr-identified s-oiv, asthma accounted for the largest percentage (28%) of all underlying medical conditions. 27 however, it is unclear whether s-oiv evokes a specific immune response among asthmatics or whether, owing to increased awareness of this particular strain, asthmatics were more likely to seek medical care when respiratory symptoms initially began. hcovs were initially described in the 1960s in studies aiming to determine the etiologic agent responsible for ari, but gained notoriety after the emergence of sars-cov in 2003. since that time, 2 additional hcovs have been described in ari studies, viral diversity in asthma indicating that there are several hcovs potentially associated with respiratory illness in humans. because of the severity of associated illness, this review excludes sars-cov and focuses solely on the 4 hcovs associated with ari and currently implicated in 1% to 4% of virus-related asthma exacerbations: hcov-oc43, hcov-229e, and the nivs, hcov-nl63 and hcov-hku1 (see table 1 ). 10, 12, 28, 29 hcovs are classified within the family coronaviridae, subfamily coronavirinae, with the genus alphacoronavirus containing hcov-229e and hcov-nl63 and the genus betacoronavirus containing hcov-oc43 and hcov-hku1. 30 hcovs possess a 1ssrna genome, which is associated with nucleocapsid (n) phosphoprotein within the core of a host cell-derived enveloped virion. the hcov virion also comprises 3 viral encoded proteins (s, e, and m), and characterization has indicated that binding to host cell receptors is mediated predominately via the spike (s) glycoprotein, with each hcov employing a specific host cell receptor during infection (see table 1 ). the virion of betacoronavirus also contains a hemagglutinin (he) protein, which is thought to be involved in either host-receptor interactions or release of virus from infected cells. [31] [32] [33] the molecular and receptor interaction differences existing between hcovs are reflected in their seasonal prevalences. studies of ari have indicated that hcov-nl63 can be detected in the spring, summer, or winter whereas hcovs -hku1, -oc43, and -229e infections mainly occur during the autumn and winter months. [34] [35] [36] [37] a recent study of hcovs -nl63, -oc43, and -229e also found fluctuations occurring between their yearly prevalence. 37 the clinical impact of each hcov also appears to vary, but all present the greatest disease burden within the childhood population. 34 in a retrospective study of clinical samples taken over a 20-year period from young children (median age 14.5 months), the percentage of lower respiratory tract illness (lrti; including asthma exacerbations and bronchiolitis) associated with any hcov, hcov-nl63, or hcov-oc43 was estimated to be 4.6%, 2.6%, and 1.9%, respectively. 37 although this study failed to include hcov-hku1 in the testing panels, other studies have associated hcov-hku1 with wheezing illness in children. 34, 38 among asthmatic adults, hcovs have been detected during both ed visits and welldefined episodes of exacerbation prompted by ari. atmar and colleagues 15 reported that hcovs were detected in 21 of 148 ed visits during a 2-year study of 122 asthmatic adults, and kistler and colleagues 39 reported detections of hcovs, oc43, hku1, and nl63 in asthmatic adults with ari, of which hcov-nl63 occurred most in episodes of exacerbations. despite being associated with ari, hcov-229e appears to be the hcov least associated with asthma exacerbations. recent studies using rt-pcr have failed to find hcov-229e in either adult or childhood episodes of asthma exacerbation. 34, 37, 39 although some previous studies detected hcov-229e in asthmatic children, detection occurred with hcov-oc43 and individual hcov detection rates were not reported, despite the investigators using hcov-oc43-and hcov-229e-specific primers and antibodies. 16 another early study of asthmatic adults detected hcov-229e through analysis of paired sera in 12 instances where exacerbation could be objectively measured. however, hcov-299e detections could not be associated with a peak expiratory flow rate (pefr) mean decrease of greater than 50 l/min. 40 the reason for the lack of hcov-229e detections in asthma exacerbations remains unclear. parainfluenza viruses (pivs) are primarily associated with bronchiolitis and laryngotracheobronchitis or croup, in children younger than 4 years of age. 41, 42 pivs also pose a serious risk to immunocompromised individuals, and outbreaks of viral pneumonia among transplant recipients and patients undergoing chemotherapy have occurred. 41, 42 the pivs consist of 4 serotypes (1-4) and 2 subtypes (4a and 4b), and as a group are responsible for 1% to 8% of virus-related asthma exacerbations (see table 1 ). 7, 10, 12, 13, 29, 43 like rsv and hmpv, pivs are nonsegmented àssrna viruses belonging to the family paramyxoviridae. 44 pivs 1 to 3, 4a, and 4b are classified within 2 of the 5 genera of the subfamily paramyxovirinae, genus respirovirus (piv-1 and piv-3) and genus rubulavirus (piv2 and piv-4a and -4b). 45 in contrast to the g glycoprotein encoded by rsv and hmpv, pivs encode a hemagglutinin-neuraminidase (hn) glycoprotein, which interacts with gangliosides (sialic acid-containing oligosaccharides) on target host cells during infection. 46, 47 seasonal and yearly prevalence of pivs have been shown to vary among the serotypes. piv-1, -2, and -4 have the highest prevalence in the autumn and winter months whereas piv-3 occurs mostly in the spring and summer. peaks in piv-1 prevalence have been shown to occur biennially. piv-2 prevalence exhibits some yearly variation and piv-3 is consistently detected each year. piv-4 is the least prevalent of all pivs. 42 although each piv has the potential to cause respiratory illness in any age group, pivs 1 to 3 appear to be more associated with a particular clinical presentation at certain ages. piv-1 is associated with croup in children 1 to 4years old, piv-2 with bronchiolitis in the age group younger than 1 year, and piv-3 is more associated with viral pneumonia in individuals older than 15 years. 42 studies of asthmatic children have revealed that each piv type plays a different role in the production of asthma symptoms. in studies where the incidence of each individual piv is described, piv-1 is detected in 1.4% to 2.9%, piv-2 in 1.4%, piv-3 in 2.9% to 6%, and piv-4 in up to 1.9% of wheezing illnesses. [12] [13] [14] 43 although pivs are largely considered as a single group in adult asthma studies, pivs are still detected in episodes of exacerbation. atmar and colleagues 15 detected pivs 1 to 3 in 16 of 138 episodes of ari in asthmatic adults, with at least one infection each of piv-2 and piv-3 resulting in an ed visit, and nicholson and colleagues 40 detected 5 cases of piv1-3 in asthmatic adults, 3 of which had instances of a pefr mean decrease of greater than 50 l/min. adenoviruses (advs) comprise a large group of dna viruses that are known to cause a wide variety of clinical syndromes including diarrhea, keratoconjunctivitis, and hemorrhagic cystitis. 48, 49 however, advs are best known as a primary cause of ari and, particularly in young children, have been implicated in the production of more severe lrti. fifty-one adv serotypes have been identified, and as a group advs are associated with up to 7% of virus-related asthma exacerbations (see table 1 ). 7, 10, 13, 29, 43 advs are classified within the family adenoviridae, genus mastadenovirus, and divided into species a through g based on biochemical and biophysical properties, hemagglutination reaction, and sequence identity. the adv virion is a nonenveloped icosahedral capsid consisting of 240 hexon and 12 penton polyproteins or capsomers. a long fiber protein protrudes from each of the 12 penton capsomers and contains a terminal "knob" domain, which interacts with host cell receptors. 49 advs have been shown to employ a diverse variety of cell receptors, including coxsackie-adenovirus receptor (car), heparan sulfate glycosaminoglycans, cd86, and an array of cell surface integrins. 50 although each serotype exhibits some variation, advs are detected primarily during the winter and spring months. 10, 48 of all the serotypes, adv-1, -2, -5, and -6 are the viral diversity in asthma most common cause of ari. 51, 52 however, similar to other respiratory viruses (eg, rsv subtype detections reported by lee and colleagues 12 versus matthew and colleagues 14 ) , location can affect the predominance of a given serotype, with adv-4, -7, and -5 being the most frequently detected in ari studies conducted in the united states. 52, 53 as with most respiratory viruses, adv infections occur primarily in infants and children, and it is within these populations specifically that advs have been associated with more serious respiratory illness. 48, 52, [54] [55] [56] in an 8-year study of children younger than 2 years hospitalized with lrti, larranaga and colleagues 55 detected adv at a rate of 8.6% (sole detections), second only to rsv (26.3%), and predominately in patients with pneumonia and wheezing bronchitis (69.8%). the investigators also typed the adv isolates and determined that the species b and c were most frequently detected among their population and that serotype-7h was particularly associated with a longer duration of hospitalization. although this study employed culture-based methods of detection, more recent studies employing pcr for adv detection describe comparable detection rates (0.4%-7%) in episodes of childhood wheeze and asthma exacerbations. 7, 10, 13, 29, 43 an interesting aspect of the association of adv with asthma was described in a study of asymptomatic asthmatic children conducted by marin and colleagues. 56 these investigators reported that adv dna was detected in 78.4% of the asthmatic group but in only 5% of the nonasthmatic control group. this study also described hrv and rsv detection rates in the asthmatic group of 32.4% and 2.7%, respectively, despite none of the participants experiencing respiratory symptoms for the duration of the study (3 weeks). however, a confounding aspect of this study is that the subjects were classified as having mild asthma that was well controlled (fluticasone 100-250 mg daily) in the 6 months before the start of the study. nevertheless, the disparity in viral detection between the asthmatic and control groups may imply some mechanism of either persistence in asthmatics or an association with the long-term compliance of glucocorticoid therapy and inhibition of symptoms during respiratory virus infection. human bocaviruses (hbov) were discovered in 2005 by allander and colleagues 57 in pooled nasopharyngeal aspirates obtained from children with lrti. further characterization in ari-focused studies has revealed that hbov is frequently associated with ari in both children and adults, with detection rates of 1.5% to 19%. [58] [59] [60] [61] in addition, hbov has been associated with wheezing and gastrointestinal illness predominately in children younger than 2 years. 57,61-75 however, the exact role of hbov in respiratory and other illnesses remains ambiguous, with a high overall codetection rate with other respiratory viruses being described (median 42.5%) and the detection of hbov dna in serum, urine, and lymph node samples. 60, 61, 66, 76, 77 hbov is a parvovirus, a single-stranded dna virus of the family parvoviridae, genus bocavirus. 65 the genome, which requires host cell dna polymerases for replication, encodes 2 structural (vp1 and vp2) and 2 nonstructural (ns1 and np1) proteins. 65 although hbov has only recently been propagated in cultured cells and its host cell interactions remain to be determined, 78 initial studies have found that hbov shares similar virion morphology with other parvoviruses, a nonenveloped icosahedral capsid consisting of 60 copies of each structural protein. 79 recently, 2 viruses related to hbov have been identified, namely hbov-2 and hbov-3, but it is unknown whether these are unique viral entities or closely related genotypes of the same virus. 80, 81 while the epidemiology of hbov is still being determined, ari studies have shown that hbov infection occurs primarily during the winter, with a smaller peak in spring. 65, 74, 82 several studies have indicated that hbov is associated with severe respiratory disease in children, particularly in those hospitalized with asthma and other wheezing illnesses. 29, 65 a study conducted by vallet and colleagues 83 of children aged 2 to 15 years hospitalized for asthma detected hbov in 13% of children with asthma exacerbations compared with only 2% in children with stable asthma, suggesting hbov plays a causative role in the development of exacerbations. similar findings were reported by nadji and colleagues, 84 who detected hbov at a rate of 6% in children younger than 10 years with asthma exacerbations, and garcia and colleagues, 69 who reported that wheezing was seen in more than 50% of children in whom hbov was the sole virus detected. although hbov is more often detected in symptomatic than healthy individuals, high levels of codetection with other respiratory viruses, particularly picornaviruses and ifvs, confounds hbov's role in respiratory illness. 25, 65 although a study of infants younger than 12 months hospitalized with bronchiolitis found that dual infections of rsv and hbov were associated with higher clinical severity scores and longer length of hospitalization than infants with a single hbov or hrv and hbov dual infections, 85 most studies have found that coinfection of hbov with another respiratory virus does not alter the severity or duration of associated illness. in 2007, 2 novel human polyomaviruses (pyvs) were described, the ki polyomavirus (kipyv) by allander and colleagues 86 and the wu polyomavirus (wupyv) by gaynor and colleagues. 87 initially identified in nasopharyngeal aspirates obtained from individuals with respiratory illness, further characterization has revealed kipyv and wupyv are detected in 2.6% and 6.2% of ari cases, respectively, suggesting these nivs have a causative role in respiratory illnesses. [88] [89] [90] [91] however, similar to hbov, a high rate of codetection (>80%) with other respiratory viruses and detection in other tissue types currently confounds any direct association of kipyv and wupyv with ari and other illnesses. 92 pyvs are classified in the single genus polyomavirus of the family polyomaviridae, and contain histone-associated circular dsdna genomes encoding 3 structural (vp1, vp2, vp3) and 2 nonstructural (large-t and small-t antigens) proteins. 87, 93 as with some other nivs (eg, hrv-c, hcov-hku1), kipyv and wupyv cannot be grown using current cell culture systems. this drawback has postponed identification of host cell receptor interactions and determination of virion morphology, although the latter is believed to be similar to the nonenveloped icosahedral configuration of other pyvs. 93 kipyv and wupyv characterization in retrospective ari-focused studies has determined that they exhibit a year-round prevalence, with the greatest peaks in detections occurring in the spring, autumn, and winter months. 90, [94] [95] [96] although no studies have yet looked specifically for kipyv and wupyv during episodes of asthma exacerbations, wheezing illness and other more serious lrti have been reported in patients positive for kipyv and wupyv. bialasiewicz and colleagues 90 showed that 15% of kipyv-positive and 23% of wupyv-positive patients had symptoms of bronchiolitis, and payungporn and colleagues 96 found that 11 of 15 combined kipyv and wupyv sole detections originated in children younger than 1 year with pneumonia. however, the overall high codetection rates (35%-80%) described in these studies again indicates the need for further clarification of the role of kipyv and wupyv in respiratory illness. an interesting aspect of the previously described human pyvs is their ability to establish a form of latency (ie, low-level persistent infection) and undergo reactivation when an infected individual's immune system experiences stress (eg, infection, inflammation, or immune suppression). 93, 97 while characterization of the host-virus interactions of kipyv and wupyv is still continuing, sharp and colleagues 98 have proposed that they may also reactivate during illness, as evidenced by mutations in the transcriptional control region of kipyv and wupyv genomes detected in autopsy tissue from immunosuppressed individuals. given our incomplete knowledge about the role of kipyv and wupyv in respiratory illness, it may be plausible that the high codetection rates observed in ari studies are not the result of bona fide dual infections, but rather may be caused by infection with another respiratory virus evoking an immune response that reactivates latent kipyv and wupyv. although sharp and colleagues 98 did not observe the high frequency of transcriptional control region mutations in kipyv and wupyv genomes detected from respiratory samples, a seroepidemiology study by nguyen and colleagues 99 may provide evidence of kipyv and wupyv reactivation during ari. these investigators observed that the proportion of kipyv-and wupyv-seropositive individuals increased at around 4 years of age, a finding that they speculated was the result of kipyv and wupyv exposure during school attendance. however, they conceded that the serum obtained for their study originated from 2 tertiary referral hospitals and was likely from individuals with underlying medical conditions. given that ari represents the most common reason for hospital visits and admissions among school-aged children, and that the incidence of other respiratory virus infections also increases among this age group, the kipyv and wupyv antibody detected may not be that produced in response to initial exposure, but rather antibody produced during kipyv and wupyv reactivation evoked by infection with another ari-causing respiratory virus. indeed, nguyen and colleagues 99 reported that a high proportion of adults were kipyv-and wupyv-seropositive which, considering the nature of the study cohort (ie, hospital-based), may not indicate preexisting immunity but again kipyv and wupyv reactivation during illness. future communitybased studies will no doubt determine when initial kipyv and wupyv exposure occurs and will better elucidate the relationships that exist between ari, viral codetections, and kipyv and wupyv reactivation. this review focuses on some of the less common respiratory viruses currently implicated in both childhood and adult asthma exacerbations. although the respiratory viruses covered here have a lesser, or in the case of nivs, an as yet uncharacterized involvement in the development of exacerbation compared with the "usual suspects" (eg, hrv, rsv, hmpv), they exemplify the diversity that exists in virus-related exacerbations. the implementation of more sensitive methods of virus detection and the identification and characterization of nivs in future asthma studies will further expand our understanding of viral diversity and the 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ki polyomavirus detected in respiratory tract specimens from patients in polyomaviruses ki and wu in children with respiratory tract infection presence of the newly discovered human polyomaviruses ki and wu in australian patients with acute respiratory tract infection identification of the novel ki and wu polyomaviruses in human tonsils no evidence for an association between infections with wu and ki polyomaviruses and respiratory disease philadelphia: lippincott-raven identification of wu polyomavirus from pediatric patients with acute respiratory infections in beijing clinical and epidemiologic characterization of wu polyomavirus infection prevalence and molecular characterization of wu/ki polyomaviruses isolated from pediatric patients with respiratory disease in thailand the role of polyomaviruses in human disease reactivation and mutation of newly discovered wu, ki, and merkel cell carcinoma polyomaviruses in immunosuppressed individuals serologic evidence of frequent human infection with wu and ki polyomaviruses key: cord-309421-725u6dau authors: wechsler, michael e.; colice, gene; griffiths, janet m.; almqvist, gun; skärby, tor; piechowiak, teresa; kaur, primal; bowen, karin; hellqvist, åsa; mo, may; garcia gil, esther title: source: a phase 3, multicentre, randomized, double-blind, placebo-controlled, parallel group trial to evaluate the efficacy and safety of tezepelumab in reducing oral corticosteroid use in adults with oral corticosteroid dependent asthma date: 2020-10-13 journal: respir res doi: 10.1186/s12931-020-01503-z sha: doc_id: 309421 cord_uid: 725u6dau background: many patients with severe asthma continue to experience asthma symptoms and exacerbations despite standard-of-care treatment. a substantial proportion of these patients require long-term treatment with oral corticosteroids (ocs), often at high doses, which are associated with considerable multiorgan adverse effects, including metabolic disorders, osteoporosis and adrenal insufficiency. tezepelumab is a human monoclonal antibody that blocks the activity of the epithelial cytokine thymic stromal lymphopoietin. in the pathway phase 2b study (nct02054130), tezepelumab significantly reduced exacerbations by up to 71% in adults with severe, uncontrolled asthma. several ongoing phase 3 trials (source, nct03406078; navigator, nct03347279; destination, nct03706079) are assessing the efficacy and safety of tezepelumab in patients with severe, uncontrolled asthma. here, we describe the design and objectives of source, a phase 3 ocs-sparing study. methods: source is an ongoing phase 3, multicentre, randomized, double-blind, placebo-controlled study to evaluate the effect of tezepelumab 210 mg administered subcutaneously every 4 weeks on ocs dose reduction in adults with ocs-dependent asthma. the study comprises a 2-week screening and enrolment period, followed by an ocs optimization phase of up to 8 weeks and a 48-week treatment period, which consists of a 4-week induction phase, followed by a 36-week ocs reduction phase and an 8-week maintenance phase. the primary objective is to assess the effect of tezepelumab compared with placebo in reducing the prescribed ocs maintenance dose. the key secondary objective is to assess the effect of tezepelumab on asthma exacerbation rates. other secondary objectives include the proportion of patients with a reduction in ocs dose (100% or 50% reduction or those receiving < 5 mg) and the effect of tezepelumab on lung function and patient-reported outcomes. conclusions: source is evaluating the ocs-sparing potential of tezepelumab in patients with ocs-dependent asthma. source also aims to demonstrate that treatment with tezepelumab in patients with severe asthma is associated with reductions in exacerbation rates and improvements in lung function, asthma control and health-related quality of life, while reducing ocs dose. trial registration: nct03406078 (clinicaltrials.gov). registered 23 january 2018. https://clinicaltrials.gov/ct2/show/nct03406078 conclusions: source is evaluating the ocs-sparing potential of tezepelumab in patients with ocs-dependent asthma. source also aims to demonstrate that treatment with tezepelumab in patients with severe asthma is associated with reductions in exacerbation rates and improvements in lung function, asthma control and healthrelated quality of life, while reducing ocs dose. trial registration: nct03406078 (clinicaltrials.gov). registered 23 january 2018. https://clinicaltrials.gov/ct2/show/ nct03406078 keywords: alarmin, asthma, asthma control, exacerbation, epithelial, oral corticosteroids, source, steroid-sparing, tezepelumab, tslp oral corticosteroids (ocs) are widely used for the maintenance treatment of severe asthma and asthma exacerbations in patients who cannot achieve symptomatic control when treated with inhaled corticosteroids (ics) and long-acting β 2 agonists (labas) [1] . approximately 20-60% of patients with severe or uncontrolled asthma require long-term treatment with ocs as an additional asthma controller medication [2] . although ocs have been shown to be effective in controlling airway inflammation in asthma, chronic use (≥ 6 months) is associated with potentially debilitating side effects including, but not limited to, metabolic disorders (e.g. diabetes) [3, 4] , osteoporosis [5] , adrenal insufficiency [3] , pneumonia [6] , cardiovascular adverse events, cataracts and weight gain [7] . ocs-related complications are dosedependently associated with long-term (≥ 6 months) ocs use at daily doses as low as 5 mg or less of prednisolone (or an equivalent dose of another corticosteroid) [8] . long-term exposure to systemic corticosteroids is associated with increased costs and healthcare resource utilization in patients with severe asthma [2] . therefore, asthma treatments that allow a reduction in ocs dose or complete cessation of treatment with ocs, while maintaining control of asthma symptoms, would reduce morbidity and improve patient health-related quality of life (hrqol). current biologic treatments (e.g. benralizumab, dupilumab and mepolizumab) may be viable alternative therapies to ocs, and can assist in tapering and discontinuing ocs therapy [9] [10] [11] . these treatments precisely target factors contributing to asthma pathogenesis and severity, such as inflammationpromoting cytokines and interleukins [9, 10, 12] , and are indicated for the treatment of patients with specific severe asthma phenotypes (e.g. eosinophilic or allergic asthma) [13] [14] [15] . targeting an upstream mediator of inflammatory pathways may have a broader effect on airway inflammation, and may provide more effective asthma control in a broader patient population than currently available biologic treatments. thymic stromal lymphopoietin (tslp) is an epithelialderived cytokine (also termed an 'alarmin') implicated in the initiation and persistence of airway inflammation, and is a key upstream regulator of many inflammatory pathways in asthma [16] [17] [18] . expression of tslp is increased in the airways of patients with asthma and correlates with disease severity [19, 20] . tslp is released in response to triggers associated with asthma exacerbations, such as allergens and viruses [21, 22] , and has been reported to be a potential mediator of corticosteroid resistance in patients with severe asthma [23] . therefore, blocking tslp in patients with ocsdependent asthma may potentially reduce tslpmediated corticosteroid insensitivity, permitting reductions in or cessation of ocs treatment. tezepelumab is a human monoclonal antibody (immunoglobulin g2λ) that binds specifically to tslp, blocking it from interacting with its heterodimeric receptor ( fig. 1) [24, 25] . in a proof-of-concept study, inhibition of tslp with tezepelumab reduced early and late bronchoconstriction after inhaled allergen challenge in adults with mild, atopic asthma [25] . in the phase 2b pathway study (clinicaltrials.gov identifier: nct02054130), tezepelumab significantly reduced asthma exacerbations over 52 weeks by up to 71% compared with placebo in patients with severe, uncontrolled asthma, irrespective of baseline biomarker status [24, 26] , and improved lung function, asthma control and patient hrqol [24] . in addition, tezepelumab reduced exacerbations in a subset of patients from pathway who were receiving maintenance treatment (for ≥ 6 months) with ocs [24] . the efficacy and safety of tezepelumab in patients with severe, uncontrolled asthma are being investigated in a number of ongoing phase 3 trials (including source, clinicaltrials.gov identifier: nct03406078; navigator, clinicaltrials.gov identifier: nct03347279; and destination, clinical-trials.gov identifier: nct03706079). in addition, the effect of tezepelumab on airway inflammation is being assessed in the ongoing phase 2 cascade study (clini-caltrials.gov identifier: nct03688074). this article describes the design and objectives of the phase 3 source study, which aims to demonstrate that tezepelumab enables a reduction in ocs use in adults with ocsdependent asthma. fig. 1 mechanism of action by which tezepelumab improves clinical outcomes in patients with asthma. tslp is released from the airway epithelium in response to insults such as viruses, allergens and pollutants, triggering an inflammatory cascade. overexpression of tslp can result in pathologic inflammation that can lead to asthma exacerbations, symptoms, and physiological effects such as bronchoconstriction and airway hyperresponsiveness and remodelling. tezepelumab specifically blocks tslp from binding to its heterodimeric receptor, thereby inhibiting the production of various inflammatory cytokines and cell types. treatment with tezepelumab has thus far been shown to reduce blood eosinophil count, ige, il-5, il-13and feno. the effects of tezepelumab on ocs use will be investigated in source. feno, fractional exhaled nitric oxide; ige, immunoglobulin e; il, interleukin; ilc2, type 2 innate lymphoid cell; ocs, oral corticosteroid; th, t-helper; tslp, thymic stromal lymphopoietin the world). eligible patients must have been receiving ocs for the treatment of asthma for at least 6 months before screening, and must have been taking a stable dose of 7.5-30 mg (prednisone or prednisolone) daily or daily equivalent for at least 1 month before screening. patients must also have been receiving medium-or high-dose ics for 12 months before screening. patients who were receiving medium-dose ics, must have had their ics dose increased to a high dose for at least 3 months before screening. in addition, patients must have been receiving a laba with or without additional controller medications, for at least 3 months before screening. patients who were using additional maintenance asthma controller medications, according to standardof-care practice, were permitted to enter the study if use of these medications had been documented for at least 3 months before screening. patients must also have had at least one asthma exacerbation in the 12 months before screening. patients who had received any marketed or investigational biologic were permitted to enter the study, provided the appropriate washout period was fulfilled (4 months or 5 half-lives, whichever was longer, before visit 1). key additional inclusion and exclusion criteria are shown in table 1 . the total study population was monitored to ensure that approximately 35% of patients had a blood eosinophil count of at least 300 cells/μl at enrolment. no other restrictions on blood eosinophil counts were imposed. the study comprises a 2-week screening and enrolment period, followed by an ocs optimization phase of up to 8 weeks and a 48-week treatment period, which consists of a 4-week induction phase, followed by a 36week ocs reduction phase and an 8-week maintenance phase (fig. 2) . during the optimization phase, the optimized ocs doses (the minimum doses at which asthma control is maintained) will be determined for all patients. asthma control was defined according to the criteria in table 2 . ocs reduction can occur every 2 weeks. in the dosing interval of 7.5 mg to 10 mg dose reductions will be 2.5 mg and in the dosing interval of > 10 mg to 30 mg dose reductions will be 5.0 mg. once the optimized ocs dose is reached, no further ocs dose reductions will be performed during this phase. during the optimization phase, patients whose asthma is controlled with an ocs dose of less than 7.5 mg, or whose asthma control is maintained after three consecutive ocs dose reductions, will be screen failed. the optimized ocs dose will be kept stable for 2 weeks before randomization, and will be considered the baseline ocs dose at start of treatment with tezepelumab or placebo. this dose will also be maintained throughout the 4-week induction phase after the first dose of study treatment (tezepelumab 210 mg or placebo). during the ocs reduction phase of the treatment period, daily ocs doses greater than 10 mg will be reduced by 5 mg every 4 weeks ( table 3 ). doses of 10 mg/ day or less will be reduced by 2.5 mg every 4 weeks. each patient who is eligible for ocs reduction will follow the same tapering or reduction schedule. after 4 weeks at a dose of 2.5 mg/day, a further reduction to 0 mg/day will be considered. however, if, in the judgement of the investigator, ocs dose reduction should be more gradually tapered, dose reductions of 1-1.25 mg/day every 1-4 weeks will be considered. patients who do not meet the asthma control criteria for continued down-titration ( table 2 ) will return to the previous effective dose (i.e. • men or women, 18-80 years old, weight ≥ 40 kg at visit 1 • documented physician-diagnosed asthma for ≥ 12 months before visit 1, and receiving medium-or high-dose ics (as per gina 2017 guidelines [1]) for 12 months before visit 1 • documented physician-prescribed laba and high-dose ics (total daily dose corresponding to fluticasone propionate > 500 μg dry powder formulation equivalent) for ≥ 3 months before visit 1 • additional maintenance asthma controller medications (e.g. lama, ltra, theophylline, secondary ics and cromones) are permitted if documented for ≥ 3 months before visit 1 • received ocs for the treatment of asthma for ≥ 6 months before visit 1 and receiving a stable dose of prednisone or prednisolone 7.5-30 mg daily or daily equivalent for ≥ 1 month before visit 1 • morning pre-bronchodilator fev 1 < 80% predicted at either visit 1 or visit 2 • documented historical fev 1 reversibility of ≥ 12% and ≥ 200 ml (15-30 min after administration of four puffs of albuterol/salbutamol) in the 12 months before visit 1 or at visit 1 or visit 2 • history of ≥ 1 asthma exacerbation event ≤ 12 months before visit 1 • received optimized ocs dose for ≥ 2 weeks before randomization • any clinically important pulmonary disease, other than asthma, associated with high peripheral eosinophil counts • any disorder that could, in the opinion of the investigator, affect the safety of the patient or influence study findings • any clinically significant infection requiring antibiotic or antiviral treatment in the 2 weeks before visit 1 or during the enrolment period • helminth or parasitic infection diagnosed in the 6 months before visit 1 that has not been treated with, or is unresponsive to, standard-of-care therapy • history of cancer, hiv, or hepatitis b or c • current smokers or patients with a smoking history of ≥ 10 pack-years • history of chronic alcohol or drug abuse ≤ 12 months before visit 1 • tuberculosis requiring treatment ≤ 12 months before visit 1 • use of any marked or investigational biologic agent in the 4 months or 5 half-lives before visit 1, or any investigational non-biologic agent in the 30 days or 5 half-lives before visit 1 • use of any immunosuppressive medication in the 12 weeks before randomization • history of anaphylaxis after biologic therapy • pregnant, breastfeeding or lactating • if, during the optimization period, asthma control requires an ocs dose < 7.5 mg or > 30 mg and/or if asthma control is still maintained after three consecutive ocs dose reductions fev 1 forced expiratory volume in 1 s, gina global initiative for asthma, hiv human immunodeficiency virus, ics inhaled corticosteroid, laba long-acting β 2 agonist, lama long-acting muscarinic antagonist, ltra leukotriene receptor antagonist, ocs oral corticosteroid the higher dose level before not meeting the asthma control criteria for down-titration) or the investigator may decide to keep the patient on the ocs dose at which the down-titration criteria were not met. in patients who do not meet the asthma control criteria for continued down-titration, the investigator may consider further attempts at dose reduction during subsequent visits. the maintenance phase will assess maintenance of asthma control, while patients continue to take the ocs dose achieved at the end of the reduction phase. patients who experience an exacerbation during this period (after the ocs bolus/burst is completed) will either return to a higher ocs dose than the dose they were receiving, or maintain the same ocs dose throughout the maintenance phase. patients will be followed up for 12 weeks post-treatment. patients were randomized 1:1 to receive subcutaneous tezepelumab 210 mg q4w (administered using a singleuse vial and syringe) or placebo q4w until week 44. neither treatment will be as administered at week 48. patients who complete the treatment period as defined in the study protocol (week 48) are eligible to enrol in a separate extension study (destination); these patients will not attend follow-up visits at weeks 54 and 60. owing to the covid-19 virus pandemic, the source protocol was amended. this amendment was necessary to address the issue of social distancing and the possibility that site visits would be limited. if site visits by patients were not possible, some efficacy and safety data may not have been collected. in addition, patients would not have been able to receive study drug. the amendment specifically allowed for virtual visits (instead of site visits) to collect appropriate efficacy and safety information, and for at-home dosing of tezepelumab or placebo when possible. written, informed consent was obtained from all patients before enrolment into the study. the study is being conducted in accordance with the principles established in the declaration of helsinki and the baseline values for the optimization phase will be calculated from electronic diary records completed for ≥ 10 out of 14 days before visit 2. similarly, baseline values for the reduction phase will be calculated from ≥ 10 out of 14 days of data collected before the randomization visit c the number of nights with asthma-related awakenings requiring rescue medication will be counted from the most recent 7 days of available data ocs oral corticosteroid, pef peak expiratory flow, saba short-acting β 2 agonist international conference on harmonisation guidelines for good clinical practice. a summary of the primary and secondary objectives and endpoints for this study is given in table 4 . the primary objective is to assess the effect of tezepelumab compared with placebo in reducing the prescribed daily ocs maintenance dose. this will be assessed by calculating the percentage reduction from baseline to week 48 in the prescribed daily ocs maintenance dose while not losing asthma control. the key secondary objective is to evaluate the effect of tezepelumab compared with placebo on asthma exacerbations, which will be assessed by the annualized asthma exacerbation rate (aaer). additional, supportive assessments related to exacerbations include time to first asthma exacerbation, rate of asthma exacerbations associated with emergency room or urgent care visits or hospitalizations, and the proportion of patients without any asthma exacerbations. additional secondary objectives related to ocs use include the effect of tezepelumab compared with placebo on the prescribed ocs daily maintenance dose, as assessed by the proportions of patients with 100% reduction and at least a 50% reduction in ocs dose at week 48, and by the proportion of patients with a daily ocs dose of no more than 5 mg at week 48. further secondary objectives include the effect of tezepelumab on lung function (pre-bronchodilator forced expiratory volume in 1 s) and inflammatory biomarkers (including fractional exhaled nitric oxide, blood eosinophils and total serum immunoglobulin e). inflammatory biomarkers will not be measured during the optimization phase and will be measured at selected visits during the reduction phase and the follow-up period; results will be blinded for the study sites and sponsor. healthcare resource use and patient-reported outcomes will be assessed, including asthma control (using the asthma control questionnaire-6), asthma symptoms (using the asthma quality of life questionnaire standardized for patients 12 years and older [aqlq(s)+12]) and hrqol. source will investigate a number of exploratory outcomes, including but not limited to: the effect of tezepelumab on post-bronchodilator lung function; the effect of tezepelumab on patient health status (using st george's respiratory questionnaire [sgrq]); the effect of tezepelumab on circulating biomarkers, including markers of type 2 inflammation; the relationship between baseline inflammatory biomarkers and the effect of tezepelumab on ocs dose reduction and clinical efficacy; and the daily average exposure to systemic corticosteroids (including temporary increase in systemic corticosteroid treatment for worsening of asthma symptoms and exacerbations). some exploratory endpoints will also be evaluated in subgroups according to high and low baseline blood eosinophil counts. throughout the study, serum samples will be collected for the analysis of tezepelumab pharmacokinetics (serum concentrations) and analysis of the potential immunogenicity of tezepelumab, measured by the incidence of antidrug antibodies and characterization of their neutralizing potential. the safety and tolerability of tezepelumab will be evaluated throughout the study by monitoring adverse events, serious adverse events, vital signs, clinical chemistry, haematology and urinalysis parameters, and digital electrocardiograms. a data safety monitoring board (an expert advisory group that will function independently of all other individuals associated with the study) will evaluate cumulative safety and other clinical trial data at regular intervals, and make appropriate recommendations based on available data. the effect of tezepelumab on glucocorticoid toxicity will be assessed using the glucocorticoid toxicity index (gti) [27] . the gti is a composite measure that captures common glucocorticoid toxicities that are sensitive to differing cumulative glucocorticoid doses over time. individual items within the gti are weighted relative to each other for severity, and the gti can measure changes from baseline in glucocorticoid toxicity. statistical analyses of efficacy outcomes will be performed on all patients who receive at least one dose of tezepelumab or placebo, according to randomized treatment assignment (full analysis set), and statistical analyses of safety and anti-drug antibody incidence will be performed according to treatment received. pharmacokinetic analyses will be performed on all patients in the full analysis set who were randomized to receive tezepelumab; samples assumed to be affected by factors such as certain important protocol deviations will not be included (e.g. use of non-permitted medications or receipt of incorrect study medication). for the primary endpoint (the percentage reduction from baseline in daily ocs dose while not losing asthma control at week 48), percentage change from baseline is defined as ([final ocs dosebaseline ocs dose])/baseline ocs dose)*100, where the final dose is the prescribed asthma maintenance ocs dose at visit 18 (week 48) or the dose received when asthma stability was last verified, expressed as dose per day (full details of derivations for specific situations are detailed in the statistical analyses plan, signed off prior to the study unblinding). percentage reductions from baseline will be categorized as: 1) 90-100%; 2) 75-< 90%; 3) 50-< 75%; 4) 0-< 50%; or 5) no reduction or any increase. the primary endpoint will be analysed using a proportional odds (ordinal logistic regression) model, with the ordered percentage reduction category number (1-5) at week 48 as the response variable. treatment and region will be included assess the effect of tezepelumab on asthma symptoms and other asthma control metrics, compared with placebo change from baseline in: • weekly mean daily asd score • weekly mean rescue medication use • weekly mean morning and evening pef • weekly mean number of night-time awakenings • acq-6 score assess the effect of tezepelumab on asthma-related and general health-related quality of life compared with placebo change from baseline in: • aqlq(s)+12 total score • eq-5d-5l score assess the effect of tezepelumab on healthcare resource use and productivity loss owing to asthma asthma-specific resource use (e.g. unscheduled physician visits, use of other asthma medications) wpai + ciq scores assess the effect of tezepelumab on biomarkers change from baseline in feno, peripheral blood eosinophil count evaluate the pharmacokinetics and immunogenicity of tezepelumab pharmacokinetics: serum trough concentrations immunogenicity: incidence of adas aaer annualized asthma exacerbation rate, acq-6 asthma control questionnaire-6 items, ada anti-drug antibody, aqlq(s)+12 asthma quality of life questionnaire standardized for patients 12 years and older, asd asthma symptom diary, bd bronchodilator, eq-5d-5l 5-dimension 5-level euroqol questionnaire, er emergency room, feno fractional exhaled nitric oxide, fev 1 forced expiratory volume in 1 s, ocs oral corticosteroids, pef peak expiratory flow, wpai + ciq work productivity and activity impairment questionnaire and classroom impairment questionnaire as factors in the model. baseline ocs dose will be included as a continuous (linear) covariate in the model. patients who discontinue treatment early will be encouraged to undergo all study-related visits and procedures for the 48-week study period; consequently. in patients who withdraw from the study and are lost to follow-up, the final ocs dose will be defined as one dose level higher than the dose received when asthma stability was last verified (i.e. no change in ocs dose for ≥ 2 weeks). if asthma stability was not verified, the final ocs dose will be the baseline dose. derivations for patients impacted by covid-19 will be documented in the statistical analysis plan. the actual percentage reductions in daily ocs dose at week 48 will also be summarized descriptively and compared between treatments using a wilcoxon rank sum test, stratified by region (van elteren test). binary (responder) endpoints that support the primary objective with regards to ocs dose reduction will be summarized using frequency tables. the odds ratio (tezepelumab:placebo) and 95% confidence interval will be estimated for each endpoint from a logistic regression model with factors for treatment and region, and baseline ocs dose included as a continuous (linear) covariate. other binary endpoints will be summarized and analysed similarly. aaer over 48 weeks (the key secondary endpoint) will be analysed using a negative binomial regression model, with the total number of asthma exacerbations experienced by a patient over the 48-week treatment period as a response variable. treatment, region and history of exacerbations (≤ 2 or > 2 in the previous 12 months) will be included as covariates in the model. the logarithm of the time at risk for exacerbation during the study (excludes duration of an exacerbation and the 7-day period after an exacerbation, during which patients are not considered at risk of exacerbation) will be used as an offset variable in the model. changes from baseline in continuous variables for other endpoints will generally be analysed using a mixed model for repeated measures, which will estimate the effect of treatment at week 48 and the 95% confidence interval for each endpoint. the response variable in the model will be the change from baseline at each scheduled post-randomization visit up to and including week 48, irrespective of whether the patient remained on treatment and/or received other treatments. treatment, visit, region and treatment-by-visit interaction will be included as factors in this model. the baseline value of the corresponding endpoint will also be included in the model as a continuous linear covariate. the overall type 1 error rate will be strongly controlled at the 0.05 level across the primary and key secondary endpoints. to account for multiplicity, a hierarchical testing strategy will be used to test the primary endpoint and then the key secondary endpoint. with approximately 76 patients per treatment group, assuming an odds ratio of 2.75 and the proportional odds assumption, and that the proportion of patients in each dose reduction category is similar to what was observed in the mepolizumab ocs-sparing study [9] , it is estimated that, using the levels of error control described, the power for the primary endpoint will be at least 90% [9] . for the key secondary endpoint (aaer over 48 weeks), assuming a placebo rate of 1.3 exacerbations per year in this study population, a conservative assumption on the dispersion parameter and uniform dropout of 10%, there will be more than 80% power to reject the null hypothesis for rate ratios up to 0.39, using a two-sided 5% significance level. additional statistical analyses required due to covid-19 will be pre-specified in the statistical analyses plan before sponsor unblinding and will be described when the results for this study are reported. regular use of ocs is often required to treat patients with severe asthma that remains uncontrolled despite treatment with ics and other controller medications; however, chronic ocs use is associated with potentially debilitating adverse outcomes [1, [3] [4] [5] . therefore, a treatment that allows a reduction in ocs dose or cessation of ocs treatment, while maintaining asthma control, would greatly improve hrqol for patients with severe, ocs-dependent asthma. a recent study in human blood and airway innate lymphoid cells from patients with asthma has suggested that tslp is a mediator of corticosteroid resistance [23] . blocking tslp with tezepelumab has been shown to be an effective strategy for reducing exacerbations and improving lung function and asthma control in patients with severe, uncontrolled asthma in the phase 2b path way study [24] . therefore, blocking tslp in patients with ocs-dependent asthma may potentially reverse corticosteroid insensitivity caused by tslp, permitting reductions in ocs dose or cessation of ocs treatment. furthermore, in the pathway study, tezepelumab reduced exacerbations irrespective of baseline blood eosinophil counts and levels of other inflammatory biomarkers, suggesting that it may be suitable for the treatment of a broad population of patients with different asthma phenotypes [24] . based on the findings from pathway, tezepelumab was granted breakthrough therapy designation by the us food and drug administration in 2019 for patients with severe asthma without an eosinophilic phenotype, who are receiving ics/laba with or without ocs and additional asthma controllers [28] . the ocs-sparing potential of tezepelumab in patients with different asthma phenotypes will be investigated in source, which has enrolled patients with high and low baseline blood eosinophil counts (66% with a blood eosinophil count < 300 cells/μl). the study population was monitored to ensure that a sufficient number of patients with both high (≥ 300 cells/μl) and low (< 300 cells/μl) blood eosinophil counts were enrolled, in order to adequately understand the effect of tezepelumab in a broad population of patients with ocs-dependent asthma. in a previous study of biologic treatment for asthma, which did not have restrictions on minimum requirements for blood eosinophil counts at baseline, the proportion of patients with high blood eosinophil counts (42%) was comparable with that for source [11] . this study has a similar design and endpoints to previous placebo-controlled, ocs-sparing studies of mepolizumab [9] , benralizumab [10] and dupilumab [11] ; however, its duration (48 weeks) is longer than that of previous studies (24-40 weeks). the ocs reduction period in previous studies of mepolizumab and benralizumab (16-20 weeks) did not prove long enough to allow patients receiving an ocs dose above 25 mg/day and 12.5 mg/day, respectively, to reduce their ocs dose to 0 mg [9, 10] . the longer ocs reduction phase in source (36 weeks) will provide patients with at least one additional opportunity to attempt to reduce their ocs dose if they lose asthma control. ocs dose reductions will occur at 2-week and 4-week intervals during the optimization phase and reduction phase, respectively, which is similar to previous ocs-sparing studies of mepolizumab [9] , benralizumab [10] and tralokinumab [12] . in addition, the maintenance phase is longer in source (8 weeks) than in previous studies of mepolizumab and benralizumab (4 weeks) [9, 10] . this will allow more time to assess the efficacy of tezepelumab in reducing the maintenance ocs dose. additional secondary endpoints (e.g. exacerbation rate, lung function, asthma control and hrqol) and exploratory endpoints (e.g. biomarkers of response to treatment) will be included in source based on greater understanding of the potential effects of tezepelumab following the phase 2b pathway study. source will assess patient quality of life using sgrq in addition to the aqlq(s)+12, which is in contrast with previous ocs-sparing studies that have only used one of these measures [9] [10] [11] 29] . the gti can objectively measure changes in the side effects of corticosteroid therapy over time, and will provide a better understanding of the impact of the ocssparing effects of tezepelumab treatment. patients enrolled in source will have the option to enrol in a double-blind, placebo-controlled, safety extension study (destination, clinicaltrials.gov identifier: nct03706079) for an additional year. patients with severe, uncontrolled asthma who are receiving long-term treatment with ocs represent a population with a significant unmet need for new treatments that obviate the requirement for maintenance ocs therapy, and that provide greater improvements in asthma outcomes than standard-of-care therapies and current biologics. source is evaluating the effect of tezepelumab in reducing ocs use in patients with ocsdependent asthma, irrespective of blood eosinophil count, and aims to demonstrate its ocs-sparing potential and impact on glucocorticoid toxicity. source also aims to provide further evidence of findings from earlier clinical studies with tezepelumab, and to demonstrate its potential to provide patients with reductions in exacerbations and improvements in lung function, asthma control and hrqol, while reducing ocs treatment. systematic literature review of systemic corticosteroid use for asthma management effect of dexamethasone on glucose tolerance and fat metabolism in a diet-induced obesity mouse model high-fat diet and glucocorticoid treatment cause hyperglycemia associated with adiponectin receptor alterations corticosteroid effects on proximal femur bone loss adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study the cumulative burden of oral corticosteroid side effects and the economic implications of steroid use doseresponse relationship between long-term systemic corticosteroid use and related complications in patients with severe asthma oral glucocorticoid-sparing effect of mepolizumab in eosinophilic asthma oral glucocorticoid-sparing effect of benralizumab in severe asthma efficacy and safety of dupilumab in glucocorticoid-dependent severe asthma tropos: designing a clinical trial to evaluate the oral corticosteroid-sparing effect of a biologic in severe asthma long-term safety and efficacy of benralizumab in patients with severe, uncontrolled asthma: 1-year results from the bora phase 3 extension trial liberty asthma quest: phase 3 randomized, double-blind, placebo-controlled, parallel-group study to evaluate dupilumab efficacy/safety in patients with uncontrolled, moderate-to-severe asthma omalizumab for asthma in adults and children human epithelial cells trigger dendritic cell mediated allergic inflammation by producing tslp increased expression of immunoreactive thymic stromal lymphopoietin in patients with severe asthma thymic stromal lymphopoietin is released by human epithelial cells in response to microbes, trauma, or inflammation and potently activates mast cells expression and cellular provenance of thymic stromal lymphopoietin and chemokines in patients with severe asthma and chronic obstructive pulmonary disease thymic stromal lymphopoietin expression is increased in asthmatic airways and correlates with expression of th2-attracting chemokines and disease severity directional secretory response of double stranded rna-induced thymic stromal lymphopoetin (tslp) and ccl11/eotaxin-1 in human asthmatic airways characteristics associated with clinical severity and inflammatory phenotype of naturally occurring virus-induced exacerbations of asthma in adults steroid resistance of airway type 2 innate lymphoid cells from patients with severe asthma: the role of thymic stromal lymphopoietin tezepelumab in adults with uncontrolled asthma effects of an anti-tslp antibody on allergen-induced asthmatic responses tezepelumab treatment effect on annualized rate of exacerbations by baseline biomarkers in uncontrolled severe asthma patients: phase 2b pathway study development of a glucocorticoid toxicity index (gti) using multicriteria decision analysis tezepelumab granted breakthrough therapy designation by us fda accessed 16 corticosteroid tapering with benralizumab treatment for eosinophilic asthma: ponente trial publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to thank gillian hunter (hunterg ltd., glasgow, scotland) for her contribution to the study design and primary endpoint derivation. medical writing support was provided by madeleine wynn, mres, of pharmagenesis london, london, uk, with funding from astrazeneca and amgen inc. gaithersburg, md, usa. 4 authors' contributions mw, gc, åh, ga, tp, ts, egg, jmg, pk and mm all contributed to the design of this study and to the drafting of the manuscript. all authors read and approved the final manuscript. this study was funded by astrazeneca and amgen inc.availability of data and materials not applicable.ethics approval and consent to participate written, informed consent was obtained from all patients before enrolment into the study. the study was conducted in accordance with the principles established in the declaration of helsinki and the international conference on harmonisation guidelines for good clinical practice. not applicable. key: cord-346751-x3gd19kq authors: kelly, frank j.; mudway, ian s.; fussell, julia c. title: air pollution and asthma: critical targets for effective action date: 2020-11-08 journal: pulm ther doi: 10.1007/s41030-020-00138-1 sha: doc_id: 346751 cord_uid: x3gd19kq evidence to advocate for cleaner air for people with asthma is not in short supply. we know that air pollution is associated with the development and worsening of the condition and that mitigating interventions can improve respiratory outcomes. we have clear targets, particularly traffic emissions, especially in urban areas, and plenty of potentially effective actions. road traffic must be reduced, and what remains should be cleaner and greener. urban green spaces, safe cycle networks and wider pavements will promote active travel and leisure time exercise. healthcare professionals must ensure people are aware of their air quality, its impact on asthma and the appropriate behaviour to safeguard health. what remains are realistic policies and effective measures, based on the correct scientific evidence, to be taken forth with political courage and investment so that air pollution no longer contributes to the development or worsening of respiratory ill health. we know that air pollution is associated with the development and worsening of asthma and that improving air quality can result in respiratory health gains. the challenge associated with achieving sustained reductions in air pollutants to reduce new-onset asthma and prevent worsening symptoms in those already afflicted should not be considered an intractable one. we have clear targets and a wealth of opportunities to effectively act and make progress. in this review, we discuss a broad array of interventions, targeted to multiple sectors of society, with the aim to bring multiple public health benefits, in addition to air quality improvements. asthma is a common and chronic condition of the lung in which inflammation causes the bronchi to swell and narrow the airways, leading to episodic periods of wheezing, shortness of breath, cough and chest tightness. it affects around 235 million people worldwide [1] . incidence and prevalence are higher in children, however morbidity and mortality are higher in adults [2] . asthma tends to be a disease of more developed economies where there is some evidence that prevalence may have peaked [3] . in contrast, rates are increasing in low-and middle-income countries where outcomes are much worst [2, 4] . superimposed upon day-to-day symptoms, sufferers experience life-threatening exacerbations lasting from days to weeks, which are caused by a variety of stressors, including respiratory viral infections, allergen exposure and air pollution. there is now consistent evidence that exposure to traffic-related air pollution (trap; particularly nitrogen dioxide [no 2 ]) is associated with an increased risk of developing asthma across the entire life course, and evidence is accumulating for a link between poor indoor air quality and new cases [5, 6] . a recent global (incorporating 194 countries and 125 major cities) estimate of the burden of paediatric asthma incidence attributable to ambient no 2 at a spatial resolution fine enough to resolve intra-urban and near-roadway exposure gradients reported that each year 4 million new paediatric asthma cases could be attributable to no 2 pollution; 64% of these in urban centres (table 1) [7] . the work also estimated that about 97% of children lived, and 92% of new asthma cases attributable to no 2 occurred, in areas with annual average no 2 concentrations lower than the world health organisation's annual air quality guideline of 40 lg/m 3 . whilst there is no known cure for asthma, pharmacological intervention significantly improves symptoms [8, 9] . unfortunately, however, despite international guidelines, treatment compliance rates ([ 80%) required to maintain disease control is often poor, even in countries where treatment is readily accessible [10, 11] . reducing the onset of asthma and safely controlling symptoms through air pollution mitigation strategies, discussed herein, should therefore be regarded a significant component of the overall armamentarium against this debilitating respiratory condition. the studies selected for inclusion in this review were collected through a search of the pubmed database and grey literature using the following keywords: 'asthma' and 'air pollution' or 'traffic' or 'indoor air' or 'particulate matter (pm)' or 'no 2 ' or 'oxides of nitrogen (no x )' or 'diesel' and 'mitigating' or 'interventions' or 'policy' or 'reducing' or 'action' or 'public awareness'. the information included in this review has been chosen to deliver a broad discussion of interventions, targeted to multiple sectors of society, to reduce the burden of air pollution on the prevalence and severity of asthma. this article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors. data from many parts of the world strongly suggest that policies designed to reduce air pollution can improve respiratory outcomes. in california, reductions in pm 2.5 (pm with a diameter \ 2.5 lm) and no 2 between 1993 and 2014 reduced the risk of incident asthma in children by 20% (fig. 1 ) [12] . in a swiss cohort of adults, a decline in pm 10 (pm with a diameter \10 lm) concentrations from 1990 to 2001 was associated with a 9% decrease in the annual rate of decline in forced expiratory volume in 1 s [13] . a follow-up study found that for every 10,000 persons in the community, a further decline in pm 10 from 1991 to 2002 was associated with 137 fewer people with wheeze or shortness of breath [14] . in japan, legislation was passed in 2001 to limit transportation-related emissions. by 2009, decreases in pm 2.5 and no 2 were linked to a lower (0.6-1.1%) prevalence of paediatric asthma [15] . benefits have also been observed following local air quality interventions associated with factory closures and hosting of olympic games. hospital admissions for childhood asthma fell by half, in association with a significant reduction in pm 2.5 , because of a 13-month closure of a steel mill in the utah valley [16] . a 17-day ''alternative transportation strategy'' implemented by the city of atlanta in the summer of 1996 brought about a 23% decrease in peak morning traffic; within 4 weeks of this decrease, there was a 42% reduction in children seeking medical care and a 19% decrease in hospitalisations for asthma [17] . in preparation for the 2008 beijing olympics, the chinese government enacted factory emission and travel restrictions that resulted in pollutant concentrations decreasing by up to 62% [18] . within 2 months, these reductions were linked to an improvement in lung function among both healthy adults and those with asthma [19] as well as 58% fewer asthma-related physician visits [18] . benefits of improving indoor air quality have also been documented. installing less polluting heating appliances (heat pump, wood pellet burner, flued gas) in homes of children with asthma in new zealand reduced symptoms, days off school, healthcare use and visits to a pharmacist [20] . australian schools randomly allocated either to retain unflued gas heaters or have replacement flued gas/electric heaters installed reported a significant reduction in breathing difficulties, chest tightness and asthma attacks in the intervention group [21] . the substantial challenges associated with achieving the sustained reductions in air pollutants necessary to reduce new-onset asthma and to prevent a worsening of symptoms in those already afflicted reflect not only the insidious nature of this environmental insult, but also the wealth and complexity of issues entwined with sub-optimal air quality. europe's car fleets have been transformed to being powered by diesel (emitting more pm and no x than their petrol or hybrid counterparts) [22] . the powering of light and heavy goods vehicles [23] , machinery on the ground [24] and ships in the port area [25] are also dominated by diesel. schools are invariably sited near busy roads and traffic junctions made worse by the 'school run' that is synonymous with idling engines as parents drop off or wait for their children [26] . in 2016, 400 schools within london were in areas exceeding the annual mean no 2 eu limit value [27] . people on low incomes and ethnic minorities tend to be more affected than others by equivalent exposure to air pollutants [28] and are also exposed to some of the worst outdoor and indoor air quality [29, 30] . indoor environments, where most human activities now take place within an enclosed space, are characterised by a chemically diverse and complex air quality [31] . furthermore, unlike tobacco smoke, healthcare professionals have yet to take effective ownership of the problems that air pollution inflicts on society. on a more optimistic note, and one that this commentary attempts to take, such a challenge should not be regarded as intractable, but one in which there plenty of opportunities and ways, some of which are discussed below, to effectively act and make progress. one of the most significant sources of air pollution in urban areas, where 55% of the world's population now resides [32] , is road traffic (exhaust emissions, as well as particles from tyre, brake and road surface wear). it is, as stated earlier, also the source that has repeatedly been shown to cause/worsen asthma. the main traps of concern to health in european cities are pm 2.5 (particularly the fraction derived from the tailpipe) and no 2 . in london in the uk, traffic is responsible for around 80% of no x and 37% of pm 10 and pm 2.5 concentrations at roadside locations [33] . this is not only due to the significant growth in vehicle numbers, but also to failures of vehicle manufacturers to ensure that they meet emissions limits in realworld driving conditions. across 11 markets, representing approximately 80% of global diesel vehicle sales, anenberg et al. [34] reported that over one-half of light-duty and nearly one-third of heavy-duty diesel vehicle emissions are in excess of certification limits. cleaning up the air in heavily populated urban areas to reduce the heavy toll on people with asthma therefore requires a reduction in road traffic as well as a cleaner and greener element to what remains on the road. cleaner fossil-fuelled vehicles require tougher regulations to reduce exhaust emissions, not only for new vehicles, but also afterwards in annual safety/roadworthy tests. commonly cited disincentives aimed at removing the most polluting components of the fleet, i.e. those fuelled by diesel, include levies on fuel, surcharges for parking and the introduction of lowemission zones (lez). however, whilst largescale lezs can deliver improvements in urban air quality, data suggest that, at least in densely populated european cities, more ambitious schemes are required to meet legislative limits and deliver improvements to childhood respiratory health, including asthma symptoms [35] . the introduction and rigorous evaluation of zones with greater reductions in pollutant concentrations are clearly warranted and may benefit from adjuvant clean air zones that introduce no vehicle idling areas, minimise congestion and support active and low-emission travel through the integration of public transport networks, including park-and-ride schemes. the continued development of new technologies by motor manufacturers in producing vehicles that rely on alternative fuels (electricity, hydrogen) coupled with seamless interfaces with sustainable energy suppliers must also be actively encouraged and incentivised. alternatively fuelled vehicles are not however the sole answer to poor air quality since zero-emission road transport does not currently exist. particulate pollution from road traffic not only includes engine emissions, but also an increasing contribution from brake/tyre wear and road surface abrasions [36] . it is noteworthy that the potential of non-tailpipe emissions to elicit health effects is largely ignored at the regulatory level despite links with pulmonary toxicity [37] . to this end, non-tailpipe particulate pollution must be tackled by considering regulation in line with exhaust emissions and innovations in the development of 'safer' tyres, brakes and road surfaces. procurement of appropriate vehicles in the public and commercial sectors is crucially important and nowhere more so than for school buses. data from the usa show that although school bus commutes usually make up only a small part of a child's day, they can contribute up to one-third of a child's 24-h overall exposure to black carbon during a school day [38] . moreover, data support the emission reduction benefits of high-efficiency cabin air filtration system [39] and anti-idling [26] , as well as health benefits associated with changing fuel from diesel to compressed natural gas [40] . it should also be stressed that cleaner road transport will not only emerge from the vehicle itself, but also from practices, such improved energy-efficient driving skills that could be introduced through tests and training programmes. for example, a smooth driving style (vs. frequent stopping and starting) ensures that motorists travel steadily at an optimum speed, thereby reducing fuel consumption and in turn air pollution through reduced exhaust emissions, as well as particles emitted from brake and tyre wear [36, 41] . the safe and efficient movement of people around towns and cities ultimately necessitates fewer vehicles. this can only be achieved through: (1) clean, efficient and expanded public transport systems coupled with car share/club schemes and (2) as much active transport in the form of walking and safe cycling as is feasibly possible. people need to be given more cost-effective and easier alternatives to move through the urban environment, be that on the school run and/or on the commute to work, without necessarily owning a car or taking one out for short journeys. a report by the european court of auditors reveals that commuters in europe are still choosing their cars over public transport, enduring ever-longer journey times into some city centres owing to traffic congestion [42] . cost, convenience and time-efficiency were all factors cited as challenges in persuading citizens to leave the comfort of their cars for other forms of transport. it is likely however that perception and beliefs also come into play, with car ownership construed to be symbols of success and social status [43] . the built environment incorporates multiple components that can influence local air quality and in turn ill health. some examples include neighborhood design (walkability, bikeability, connectivity), housing quality, schools, transport facilities (roads, railways, ports, airports), power plants, industrial facilities, accessibility to shops and green space. cities created prior to the introduction of cars tend to be more densely populated and more walkable compared to newer conurbations, which tend to be less populated and more reliant on cars for transport. a vicious circle often ensues in that the mass use of cars in newer cities often goes hand in hand with inadequate public transport, poor infrastructure for active commuting, lack of green space and higher exposures to air pollution. strategies to clean up the air in cities of all ages should focus on the 'cleaner/fewer vehicles' formula already discussed. a cleaner element should be encouraged by not only providing, but also maintaining, adequate charge points for electric vehicles. fewer vehicles will ensue from siting new buildings in locations near essential amenities, thereby reducing the requirement for motorised travel and thus minimising the exposure of vulnerable/disadvantaged groups to inadequate air quality. this could be achieved by locating new homes for essential workers, schools, nurseries and care homes away from roads and avoiding the creation of configurations such as deep street canyons that encourage dangerous concentrations of air pollution to build up [44] . when air pollution limits are exceeded, local authorities need to act strategically to close or divert roads to reduce the volume of traffic, especially near schools and vulnerable communities. this of course can only be achieved by adequate, accurate and accessible air pollution monitoring programmes. planting trees and the construction of green walls and roofs to create an organic barrier to intercept pm and absorb gaseous pollutants have had mixed results by either improving air quality or in fact worsening it by restricting street ventilation. that the absolute effect of urban greening strategies will depend on factors such street configuration and canopy design means that the appropriate management of urban vegetation (siting, choice of species, maintenance regimes) is critical to maximise potential benefits [45] . with relevance to asthma, any beneficial and cost-effective to these greening strategies should avoid the use of highly allergenic plants. failure to do so risks marginal gains in air quality being offset by a significant increased risk of exposure to known triggers of asthma exacerbations [46] . compared to the growth in the volumes of road traffic in the uk over the last 60 years, active transport (walking and cycling) has been on the decline [5] despite its social, economic and health benefits [47] [48] [49] . well-designed and maintained urban green spaces, coupled with fewer vehicles on the road to permit expanded safe cycle networks, wider pavements and other public areas (as discussed above) will create the much-needed opportunities for active travel. additional mechanisms to promote a step change include mandatory cycle training at schools, cycle-to-work schemes and steps to support cyclists and pedestrians by, for example, providing a choice of routes to avoid highly polluted roads. beyond active transport to reach schools, higher education establishments and workplaces, the provision of pleasant and mixed-activity spaces will also encourage more exercise taken as a form of leisure. a marvellous exemplar is the infamous la ciclovã­a in bogotã¡ that, every sunday between 0700 and 1400 hours, hands 75 miles of its usually choking city streets over to over 1 million cyclists, skaters, walkers, runners and other athletes (fig. 2) [50] . this much-loved programme began in 1974 as a citizen protest that the city was becoming too car-focused, and now attracts city-dwellers of all ages and social backgrounds who exercise alongside each other through the colourful neighbourhoods of columbia's capital city [51] . as one of the world's most successful mass recreation events, it has become one of the city's most famous exports. ciclovã­as have sprung up in numerous south american countries as well as cities in canada and the united states. we need more ciclovã­as around the world to provide a tangible vision of what a city with more cycle paths and fewer cars might look like, not just for weekly recreation, but also how cities could be designed and run differently. in addition, by truly embracing young children, they can create a generation that look at the street from a completely different perspectiveone that feels like an extension of their driveway and is therefore a safe place for recreation in a dense urban metropolis. promoting physical activity in car-free urban spaces is a double positive for asthmatics in reducing trap, increasing exercise and promoting healthier lifestyles and wellbeing. evolving research suggests that structured exercise routines may help improve some aspects of asthma control. indeed, results from several recent systematic reviews and meta-analyses not only strongly support the safety of structured exercise routines in children and adults with asthma, but also suggest such routines favour improvements in asthma symptoms and quality of life [52] . up until relatively recently, air pollution was invariably deemed to be solely an outdoor issue, in the general belief that the confines of an inside space, and particularly one's home, offer protection. there are however unique factors which, when combined, have created challenges to indoor living: increased time spent indoors owing to dramatic changes in the lifestyle and working conditions of modern society [6] ; the transition from natural (wooden floors and woolen carpets) to synthetic (synthetic floor coverings with added stain repellants and flame retardants) materials that have been introduced into indoor spaces [53] ; the construction of energy-efficient-and with this, airtight-homes that lack inadequate ventilation and promote the buildup of air pollutants [54, 55] . in response to these trends and evidence that ill-health, including the severity and/or prevalence of asthma, is heightened by many indoor air pollutants, including no x from gas cooking [56] , cleaning products [57] , formaldehyde [58] , phthalates [59] , allergens [60] , mould [61] and carbon monoxide [62] , a set of recommendations from experts and young people have recently been published [6] . this welcome initiative provides wide-ranging advice for government, local authorities, building and child healthcare professions and the public about the changes that are needed ensure that air quality in homes, nurseries and schools does not pose a health risk to children. there is clearly ample evidence to advocate for cleaner air for people with asthma, but since clear and objective scientific assessments are so crucially important to guide the development of evidence-based public health policies, there remains the need for further cross-disciplinary research into the respiratory health effects of air pollution, as well as the effectiveness of mitigation strategies. for example, the independent effects of no 2 and pm are still unclear and need to be deciphered, especially at a time when uptake of electric vehicles is eliminating no 2 emissions, with little of no impact on pm emissions from tyre and brake wear [63] . another area of uncertainty is the potential of pm from biomass burning to contribute to asthma. this is especially pertinent in the light of the fashionable return of residential wood burning in europe owing to aesthetic appeal and quest to reduce fossil fuel combustion [64] . research themes applicable to indoor spaces that require greater scientific understanding include the benefits of indoor air filtration, placement of building air intake away from sources of air pollution and vegetative/physical barriers between roadways and homes and schools. such areas of research will benefit from the considerable advances in mobile sensors that can be carried by individuals to monitor personal air pollutant exposure, as well by modeled-based approaches using big data. one such exemplar that is the breathe london: wearables study that provided 250 children and 33 teachers with wearable sensors to carry to and from school to characterise london's school children's exposure to air pollution [65] . initiatives such as this one, which gathered 490 million measurements, create unique data sets to determine where children may be exposed to elevated concentrations and which forms of transport are more polluting, and to compare air quality within and surrounding schools. validation studies are also reporting coherent epidemiological trends that support the use of smart phone application (app)-sourced data to examine relationships between asthma symptoms and air quality [66, 67] . these rapidly evolving technologies will enable estimates of personal air pollution exposures for large populations-currently an elusive goal, but a central one to determine health impacts, evaluate exposure sources, detect susceptible populations and identify intervention opportunities. when individuals, especially vulnerable patients with respiratory problems such as asthma and chronic obstructive pulmonary disease, are exposed to such a well-established and preventable cause of ill health and premature death, our public health and healthcare professionals must have the knowledge to provide sound, evidence-based advice. this requires training about air quality and health risks and being equipped with toolkits to screen and identify at risk populations, raise public awareness, influence behavioural change, help prevent and/or control associated disease and take collective action to bring about positive change. defining patient exposure to air pollution can be difficult since sources and composition vary between communities and within households. one way to open up knowledge and awareness would be for primary healthcare workers to simply pose pertinent questions to patients, alongside those already asked about diet, exercise, smoking and alcohol, and document the answers in medical records [68] . for indoor air pollution, asking what type of fuel is used for cooking and heating, how the home is ventilated and what sort of cleaning, do-ityourself and personal care products are routinely used may provide important information to help gauge the extent of exposure and advise on lifestyle or products changes that can improve indoor air quality. an understanding of outdoor air pollution exposure requires clinicians to be equipped with reliable local air pollution data supplied by a reputable source, whilst questions to patients should focus on proximity of the household/workplace to urban or industrial environments, commuting practices, occupation and time spent near heavy traffic. additional inquiries to provide a qualitative picture of exposure should focus on outdoor physical exertion (e.g. active transport during commutes, manual work, exercising) and open-ended questions about air pollution in the local community to identify any sources of risk that may otherwise go undetected. such a screening approach will allow clinicians to be better placed to design and discuss individualtailored strategies. recommendations to reduce exposure should always emphasize the importance of avoiding the pollutant source-the most effective intervention. they must also be practical and inexpensive and guard against negative behavioural patterns, such as healthy individuals avoiding outdoor exercise. furthermore, recommendations must avoid advocating the use of inaccurate personal pollution-monitoring devices and any interventions designed to reduce air pollution exposure/the risk of adverse respiratory outcomes that are scientifically unproven. the public must also have access to engaging and high-quality educational materials in primary care and hospital settings. this will go some way in ensuring patients (including low-risk individuals) are better informed on this key issue. as influential members of the community, healthcare workers have a particularly important role to play in advocating for cleaner and safer air on behalf of their patients and thereby advance the global effort to combat the adverse effects of air pollution. a hugely successful analogy is the effective anti-tobacco campaigns that facilitated the smoke-free legislation. the resulting health gains documented worldwide exceeded expectation, including a reduction in childhood and adult hospital admissions for asthma [69] . outside of clinical settings, approaches to raise awareness of air quality where people, and especially susceptible individuals, congregate (e.g. bus stops, rail stations, shopping areas, etc.) are a crucial as a way of warning of the potential health risks. in an ideal world, people should also regularly check an air quality index (using traditional and social media) or a smart phone app before going to work or school or pursuing leisure activities, prompting them to take action (reduce exposure and/or increase use of inhaled reliever medication) in the event of increased pollution [70] . alert services accessed via apps are becoming increasingly informative and engaging by providing realtime data and proactively warning registered users of impending pollution events (fig. 3 ) [71, 72] . these services also offer tailored advice on how specific groups can reduce emissions by, for example, providing low-pollution journey planners to reduce exposure. the breathe london: wearables study described earlier spans the scientific research/public awareness divide by introducing initiatives such the relatable presentation of collected data to participating school communities, science lessons and surveys/focus groups for children and parents to assess views and perceptions of air pollution [65] . to recap, we do not have a shortage of evidence to advocate for cleaner air for people with asthma. we know that air pollution is associated with the development and worsening of the condition and, importantly, since we are dealing with an avoidable health risk, mitigating interventions can result in prompt and substantial health gains. we also have a clear target, namely traffic emissions, especially in urban areas, and plenty of potential actions to safeguard the health of people of all ages. this is all good news. a crucial component to what remains is political will, guided by the science, since the recommendations discussed herein would need to be supported by a new clean air act, based upon world health organisation health-based air quality limits, the adequacy of which are currently being revisited. however, deciding upon and executing the necessary policies is a complex challenge when it necessitates among other measures, a reduction in road traffic and a cleaner and greener element to what remains on the road-coupled to a heavy burden of expenditure. policymakers are invariably torn between tightening controls on emissions to enhance health and succumbing to economic pressures not to reduce emissions. several actions in combination must however be taken since multiple measures, each producing a benefit of varying size, are likely to act cumulatively to produce significant change. the response to the coronavirus disease 2019 (covid-19) pandemic across the world, in the form of economic rescue packages, has however clearly demonstrated the power of governments and the speed at which they can act when the political will is there and when there is a shared sense of an emergency. we really need to hold onto this, and must guard against voices that may say we need to de-regulate to get the economy going again in a non-sustainable way. in support, findings suggest that the pandemic and, specifically, imposed lockdown measures could result in behavioural changes and thus environmental improvements to benefit those living with asthma. it has clearly given people the opportunity to appreciate how much they depend on exercise in treasured green spaces. there are also glimmers of hope that reduced reliance on the car and increased active travel may emerge. in the uk, an aa-populus poll fig. 3 cityair smartphone app. the app shows: (1) advice tailored to specific user groups; (2) air pollution forecast; (3) low-pollution journey planners survey reported that one-fifth of drivers will use their cars less when restrictions are lifted [73] . fear of contracting coronavirus on public transport has also led to a boom in cycle-towork schemes, whilst demand for greater mobility and exercise amid lifestyle changes has also boosted bike sales across the uk [74] . mindset shifts such as these should now be skilfully harnessed with realistic policies and effective measures. in turn, they must be taken forth with political courage and investment so that air pollution no longer contributes to the development or worsening of respiratory ill health. between public health england and imperial college. the views expressed are those of the author(s) and not necessarily those of the nihr, public health england or the department of health and social care. the study was also part supported by the mrc centre for environment and health, which is currently funded by the medical research council (mr/s0196669/1, 2019-2024). infrastructure support was provided by the nihr imperial biomedical research centre (brc). no rapid service fee was received by the journal for the publication of this article. authorship. all named authors meet the international committee of medical journal editors (icmje) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. disclosures. frank kelly, ian mudway and julia fussell have nothing to disclose. compliance with ethics guidelines. this article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors. data availability. data sharing is not applicable to this article, as no datasets were generated or analysed during the current study. open access. this article is licensed under a creative commons attribution-non-commercial 4.0 international license, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/bync/4.0/. chronic respiratory diseases: asthma. q&a detail 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burning. london: institute of public policy research wearables study: engaging primary school children to monitor air pollution in london the asthma mobile health study, smartphone data collected using researchkit can smartphone data identify the local environmental drivers of respiratory disease? developing a clinical approach to air pollution and cardiovascular health smoke-free legislation and child health monitoring air pollution: use of early warning systems for public health london air. mobile apps cityair app automobile association (aa) coronavirus: boom time for bikes as virus changes lifestyles funding. this study was funded by the national institute for health research (nihr) health protection research unit in environmental exposures and health, a partnership key: cord-015893-e0fofgxq authors: ryhal, bruce title: viral disease, air pollutants, nanoparticles, and asthma date: 2011-05-03 journal: bronchial asthma doi: 10.1007/978-1-4419-6836-4_11 sha: doc_id: 15893 cord_uid: e0fofgxq health care providers who treat patients with respiratory disease are often asked by their patients, “what caused my asthma? and what causes my asthma suddenly to become worse?” these questions have always been difficult to answer, and moving directly to a discussion of the management of asthma is a much easier road to take. in recent years, though, enough information has accumulated about the causes of asthma that one can weave a story containing useful advice that may help patients participate in the management of their disease. and there are also recent studies that can provide answers to the questions posed by physicians who have watched in puzzlement as their previously well-controlled asthma patients have spiraled rapidly out of control. this story has been growing increasingly complex, with an ever-expanding cast of players that sometimes creates a tangled web of interactions. viral respiratory tract infections are the most common triggers of significant asthma • exacerbations. "upper respiratory tract infections" (uris) do not just involve the upper respiratory • tract. human rhinovirus (hrv), which causes the common cold, is the virus most likely to • trigger an asthma exacerbation. in contrast to the usual spring and summer temperate zone pollen season, viral infec-• tions begin to peak in the fall. the number, species, and typical course of viral respiratory tract infections that trigger • asthma vary with a person's age. both acute sinusitis and asthma exacerbations are associated with viral respiratory tract • infection and therefore antibiotics are rarely needed in uncomplicated cases. sulfur dioxide, nitrogen dioxide, ozone, and particulate matter in air pollution may • exacerbate asthma, and patients should be cautioned to stay indoors when levels of these irritants are high. indoor air pollution, especially from tobacco smoke, can be reduced with benefit to the • asthma patient. introduction health care providers who treat patients with respiratory disease are often asked by their patients, "what caused my asthma? and what causes my asthma suddenly to become worse?" these questions have always been difficult to answer, and moving directly to a discussion of the management of asthma is a much easier road to take. in recent years, though, enough information has accumulated about the causes of asthma that one can weave a story containing useful advice that may help patients participate in the management of their disease. and there are also recent studies that can provide answers to the questions posed by physicians who have watched in puzzlement as their previously well-controlled asthma patients have spiraled rapidly out of control. this story has been growing increasingly complex, with an ever-expanding cast of players that sometimes creates a tangled web of interactions. this chapter will look at how viral infections, air pollution, and possibly nanoparticles may act as causal agents of asthma. the concept of causal agent, though, has a variety of different interpretations. in general, agents may act on the respiratory tract to initiate asthma or to exacerbate it. initiation (or inception or development) of asthma refers to the start of asthma in a patient who was previously entirely free of this problem. an exacerbation (or trigger or precipitating event) means the significant and often sudden worsening of an established chronic asthmatic condition. avoidance of a proven initiating factor, if possible, could permit the primary prevention of asthma. in contrast, avoidance of triggering events will not halt the disease but only decrease the number of exacerbations in someone who already has chronic illness. in studying and treating asthma, identification of a specific trigger is usually much easier than trying to prove an initiating cause. viruses that affect asthma are acting on a complex and varied phenotype, and therefore the outcome of each infection can be quite varied. a simple linear cause-and-effect relationship between a viral infection and an asthmatic episode usually does not exist. koch's modified postulates for infection-caused disease are: the microorganism must be present in every case of the disease. • the microorganism must be isolated from a diseased organism and grown in pure • culture. the cultured microorganism should cause disease when introduced into a healthy • organism. the microorganism must be recovered from an inoculated, diseased experimental host. • this linear way of looking at viral-induced disease is not comprehensive enough to allow sufficient insight into the relationship between viral illness and asthma. no one viral infection consistently causes asthma in all or even most individuals. systems biology, though, can provide a conceptual framework for better understanding of the virus-asthma interaction. systems biology looks at the web of factors in the initial state of the individual patient and then examines how one or more external or internal influences perturb this state (1). in fig. 1 , the path taken by system a illustrates how one factor, for example a simple rhinovirus infection, may have very little long-term effect on mucosal inflammation in an individual with no atopic stressors and no genetic propensity toward asthma. this individual will return quickly to equilibrium and a low inflammatory state. the path of system b illustrates how multiple stressors, including genetic factors and atopic immune development, may interact with a viral infection to cause a long lasting or perhaps permanent change in the level of mucosal inflammation. some details of risk factors will be outlined and discussed in this chapter, but systems biology or systems medicine cannot yet specify each feature of the set of interactions in a way that leads to firm predictions about asthma. out of the complexity of the systems approach, though, some simple and compact principles do emerge, so that every precondition does not have to be known to predict the outcome of intervention or treatment. some general factors that appear to be important in the asthmatic response to viral infection include: though two-dimensional paper does not allow multidimensional maps, we can walk down a branching path in a narrative fashion to show the interaction of factors important in viral-caused asthma. in most of the twentieth century, the office or hospital diagnosis of viral respiratory infection was most often a good guess, a probability statement. common and more affordable viral molecular diagnostics, especially reverse transcriptase pcr (rt-pcr), and viral culture can now improve the accuracy of the guess when precision is needed. viruses may be detected in symptomatic or in asymptomatic patients. two thirds or more of acute respiratory tract infections (rtis) occurring in the community can be identified as viral. traditionally, these have been divided into upper and lower rti, but the difference between upper and lower infection seems to be more indistinct than previously believed. human rhinovirus (hrv), for example, replicates initially in the upper respiratory tract yet may cause extensive lower respiratory tract illness. the frequently used term viral upper rti (urti) is somewhat of a misnomer. the most commonly occurring respiratory virus is hrv, which accounts for nearly half of cases of viral respiratory illness, followed by influenza virus and coronavirus, with lesser contributions from parainfluenza virus, respiratory syncytial virus (rsv), adenovirus, metapneumovirus, and other miscellaneous viral species (2) (see table 1 ). the three main types of viruses that are known to affect asthma are hrv, rsv, and influenza. the peak periods of viral infection tend to vary from year to year, but generally in north america rhinovirus peaks in the fall and early spring, influenza in the early winter, and rsv in midwinter (fig. 2) . many communities can monitor the progress of these annual epidemics with viral culture and molecular diagnostics, thereby giving physicians a higher probability of knowing in advance what virus a patient may have. a molecular diagnostic panel is commercially available for identifying acute viral respiratory infection, though the cost-effectiveness of this type of testing for routine clinical use is yet to be determined. more details of the immunobiology of the major asthmogenic viral infection, hrv, have been revealed in the past several years (3) . the intercellular adhesion molecule icam-1 found on nasal epithelial cells is the attachment point for the majority of serotypes of hrv(4). hrv is divided into clades or strains hrv-a, hrv-b, and hrv-c. hrv-c has proven extremely difficult to culture. there are over 100 different serotypes (5). viral species influence asthma in the various age groups in different ways. age is a marker for the development and maturation of the immune system, which diversifies greatly over time. as the human body ages, the immune system molds itself to the environment to become a mirror image of specific, usually protein, molecules in the external local surroundings. age also has an important effect on the physics of scaling in the respiratory system. airway resistance is inversely proportional to the fourth power of diameter, which enlarges with age until young adulthood and then slowly declines. small increases in airway diameter therefore lead to huge reductions in airway resistance and give more "breathing room." about 80% of significant, prolonged wheezing episodes in children are triggered by respiratory viruses and hrv is most often involved (3). the common rhinovirus cold accounts in large part for the fall seasonal peak of asthma in school-age children. epidemiologic evidence combined with viral molecular diagnosis has suggested that this peak is a consequence of children returning to the classroom with the subsequent spread of respiratory viruses, mainly rhinoviruses (6) . viral exacerbations of asthma tend to be prolonged and severe. triggers such as a gust of pollen-laden breeze may be ameliorated by moving the young patient indoors, and exercise triggers can be removed by stopping the exercise, but a viral trigger is usually steady and persistent and replicates within the body. a study of children aged 6-8 years with asthma concluded that an asthma exacerbation was of a greater severity if a viral infection was present as opposed to a nonviral illness (7) . airway hyperreactivity and a corresponding cough and wheeze may be noted for well over 4 weeks after a rhinovirus infection in the asthmatic child. atopy confers additional risk on asthmatic children who become ill with respiratory virus infection (10) . school-aged children with atopic asthma, as opposed to those with nonatopic asthma, have been noted in a number of studies to experience more frequent symptomatic colds, more episodes of viral-triggered asthma, and more prolonged airway hyperreactivity after the colds (7) (8) (9) . the tendency to have higher numbers of symptomatic rtis and a longer duration of illness was also noted for allergic children in general, with and without asthma (9) . parents of children with atopy and asthma tend to be frustrated by the prolonged recovery time compared with their nonatopic siblings, and school absences are more problematic. inhaled corticosteroids and leukotriene receptor antagonists (ltras) are well known to control the number of wheezing exacerbations in school-age children with chronic persistent asthma, an effect that appears to encompass those episodes caused by viral illness. a survey of school children in ontario found that children presenting in september to the emergency department for asthma exacerbations, presumably mostly viral triggered, were less likely to have used preventive anti-inflammatory medications than their counterparts who did not have such severe exacerbations (12) . a retrospective study suggested that inhaled fluticasone and salmeterol administered prior to and during the fall could reduce the morbidity of the fall viral season in patients with asthma (13) . a trial of a montelukast added to usual asthma therapy was able to attenuate the fall asthma peak in one study (14) though this effect did not reach statistical significance in a later trial (15) . inhaled corticosteroids might be expected to prevent viral-induced wheezing in children with minimal chronic disease as well. a preventive effect, though, has not been consistently shown in clinical trials. a study conducted in school-aged children without persistent disease but with a history of viral-triggered wheezing demon strated that inhaled beclomethasone diproponate was not superior to placebo in reducing future episodes. the inhaled steroid failed to reduce days with symptoms, or the frequency, severity, or duration of episodes of upper or lower respiratory illness (11) . preventive medication should therefore be targeted especially to those patients with persistent chronic asthma. for acute treatment of a viral-provoked asthma exacerbation, oral systemic corticosteroids continue to be the most effective choice (16) and are part of the current therapy protocols (17). use of high-dose acute corticosteroid inhalers continues to be studied with varying success. whether vaccination can prevent asthma exacerbations is unclear. the expert panel report concluded that influenza vaccine does not reduce the frequency or severity of asthma exacerbations during the influenza season (17). many patients in the community with asthma experience severe complications from an influenza infection, so all reasonable means of prevention should still be taken, including vaccination. the influenza virus appears to be a less potent trigger of asthma than hrv, and influenza peaks are not as well correlated with childhood asthma peaks as in the case of hrv. an oral influenza antiviral (oseltamivir) improved pulmonary function and reduced exacerbation frequency in one randomized, placebo-controlled trial in school-age asthmatic children who had influenza (18) . unfortunately, increasing resistance of the influenza virus to antiviral agents limits their use as a long-term strategy to reduce illness in asthmatic children. the concept of using antivirals to reduce asthma morbidity in children seems theoretically promising. the preschool years can lay the groundwork for the later asthma issues of the type that have been discussed. diagnosing viral-triggered asthma in infants and preschool children, though, must be done with caution. asthma is defined as a chronic disease, and several, or even many, self-limited acute wheezing illnesses do not necessarily add up to a chronic illness. often children in this age group will experience wheezing in association with a variety of viral infections. parents are naturally anxious about treatment and prognosis in these children. preschool children who experience rsv-and hrv-induced wheezing are more likely to develop asthma in later years. the childhood origins of asthma study (coast) showed that viral wheezing illnesses in infancy and early childhood caused by hrv were the most significant predictors of the subsequent development of asthma at age 6 (19) . a bidirectional causation has been proposed with rsv: severe rsv was associated with a short-term increase in bronchial hyperresponsiveness, and, in turn, the presence of asthma was associated with long-term increased susceptibility for severe rsv disease (20) . whether early childhood viral infection initiates a series of events that lead to asthma has been an area of much interest and study. one analysis showed that infants reaching 4 months of age at the winter virus peak had a 29% increased risk of developing later asthma compared with those reaching age 1 year at the winter peak (21) . if viruses do initiate asthma in some patients, then prevention of rsv or hrv or a similar illness in a critical time period might prevent or reduce the frequency of asthma in later years. nonatopic infants who had received palivizumab (a humanized mab against rsv) for prevention of rsv infection showed an 80% reduction in risk of recurrent wheezing from ages 2 to 5 (22) , though no effect was noted in atopic children. the hypothesis that early viral infections lead to asthma is made less convincing by epidemiologic studies showing that frequent exposure to viral rtis throughout early childhood may actually decrease the risk of later asthma. studies in the united states and in the united kingdom have shown that day care attendance and other factors that increase the frequency of viral rtis reduce the risk of later (after 5-6 years) frequent wheezing (23, 24) . one interesting medical editorial on this topic was subtitled with tongue-in-cheek, "please sneeze on my child" (25) . that strategy may not be practical, but clinicians should be able to reassure worried parents that day care exposure does not seem to result in a long-term risk of asthma. while the factors that contribute to the development of asthma are still unclear, there is little doubt that viral infections act as potent triggers of asthma in preschool children. as noted, hrv is the most potent of triggers, though all hrvs do not seem to be alike. pathogenicity of hrv appears to vary among groups a, b, and c. hrv-c was found in a study of hospitalized preschool children to be associated with asthma more often than hrv-a (26), and hrv-c was noted to be the most frequent type found in patients presenting to the emergency department (27) . in contrast, experimental infection with a type of hrv-a resulted in no worse illness in allergic than in nonallergic subjects (28) . knowledge of a circulating virulent hrv strain in the community could put clinicians on the alert for more serious symptoms in their asthmatic patients with colds. there are several competing classification systems for the wheezing preschool child that aim to help with prognosis and treatment ( table 2) . as a conceptual model, one can create two opposing poles. at one pole is the small child who experiences rare mild wheezing with acute viral illness, has no wheezing or cough between episodes, and has no atopy or parental asthma. these children appear to benefit very little or not at all from acute or chronic corticosteroid therapy for viral-triggered wheezing illness (29) . at the other pole are children who wheeze daily or weekly, have an atopic history, have a parental history of asthma, and may be on chronic controller therapy. a viral infection in these children appears to be a trigger that requires a step up in asthma therapy, perhaps to a burst of oral corticosteroids. between these poles of severity are many children whose therapy must be individualized. the criteria from the national asthma education and prevention program help select preschool children who may benefit from acute and/ or chronic corticosteroids. these guidelines use the asthma predictive index (30) to specify which wheezy small children have or likely will have chronic asthma and could benefit from various forms of inhaled and oral corticosteroid therapy. owing to concerns about oral corticosteroids, other forms of treatment for viral wheezing have been examined in preschool children. a study in 1-to 6-year-old children showed a benefit of episodic high-dose inhaled steroids with viral rti and wheezing (31) , though some adverse effects on growth were noted. the effectiveness of a ltra, montelukast, was examined in a study of 2-5 year olds with a history of intermittent asthma. this study showed a reduction of typically viral-induced asthma exacerbations in children given the ltra as a daily controller (32) . both inhaled corticosteroids and ltras are options to control chronic asthmatic wheezing in this age group (17). prolonged or chronic cough after viral rti may be a problem. preschool children, whether asthmatic or not, spend a considerable percentage of the year with viral rti symptoms that are distressing to patient and parent. the years from teen through young adulthood tend to be the healthiest years of an individual's life. an expanded antiviral immunologic repertoire helps in reducing the number of annual viral rtis. while childhood is the time of most frequent viral rtis, young adults who are exposed to their own small children may have a secondary peak near their 30s. acute sinusitis is a common problem in this age group. sinusitis has been known to precede a worsening of asthma, and episodes of acute sinusitis have often been the occasion for a course of antibiotics. the entity of viral rhinosinusitis, though, is far more common than previously believed. a viral rti can produce a week or more of purulent discharge and radiographic abnormalities of the sinus cavities on ct scans (33) . most acute sinusitis is not predominantly initiated by bacteria nor, at least in the first week or so, antibiotic-responsive (34, 35) . the mechanism by which acute viral sinusitis becomes linked with worsening asthma is generally through the association of both diseases with viral infection (fig. 3) . the adult group of patients with asthma diverges into several different phenotypes, likely representing various diseases. asthma is often said to be a syndrome rather than one disease. different phenotypes may have varying responses to viral infection. a cluster analysis divided asthma patients into five different groups. one group, "benign asthma" seemed to have well-controlled symptoms regardless of triggers, viral or otherwise. another group that was female preponderant, "obese nonesosinophilic," had minimal atopy or eosinophilic inflammation yet a high level of symptoms in response to typical triggers (36) . chronic adult diseases of previously unknown cause have occasionally been found, in whole or in part, to have an infectious etiology. these include peptic ulcer disease (helicobacter pylori), polyarteritis nodosa (hepatitis b and c), reactive arthritis (shigella and chlamydia), and lyme arthritis (borrelia burgdorferi). a survey of asthma patients, of mean age 38, suggested that 45% of initial attacks started after an illness suggestive of a respiratory infection (37) . this subset tended to be nonatopic and may represent a distinct phenotype. viral and nonviral initiating infectious agents have been proposed for adult "infectious asthma," including mycoplasma, chlamydia, adenovirus, and adult rsv, but reasonable proof of an infectious mechanism is still pending. regardless of initiating cause, asthma is exacerbated in adults, as in children, by viral respiratory infections. respiratory virus is found at least 50% of the time in adults with asthma exacerbations, but not as frequently as in childhood acute significant wheezing episodes (3). older and elderly adults experience some degree of immune senescence but also have expanded specific antiviral immunity. the types of viral illness that exacerbate asthma are slightly different than in younger years. the peak of ed visits and asthma admissions for adults over 50 tends not to be in the fall but rather from december to january, suggesting a broader range of viral triggers than in the fall rhinovirus peak (38) . the contribution of influenza to excess morbidity in older adults is well known, but less generally appreciated is the contribution of rhinovirus to serious illness. concomitant heart disease, chronic obstruction pulmonary disease, and hypertension can make viralexacerbated asthma a more complicated and serious illness in older adults. a rhinovirus outbreak in a nursing home for elderly patients resulted in two thirds of the affected patients having lower respiratory tract symptoms, nearly one-third requiring corticosteroid or bronchodilator therapy, and three individuals having serious morbidity including one death (39) . a peak of rhinovirus rti may be seen in grandparents who care for small children. consistently effective treatments for viral-caused respiratory disease have been frustratingly slow to arrive in the modern pharmacopoeia. despite these obstacles, however, a proactive approach, including vaccination and respiratory hygiene, can improve the care of the patient at risk for viral illness and bronchospasm and avert complications. since the time of albert einstein, scientists have known to be wary of "spooky action at distance." particles that affect the respiratory tract must first be dispersed into the air and enter and contact the respiratory tissue to have an effect. these particles vary in size from molecules in the angstrom range (1 × 10 −10 m), to so-called nanoparticles (1-100 × 10 −9 m), to large pollen grains (50 × 10 −6 m), on up to the largest dust particles that can remain suspended in air (about 100 × 10 −6 m). air particles are divided into several common ranges for study purposes: • pm10 -particulates of an aerodynamic diameter of less than 10 mm or 10,000 nm • fine particles of diameters below 2.5 mm or 2,500 nm • ultrafine particles or nanoparticles of diameters below 0.1 mm or 100 nm study of the real-world, clinical effects of the individual components of air pollution is challenging since most or all components tend to be released into the air at about the same time. unwanted and/or unhealthy gases and particles make up the components of air pollution. outdoor air quality issues vary to great extent by specific location and depend on weather and climate, the level of vehicle traffic, and the type of fuel used for energy and manufacture. in the united states, the office of air quality planning and standards (oaqps) has established the national ambient air quality standard (naaqs) for each of the several pollutants. carbon monoxide, lead, nitrogen dioxide (no 2 ), ozone, sulfur dioxide (so 2 ), and particulate matter in the air have maximum exposure standards (fig. 4) . studies of the effect of air pollution on health attempt to use statistical analysis to separate the individual contribution of each component of pollution. additionally, provocation/exposure testing can be performed in the laboratory. many of the same questions that can be asked about viral disease can be asked about air pollution -does it initiate asthma and does it trigger asthma? clearly not everyone breathing air pollution gets asthma or wheezing, but exposure does seem to increase the risk. a population study in the netherlands found that children with higher exposure to traffic-related pollutants (no 2 , particulate matter) were more likely to develop asthma (40) . data from the taiwan children health study showed an increased prevalence of bronchitic symptoms among children with long-term exposure to outdoor air pollutants (41) . in addition to irritant properties, air pollution may contain immunologically active particles. nanoparticles, including particles of diesel exhaust, which are suspended in air are especially interesting to immunologists studying the development of asthma. they have been proposed to act as adjuvants and immunomodulators (42) . most diesel particulates have sizes of less than 1 mm and represent a mixture of fine particles and nanoparticles. acute wheezing may be triggered by exposure to high levels of pollutant gases including nitrogen dioxide, sulfur dioxide, and carbon monoxide. burning of fossil fuels is the main source of these pollutants in most locations. nitrogen dioxide and sulfur dioxide gases diffuse rapidly and impact upon the wet respiratory tract to produce highly irritating acids. sulfur dioxide can cause respiratory constriction in asthmatic patients at concentrations of 0.1 ppm when exercising (44) . healthy adults begin experiencing increased airway resistance at 5 ppm, and even nonasthmatic adults will develop bronchospasm at 20 ppm, though these levels would be highly unusual in outdoor air pollution. nitrogen oxides, and especially no 2 , are also irritating to the upper and lower respiratory tracts at low levels, and patients with asthma are more susceptible to these adverse effects. higher concentrations of outdoor no 2 were associated with more asthma symptoms in a study of inner city children (45) . though the mechanism of action is uncertain, exposure to carbon monoxide in city air was found in one european study to worsen lung function in adult patients with asthma (43) . ozone, while of critical importance to global health in the upper atmosphere, is an especially noxious chemical when generated at or near ground level. ozone (o 3 ) is not produced directly by traffic or by hydrocarbon burning. instead, the combination of no 2 and hydrocarbons with air and sunlight form the secondary pollutant ozone. high average ozone and airborne particulate matter were associated with more frequent asthma symptoms and ed visits and hospital stays in a study of asthma sufferers in the san joaquin valley in california (46) . ozone from air pollution has been shown to exacerbate asthma in children and adults, though this effect may be greater in children (47) . a study of over 90,000 emergency department visits in atlanta for pediatric asthma showed a relationship to ozone and primary pollutant concentrations from traffic sources. these pollutants increased ed visits even at relatively low concentrations (48) . the study of particulate matter in the air is quite complex, since the exact composition varies geographically. in general, high levels of particulate matter have long been associated in epidemiological studies with increased levels of respiratory disease. ongoing research is examining the importance of particle size, fine versus more coarse, in asthma and chronic respiratory illness. one study in turkey showed an 18% rise in asthma admissions when air contained high levels of coarse particles (49) . in contrast, a us study did not find increased hospitalizations for respiratory disease during those periods with high coarse particle levels (50) . the evidence for a negative effect on health from suspended fine particles is stronger (51) . genetic and phenotype differences may be important in the sensitivity of the asthma patient to air pollution. the risk of childhood asthma in mexico city was modulated in some children by genes controlling the response to oxidative stress, such as might occur while breathing ozone (52) . advice on how to avoid high concentrations of air pollutants is important for asthma patients. air pollution, like pollens and viruses, follows a seasonal pattern, and knowledge of the local pattern can help the primary physician with diagnosis and treatment. in the united states, a daily air quality index (aqi) is computed and distributed for most large population areas. the aqi, which is determined on the basis of the highest pollutant of the day, may be considered safe for patients with chronic respiratory disease if less than 50 (green zone). on days with poor air quality, asthma sufferers should come inside where pollutant levels are typically much lower. indoor ozone levels vary from 10 to 80% of outdoor concentrations, depending on the size of outdoor air flows into a building (53) . although asthma patients should continue their controller therapy during periods of high air pollution, pretreatment with controller medications may not always be successful. budesonide treatment in one study was not successful in preventing ozone-triggered functional airways impairment in test subjects with mild persistent asthma (54). while outdoor air pollution rightly receives a great deal of media and government attention, indoor air pollution can make living inside hazardous as well. fortunately, indoor air problems are usually amenable to personal control and behavioral advice. air quality issues may occur in both home and work environments. the field of occupational medicine examines workplace concerns and is reviewed in another chapter. home air quality is typically not regulated, though pollution may result from several indoor sources. hydrocarbon fuels are, of course, burned inside as well as outdoors. indoor gas cooking and heating stoves may produce no 2 , high levels of which have been associated with increased asthma symptoms in children (55) . good ventilation is essential if natural gas is to be burned indoors. indoor nitrogen oxides are also produced by wood-burning stoves, especially if not well vented. the most serious and prevalent type of home air pollution is secondhand or environmental tobacco smoke (ets). the risk from this indoor pollutant begins in utero. maternal smoking during pregnancy is associated with increased infant wheezing (56) . this risk of respiratory morbidity continues to increase with postnatal parental smoking (57) . laws regulating indoor tobacco smoking in one european country were followed by improved quality-of-life scores in a group of asthmatic indoor workers (58) and also by a reduction in the overall rate of hospitalizations for childhood asthma (59) . as noted previously, indoor ozone is usually much less than outdoor levels. in recent years, though, indoor ozone generators have been marketed to the public for odor control and purported heath benefits. a us epa review has warned the public about the potential hazards of adding an additional amount of a measured air pollutant to the indoor air. this chapter has examined some of the most significant initiating and exacerbating causes of asthma. viral respiratory infections, and to a lesser extent air pollution, are common triggers of exacerbations and may interact with individuals to affect the development of some forms of asthma. these causal factors do not exist in isolation but rather interact with the personal attributes of each patient, including his or her genetic and environmental background. the role of viruses and pollutants in asthma is important knowledge that has consequences for prevention, treatment, and avoidance of illness. helpful education may be given to patients and appropriate treatments selected, and health care providers can avoid the considerable human effort and resources wasted on interventions that are useless or harmful. viral and pollutant triggers demonstrate that the highly complex inflammatory asthmatic response is called forth on many more occasions than simply by the contact of pollen grains and other allergens with the respiratory tract. since so much of immune inflammation seems to have arisen from the need to combat infection, the interaction between asthmatic inflammation and viral infection is a natural topic for further investigation. some of the most significant advances in medical care have come through the treatment and prevention of viral illnesses, and furthering the understanding of respiratory viruses is a worthy priority for the future study of asthma prevention and treatment. in addition to natural harmful infectious particles, humans in recent decades have added many substances of their own creation, including the molecules and particles that constitute indoor and outdoor air pollution. control of this problem is very important for overall respiratory health. important action and advice is available for each asthma patient. by understanding and anticipating respiratory viral infections and air pollution as important causes of asthma, the health care provider can provide superior care for those who suffer from this chronic disease. thanks to albin leong md and denise ryhal bsn for helpful comments and for reviewing portions of this manuscript. the clinical applications of a systems approach a case-control study of acute respiratory tract infection in general practice patients in the netherlands the role of rhinovirus in asthma exacerbations expresssion of intercellular adhesion molecule-1 (icam-1) in nasal epithelial cells of atopic subjects: a mechanism for increased rhinovirus infection? common cold, uncommon variation understanding the september asthma epidemic weekly 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key: cord-323761-9m177ozm authors: wang, huijie; li, na; huang, huaqiong title: asthma in pregnancy: pathophysiology, diagnosis, whole-course management, and medication safety date: 2020-02-22 journal: can respir j doi: 10.1155/2020/9046842 sha: doc_id: 323761 cord_uid: 9m177ozm asthma in pregnancy is a health issue of great concern. physiological changes and drug compliance during pregnancy can affect asthma control in varying degrees, and the control level of asthma and the side effects of asthma medications are closely related to the adverse perinatal outcomes of mother and fetus. this article provides an update on the available literature regarding the alleviating or aggravating mechanism of asthma in pregnancy, diagnosis, disease assessment, and systematic management, to provide a new guidance for physician, obstetric joint doctor, and health care practitioner. asthma in pregnancy is a common respiratory disease, and the burden of it has gradually increased worldwide, which has become one of the most common public health problems. e incidence of asthma in pregnancy increases from 3% to 8% in the united states after 1994 [1] and 8% of women suffer from asthma during pregnancy in britain [2] and 12% in australia [3] . asthma control levels often change during pregnancy. it is generally believed that one-third of asthma patients are aggravated due to pregnancy, and most occur in the middle of pregnancy; one-third improved, and no significant changes are observed in the remaining 1/3 of patients. but a latest multicase-control study shows that the percentage of asthma worsening during pregnancy is 18.8%, lower than the previous data, and the worsening is significantly associated with the severity of the disease [4] . ere are also many problems in the control of asthma during pregnancy. studies show that about 65% of patients have poor control of asthma during pregnancy, inhaler technology is not correct in 64.4% of cases, only 38% of patients know the difference between asthma reliever and controlled medications, 12.7% of patients receive a written asthma action plan, 17% of patients have spirometry in the past 5 years, and 3.8% of them have peak expiratory flow meter at home [5] . studies have shown that maternal asthma increases the risk for adverse complications in fetuses and mothers, including sga (small for gestational age), lbw (low birth weight), congenital malformations (cleft lip or cleft palate), increased perinatal mortality, pb (premature birth), maternal preeclampsia, gestational hypertension, gestational diabetes, prenatal hemorrhage, caesarean section, urinary tract infection, excessive amniotic fluid, and premature rupture of membranes, especially for those patients with severe or uncontrolled asthma during pregnancy [6, 7] . onset during pregnancy e pathogenesis of asthma remission or aggravation during pregnancy is related to the physiological or pathological changes caused by pregnancy, mainly including the mechanical changes caused by uterine enlargement and the direct or indirect effects of hormonal changes during pregnancy. with the increase of uterus and abdominal pressure, the diaphragm is elevated by 4-5 cm, subcostal angle increased 50% (68°to 103°from early to late pregnancy), and the transverse and anteroposterior diameter of thoracic increased. e above changes are partially compensated by relaxation of ligamentous attachments of the ribs which leads to the decrease of the thoracic compliance. as a result, the total lung volume decreases by 5% and frc (functional residual capacity) decreased by 20% [8] . moreover, the increased body weight leads to larger neck circumference and smaller oropharyngeal area which contributes to dyspnea during pregnancy [9] . during pregnancy, in order to meet the needs of maternal and fetal metabolism, a series of important changes occur in hormone levels, including the obvious increase of progesterone, estrogen, cortisol, and prostaglandin, all of which have different effects on the course of asthma. progesterone is a stimulant of respiratory dynamics, which can increase the sensitivity of respiratory center to carbon dioxide, while estrogen can increase the sensitivity of progesterone receptor in respiratory center and jointly participate in the change of respiratory function [10] . e minute ventilation increases by 30%-50% which is mainly due to a 40% increase in tidal volume, while there is no significant change in respiratory rate. tlc (total lung capacity), vc (vital capacity), lung compliance, and dlco (diffusion capacity) remain unchanged. fvc (forced vital capacity), fev1 (forced expiratory volume in 1 s), the ratio of fev1 to fvc, and pefr (peak expiratory flow rate) have no significant changes during pregnancy compared with nonpregnancy [8] . erefore, spirometry can be used to identify dyspnea in normal pregnancy and reflect the changes in respiratory diseases. in addition to acting on the respiratory center, progesterone can mediate mucosal vasodilation and congestion, resulting in the increase of pregnancy rhinitis and epistaxis incidence [11] and oropharyngeal and laryngopharyngeal airways that contribute to the attack of asthma in pregnancy. estradiol can increase maternal innate immunity and cell-or humoral-mediated adaptive immunity. low concentration of estradiol can promote cd4+ 1 cell response and cell-mediated immunity. high concentration of estradiol can enhance cd4+ 2 cell response and humoral immunity. progesterone inhibits the maternal immune response and changes the balance between 1 and 2 responses. although cell-mediated immunity is more important in respiratory viral infections, the transfer of 1 to 2 immunity is considered to be an important mechanism for asthma induced by hormones during pregnancy [12, 13] . women are in the state of hypercortisonism during pregnancy; meanwhile, the placenta secretes both crh (corticotropin-releasing hormone) and acth (adrenocorticotropic hormone), which results in the increase of free cortisol and conjugated cortisol during pregnancy. e increased free cortisol mediates the increase of beta-adrenoceptor and the enhancement of bronchiectasis [9] . increased secretion of prostaglandin e2 (pge2) during pregnancy, through anti-inflammatory, inhibition of smooth muscle cell proliferation, bronchial relaxation, and other mechanisms, has a protective effect on the incidence of asthma. in addition, progesterone also has the effect of changing the airway smooth muscle tension and causing bronchiectasis [10] . ese factors are associated with asthma remission during pregnancy. generally speaking, the effects of mechanical and biochemical changes on the respiratory system of pregnant are very complex, especially the effects of various hormones on the respiratory center, peripheral airway, and immune system, leading to nonasthmatic pregnant women experiencing varying degrees of dyspnea during pregnancy. for pregnant women with asthma, it is very important to strengthen the management of asthma during pregnancy to avoid maternal hypoxia and maintain adequate fetal oxygenation. general asthma is defined by the history of more than one type of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, often appear or worsen with viral infections, and attack at night or on waking, usually triggered by exercise, laughter, allergens, and cold air, together with variable expiratory airflow limitation [14] . if one of the tests is positive including bronchodilator reversibility test, bronchial provocation tests, and pef variability, it can confirm variable expiratory airflow limitation. compared with general asthma, asthma in pregnancy has similar clinical manifestations. however, if a pregnant woman only complains of shortness of breath or chest tightness, we must be careful to diagnose based on her medical history. as we know, over two-thirds of pregnant women experience some form of shortness of breath or chest tightness during the gestation period because of physiological changes of pregnancy [11] . in addition, it would not be advisable to carry out a bronchial provocation test to prevent maternal hypoxia and fetal distress. assessment of asthma usually includes asthma control (both symptom control and future risk of adverse outcomes), treatment issues particularly inhaler technique and adherence, and any comorbidities that can contribute to symptom burden and poor quality of life [14] . lung function, feno (exhaled nitric oxide), act (asthma control test) scores [15] , and blood eosinophil counts are important tools for asthma assessment. pefr is used to monitor lung function, which should be 380 to 550 l/min, but the personal best value is required. maintaining 80-100% of personal best value is considered normal range for asthma patients. feno is an indicator of airway inflammation; studies have found that pregnant women with asthma have the same feno as before, which is associated with asthma control [16] [17] [18] . adjusting treatment of asthma in pregnancy according to feno can reduce acute attacks and neonatal admission rate. e assessment of asthma in pregnancy is a collaborative effort by physician, obstetric joint doctor, and health care practitioner. it is necessary not only to evaluate pregnant women but also to comment on the growth and development of the fetus. and the frequency of assessments needs to be more frequent, once a month is recommended by gina (global initiative for asthma). whole-course management of asthma in pregnancy can reduce the negative effects of fluctuations in asthma symptoms or acute exacerbation on pregnant women and the fetus. e gina guidelines suggest that poor asthma control and acute exacerbations during pregnancy are more risky than taking asthma medications. e long-term goals of asthma management are to achieve good symptom control, maintain normal activity levels, and minimize the risk of acute attacks, irreversible damage to lung function, and drug-related adverse effects. for asthma in pregnancy, it is also essential to avoid side effects of drugs on pregnant and fetuses and give birth to healthy babies. e principle of asthma treatment is defined as the selection of appropriate treatment based on the severity and control level of patient. a written asthma control plan should be developed for each newly diagnosed patient, regular follow-up and monitoring, and adjusting treatment according to patient control level to achieve and maintain asthma control. ough the principles of medication for asthma in pregnancy are similar to those of nonpregnant patients, there are differences between them in the implementation of stepwise approach. for general asthma, the control level of asthma is assessed at 3 months after the use of controller medication. ose with good asthma control are treated with step down treatment, while those with persistent asthma symptoms or acute exacerbation are treated with step-up treatment. for asthma in pregnancy, the gina guidelines and the australian asthma handbook recommend that asthma control levels should be assessed monthly. step-down treatment is not a priority in order to avoid acute exacerbation of asthma unless the pregnant woman's drug dosage is inappropriate [14, 19] . in addition, anti-ige monoclonal antibodies and specific immunotherapy should not be initiated during pregnancy [20] . currently, the most commonly used and safe drugs during pregnancy include glucocorticoids, beta2-agonist, anticholinergics, theophylline, leukotriene receptor antagonists (ltras), omalizumab, and allergen immunotherapy (ait). among glucocorticoids, inhalation administration is predominant. inhaled glucocorticoids (ics) can effectively inhibit the number and activity of inflammatory cells in the airway; moreover, it can significantly reduce the side effects of systemic medication since its effect on local airway. budesonide is the most commonly used and safe ics during pregnancy. a study based on danish medical registries, of 83043 primiparous women who gave birth to a live-born singleton in 1999-2009, has found no association between use of glucocorticoids (both ics and oral glucocorticoids, ocs) in early pregnancy and risk of oral clefts or congenital malformations overall in the offspring [21] . tegethoff et al. have studied 4083 mother-child pairs from the danish national birth cohort and found that ics for asthma treatment during pregnancy (n � 1231; 79.9% budesonide, 17.6% fluticasone, 5.4% beclomethasone, and 0.9% other or unspecified glucocorticoids) is not associated with offspring disease risk in most categories, except for offspring endocrine, metabolic, and nutritional disorders [22] . however, mortenet al. have indicated that fraction of exhaled nitric oxide-(feno-) guided asthma management during pregnancy reduces doctor-diagnosed asthma in the offspring at the stage of preschool, partly mediated through alterations in use and dosing of ics during the trial of managing asthma in pregnancy [23] . many studies have failed to clarify whether the use of ics increases the risk of teratogenic, but it is clear that asthma patients who do not use ics have a significantly increased risk of giving birth to low-weight children, suggesting that the risk of poor asthma control is much higher than medication [24] . vicki et al. support this conclusion. eir research suggests that the placenta plays an important role in regulating fetal growth by producing an enzyme, 11βhydroxysteroid dehydrogenase-2 (11β-hsd-2), which can convert endogenous and exogenous glucocorticoids derived from the maternal circulation to their inactive metabolites. as a consequence, 11β-hsd-2 activity has a positive correlation with birth weight. asthmatic patients without using ics and 11β-hsd-2 activity are reduced in placentae of female fetuses and that may be associated with inflammatory factors produced during the pathogenesis of asthma. while using low, moderate, or high doses ics will not affect placental capacity to metabolise glucocorticoids, so it does not affect the birth weight, which may be related to the fact that ics is able to increase production of placenta 11β-hsd-2. additionally, uncontrolled asthma frequently shows associations with adverse perinatal outcomes, as previously demonstrated with exacerbations in cohorts of asthma in pregnancy, and the continued use of ics with budesonide is recommended and has a particularly good safety profile [25] . in short, asthma itself has more adverse effects on the placenta than its treatment [26] . in addition, studies have shown that low doses of ics in patients with asthma during pregnancy can reduce the risk of acute exacerbation and readmission, but there are safety issues with high-dose ics. lucie blais et al. have conducted a cohort study of 13280 pregnancies of women with asthma (1990) (1991) (1992) (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) and found that women who use >1000 μg/day ics are significantly more likely to have a baby with a malformation than the women who use >0 to 1000 μg/day, while women who use >0 to 1000 μg/day are not found to be more at risk than women who do not use icss during the first trimester [27] . a cohort study incorporating 7376 pregnancies also discovers no increased prevalence of lbw, pb, and sga in pregnant women with asthma for longacting beta2-agonists (laba) use and ics doses <125 μg/ day, while a trend for an increased prevalence of the outcomes is seen for ics doses above 125 μg/day. maternal glucocorticoid-regulated systems are susceptible to ics canadian respiratory journal (800 μg/day for first and second trimester and 900 μg/day for third trimester) for asthma during pregnancy, but glucocorticoid-regulated pathways in the fetus are not affected by ics use, which implied that ics use for the control of asthma during pregnancy is unlikely to contribute to adverse effects on fetal growth and development [28] . ocs is sometimes necessary depending on the severity of asthma. but we should keep in mind that, among all ocs, prednisone, prednisolone, and methylprednisolone can cross the placenta at very low concentrations, while dexamethasone and betamethasone reach the fetus at higher concentrations. among them, prednisone is the most common ocs. before entering the fetal blood circulation through the placenta, 87% of blood concentration is inactivated by the action of 11β-hsd-2, with little impact on the fetus. accumulating evidence suggests that the use of ocs can increase the incidence of cleft lip and palate in the fetus, especially in the first trimester of pregnancy. e incidence of cleft lip and palate in general population is 0.1%, while in oral glucocorticoids-taking pregnant women it is 0.3% [29] . however, there is also study which believed that the risk of cleft palate is uncorrelated with the application of ocs during pregnancy [30] . and using ocs throughout pregnancy may increase the incidence of preeclampsia, preterm birth, and low birth weight [29] . an animal experiment shows that glucocorticoid exposure in early placentation could contribute to preeclampsia, with the mechanisms involving inhibition of trophoblast proliferation, migration, invasion, and epithelial-mesenchymal transition by glucocorticoid [31] . in population-based studies, ocs has also been reported to increase the risk of preeclampsia [32] . jennifer et al. have conducted a meta-analysis on papers from 1975 to 2012 which are related to the risk of adverse outcomes in neonates with acute attack of asthma, oral corticosteroid, or asthma severity, which shows that acute attack of maternal asthma and oral corticosteroid use have a significant effect on low birth weight and preterm delivery; moderate-to-severe asthma during pregnancy is also associated with an increased risk of sga and low birth weight infants [33] . ere is evidence that asthma in pregnancy perceives a higher risk of ocs medication use on the fetus, compared with ics treatment, which may lead to abnormal behavior of women during pregnancy [34] . in terms of the risk tradeoffs between poor asthma control and the use of ocs, the current consensus remaining is that the risk of inadequate treatment is higher than the potential risk of systemic glucocorticoids. beta2-agonists are suitable for asthma patients of all levels during pregnancy, and quantitative inhalation or atomization of solution is the main administration method. short-acting beta2-agonist (saba) including salbutamol, terbutaline, and pirbuterol is used as reliever medications. naepp recommended that the preferred choice in saba is salbutamol because of its safety data for pregnant with asthma. laba, salmeterol, and formoterol are as controlled medications. laba is similar to salbutamol in pharmacologic and toxicologic profile; while there are limited data on their use during pregnancy, salmeterol might be chosen which has been available longer [29] . report indicates that using of long-acting beta2-agonists (laba) during pregnancy will not increase the prevalence of the perinatal outcomes [35] . however, in the current studies, the relationship between beta2-agonists and perinatal adverse outcomes is still controversial. a research finds no significant relationships between major congenital malformations and sga infants with exposure to beta2-agonists, theophylline, cromolyn, and corticosteroids during the first trimester or at any time [36] . a retrospective cohort study of 13117 pregnancies finds no increased risk of congenital malformations with saba exposure during the first trimester, while using laba in the first trimester is significantly associated with a higher risk of major "cardiac malformations" and major "other and unspecified congenital malformations." however, bias due to different asthma severity or chance should be considered [37] . a review identified 21 original studies; 4 studies report that use of saba during pregnancy increases risk of congenital malformations, while one study reports that high doses of saba decrease the risk. four studies indicate that beta2-agonists (saba and/or laba) contribute to increased risk of congenital malformations; one study shows a significant increased risk with laba. one study shows that laba led to low birth weight babies [38] . a populationbased case-malformed control study including 76,249 registrations of congenital anomalies from 13 euromedicat registries finds that exposure to first trimester with inhaled beta2-agonists increases the risk of cleft palate and gastroschisis. also, exposure to the combination of laba and ics is associated with renal dysplasia [39] . however, in the cohort study of 567 cases of hypertensive disorders of pregnancy and 256 cases of preeclampsia/eclampsia, laba use is not associated with increased risks of hdp or preeclampsia/eclampsia, suggesting the safety of labas for the cure of asthma in pregnancy [40] . besides, maternal asthma is closely associated with increased risk of offspring autism spectrum disorder (asd), but this adverse effect is not associated with prenatal exposure to asthma medications including laba [41] . gina (2019) suggests that saba alone is no longer as the recommended therapeutic strategy for asthma; instead gina recommends that all adults and adolescents with asthma should receive either symptomdriven (for mild asthma) or daily inhaled anti-inflammatory controller treatment, to reduce their risk of serious exacerbations and to control symptoms. anticholinergics include the shortacting muscarinic antagonist (sama), ipratropium bromide, and long-acting muscarinic antagonists (lamas), tiotropium bromide. gina guidelines suggest that combination of formoterol and saba could be used to treat severe acute asthma attacks. previous studies also have demonstrated that the use of saba plus ipratropium bromide can effectively improve severe acute asthma control. however, there is still much controversy over whether ipratropium bromide can reduce the admission rate of patients and improve their lung function [42] . a study finds that, for patients with poor asthma control by applying ics or ics combined with laba, tiotropium as add-on therapy can improve pulmonary function and reduce the frequency of exacerbations [43] . in a systematic review of 13 randomized-placebo controlled trials, the use of anticholinergic tiotropium ameliorates asthma control in patients with moderate symptomatic asthma who have already received medium-to-high doses ics or ics/laba [44] , while there are few studies on the use of anticholinergics in asthma patients during pregnancy. more studies are needed to confirm the relationship between anticholinergic drugs and perinatal adverse outcomes. low-dose theophylline is considered as an alternative for mild persistent asthma during pregnancy and as an alternative adjunctive long-acting bronchodilator therapy for moderate-to-severe asthma when ics alone cannot provide adequate control of patient's asthma [45] . eophylline can pass through the placental barrier. ere is no significant difference in theophylline concentration between maternal and umbilical cord serum, when the levels of theophylline are greater than 10 μg/ml, transient neonatal vomiting, tremor, and tachycardia can occur [46] . e blood concentration should be maintained at 5-15 μg/ ml in nonpregnant asthma patients and 5-12 μg/ml in pregnant women [47] . when serum theophylline is higher than 20 μg/ml, the risk of theophylline toxic reactions will increase [46] . since the recommended dose of theophylline is close to the toxic dose, the plasma or urine concentration must be closely monitored during the treatment, especially for pregnant women whose liver metabolic function decreased. e updated gina guidelines indicate that lowdose theophylline (serum concentrations must be monitored closely) is considered as an alternative, but not a preferred treatment for mild persistent asthma during pregnancy. for moderate-to-severe asthma during pregnancy, theophylline may be considered as an alternative adjunctive long-acting bronchodilator therapy but not a preferred therapy when ics alone does not provide adequately asthma control during pregnancy. additionally, theophylline use has no or minimal effects on fetal growth and reduces perinatal complications when maternal asthma is adequately controlled [45] . in a multicenter prospective study, compared with the effects of ics and oral theophylline on asthmatic pregnant women, the two cohorts have similar rates of asthma exacerbations, asthma outcomes, and obstetric and perinatal outcomes, while theophylline group has more adverse events, drug withdrawal rate during observation period and fev1 <80% predicted value of lung function than glucocorticoids group [48] . at present, the use of controlled-release theophylline preparations is advocated, which can dilate bronchus for 10-12 hours, and is conducive to the control of night asthma. intravenous aminophylline is mostly used in acute asthma attacks, and no teratogenic effect has been found. antileukotrienes are divided into two categories: ltras including zafirlukast and montelukast and 5-lipoxygenase pathway inhibitors, zileuton. among them, zileuton is not recommended for use in pregnancy because of the lack of relevant research and the need to monitor liver function during medication. ltras alone are less effective compared with ics and they are generally taken in combination with other asthma medications. however, the use of ltras in combination with ics has the same effect as those of labas in combination with ics in steroid-naïve asthmatic patients [49] . with the exposure to ltras in asthma patients during pregnancy, no increased risk for major birth defects is observed in a cohort study of 1164 first-trimester-exposed pregnancies [50] . and adverse outcomes including pregnancy loss, gestational diabetes, preeclampsia, low maternal weight gain, preterm delivery, low apgar scores, or small size are discovered in a cohort study of 96 infants treated with leukotriene receptor antagonists in pregnancy [51] . e ltras are only recommended for patients who had a favorable response to them before becoming pregnant. ey are an alternative to icss and are not preferred as a treatment option in mild persistent asthmatics during pregnancy [45, 52] . anti-ige monoclonal antibody omalizumab is as an add-on therapy for the treatment of nonpregnant patients with moderate-to-severe persistent asthma that is inadequately controlled with ics and has the effect of preventing exacerbation, reducing the frequency of asthmatic symptoms, reducing the frequency of emergency room visit or hospital admission, and reducing the steroid dose. a prospective, observational study, expect (the omalizumab pregnancy registry), includes 191 pregnant women who exposed to ≥1 dose of omalizumab within 8 weeks prior to conception or at any time during pregnancy and collected data on 169 pregnant women at the time of data cut-off. e proportions of major congenital anomalies (4.4%), prematurity (14.5), low birth weight (3.2%), and sga (10.9%) observed in the expect registry are consistent with findings from other studies in this asthma population. e prevalence of major congenital defects in expect is no higher than those reported in the general population with asthma. omalizumab does not appear to increase the risk of prematurity or sga infants beyond that seen in general asthma population [53] . while considering the possible anaphylaxis, this therapy is not initiated in pregnancy though sometimes may be continued if already in progress [54] . in addition to the safety, there is still a notable problem, namely, the dose titration of omalizumab. omalizumab should be dosed according to body weight and pretreatment canadian respiratory journal serum total ige levels and is injected subcutaneously once every 2 or 4 weeks. each injection ranges from 75 to 600 mg, and the maximum dose is no more than 375 mg every 2 weeks in the united states of america and 600 mg in the european union. in the european union, the eligible baseline ige level is 30-1500 iu/ml. in all countries, body weight must be no more than 150 kg. accordingly, patients whose body weight or baseline ige levels are not in the above range should not receive the treatment [55] . for pregnant women with asthma, maternal weight changes persistently over a short period of time as the fetus grows; therefore, the method of adjusting the amount of omalizumab according to body weight is a challenge for maternal asthma. after the use of high-dose ics, approximately 40-50% of uncontrolled asthma patients still have persistent airway eosinophilia. accumulating evidence suggests that interleukin-(il-) 5 contributes to airway eosinophilic inflammation. in addition to omalizumab, another two anti-il-5 monoclonal antibodies, mepolizumab and reslizumab, have also been approved as maintenance treatment program for patients with uncontrolled, persistent eosinophilic asthma with an exacerbation phenotype. mepolizumab has been approved by fda for maintenance therapy of severe asthma patients aged 12 or older and can reduce exacerbations by approximately 50% in patients with severe asthma [56] . and reslizumab is also fda approved for maintenance therapy of severe asthma in patients aged 18 or older [57] . benralizumab, another humanized monoclonal antibody selective for il-5 receptor, has also been approved by fda for add-on maintenance treatment of severe asthma in patients aged 12 or older with an eosinophilic phenotype. ere are no adequate studies of monoclonal antibodies such as mepolizumab, reslizumab, and benralizumab use in pregnant women due to the fact that monoclonal antibodies can cross the placenta during the third trimester. however, in a study of cynomolgus monkey, no harmful effects were observed on the fetus or on neonatal growth up to 6.5 months after birth when monkeys were given iv benralizumab every 2 weeks which is the maximum recommended human dose throughout pregnancy [58] . collectively, there is rarely report on the use of monoclonal antibodies against il-5 in asthma during pregnancy and their adverse effects on the maternal health or the development of the offspring. ait is currently considered to be the only treatment for the etiology of asthma, which relieves asthma symptoms and reduces asthma attacks by regular subcutaneous injection, oral administration, or sublingual administration of an injection or oral preparation of known allergens. for the general asthma patients whose symptoms are well controlled or partially controlled and are clearly linked to a relevant allergen [59] , it is a valuable treatment challenge to apply ait after weighing the pros and cons in order to improve asthma symptoms, lung function, or bronchial hyperreactivity and reduce medication requirements, but for the pregnant women with asthma, we should be more cautious. a review reports that uterine cramps may occur during anaphylaxis, also there are possible side effects of venom immunotherapy, and a 28year-old woman under wasp venom desensitization has a premature birth in her 24th week of pregnancy [60] . it is generally recognized that ait should not be initiated during pregnancy because the risk of anaphylaxis is unknown and the benefits appear minimal. however, it can be continued in patients who already received an allergic vaccine, on a stable and nonescalating dose, and whose symptoms appear to improve [54] . a group of 121 pregnancies from 90 atopic mothers who have received immunotherapy during pregnancy are studied retrospectively. e incidence of prematurity, toxemia, abortion, neonatal death, and congenital malformation is not greater than that for the general population. it suggests that ait can be cautiously continued during pregnancy without significant risk to either mother or fetus [61] . ere are still studies concluding that ait (sublingual or subcutaneous) is safe during pregnancy, even when initiated for the first time in a pregnant patient. a retrospective study included 81 patients (109 pregnancies) receiving subcutaneous immunotherapy and 60 pregnant patients (82 pregnancies) without receiving immunotherapy. in the treatment group, the incidence is similar to or less than the general population with regard to abortion, perinatal mortality, prematurity, toxemia, and congenital malformation. in the control group, there is a higher incidence of abortion, prematurity, and toxemia as compared with those treated with immunotherapy. in addition, seven patients of the treatment group who are already pregnant when immunotherapy is initiated did not develop any complications and all delivered normally [62] . in a prospective study, the subjects are divided into three groups: the treatment group receiving slit (sublingual ait, n � 155) with either house dust mite or a mixture of up to five allergens, of which 24 pregnancies received sublingual immunotherapy for the first time during pregnancy, the control group a received budesonide 400 μg twice daily (n � 85), and the control group b receives rescue treatment with salbutamol (n � 40). after follow-up for six years, the incidence of perinatal deaths, prematurity, and toxemia of pregnancy is less than that in the general population but the incidence of complications is higher in both control groups. none of the 24 patients develops complications during pregnancy and none has reactions to slit [63] . asthma attack in pregnancy is defined as requiring medical intervention during pregnancy, including unscheduled doctor visits, emergency department presentations, hospitalization, or requirement for ocss, with the occurrence rate of at least 20%-45%, and 5%-11% of women suffering severe attack (requiring ocs). e risk of severe attack in patients with mild, moderate, and severe asthma is 8%, 47%, and 65%, respectively, reported by a prospective cohort study of 146 women with asthma and pregnancy. and attack during pregnancy occurs mainly in the late second trimester, a mean of 25.1 ± 0.9 weeks of gestation. e major triggers are viral infection and nonadherence to ics; besides, the undertreatment of asthma and changes in hormone levels also play a role [64] [65] [66] . attack of asthma during pregnancy is connected with increased risk of adverse pregnancy and perinatal outcomes. current studies have shown that acute attack increases the risk of lbw; however, the relationship between acute attack and other adverse outcomes is still controversial, such as pb, sga, congenital malformations, neonatal death, and hospitalizations, as well as a range of maternal and placental complications, preeclampsia, gestational diabetes, placenta previa, and caesarean section [66, 67] . for asthma management, early identification of asthma attack during pregnancy is very important. symptoms worsening is the main manifestation of the patient, combined with pef monitoring and attention to fetal activity which is helpful in judging the condition. if pef decreases more than 50%, personal predicted suggests severe exacerbation [29] . patients with asthma in pregnancy can be treated by themselves in the early stage of asthma attack, and the specific steps and medication are the same as nonpregnancy asthma. once the patient's asthma symptoms are poor relieved or even worse, they should be hospitalized in time. in order to avoid hypoxia of pregnant women and fetuses, consider the following: giving oxygen inhalation to pregnant women, continuously monitoring oxygen saturation and fetal heart rate, using saba and ics actively, adding ocs if the patients are with poor effect, and even using intravenous hormone as soon as possible for the patients with respiratory failure. management. 90% of asthmatic pregnant women will not have an acute attack during childbirth, and only inhaling bronchodilators can control symptoms, while patients with chronic or frequent use of steroids may be at risk of adrenal insufficiency during delivery, and a pressure dose (100 mg of hydrocortisone every 6-8 hours) can be used to prevent adrenal insufficiency during delivery and on the first day after delivery. furthermore, if mothers use saba in large doses, newborns, especially premature babies, need to be tested for blood glucose within 24 hours. in addition, asthma patients should also be cautious about using some common measures during delivery such as drugs for cervical ripening, analgesic, and anesthesia. oxytocin and prostaglandin e2 can be to induce labor in asthmatics. fentanyl is an acceptable drug to relieve pain; however, morphine, meperidine, or other narcotics for analgesia are likely to cause the release of histamines and bronchospasm. epidural rather than general anesthesia is recommended for asthmatics who need a painless delivery to reduce the risk of pulmonary infection and atelectasis [68, 69] . intervention is equal in importance with the pharmacologic treatment. as mentioned at the beginning of the article, poor drug compliance and incorrect use of inhaled drugs are important factors that make asthma difficult to control, especially in pregnant women, given the potential risks of drugs to mothers and fetuses. e purpose of education is to improve patients' compliance, standardize medication according to the asthma action plan, master correct inhalation techniques, and self-monitor the condition. triggers. asthma patients should avoid or reduce irritants such as allergens, climate change, drugs, sports, specific environments, and occupations and try specific environmental controls such as air filtration or special bed covers. in addition to the above factors, avoiding infection is an important measure to reduce asthma attacks. viral infection has been identified as an important trigger for asthma attacks, and the risk of viral infection in asthma during pregnancy is higher than that in nonpregnant women. a prospective cohort study of 168 asthmatic pregnant women and 117 nonasthmatic pregnant women finds that 71% of asthmatic pregnant women and 46% of nonasthmatic pregnant women have a common cold during pregnancy (incidence rate ratio: 1.77, 95% ci: 1.30-2.42, p < 0.0001). among asthmatic pregnant women, rhinovirus is detected in 38.5%, coronavirus in 13.8%, influenza virus a or b in 12.3%, and enterovirus in 9.2%. one-third of patients who tested positive for respiratory virus pcr are associated with acute exacerbation of asthma, and one-third lost control of their asthma [70] . asthma patients often have comorbidities (like allergic rhinitis, sinusitis, gastroesophageal reflux, obesity, chronic obstructive pulmonary disease, bronchiectasis, obstructive sleep apnea syndrome, depression and anxiety, etc.), especially those with severe and uncontrolled asthma. in pregnant women, the prevalence of gestational rhinitis, gerd, overweight or obesity (in europe), and depression is 22%, 30-50%, 25.6%-48.4%, and 11%, respectively [71] [72] [73] [74] . since these comorbidities may lead to worsening of symptoms and drug interactions, even increases the risk of perinatal adverse outcomes in pregnant women, active treatment should be given and followed. for pregnant women, physical structural changes, the direct effect of hormones, and the changes of immune function induced by hormones are involved in the control of asthma; one-third of asthma patients are aggravated due to pregnancy. to minimize maternal and fetal perinatal risks, assessing patient's condition by early identification of new onset asthma in pregnancy, monitoring changes of asthma symptoms, pef variability, feno, and fetal activity, education for improving patients' compliance and standardizing medication, avoiding triggers, treating complications actively, and using drug therapy by a stepwise approach are all needed to be written in asthma control plan. many studies and guidelines support the fact that inadequate treatment has a greater impact on mothers and fetuses than potential drug side effects. achieving a good whole-course management of asthma patients in pregnancy still requires continuous efforts of clinicians and patients themselves. canadian respiratory journal 7 conflicts of interest e authors declare that they have no conflicts of interest. asthma prevalence among pregnant and childbearing-aged women in the united states: estimates from national health surveys effect of maternal asthma on birthweight and neonatal outcome in a british inner-city population e course of asthma during pregnancy in a recent, multicase-control study on respiratory health asthma knowledge, care, and outcome during pregnancy: the qakcop study asthma in pregnancy: a hit for two perinatal outcomes following 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controlled, eosinophilic asthma benralizumab (fasenra) for severe eosinophilic asthma clinical contraindications to allergen immunotherapy: an eaaci position paper arguing the misconceptions in allergen-specific immunotherapy e safety of immunotherapy during pregnancy a retrospective study on the safety of immunotherapy in pregnancy a prospective study on the safety of sublingual immunotherapy in pregnancy severe asthma exacerbations during pregnancy asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes asthma during pregnancy: exacerbations, management, and health outcomes for mother and infant determinants of low risk of asthma exacerbation during pregnancy asthma management across the life span: the childbearing woman with asthma a prospective study of respiratory viral infection in pregnant women with and without asthma are proton pump inhibitors safe during pregnancy and lactation? evidence to date risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews depression during pregnancy key: cord-016173-ro7nhody authors: louis, mariam; oyiengo, d. onentia; bourjeily, ghada title: pulmonary disorders in pregnancy date: 2014-08-13 journal: medical management of the pregnant patient doi: 10.1007/978-1-4614-1244-1_11 sha: doc_id: 16173 cord_uid: ro7nhody pregnancy is associated with some profound changes in the cardiovascular, respiratory, immune, and hematologic systems that impact the clinical presentation of respiratory disorders, their implications in pregnancy, and the decisions to treat. in addition, concerns for fetal well-being and safety of various interventions complicate the management of these disorders. in many circumstances, especially life-threatening ones, decisions are based upon a careful assessment of the risk benefit ratio rather than absolute safety of drugs and interventions. in this chapter, we review some of the common respiratory disorders that internists or obstetricians may be called upon to manage. asthma is the most common respiratory disease during pregnancy. asthma affects 4-8 % of pregnancies in the united states and up to 12 % in the united kingdom and australia. difference in prevalence around the world may be related to reporting methods, diagnostic methods, or possibly some environmental or genetic infl uences. pregnancy is a state of important physiological changes in the respiratory system. these physiological changes vary across the course of the pregnancy and are summarized in table 11 .1 . • 105-106 in fi rst trimester and 101-106 by third trimester paco 2 (mmhg) • 28-29 in fi rst trimester and 26-30 by third trimester ph • 7.43 hco 3 (meq/l) • 17-18 tlc total lung capacity, erv expiratory reserve volume, rv residual volume, frc functional residual capacity, vc vital capacity, ic inspiratory capacity, irv inspiratory reserve volume, fev1 forced expiratory volume in 1 s, fvc forced vital capacity, pao 2 partial arterial pressure of oxygen, paco 2 partial arterial pressure of carbon dioxide the course of asthma during pregnancy is variable. the majority of patients who improve in pregnancy tend to worsen in the postpartum period and vice versa [ 1 ] . in general, asthma improves toward the end of the pregnancy, including labor and delivery. however, the rate of asthma exacerbations is increased between gestational weeks 17 and 32 [ 1 , 2 ] . this may in part be due to medication noncompliance during the earlier part of the pregnancy upon discovery of the pregnancy but may also have to do with other pregnancy-related factors such as esophageal refl ux, nasal congestion, hormonal factors, and alterations in immunity that may result in increased susceptibility to infections. the major predictor of disease course is the severity of asthma prior to the pregnancy, but race and obesity may also play a role. african american and hispanic women are more likely to have asthma exacerbations. poor compliance with medications and diffi culties with access to medical services may be important confounders. additionally, obese women tend to have more severe asthma as both asthma and obesity share a common infl ammatory pathway at the cellular level. asthma also tends to behave in a similar fashion in subsequent pregnancies. while well-controlled asthma does not appear to have adverse consequences during pregnancy, poorly controlled asthma may negatively impact some maternal and fetal outcomes. in the largest study performed to date on over 37,000 women with asthma and over 280,000 controls, asthmatic women were more likely to have pregnancies complicated by miscarriage, antepartum and postpartum hemorrhage, anemia, and depression [ 3 ] . however, the risk of other negative outcomes such as gestational hypertensive disorders and stillbirths was not signifi cant in this study. in other large studies, a small, but statistically signifi cant risk of perinatal mortality, preeclampsia, and preterm deliveries have been reported [ 4 , 5 ] . a more recent retrospective cohort study performed in 12 clinical centers in the united states has shown increased risk of preeclampsia, gestational diabetes, and all preterm births [ 6 ] . secondary analysis of a recent randomized controlled trial showed that women with perception of good asthma control had a reduced risk of planned cesarean deliveries, asthma exacerbations, and preterm birth [ 7 ] . in the same study, women with increased anxiety had a higher risk of exacerbations. there is some evidence suggesting that poorly controlled asthma also confers an increased risk of small for gestational age, and low birth weight [ 8 ] . growth restriction may, however, be confounded by smoking. babies born to severe asthmatics are possibly more likely to have congenital anomalies [ 5 ] . the treatment of asthma involves assessment and management from preconception to the postpartum period. please refer to table 11 .3 and figure 11 .1 for a general overview of the classifi cation and management of chronic asthma. there are four general components of asthma care, irrespective of gestational age. these are (1) monitoring of respiratory status, (2) avoidance of possible triggers, (3) patient education, and (4) pharmacological treatment. patients should get a baseline spirometry and be instructed in how to follow their peak expiratory fl ow rate (pefr) at home. ideally, this should be done twice a day in patients with persistent disease. since pregnancy does not affect fl ow rates, reductions in these numbers usually indicate a worsening degree of airfl ow obstruction and should prompt quick medical evaluation. second, it is critical that patients avoid their known triggers to asthma including tobacco, dust, extreme temperatures, and allergens such as pollen and pet dander. third, patients need to be educated about their disease. pregnancy constitutes a perfect window to educate women given the multiple contacts with providers increased motivation due to concerns for fetal well-being. trigger control from washing bed sheets to vacuuming to rodent control are important strategies to review, especially since in most circumstances, women are more likely to be exposed to these triggers. important topics that need to be reviewed also include inhaler technique, early recognition of symptoms of worsening asthma, an action plan for acute asthma exacerbations, as well as an overview of how poorly controlled asthma can affect the pregnancy. patients should also be provided with the opportunity to express their concerns and ask questions. in a multi-institutional prospective study, lower forced expiratory volume in 1 s (fev1), but not asthma symptom frequency, was shown to be associated with adverse perinatal outcomes [ 9 ] . these data may be a refl ection of the effect of asthma severity or poor asthma control on perinatal outcomes and emphasize the possibility of discrepancies between symptom-based assessment and more objective measurement of lung function in pregnant women with asthma. finally, women with asthma need to receive the appropriate pharmacological treatment to achieve disease control. populationbased data do show that well-controlled asthmatics without exacerbations have better outcomes than women with exacerbations, but for obvious reasons, there are no randomized controlled trials evaluating this particular question. although most clinical practices use symptom-based, guideline-directed assessments to decide on medication use, recent data from a randomized controlled trial suggest lower rates of exacerbation, improved quality of life, and reduced neonatal hospitalization when management decisions were based on measurements of exhaled nitric oxide in pregnancy [ 10 ] . it is likely that this improvement in outcomes is due to improved control, rather than the method of assessment itself. table 11 .2 provides an overview of the asthma medications that are used in pregnancy. as in the nonpregnant population, the choice of pharmacological agent depends on disease severity. a frank discussion with the expectant mother and her partner should occur to encourage them to voice their concerns regarding asthma treatment in pregnancy. most women are told to stop their inhalers at the time of pregnancy diagnosis because of fda category listing. for that reason, a good amount of time should be spent on counseling about the use of asthma drugs in pregnancy. explaining to women that asthma control is key to the health of the pregnancy and their baby is an important part of counseling and may have to be done repeatedly during the course of pregnancy. in general, most asthma medications are justifi able in pregnancy, and some have adequate safety data. as noted in table 11 .2 , many of the drug choices are category c according to the fda classifi cation; however, these drugs are used routinely in the care of pregnant women with asthma. in addition, although leukotriene inhibitors are listed as category b, safety data are less reassuring than other drugs classifi ed as category c. omalizumab is classifi ed as category b by the fda despite the fact that all of the initial trials have excluded pregnant women. these safety data are based on animal studies which are limited by the fact that teratogenicity may be species specifi c. in addition, although prednisone may be associated with a small risk of cleft palate when administered in early pregnancy, the benefi t of this drug in an acute exacerbation of asthma by far outweighs the small risk of malformation. table 11 .3 reviews the classifi cation of asthma severity, which includes not only symptoms but also peak fl ow meter measurements. other coexisting diseases may worsen asthma and may have to be treated in order to achieve optimal control. the most common of these disorders are allergic rhinitis, gastroesophageal refl ux disease (gerd), sleep apnea, and psychiatric illnesses. allergic rhinitis occurs in 80-90 % of nonpregnant asthmatics and worsens asthma symptoms. management of the allergic rhinitis with drugs such as steroidal nasal sprays often improves asthma symptoms. women who are pregnant can also develop a different form of rhinitis, called rhinitis of pregnancy. this typically occurs in the latter part of pregnancy and resolves completely within 2 weeks after delivery. the prevalence of gerd among nonpregnant asthmatics varies between 30 and 90 %. in pregnant women with asthma, this number is likely higher given that gerd has been reported to be present in nearly 75 % of all pregnant women [ 11 ] . gerd can worsen bronchoconstriction via increased vagal tone, heightened bronchial reactivity, and microaspiration of gastric contents into the upper airway. patients who have symptoms of gerd benefi t from treatment. although proton pump inhibitors are not expected to increase the risk of congenital malformation in experimental animal studies and limited human pregnancy exposures, ranitidine constitutes a safer fi rst choice. finally, asthma and psychiatric comorbidities may coexist. stress and mental illness can worsen asthma in the pregnant women and may also complicate compliance. during labor, the general management of asthma is not signifi cantly different than above. most patients with asthma do not require a labor and delivery plan. however, patients with more severe disease or those who suffered an exacerbation close to term would require a detailed plan. stress dosing with steroids during labor can be considered in patients who have been on prolonged periods of systemic steroids during the pregnancy. patients with active symptoms or more severe asthma may benefi t from regional anesthesia. epidural anesthesia reduces minute volume and oxygen consumption and may help prevent hyperinfl ation in patients with active symptoms and reduce oxygen consumption. if general anesthesia is to be considered, then ketamine and halogenated anesthetics are preferred. it is safe to use oxytocin and prostaglandin e2. however, ergotamine and ergot derivatives, 15-methyl prostaglandin f2 alpha, morphine, and meperidine should be avoided in pregnant women with asthma as they may be associated with an increased risk of bronchospasm. an overview of the management of acute asthma exacerbations in the pregnant woman is detailed in fig. 11 .2 . more detailed information can be found in national heart lung and blood institute guidelines on asthma and pregnancy published in 2004. the treatment is similar to nonpregnant women with a few key differences that need to be highlighted. the fi rst is to remember that during pregnancy, the normal paco 2 is lower than in the nonpregnant state. therefore, a normal or high paco 2 heralds worsening respiratory failure and should be acted upon quickly. second, hypoxia during asthma exacerbations can lead to fetal distress and decelerations. therefore, immediate bronchodilators and supplemental oxygen should be administered. finally, it should be noted that while the indications for airway intubation are the same in the pregnant asthmatic as the nonpregnant asthmatic, intubation during pregnancy, especially in the third trimester, can be more diffi cult. this is due to increased airway edema, low frc and oxygen reserve, and a more profound response to sedatives from decreased venous return. hence, the most experienced member of the team should perform the intubation and be familiar with diffi cult airway management procedures. airway intubation is discussed in more detail in the critical care chap. 2 . pneumonia is one of the leading causes of non-obstetric maternal deaths in the united states [ 12 ] . there are several categories of pneumonia based on the likely spectrum of pathogens: community-acquired pneumonia (cap), healthcareassociated pneumonia, hospital-acquired pneumonia, and ventilator-associated pneumonia as well as pneumonia in the immune-compromised host. as pregnant women are usually young and healthy, cap predominates. the overall rate of cap in pregnant women is 0.5-1/1,000 pregnancies depending on the population being studied [ 13 -15 ] . the risk of pneumonia is notably increased in gravidas with comorbid conditions such as asthma, anemia, and human immunodefi ciency virus [ 16 ] . tobacco and substance abuse have also been independently associated with an increased risk for pneumonia. infl uenza increases the risk for development of bacterial pneumonia by denuding the respiratory epithelium and predisposing the host to infection. in adults, the causative agents for cap are identifi ed in 40-60 % of cases when advanced testing techniques are utilized [ 17 , 18 ] . the yield is much lower, in the range of 10-25 %, with regular testing. though specifi c studies in pregnant women are lacking, the likely pathogens are not considered to be signifi cantly different • less severe symptoms • pefr between 50-80% predicted [ 19 ] . pregnant women may be more likely to contract viral infections and tend to have more severe disease than the nonpregnant population. therefore, the estimates above may be somewhat different in pregnancy. gingival hyperplasia in pregnancy may promote changes in oral fl ora and promote growth of anaerobic bacteria. aspiration risk and heartburn [ 11 ] may be increased in pregnancy, especially when undergoing sedative procedures or general anesthesia. whether these changes and increased gastroesophageal refl ux disorders are associated with increased risk of pneumonia is not clear. immune alterations in pregnancy that promote maternal tolerance to the fetus may impair optimal function of host defense mechanisms and increase the risk of infections. pregnant women have decreased lung capacity and decreased erv and rv resulting in a reduction in functional residual capacity. a state of compensated respiratory alkalosis is established by increasing minute ventilation. this is largely secondary to an increase in tidal volume and to a lesser extent an increase in respiratory rate. healthy gravid subjects have increased cardiac output and decreased oncotic pressure which peaks in the third trimester that promotes transudation of fl uid into the pulmonary interstitium. these changes diminish oxygen reserve, increase the risk of development of pulmonary edema with fl uid resuscitation, and predispose to respiratory failure and predispose women to more severe disease. pneumonia may be complicated by hypoxia, respiratory failure, or death, and preterm delivery appears to be the most common obstetric complication associated with maternal pneumonia. while intrauterine infection is known to cause preterm delivery, a causal relationship between pneumonia in pregnancy and preterm delivery is not well established. it is possible that higher levels of cytokines and other mediators such as tnf-α and prostaglandin f2 reported in bacterial infections may lead to preterm delivery and low birth weight. other reported complications include placental abruption, preeclampsia and eclampsia, and low apgar scores [ 20 -22 ] . it is unclear, however, whether these complications are related to the actual infection or to other host factors. common causes for respiratory distress in pregnancy include infection such as urinary tract infection, pulmonary edema, asthma, aspiration, and pulmonary embolus. the clinical spectra of pneumonia caused by different pathogens overlap considerably. thorough history and examination along with microscopic examination of respiratory secretions may narrow the differential diagnosis and identify the offending pathogen. urine pneumococcal and legionella antigen may also aid in guiding antibiotic therapy and should be considered for patients requiring admission. during infl uenza seasons, respiratory viral panel should be sent. though blood cultures are usually negative and of low yield, they may add value in the patient requiring admission to the intensive care unit (icu). arterial blood gas should be done for all patients with hypoxia or those requiring admission to the icu and interpreted according to pregnant status. chest x-ray should be performed in patients suspected of having pneumonia and helps confi rm the diagnosis or show evidence of a complicated pneumonia such as lung abscess or pleural effusion. computed tomography scan is unlikely to add value in the management of pneumonia, unless empyema is suspected. ultrasound guidance likely reduces the risk of complications with thoracentesis in pregnancy given the cranial displacement of the diaphragm in pregnancy. bronchoscopy though rarely needed can be performed safely in pregnancy and should not be withheld when indicated. general supportive measures are similar in patients with various types of pneumonia. for patients with a viable fetus who require admission, the obstetric team should be consulted for fetal monitoring as well as timing of delivery in the event of fetal distress. hypoxia, acidosis, and fever should not be tolerated as they are independently associated with poor fetal outcomes. oxygen should be supplemented for goal saturations > 95 % or pao 2 above 70. fever should be treated aggressively for a goal temp of less than 38 °c. in cases of severe pneumonia associated with respiratory failure, early intubation should be considered. intubations in pregnancy have a higher failure rate than the general surgical population (see chap. 2 on airway intubation ). attempts to maintain co 2 within an acceptable range may be challenging in the event of acute respiratory distress syndrome (ards) and the use of lung protective strategies. low tidal volume ventilation strategy with a target tidal volume of 6 ml/kg is recommended for ards [ 23 ] . though pregnant women were excluded in the acute respiratory distress network studies on lung protective strategies, low tidal volume ventilation should be attempted, initially with a higher respiratory rate to maintain ventilation given the survival benefi t observed in the nonpregnant population. however, higher tidal volumes may be required to correct acidosis that may compromise the fetus, in such instances attempts should still be made to keep the plateau pressure below 30 cm of water as barotrauma is thought to contribute signifi cantly to lung injury. paco 2 levels need to be watched closely, and given the 10 mmhg gradient between fetal and maternal, maternal paco 2 should be kept at 55 mmhg or lower. use of bicarbonate to correct the ph has been suggested in the nonpregnant population though clinical studies to support this approach are limited. it is thought that the transfer of bicarbonate across the placenta is slow and may not be adequate to correct fetal acidosis. while the decision to admit patients to the icu is complex and should be individualized, clinicians should have a lower threshold when evaluating pregnant mothers. antibiotic therapy should be initiated empirically while awaiting confi rmatory tests that may aid in narrowing the antimicrobial coverage. in infl uenza season, antiviral (usually oseltamivir) should be started empirically as well. decisions about antibiotic choice should address the most likely pathogen, adverse effect on the mother, and should also weigh the risk of the specifi c drug to the fetus against the risk of inappropriately treated disease. an optimal drug would be one with maximal efficacy against the known pathogen and no risk to the fetus. however, such drugs are scarce, and in most circumstances, a drug with more benefi t than risk can be selected. other than concern for fetal safety, preferred antibiotics are not different from those in nonpregnant women, but dosing should take into account increased hepatic and renal clearance and increased volume of distribution. there is a theoretical concern that aminoglycosides and vancomycin may be associated with hearing and kidney dysfunction in the offspring, but this possibility has not been confi rmed clinically. penicillins, clindamycins, and most macrolides except clarithromycin have a good safety profi le. fluoroquinolones are usually avoided in pregnancy due to a theoretical risk of arthropathy in the offspring. however, some experts argue that this issue is not clinically signifi cant in humans. tetracyclines should be avoided as they may cause permanent dental discoloration. varicella (chicken pox) is caused by varicella zoster virus (vzv). varicella is predominantly a childhood illness that is usually self-limited and rarely results in severe disease. in adults, however, it is much more likely to be severe. vzv is not only likely to have increased morbidity and mortality in pregnancy but may also be associated with congenital abnormalities and poor fetal outcomes. varicella pneumonia is among the most severe maternal complication of vzv infection [ 24 -27 ] . viral particles are shed from varicella-associated vesicles and get airborne. inhalation or contact with the conjunctiva results into contraction of the infection with entry of the virus through the respiratory mucosa. crusting over of the last crop of vesicles usually marks the end of the contagious period. patients are known to be infectious 2-3 days prior to development of the vesicular rash; for this reason, an alternative viral shedding site such as the respiratory tract is believed to exist [ 28 ] . varicella is highly contagious with seasonal variation in incidence, being most prevalent in the winter and spring. it has a very high clinical attack rate of 65-86 % following exposure to susceptible individuals [ 29 ] . following a primary infection with varicella, lifelong immunity is usually established in the majority of subjects; in a few people, however, second attacks of varicella may occur [ 30 ] . while varicella follows a benign course in children, adults have up to 25 times increased risk of severe disease [ 31 ] . pregnant women are at a uniquely increased risk for infection. in the united states, the incidence of primary varicella averages 0.7-3 cases/1,000 pregnancies. varicella pneumonia complicates 10-20 % of all cases, and 40 % of mothers with pneumonia require mechanical ventilation [ 32 , 33 ] . maternal mortality from varicella pneumonia used to be high at 20-45 % before the introduction of antiviral therapy but is currently estimated at less than 3-14 % [ 34 , 35 ] . changes in physiology and immunity associated with pregnancy may increase the risk of infection and severe outcomes in the pregnant women. in an effort to promote maternal tolerance to fetal antigens, pregnancy is associated with a shift from th1 to th2 lymphocyte responses and associated cytokines at the maternal fetal interface. macrophage and lymphocyte-secreted th2 cytokines stimulate b lymphocytes promoting a humoral response while suppressing cytotoxic lymphocytes. while pregnancy may not necessarily be an immune-suppressed state in the real sense, immunity against vzv infection is primarily cell mediated, and a systemic shift away from cell-mediated immunity may increase susceptibility to intracellular viral pathogens, parasites, and bacteria. primary varicella (chicken pox) is associated with several adverse effects in pregnancy such as preterm delivery and low birth weight. in one study involving 106 pregnant women with varicella compared to a similar number of noninfected controls, 14.3 % of pregnant women with chicken pox had a preterm delivery as compared to 5.6 % of controls [ 36 ] . low birth weight and intrauterine growth restriction have been described. nearly 1-2 % of cases of maternal primary vzv infection result in congenital varicella syndrome (cvs), which is associated with a mortality of up to 30 % in the fi rst few months of life and severe disability in survivors. primary vzv infection prior to the 20th week of pregnancy is associated with the highest risk for cvs [ 24 , 36 ] . clinical features of cvs include skin lesions in a dermatomal distribution that may lead to eventual scarring in up to 70 % of cases, muscle and limb hypoplasia in up to 72 % of cases, chorioretinitis and cataracts in up to 52 % of cases, and abnormalities of gastrointestinal, genitourinary, and cardiovascular system in 7-24 % of cases [ 37 , 38 ] . neurological abnormalities such as mental retardation, microcephaly, and hydrocephalus occur in 48-62 % of cases resulting in learning diffi culties and developmental delays [ 39 ] . the pathobiology of cvs is thought to be in utero reactivation similar to that of herpes zoster with a shortened latency period that is likely due to immature fetal cell-mediated immunity. while up to 25 % of babies born to mothers with primary vzv infection have serologic evidence of infection, there is no serologic evidence of infection in babies born to mothers with herpes zoster. similarly, infants do not appear to be at risk of infection if maternal zoster occurs near delivery [ 40 ] . unless disseminated, herpes zoster is thus not associated with a signifi cant increase in adverse fetal outcomes [ 37 , 41 ] . peripartum varicella infection places the infant at risk for neonatal varicella, which is associated with mortality rate as high as 20 %. following a 2-to 3-week incubation period, fever, headache, malaise, anorexia, and other constitutional symptoms precede the occurrence of the rash by 2-3 days. the rash is typically vesicular, generalized, and intensely pruritic. varicella pneumonia can develop anywhere from day 1 to day 6 after the onset of the rash. late onset of respiratory symptoms with recurrence of fevers is suggestive of bacterial coinfection rather than primary viral pneumonia. skin superinfection with staphylococcal bacteremia and neurological involvement with encephalitis may occur. a thorough history and skin exam may strongly suggest the diagnosis of varicella. chest radiograph pattern in varicella pneumonia is nonspecifi c and may be normal or show unilateral or patchy areas of consolidation or nodular opacities. ct fi ndings include multicentric hemorrhage and necrosis centered around the airways and small nodular opacities surrounded by ground glass which may coalesce to form consolidations. healed and calcifi ed pulmonary nodules may persist [ 42 ] . skin lesion (rather than bronchoscopic) sampling offers a high yield and should be attempted fi rst. the base of newly erupted vesicles has the highest yield and should be sampled. specimens can then be sent for viral culture, polymerase chain reaction (pcr), and immunofl uorescence (dfa). direct fl uorescent antibody test is rapidly available in most institutions. though bronchoscopy in most cases is not necessary, varicella may be recovered from bronchial washings by viral pcr and viral culture techniques. pregnant women suspected of having varicella should be admitted for initiation of antivirals and other supportive treatment. chest imaging should be performed on admission to evaluate for pulmonary involvement. antiviral therapy is associated with a reduction in the duration of symptoms when initiated within the fi rst 24 h of onset of the varicella rash. due to the high risk of varicella pneumonia in pregnancy, empiric antiviral therapy should be initiated while awaiting confi rmatory results. acyclovir or valacyclovir are the antivirals of choice. oral acyclovir has low bioavailability that requires it to be administered in frequent doses to achieve therapeutic levels. valacyclovir has high oral bioavailability and less frequent dosing intervals and is an alternative oral formulation. there is however less experience with valacyclovir compared to acyclovir. presence of pulmonary symptoms should prompt admission to the icu and initiation of intravenous acyclovir which has a guaranteed and higher bioavailability. antiviral therapy is associated with significantly less morbidity and mortality when initiated prior to 72 h. late presentation with varicella pneumonia should not obviate the initiation of antiviral therapy. a dose of 10-15 mg/kg intravenously every 8 h for 5-10 days is recommended for vzv pneumonia. pulmonary bacterial superinfection may occur. studies characterizing bacterial pathogens likely to cause superinfection are lacking. thus, empiric broad-spectrum antibiotic coverage should be initiated in pregnant women with pneumonia. despite acyclovir crossing the placenta in signifi cant amounts, there appears to be no reduction in congenital varicella syndrome with treatment. the neonate should be isolated from the mother in the peripartum period until the mother is deemed noncontagious. consultation with high-risk obstetrics and neonatology would be useful given the risk of preterm labor and growth restriction. immunity to varicella consists of both vzv-specifi c neutralizing antibodies and cell-mediated immunity. immunity against vzv can be assessed by the use of antibody serologic assays. though there are no adequate controlled trials examining the effectiveness of vzig prophylaxis, vzig is associated with more than 40-50 % reduction in risk of contracting varicella and a signifi cant reduction in risk of severe disease [ 40 ] . vzv can be prevented by vaccination. vzv vaccine is a live attenuated vaccine and is generally not recommended in pregnancy and in immune-suppressed individuals. varicella can be contracted from herpes zoster lesions as well. family members with such lesions should minimize contact and cover their lesions to decrease the risk of transmission. healthcare workers who deal with pregnant women should be screened and vaccinated, and similarly pregnant healthcare workers should avoid contact or exposure to patients with varicella. infection with infl uenza virus can result in an acute respiratory illness of varying severity. the majority of healthy individuals infected with infl uenza is asymptomatic or has minimal symptoms. however, adults with comorbidities, elderly subjects, and healthy pregnant women are at increased risk of severe disease and death. in addition, infl uenza infection during pregnancy increases the risk of adverse fetal outcomes. in a regular endemic season, infl uenza is estimated to result in 200,000 hospitalizations and 36,000 deaths in the united states. pregnant women are at increased risk for morbidity (including cardiorespiratory complications) and mortality from infl uenza compared with nonpregnant controls [ 43 -46 ] that is more pronounced in the second and third trimester of pregnancy [ 47 ] . in 2010, the pandemic h1n1 infl uenza in pregnancy working group reported on 788 pregnant women in the united states with 2009 infl uenza a(h1n1). among those, 30 died (5 % of all reported 2009 infl uenza a (h1n1) infl uenza deaths in this period). most hospitalizations and deaths occurred in the third trimester [ 47 ] . pregnant women with comorbidities or those who smoke have an increased risk for severe disease requiring hospital admission compared to those without comorbidities [ 48 , 49 ] . as discussed above, these physiological changes make pregnant women more susceptible to acquiring viral infections and subsequent development of severe disease. apart from direct effects to the mother, infl uenza has been associated with undesirable effects to the fetus. risks of adverse fetal outcomes vary with the severity of maternal disease. preterm delivery appears to be the most common and consistent complication associated with infl uenza pandemics. in the pandemic of 1918 and 1957, higher rates of pregnancy loss, premature delivery, preterm deliveries, as well as other adverse effects were reported. in several reports during the pandemic infl uenza of 2009 among pregnant women requiring admission, preterm delivery was close to 30 % and was even higher among mothers who were admitted to the icu [ 48 , 50 , 51 ] . several other adverse fetal outcomes of maternal infl uenza have been reported especially during pandemics, including abortion, fetal distress, and placenta abruption [ 50 , 52 ] . symptoms of infl uenza in pregnancy are similar to symptoms outside of pregnancy. infl uenza virus-mediated leukopenia may make the host more susceptible to bacterial infections. secondary bacterial pneumonia is characterized by the appearance of a new fever and productive cough during early convalescence. radiologic fi ndings are generally similar to other viral pneumonias, and more extensive fi ndings are associated with more severe complications. tree in bud opacities may also be seen. laboratory fi ndings may include an elevated or low white count, lymphopenia, and hyponatremia. myoglobinuria and renal failure can occur rarely. cardiac muscle damage with associated electrocardiographic changes, disturbances of rhythm, and high levels of cardiac enzymes have been reported after infl uenza virus infection. sputum cultures may be revealing in the event of bacterial superinfection. streptococcus pneumoniae , staphylococcus aureus , haemophilus infl uenzae , and group a hemolytic streptococci are the bacterial pathogens most commonly isolated in adults with infl uenza. a defi nitive diagnosis of infl uenza requires laboratory confi rmation. diagnostic tests for infl uenza fall into four broad categories: virus isolation [culture], detection of viral proteins, detection of viral nucleic acid, and serological diagnosis. detection of viral nucleic acid allows for typing and subtyping of the specifi c virus strain. treatment of infl uenza consists of supportive management and specifi c antiviral therapy. optimizing supportive treatment is central to the management of infl uenza and probably of more benefi t than specifi c antiviral therapy. supportive therapy is similar to other types of pneumonia as discussed above. as with most drugs, information about safety and effectiveness of anti-infl uenza drugs during pregnancy is scarce. in view of potential severe maternal disease from infl uenza and adverse fetal outcomes, benefi ts of treatment with antivirals likely outweigh the potential risks to the fetus. there are two classes of antiviral drugs currently in general clinical use: adamantanes, (examples of which include amantadine and rimantadine) and neuraminidase inhibitors such as oseltamivir, zanamivir, and peramivir . adamantanes are active against infl uenza a only, increase infl uenza a resistance to adamantanes, and are associated with embryotoxicity in animal studies. as such they are not recommended in pregnancy. neuraminidase inhibitors are active against infl uenza a and b viruses. they are preferred in all adults and in pregnancy. though studies in pregnancy are inadequate, extensive use of oseltamivir in pregnancy during the 2009 hin1 pandemic was not associated with adverse effects specifi c to the drug. neuraminidase inhibitors reduce the duration and severity of symptoms and duration of viral shedding when initiated within 48 h of symptom onset [ 43 , 48 , 53 , 54 ] . there is also evidence to support reduction in complication rate, duration of hospitalization, and mortality in adults. observational studies published during the 2009 pandemic demonstrated that, among pregnant women hospitalized with pandemic h1n1 infection, treatment with oseltamivir was associated with fewer intensive care unit admissions, less use of mechanical ventilation, and decreased mortality [ 43 , 48 ] . empiric treatment should always be initiated in the gravid woman when infl uenza is suspected while awaiting confi rmatory results as delay in initiation of treatment is associated with an increased risk of severe outcomes, icu admission, and death [ 48 , 49 , 55 ] . pregnant mothers presenting after 48 h of symptom onset should still be initiated on therapy as there is evidence of benefi t even when initiated after 2 days of symptom onset. initiation of antiviral therapy within the fi rst 48 h is associated with the most benefi t [ 43 , 48 , 49 , 53 , 56 ] . there is less experience with zanamivir which is administered by inhalation route. zanamivir is also contraindicated in patients with asthma as it has a potential of worsening respiratory symptoms [ 57 ] . for patients requiring admission to icu for infl uenza pneumonia or in cases of suspected secondary bacterial infection, empiric antibiotic therapy should be initiated. sputum culture may be helpful in the case of isolation of resistant bacteria that may warrant changes or broadening of antibiotic coverage. in pregnant women, infl uenza vaccination induces an antibody response similar to that in nonpregnant women. cdc and who recommend pregnant women or women who will be pregnant during the winter or peak infl uenza season to be prioritized for vaccination. in addition to protection to the mothers, infl uenza vaccination may offer protection to the neonate as well as contribute to herd immunity in other family members. pregnant mothers who have not been vaccinated or those with comorbidities such as asthma who have been exposed to infl uenza may benefi t from antiviral prophylaxis. oseltamivir is preferred for prophylaxis due to its ease of administration. sleep-disordered breathing (sdb) is a spectrum of disorders that encompasses snoring and upper airway resistance, obstructive sleep apnea (osa), and other disorders. osa is a disorder characterized by periodic and recurrent collapse of the upper airway during sleep. obesity, age, and upper airway and facial abnormalities are the most recognized risk factors for the disorder. osa is prevalent in patients with chronic hypertension, cardiovascular disease, and metabolic disorders such as diabetes mellitus. the pregnant population appears to be at risk for the disorder given anatomic upper airway changes that occur in pregnancy as well as physiological changes and hormones. snoring occurs in close to 35 % of pregnant women [ 58 ] . the prevalence of osa in pregnancy is not well known, but preliminary data suggest that close to 60 % of loud snorers in pregnancy have at least mild osa. the natural history of snoring around pregnancy is, however, unclear. there are some data suggesting that osa actually improves in untreated postpartum women around 3 months after delivery. data on osa predating pregnancy is missing and pregestational and gestational osa may have different clinical consequences. there is a signifi cant lack in screening for the disorder by obstetric providers according to a recent study, even in obese patients [ 59 ] . notably, the berlin questionnaire, a widely used screening tool in the nonpregnant population, appears to have poor positive and negative predictive values in pregnancy [ 60 ] . snoring and excessive daytime sleepiness may be important predictors [ 61 ] . chronic hypertension, age, obesity, and snoring appear to have a good predictive value for osa in high-risk populations [ 62 ] . further validation of this potential predictive model in different pregnant populations is needed. snoring and osa have been shown to be associated with a variety of adverse pregnancy outcomes including gestational hypertension, gestational diabetes, and cesarean deliveries. gestational hypertension is the most studied link with numerous studies on snoring as well as osa showing a two-to threefold increased risk of gestational hypertension in snorers, even after adjusting for confounders such as body mass index [ 63 ] . mechanistic studies are lacking and the directionality of the association not well clarifi ed, but it is possible that intermittent hypoxia, fl ow limitation, poor sleep, and arousals may play a role in causing endothelial dysfunction, infl ammation, and hypercoagulability that are common to the two disorders. a few studies to date have also shown worse abnormalities in glucose metabolism and a higher prevalence of gestational diabetes in women complaining of loud snoring and poor sleep [ 58 , 64 ] . gestational diabetes has been associated with a fi vefold increase in the risk of type ii diabetes at 5 years and a ninefold risk at 9 years [ 65 ] . snoring, poor sleep, and osa have all been associated with a higher risk of unplanned cesarean deliveries. this association may be harder to explain and may depend on the actual reason leading to unplanned cesarean delivery such as obstetric, fetal, or medical causes. the impact of sdb on fetal and neonatal outcomes has also been studied, but the results of such studies have been more confl icting. growth restriction has been reported to be associated with snoring in some studies but not in others. the effect on apgar scores also appears to be controversial. there are some case reports and case series suggesting fetal decelerations secondary to sleep apnea, but a recent study evaluating synchronized limited sleep studies and fetal monitors have failed to show a signifi cantly higher prevalence of late decelerations [ 60 ] . once diagnosed, treatment of osa is approved in patients with an apnea hypopnea index ahi >15 or those with ahi >5 who have symptoms that are known to respond to therapy such as daytime sleepiness. there are no specifi c guidelines on therapy initiation in pregnancy yet for various reasons. as stated above, the natural history of the disorder around the perinatal period is not well known. thus, it is possible that, with weight loss and reversal of pregnancy physiology, the disorder may resolve or at least improve in the postpartum period. in addition, there have been no trials to date that have shown that treatment of osa in pregnancy would improve pregnancy or fetal outcomes. this reason likely contributes to the fact that the disorder remains underscreened and underdiagnosed [ 59 ] . based on current data, weight loss is unlikely to be an option in pregnancy because of concern that it may affect the nutritional status of the mother and therefore fetal well-being. alcohol and cigarette smoking avoidance is another therapeutic strategy in pregnancy that carries additional pregnancy-specifi c benefi ts. outside of pregnancy, cpap therapy has been shown to improve quality of life and daytime sleepiness with some data suggesting improvement in cardiovascular outcomes such as hypertension. it is likely that these effects of cpap are also true in pregnancy. observational studies have shown improvement in daytime fatigue and daytime somnolence in pregnant women with osa treated with cpap and re-titrated around midpregnancy [ 66 ] . in women with preeclampsia, small, randomized trials have shown that in-laboratory positive airway pressure therapy improves hemodynamics, uric acid, and cardiac output compared to untreated women [ 67 , 68 ] . until future studies of cpap therapy are available in pregnancy, indications for therapy are likely the same as in the nonpregnant population. we are awaiting trials evaluating the effect of pap therapy on pregnancy-specifi c outcomes to be able to determine the "urgency" of starting pap therapy in pregnancy. the type of pap therapy that is most benefi cial in pregnancy is unknown. however, auto-titrating pap therapy has the advantage of avoiding repeat re-titration of pressure requirements. in summary, pregnant women with the above disorders need to be managed with pregnancy physiology and fetal effects of the disease and the therapy in mind. the course of asthma during pregnancy, post partum, and with successive pregnancies: a prospective analysis acute asthma during pregnancy a comprehensive analysis of adverse obstetric and pediatric complications in women with asthma asthma during pregnancy-a population based study infant and maternal outcomes in the pregnancies of asthmatic women obstetric complications among us women with asthma psychosocial variables are related to future exacerbation risk and perinatal outcomes in pregnant women with asthma effects of asthma severity, exacerbations and oral corticosteroids on perinatal outcomes spirometry is 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literature pandemic 2009 infl uenza a (h1n1) in 71 critically ill pregnant women in california infl uenza a/h1n1v in pregnancy: an investigation of the characteristics and management of affected women and the relationship to pregnancy outcomes for mother and infant novel infl uenza a(h1n1) virus among gravid admissions california pandemic working g. severe 2009 h1n1 infl uenza in pregnant and postpartum women in california antiviral agents for the treatment and chemoprophylaxis of infl uenza --recommendations of the advisory committee on immunization practices (acip) severe, critical and fatal cases of 2009 h1n1 infl uenza in china severity of 2009 pandemic infl uenza a (h1n1) virus infection in pregnant women product information: relenza(r) oral inhalation powder, zanamivir oral inhalation powder. glaxosmithkline (per fda) pregnancy and fetal outcomes of symptoms of sleep-disordered breathing patient and provider perceptions of sleep disordered breathing assessment during prenatal care: a survey-based observational study prospective trial on obstructive sleep apnea in pregnancy and fetal heart rate monitoring excessive daytime sleepiness in late pregnancy may not always be normal: results from a cross sectional study development of a pregnancy-specifi c screening tool for sleep apnea sleep-disordered breathing in pregnancy glucose intolerance and gestational diabetes risk in relation to sleep duration and snoring during pregnancy: a pilot study type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis pregnancy, sleep disordered breathing and treatment with nasal continuous positive airway pressure reduced nocturnal cardiac output associated with preeclampsia is minimized with the use of nocturnal nasal cpap nasal continuous positive airway pressure reduces sleep-induced blood pressure increments in preeclampsia key: cord-289697-g24xib4l authors: macdowell, ana l.; bacharier, leonard b. title: infectious triggers of asthma date: 2005-03-01 journal: immunol allergy clin north am doi: 10.1016/j.iac.2004.09.011 sha: doc_id: 289697 cord_uid: g24xib4l there is abundant evidence that asthma is frequently exacerbated by infectious agents. several viruses have been implicated in the inception and exacerbation of asthma. recent attention has been directed at the role of infections with the atypical bacteria mycoplasma pneumoniae and chlamydia pneumoniae as agents capable of triggering asthma exacerbations and potentially as inciting agents for asthma. this article examines the evidence for interaction between specific infectious agents and exacerbations of asthma, including the immunopathology of infection-triggered asthma, and the current therapeutic options for management. the rise in the incidence of atopic disease, including asthma, over the past several decades has not been limited to a particular geographic area and has occurred in developed and developing countries. several factors influence the development and severity of asthma, including atopy, environmental exposures, genetic predisposition, gene-environment interactions, stress, obesity, diet, socioeconomic status, and infection. the ''hygiene hypothesis'' [1, 2] has focused attention on the role of infection in the development of allergic disease. this hypothesis suggests that infections in early life can have a protective effect on the development of asthma and atopy. other researchers have suggested, however, that infection may be a cause for the onset and persistence of asthma. in this ''hit and run hypothesis,'' a pathogen promotes dysregulation of the immune system, leading to prolonged inflammatory responses even after the pathogen has been cleared [3] . thus, the role of infectious agents in the development of asthma is complex: evidence implicates infections as causal and protective with respect to asthma development. in addition to the potential role of infection in the inception of asthma, infection has been implicated as the most common precipitant of asthma exacerbations. several clinical observations have indicated that most asthma episodes are precipitated by factors other than allergen exposure. many asthma episodes are preceded by upper respiratory tract symptoms and may last several days to weeks, in contrast with allergen-induced asthma exacerbations, where exposure often leads to a rapid onset of symptoms with a recovery time of approximately 24 hours [4, 5] . infections have been linked to asthma exacerbations since the 1950s, and over the past several decades there has been extensive investigation 0889 of infectious agents as they relate to asthma development and exacerbations. in this article, we examine infections as triggers of asthma, with a focus on asthma exacerbations. respiratory tract infections (rtis) are the most common cause of acute illness in adults and children, with upper respiratory infections (uris) constituting the majority of such illnesses [6] . adults typically experience two to four uris per year, and children may have up to 12 uris per year [7] . rtis are the major cause of visits to primary care physicians [8] and are associated with significant work and school absenteeism, with an estimated 150 million lost workdays annually. consequently, rtis have great economic impact, with an estimated cost of $40 billion annually in the united states [9] . numerous viruses produce uris (table 1) , and because the symptom patterns are common between many viruses, it is difficult to determine clinically the specific viral etiology of an acute illness ( table 2) . viral infections commonly trigger asthma exacerbations, having been noted in nearly half of asthma exacerbations in adults [10] and in an even greater percentage of exacerbations in children. this was demonstrated in a 13-month study investigating the role of viral infections in asthma exacerbations in 114 children 9 to 11 years of age with asthma [11] . peak expiratory flow (pef) rate was performed twice daily, and upper and lower respiratory tract symptoms were recorded daily. virologic samples were obtained within 48 hours of an increase in upper or lower respiratory symptoms, a fall in pef by more than 50 l/min from the child's baseline, or if the parent subjectively felt that the child was developing a cold. evidence of a viral infection was detected in 80% to 85% of episodes with respiratory tract symptoms, fall in pef, or both. the highest detection rate occurred during reported episodes of wheeze, cough, and upper respiratory tract symptoms, together with a decline in pef. in addition, the severity of a respiratory illness may influence the outcome of a uri because more severe viral infections seem more likely than mild infections to lead to exacerbations of asthma [5] . viral infection has been noted more often during severe exacerbations of asthma than during milder exacerbations [12] . the advent of more sensitive diagnostic tools to detect specific infectious pathogens, such as detection of microbial dna or rna using the polymerase chain reaction (pcr), has strengthened the evidence for viruses as a primary triggering factor in asthma exacerbations [13] . a recent study confirmed a significant increase in the weighted average viral identification in patients of all ages with asthma exacerbation in studies that used pcr when compared with the pre-pcr studies [14] . the same study suggests that viral recovery occurs more often in asthmatic patients who are having an acute exacerbation than in asymptomatic asthmatics or nonasthmatic individuals. almost 100% of children are infected with rsv by 2 y of age. it is the most common cause of bronchiolitis and pneumonia in infants. varied -includes cough, coryza, fever, irritability, anorexia, wheezing, pharyngitis, vomiting, or diarrhea unknown by 5 y of age nearly 100% individuals have been infected most commonly causes respiratory illnesses such as acute bronchitis, including pharyngitis, and occasionally otitis media, which may be bullous. ten percent of infected individuals develop pneumonia within a few days that may last for 3-4 wk. causes disease only in humans; it is highly transmissible by droplets. epidemics occur every 4-7 y because immunity is not long lasting. the long incubation period (ranging from 1-4 wk) along with long asymptomatic carriage (for weeks to months) facilitates familial spread, which may continue for months. responsible for a variety of respiratory diseases including pneumonia, acute bronchitis, and, less commonly, pharyngitis, laryngitis, otitis media, and sinusitis. many infected patients are asymptomatic or mild to moderately ill. a prolonged illness may be present with cough persisting for 2-6 wk, sometimes with a biphasic course. assumed transmission is person-toperson, via infected respiratory secretions. recurrent infection is common, especially in adults. in tropical, less-developed areas, infection seems to occur earlier in life. in the united states, 50% of adults have antibodies by 20 y of age, with initial infection peaking between 5 and 15 y of age. another important observation that links viral infection with asthma exacerbation is the seasonal pattern of distribution of viral infections and asthma exacerbations, especially severe cases requiring hospitalization. in a 2-year study comparing asthma exacerbations due to seasonal allergens, other environmental triggers, and viral infections, a strong relationship was found between the seasonal incidence of asthma and viral infection, although there was no correlation with pollen and spore counts [15] . similarly, viral infections were the major identifiable risk factor for autumnal asthma exacerbations [16] . in addition to viral infections, rtis with atypical organisms, such as mycoplasma pneumoniae and chlamydia pneumoniae, precipitate a significant proportion of acute episodes of wheezing, contribute to the severity and persistence of asthma, and may serve as the initial insult that leads to development of asthma [17] [18] [19] . human rhinovirus (rv) causes nearly half of all upper respiratory illnesses. although rv infection was initially believed to be limited to the upper airways [20] , lower airway epithelial rv infection has been demonstrated [21] . although infection of the lower respiratory tract may occur, the mechanisms through which viral infections, including rv, provoke asthma are unclear but may include direct extension of upper rtis to the lower respiratory tract. the mechanism may be indirect and involve effects on airway responsiveness independent of the direct epithelial damage and inflammation associated with lower rtis (lrtis). rv infection can enhance the immediate and late-phase responses to allergen [22] , potentially augmenting the allergic inflammation within the airway and precipitating asthma exacerbations. rv infection can lead to profound exacerbation of asthma and is responsible for the majority of hospitalizations for childhood asthma, although less so in adults [20] . rv infections are associated with declines in lung function in asthmatics compared with normal subjects within 2 days after development of a rv infection [23] . rv infection augments airways hyper-responsiveness 4 days after experimental rv infection, an effect that was more pronounced in those with a severe cold [24] . the rise in airways hyper-responsiveness was accompanied by an increase in nasal interleukin (il)-8 in the rv-infected group at days 2 and 9; the increase in nasal il-8 at day 2 correlated significantly with the change in airway responsiveness at day 4. coronavirus is the second most common virus associated with asthma episodes in children and adults. infections due to coronavirus may be associated with less severe lower respiratory tract symptoms than infections with other viruses. this is suggested by the finding that coronavirus-associated asthma episodes in asthmatic school-age children were associated with smaller median declines in pef (56 l/min) compared with episodes triggered by other viruses (85.5 l/min) [11] . in a study of elderly adults, coronavirus was associated with lower respiratory illness in more than 40% of patients, and one quarter of patients consulted a medical practitioner and received antibiotics. more impressive was the observation that coronavirus infection produced a greater disease burden value than influenza or respiratory syncytial virus [25] . influenza virus triggers asthma exacerbations in all age groups [11, 26] . in addition, asthmatic individuals seem to be more susceptible to death associated with influenza infections, as observed in the asian pandemic in 1957 [27] . the time course of influenza-induced asthma exacerbations was examined retrospectively in 20 asthmatic children 8 to 12 years of age with acute respiratory symptoms [28] . fifteen of 20 patients had decreases in fev 1 n20% from baseline during the acute stage, beginning from onset of symptoms in all but one subject, whose fev 1 decreased during the incubation period. fev 1 decreased maximally on the second day of illness by an average of 30%. improvement began on the third day, and fev 1 returned to within 10% of normal between the seventh and tenth day. the rate of adenoviral infection declines with age until 9 years and then increases. the exception to this pattern is infection with serotype 7, whose infection rate increases with age [29] . infection is frequently associated with wheezing, as demonstrated in a retrospective chart review study [30] where wheezing was noted in 58.3% of nonasthmatic children under 2 years of age admitted to an intensive care unit with adenoviral acute lrti. in this study, the mortality rate was 16.7%, generally in the setting of infection with adenoviral serotype 7. adenoviral infection has been demonstrated during acute asthma episodes, but the frequency of adenoviral infection is substantially lower that the frequency for rhinovirus and coronavirus [31] . latent adenoviral infection may have a role in the genesis of asthma. furthermore, adenoviral shedding may be prolonged, lasting up to 906 days. when nasopharyngeal swabs from 50 asymptomatic asthmatic children and 20 healthy control subjects were examined by pcr, adenovirus dna was found in 78.4% of asthmatic children, compared with only 5% of healthy control subjects [32] . adenovirus has been recovered from bronchoalveolar lavage (bal) in children with asthma 12 months or more after acute infection [33] . in this study, bal was performed in 34 children (mean age of 5 years) with unfavorable responses to standard corticosteroid and bronchodilator therapy. adenoviral infectious triggers of asthma antigens were detected in bal fluid (balf) from 94% of subjects. repeat studies within 1 year showed that six of eight subjects were positive for adenovirus on two occasions and that three were positive when sampled three times. cultures of the balf were positive for adenovirus in all cultures performed, indicating that the virus was capable of replication. similar studies performed in control patients without persistent asthma failed to detect evidence of adenovirus. respiratory syncytial virus (rsv) infects almost 100% of children by 2 years of age and is the most common cause of bronchiolitis and pneumonia in infants [34] . in addition to causing acute lrti, rsv serves as a trigger for exacerbations of asthma and other chronic lung diseases. infants who experience severe rsv bronchiolitis seem to have increased frequencies of wheeze and asthma later in life. a comparison of several retrospective studies of children admitted for bronchiolitis found that the postbronchiolitis group had a significantly higher frequency of bronchial obstructive symptoms 2 to 10 years later and, when pulmonary function studies were performed, diminished fev 1 or increased bronchial reactivity compared with healthy control subjects [35] . these findings were confirmed in a prospective study when children hospitalized with confirmed rsv bronchiolitis were evaluated at 7.5 years of age and compared with age-and gender-matched control subjects [36] . by 7.5 years of age, the cumulative prevalence of asthma was 30% in the rsv group versus 3% in the control group, and current asthma was present in 23% of the rsv group versus 2% of the control group. however, the duration of the effect of rsv infection on asthma-related symptoms appears to be limited. in a prospective study of 1246 children enrolled at birth, 207 developed an rsv ltri not requiring hospitalization during the first 3 years of life [37] . when compared with a control group of children with no lrti documented during the first 3 years of life, the group with mild rsv lrti had a substantially increased risk of frequent wheeze at 6 years of age (odds ratio [or] 4.3), and the risk for frequent wheeze remained significantly increased at 11 years of age (or 2.4), at which time prebronchodilator fev 1 , but not postbronchodilator fev 1 , was significantly lower in the rsv group. by age 13 years, there were no significant between-group differences in terms of increased risk for frequent or infrequent wheezing. these studies demonstrate that rsv bronchiolitis is a significant independent risk factor for subsequent frequent wheezing, although this effect seems to decrease with age and may be dependent upon the severity of the rsv infection. similar to adenoviral infection, the persistence of rsv may underlie in part the sequelae of severe rsv disease. infection may lead to alteration in the patterns of local interferon, chemokine, and cytokine production [38] , potentially leading to chronic inflammation [39] . furthermore, the age at first viral infection may direct the pattern of disease later in life by generating a th2-biased memory response to rsv, which may direct responses to other antigens in the lung toward an allergic phenotype. this is suggested by a study in which mice infected with rsv at different ages (1, 7, 28, or 56 days) demonstrated stronger th2 responses in the group primed at the youngest age when reinfected with rsv at 12 weeks of age [40] . the parainfluenza viruses (piv) cause a spectrum of respiratory illness similar to that caused by rsv but result in fewer hospitalizations [41, 42] . most illnesses are limited to the upper respiratory tract [41] , although approximately 15% involve the lower respiratory tract, and 2.8 of every 1000 children with such infections required hospitalization [42] . although less common than rv or coronavirus infection, piv was detected in 14% of episodes of increased symptoms or decreased pef in school-aged children [11] . more frequent and severe wheezing has been correlated with elevated levels of ige antibody to rsv and piv in nasal secretions of children with bronchiolitis due to rsv and piv [43] . human metapneumovirus (hmpv) was identified in 2001 in respiratory samples from children with respiratory disease in the netherlands [44] . the clinical symptoms experienced by infected individuals are diverse and may consist of upper or lower respiratory tract symptoms ranging from otitis media to bronchiolitis, croup, pneumonia, and possibly exacerbations of asthma [45] . hmpv is responsible worldwide for community-acquired acute rtis affecting children and other age groups, with a mean age of illness of 11.6 months and a male predominance (male/female ratio 1.8:1). the broad epidemic seasonality and the evidence of genetic variability suggest that there may be more than one serotype of hmpv [44] . wheezing is part of the clinical symptomatology associated with hmpv infection. more than half of otherwise healthy children presenting with acute respiratory illness and evidence of hmpv infection experienced wheezing in one study [45] . in series of 19 children with evidence of hmpv infection, bronchiolitis was the most common diagnosis, and 50% of patients had wheezing [46] . both of these studies evaluated specimens collected from previously healthy children during an acute respiratory illness during which no other pathogen was identified and detected evidence of hmpv in 6.4% [46] and 20% [45] of the previously negative samples. although hmpv infection is often accompanied by wheezing, there have been conflicting reports linking hmpv infections and asthma exacerbations [47, 48] . nevertheless, bronchiolitis is a common cause for hospitalization, and given the increasing hospitalization rates over the past two decades [49] , it is possible that hmpv may be responsible for a portion of hospitalizations in children with infectious triggers of asthma 53 bronchiolitis and wheezing unrelated to rsv infection [46] . furthermore, coinfection with rsv and hmpv may augment the severity of bronchiolitis [47] . m pneumoniae and c pneumoniae initial evidence suggested that infection with m pneumoniae and c pneumoniae was associated with asthma chronicity. several case reports suggest associations between infections with atypical organisms with decreased expiratory flow rates and increased airway hyper-responsiveness in nonasthmatic individuals [50] and the onset of asthma symptoms in previously healthy nonasthmatic adults [51, 52] . most of these individuals present with complaints of malaise, shortness of breath of gradual onset, and wheezing, which typically resolve after treatment with macrolide antibiotics or oral corticosteroids [51] . symptoms may progress and persist, as illustrated by an adult male with fever, severe cough, shortness of breath, consolidation on chest radiograph, and evidence of m pneumoniae infection based on a rise in serum antibody titers who subsequently developed wheezing episodes with reversible airway obstruction and airway reactivity to methacholine [52] . infections with these organisms can persist for months, and animal studies show that m pneumoniae can be detected by pcr for up to 200 days after infection, even though the animals become antibody and culture negative by 70 days [53] . these reports suggest that m pneumoniae may serve as a cause of acute wheezing and a triggering factor for the onset of asthma. the most comprehensive evaluation of the role of m pneumoniae and c pneumoniae infections in patients with chronic asthma evaluated 55 adult patients with chronic asthma and 11 control subjects by using pcr, culture, and serology to detect m pneumoniae species, c pneumoniae species, and viruses from the nasopharynx, lung, and blood [54] . fifty-six percent of the asthmatic patients had positive pcr studies for m pneumoniae (n = 25) or c pneumoniae (n = 7), which were mainly found in balf or biopsy samples. only 1 of 11 control subjects had a positive pcr finding for m pneumoniae. cultures for these organisms were negative in all patients. a distinguishing feature between pcr-positive and pcr-negative patients was a significantly greater number of tissue mast cells in the group of patients who were pcr positive. of additional significance is the link of atypical infectious organisms with asthma exacerbations. in a serologically based prospective study, 100 adult patients hospitalized with exacerbations of asthma were compared with hospitalized surgical patients with no history of lung disease at any time or uri in the month before admission [55] . in this series, m pneumoniae was identified more often than any other pathogen in the asthmatic group (18 m pneumoniae, eight c pneumoniae, 11 influenza a, five influenza b, three piv-1, two piv-2, one piv-3, six adenovirus, two rsv, three s. pneumoniae, and five legionella spp.) and in the control group (three m pneumoniae). however, only 8 of the 18 patients had m pneumoniae identified as the sole infectious agent, making it difficult to ascertain the culpability of m pneumoniae as the cause of hospitalization. a study of 71 children with acute wheezing and 80 age-matched healthy children detected m pneumoniae in 22.5% and c pneumoniae in 15.5% of children with wheezing compared with 7.5% and 2.5%, respectively, in healthy control subjects [56] . when the children who were infected with either organism were treated with clarithromycin, improvement in the course of the disease was observed, further supporting the role of these atypical organisms in the exacerbation of asthma. these findings were recently confirmed in a french series, where m pneumoniae infection was found in 20% and c pneumoniae infection was found in 3.4% of children during an acute asthma exacerbation [19] . acute m pneumoniae infection was confirmed in 50% and c pneumoniae in 8.3% of patients experiencing their first wheezing episode. further studies are needed to confirm the association between infection and asthma exacerbation, to determine the prevalence of such infections in patients with acute exacerbations of asthma, and to examine if infection with these organisms modifies the severity of the exacerbation or the response to therapy. viral-induced wheeze (viw) is characterized by brief episodes of lower respiratory symptoms and decreased pulmonary function in the setting of an acute viral uri, interspersed with longer asymptomatic periods with normal pulmonary function [11, 57] . this differs from classic childhood asthma, which is characterized by chronic symptoms, with atopy being a major risk factor [58] . classic asthma and viw were considered two different entities until 1969, when a report suggested that the two groups have similar characteristics [59] and benefited similarly from the same prophylactic treatment [60] . in the 1990s, there was a division of the wheezing phenotypes, especially in children [58] . patients with viw alone seem to outgrow the symptoms by age 6; however, in some patients, the pattern of viw may continue into adulthood with less severe symptoms, negative methacholine challenges, and pulmonary functions that remain normal [61] . the inability to reliably differentiate between viw and asthma, especially in young children, complicates the evaluation of the influence of viral infections on exacerbations of wheezing. furthermore, this heterogeneity in wheezing phenotypes has implications in terms of the efficacy of therapies used to treat such episodes. viruses typically enter the body through contact with mucosal surfaces. the cell-specific distribution of viral receptors determines the viral tropism. once the viral particles are internalized, nucleic acids are released, and transcription and production of viral proteins starts. the viral genome is replicated, and virions are one of the earliest responses to viral infection is the production of ifns by different cell types; ifn-a is produced by leukocytes, ifn-b is produced by fibroblasts, and inf-g is produced by th1 cells and natural killer (nk) cells. ifns induce transcription of many genes, including two with direct antiviral activity, and lead to increased expression of mhc class i and ii genes. interferons are potent activators of antiviral effector cells such as nk cells, cd8 t lymphocytes, and macrophages. although the inflammatory process generated by virus infection is generally viewed as a th1 pattern with a predominance of interferons, especially inf-g, in atopy there is a predominance of the th2 cytokine profile. however, viral infections promote increased cytokine-mediated inflammation through direct induction of specific cytokines produced by different viral agents [62] . the ability of certain pathogens to stimulate the production of th2 cytokines [63] may explain why certain pathogens are more strongly associated with asthma exacerbation than others. viruses have been implicated in the inception of asthma because viral infections with a propensity for lower airway involvement during infancy have been associated with chronic lower respiratory tract symptoms and asthma [64] . this seems to be particularly relevant to rsv bronchiolitis, which has been demonstrated to be a significant independent risk factor for subsequent frequent wheezing [37] . the sequelae of severe rsv disease could be explained in part by viral persistence [39] . this has been supported by a recent study demonstrating the persistence of viral genomic and messenger rna in lung homogenates of balb/c mice up to 100 days post rsv infection, whereas virus could no longer be detected in balf after day 14 post-infection [65] . another possible mechanism by which a virus could promote asthma is by generating changes in patterns of pro-inflammatory cytokine production, which could facilitate virus persistence, as demonstrated with rsv [38] . viral infection may exert direct effects on airway cells. an increase in the production of il-10 by nonspecifically stimulated peripheral blood mononuclear cells during acute and convalescent phases of rsv infection requiring hospitalization has been demonstrated [66] . in animal studies, it was suggested that il-10 may have a direct effect in airway smooth muscle and in the regulation of airway tone [67] . although there is evidence supporting the role of viral infections in the development of asthma, further investigation is necessary to confirm this hypothesis because the mechanisms that could allow persistency or latency of viral infection are poorly understood. it has been hypothesized that asthmatic individuals have increased susceptibility to viral infections. some researchers have found an increased incidence of viral infections in asthmatic children when compared with nonasthmatics [14, 26] , a pattern that could be explained by the increased expression of icam-1, the receptor for rv, in asthmatics subjects [68] . however, this finding was not confirmed in a study that followed cohabitating couples consisting of an atopic asthmatic and a healthy nonatopic, nonasthmatic individual [23] . in this study, subjects completed daily diary cards of upper and lower respiratory tract symptoms and measured pef twice daily. nasal aspirates were taken and examined for rhinovirus every 2 weeks. rhinovirus was detected in 10.1% of samples from the asthmatics and 8.5% of samples from the nonasthmatic participants. after adjustment for confounding factors, asthma did not significantly increase the risk of infection with rhinovirus in asthmatic individuals (or 1.15). the effect of atopic status on the rate of viral infection is unclear; evidence exists suggesting no difference between the rate of viral infection between atopic and nonatopic individuals [69] or an even lower rate of viral infections among atopic individuals [15, 70] , although these studies did not have adequate statistical power to confirm this trend. there is an increased risk of acute wheezing when atopy is combined with viral infection when compared with atopy or virus infection alone [70] , and infants with a family history of atopy seem more likely to develop bronchiolitis with a higher rate of hospitalization [71] . even if asthmatics do not experience more frequent infections than nonasthmatics, it is possible that asthmatics have a higher incidence of symptoms when experiencing viral infections. during rhinoviral infection, there is a greater incidence of symptoms in asthmatics compared with nonasthmatics [72] . this is further suggested by a report that asthmatics experienced seroconversion to influenza a virus at the time of asthma exacerbation even in the absence of signs of respiratory infection [5] . although there is evidence supporting the role of infection in the genesis of asthma and allergy, a protective effect of infections in the development of atopy has also been postulated. an inverse relationship between infection and allergy was first noted when a study comparing white families with native americans reported that ige levels and the prevalences of asthma and eczema were higher in the white population, whereas helminthic, viral, and bacterial infections were more prevalent in the native americans [1] . it was observed that increased family size, often associated with more frequent infections in early childhood, had an inverse relationship with the prevalence of allergic rhinitis [2] and asthma [73] . this was further supported by studies reporting an inverse relationship between the age of day care entry and the diagnosis of asthma [74, 75] . one potential explanation for this pattern is that at birth there is a predominant th2 response, and, as exposure to infections occurs, there is a gradual shift toward a th1dominant response. however, if the skewing of the immune response to th1, which regulates response to viral infection, is impaired, a th2 response would infectious triggers of asthma predominate, favoring the development of allergy. ex vivo studies have shown that asthmatics exposed to viral infections lack the capacity to mount a strong th1 response [76, 77] . there is no clinically effective treatment for the common cold. as the mechanisms of viral-induced wheezing and asthma are elucidated, new forms of treatment may emerge. the involvement of many inflammatory pathways suggests that antiviral and anti-inflammatory therapies have potential roles for intervention after onset of symptoms; however, a combination of both therapeutic approaches may have the greatest impact. prophylaxis for the acquisition of viral infections, in the form of vaccination or pharmacologic therapy, offers the best hope of disease control. the major obstacle for treatment is the wide variety of organisms associated with uris, including viral and bacterial agents ( table 2 ). in addition, accurate and timely diagnosis is essential for the appropriate targeting of specific antiinfective therapies. the rapid rate of mutation of viruses leads to the emergence of resistant strains. in addition, there are difficulties with the delivery, expense, and efficacy of drugs [78] . treatment for viral rtis remains symptomatic, although future approaches will likely be directed toward reducing the inflammatory response elicited by the virus. vaccination remains the mainstay of prophylaxis against infections. however, with the exception of influenza, vaccine development for respiratory viruses has been slow and disappointing. influenza vaccine contains three strains (two a and one b) of inactivated virus, one or two of which are modified yearly based upon predictions of the upcoming viral strains. they are produced in embryonated hen eggs and are highly immunogenic, conferring protection in 70% to 80% of the vaccine recipients with minimal adverse effects. whole-cell influenza vaccine is no longer available, and the current vaccines consist of subvirion (prepared by disrupting the lipid membrane) or purified surface antigen. recently, a liveattenuated, cold-adapted, trivalent, intranasal influenza vaccine (flumist) has been introduced, but it is contraindicated in asthmatics [79] . a long-standing concern that influenza vaccination may trigger exacerbations of asthma was addressed in a multicenter, randomized, double-blind, placebocontrolled, crossover trial in 2032 patients with asthma (age range 3-64 years). this study confirmed the safety of the influenza vaccine in asthmatics by demonstrating that the frequency of exacerbations of asthma was similar in the 2 weeks after vaccination with the active influenza vaccine or placebo (28.8% and 27.7%, respectively) [80] . although yearly influenza vaccination is recommended as a routine element of asthma management [81] , a recent study generated concern about the usefulness of influenza vaccine in preventing influenza-related asthma exacerbations. this randomized, double-blind, placebo-controlled trial showed that the number, se-verity, and duration of influenza-related asthma exacerbation was similar between the group receiving influenza vaccination and the group receiving placebo over the course of one influenza virus season [82] . vaccinated children tended to have shorter exacerbations (by approximately 3 days) than nonvaccinated children. antiviral therapy targets the source of infection directly, decreasing the number of infectious agents and therefore reducing inflammatory process. the only licensed antiviral therapies are directed against influenza a (amantadine and rimantadine), influenza a and b (zanamivir and oseltamivir), and rsv (ribavirin). the neuraminidase inhibitors, zanamivir and oseltamivir, have an advantage over adamantanes, amantadine, and rimantadine because they have a broader spectrum and are effective against the a and b strains of influenza virus. the inhibition of neuraminidase, whose active site consists of 11 amino acids conserved in all naturally occurring influenza virus [83] , prevent cleavage of sialic acid from newly acquired membrane, leaving emerging virus inactive and thereby decreasing infectivity [84] . both neuraminidase inhibitors improve respiratory outcomes in patients with asthma and acute influenza infections [78] and have the added benefit of being effective in the prophylaxis against influenza infections [85] . although it is generally well tolerated, there are case reports of bronchospasm after treatment with inhaled zanamivir [86] ; however, it is difficult to separate these symptoms from the effects of the influenza infection. the disadvantage of current antiviral therapy is the specificity for influenza and the need for initiation of treatment within 48 hours of onset of infection. the toxicity profile of ribavirin, approved for use in severe rsv infections, limits its clinical use except in settings of severe illness in immunocompromised hosts. antibiotic use is appropriate if there is evidence of bacterial infection contributing to asthma exacerbations, although pyogenic lung infections rarely exacerbate asthma and are rarely associated with wheezing. although some macrolide antibiotics have been reported to have antiviral effects in vitro against rhinoviruses [87] , these effects have not been confirmed in vivo, and a recent cochrane review does not support the use of antibiotics for the treatment of the common cold [88] . the anti-inflammatory effects of macrolide antibiotics are not limited to their ability to interfere with corticosteroid metabolism [89] , as evidenced by inhibition of the neutrophil oxidative burst [90] , reduction of cytokine formation [91] , and reduction of icam-1 production [92] . asthmatic patients infected with m pneumoniae or c pneumoniae may benefit from prolonged treatment with clarithromycin, as evidenced by significant improvement in fev 1 [18, 93] . furthermore, in a double-blind, randomized, crossover study, 17 patients with stable mild or moderate asthma not evaluated for m pneumoniae or c pneumoniae received 200 mg of clarithromycin or placebo twice daily for 8 weeks. methacholine responsiveness improved in all the patients after 8 weeks of clarithromycin treatment [94] . improvement in airway hyperresponsiveness after 8 weeks of clarithromycin treatment was confirmed in a group of patients with asthma receiving concomitant therapy with inhaled corticosteroids who were not selected on the basis of infection with m pneumoniae or c pneumoniae [95] . it remains unclear as to the mechanism by which macro-infectious triggers of asthma lide antibiotics improve airway hyper-responsiveness in patients with asthma, but possibilities may include treatment of occult or chronic infection, interference with steroid metabolism, or the anti-inflammatory properties of this class of antimicrobials. although there are international guidelines for the management of asthma [81, 96] , there is a relative paucity of evidence regarding therapeutic strategies specifically for viw in asthmatics or healthy subjects. because most acute exacerbations of asthma are induced by viral infections and because many forms of asthma therapy, especially inhaled corticosteroids, reduce the frequency and severity of exacerbations, one would presume that the current treatment for chronic asthma would be efficacious in preventing viw. however, the varying phenotypes of wheezing, especially in childhood, seem to respond differently to such management approaches. this is particularly true for rsv-associated wheezing, which does not consistently respond to medications often used to treat asthma exacerbations, including bronchodilators and corticosteroids [97] . thus, despite the efficacy of inhaled corticosteroids in the control of asthma and reduction of exacerbations, patients continue to experience exacerbations, particularly in the setting of viral rtis. several treatment approaches have been investigated in an attempt to reduce the morbidity associated with wheezing associated with rtis. brunette et al [98] examined the effect of a short course of oral corticosteroid administered in an unblinded manner at onset of uri symptoms in a group of children with histories of recurrent wheezing in the setting of viral infections. over a 1-year period, the group receiving oral corticosteroids at the early signs of rtis experienced reductions in the frequencies of wheezing, emergency room visits, and hospitalizations. however, a recent double-blind, placebo-controlled trial evaluating the use of parent-initiated oral corticosteroids at the early signs of an episode of presumed viral-induced wheezing did not detect a difference between oral corticosteroid therapy and placebo in terms of symptom scores and rate of hospitalization [99] . thus, the role for the use of oral corticosteroids at the early signs of illness in children with recurrent viral wheezing is unclear, and additional investigation is required to determine the efficacy of this approach in the management and attenuation of wheezing episodes. the repeated use of systemic corticosteroids for such episodes remains a clinical concern. given the efficacy of inhaled corticosteroids (ics) in the daily management of asthma and their favorable safety profile when compared with systemic corticosteroids, the use of ics in the management of viw has been explored. although ics are effective in the management of persistent asthma, current evidence suggests a lack of efficacy in the regular use of ics in patients with mild viw [100, 101] . a recent meta-analysis concluded that the use of ics episodically for viral-triggered wheezing in children not using them as maintenance may decrease the rate of oral corticosteroid requirement [101] . in patients receiving daily ics therapy, the common clinical practice of doubling the dose of ics at the onset of an asthma exacerbation has been shown to be ineffective in preventing symptom progression [102] . however, a recent study in adults demonstrated the valuable effects of quadrupling the ics dose with acute asthma exacerbations [103] . these data suggest that corticosteroids, taken orally or inhaled, may be used as treatment and preventive therapy for asthma exacerbations in the setting of rtis. the cysteinyl leukotrienes (cyslts) have been identified as important mediators in the complex pathophysiology of asthma. cyslts are detectable in the blood, urine, nasal secretions, sputum, and balf of patients with chronic asthma. elevated cyslts have been detected in respiratory secretion of children with viral induced wheezing [104] . similar to elevated levels in asthmatics, 20 infants with prolonged or persistent wheeze (mean 14.9 months) and a history of viral illness at wheeze onset had significant elevations of leukotrienes in bal despite the fact that 12 of 20 infants were receiving daily ics therapy ( 450 mg/d) [105] . these findings suggest that, similar to asthma pathophysiology, cyslts play a role in the pathophysiology of viral-induced wheeze. additionally, based on the above study, the cyslts are not fully suppressed by the preferred standard antiinflammatory therapy, inhaled corticosteroids. thus, antagonism of the effects of cyslt using the leukotriene receptor antagonists may provide clinical benefit to patients with viw. the relative efficacies of these intervention strategies aimed at reduction of wheezing and asthma in the setting of rtis depend upon the wheezing phenotype and probably the timing of the initiation of therapy. investigation of other therapeutic approaches to viw is ongoing and may provide insight as to the optimal treatment approach for this challenging condition. infections have been implicated in asthma exacerbations and in the inception of asthma. several studies support the concept that viruses and atypical infectious agents may induce asthma exacerbations and contribute to the chronicity of asthma. the further elucidation of the mechanisms that underlie the interaction between infectious agents and asthma will lead to improvements in treatment and prevention of such exacerbations. studies are needed to explore the vast domain of infectious triggered asthma exacerbations. serum ige levels in white and metis communities 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controlled trial effect of continuous treatment with topical corticosteroid on episodic viral wheeze in preschool children inhaled steroid for episodic viral wheeze of childhood treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid low-dose budesonide with the addition of an increased dose during exacerbations is effective in long-term asthma control increased production of ifn-gamma and cysteinyl leukotrienes in virus-induced wheezing persistent wheezing in very young children is associated with lower respiratory inflammation key: cord-346253-0mnsm6s4 authors: ahanchian, hamid; jones, carmen m; chen, yueh-sheng; sly, peter d title: respiratory viral infections in children with asthma: do they matter and can we prevent them? date: 2012-09-13 journal: bmc pediatr doi: 10.1186/1471-2431-12-147 sha: doc_id: 346253 cord_uid: 0mnsm6s4 background: asthma is a major public health problem with a huge social and economic burden affecting 300 million people worldwide. viral respiratory infections are the major cause of acute asthma exacerbations and may contribute to asthma inception in high risk young children with susceptible genetic background. acute exacerbations are associated with decreased lung growth or accelerated loss of lung function and, as such, add substantially to both the cost and morbidity associated with asthma. discussion: while the importance of preventing viral infection is well established, preventive strategies have not been well explored. good personal hygiene, hand-washing and avoidance of cigarette smoke are likely to reduce respiratory viral infections. eating a healthy balanced diet, active probiotic supplements and bacterial-derived products, such as om-85, may reduce recurrent infections in susceptible children. there are no practical anti-viral therapies currently available that are suitable for widespread use. summary: hand hygiene is the best measure to prevent the common cold. a healthy balanced diet, active probiotic supplements and immunostimulant om-85 may reduce recurrent infections in asthmatic children. asthma is a major public health problem with a huge social and economic burden affecting 300 million people worldwide [1] . viral respiratory infections are the major cause of acute asthma exacerbations and contribute to asthma inception in high risk young children with susceptible genetic background. a history of wheeze associated with respiratory viral infections early in life is one of the major risk factors for the later development of asthma [2] [3] [4] [5] [6] [7] , together with sensitization to aeroallergens in early life and a family history of asthma and allergies, reflecting a genetic predisposition. respiratory viral infections are also the principal cause of asthma exacerbations in children and adults [8] [9] [10] [11] [12] [13] . however, the question of whether viral infections "select" susceptible hosts or whether viral infections may induce asthma de novo by "damaging" airways is not settled. in other words, do viruses cause or simply unmask asthma? respiratory viruses first infect nasal epithelial cells which triggers an antiviral response. this response is driven by type i (α/β) and iii (λ) interferons (ifn) that are induced following recognition of viral ribonucleic acid (rna) by pattern recognition receptors (prrs). toll-like receptors (tlrs) are cell surface and endosomal prrs, whilst the rna helicase receptors (rig-i and mda-5) and nodlike receptors (nod2), detect viral rna in the cytoplasm. signalling via the prrs activates transcription factors (irf-3, irf-7, nf-κb), which lead to the production and secretion of type i and iii ifn. the ifns then bind to cell surface receptors to activate a separate pathway leading to the production of interferon stimulated genes (isgs) which encode antiviral proteins that combat infection, as well as prrs and transcriptional factors which further amplify ifn production. the respiratory syncytial virus (rsv), human meta-pneumovirus (hmpv) and human rhinovirus (hrv) are all single stranded rna viruses but engage differently with cell signalling pathways. in airway epithelial cells rsv and hmpv rna are primarily detected by rig-i in the cytoplasm [14, 15] . rsv can also be detected by nod2 [16] . hrv is endocytosed by epithelial cells, and is therefore primarily detected by tlr3 in the endosome early in the infection process and by rig-i and mda-5 later in infection following upregulation of these prrs [17] . the fusion (f) protein of rsv is recognised by tlr4 at the epithelial cell surface [18] . a successful antiviral response would see the infection limited to the upper airway, as is the case clinically with the majority of viral infections in healthy individuals. should such a response be deficient, then predominantly upper-airway viral infections, such as hrv, may spread to the lower airways, causing lower respiratory symptoms and an exacerbation of asthma in predisposed individuals. while definitive data are yet to be produced, experimental hrv infections in adult volunteers initially suggested that asthmatics were more likely to develop lower respiratory infections (lri) than healthy adults, i. e. less likely to be able to limit viral replication to the upper airways [19, 20] . subsequent in vitro infection of primary airway epithelial cells from asthmatic and healthy adults with hrv have demonstrated that asthmatic cells produce less ifn-β [21] and ifn-λ [22] making them potentially more susceptible to infection, slower to clear infection, and more susceptible to virus-induced cell cytotoxicity. deficiencies in the ifnα response of peripheral blood mononuclear cells and plasmacytoid dendritic cells from asthmatic adults and children has also been observed, in these particular studies, in response to rsv, hrv [14, 15] and influenza a [23] . it is likely that the overall impaired innate immune response of the asthmatic airway epithelium is a result of deficiencies in the antiviral response of both epithelial cells and immune cells. childhood, especially infancy, is characterized by developmentally-regulated deficiencies in innate and adaptive immunity [24] . such deficiencies are likely to increase the risk of viral lri in children, especially in those at high risk for asthma and allergies. each year, at the end of summer, parents of asthmatic children are concerned about acute asthma exacerbations following a common cold, asking how to minimize the risk during the winter viral season. it is a valid concern as up to 70% of asthmatic children have an intermittent or wheeze which is mostly symptomatic after viral infections [25, 26] . asthmatics with exacerbationprone phenotype are susceptible to acute exacerbations requiring hospitalization or an unscheduled visit for medical attention. major risk factors for acute exacerbations include previous acute exacerbation, allergy, young age, poorly controlled asthma, and, in particular, viral respiratory infections. moreover, recent data suggests an interaction between allergies and viral infections occurs to increase the risk of asthma exacerbation [27] . acute exacerbations are associated with decreased lung growth or accelerated loss of lung function and, as such, add substantially to both the cost and morbidity associated with asthma [28, 29] . viral respiratory infections are the main cause of asthma exacerbations in children (80-85%) and are a major risk factor for admission in hospital every autumn [30] [31] [32] . hrv are the most common viral agents [33] ; other respiratory tract viruses detected in children with an asthma exacerbation include rsv, influenza, coronavirus, hmpv, parainfluenza virus, adenovirus, and bocavirus [34] [35] [36] . current drugs for the prevention and treatment of virus-induced exacerbation of asthma are poorly effective and novel alternative therapies are needed. much research interest has focused on the potential role respiratory viral infections play in the inception of asthma. it is well established that hospitalization for rsv bronchiolitis is a risk factor for asthma during childhood [37, 38] . epidemiological studies have shown an increased risk of asthma with lri caused by hrv. in the childhood origin of asthma (coast) birth cohort study, wheezing with rsv (odds ratio [or], 2.6), hrv (or, 9.8), or both hrv and rsv (or, 10) was associated with increased asthma risk at age six years [7] . the childhood asthma study (cas) in perth, australia showed that wheezing with hrv or rsv in the first year of life was a risk factor (or, 2.5) for current wheeze at five years of age [4] . infant birth about four months before the winter virus peak carried the highest risk of developing asthma compared with birth 12 months before the peak [39] . the risk of asthma is increased by severe lri (slri), especially in the presence of allergic sensitization in early life [4, 25] . there appears to be a synergistic interaction between viral infection and allergic sensitization, suggesting a "two hit" model for induction of persistent asthma. these data also provide a series of novel strategies for the primary prevention of asthma by prevention of either allergic sensitization or of slri in high risk children. this strategy is also supported in a study by simoes et al. [40] , in which the use of palivizumab to prevent rsv infection decreased the risk of recurrent wheezing in nonatopic premature infants. the crucial period, with respect to asthma initiation, appears to be the first two to three years of life during which the growth and remodelling of lung and airways proceeds at maximum rates. pulmonary inflammation resulting from atopy and slri occurring during this vulnerable time is hypothesized to perturb underlying tissue differentiation programs, resulting in deleterious long term effects on respiratory functions. as a result, there is widespread belief amongst the paediatric respiratory community that intervention measures that can lower the frequency and/or intensity of slri in early life amongst the high risk atopic subgroup of children are likely to be successful at preventing asthma. if successful, these strategies would have major implications for reducing the high impact of this chronic disease on the community [17, 41, 42] . recent studies using culture-independent techniques have challenged the long-held dogma that lungs are sterile and have demonstrated that a microbiota community exists in the lung [43] [44] [45] . the implications of these new data are not clear, however new concepts and more research is required. the resident microbiome is different in the presence of respiratory disease [45, 46] ; therefore interactions between respiratory viruses and the resident pulmonary microbiome are postulated. the pulmonary and gastrointestinal microbiota influence the immune system and interventional approaches (by bacterial immunostimulants, prebiotics and/or probiotics) to create a healthy gut and respiratory microbiota are potential strategies for the prevention of viral infections [45] . children are important vectors for hrv transmission to family members particularly siblings [47, 48] . hrv shedding peaks two to four days after infection and decreases sharply thereafter, although nasal samples can be positive for rhinovirus for up to five weeks after a symptomatic infection [49] . there are three ways of common cold transmission in children. first, inhalation of small particles aerosolized by coughing; second, large particle droplets from saliva expelled while sneezing; and third, self-inoculation of one's own conjunctivae or nasal mucosa after touching a person or object contaminated with the cold viruses. the first two methods are inefficient [50] , while the third is the most important method of transmission. the mode of transmission could differ with age of the index case, duration of contact, and other factors. moreover, there is some evidence that the daily activities of infected people can lead to the contamination of environmental surfaces with hrv e.g. light switches, telephone dial buttons and handsets [48] . meticulous hand hygiene is the best measure to prevent the common cold; frequent hand washing and avoid touching one's nose and eyes [51] [52] [53] . the use of alcohol-based hand sanitizers is also effective [54, 55] . the promotion of handwashing was associated with a 12-34% reduction in respiratory-tract infections and colds in child-care centres in the usa [56] canada [57] and australia [58] and a 21% decrease in absences due to respiratory illness in the school setting [56] . hand hygiene campaigns were also successful in reducing absenteeism caused by influenza-like illnesses among schoolchildren in egypt [59] . similar programs within families would be expected to reduce transmission of hrv between family members. a recent cochrane review which included data from 67 randomised controlled trials and observational studies, investigated the effectiveness of physical interventions to reduce the spread of respiratory viruses. the authors concluded that respiratory virus spread can be reduced by hygiene measures (such as handwashing), especially around younger children and can reduce transmission from children to other family members [51] . controversy still exists and a newly published study showed that an antiviral hand treatment used by adult volunteers, recruited from a university community, did not significantly reduce rv infection or rv-related common cold illnesses [60] . asthmatic children should avoid close contact with people who have colds especially during the first three days of their illness. there is little evidence to support the effectiveness of face masks to reduce the risk of viral respiratory infections and consequently, the use of mask is generally not recommended for prevention of common cold [51, 61] . immune function and anti-viral defenses have a number of components, both specific and non-specific. asthmatic children can improve their immune function by following some simple advice including a healthy life style with regular exercise, a balanced diet, adequate sleep and avoiding environmental tobacco smoke, stress and unnecessary antibiotics. exercise has anti-inflammatory effects and in the long term can protect the development of chronic diseases and obesity [62] . regular exercise of moderate-intensity is associated with a reduced incidence of upper respiratory tract infection. however, long hours of intensive training appear to make children more susceptible to upper respiratory tract infections [63] [64] [65] . the recommended means of aerobic exercise is walking, with an optimal frequency of three to five days a week and an optimal duration of 20 to 30 minutes of continuous activity [66] . in a recent study, the iga secretion rate was negatively correlated with the incidence of infections [67] . a recent randomized trial comparing meditation and exercise with wait-list control among adults aged 50 years and older found significant reductions in ari illness [68] . malnutrition is the most common cause of immune deficiency worldwide and a balanced diet is fundamental for a healthy immune system. vitamin d deficiency has been associated with increased risk of infections, earlylife wheeze and reduced asthma control [69, 70] . vitamin a derivatives are involved in the regulation of the immune system and tissue inflammation as well as prevention of respiratory infections [71] . zinc, selenium and other trace elements are necessary for function of both innate and adaptive immune function. a high intake of fruit and vegetables ensures adequate consumption of nutrients and antioxidants and appears to be beneficial for asthma. although recent reviews have shown that zinc [72] , garlic [73] , echinacea purpurea [74] or ginseng [75] supplementation for several months may reduce cold incidence, there is insufficient evidence to recommend any vitamin or mineral supplementation in the management of asthmatic children without nutrient deficiency [76, 77] . however, a large controlled trial showed echinacea was ineffective in reducing infection rate or symptom severity of hrv infection in healthy young adult volunteers [78] . vitamin c supplementation failed to reduce the incidence of colds in the general population except in those exposed to short periods of extreme physical stress [79] . finally, it is worth remembering that infants who are not breastfed have significantly higher risk of respiratory, gastrointestinal, and other infections, as breast milk is a biologically active substance containing antimicrobial and immunomodulatory elements [80] [81] [82] . sleep and the circadian system exert a regulatory influence on immune functions. sleep deprivation can affect immune function in several ways including reduced natural killer cell activity, suppressed interleukin-2 production and increased levels of circulating proinflammatory cytokines [83, 84] . there is also evidence for an enhanced susceptibility to the common cold and pneumonia with poor sleep efficiency [85, 86] . air pollutants (nitrogen dioxide, ozone, particulate matter) and environmental tobacco smoke (ets) have long been correlated with multiple adverse effects on the immune system and susceptibility to viral respiratory tract infections in children [87] [88] [89] [90] . studies in europe and the united states have shown that 40% of children live with a smoker [34] and they have approximately twice the risk of contracting a serious respiratory tract infection in early life [91] . cigarette smoking leads to a longer duration of cough, greater frequency of abnormal auscultatory findings during acute respiratory tract illness [92, 93] and higher risk for severe exacerbations [94] . urinary leukotriene e4 levels identify children exposed to ets at high risk for asthma exacerbation [94] . there is strong evidence that some pharmacological preparations can help prevent viral infection by specific effects on immune system. these results have been promising with a hope that using these strategies can attenuate the role of viruses in asthma inception. ancient physicians of the middle east prescribed yogurt for curing disorders of the stomach, intestines and for stimulation of appetite. it is written in the old persian testament that "abraham owed his longevity to the consumption of sour milk" [95] . the popularity of probiotics and intestinal microbiota significantly increased when the nobel prize-winning russian scientist eli metchnikoff suggested in 1908 that the long life of bulgarian peasants resulted from their consumption of fermented milk products [96] . the term probiotic, meaning for life, is used for live micro-organisms (typically of the bifidobacterium and lactobacillus species) administered in adequate amounts which confer a beneficial physiological effect on the host. prebiotics are nutrients, in particular oligosaccharides, which foster the growth of probiotics in the colon. the term synbiotics is used when a product contains both probiotics and prebiotics [97] . up to 100 trillion bacteria from different species colonize the human gut [98] . this microbiota participates in: host metabolism, vitamin synthesis, control of epithelial cell growth, protection from infectious microbes, and helps proper development and function of the immune system. there is constant cross-talk between microbiota and gut-associated lymphoid tissue (the largest lymphoid tissue of the human body which contains more than 60% of all body lymphocytes) to establish mucosal immune tolerance in the gut. common mucosal immunity describes the phenomenon where immune cells, especially regulatory t-cells, traffic to and influence responses at other mucosal surfaces, including the lungs [99] . alteration in the microbiota composition (dysbiosis) results in immunological dysregulation that may underlie many human diseases such as inflammatory diseases [100] , obesity [101] , allergy [102] and autoimmunity [103] . reduced bacterial diversity in the infant's gastrointestinal tract has been associated with an increased risk of allergic sensitization and allergic rhinitis but not asthma or atopic dermatitis [102] . in the first year of life, especially the first few weeks, the microbiota of the newborn is highly variable during this critical time of post-natal maturation of the immune system. microbiota is shaped by genetic and environmental factors including: mode of delivery, neonates born by means of vaginal delivery are exposed to mothers gut, skin, and vaginal flora [104] ; breast feeding and diet [105] ; farm or urban living [106] ; vitamin d status [107] ; and antibiotic consumption [98, 108] . this knowledge stimulated interest in the use of probiotics and prebiotics as the intentional introduction or encouragement of specific microbes to shape immune system development. specifically, the microbiota can activate distinct tolerogenic dendritic cells in the gut and through this interaction can drive regulatory t-cell differentiation that modulates both th1 and th2 responses inside and outside the gut [109] [110] [111] . probiotics have been successfully used for the treatment of several gastrointestinal disorders (viral and antibiotic-associated diarrhea, inflammatory bowel disease) [112, 113] . however, attempts to prevent or treat allergic disorders such as eczema, asthma and allergic rhinitis have had inconsistent results [99, 109, [114] [115] [116] . there are a growing number of clinical trials using probiotics for the prevention and management of respiratory infections. while the precise mechanisms are largely unknown, speculations include: probiotics compete against pathogens; increase the barrier function in respiratory epithelium; immunostimulatory effects by enhancing cellular immunity with increased activity of natural killer cells and macrophages in airways [117] . probiotics reduce the frequency of gastrointestinal and respiratory tract infections in children who attend day care centres [118] . they have also been found to reduce the incidence of ventilator-associated pneumonia, respiratory infections in healthy and hospitalized children, and reduce the duration of common cold symptoms [119] [120] [121] [122] . one study demonstrated that that daily probiotic supplementation for six winter months in children three to five years of age reduced the incidence of fever, coughing and rhinorrhea by 32-43% with no notable adverse events [123] . probiotic combination with vitamins and minerals also reduced the duration and severity of common cold [124] . a recent cochrane review of 14 randomised controlled trials showed that probiotics were better than placebo in reducing the number of episodes of acute upper respiratory infections (uris) and reducing antibiotic use, while there were no differences in the mean duration of an episode and no increase in adverse events [125] . probiotic foods such as probiotic milk or yogurt (functional foods) containing well-defined probiotic strains may reduce the risk of catching the common cold and represent a simple, safe, effective, available and affordable method for preventing respiratory infections in children [112, 120, [126] [127] [128] [129] [130] [131] . although there are several clinical trials that showed the preventive effect of probiotic, prebiotic [132] or synbiotics treatments [133] on respiratory infections, not all studies are positive with some failing to show any significant preventive effect [134] . to explain the different results in clinical trials, it is of particular importance to point out that the immunomodulatory capabilities of probiotics are strain-dependent. difference in dosage, duration of intervention, population and environmental background may also affect the results. one major limitation in this field is that it is not possible to test just how "probiotic" a particular preparation is. technical advances will be required before some of the apparent discrepant results of studies can be resolved. several immunostimulants, including herbal extracts, bacterial extracts, synthetic compounds, have been promoted as increasing the immune defences of the respiratory tract. a recent cochrane review included data from 35 placebo-controlled trials including 4060 participants below the age of 18 years in which various types of "immunostimulants" were used to reduce acute respiratory tract infections, involving either upper or lower airways. the authors concluded that immunostimulants reduced the incidence of acute respiratory infections by 40% on average in susceptible children, but that trial quality was generally poor and a "high level of statistical heterogeneity was evident". a subgroup analysis focusing on bacterial immunostimulants, including om85, produced similar results with lower statistical heterogeneity [135] . om-85 bv (broncho-vaxom) is an immunostimulant extracted from eight common bacterial pathogens of the upper respiratory tract: haemophilus influenzae, diplococcus pneumoniae, klebsiella pneumoniae and ozaenae, staphylococcus aureus, streptococcus pyogenes and viridans, neisseria catarrhalis and has been used in several countries around the world for as long as 20 years [136] . recent studies showed that om-85 bv can reduce the number of acute respiratory infections by 25% to 50% compared with placebo in children with a history of recurrent infection [137] . of particular interest, razi et al. showed that children between the age one and six years with recurrent wheezing who were given om-85 bv had a 40% reduction in the rates of wheezing over the subsequent 12 months, compared to placebo (p < 0.001). in addition, the duration of each wheezing attack was two days shorter in the group given om-85 bv than in the group given placebo (p = 0.001) [138] . again, direct evidence of the mechanisms involved are lacking from human studies. however, recent data from rodents shows that baseline regulatory t lymphocyte activity in the airways can be boosted by microbe-derived stimulation of the gut [139] . bacterial immunostimulants were also shown to enhance innate immunity (i.e. intensification of phagocytosis) and adaptive immunity [140] . as discussed above, evidence exists for an impaired innate immune response to respiratory viral infections in asthmatics [141] . entry of rhinovirus into normal epithelial cells initiates a vigorous innate immune response with ifn-β secretion and apoptosis induction. in asthma, ifn-β and ifn-λ responses are impaired, resulting in viral replication, cell cytotoxicity, enhanced virion shedding and increased susceptibility to common cold [17, 142] . epithelial cells of asthmatic patients responded to exogenous treatment with ifn-β exhibiting reduced rhinovirus release (cakebread, xu et al. 2011; jackson, sykes et al. 2011). if the proposed deficiency of type i and iii contribute to asthma exacerbations [21, 22, 143] , correcting this deficiency with exogenous interferons would be a logical approach. the advantages of interferon application include the broad spectrum of activity with low risk of resistance development [47] . prophylactic intranasal recombinant ifn-α and ifn-β have been shown to be effective against rhinovirus infection in humans [144] [145] [146] . the results of these clinical trials are awaited with interest [147, 148] . however, the systemic symptoms associated with severe viral infections, e.g. influenza, are associated with interferons, so careful dosing may be required. considering the occurrence of the local side effects, neutropenia and cost, the use of long-term prophylaxis with daily, intranasal administration of interferons is not feasible [144] . however, randomized clinical trials using similar strategies are currently underway in adults with chronic respiratory disease and the results are keenly awaited. vitamin d deficiency is a common worldwide problem [149] [150] . beside importance for bone health, vitamin d plays an important role in adequate function of both the innate and adaptive immune systems including development of dendritic cells and regulatory t lymphocytes [151, 152] production of antimicrobial proteins by airway epithelium [153] , modifying the effect of intestinal flora on inflammatory disorders [107] , and modulation of the inflammatory response to viral infections [154] . recent reports suggest that vitamin d might play a role in the recent increase in allergic disease [155] [156] [157] . vitamin d insufficiency has been associated with a higher incidence of respiratory tract infection, wheezing illness in children [158] , reduced asthma control [159] , emergency department visits, severe asthma exacerbations and hospitalizations [70, 160] . in a recent study of 48 children from five to 18 years of age, with newly diagnosed asthma, vitamin d supplementation during the northern hemisphere winter months (september to july) prevented declining serum concentrations of 25(oh) d and reduced the risk of asthma exacerbation triggered by acute respiratory tract infections [161] . macrolides possess anti-inflammatory and immunomodulatory properties extending beyond their antibacterial activity [162] . indeed, they can attenuate pro-inflammatory cytokine production by bronchial epithelial cells, neutrophils and macrophages that may contribute to clinical improvement in many patients with chronic airway inflammation [163] [164] [165] . azithromycin has anti-rhinoviral activity and can reduce hrv replication and release by increasing interferon production from epithelial cells [42, 166, 167] . macrolide antibiotics inhibit rsv infection in human airway epithelial cells [168] . a three weeks treatment with clarithromycin in rsv bronchiolitis had statistically significant effects on hospital length of stay and rate of readmission to the hospital within six months after discharge [169] . however, direct evidence of macrolides preventing respiratory viral infection in children is lacking. as the majority of respiratory viral infections in young children are caused by hrv or rsv, we will briefly discuss anti-viral strategies to prevent hrv or rsv infections in asthmatic children. because there are more than 100 serotypes of hrv, antiviral drugs are considered to be more effective than vaccination. antiviral agents have been designed to inhibit rhinovirus attachment, entry to the cell, viral uncoating, and rna and protein synthesis [47] . table 1 shows how intervention strategies can be targeted to various steps in the infective process. hrv has the icosahedrally shaped capsid formed by 60 identical copies of viral capsid structural proteins vp1-4. the capsid protects the single-stranded, positive sense rna genome. while hrv-a and -b most often induce a self-limited upper respiratory infection, the recently discovered hrv-c was associated with slris in infants, bronchiolitis, and asthma exacerbations in children [170, 171] . prevention of attachment, entry and uncoating hrv deposits on nasal or conjunctival mucosa and is transported to the posterior nasopharynx by mucociliary action of epithelial cells [172] . the so-called major group of hrv uses intercellular adhesion molecule-1 (icam-1) as their receptor [173] and the minor group attach to low density lipoprotein (ldl) receptor and very-ldl (vldl) receptors on epithelial cells in the adenoid area to bind and enter cells [174, 175] . viral attachment can be prevented by specific anti-hrv neutralizing antibodies, anti-receptor antibodies and soluble receptor molecules. endothelial cells express histamine receptors and increased adhesion molecule expression, such as icam-1, was demonstrated by histamine infusion. second-generation h1-antihistamines decrease expression of icam-1 on cultured bronchial epithelial cells [176] . zinc may also act as an antiviral agent by reducing icam-1 levels [177] . the monoclonal antibody to the cellular icam-1 was not effective. cfy196 (coldsol) is a nasal spray multivalent fab fusion proteins against icam-1 with a better avidity and in vitro potency against hrv [178] . tremacamra, a soluble intercellular adhesion molecule 1 reduced the severity of experimental rhinovirus infection [179] . pleconaril, an orally administered antiviral drug, acts by binding to a hydrophobic pocket in viral protein 1, and stabilizes the protein capsid so that the virus cannot release its rna genome into the target cell. outcomes of clinical trials with pleconaril have revealed mixed results and new compounds are currently being developed [180] . despite extensive research, no agent has been approved for prevention and/or therapy of rhinovirus-induced diseases so far. ruprintrivir selectively inhibits hrv 3c protease and shows potent, broad-spectrum anti-hrv activity in vitro. ruprintrivir nasal spray (2% solution) prophylaxis reduced the proportion of subjects with positive viral culture by 26% and reduce viral titers, but did not decrease the frequency of colds [181] . hrv rna synthesis during replication can be blocked by deoxyribozymes [182] , morpholino oligomers [183] , and small interfering ribonucleic acids [184] . the novel antiviral therapies that have been discovered recently, may one day add significantly to the armamentarium of antiviral agents, against respiratory viral infections in asthmatic children. maternally-derived rsv neutralizing antibodies help to protect infants against rsv hospitalization [185] . palivizumab, a humanised monoclonal antibody against the rsv fusion protein is effective against rsv and wheezing in children and reduces hospitalization in high-risk individuals [185, 187] . rsv prophylaxis with palivizumab significantly reduced the relative risk of subsequent recurrent wheezing in nonatopic premature infants [40] . motavizumab is another monoclonal antibody against rsv, with an approximately 20-fold increase in ability to neutralize rsv and 100 fold increase in ability to reduce viral titers compared to palivizumab [188, 189] . motavizumab was also found to be superior to palivizumab in reducing outpatient medically attended lower respiratory illness by 50% [190] . vaccination against hrv and rsv have been in development for quite some time, but there are no safe and effective vaccines at present [33, 191] . high rates of exposure to viruses in early life, presence of more than 100 serotypes of hrv, the presence of maternal antibodies, the risk of vaccine induced disease and relative immaturity of the infant immune system make effective vaccination difficult [186, 192, 193] . respiratory viral infections are major contributors to the global burden imposed by asthma. in early life, they contribute to the inception of asthma and are responsible for most of the acute exacerbations for asthma in childhood. while the debate is not completely settled, children at high risk of developing asthma and those with established asthma may be at increased risk of acquiring respiratory viral infections and may be less able to contain these to the upper airway. several simple general strategies can be used to help prevent respiratory viral infections in asthmatic children (table 2) , with good personal hygiene, hand-washing and avoidance of cigarette smoke likely to reduce respiratory viral infections. general immuno-stimulatory strategies, such as eating a healthy balanced diet, active probiotic supplements and bacterial-derived products, e.g. om-85, may reduce recurrent infections in susceptible children. while research continues on specific anti-viral therapies, including vaccination, there are no currently available practical therapies that are suitable for widespread use. the role of preventative strategies in primary prevention of asthma in high risk children is of considerable academic interest and a number of studies are currently in the pipeline. the results are awaited with interest. the authors declare they have no competing interests. author's contribution ha and pds conceived and designed the review. all authors reviewed the articles, abstracted data, and participated in the data synthesis. ha, pds, ysc drafted the current manuscript, with critical review by pds and cmj. all authors contributed, 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recurrent wheezing development of motavizumab, an ultra-potent antibody for the prevention of respiratory syncytial virus infection in the upper and lower respiratory tract a review of palivizumab and emerging therapies for respiratory syncytial virus motavizumab for prophylaxis of respiratory syncytial virus in high-risk children: a noninferiority trial vaccination for asthma exacerbations viral respiratory tract infections and asthma: the course ahead association between human rhinovirus c and severity of acute asthma in children submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution the authors wish to acknowledge dr. catherine gangell for reviewing the manuscript. key: cord-342464-6vk2oxo5 authors: edwards, michael r.; bartlett, nathan w.; hussell, tracy; openshaw, peter; johnston, sebastian l. title: the microbiology of asthma date: 2012-06-06 journal: nat rev microbiol doi: 10.1038/nrmicro2801 sha: doc_id: 342464 cord_uid: 6vk2oxo5 asthma remains an important human disease that is responsible for substantial worldwide morbidity and mortality. the causes of asthma are multifactorial and include a complex mix of environmental, immunological and host genetic factors. in addition, epidemiological studies show strong associations between asthma and infection with respiratory pathogens, including common respiratory viruses such as rhinoviruses, human respiratory syncytial virus, adenoviruses, coronaviruses and influenza viruses, as well as bacteria (including atypical bacteria) and fungi. in this review, we describe the many roles of microorganisms in the risk of developing asthma and in the pathogenesis of and protection against the disease, and we discuss the mechanisms by which infections affect the severity and prevalence of asthma. asthma is a chronic airway disease for which the symptoms are wheezing, breathlessness, chest tightness and coughing, with variable and often reversible airway obstruction accompanied by airway hyperreactivity. these symptoms result from a range of processes, including contraction of airway smooth muscle (asm), airway inflammation, airway infections, immunoglobulin e-mediated allergic responses, exposure to pollutants, exercise, stress and the stimulation of cholinergic and sensory nerves 1 . a key feature of asthma is decreased lung function, measured as a reduction in either the peak expiratory flow (pef) or the forced expiratory volume in 1 second (fev 1 ). some of the immediate symptoms of asthma are reversed by a short-acting inhaled β 2 agonist, but longer-term control requires inhaled anti-inflammatory glucocorticoids. worldwide, asthma affects ~300 million people, including both adults and children. it is associated with onset early in life and is increasing in incidence in the developed world. an interesting aspect of asthma is its heterogeneous, complex nature and the fact that it can present as a chronic, stable disease and as asthma exacerbations. asthma can be severe or mild, and can vary spontaneously in activity and greatly in terms of the time of onset or the response to therapy. indeed, whether asthma is one disease or a spectrum of related but subtly different conditions is often debated 2 , and asthma has recently been divided into separate pheno types, which are in turn subdivided into several endotypes 3 (table 1) . asthma exacerbations are often triggered by multiple factors that may work in an additive or synergistic manner. this complex pathogenesis has made it challenging to understand the cellular mechanisms that are responsible for asthma, to decipher candidate genetic predispositions and to identify causative agents. the causes of asthma are multifactorial, and epidemiological studies spanning three decades across five continents have proved that there is a strong association between respiratory infections and the risk and pathogenesis of asthma. in this review, we summarize the association of microorganisms with asthma, discuss the importance of such organisms for the disease and consider the idea that part of the cause and at least some of the patho genesis of asthma -in particular, of asthma exacerbations -result from microorganisms and their components. we also discuss the potential therapeutic value of micro organisms and their products for treating asthma and argue that future treatment and management of the disease must carefully consider the role of microorganisms. the hygiene hypothesis. the hygiene hypothesis posits that repeated exposure to diverse common infections (in particular, with bacteria, food-borne and oro faecal parasites 4 , and hookworms 5 ) and exposure to environmental microbiota during childhood 6, 7 are strongly associated with a healthy maturation of the immune system and with protection from the development of asthma and allergies later in life 8, 9 . our understanding of the importance of microorganisms in protection from allergies and asthma has been recently enhanced by a molecular analysis of the microbiome. populations that live in environments with diverse microbiological fluid or mucus in the airways, which gives rise to a typical 'wheezy' sound when breathing. flora are associated with a low incidence of asthma, whereas populations that live in environments with low micro biological diversity are associated with a higher incidence of asthma 7 . the incidence of bacteria and their components in different environments has been studied using culture-dependent and molecular methods [10] [11] [12] , and both qualitative and quantitative differences are found between countries with a high incidence of atopy and those with a low incidence of atopy 10 . evidence for the hygiene hypothesis is also supported by experiments in mice, whereby intranasal exposure to escherichia coli 13 or acinetobacter lwoffii str. f78 protects against allergic inflammation of the airways 14 . in addition, a link has been established between the fermentation of dietary fibre by the mouse intestinal microbiota and protection against inflammatory diseases, including asthma 15 . although these studies provide experimental support for the hygiene hypothesis, our understanding of the mechanistic basis of this phenomenon is still in its infancy. these studies have also promoted the use of bacterial components such as toll-like receptor (tlr) ligands and other pathogenassociated molecular patterns as potential therapies for asthma (table 2) . much evidence points to a relationship between severe lower respiratory infections with human respiratory syncytial virus (human rsv; referred to hereafter as rsv) or human rhinoviruses (rvs) early in life and the development of recurrent wheeze followed by asthma diagnosis in later childhood. rsv is a negative-sense single-stranded rna (ssrna) virus of the paramyxoviridae family. it is an important pathogen of young children (<2 years of age) and accounts for ~70% of severe infantile viral bronchiolitis cases 16 . serological monitoring shows that rsv infects nearly all children in their first 2 years of life; however, only ~40% of children exhibit clinical signs of infection in the lower respiratory tract. for unknown reasons, some children with bronchiolitis develop recurrent respiratory symptoms. rvs are members of the family picornaviridae, are composed of a positive-sense ssrna genome of approximately 7.1-7.5 kb and can be grouped into the major and minor groups on the basis of their host receptors: major group viruses bind intercellular adhesion molecule 1 (icam1), whereas minor group viruses bind low-density-lipoprotein receptor (ldlr). rvs can also be classified into three groups on the basis of nucleotide sequence identity (rv-a, rv-b and rv-c). the recently proposed rv-c group viruses 17, 18 have unique sequences at the icam1-and ldlr-binding sites, suggesting that they use a different (but currently unknown) receptor 19 . it is estimated that there are more than 100 serotypes of rvs, meaning that multiple serotypes may infect an individual throughout the year 20 . recent cohort studies suggest that lower respiratory infections by rvs are as important as infections by rsv in terms of the risk of later asthma development 21-23 . whether these viruses are true causative agents of asthma or (owing to shared risk factors) simply act as markers for an increased risk of asthma development, or even whether both possibilities are true, is unclear and much debated. rsv-mediated bronchiolitis is clearly associated with later asthma development 24,25 , perhaps owing to an inappropriate or overexuberant immune response to the infection 26 . although associations between rsv, wheeze and asthma development are evident, birth cohort studies have shown that 90% of nonatopic wheezers lose this phenotype at school age and have normal lung function, indicating that asthma and virus-induced wheeze may be distinct diseases 27 . the association of rsv with asthma is most clearly demonstrated in a long-term (18 years) study of a cohort of swedish children. the most recent update from this study 28 reports that, compared with controls, children who have rsv-mediated bronchiolitis in infancy are more likely to be asthmatic at 18 years old (39% versus 9%), show increased sensitization to perennial allergens (41% versus 14%) and have striking persistent and recurrent wheeze (30% versus 1%). children with a history of bronchiolitis have an enhanced interleukin-4 (il-4) (that is, t helper 2 (t h 2) type) response to rsv and cat allergens, whereas controls have an equally strong interferon-γ (ifnγ) (that is, t h 1 type) response to rsv antigens 29 . however, it is not yet clear whether the inflammation caused by viruses causes long-term respiratory disease or is associated with wheeze and asthma diagnosis because of shared risk factors. animal studies have further contributed to our understanding of this phenomenon 30 , and although many clinical studies are compatible with a direct effect of rsv on the later development of recurrent childhood wheeze, it has been hard to prove this direct causal relationship. the strongest evidence that human rsvmediated bronchiolitis has long-term effects comes from studies of palivizumab (synagis; medimmune), a monoclonal antibody that prevents infection by rsv in infancy. these studies suggest a causal link between infantile rsv-mediated disease and wheeze followed by asthma diagnosis in later childhood; in a study of a measure of the ratio of the probability that an event will occur in one group versus another. 191 palivizumab-treated and 230 control (untreated) premature babies who were followed for 24 months, the rates of recurrent wheeze were about 50% lower in those who had prophylactic treatment with palivizumab 31 . more recently, palivizumab prophylaxis was shown to be associated with a similar substantial protection against recurrent wheeze in children aged 2-5 years 32 . much debate has focused on which of these viruses are more important to asthma development, rsv or the rvs. the answer is likely to be complicated and may involve host genetics and susceptibility factors as well as the nature of the viruses themselves. it is possible that rsv and rvs contribute to asthma development in different ways. a recent study has shown that allergic sensitization precedes or is a risk factor for symptomatic infection with rvs, and both sensitization and rv infection are strongly correlated with the occurrence of asthma at 6 years of age 33 . by contrast, the role of rsv infection in this study seemed to be different, as sensitization did not increase the risk of infection in this cohort. in the absence of independently conducted, placebocontrolled prospective studies of specific prophylaxis measures, doubt will remain about the nature of the association between infections with these viruses in infancy and the later development of childhood asthma. however, the evidence obtained so far raises hope that preventing such infections will have long-term beneficial effects on asthma development. specific asthma phenotypes or endotypes stable asthma. microorganisms are now also thought to be important in the development and pathogenesis of stable asthma. 16s ribosomal rna gene sequencing was carried out on bronchial brushings or bronchoalveolar lavage (bal) from patients with stable asthma, patients with chronic obstructive pulmonary disease (copd) and healthy controls 34 , and revealed 5,054 bacterial sequences that were unique to the 43 subjects with asthma or copd, with each bronchus containing a mean of 2,000 bacterial genomes per cm 2 surface sampled. pathogenic proteobacteria, particularly haemophilus spp., were more frequent in the bronchi of adults with asthma or copd than in the bronchi of controls. similar increases in proteobacteria were found in children with asthma. in addition, there was a lack of members of the phylum bacteroidetes in individuals with asthma when compared with controls, suggesting a potential role for commensals as well as pathogens in influencing asthma 34 . it is thought that such commensals may stimulate the immune system such that pathogenic species are eliminated if and when infection occurs (fig. 1) . changes in the abundance and diversity of commensals can also affect subsequent infection by influenza viruses in mice 35 . the lower airway thus contains a characteristic microbiota that is quantitatively and qualitatively different in patients with stable asthma or copd than in control subjects 34 . this study challenges the previously held belief that in healthy individuals the lower airway is a sterile environment that does not support a complex microbial ecology. the diversity of bacteria that has now been revealed suggests that clinically important microorganisms which are unidentifiable by culture have roles in airway diseases such as asthma. invasive pneumococcal infection (ipi), which is caused by the common pathogen streptococcus pneumoniae, has also been linked to asthma. adults with stable asthma have been shown to have a greater incidence of s. pneumoniae carriage 36 , and asthma has been shown to be a risk factor for ipi in both adults 37,38 and children 39 . one study had a particularly important finding 37 : for low-risk asthma (as defined by the need for prescription medication for asthma) the odds ratio for ipi (versus no ipi) was 2.8-fold, whereas for high-risk asthma (as defined by hospitalization for asthma in the past 12 months) it was over 12-fold. together, these studies show the importance of asthma in the risk of invasive s. pneumoniae infections, and combined with the other studies they strongly advocate the need for antipneumococcal vaccination for individuals with asthma. atopic asthma is the most common form of asthma and is often characterized by eosinophils in bal and sputum. filamentous fungal species of the aspergillus, alternaria, cladosporium, penicillium and didymella genera (in the phylum ascomycota) produce spores that may act as allergens and initiate bronchial asthma in atopic individuals 40 . comparative genomics studies have identified proteins that act as allergens in 22 fungal species 41 , many of which are ubiquitous in the environment and commonly found on grains and cereals. the release and abundance of fungal spores is affected by environmental factors, including season, humidity, rainfall and temperature 42 . many fungal aeroallergens increase in abundance in the summer along with pollen levels and have been shown to be further increased by summer storms that include lightning strikes. indeed, fungal aeroallergens have been associated with asthma epidemics that occur during summer figure 1 | the microbiome is influenced by and may determine factors affecting asthma. the microbiome is regulated by diet, environmental factors (such as smoking and pollution), treatment, host genetics, and previous infections and host immunity. the diversity of the microbiome may in turn affect asthma development, as suggested by the hygiene hypothesis, and may influence the pathogenic species that contribute to stable and severe asthma and asthma exacerbations. an abnormal increase in the number of neutrophils in a body fluid such as bronchoalveolar lavage. a chronic, irreversible inflammatory condition of the airways, involving tissue destruction and neutrophilic inflammation. bronchiectasis has a wide range of causes and is associated with bacterial and fungal infections. it can occur in parallel with asthma. lightning strikes 43 , possibly owing to spore aerosolization and fragmentation to produce finer particles that easily find their way to the lower respiratory tract. neutrophilic asthma is a less common form of the disease that is characterized by neutrophils, with or without eosinophils, being the most abundant granulocyte in the airways of the patient 44 . respiratory viral infections have been associated with airway neutrophilia: asthmatic adults experiencing asthma exacerbations show increased airway neutrophilia 45 , including neutrophil elastase in their sputum 46 . respiratory viruses can induce neutrophil chemokine synthesis and release 45,47 , providing a mechanistic link between neutrophilic asthma and virus infections. bacterial pathogens such as haemophilus influenzae, staphylococcus aureus, moraxella catarrhalis and pseudomonas aeruginosa have also been associated with neutrophilic asthma, with one study showing an association between airway neutrophils, increased bacterial load and the neutrophil chemokine il-8 (also known as cxcl8) 48 . recently, a molecular approach was used to investigate the microbiota in poorly controlled asthma 49 , and the results suggest an association between the families comamonadaceae, sphingomonadaceae and oxalobacteraceae and airway hyper-reactivity. furthermore, this study shows that the bacteria which are found in the lung differ in health and disease and that the abundance of particular phylotypes, including members of the families comamonadaceae, sphingomonadaceae, oxalobacteraceae and others, is highly correlated with the degree of bronchial hyper-responsiveness (disease severity). fungi have also been associated with severe asthma 50,51 . in fact, severe asthma with fungal sensitization (safs) has been considered as an independent subgroup of severe asthma, and patients with safs may benefit from antifungal therapy. in a recent clinical trial of antifungal therapy in patients with safs, improvements were seen in antifungal-treated patients (versus placebo-treated patients) in terms of asthma-related quality of life, rhinitis score, lung function and total serum ige 52 . allergic bronchopulmonary aspergillosis. allergic bronchopulmonary aspergillosis (abpa) is a unique form of asthma that is caused by colonization of the lower respiratory tract with aspergillus spp. chronic infection with aspergillus fumigatus can lead to bronchiectasis 53 , a disease that can occur in parallel with asthma and is characterized by neutrophilic inflammation, epithelial destruction and degradation of the connective tissue matrix. in this disease, the fungus acts as both a source of allergen and a pathogen, and symptoms of abpa can be attributed to both functions. aspergillus spp. are widespread fungi and potent sources of allergens 54 , as shown by the reactivity of human ige to at least 12 allergens derived from these species 55 . recently, the genome of a. fumigatus was sequenced 56 , and nine new potential allergens were identified on the basis of sequence identity with other known allergens. the predicted and known allergens of a. fumigatus are diverse in nature and include secreted proteases, glucanases and cellulases. recent work suggests that some a. fumigatus allergens are 'hidden' from the immune system; hydrophobin (roda) is an immunologically inert surface protein on dormant conidia, and removal of roda through chemical or genetic means produces conidia that are able to activate the immune system, potentially explaining why fungal species often do not evoke immune responses in healthy individuals 57 . colonization by a. fumigatus results in sensitization to fungal allergens and, subsequently, leads to allergic and/or asthma symptoms, eosinophilic and neutrophilic pneumonia 53 , and lung damage caused by the extra cellular hyphae and lung inflammation. an infection model in mice using a bioluminescent a. fumigatus strain 58 revealed that infection results in extensive haemorrhagic bronchopneumonia, characterized by inflammatory lesions on the bronchi and bronchioles, underscoring the potentially aggressive nature of this pathogen in affected individuals. furthermore, a. fumigatus infection has been linked to ige sensitization, airway neutrophilia and decreased lung function in abpa, and antifungal therapy has also recently been shown to be effective in patients with abpa 59 . microorganisms in asthma exacerbations. respiratory viruses are the major viruses associated with asthma exacerbations, accounting for 50-60% of exacer bations in all age groups 60,61 (fig. 2) . rv-c may represent a group that causes more severe exacerbations, although how this occurs is unknown 18 . epidemiological studies have shown that, in the northern hemisphere, infections by rvs result in a marked increase in emergency room admissions owing to asthma exacerbations. in fact, this 'asthma epidemic' has been shown to coincide with labour day in canada 60 , which is in the third week of september, ~2 weeks after children return to school, highlighting the important role of school-age children as vectors of virus-induced asthma exacerbations. mouse models of infection with major and minor group rvs 62,63 and of rv-mediated exacerbations of airway allergen challenge 62,64 have recently been developed and used to demonstrate the ability of rv infection to augment airway inflammation caused by allergen sensitization and challenge. despite common bacterial infections first being suggested to have a role in asthma exacerbations as early as the 1940s 65 , it was not thought that such infections were important in the pathogenesis of asthma exacerbations 66 until recently. however, we now realize that patients with asthma have an increased susceptibility to respiratory bacterial infections 37-39 and increased carriage of pathogenic respiratory bacteria (identified by both culture methods 36 the atypical bacteria mycoplasma pneumoniae and chlamydophila pneumoniae are common respiratory pathogens and have also been associated with asthma, wheeze and asthma exacerbations in both adults and children 69-71 . detection rates for these bacteria can be as high as 80% in patients with these conditions 69 , and serological positivity rates for these atypical bacteria are often 40-60% 69,71 , indicating that viral and atypical bacterial infections probably interact to increase the risk of asthma exacerbations. the macrolide antibiotic clarithromycin has previously shown efficacy in patients with stable asthma who are known to be carrying either m. pneumoniae or c. pneumoniae; in such patients, the drug improves lung function and reduces tumour necrosis factor (tnf) production 72 . more recently, the ketomacrolide telithromycin has shown efficacy in patients with asthma exacerbations, resulting in substantial reductions in the asthma symptom score and improvements in lung function 71 . however, the effects of telithro mycin were found to be not necessarily related to c. pneumoniae or m. pneumoniae exposure, suggesting that telithromycin has additional protective properties that are independent of its antibacterial properties. the identification of key microorganisms that are linked with asthma development or asthma pathogenesis raises the important question of which properties of these microorganisms promote asthma. the microorganisms that commonly infect different areas of the lower airway are shown in fig. 3 . some of these microorganisms may be found systemically in more severe disease, as has been shown for rvs 73 . a key feature of a microorganism in promoting asthma is the ability to induce lung inflammation, injury, or repair and remodelling. many of the innate receptors that recognize respiratory fungi, viruses or bacteria, including tlrs, rig-i-like helicases and nod-like receptors, activate the nuclear factor-κb (nf-κb) family of transcription factors, which induce more than 100 pro-inflammatory and host response genes 74 . rsv and rvs induce a range of pro-inflammatory cytokines, chemokines, growth factors, adhesion molecules and mucins. mucins cause mucous plugging of the airway and may provide a substrate for bacterial colonization, whereas cytokines facilitate cellular chemotaxis, and activation and proliferation of immune cells in the infected airway 45,75 . microorganisms may damage and compromise the integrity of the airway by infecting airway epithelial cells, causing cell death 76 and shedding 77 . they can also affect epithelial permeability, leading to increased airway inflammation and creating opportunities for increased infection 78 , allergen uptake 79 or exposure to environmental pollutants, all of which are important contributing factors in asthma (fig. 4) . respiratory pathogens can also induce mediators that are required for airway repair, resulting in airway scarring or remodelling. these processes include angiogenesis, increased asm proliferation and hypertrophy, and thicker basement membranes owing to collagen and fibronectin deposition, as well as the generation of new lymphatic vessels that ultimately result in thicker airway walls and reduced lung function. whether or not viral or bacterial infections directly initiate this process is unclear; however, what is clear is that respiratory infections, including by mycoplasma pulmonis, rvs, rsv and a. fumigatus spores, can induce some of these pro-angiogenic mediators, including fibroblast growth factors and vascular endothelial growth factors [80] [81] [82] , and the structural proteins perlecan (also known as hspg) and collagen 83 , the building blocks of airway remodelling. asthma treatment often requires daily treatment with a range of immunomodulatory or immunosuppressive agents, such as macrolide antibiotics or glucocorticoids, suggesting another way that microorganisms interact with asthma. surprisingly, scant attention has been paid to the possible effects of such treatments on an individual's microbiota and their antimicrobial responses. however, some studies provide indirect evidence for an immunosuppressive effect. for example, increases in bacterial pneumonia have been noted in patients with copd who are treated with glucocorticoid therapy 84 . furthermore, an increased incidence of upper respiratory tract infections following treatment with the leuko triene receptor antagonist montelukast has been reported in young children with asthma 85 . it is also interesting to speculate whether the fact that asthma is a risk factor for ipi, as previously discussed, is directly attributable to asthma therapies such as glucocorticoids. conversely, there is some experimental evidence suggesting that the action of glucocorticoids confers benefits a substance that interferes with the association of two liquids or a solid and a liquid. detergents are surfactants that function by lowering the surface tension of liquids. substances that enhance adaptive immune responses (both b cell and t cell responses) to immunogens. adjuvants are not recognized by t cells or b cells themselves but may function by activating specific cells or acting as a long-term depot for slow and effective immunogen release. to antimicrobial immunity. in vitro, glucocorticoids have been shown to induce a number of antimicrobial peptides, pentraxins, collectins and complement proteins 86 . furthermore, clinical studies support the benefits of glucocorticoid use: in preschool children, the use of glucocorticoids for 2 years reduces asthma exacerbations (as measured by exacerbations that require systemic gluco corticoid administration and hospital admissions) 87 . although several studies support the use of macrolide antibiotics for the treatment of atypical pathogens in patients with asthma exacerbations 88 , it is important to consider how the microbiome is affected by macrolides or other antibiotics and how this might affect asthma and the host responses to infection. treatment of mice with the antibiotics vancomycin, neomycin, metro nidazole and ampicillin greatly changes their airway and gut microbiome and impairs their antiviral responses to influenza viruses 35 . in human studies, it is currently unclear whether the genera that seem to colonize the airways of patients with asthma or copd and of individuals without asthma or copd differ because of treatment-specific effects 34 . more research is needed to understand whether the microbiome of patients with asthma is actually a consequence of active therapy. further large clinical trials with such treatments are required to understand the relationships between microorganisms and asthma treatments. infections or environmental stresses may induce alterations in epithelial cells and underlying stromal cells, and these alterations may modify the response of these cells to further stimulation or may influence barrier function. for example, enhanced permeability caused by virusinduced cytopathology may lead to inhaled allergens, pollutants and other irritants having greater access to basal cells and the underlying airway tissue, which could be detrimental because submucosal antigen-presenting cells (apcs) are not restrained like their airway lumen counterparts. epithelial cells orchestrate innate immune regulation in the airway lumen, preventing an inflammatory response to non-injurious stimuli by controlling tlr signalling and phagocytosis through the expression of surfactant proteins 89 . epithelial cells also express mucin 1 (muc1), which suppresses alveolar macrophage responses by binding to tlrs 90 . il-10 and transforming growth factor-β (tgfβ) from airway epithelial cells can influence the immune milieu by raising the threshold of activation of airway macrophages 91 and driving the expression of the inhibitory receptor cd200r on alveolar macrophages. the ligand for cd200r, cd200 (also known as ox2), is expressed on the luminal aspect of the airway epithelium, and the interaction of these two proteins prevents the activation of alveolar macrophages in the presence or absence of inflammatory stimuli 92 . thus, macrophages in the airspaces are less proficient at antigen presentation than submucosal macrophages, are poorly phagocytic and secrete prostaglandins and tgfβ to reduce t cell responses, leading to reversible t cell inactivation 93 . alveolar macrophages also actively inhibit interdigitating dendritic cells (dcs) in the airways 94 , which in turn secrete il-10. apcs in the submucosal tissues are less restrained by these factors simply because the cells are not exposed to these epithelium-derived innate suppressors. should any of these pathways be altered through infection, the less restrained apcs may recognize innocuous antigens or allergens, ultimately contributing to inflammation and disease. recognition of respiratory microorganisms by pattern recognition receptors can inadvertently initiate or exacerbate an unrelated inflammatory condition. for instance, tlr agonists may act as microbial adjuvants that enhance the recognition of concurrent allergens 95 . the major cat allergen fel d 1 is often contaminated with tlr ligands derived from microorganisms found in the feline oral cavity, and the house dust mite often contains the commensal fungus aspergillus penicillioides, which activates tlr2 and tlr4. these allergen preparations can contain dna from gram-negative microorganisms 96, 97 . the relationship between tlrs and allergens has recently become more complex, with evidence showing that allergens themselves may be direct tlr agonists 98, 99 . molecular mimicry between allergens and microbial components 100 raises the idea that tlrmediated recognition of allergens may be an important part of sensitization to these molecules. infection also causes the recruitment of apcs in high numbers and for long periods following pathogen lymphoid tissue that develops only after stimulation with antigen, such as in the process of inflammation. the lymphocytes of tertiary lymphoid tissue are typically derived from primary or secondary lymphoid tissue. the body or bulk of a tissue, such as the lungs. the lung parenchyma typically encompasses the alveoli and cells within. clearance. for example, cells expressing cd11c (also known as integrin αx) display enhanced antigen presentation long after the resolution of an acute infection by influenza virus or rsv 101, 102 . such cells are long lasting 103 , suggesting that an enhanced mature apc compartment assists immunological responses on subsequent exposure to environmental allergens. this would also be facilitated by an increase in tertiary lymphoid tissue in the lung parenchyma, which is a common feature following respiratory tract infection 104 , in human asthma 105 and in experimental mouse models of asthma 106 . successive infections may also alter the lung environment and affect the delicate balance between host, pathogen and chronic airway disease. bacterial infections are known to follow influenza virus infections; indeed, many of the individuals who died in the influenza pandemics exhibited coexisting bacterial pneumonia 107 . this has implications for asthma: what is assumed to be a virusinduced asthma exacerbation may in fact include a secondary bacterial infection. data suggesting that this does occur have been reported for c. pneumoniae 69 , but further studies are required to determine whether secondary bacterial infections commonly follow viral infections in asthma. thus, by causing barrier disruption, viruses may initiate a cascade that, as described above, allows environmental bacteria better access to the underlying tissue (fig. 4) . microorganism and host factor synergy t helper 2 type immunity. t h 2 cells are cd4 + t cells that produce a defined array of cytokines -classically, il-4, il-5, il-9 and il-13 -and home to sites of inflammation. t h 2 cells are involved in defence against gastrointestinal nematodes and are also strongly implicated in the pathogenesis of asthma and asthma exacerbations. case control studies show a clear link between respiratory virus infection together with allergen exposure in sensitized children 108 and adults 109 in increasing the risk of hospital admissions due to asthma exacerbations. furthermore, experimental rv infection models have shown that patients with asthma have more severe lower respiratory tract symptoms and greater reductions in lung function than control patients, and have increases in bronchial hyper-reactivity 75 . exacerbation severity is strongly correlated with both t h 2 type cytokine production from bal cd4 + t cells and viral load. rv infection in mouse asthma models supports these observations, as rvs enhance t h 2 type cytokine production by sensitized mice that are simultaneously challenged with aeroallergen 62 . how viral infection can synergize with or act additively to t h 2 type immunity is shown in fig. 5. excessive t h 2 type responses are implicated in the pathogenesis of rsv-mediated bronchiolitis 110 , and increased production of il-5 by t cells at birth is associated with a greater risk of severe respiratory infection 111 . genetic associations also link polymorphisms in the t h 2 gene locus to severe rsv-mediated disease 112, 113 . increased t h 2 type responses are reported in peripheral blood mononuclear cells and sputum preceding acute asthma exacerbations in vivo and also in mixed t h 1-t h 2 cell populations during acute exacerbations in vivo 114 . , cxcl5 (also known as ena78) and cxcl8 (also known as il-8)), and t helper 1 (t h 1) type chemokines (cc-chemokine ligand 5 (ccl5; also known as rantes), cxcl10 (also known as ip10) and cxcl11 (also known as itac)), and increases epithelial permeability. neutrophils secrete several mediators that can contribute to inflammation and the integrity of the airway, including matrix metalloproteinases (mmps), elastase and reactive oxygen species (ros). epithelial cells normally express luminal cd200, which, when bound to its receptor, cd200r, on lumen macrophages, prevents the macrophage response to inflammatory stimuli. lumen macrophages are normally inhibitory, as they produce transforming growth factor-β (tgfβ), which inhibits inflammatory airway dendritic cells (dcs). a higher epithelial permeability or epithelial damage as a result of infection allows the unrestrained submucosal macrophages access to the allergen and to other stimuli, and this can promote overzealous inflammation. submucosal macrophages and epithelial cells are triggered by exposure to bacteria or viruses (and their products) to produce interleukin-1β (il-1β), il-6 and tumour necrosis factor (tnf), which promote inflammation. asm, airway smooth muscle; gm-csf, granulocytemacrophage colony-stimulating factor; ifnγ, interferon-γ; mhc, major histocompatibility complex; t h 1, t helper 1. also known as tarc), a chemokine that binds with high affinity to cc-chemokine receptor 4 (ccr4), which is abundantly expressed on t h 2 cells. in mice, rsv was found to induce ccl17 production, and this finding was reinforced in a t h 2-biasing model in which mice were first vaccinated with recombinant vaccinia virus expressing rsv major surface glycoprotein g and then infected with rsv 115 . in vitro, production of ccl17 by human becs infected with human rsv requires the presence of t h 2 type cytokines and is associated with activation of both nf-κb and stat6 (signal transducer and activator of transcription 6) 115 . recently, the signalling molecule endoplasmic reticulum ifn stimulator (eris; also known as tmem173) has been shown to induce stat6 activation in viral infections 116 , providing a potential mechanism for how viruses induce t h 2 type cytokines or chemokines. thymic stromal lymphopoietin (tslp) is a t h 2 cell-promoting cytokine that is produced by becs and can be induced by both bacterial (tlr2 and tlr9 activating) and viral (tlr3 and tlr8 activating) ligands 117 . this cytokine matures the dc network and, in humans, enhances the cytolytic activity of cd8 + t cells and the production of t h 2 type cytokines, leading to enhanced airway hyper-reactivity. furthermore, mast cells in the bronchial mucosa of patients with asthma express the tslp receptor. together with il-1, supernatants from tlr2-activated airway epithelial cells induce mast cell production of il-5 and il-13, which have pivotal roles in the development and maintenance of asthma 117 . both rv-and rsv-infected becs produce tslp. human rsv-induced tslp production stimulates dc expression of the t h 2-associated molecules ccl17 and ox40 ligand (ox40l; also known as tnfsf4) 118 . rv-induced tslp production is synergistically enhanced by il-4 (ref. 119 ). becs from patients with asthma also produce higher levels of tslp than becs from healthy individuals when polyinosinicpolycytidylic acid stimulation is used as a surrogate for viral infection 120 . thus, by producing tslp in response to infection, the airway epithelium may orchestrate the pathophysiology of asthma. il-25 is structurally related to members of the il-17 cytokine family but, like tslp, is another t h 2 cellamplifying cytokine that is expressed by a number of different cells, including becs. a recent study using a mouse rsv infection model demonstrated the importance of il-25 in regulating airway disease following viral infection. natural killer cell-depleted mice exhibit enhanced t h 2 type airway inflammation following rsv infection. using an il-25-neutralizing antibody, this rsv-specific t h 2 cell-skewed response was shown to be dependent on il-25 production by airway epithelial cells 121 . allergen-specific ige is a key mediator in allergic reactions and has a central role in the pathogenesis of asthma. il-4 and il-13 stimulate the production of ige, which binds allergen, allowing crosslinking of ige receptors on mast cells and basophils; this causes the release of mediators that have profound effects on airway inflammation and hyper-reactivity. analysis of nasal secretions from rsv-infected infants revealed the presence of rsv-specific ige, and ige levels were found to positively correlate with wheeze and higher levels of histamine 122 , although these studies have been hard to replicate. in mice, primary rsv infection is usually dominated by t h 1 type effects but may induce il-4 and il-13 expression in the lungs as well as the production of rsv-specific ige in serum under some conditions. transfer of rsv-specific ige to naive mice increases airway hyper-reactivity following rsv infection, an effect that is dependent on expression of high-affinity ige receptor 123 . rsv infection in neonatal mice also induces t h 2 type cytokine-dependent rsv-specific ige. re-infection with rsv 5 weeks later induces a t h 2 cell-skewed immune response that is reduced in magnitude by ige-specific antibody therapy 124 . a mechanism has been proposed to explain how ige against a related paramyxovirus, sendai virus (sev), enhances t h 2 cell-associated airway disease in mice. this suggested mechanism involves infection-induced upregulation of high-affinity ige receptor on conventional lung dcs. the authors speculate that the later appearance of sev-specific ige, after viral clearance, crosslinks ige receptors (with viral antigen) on conventional dcs, stimulating the production of ccl28, which in turn recruits activated il-13-producing t h 2 cells to the lung 125 . although there is still much to learn, it has become clear that understanding how respiratory infections interact with t h 2 type immunity, thereby increasing the severity of allergic airway inflammation, may provide opportunities for the development of novel strategies to treat asthma. therapies targeting t h 2 type immunity and ige (table 2) are already yielding encouraging results. the idea that patients with asthma might be more susceptible to viral infections than healthy individuals first surfaced through the study of co-habiting spouse pairs with and without asthma 126 . although individuals with and without asthma had the same incidence of rv infections, individuals with asthma had lower respiratory tract symptoms for longer than individuals without asthma, and had an increased severity of symptoms. cultured primary becs from adults with allergic asthma exhibit lower levels of rv-induced ifnβ (a type i ifn), lower levels of virus-induced apoptosis and higher rv loads than cells from control adults 127 . a deficiency in the antiviral type iii ifns, ifnλ1 (also known as il-29), ifnλ2 (also known as il-28a) and ifnλ3 (also known as il-28b), has also been described 128 . ifns may therefore be protective against rv-induced asthma exacerbations. however, two similar studies failed to see any difference between individuals with and without asthma regarding rv-induced ifn expression in similar model systems 129, 130 , suggesting that impaired ifn expression is a feature of a subset of patients with asthma. these studies raise the possibility of using ifnβ and ifnλs as therapeutics against asthma exacerbations. although epidemiological data clearly show that asthma is a risk factor for ipi, there are few studies that have considered a mechanistic rationale for this. genome-wide association studies in individuals with asthma or atopy do, however, highlight polymorphisms in innate immune genes such as those encoding tlrs and transcription factors, and such polymorphisms potentially explain the increased susceptibility of these individuals to viruses, bacteria and fungi [131] [132] [133] . deficiencies in the t h 1 type cytokines ifnγ and il-12 in patients with asthma 75 also suggest that impaired host defence responses to bacteria are probably implicated. an understanding of how these genetic and cytokine differences affect host susceptibility to infection may help in establishing new therapies for asthma. advances in molecular microbiology offer new avenues by which to discover the roles of microorganisms in asthma pathogenesis and exacerbation. there is now overwhelming evidence that asthma can be viewed as a chronic inflammatory condition which is initiated, triggered and maintained by the respiratory microbiota. microorganisms have roles in the onset and development of asthma but can also be protective (the hygiene hypothesis). it is not yet clear whether some organisms (especially rsv) actually cause atopic disease or are instead associated with atopy because individuals who are prone to atopy suffer more from infantile bronchiolitis. viruses undoubtedly cause most asthma exacerbations, but some non-viral pathogens may also play a part. certain fungi and bacteria have diverse roles in driving the pathogenesis and increasing the severity of asthma, and various microorganisms play different parts in different asthma endophenotypes. more research is needed, but our ultimate goal is to identify microbial targets that are amenable to manipulation with vaccines or anti microbial drugs and thus to reduce the burden of asthma on society. global strategy for asthma management and prevention: gina executive summary asthma: defining of the persistent adult phenotypes salmeterol: an inhaled β2-agonist with prolonged duration of action exposure to foodborne and orofecal microbes versus airborne viruses in relation to atopy and allergic asthma: epidemiological study asthma and current intestinal parasite infection: systematic review and meta-analysis the 'hygiene hypothesis' for autoimmune and allergic diseases: an update this study shows that microbial diversity is inversely related to the risk of developing asthma family size, infection and atopy: the first decade of the "hygiene hypothesis the coming-of-age of the hygiene hypothesis predominance of gram-positive bacteria in house dust in the low-allergy risk russian karelia diversity and seasonal dynamics of bacterial community in indoor environment culture-independent analysis of bacterial diversity in a child-care facility bacterial-induced protection against allergic inflammation through a multicomponent immunoregulatory mechanism maternal tlr signaling is required for prenatal asthma protection by the nonpathogenic microbe acinetobacter lwoffii f78 regulation of inflammatory responses by gut microbiota and chemoattractant receptor gpr43 the burden of respiratory syncytial virus infection in young children sequencing and analyses of all known human rhinovirus genomes reveal structure and evolution this study shows the protective effects of the ketomacrolide antibiotic telithromycin in asthma exacerbations, suggesting that targeting atypical bacteria with anti-infectives protects against asthma exacerbations mycoplasma pneumoniae and chlamydia pneumoniae in asthma: effect of clarithromycin rhinovirus viremia in children with respiratory infections the family of five: tirdomain-containing adaptors in toll-like receptor signalling rhinovirus-induced lower respiratory illness is increased in asthma and related to virus load and th1/2 cytokine and il-10 production rhinovirus infection induces cytotoxicity and delays wound healing in bronchial epithelial cells shedding of infected ciliated epithelial cells in rhinovirus colds dispersal of staphylococcus aureus into the air associated with a rhinovirus infection allergic airway inflammation is exacerbated during acute influenza infection and correlates with increased allergen presentation and recruitment of allergenspecific t-helper type 2 cells synergistic effects of fluticasone propionate and salmeterol on inhibiting rhinovirusinduced epithelial production of remodellingassociated growth factors respiratory syncytial virus infection provokes airway remodelling in allergen-exposed mice in absence of prior allergen sensitization pathogenesis of persistent lymphatic vessel hyperplasia in chronic airway inflammation rhinovirus infection induces extracellular matrix protein deposition by primary bronchial epithelial cells and lung fibroblasts salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease safety and tolerability of montelukast in placebo-controlled pediatric studies and their open-label extensions glucocorticoids enhance or spare innate immunity: effects in airway epithelium are mediated by ccaat/enhancer binding proteins long-term inhaled corticosteroids in preschool children at high risk for asthma the role of antibiotics in asthma pulmonary surfactant protein a regulates tlr expression and activity in human macrophages muc1 mucin is a negative regulator of toll-like receptor signaling inhibition of il-10 receptor function in alveolar macrophages by toll-like receptor agonists a critical function for cd200 in lung immune homeostasis and the severity of influenza infection differential role of cd80 and cd86 on alveolar macrophages in the presentation of allergen to t lymphocytes in asthma downregulation of the antigen presenting cell function(s) of pulmonary dendritic cells in vivo by resident alveolar macrophages lipopolysaccharide-enhanced, toll-like receptor 4-dependent t helper cell type 2 responses to inhaled antigen bacterial 16s ribosomal dna in house dust mite cultures the contribution of toll-like receptors to the pathogenesis of asthma short ragweed pollen triggers allergic inflammation through toll-like receptor 4-dependent thymic stromal lymphopoietin/ox40 ligand/ox40 signaling pathways house dust mite allergen induces asthma via toll-like receptor 4 triggering of airway structural cells allergenicity resulting from functional mimicry of a toll-like receptor complex protein sustained increases in numbers of pulmonary dendritic cells after respiratory syncytial virus infection pulmonary dendritic cells and alveolar macrophages are regulated by γδ t cells during the resolution of s. pneumoniae-induced inflammation essential contribution of monocyte chemoattractant protein-1/c-c chemokine ligand-2 to resolution and repair processes in acute bacterial pneumonia role of inducible bronchus associated lymphoid tissue (ibalt) in respiratory immunity aggregations of lymphoid cells in the airways of nonsmokers, smokers, and subjects with asthma interleukin-5 expression in the lung epithelium of transgenic mice leads to pulmonary changes pathognomonic of asthma the 1918 influenza pandemic: insights for the 21st century study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children synergism between allergens and viruses and risk of hospital admission with asthma: case-control study type 1 and type 2 cytokine imbalance in acute respiratory syncytial virus bronchiolitis interleukin-10/interleukin-5 responses at birth predict risk for respiratory infections in children with atopic family history peripheral blood cytokine responses and disease severity in respiratory syncytial virus bronchiolitis genetic association study for rsv bronchiolitis in infancy at the 5q31 cytokine cluster t-cell activation during exacerbations: a longitudinal study in refractory asthma respiratory syncytial virus synergizes with th2 cytokines to induce optimal levels of tarc/ccl17 activation of stat6 by sting is critical for antiviral innate immunity thymic stromal lymphopoietin is released by human epithelial cells in response to microbes, trauma, or inflammation and potently activates mast cells tslp from rsv-stimulated rat airway epithelial cells activates myeloid dendritic cells tlr3-and th2 cytokine-dependent production of thymic stromal lymphopoietin in human airway epithelial cells double-stranded rna induces disproportionate expression of thymic stromal lymphopoietin versus interferon-β in bronchial epithelial cells from donors with asthma this study demonstrates the important role of natural killer cell-derived ifnγ in controlling il-25 production during human rsv infection the development of respiratory syncytial virus-specific ige and the release of histamine in nasopharyngeal secretions after infection the role of virus-specific immunoglobulin e in airway hyperresponsiveness virus-specific ige enhances airway responsiveness on reinfection with respiratory syncytial virus in newborn mice induction of high-affinity ige receptor on lung dendritic cells during viral infection leads to mucous cell metaplasia frequency, severity, and duration of rhinovirus infections in asthmatic and non-asthmatic individuals: a longitudinal cohort study asthmatic bronchial epithelial cells have a deficient innate immune response to infection with rhinovirus this investigation shows the important protective role of ifnλ proteins in asthma exacerbations and that patients with asthma have impaired ifnλ expression and protein production rhinovirus-induced modulation of gene expression in bronchial epithelial cells from subjects with asthma in vitro susceptibility to rhinovirus infection is greater for bronchial than for nasal airway epithelial cells in human subjects toll-like receptor heterodimer variants protect from childhood asthma irf-1 gene variations influence ige regulation and atopy polymorphisms in toll-like receptor genes and susceptibility to pulmonary aspergillosis viruses and bacteria in acute asthma exacerbations -a ga 2 len-dare systematic review t helper type 2-driven inflammation defines major sub-phenotypes of asthma lebrikizumab treatment in adults with asthma interleukin-4 receptor in moderate atopic asthma. a phase i/ii randomized, placebocontrolled trial effects of an interleukin-5 blocking monoclonal antibody on eosinophils, airway hyperresponsiveness, and the late asthmatic response randomized trial of omalizumab (anti-ige) for asthma in inner-city children the role of a soluble tnfα receptor fusion protein (etanercept) in corticosteroid refractory asthma: a double blind, randomised, placebo controlled trial serum vitamin d levels and severe asthma exacerbations in the childhood asthma management program study randomized trial of vitamin d supplementation to prevent seasonal influenza a in schoolchildren reversing the defective induction of il-10-secreting regulatory t cells in glucocorticoidresistant asthma patients probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial randomized placebo-controlled trial of lactobacillus on asthmatic children with allergic rhinitis microbial manipulation of immune function for asthma prevention: inferences from clinical trials treatment with the tlr7 agonist r848 induces regulatory t-cell-mediated suppression of established asthma symptoms toll-like receptor 7-triggered immune response in the lung mediates acute and long-lasting suppression of experimental asthma clinical and immunological effects of low-dose ifn-α treatment in patients with corticosteroid-resistant asthma il-28a (ifn-λ2) modulates lung dc function to promote th1 immune skewing and suppress allergic airway disease the authors declare no competing financial interests. key: cord-016931-il8o0fps authors: kroegel, c.; bartuschka, b.; henzgen, m. title: allergie, pathomechanismen, krankheitsbilder date: 2008 journal: klinische pneumologie doi: 10.1007/978-3-540-37692-7_3 sha: doc_id: 16931 cord_uid: il8o0fps etwa ein fünftel der bevölkerung industrialisierter länder leidet an mindestens einer erkrankung aus dem allergischen formenkreis. hierzu gehören neben manifestationen der haut und des gastrointestinaltrakts insbesondere die allergischen erkrankungen der oberen und unteren atemwege. aufgrund der hohen und weiter steigenden prävalenz von allergien und den sich hieraus ableitenden volkswirtschaftlichen belastungen ist die allergologie in den letzten jahren mehr und mehr in den mittelpunkt des allgemeinen interesses gerückt. zudem haben neue wissenschaftliche erkenntnisse zu einer erweiterung des pathogenetischen verständnisses insbesondere allergischer atemwegserkrankungen geführt, die zunehmend auch die therapeutischen möglichkeiten erweitern. etwa ein fünftel der bevölkerung industrialisierter länder leidet an mindestens einer erkrankung aus dem allergischen formenkreis. hierzu gehören neben manifestationen der haut und des gastrointestinaltrakts insbesondere die allergischen erkrankungen der oberen und unteren atemwege. aufgrund der hohen und weiter steigenden prävalenz von allergien und den sich hieraus ableitenden volkswirtschaftlichen belastungen ist die allergologie in den letzten jahren mehr und mehr in den mittelpunkt des allgemeinen interesses gerückt. zudem haben neue wissenschaftliche erkenntnisse zu einer erweiterung des pathogenetischen verständnisses insbesondere allergischer atemwegserkrankungen geführt, die zunehmend auch die therapeutischen möglichkeiten erweitern. im nachfolgenden kapitel wird versucht, diese aktuellen aspekte der allergologie im spannungsfeld zwischen epidemiologie, ökonomie, pathogenese und therapie integriert darzustellen. neben dermatologen und hals-nasen-ohren-ärzten sind die pneumologen die fachärzte, die am häufigsten die zusatzbezeichnung allergologie in einer 18-monatigen ausbildungszeit erwerben, was die einteilung dieses kapitels rechtfertigt. unter allergien fasst man eine gruppe bestimmter erkrankungen der haut, des gastrointestinaltrakts und vor allem der lunge zusammen, die auf eine immunreaktion gegenüber definierten antigenen, allergenen oder haptenen aus der unmittelbaren umgebung zurückgeht. das klinische bild ist je nach der auslösenden substanz, dem beteiligten immunmechanismus und dem betroffenen organ unterschiedlich. die einteilung der erkrankungen erfolgt am sinnvollsten auf dem boden der zugrunde liegenden immunologischen mechanismen, die sich an der 1963 von coombs u. gell vorgeschlagenen klassifikation orientiert (⊡ tab. 3.1). neben den 4 ursprünglichen immunmechanismen werden granulomatöse formen als typ-v-reaktionen abgegrenzt, wenngleich sie aufgrund der zellvermittelten reaktion grundsätzlich zu den typ-iv-reaktionen gerechnet werden könnten. da bei dem granulomatösen typ jedoch nicht lymphozyten, sondern makrophagen das entzündliche geschehen dominieren, ist eine gesonderte gruppierung dieser formen gerechtfertigt. zudem entstehen im gegensatz zu den typ-iv-reaktionen die granulomatösen reaktionen vom typ v durch partikuläre, unlösliche allergene. es bleibt allerdings abzuwarten, ob sich diese nomenklatur durchsetzt. schließlich sei die kutane basophile hypersensitivität (jones-mote-reaktion) erwähnt, deren klinische und pathophysiologische bedeutung jedoch unklar ist. die in ⊡ tab. 3.1 dargestellte einteilung in 5 allergische reaktionen zeigt, dass sich die pathogenetischen mechanismen einzelner erkrankungen überlappen können. in ⊡ abb. 3.1 sind deshalb die auf mehrere mechanismen zurückgehenden erkrankungen den auf einem isolierten mechanismus beruhenden krankheiten gegenübergestellt. eine detaillierte besprechung aller in tab. 3.1 aufgeführten allergischen erkrankungen würde den zur die diagnostische abklärung erfolgt durch bestimmung des spezifischen ige gegenüber insektengiftbestandteilen (phospholipase, melittin etc.) und durch einen hauttest in verbindung mit der anamnese. da reaktionen nach insektenstich gelegentlich tödlich enden, besteht nach auftreten allergischer allgemeinsymptome jeglicher art die indikation zur hyposensibilisierung. außerdem müssen insektengiftallergiker obligat mit notfallmedikamenten (z. b. kortisonpräparat, antihistaminikum, adrenalinselbstinjektor) ausgestattet werden. sämtliche symptome, wie z. b. asthma, rhinitis, urtikaria, die auf eine allergische sofortreaktion hinweisen, können auch durch nichtimmunologische mechanismen bisher nicht sicher geklärter pathogenese ausgelöst werden. als klassische beispiele sind hier die histaminfreisetzung aus mastzellen oder basophilen granulozyten durch opiate, nichtsteroidale antiphlogistika oder jodhaltige röntgenkontrastmittel, lokalanästhetika, plasmaexpander und konservierungsmittel zu nennen. in diesen fällen spricht man von einer pseudoallergie. die rhinitis allergica, im volksmund auch heuschnupfen genannt, findet erstmals im 6. jahrhundert in der dissertationsarbeit von rhazes über die ursache der coryza des frühlings erwähnung. spätere arbeiten von bostock, wyman, blackley und wolff-eisner etablierten die rhinitis als klinische manifestation der atopie. heute lässt sich die rhinitis als entzündung der nasalen mukosa definieren, die einhergeht: ▬ klinisch mit hypersekretion, niesreiz sowie nasaler kongestion, ▬ immunologisch auf dem boden ige-vermittelter mechanismen gegenüber allergenen mit lokaler sekretion von zytokinen, eosinophilem kationischem protein (ecp) und anderen mediatoren, ▬ histologisch mit einer infiltration vor allem durch eosinophile granulozyten und ▬ immunhistologisch mit einer anreicherung aktivierter t-lymphozyten und degranulierter eosinophiler granulozyten. je nach umfang und ausmaß der allergensensibilisierung reicht die klinische manifestation von leichten saisonalen bis zu schweren perennialen formen und tritt in der regel gemeinsam mit der conjunctivitis allergica auf. sie ist eng mit dem asthma korreliert. unter urtikaria oder nesselsucht versteht man eine allergische überempfindlichkeit der haut und schleimhäute, die auf dem boden einer immunreaktion vom typ i hervorgerufen wird. urtikarielle hauterscheinungen imponieren klinisch als umschriebene, erhobene, erythematöse und juckende quaddeln oder unter einbeziehung der subkutis als angioödem und werden durch eine immunologische typ-i-reaktion vermittelt. darüber hinaus können andere ursachen wie physikalische mechanismen (wärme, kälte, druck), infekte und autoimmunmechanismen eine manifestation der erkrankung auslösen. von der allergischen urtikaria ist die nichtallergische urtikaria abzugrenzen. hierzu gehört die »physikalische« urtikaria (urticaria factitia, kälte-bzw. wärmeurtikaria, lichturtikaria und druckurtikaria), die »cholinerge« urtikaria (durch psychische alteration und stress, schwitzen, körperliche anstrengung) sowie eine urtkaria im rahmen von vaskulitiden. zur prävalenz allergischer erkrankungen in deutschland liegen in der zwischenzeit verschiedene studien an kindern und erwachsenen vor. in bayern und nordrhein-westfalen weisen etwa ein drittel aller schulanfänger eine allergische sensibilisierung gegenüber aero-oder seltener nahrungsmittelallergenen auf. davon leiden rund 12% an rhinokonjunktivitis, 12% an atopischem ekzem, 7% an nahrungsmittelallergien und 5% an asthma bronchiale. bei einer epidemiologischen querschnittsuntersuchung an 9.403 9-bis 11-jährigen schulkindern im raum münchen wiesen 33% der kinder eine allergische erkrankung (rhinitis allergica, allergisches asthma, atopische dermatitis) auf. zu vergleichbaren ergebnissen kam eine studie an schulkindern aus südbaden. im rahmen einer multizentrischen studie an 11.838 erwachsenen im reproduktionsfähigen alter wurde die lebenszeitprävalenz allergischer erkrankungen mittels fragebogen ermittelt. dabei zeigte sich, dass 21% der väter und 22% der mütter an mindestens einer allergischen manifestation leiden. im einzelnen litten 3,6 bzw. 4,1% der befragten an asthma bronchiale, 16,0 bzw. 15,5% an rhinitis allergica und 1,7 bzw. 3,5% an atopischer dermatitis. aus globaler perspektive zeigt die prävalenz allergischer erkrankungen regional erhebliche unterschiede. wie die erste der 3 geplanten isaac-studien (international study on asthma and allergy in children) an 463.801 kindern im alter von 13-14 jahren aus 5 erdteilen darlegt, klagen vor allem kinder aus england, irland, neuseeland, australien und kanada in der 12-monatigen erfassungsperiode über allergische symptome (jeweils ca. 30% mit asthmasymptomen, 18% mit symptomen einer rhinokonjunktivitis und 10-15% mit symptomen einer atopischen dermatitis). bemerkenswert ist, dass auch in einzelnen afrikanischen und lateinamerikanischen län-dern (nigeria, peru, paraguay, kenia, uruguay) eine hohe prävalenz allergischer erkrankungen beobachtet wird. in deutschland beträgt die anzahl der im rahmen der isaac-studie ermittelten kinder mit asthmatischen und rhinokonjunktivitischen beschwerden jeweils 14% und die der kinder mit atopischer dermatitis 7%. in indonesien ebenso wie in indien, china, griechenland und mehreren osteuropäischen staaten war dagegen die prävalenz der 3 allergischen manifestationen mit weniger als 5% vergleichsweise gering. die ursachen für die erhebliche länderabhängige variation der prävalenz allergischer erkrankungen sind bisher nicht bekannt. hierzu wird möglicherweise die 2. stufe des isaac-projekts weiteren aufschluss geben, in der die beziehung zwischen der erkrankung und dem sozialen status, dem impfstatus, dem klima und den ernährungsgewohnheiten untersucht werden soll. die prävalenz allergischer erkrankungen nimmt weltweit zu. verschiedene faktoren werden mit dieser entwicklung in verbindung gebracht, ohne dass deren ursächliche und relative bedeutung bisher eindeutig definiert werden konnte. so werden neben der steigenden umweltbelastung, urbanisierung und den klimatischen veränderungen auch die sich ändernden sozialen und diätetischen lebensgewohnheiten sowie die möglichkeiten des modernen wohnungsbaus diskutiert. beispielsweise könnte die steigende prävalenz mit der zunehmenden schadstoffbelastung der umwelt in zusammenhang stehen. aber auch die einführung von gepolstertem mobiliar bei verbesserten isolierungstechniken für fenster und türen dürften die konzentration von aeroallergenen und hausstaubmilben erhöhen. in diesem sinne könnten ferner klimatische veränderungen, die neben dem pollenflug auch das wachstum von insekten, milben oder schimmelpilzen begünstigen, einen einfluss besitzen. andere ursachen für die allergische sensibilisierung könnten in der synergistischen wirkung von umweltverschmutzung und nikotinabusus liegen. auch die zunehmende urbanisation scheint mit der ansteigenden prävalenz allergischer erkrankungen assoziiert zu sein. andere faktoren diätetischer und sozioökonomischer natur werden ebenfalls diskutiert. hinweise auf die relative bedeutung der oben genannten faktoren ergeben sich aus vergleichenden untersuchungen zur prävalenz allergischer erkrankungen zwischen west-(münchen) und ostdeutschland (leipzig) . die erste studie wurde in den jahren 1991/92 mittels fragebogen an kindern im alter von 9-11 jahren durchgeführt. während die häufigkeit der bronchitis im osten mit 30,9% etwa doppelt so hoch war, erwies sich im westen die prävalenz von heuschnupfen (2,4% vs. 7,7%), asthma bronchiale (6,6 vs. 7,7%) und atopischer dermatitis (13,0 vs. 13,9%) als höher. gleichzeitig war der schwefeldioxid-und schwebstaubgehalt im osten deutlich größer, während die luftverschmutzung durch stickoxide (autoabgase) in münchen höher lag. eine folgestudie aus den jahren 1995/96 ergab, dass die prävalenz der rhinitis in leipzig mit 5% in der zwischenzeit auf das doppelte angestiegen war. darüber hinaus stieg in diesem zeitraum die häufigkeit positiver hauttestreaktionen gegenüber hausstaubmilben, gras-, hasel-und birkenpollen um 30% auf 80% an. während die sensibilisierungsrate der kinder im westen im vergleich zur voruntersuchung unverändert mit 36% blieb, war im osten insgesamt die prävalenz aller allergischer beschwerden von 19 auf 27% angestiegen. parallel hierzu war der gehalt an schwefeldioxid in den 4 jahren auf rund ein fünftel zurückgegangen, der von stickoxiden dagegen um fast die hälfte gestiegen. andere potenzielle risikofaktoren wie passive nikotinexposition, wohnungsfeuchtigkeit und haustierhaltung nahmen in leipzig zu. interessanterweise ergab die studie eine positive korrelation zwischen dem konsum von margarine und heuschnupfen, während der verbrauch von butter mit einer niedrigeren prävalenz der rhinitis assoziiert war. diese daten deuten darauf hin, dass sowohl bestimmte umweltschadstoffe als auch lebensgewohnheiten als ursache für die steigende prävalenz allergischer erkrankungen in betracht kommen. allergische erkrankungen führen nicht selten zu einer beträchtlichen mortalität. hierzu gehören vor allem die plötzlichen todesfälle im rahmen des allergischen asthma bronchiale, der anaphylaxie (insektengift, antibiotika etc.) und der vorzeitige tod im fortgeschrittenen stadium der eaa. laut todesscheindiagnose (icd-nummer 493=asthma) sterben pro jahr etwa 1.000 personen an den folgen eines asthmas, was einer mortalität von einem todesfall pro 100.000 bundesbürgern entspricht. damit liegt die asthmamortalität in deutschland unter der anderer länder (4-6 todesfälle pro 100.000 einwohner). allerdings müssen diese zahlen mit einer gewissen vorsicht interpretiert werden, da aufgrund der gelegentlich schwierigen differenzialdiagnostischen abgrenzung anderer obstruktiver erkrankungen asthmabedingte todesfälle in den icd-positionen 490-496 versteckt sein dürften. umgekehrt ist aber auch anzunehmen, dass chronische obstruktive bronchitiden (copd) fälschlicherweise unter dem icd-schlüssel 493 notiert werden. die inzidenz asthmabedingter todesfälle scheint weltweit anzusteigen. die hierfür verantwortlichen faktoren sind bisher nicht bekannt, dürften aber mit der generellen zunahme der allergischen erkrankungen im zusammenhang stehen. trotzdem lassen sich einige risikofaktoren identifizieren, die mit einem todesfall assoziiert sind (s. übersicht). hohe serum-ige-konzentrationen scheinen nach einem autosomal rezessiven modus mit zusätzlicher polygenetischer komponente übertragen zu werden. andere studien identifizierten einen autosomal dominanten erbgang, bei dem die verantwortlichen gene auf chromosom 11q13, 5q13-q33 und 6p21.3 lokalisiert sind. das gen wird jedoch nur dann exprimiert, wenn es mütterlicherseits vererbt wird. auch für die bronchiale hyperreagibilität scheint ein genetischer hintergrund zu bestehen, der mit allelen der regionen 5q31-p33 bzw. 11p13 assoziiert ist. auf chromosom 5 finden sich auch die gene für verschiedene relevante zytokine (il-3, il-5, gm-csf) und die β-untereinheit des hochaffinen ige-rezeptors. mutationen in diesem bereich könnten durch eine aktivierung der immunologischen reaktion für die genetische komponente des asthma bronchiale verantwortlich sein. diese daten belegen die vermutung einer genetischen prädisposition allergischer erkrankungen und sprechen insgesamt für einen polygenetischen erbgang. die daten zum zeitlichen verlauf und zur prognose allergischer erkrankungen sind aufgrund des langen zeitlichen aspekts begrenzt. einige größere der bisher veröffentlichten untersuchungen sollen hier kurz dargestellt werden. panhuysen typ-i-reaktion. die immunreaktion vom typ i mit der bildung von spezifischen ige, mastzellsensibilisierung, aktivierung von th2-lymphozyten und infiltration durch eosinophile granulozyten ist die häufigste form der allergischen immunreaktion. sie gilt als die klassische allergische immunreaktion bei rhinitis allergica, allergischem asthma bronchiale und atopischer dermatitis, bildet aber auch eine komponente der immunologischen reaktion bei der allergischen bronchopulmonalen aspergillose. im gegensatz zur typ-i-reaktion werden typ-ii-und typ-iii-reaktionen durch antigenspezifisches igg vermittelt. hierbei kommt es entweder zur aktivierung der komplementabhängigen oder von phagozytenabhängigen effektormechanismen, die jeweils unterschiedliche pathologische veränderungen und symptome induzieren. typ-ii-reaktionen sind gegen zelloberflächen oder matrixassoziierte antigene gerichtet. sie spielen im rahmen allergischer bzw. anaphylaktischer reaktionen bei medikamenteninduzierten krankheiten eine rolle. typ-iii-reaktion. dagegen erfolgt die typ-iii-reaktion gegen lösliche antigene, die über die bildung von immunkomplexen die entzündung hervorruft, wie man sie im rahmen der exogen-allergischen alveolitis oder autoimmunologischer erkrankungen findet. typ-iv-reaktionen werden durch t-lymphozyten vermittelt, die sich wiederum in 2 klassen unterteilen lassen. die erste form erfolgt über die bildung von regulatorischen th1-zellen die vor allem über die aktivierung von makrophagen eine gewebeentzündung induzieren. die zweite unterform geht mit differenzierung von zytotoxischen t-zellen einher, die aufgrund ihrer funktion direkt eine gewebeschädigung hervorrufen. diese spielen z. b. bei der kontaktdermatitis eine rolle. die oben skizzierten formen der allergischen entzündung lassen sich als komplexe immunologische vorgänge verstehen, an denen eine ganze palette verschie-denster zellen beteiligt ist. hierzu gehören granulozyten, thrombozyten, lymphozyten, dendritische zellen, fibroblasten und selbst epithelzellen. darüber hinaus wird bestimmten subpopulationen von makrophagen eine funktion im rahmen der allergenpräsentation zugeschrieben. die relative bedeutung der einzelnen zelltypen wird von der klasse der induzierten immunreaktion bestimmt. die verschiedenen an der entzündung beteiligten zellen lassen sich, mit einigen ausnahmen und überschneidungen entsprechend ihrer jeweils im vordergrund stehenden rolle untergliedern in: ▬ initiierende und amplifizierende zellen, ▬ effektorzellen, ▬ effektorzielzellen oder strukturzellen. die zu dieser gruppe gehörenden zellen setzen die immunreaktion entweder durch indirekte exposition mit inhalierten allergenen (typ i und iii) oder direkten kontakt (typ iv) in gang. nach heutiger vorstellung gehören hierzu die dendritischen zellen sowie makrophagen/ monozyten, die als allergenpräsentierende zellen (apc) begrifflich zusammengefasst werden. ausgangspunkt einer immunologischen reaktion, wie auch der im rahmen allergischer erkrankungen, ist die interaktion des antigens/allergens mit apc und einem genetisch definierten, spezifischen t-zellklon. folgende eigenschaften der apc sind für ihre funktion bei allergischen erkrankungen relevant: ▬ apc (langerhans-zellen) bzw. apc-ähnliche zellen (mononukleäre zellen) finden sich konstitutionell in allen geweben und sind nach antigenexposition im atemwegsepithel von asthmatikern vermehrt nachzuweisen. ▬ bestimmte blutmonozyten mit antigenpräsentierenden eigenschaften infiltrieren in die atemwege und lunge z. b. fc ε ri-exprimierende zellen deren aktivität durch bindung von ige um ein vielfaches gesteigert wird. ▬ apc verarbeiten das allergen und präsentieren der allergenrestringierten cd4 + -zelle immunogene sequenzen im kontext von klasse-ii-mhc-antigenen und einem oder mehreren kostimulatorischen signalen. lymphozyten stellen eine funktionell sehr heterogene gruppe von zellen dar, die auf verschiedenen ebenen in die pathogenese der allergischen entzündung eingreift. während b-lymphozyten nach differenzierung in plasmazellen das ige bilden, sind cd4 + -(helfer-bzw. inducerzellen) und cd8 + -t-lymphozyten (zytotoxische bzw. suppressorzellen) sowohl an der allergenerkennung als auch an der regulation des entzündungsablaufs beteiligt: ▬ in den atemwegen von asthmatikern oder rhinitikern oder der haut von patienten mit atopischer dermatitis finden sich charakteristischerweise aktivierte, il-2-rezeptor-tragende (il-2r + -)t-lymphozyten. ▬ innerhalb der cd4 + -lymphozyten dominiert der th2-subtyp mit sekretion von il-4, il-5, il-6 und il-13. ▬ th2-lymphozyten dürften über die freisetzung von il-4, il-5 und il-13 die synthese von ige durch b-lymphozyten regulieren. ▬ th2-zellen aktivieren mittels il-4 und il-13 mastzellen und mittels il-5 und il-13 eosinophile granulozyten. ▬ th2-lymphozyten induzieren über die freisetzung von il-4 und il-13 z. b. die expression des adhäsionsmoleküls vcam-1 auf endothelzellen und tragen zur regulation der ige-synthese sowie mittels il-5 zur selektiven rekrutierung von eosinophilen aus der zirkulation bei. ▬ th1-lymphozyten mit sekretion von il-2 und inf-γ spielen dagegen im rahmen der kontaktallergie eine pathogenetische rolle über die regulation der igg-synthese und der zellulären immunreaktion vom verzögerten typ (typ iv nach coombs u. gell). an entzündungsreaktionen sind neben effektorlymphozyten auch t-zellpopulationen mit spezifischen suppressiven bzw. regulatorischen eigenschaften beteiligt. hierzu gehört eine erst vor wenigen jahren beschriebene, im thymus heranreifende, natürliche population von antigenspezifischen t-regulatorischen cd4 + -t-lymphozyten (»t-regulatory cells«; tregs), von denen die meisten das cd25 + -antigen und andere antigene wie das t-lymphozyten-assoziierte antigen-4 (ctla-4), den glukokortikoidinduzierten tumor necrosis factor receptor (gitr) und in hohem umfang l-selektin (cd62-l hi ) konstitutiv auf ihrer oberfläche exprimieren. sie vermitteln ihre suppressive wirkung bei direktem zell-zell-kontakt durch membranassoziierte moleküle. aufgrund ihrer funktion werden cd4 + cd25 + -t-zellen als »natürliche« suppressorzellen (trn) oder »adaptive« tregs (tra), und letztere nochmals in tr1 und tr2(th3)-zellen unterteilt. sowohl trn als auch tra exprimieren den transkriptionsfaktor (foxp3) (»forkhead transcription factor«; scurfin/foxp3), der für die entwicklung und funktion der tregs verantwortlich ist. neben ihrer rolle bei autoimmunopahtien sind tregs ebenfalls an der pathogenese allergischer erkrankungen beteiligt. unter effektorzellen versteht man enddifferenzierte zelltypen, die am distalen ende der immunreaktion den proentzündlichen effekt der immunreaktion am zielorgan über verschiedene pharmakologische oder zytotoxische mechanismen vermitteln. zu den effektorzellen zählen mastzellen, basophile und eosinophile granulozyten (typ i), makrophagen und zytotoxische t-lymphozyten (typ iv). thrombozyten sind polymorph geformte, kernlose zellen, die aus megakaryozyten im knochenmark hervorgehen. obwohl ihre funktion vor allem im rahmen der (patho-)physiologischen gerinnungsprozesse zu suchen ist, wird den thrombozyten seit einiger zeit auch eine rolle im rahmen allergisch-entzündlicher vorgänge zugeschrieben: ▬ thrombozyten spielen eine rolle bei der entwicklung der allergischen spätreaktion und der gewebeinfiltration durch eosinophile granulozyten. ▬ thrombozyten werden durch zytokine, anti-ige und paf aktiviert. ▬ sie produzieren verschiedene lösliche faktoren (»platelet-derived histamine releasing factor«, plättchenfaktor 4, rantes [»regulated on activation normal t-cell expressed and secreted«] oder paf), die aufgrund ihrer chemotaktischen eigenschaften an der orchestrierung des entzündlichen infiltrats beteiligt sein dürften. als effektorzielzellen werden die strukturzellen der atemwege bezeichnet, in deren unmittelbarer nachbarschaft entzündungszellen infiltrieren und in deren umgebung sich die eigentliche entzündung ausbreitet. erst in den letzten jahren wurde deutlich, dass diese zellen dabei nicht als passive »bystander« zu betrachten sind. vielmehr nehmen sie unter physiologischen bedingungen aufgaben bei der aufrechterhaltung der homöostase wahr und können unter pathophysiologischen bedingungen offenbar sowohl pro-als auch antiinflammatorisch auf die entzündlichen vorgänge einfluss nehmen. zu den mediatoren mit überwiegend regulatorischen funktionen gehört die große gruppe der zytokine einschließlich der chemokinine. zytokine bilden eine große gruppe von zentral und peripher wirkenden proteinmediatoren. matrixmetalloproteinasen (mmp) bezeichnen eine gruppe zinkhaltiger enzyme, die proteine und proteoglykane der extrazellulären matrix (ecm) des bindegewebes abbauen. sie spielen eine wesentliche rolle bei der normalen gewebehomöostase. ein gleichgewicht zwischen der aktivität der mmp und ihren endogenen gewebeinhibitoren (timp) sorgt vermutlich für eine kontinuierliche erneuerung und reparatur des ecm-maschenwerks mit wiederherstellung der ursprünglichen physiologischen bedingungen nach passageren störungen. im rahmen chronisch entzündlicher prozesse kann es jedoch über eine imbalance zwischen mmp und timp zu einer verschiebung des gleichgewichts zwischen abbau und ablagerung der ecm-proteine kommen. da asthma mit einer zunahme der ecm in den subepithelialen schichten der atemwege einhergeht, liegt es nahe zu vermuten, dass das mmp-timp-system auch bei der asthmatischen entzündung eine rolle spielt. während eine beteiligung dieses systems im rahmen der tumorinvasion, metastasierung und angiogenese vermutet wird, finden sich nun auch hinweise dafür, dass es beim asthma bronchiale eine aktive rolle spielt. so zeigte sich bei untersuchungen zur ultrastruktur der atemwege ein abbau von elastin bei einigen asthmatikern. darüber hinaus ließen sich während symptomatischer perioden der asthmaerkrankung im urin proteoglykanderivate als ausdruck des gesteigerten ecm-metabolismus nachweisen. untersuchungen an patienten mit natürlichem asthma und am modell der segmentalen allergenprovokation zeigen ferner, dass mmp im rahmen der verzögerten allergischen reaktion in den atemwegen freigesetzt werden. danach kommt es im rahmen der asthmatischen spätreaktion vor allem zur sekretion der mmp-9 und mmp-2. parallel hierzu finden sich in der bal-flüssigkeit auch vermehrte konzentrationen der timp-1. aufgrund der potenziellen bedeutung des atemwegsremodelling für den langzeitverlauf des asthma bronchiale wird das mmp-timp-system in den kommenden jahren stärker in den mittelpunkt des interesses rücken. arbeiten aus den letzten jahren haben eine reihe von peptiden aus nervenendigungen charakterisiert, die die funktion des bronchialsystems modifizieren können. diese neuropeptide beeinflussen den muskeltonus von bronchien und lungengefäßen und erhöhen die bronchiale mukussekretion. das vasoaktive intestinale peptid (vip) oder das »peptide histidin methionin« (phm) zeigen beispielsweise starke bronchodilatatorische eigenschaften. während der asthmatischen entzündungsreaktion werden beide peptide rascher abgebaut und tragen hierdurch zu einer erhöhten bronchialen reagibilität bei. andere neuropeptide aus sensorischen nervenendigungen, wie die substancep (sp), das neurokinin a (nka) oder das »calcitonin gene-related peptide« (cgrp), besitzen proinflammatorische eigenschaften und sind so direkt an den entzündlichen vorgängen beteiligt. die pharmakologische wirksamkeit der derzeit zur verfügung stehenden neuropeptidrezeptorantagonisten ist bisher allerdings nur wenig überzeugend. weiterführende untersuchungen zur bedeutung der neuropeptide beim asthma bronchiale sind daher erforderlich. unter dem begriff endotheline werden 3 isoformen eines aus 21 aminosäuren aufgebauten ubiquitären peptids zusammengefasst. sie werden von epithelzellen, endothelzellen, makrophagen, thrombozyten und pulmonalen neuroendokrinen zellen unter dem einfluss verschiedener mediatoren gebildet, zu denen il-1α, il-1β, tnf-α, tgf-β, thrombin sowie ige-anti-ige-komplexe und lipopolysaccharide gehören. ▬ endotheline spielen eine rolle bei der regulation des gefäßtonus. ▬ endothelin-1 und endothelin-2, möglicherweise auch endothelin-3, kontrahieren isolierte atemwegsmuskulatur. ▬ endotheline induzieren ferner ein lokales mukosaödem und tragen zur entwicklung der bronchialen hyperreagibilität sowie glandulären hypersekretion bei. stickstoffmonoxid ( beim vorliegen der akuten form einer exogen-allergischen alveolitis treten andere beschwerden in den vordergrund. hier wird von einer rekurrierend auftretenden und beeinträchtigenden erkrankung mit fieber, husten, rezidivierender dyspnoe und myalgien berichtet, die 6-8 h nach antigenexposition (z. b. stallarbeiten) auftreten. subakute oder chronische formen bieten dagegen weniger klare anamnestische hinweise, da der episodische charakter nicht so eindeutig zur darstellung kommt. es überwiegen unspezifische beschwerden wie chronischer husten, belastungsdyspnoe und gewichtsabnahme. eine gewisse eingrenzung der möglichen ursächlich verantwortlichen antigene lässt sich durch gezielte fragen erreichen (s. übersicht). bei der frühen form der akuten exogen-allergischen alveolitis findet sich ein schwer erkrankter patient mit fieber, tachypnoe und feinblasigen rasselgeräuschen. eine sklerophonie als feines, endinspiratorisch betontes knisterrasseln (klettverschluss!) findet sich bei manifesten lungenfibrosen, wie sie z. b. im fortgeschrittenen stadium einer exogen-allergischen alveolitis. im vordergrund der veränderungen des differenzialblutbildes steht eine grenzwertig normale bis hohe eosinophilenzahl. diese ist allerdings nicht spezifisch und normale bis niedrige werte schließen das vorliegen einer allergie nicht aus. hier bietet der nachweis von eosinophilen im sputum einen verlässlicheren parameter, der gelegentlich bei der differenzialdiagnostischen abgrenzung zu anderen chronisch-obstruktiven atemwegserkrankungen (chronisch-obstruktive bronchitis, lungenfibrose) nützlich sein kann. für die beurteilung der eosinophilenzahl im blut oder sputum sollte eine kürzlich zurückliegende (bis zu 5 tagen) oder eine bestehende kortikosteroidbehandlung berücksichtigt werden, da kortikosteroide dosisabhängig zur elimination der zellen aus dem blut und den atemwegen führen. die bestimmung der gesamt-ige-konzentration im serum bildet einen wesentlichen bestandteil der allgemeinen allergiediagnostik (übersicht 9-4). da die höhe des ige-spiegels mit der häufigkeit und der dauer der allergenexposition im zusammenhang steht, kommt dem zeitpunkt der untersuchung eine gewisse bedeutung zu. so weisen patienten mit einer pollinosis während der pollenflugzeit höhere gesamt-ige-konzentrationen auf als während des übrigen jahres. im gegensatz zur eosinophilenzahl unterliegt der ige-serumspiegel aber nur geringen schwankungen unter kortikosteroidbehandlung. bei erhöhtem gesamt-ige ist die weitergehende diagnostik mit ermittlung der allergenspezifischen ige, hauttestung und ggf. auch der allergenprovokation indiziert. eine erweiterung der eosinophilenzählung bildet die bestimmung des ecp-spiegels im serum oder sputum. obwohl der aussagewert dieses löslichen markers aus eosinophilen granulozyten nach wie vor umstritten ist, sprechen verschiedene befunde dafür, dass er neben der eosinophilenzahl auch den aktivierungsgrad der zellen wiedergibt. innerhalb der allergischen erkrankungen ist die konzentration des serum-ecp im rahmen der atopischen dermatitis besonders hoch, gefolgt vom asthma bronchiale und der rhinitis allergica, wenngleich auch hier normwerte vorkommen können. bei verdacht auf vorliegen eines asthma bronchiale kann die bestimmung der ecp-konzentration, aber auch der eosinophilenzahl im sputum, insbesondere bei der abgrenzung zur chronisch-obstruktiven bronchitis, nützlich sein. allgemeine laborparameter der entzündung stehen bei der diagnostik allergischer erkrankungen im hintergrund. entzündungsparameter (bsg, crp, elektrophorese, fibrinogen etc.) sind zur erfassung einer systemisch entzündlichen konstellation, z. b. im rahmen einer interkurrierenden pneumonie oder anderer infekte, sinnvoll. darüber hinaus sind sie wenige stunden nach antigenexposition bei der exogen-allergischen alveolitis zu finden. die serumkonzentration des angiotensinkonversionsenzyms (ace) ist neben der sarkoidose und einigen anderen nichtallergischen erkrankungen zu 70% im rahmen einer berylliose erhöht. radiologische untersuchung des thorax mittels der klassischen röntgenaufnahme oder der hochauflösenden computertomographie spielen vor allem bei der differenzialdiagnose zum ausschluss bestimmter lungenerkrankungen eine rolle. hierzu gehören z. b. der nachweis emphysematöser veränderungen, die bei der chronischobstruktiven bronchitis (z. b. zentrilobuläres und panazinäres emphysem bei chronischem nikotinabusus), nicht aber bei einem reinen allergischen asthma bronchiale (allenfalls akute überblähung, aber ohne emphysem) nachzuweisen sind. auch andere erkrankungen, wie z. b. bronchialkarzinome, fremdkörperaspiration, lungenembolien, sarkoidose (bihiläre lymphadenopathie, retikulonoduläre muster) oder das churg-strauss-syndrom (flaue wechselnde infiltrate) können asthmatische symptomatik imitieren. im rahmen der allergischen bronchopulmonalen aspergillose (abpa) finden sich radiologisch neben diffusen infiltraten typischerweise segment-bzw. lappenatelektasen als folge der bronchialobstruktion durch mukoide ausgüsse (»mucoid impaction«). zusätzlich zeigt sich eine entzündliche verdickung der bronchialwände, die an trambahnschienen (»tram-line shadows«) oder ringschatten (»gloved-ring shadows« oder »ring shadows«) erinnern. in all diesen fällen können röntgenuntersuchungen indiziert sein, nicht aber beim unkomplizierten asthma. die spezielle diagnostik allergischer erkrankungen umfasst standardisierte und nichtstandardisierte hauttests (einschließlich epikutantests), die verschiedenen invitro-testverfahren, die lungenfunktionsuntersuchung sowie die unspezifischen und spezifischen provokationstechniken. gelegentlich sind zur diagnostik allergischer alveolitiden auch invasivere maßnahmen (bronchoskopie mit bronchoalveolärer lavage und biopsie) angezeigt. hierzu gehören der epikutane reibetest und patch-test sowie die kutanen prick-, reibe-, scratch-und intrakutantests. die meisten klinisch relevanten allergene sind in form von naturextrakten kommerziell verfügbar (s. unten). im einzelfall ist aber auch die verwendung des nichtextrahierten, natürlichen allergens erforderlich. bei der durchführung der hautteste ist grundsätzlich auf das anlegen einer negativ( ein positiver ausfall des hauttests weist auf eine bestehende sensibilisierung gegenüber dem ausgetesteten allergen bzw. antigen oder hapten mit der existenz spezifischer ige-antikörper (typ i) hin. er gibt keine auskunft über die klinische relevanz des allergens oder antigens. sensibilisierungen kommen bei 20-40% der bevölkerung auch ohne jegliche erkrankung vor (latente oder subklinische sensibilisierung). das ergebnis des hauttests muss daher mit der anamnese, den symptomen und den übrigen befunden integriert beurteilt werden. die hauttestung erfolgt derzeit mit allergenextrakten aus natürlichen allergenträgern, die in etwa 90% der fälle eine ausreichende sensitivität und spezifität aufweisen. im gegensatz zu der vergleichsweise konstanten anzahl ige-bindender komponenten der insektengift-und birkenpollenallergene bestehen andere kommerziell erhältliche allergenextrakte aus einer großen zahl an allergenen determinanten. dieser umstand führt zu einer diagnostischen unsicherheit, die z. b. bei testungen mit pilzallergenen, lebensmittel-und vereinzelten pollenallergenen am deutlichsten zum ausdruck kommt. zudem enthalten die aus natürlichen allergenträgern hergestellten extrakte eine größere anzahl nichtallergischer komponenten, die z. t. über eine ige-unabhängige mediatorauschüttung zu falsch-positiven testergebnissen führen. schließlich ist die zahl, menge und die chemische beschaffenheit der extrahierten allergene nur unzureichend definiert. inwieweit molekulargenetisch hergestellte, hochreine allergene die diagnostische sicherheit der hauttestung zukünftig verbessern, muss derzeit noch offen bleiben. die indikation zum reibetest besteht, wenn eine hochgradige sensibilisierung vermutet wurde oder wenn kein standardisiertes allergen zur verfügung steht. hierzu wird das native allergen (nahrungsmittel, medikamente, stäube etc.) auf der beugeseite des unterarms mehrmals (ca. 10-mal) unter leichtem druck gerieben. bei bestehender typ-i-allergie entwickelt sich nach 10-30 min eine follikuläre urtikarielle effloreszenz, die zur quaddel konfluiert. als kontrolle dient eine vergleichbare physikalische provokation am anderen arm (physikalische urtikaria!). der reibetest gilt heute allerdings als veraltet und wird kaum noch eingesetzt. der patch-test wird vor allem zur ermittlung einer typ-iv-reaktion (epikutantest), gelegentlich auch bei typ-i-reaktionen (atopie-patch-test) eingesetzt. hierzu platziert man das zu untersuchende allergen (z. b. arzneimittel in weißer vaseline mit oder ohne dmso bzw. anderen lösungsmitteln) offen oder geschützt unter einem dicht abschließenden testpflaster (»finn chambers«) auf den rücken oder den unterarm. die lokale reaktion wird nach 30 min, 24 und 48 h bewertet. beim atopie-patch-test wird das lokale erythem mit quaddel bewertet (s. oben). der positive ausfall des epikutantests zeigt sich durch die entwicklung typischer klinischer veränderungen einer kontaktdermatitis. trotzdem bietet gerade beim epikutantest die differenzierung zu unspezifischen irritativen veränderungen der haut selbst für einen erfahrenen nicht selten probleme. darüber hinaus sollten patienten nach durchführung des tests für mindestens 3 h unter ärztlicher aufsicht bleiben, da sich nach epikutantestung anaphylaktische reaktionen entwickeln können (besonders bei pyrazolonderivaten, penizillinen und aminoglykosiden; cave: innerhalb von 30 min auftretende hautreaktion). der prick-test ist gegenwärtig das verfahren der wahl zum nachweis einer typ-i-allergie. die heute verwendeten standardisierten allergenextrakte und prick-test-nadeln können als ungefährlich gelten und lassen sich ohne bedenken auch bei kindern anwenden. auch der prick-test wird gewöhnlich an der volarseite des unterarms vorgenommen, wobei an jedem arm verschiedene allergene gleichzeitig getestet werden können. im gegensatz zum scratch-test wird hierzu zunächst die allergenlösung auf die haut getropft und mit einer speziellen prick-lanzette durch anstechen und anheben der haut inokuliert. als positives ergebnis (semiquantitative bewertung: »einfach positiv«) gilt eine quaddel mit einem maximalen durchmesser von 3 mm und einem erythem von über 3-5 mm, sofern die negativkontrolle keine reaktion zeigt (⊡ tab. 3.4). deutliche hautreaktionen bestehen bei einem erythem mit einem durchmesser >20 mm und einer quaddel mit einem durchmesser >6 mm sowie pseudopodien (semiquantitative bewertung: »vierfach positiv«). die angabe der tatsächlichen hautreaktion in millimetern erythem/quaddel (z. b. 6/20) ist der subjektiveren semiquantitativen bewertung vorzuziehen. der scratch-test eignet sich insbesondere zur darstellung einer allergischen diathese gegenüber nutritiven, medikamentösen und nativen allergenen. hierzu wird die haut an der beugeseite des unterarms mit einer lanzette oberflächlich angeritzt. im unterschied zum prick-test wird das zu testende allergen, kochsalz und histamin erst danach aufgebracht und die reaktion nach 20 min beurteilt. eine positive reaktion äußert sich, bezogen auf die negativkontrolle, durch die entwicklung einer quaddel mit pseudopodien. für die beurteilung der zellulären immunreagibilität noch besser geeignet ist der multitest merieux, der neben tuberkulin noch 6 weitere recall-antigene (bakterienund pilzantigene) enthält. die bezeichnung recall bezieht sich darauf, dass der organismus bereits früher mit diesen antigenen in kontakt gekommen sein muss (sekundäre antigene). die kutane reaktion gegenüber den substanzen führt bei manifester hiv-infektion oder anderen immundefekten, fieberhaften erkrankungen, sarkoidose, immunsuppressiver therapie sowie unmittelbar nach virusinfekten (z. b. masern, röteln, windpocken und schwere grippale infekte) zu falsch-negativen ergebnissen. gleiches gilt auch für die oben genannten provokationstests mit tuberkulin. dieser intrakutantest dient der ermittlung einer sensibilisierung gegenüber beryllium. hierzu werden ansteigende konzentrationen (0,05%, 0,01% und 0,005%) einer beso 4 -lösung streng intrakutan injiziert. bei positivem ergebnis lässt sich nach 2-4 tagen eine dosisabhängige erythematöse induration nachweisen. in der höchsten dosis treten in einigen fällen unspezifische reaktionen auf, sodass eine epitheloidzellige, nicht verkäsende granulomatöse entzündung 4 wochen nach testung bioptisch gesichert werden sollte. ein weiteres standbein der speziellen diagnostik allergischer erkrankungen bildet der nachweis einer erhöhten serumkonzentration spezifischer immunglobuline vom typ e, g und a. zunehmend gewinnt der spezifische ige-nachweis mittels immunoblot für spezielle diagnostische fragestellungen (z. b. insektengiftallergie) in den fällen an bedeutung, bei denen die antikörperbestimmung mittels cap bzw. rast infolge blockierung relevanter epitope falsch-negativ ist. aufgrund der integrierten beurteilung der eosinophilenzahl, der konzentration des gesamt-ige und des ecp sowie des rast-bzw. cap-befundes kann eine diagnostische beurteilung erfolgen (⊡ tab. 3.5). die diagnostische bedeutung des spezifischen ige in bezug auf hauttestergebnis und anamnese ist in ⊡ tab. 3.6 dargestellt. allergenspezifische gliadinantikörper der immunglobulinklasse a im serum lassen sich im rahmen einer zöliakie (sprue) nachweisen. ein mangel an sekretorischen iga-dimeren in dem die schleimhäute bedeckenden flüssigkeitsfilm prädisponiert nicht nur zu häufigen infekten, sondern auch zur entwicklung von autoimmunerkrankungen und allergien. dieser assay beruht auf der freisetzung von histamin aus blutbasophilen in vitro nach zugabe spezifischen allergens. anhand von dosis-wirkungs-kurven wird die konzentration des allergenextrakts ermittelt, die 30% des gesamthistamingehalts der zellen freisetzt. der hra ist spezifischer als die bestimmung des spezifischen ige, jedoch ungleich aufwendiger und zeitintensiver. er ist zudem abhängig von der medikation und bei etwa 5% der patienten negativ (non-responder). seine anwendung ist daher auf wissenschaftliche fragestellungen begrenzt. der test beruht auf der proliferationsrate bronchoalveolärer oder blutlymphozyten unter exposition mit an-steigenden konzentrationen an beso 4 (10 -4 -10 -6 molar) in vitro. bei einem positiven testergebnis lässt sich im vergleich zur negativkontrolle nach 5 tagen eine dosisabhängige proliferation ( 3 h-thymidin-oder pdu-einbau) nachweisen. der be-ltf-test weist sehr spezifisch eine sensibilisierung gegenüber beryllium nach, besitzt jedoch nur eine geringe sensitivität (ca. 40% falsch-negative ergebnisse). hierzu gehören als einfachste möglichkeit die verlaufskontrolle der atemwegsobstruktion durch die morgendliche und abendliche messung des maximalen exspiratorischen flusses (pef) mittels eines peak-flow-meters bei asthmaverdacht oder zur therapiekontrolle. typischerweise zeigen sich beim asthma bronchiale niedrigere pef-wert am morgen mit großer variabilität und deutlicher besserung unter therapie mit inhalativen β 2 -sympatikomimetika. mithilfe von peak-flow-protokollen lassen sich auch hinweise auf mögliche auslöser (z. b. arbeitsplatz, wohnung, tierkontakt) gewinnen bzw. die lungenfunktion ist bei allergischen personen mit asthma im beschwerdefreien intervall nicht selten normal. aus diesem grund bildet der nachweis einer bronchialen hyperreagibilität eine wichtige säule bei der diagnostik des asthma bronchiale. hierzu wird histamin oder ein azetylcholinderivat (carbachol, metacholin) stufenweise in ansteigender konzentration standardisiert inhaliert. zwischen den einzelnen stufen erfolgt die messung bestimmter lungenfunktionsparameter. der unspezifische bronchiale provokationstest umfasst 4 konzentrationsstufen bis zum erreichen der maximaldosis. nach den empfehlungen der deutschen gesellschaft für pneumologie (dgp) liegt eine bronchiale hyperreagibilität dann vor, wenn eine der folgenden kriterien erfüllt ist: ▬ abfall des absoluten exspiratorischen volumens in einer sekunde (fev 1 ) um 20%, ▬ anstieg des atemwegswiderstands (r aw ) um 100% und 0,6 kpa/(l/s), ▬ anstieg des spezifischen atemwegswiderstands (sr aw ) um 100% und 0,2 kpa×s, ▬ abfall der spezifischen atemwegsconductance (sg aw ) um 40% und 0,5 /(kpa×s). als bezugspunkt hierfür gelten die messwerte vor provokation, die im normbereich liegen sollten. nach der provokation sollte sich eine bronchospasmolyse durch inhalation β 2 -mimetika anschließen. die bronchiale provokation sollte nicht durchgeführt werden bei: ▬ mittelschwerer bis schwerer obstruktion (fev 1 <1,2 l, asthmaexazerbation), ▬ schweren kardiovaskulären erkrankungen (herzrhythmusstörungen, aneurysma, herzinsuffizienz), ▬ schwerer hypertonie, ▬ schwangerschaft. zu berücksichtigen ist ferner, dass eine vorbestehende atemwegsobstruktion, vorausgegangene belastungen, virale infekte oder die behandlung mit β-blockern, parasympathikomimetika und α-sympathikomimetika die bronchiale hyperreagibilität verstärken können. andererseits schwächen β 2 -sympathikomimetika, kortikostero-ide, parasympatikolytika, theophyllin, antihistaminika, dinatriumcromoglycat (dncg), ketotifen und nedocromil die bronchiale reagibilität ab und sollten daher vor der untersuchung abgesetzt werden. weitere details zur durchführung und auswertung unspezifischer bronchialer provokationen sind den empfehlungen der dgp zu entnehmen. unsere eigenen untersuchungen zeigen, dass spezifität und sensitivität des provokationstests durch messung zweier unabhängiger obstruktiver parameter (fev 1 und r aw ) erheblich zunimmt. in einzelfällen ist die diagnose mit den oben beschriebenen verfahren nicht eindeutig zu sichern. in diesen fällen ist die durchführung einer allergenprovokation an den betroffenen organen indiziert. eine weitere indikation bilden rechtliche fragen im rahmen von gutachterlichen stellungnahmen. je nach fragestellung wird hierbei zwischen bronchialer, nasaler, konjunktivaler und gastrointestinaler provokation unterschieden. eine übersicht der spezifischen provokationsverfahren gibt ⊡ tab. 3.7. das prinzip der methode beruht auf der schrittweisen exposition des zu untersuchenden organs mit zunehmenden konzentrationen bzw. mengen des jeweiligen allergens. die provokationsuntersuchung bedarf einer kontinuierlichen ärztlichen überwachung einschließlich einer mehrstündigen nachbeobachtung sowie der möglichkeit einer intensivmedizinischen betreuung. mittels bronchoskopie lassen sich atemwegsgewebe (bronchialbiopsien) und -zellen (bürste), lungengewebe (transbronchiale biopsie) sowie bronchoalveoläre zellen (bronchoalveoläre lavage) gewinnen. die bronchoskopie im rahmen allergischer erkrankungen ist auf bestimmte fragestellungen begrenzt. zu den indikationen gehören: ▬ differenzialdiagnostischer ausschluss interstitieller, infektiöser und maligner lungenkrankheiten, ▬ diagnostik im rahmen der exogen-allergischen alveolitis, ▬ therapeutische lavage bei verlegung der atemwege durch eingedickten mukus (status asthmaticus, allergische bronchopulmonale aspergillose), ▬ differenzialdiagnostische abgrenzung zwischen asthma bronchiale und anderen obstruktiven und nicht obstruktiven erkrankungen (nur selten erforderlich), ▬ gezielte wissenschaftliche fragestellungen. die hierfür erforderlichen vorsichtsmaßnahmen sind detailliert in den empfehlungen der dgp dargestellt. das diagnostische vorgehen bei verdacht auf eine allergische erkrankung beruht auf der durchführung allgemeiner und spezieller diagnostischer methoden. zur allgemeinen diagnostik gehören anamnese, körperlicher untersuchungsbefund, allgemeine laboruntersuchungen und das konventionelle thoraxröntgen. die weiterführende spezielle diagnostik umfasst spezielle gezielte laboruntersuchungen (spezifisches ige, ecp, proliferationsteste etc.), hautprovokationstests, die lungenfunktionsuntersuchung sowie die unspezifische und spezifische inhalative provokation. ein mögliches vorgehen ist in ⊡ abb. 3.6 dargestellt. je nach bereits vorliegenden befunden sollte der zugang modifiziert werden. differenzialdiagnostisch müssen erkrankungen der atemwege und des lungenparenchyms berücksichtigt werden. vom eigentlichen asthma abzugrenzen ist ein spektrum von erkrankungen, die alle mit einer beteiligung der atemwege einhergehen und andere beim asthma vorkommende, pathophysiologische, laborchemische oder histologische elemente aufweisen. während die immunologische endstrecke in der pathogenese beim intrinsischen und extrinsischen asthma im sinne einer von eosinophilen dominierten entzündung miteinander vergleichbar ist, scheinen sich jedoch die zentralen regulatorischen immunprozesse beider formen zu unterscheiden. so findet sich beim intrinsischen asthma parallel zur fortbestehenden bluteosinophilie eine auch im symptomarmen intervall anhaltende aktivierung der cd4 + -und cd8 + -t-lymphozyten im blut und in der bal, die sich durch die expression der il-2r-, hla-dr-und vla-1-oberflächenantigene äußert. die intrinsische form des asthma bronchiale zeichnet sich ferner durch eine umverteilung peripherer lymphozyten in sog. »memory«-t-zellen (cd45r0) aus, die beim extrinsischen allergischen asthma nicht nachweisbar ist. diese beobachtungen deuten auf einen pathogenetischen unterschied zwischen extrinsischem und intrinsischem asthma bronchiale hin. es wird spekuliert, dass das intrinsische asthma bronchiale ätiologisch auf eine autoimmunologische entzündung, z. b. gegen ein bislang nicht definiertes antigen in der bronchialschleimhaut, zurückgeht. erkrankungen mit blut-und atemwegseosinophilie finden sich bei allen mit eosinophilen assoziierten pulmonalen krankheiten wie dem löffler-syndrom, der chronischen eosinophilen pneumonie, der tropischen eosinophilie, der allergisch bronchopulmonalen aspergillose ⊡ abb. 3.6. algorithmus des praktischen vorgehens bei verdacht auf eine allergische erkrankung. eckige kästen beziehen sich auf die diagnostischen verfahren, runde und schattierte kästen auf die möglichen befunde v.a. allergische erkrankung positiv positiv negativ negativ positiv oder dem churg-strauss-syndrom. alle aufgeführten erkrankungen können histopathologisch mit einer eosinophilen bronchitis und der ausbildung einer bronchialen hyperreagibilität sowie der hiermit assoziierten asthmatischen symptomatik einhergehen. zudem findet sich beim churg-strauss-syndrom auch eine meist sehr deutliche vermehrung der gesamt-ige-konzentration im serum, ein umstand, der die abgrenzung zum extrinsischen asthma zusätzlich erschwert. im gegensatz zum klassischen asthma kommt es jedoch im rahmen der oben genannten erkrankungen auch zu einer parenchymalen beteiligung mit zumeist wechselnden interstitiellen infiltraten, die radiologisch als flaue, sich in ausdehnung und lokalisation ändernde verschattungen imponieren. die in der praxis häufigste und schwierigste differenzialdiagnose des asthma bronchiale bildet die chronischobstruktive bronchitis mit oder ohne emphysem. hierbei handelt es sich um eine unspezifische reaktion des bronchialsystems auf eine langjährige inhalation von umweltnoxen, wobei hierbei eine langjährige tabakrauchinhalation ätiologisch meist im vordergrund steht. die erkrankung beginnt als einfache chronische bronchitis mit mukushypersekretion und kann sich allmählich zur chronisch-obstruktiven lungenerkrankung entwickeln. im fortgeschrittenen stadium kommt es bei einer untergruppe dieser patienten zu irreversiblen emphysematösen lungenstrukturveränderungen (zentrilobuläres emphysem) mit pulmonaler hypertonie und cor pulmonale (s. auch kap. 7.2) . welche endogenen faktoren für die emphysementwicklung eine rolle spielen, ist bisher nicht bekannt. im gegensatz zur chronisch-obstruktiven bronchitis wird beim asthma bronchiale kein emphysem gefunden. die wichtigsten unterschiede zwischen dem allergischen asthma bronchiale und der chronisch-obstruktiven bronchitis sind in ⊡ tab. 3.8 zusammengestellt. obwohl primär eine erkrankung des interstitiums, kann die sarkoidose in fast der hälfte der fälle mit einer bronchialen hyperreagibilität, husten und bronchialobstruktion einhergehen und sollte differenzialdiagnostisch in betracht gezogen werden. die pathogenese der bronchialen hyperreagibilität ist ausdruck einer granulomatösen atemwegsbeteiligung im rahmen der grunderkrankung (s. kap. 8.7). unter der gastroösophagealen refluxkrankheit (»gastroesophagel reflux disease«; gerd) versteht man unspezifische pulmonale beschwerden, die durch einen gast der prototyp der allergischen parenchymerkrankung ist die exogen-allergische alveolitis, die mit einer chronischen interstitiellen entzündung durch kontakt mit organischen stäuben entsteht. hiervon differenzialdiagnostisch abzugrenzen sind andere interstitielle erkrankungen wie idiopathische pulmonale fibrose (ipf), sarkoidose, kollagenosen mit lungenbeteiligung (sklerodermie, anti-jo-1-syndrom etc.), allergische bronchopulmonale aspergillose sowie die gruppe der mit eosinophilen assoziierten pulmonalen parenchymerkrankungen. zum monitoring allergischer erkrankungen unter therapie eignen sich: ▬ einfach zu messende lungenfunktionsparameter (fev 1 , exspiratorischer spitzenfluss=peak flow), ▬ die bestimmung der unspezifischen bronchialen hyperreagibilität, ▬ bestimmte laborchemische parameter. während fev 1 oder pef-veränderungen als nachweis einer bestehenden obstruktion interpretiert werden können, lassen die bronchiale hyperreagibilität bzw. hypersensitivität sowie die laborparameter rückschlüsse auf die entzündliche aktivität der erkrankung zu. ohne die objektive bestimmung der lungenfunktion lässt sich weder von seiten des patienten noch des arztes der grad der atemwegsobstruktion verlässlich abschätzen. so können sich patienten selbst mit signifikanter obstruktion durchaus noch wohlfühlen. ebenso ist der typische auskultationsbefund einer atemwegsobstruktion in form trockener nebengeräusche nicht immer zu erheben, selbst bei schwerer obstruktion (»silent lung«). die grundsätzlich gilt auch für das ecp, dass der parameter nach beginn einer wirkungsvollen antientzündlichen therapie abfallen sollte. je höher der ausgangswert, um so deutlicher stellt sich dabei die nachweisbare konzentrationsabnahme dar. in den vergangen jahren haben verschiedene studien zeigen können, dass sich die konzentration des stickstoffmonoxids (no) in der ausatemluft als nichtinvasiver biomarker der asthmatischen entzündung eignet. no wird von allen zellen der atemwege freigesetzt, wenngleich das atemwegsepithel den größten anteil bildet. die messung selbst ist vergleichsweise einfach und unter standardisierten bedingungen gut reproduzierbar, sofern beimengungen nasalen ursprungs vermieden werden. allerdings sind die kosten für das analysegerät nicht unerheblich. no findet sich im gegensatz zu anderen obstruktiven atemwegserkrankungen (chronisch-obstruktive bronchitis, mukoviszidose) beim asthma in erhöhten konzentrationen im exhalat. nach allergenprovokation steigt die no-konzentration während der asthmatischen spätreaktion an. unter antientzündlicher therapie mit kortikosteroiden nimmt die konzentration wieder ab. erhöhte no-konzentrationen finden sich jedoch auch bei rauchern und im rahmen respiratorischer infekte. die schulung findet am günstigsten in der gruppe statt, weil die solidarisierung der betroffenen und der erfahrungsaustausch zwischen den gruppenmitgliedern positiv wirken. patientenschulungen werden in der zwischenzeit in vielen zentren von ärzten, krankenschwestern bzw. pflegern, arzthelferinnen, pädagogen und psychologen angeboten. dabei bemüht sich die sektion prävention und rehabilitation der dgp um eine qualitative optimierung der schulung durch »train-the-trainer-seminare«. die spezifische immuntherapie (desensibilisierung, hyposensibilisierung) als kausale behandlung allergischer erkrankungen geht auf noon und freeman zurück, die bereits 1911 am st. mary's hospital in london die ersten hyposensibilisierungen durchführten. seither haben verschiedene kontrollierte studien, meistens mit einem einzigen allergen, gezeigt, dass die hyposensibilisierung der allergischen rhinokonjunktivitis die beschwerden lindert. die studien zeigen auch, dass bei adäquater dosierung und konsequenter durchführung eine signifikante reduktion der beschwerden gelingt. im gegensatz zur allergischen rhinokonjunktivitis ist der einsatz der spezifischen immuntherapie beim asthma bronchiale gegenstand kontroverser diskussion. entsprechend den aktuellen leitlinien der dgai, des äda und der gpa von 2006 ist beim intermittierenden und geringgradig-persistierenden, ige-vermittelten allergischen asthma die spezifische immuntherapie (slit) gut untersucht und als therapieoption neben allergenkarenz und der pharmakotherapie zu empfehlen. eine frühzeitige spezifische immuntherapie ist zu-dem unter präventiven aspekten durchzuführen, um das risikos, ein asthma zu entwickeln (etagenwechsel), und ein zunehmen des sensibilisierungsspektrums zu vermeiden. wegen der möglichkeit von ernsten nebenwirkungen (anaphylaktischer schock, asthmaattacke) sollte eine hyposensibilisierungsbehandlung ausschließlich von erfahrenen allergologen durchgeführt werden, die über ein entsprechend ausgebildetes personal und eine intensivmedizinische überwachungseinheit verfügen, um lebensbedrohlichen reaktionen adäquat zu begegnen. grundsätzlich sollte eine hyposensibilisierung in erwägung gezogen werden, wenn ▬ eine allergenkarenz nicht oder schwer möglich ist (z. b. gegenüber pollen oder hausstaubmilben), ▬ eine klare beziehung zwischen symptomen und der exposition mit einem relevanten allergen besteht (provokationstestungen), ▬ eine ige-vermittelte sensibilisierung (hauttest und in-vitro-diagnostik) nachgewiesen ist, ▬ sich die beschwerden nicht durch eine adäquate therapie ausreichend kontrollieren lassen, ▬ standardisierte bzw. qualitativ hochwertige allergenextrakte verfügbar sind und ▬ die wirksamkeit einer geplanten immuntherapie für die jeweilige indikation nachgewiesen ist (mod. nach kleine-tebbe et al. 2000) . die klassische und verbreitetste technik der desensibilisierungsbehandlung basiert auf der regelmäßigen (meist wöchentlichen), streng subkutanen applikation allmählich ansteigender dosen des relevanten spezifischen allergens bis zum erreichen einer maximalen, vom patienten individuell noch tolerierten dosis. diese maximale allergenmenge wird dann in regelmäßigen abständen (1-4 wochen) verabreicht, um eine möglichst hohe kumulative allergendosis zu erreichen. die ganzjährige behandlung, z. b. auch während der pollensaison, ist daher einer präsaisonalen behandlung überlegen. eine modifikation der hyposensibilisierungstechnik stellt die rush-bzw. ultrarush-desensibilisierung dar, bei denen mit insektengiftextrakten in wässriger lösung unter schneller dosissteigerung mehrere injektionen (meist 4) innerhalb weniger stunden über einen zeitraum von 8-10 tagen vorgenommen werden. die aktuelle leitlinie zur spezifischen immuntherapie empfiehlt die sublinguale allergenapplikation bei allergischer rhinokonjunktivitis gegenüber pollen bei erwachsenen dann, wenn eine subkutane applikation nicht infrage kommt. bei hausstaubmilbenallergie bzw. allergischem asthma durch inhalationsallergene stellt die sublinguale immuntherapie (slit) keinen ersatz für die subkutane immuntherapie (scit) dar. eine regelmäßige anwendung wird derzeit bei kindern und jugendlichen nicht empfohlen. das ziel der densibilisierungsbehandlung besteht darin, den ablauf zugrunde liegender entzündlicher prozesse und damit der allergischen beschwerden zu reduzieren. während noch in den 70er-jahren ihre wirkung auf die bildung sog. blockierender allergenspezifischer iggund igg 4 -antikörper zurückgeführt wurde, scheinen verschiedene andere vorgänge ebenfalls von bedeutung zu sein. bei patienten mit allergischer rhinitis vermindert eine hyposensibilisierung die konzentration von entzündungsmediatoren im nasensekret, reduziert die zahl sowie die reaktivität eosinophiler granulozyten und bessert die nasale hyperreagibilität. auch histologisch zeigt sich eine verminderte zahl an aktivierten eg2 + -eosinophilen. gleichzeitig nimmt die reagibilität allergenspezifischer t-zellklone (klonale anergie) ab. andere untersuchungen konnten zeigen, dass unter der immuntherapie die sekretion von il-4 aus lymphozyten abnimmt, sodass auch eine verschiebung der th-differenzierung in richtung des th-1-phänotyps als zugrunde liegender mechanismus diskutiert wird (immundeviation). die medikamentöse behandlung allergischer erkrankungen beruht auf einer palette von medikamenten, die je nach vorliegender organmanifestation und schwere intravenös, systemisch oder topisch appliziert und in unterschiedlicher form kombiniert werden (⊡ tab. 3.10). nach der dominierenden pharmakologischen wirkung lassen sich die antiallergika willkürlich in 4 gruppen unterteilen (⊡ tab theophyllin ist ein unspezifischer phosphodiesteraseinhibitor, der seine pharmakologische wirkung über die erhöhung der intrazellulären camp-konzentration in muskel-, epithel-und nervenzellen vermittelt. die pharmakologische wirkung des theophyllins bei einer serumkonzentration zwischen 10-20 mg/l umfasst daher ▬ eine bronchodilatation, ▬ eine steigerung der mukoziliären clearance sowie ▬ eine schwache zentrale atemstimulation. bei geringerer serumkonzentration von 5-10 mg/l hat theophyllin einen schwachen antientzündlichen effekt, der möglicherweise über purinerge rezeptoren vermittelt wird. nicht retardiertes theophyllin steht zur intravenösen akuttherapie im rahmen eines asthmaanfalls zur verfügung. demgegenüber kommt retardiertes, lang wirksames theophyllin gegenwärtig als adjuvante behandlung beim asthma bronchiale zum einsatz und ist besonders wirkungsvoll zur kontrolle nächtlicher beschwerden. aufgrund der individuell unterschiedlichen metabolisierung des theophyllins und der komplexen interaktionen mit anderen arzneimitteln, aber auch zur vermeidung akzidenteller überdosierungen sind kontrollen des blutspiegels bei der einstellung und während der therapie unerlässlich. bei einer konzentration von über 20 mg/l, gelegentlich bereits schon bei 15 mg/l, kann es zu unruhe, schlaflosigkeit, kopfschmerzen, übelkeit und erbrechen, in noch höheren konzentrationen sogar zu krampfanfällen, kommen. ren, sodass sie vermutlich eine differenzierte behandlung allergischer erkrankungen erlauben werden. zu diesen medikamenten gehören: ▬ spezifische typ-iii-und typ-iv-phosphodiesteraseinhibitoren, ▬ subtypspezifische muskarinrezeptorantagonisten, ▬ interleukin-5-rezeptorantagonisten, ▬ interleukin-4-rezeptorantagonisten, ▬ neutralisierende anti-ige-antikörper (e25), ▬ tryptaseinhibitoren und ▬ chemokinrezeptorantagonisten. selbst wenn einzelne der oben aufgeführten substanzen aufgrund von nebenwirkungen, unzureichender wirksamkeit oder aus anderen gründen nicht zum klinischen einsatz gelangen, darf damit gerechnet werden, dass bestimmte medikamente ihren weg in die pharmakotherapie allergischer erkrankungen finden. so könnte in zukunft ein spektrum neuer antiallergisch wirkender therapeutika verfügbar werden, die es nicht nur erlauben allergische erkrankungen wirksamer zu behandeln, sondern auch eine behandlung an individuelle bedürfnisse anzupassen. atopie in deutschland. untersuchung zur vorhersagemöglichkeit einer atopie bei geburt natural history of childhood asthma. 20 year follow-up eosinophilic inflammation in asthma leitlinie zur diagnostik und therapie von patienten mit asthma bronchiale prävalenz allergischer manifestationen im schulkindalter in südbaden prognosis of asthma from childhood to adulthood global initiative for asthma. gina workshop report, global strategy for asthma management and prevention. www.ginastma.org, 22 worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: isaac gegenwärtige behandlung des asthma bronchiale die spezifische immunotherapie (hyposensibilisierung) mit allergenen eosinophil activation in cystic fibrosis pathomechanismen der asthmatischen entzündungsreaktion pathogenetische grundlagen des asthma bronchiale evidence for eosinophil activation in bronchiectasis unrelated to cystic fibrosis and bronchopulmonary aspergillosis: discrepency between blood eosinophil counts and serum eosinophil cationic protein levels interferon-acon-1 treatment of three patients with severe glucocorticoid-dependent asthma -effect on disease control and systemic glucocorticosteroid dose omalizumab. in: dübel s (hrsg.) handbook of therapeutic antibodies, 1. aufl interferon-gamma as a possible target in chronic asthma frequency of atopic diseases and allergic sensitization in preschool children in different parts of food allergy in gastroenterologic diseases: review of literature asthma from childhood at age 21: the patient and his (or her) disease die allergische bronchopulmonale aspergillose diagnostik des asthma bronchiale activation of platelets in bronchial asthma follow-up on children with asthmatic bronchitis. a view to prognosis increasing prevalence of hay fever and atopy among children in guidelines for the diagnosis and management of asthma adult patients may outgrow their asthma. a 25-year follow-up study the role of allergens in airway disease prevention of asthma empfehlungen zum strukturierten patiententraining bei obstruktiven atemwegserkrankungen asthma in children: follow-up study of 688 patients after intervl of 20 years is asthma a fibrotic disease breastfeeding as prophylactis against atopic disease: prospective follow-up study until 17 years old kosten der asthmatherapie nach schweregrad. eine empirische untersuchung epidemiology of childhood asthma tagung der arbeitsgemeinschaft eogen-allergische alveolitis relationship between mite densities and the prevalence of asthma: comparative studies in two populations in the eastern highlands of papua new guinea matrix metalloproteinases in bronchoalveolar lavage fluid following antigen challenge medizinische und ökonomische bedeutung einer volkskrankheit. rupp, stuttgart wüthrich b (1995) pollenallergie. aktuelles zur epidemiologie, pathogenese der effekt lokal wirkender antientzündlicher medikamente erstreckt sich vorwiegend auf entzündungszellen wie z. b. mastzellen. zu den medikamenten dieser gruppe gehören das dinatriumcromoglycat (dncg), nedocromilnatrium und h 1 -antagonisten. der wirkmechanismus von dncg und nedocromilnatrium ist noch nicht vollkommen aufgeklärt, schließt aber vermutlich eine blockade von chloridkanälen in der zellmembran ein. bezogen auf wirkstärke und -spektrum sind beide substanzen miteinander vergleichbar; sie hemmen die mediatorfreisetzung aus mastzellen und die rekrutierung eosinophiler granulozyten aus dem blut.ihre wirkung erstreckt sich sowohl auf die allergische früh-und spätreaktion nach allergenprovokation als auch auf die durch körperliche belastung oder kaltluft ausgelöste atemwegsobstruktion. beide medikamente werden topisch zur behandlung milder formen des asthma bronchiale, der rhinitis allergica und der conjunctivitis allergica eingesetzt (⊡ tab. 3.10 und 3.11). sie spielen auch eine rolle bei der behandlung allergischer erkrankungen im kindesalter. zur gruppe der auf die sofortreaktion wirkenden antientzündlichen medikamente gehören auch die h 1 -ant-agonisten oder antihistaminika (⊡ tab. 3.12). sie wirken als spezifische rezeptorantagonisten und unterdrücken die proinflammatorische wirkung des aus mastzellen und basophilen granulozyten freigesetzten histamins. antihistaminika reduzieren auf diese weise pruritus, gefäßdilatation mit erythem und ödem und sind sowohl nach systemischer als auch topischer gabe wirksam.h 1 -rezeptorantagonisten der 2. generation sind aufgrund ihrer geringen liquorgängigkeit besser verträglich als die substanzen der 1. generation. neben ihrer symptomatischen wirkung als histamin-1-rezeptorblocker besitzen sie offenbar eine nicht h 1 -rezeptor-vermittelte, antientzündliche wirkkomponente, auch wenn die hier zugrunde liegenden molekularen mechanismen noch nicht im detail bekannt sind. cetirizin beispielsweise hemmt die gewebeinfiltration durch eosinophile granulozyten sowie verschiedene effektorfunktionen der zelle.die indikation zur behandlung mit h 1 -rezeptorantagonisten der 2. generation umfasst die der rhinitis allergica und conjunctivitis allergica. im rahmen der atopischen dermatitis ist ihre wirkung nicht eindeutig belegt, die verträglichkeit der leukotrienrezeptorantagonisten ist im allgemeinen gut. nur selten klagen die patienten über kopfschmerzen. bei den unter behandlung mit zafirlukast aufgetretenen 8 fällen einer infiltrativen, eosinophilie-assoziierten lungenerkrankung handelt es sich vermutlich um die exazerbation eines primär als asthma bronchiale fehldiagnostizierten churg-strauss-syndroms, zu der es nach reduktion der oralen kortikosteroiddosis kam. diese gruppe von medikamenten entfaltet ihre wirkung entweder direkt auf die glatte muskulatur (β 2 -sympathikomimetika) oder auf die neurale regulation des bronchotonus (anticholinergika). bei den β-sympathikomimetika handelt es sich um rezeptorspezifische medikamente, die den β 2 -adrenergen rezeptorsubtyp auf den glatten muskelzellen der atemwege besetzen. β 2 -mimetika sind die stärksten gegenwärtig verfügbaren bronchospasmolytika. dieser pharmakologische effekt wird ergänzt durch: ▬ verringerung der permeabilität im bereich der kapillaren und ▬ verbesserung der mukoziliären clearance. der therapeutische effekt der anticholinergika beruht auf der blockade cholinerger (muskarinerger) rezeptoren (m-rezeptoren), wodurch die substanzen mit der vagalen bzw. azetylcholinvermittelten bronchokonstriktion interferieren. von den 5 bisher bekannten muskarinergen bindungsstellen ist die funktion des m1-rezeptorsubtyps auf submukösen drüsenzellen und des m3-rezeptorsubtyps auf glatten muskelzellen für die pathogenese des asthma bronchiale relevant. die beiden derzeit zur verfügung stehenden substanzen ipratropiumbromid und oxitropiumbromid wirken unspezifisch auf alle rezeptorsubtypen.die wirkung der oben genannten anticholinergika tritt etwas verzögerter ein als die der kurz wirksamen β 2 -mimetika, hält dafür aber auch länger an (bis zu 6 h). ihr bronchodilatorischer effekt ist schwächer ausgeprägt als der von β 2 -sympathikomimetika und eine universale wirksamkeit für die langzeitbehandlung des asthma konnte nicht belegt werden. während exazerbationen kann allerdings die kombination von anticholinergika mit β 2 -mimetika sinnvoll sein (z. b. berodual). auch die inhalation von ipratropiumbromid und eines β 2 -mimetikums mittels düsenvernebler (z. b. pari-boy; jeweils 8 tropfen auf 2 ml nacl) alle 3 h im wechsel hat sich bei mittelschweren bis schweren asthmaattacken als günstig erwiesen.relevante nebenwirkungen werden nach gabe von anticholinergika kaum beobachtet. gelegentlich kann es zu mundtrockenheit oder unangenehmem geschmack kommen. schwere asthmaattacken und anaphylaktische reaktionen unterschiedlichster ätiologie können zu lebensbedrohlichen situationen führen. dabei geht es vor allem darum, bereits bei geringsten klinischen anzeichen möglichst frühzeitig eine effektive behandlung einzuleiten. daher sollten beispielsweise patienten mit bekannter schwerer insektengiftallergie kortison in form von tabletten oder suppositorien sowie ein adrenalininjektionsbesteck stets mitführen, um in der lage zu sein, selbst maßnahmen einzuleiten. dieses und andere notfallmedikamente zur akutbehandlung lebensbedrohlicher allergischer erkrankungen sind in ⊡ tab. 3.12 aufgeführt. gegenwärtig befinden sich eine ganze palette verschiedener antiallergisch wirkender medikamente mit antiasthmatischer und antiallergischer wirkung in der klinischen prüfung. ihr wirkmechanismus beruht auf den fortschritten im verständnis der pathogenese allergischer erkrankungen. deshalb handelt es sich bei den substanzen um medikamente, die selektiv die funktion eines rezeptors oder eines mediators blockieren bzw. neutralisiekey: cord-017412-1avevzya authors: losada, liliana; ghedin, elodie; morris, alison; chu, hong wei; nierman, william c. title: the human lung microbiome date: 2010-10-11 journal: metagenomics of the human body doi: 10.1007/978-1-4419-7089-3_7 sha: doc_id: 17412 cord_uid: 1avevzya the human lower respiratory tract is considered sterile in normal healthy individuals (flanagan et al., 2007; speert, 2006) despite the fact that every day we breathe in multiple microorganisms present in the air and aspirate thousands of organisms from the mouth and nasopharynx. this apparent sterility is maintained by numerous interrelated components of the lung physical structures such as the mucociliary elevator and components of the innate and adaptive immune systems (discussed below) (reviewed in (diamond et al., 2000; gerritsen, 2000)). however, it is possible that the observed sterility might be a result of the laboratory practices applied to study the flora of the lungs. historically, researchers faced with a set of diseases characterized by a changing and largely cryptic lung microbiome have lacked tools to study lung ecology as a whole and have concentrated on familiar, cultivatable candidate pathogens. the human lower respiratory tract is considered sterile in normal healthy individuals (flanagan et al., 2007; speert, 2006) despite the fact that every day we breathe in multiple microorganisms present in the air and aspirate thousands of organisms from the mouth and nasopharynx. this apparent sterility is maintained by numerous interrelated components of the lung physical structures such as the mucociliary elevator and components of the innate and adaptive immune systems (discussed below) (reviewed in (diamond et al., 2000; gerritsen, 2000) ). however, it is possible that the observed sterility might be a result of the laboratory practices applied to study the flora of the lungs. historically, researchers faced with a set of diseases characterized by a changing and largely cryptic lung microbiome have lacked tools to study lung ecology as a whole and have concentrated on familiar, cultivatable candidate pathogens. with the availability of new technologies for cultivation-independent analysis of microbial populations, it is now possible to follow individuals by sampling their lung microbiome sequentially during episodes of disease and recovery in order to identify associations between the lung microbiome and health and disease. any respired contaminating particles or pathogens that evade the lung's physical and immune barriers are usually eliminated by dendritic cells and alveolar macrophages that deliver them into local draining lymph nodes. macrophages kill invading microorganisms while en route to the draining lymph nodes, and in some cases at the nodes themselves (bozza et al., 2002; kirby et al., 2009) . thus, it is not unusual to isolate viable bacteria or fungi from "normal" lung tissue (lass-florl et al., 1999) , and the term "sterile" should be applied with caution. it is perhaps more accurate to say that there is no resident flora that permanently colonizes normal lungs. even normal healthy lungs are not microbe free all the time. lower airway infections by bacteria, viruses, or fungi are among the most prevalent causes of transmissible disease in humans, with two to three million community-acquired (non-hospital-acquired) cases per year in the united states (segreti et al., 2005) . in 2006, the number of deaths attributed to pneumonia (bacterial and viral) and influenza in the united states was 60,000 (gao et al., 2008) www.cdc.gov/ nchs/fastats/deaths.htm). in 2009, nearly 9.3 million new cases of tuberculosis were reported around the world (http://www.who.int/mediacentre/factsheets/ fs104/en/index.html). with proper treatment, the lungs of individuals with these infectious diseases will revert to their normal "sterile" state. little is known about the composition of the microbial population of the upper and lower airways in health or disease. it is likely, given the multiple microorganisms already implicated in chronic lung diseases such as chronic obstructive pulmonary disease (copd) , that there are other undetected organisms and that there are complex relationships between multiple pathogens involved that are not currently understood. a few studies have examined microbial species in limited numbers of normal subjects and patients with various respiratory disorders. one study using 16s rdna clone libraries and microarrays did not detect any bacteria in the lungs of patients without respiratory disease who were briefly intubated for surgery (flanagan et al., 2007) . the same study reported that all patients intubated for longer periods had detectable 16s rdna and that the bacterial diversity present decreased during antibiotic usage. another study used 16s rdna amplification to identify bacterial species in 16 patients with ventilator-associated pneumonia (bahrani-mougeot et al., 2007) . this study identified bacterial pathogens not seen using conventional culture techniques, especially anaerobes, and found that oral bacteria could be detected in the lung. in one study, sputum samples from 25 cystic fibrosis (cf) patients were analyzed using 16s gene profiling and the authors identified an average of 7.2 species present per subject (bittar et al., 2008) . viruses have also been examined in nasal lavages in both asthmatic and normal subjects with cold symptoms using the virochip microarray (kistler et al., 2007) . the microarray technology identified more viruses than conventional culture methods and had excellent sensitivity and specificity compared with pathogen-specific polymerase chain reaction (pcr). an unexpected diversity of human coronavirus and rhinovirus strains was discovered in the subjects. so if the lung is generally sterile, why do some individuals become chronically colonized? what organisms colonize the lungs? those with physically compromised airways or immune system deficiencies are subject to chronic microbial colonization of their airways and to high-frequency episodes of viral, bacterial, or fungal lower respiratory infections. perhaps in no other body site is the direct relationship between disease and microbiome more explicit than in the lungs where there is a distinct and obvious microbial difference between normal and diseased individuals. the lower respiratory tract, composed of the trachea and lungs, is quite different in structure and function from the upper respiratory tract, which is highly colonized by microorganisms. the lungs themselves are divided into different sections according to their function and structures: the bronchi, bronchioles, and alveoli. bronchi and bronchioles are primarily conductive airways surrounded by thick cartilage that allow easy airflow into the parenchyma (or alveolar tissue) of the lungs, where gas exchange occurs. conductive airways are covered in ciliated epithelium interspersed with different types of secretory cells that release mucins, immunomodulatory proteins, surfactants, and proteases. together, the physical and chemical barriers protect against physical and biological damage by establishing a mucociliary elevator, which brings about an upward transport of a mucus stream for the lungs (fraser, 2005) . the secretory cells decrease in proportion from 20 to 30% in the trachea to less than 1% in the distal and alveolar parts of the lungs. in addition to the physicochemical protection provided by cilia and mucus, the epithelium is also protected by several immune cells, including dendritic, langerhans, t lymphocytes, and mast cells, that respond to inhaled antigens establishing a robust immunity (fraser, 2005) . it is thought that in conjunction with the physical barriers provided by the nose and upper respiratory mucosa, these defenses are enough to maintain sterility in the lower respiratory tract. the vast majority of the lung surface epithelium, however, is alveolar. it is estimated that 87% of the total volume of the lungs is alveolar, with only 6% of this being tissue and the remainder gas (stone et al., 1992) . the primary role of this tissue is to carry out gas exchange. the epithelium is mostly a continuous single layer of cells overlying a thin interstitium, which contains numerous capillaries that supply ample blood for gas exchange (fraser, 2005; stone et al., 1992) . unlike the epithelium in the conducting airways, the respiratory epithelium is not ciliated or protected by mucus. instead, it is covered by surfactant proteins that maintain the surface tension for efficient gas exchange. the lack of mucus or secretory cells is compensated by the presence of alveolar macrophages, mast cells, lymphocytes, dendritic cells, and other monocyte-like cells that protect the epithelium from potential pathogens and help maintain sterility. recent world health organisation (who) figures rank lower respiratory diseases second in an assessment of the burden of disease worldwide (http://www.who.int/ respiratory/en/). in 2006, 124, 500 people died in the us due to chronic lower respiratory disease (www.cdc.gov/nchs/fastats/deaths.htm). chronic respiratory diseases include: asthma, copd, cf, and bronchiectasis. these diseases generally lead to impaired clearance and function of the mucociliary elevator and/or the immune protection of the lung. in addition, immune deficiency such as that caused by the human immunodeficiency virus (hiv) also disrupts the typical immune homeostasis in the lungs. without the normal protective barriers, the lungs fall victim to persistent and severe colonization that can ultimately lead to death, particularly for cf patients. as discussed below, the lung microbiome in each of these diseases is very different from normal individuals. the data discussed in the following sections demonstrate a clear link between microbial colonization and severity of disease symptoms. it is unclear, however, what exact role these different microbial populations play in initiating and enhancing the progress of such chronic respiratory diseases. lastly, in some cases, the data hint that some population structures might actually be protective against further decline, but much more research needs to be conducted in this area to make a definitive claim. this chapter discusses the methods for sampling and characterizing the microbiome of the lungs. in addition, it reviews the current status of our understanding of the lung microbiome in asthma, idiopathic bronchiectasis, cf, copd, and during immune deficiency due to hiv infection. several procedures have been developed for sampling the microbial population of the human lung econiche. in order of increasing invasiveness they are sputum induction, bronchoalveolar lavage (bal), bronchial brushing, endobronchial biopsy, and transbronchial biopsy. sputum induction by inhalation of hypertonic saline is a noninvasive method to obtain samples from the lower respiratory tract for cell and microbial analysis (bickerman et al., 1958) . the quality of samples varies and can be scored on the volume of the obtained sputum plugs and the level of salivary contamination as measured by squamous cells observed by microscopy. bal is a procedure in which a bronchoscope is passed through the mouth or nose into the lungs and saline is instilled into a segment of the lung and then recollected for examination (henderson, 1994; reynolds and chretien, 1984) . bal is most commonly used to diagnose infections in both immunocompetent and immunosuppressed patients. bal is the most common procedure for sampling the lower respiratory system microbial colonization/infection status, to sample the components of the epithelial lining fluid, and to determine the protein composition of the airways. it is often used in evaluating the patient's lung immunological status by sampling cells and pathogen levels. bal is an invasive procedure and thus is less ideal for research purposes. bronchial brushing provides access to cells and microbes that are adherent to the luminal surfaces of the lower airways. in this procedure, a flexible fiber optic bronchoscope is used for brushing a targeted lesion or site (fennessy, 1967; zavala et al., 1973) , where induced sputum and bal procedures will allow sampling of cells and microbes that can be washed from the lumen surface, brushing will recover adherent cells (e.g., bronchial epithelial cells) and microbes. recently, brushing techniques have been developed to sample distal lung (i.e., small airway) epithelial cells and associated microbes (ammous et al., 2008) . this technique will enable investigators to further study the microbiome in lung diseases such as copd. endobronchial biopsy involves using the fiber optic bronchoscope to identify appropriate target sites in the lung and obtain large airway tissue samples using inserted alligator forceps, cup forceps, or curette passed through the endoscope's central channel. this procedure poses a higher risk than bal but allows sampling the invasive microbes within the airway tissue (scott et al., 1991; trulock et al., 1992) . transbronchial biopsy, the most invasive of these sampling procedures, is routinely performed for clinical care and allows clinicians and researchers to obtain distal (small) airway tissues as well as alveolar tissues. this procedure has been safely done by several research groups (balzar et al., 2005) and will likely further our understanding of the microbiome in human distal lung tissues, but carries a significant risk of complications. standard microbiological and virologic methods detect only a small proportion of the bacteria and viruses present in various body sites because the great majority of these organisms are uncharacterized or uncultivable. to understand the real diversity, culture-independent methods, such as sequencing, are thus a necessity. sequenced-based identification of microbial species is facilitated by decreased costs of sequencing, and the availability of next-generation sequencing technologies, further enhances the capacity to generate large amounts of data. for the identification of bacterial species within an environment, the amplification of 16s rrna genes (or 16s rdna) using universal primers are useful for diversity characterization because this genetic locus is present in all bacterial species (relman et al., 1991) . the nine hypervariable regions of the 16s rdna can be used for bacterial species identification (chakravorty et al., 2007; rokas et al., 2007) with some regions having better discriminatory value than others. the sequencing and phylogenetic analysis of bacterial 16s rrna derived from microbiome samples has been the primary method used to investigate bacterial diversity in the human body (bik et al., 2006; dekio et al., 2005; eckburg et al., 2005; gao et al., 2007; hugenholtz et al., 1998; hyman et al., 2005; zhang et al., 2006) . these studies have revealed a far higher level of diversity than conventional culture techniques (aly et al., 1976; bik et al., 2006; dekio et al., 2005; kazor et al., 2003; korting et al., 1988; kroes et al., 1999; paster et al., 2001) . these studies revealed that the majority of bacterial sequences correspond to uncultivated species and novel organisms. there was significant intersubject variability and variability between stool and mucosal microbial populations. for example, recent studies by blaser and colleagues at new york university have demonstrated substantial changes in the ratio of the genus streptococcus to propionibacterium in skin samples from healthy persons and in normal skin of patients with psoriasis (ratio = 0.4; n = 2, 649 clones), and from psoriatic lesion samples (ratio = 5.0; n = 1, 314 clones; p = 0.01) (gao et al., 2008) . in a lung study, bacterial diversity was analyzed in the endotrachael aspirates from seven intubated patients colonized with pseudomonas aeruginosa using both sequencing from 16s rrna clone libraries and an oligonucleotide microarray termed as the phylochip (flanagan et al., 2007) . controls were subjects briefly intubated for elective surgery. bacteria were not detected by either method in samples from the controls. sequencing from the clone libraries detected the presence of many orally, nasally, and gastrointestinal associated bacteria including known pathogens. the phylochip detected the same organisms and many additional bacterial groups present at low abundance. following antibiotic therapy, the bacterial populations' diversity decreased and was dominated by a single respiratory pathogen. in six of the seven patients, the dominant species was p. aeruginosa in spite of targeting this organism with antibiotics to which it was reportedly sensitive. the authors hypothesize that the loss of population diversity may directly contribute to pathogenicity, persistence, and development of pneumonia. similarly, amplification of regions from the 18s and internal transcribed spacer (its) regions of the rrna, a conserved fungal gene, allows discrimination of fungal species (fujita et al., 2001; makimura, 2001) . a preliminary study was undertaken to examine the efficacy of a community sequencing method to identify the fungal species in bal lung samples from 23 human subjects. the fungal its1-5.8s-its2 region was amplified and the results showed that 4 of 23 patients (17%) had fungal dna levels that could be reproducibly detected by pcr. the detected fungi included aspergillus fumigatus, candida tropicalis, and penicillium digitatum, among others (denning, unpublished) . these data agree with a culture-based study that showed that 63% of their sample population had evidence of pulmonary fungal colonization (lass-florl et al., 1999) , most commonly with a. fumigatus and other candida species, and also zygomycetes. the results also demonstrate that rrna sequencing is a viable platform for characterization of fungal communities in the human body. although there are no conserved genes that can be targeted for determination of viral diversity, whole genome shotgun of a sample enriched for viruses (such as by filtering) can lead to an effective characterization of viral communities (angly et al., 2006) . hundreds of viral genome sequences can be completed in a single sequencing reaction run using the gs-flx (454/roche) sequencing platform. using this technology and a random priming-based method, referred to as sequence independent single primer amplification (sispa), near-full-length genomes of rna or dna viruses can be sequenced. sispa can be used to sequence known and unknown viral genomes (djikeng et al., 2008) . this viral sequencing methodology can potentially be adapted for the determination of viruses within bal by enrichment using nuclease treatment and filtration followed by taking the extracted total rna and dna through the sispa process followed by sequence comparisons to known viruses. the initial studies of small 16s rrna described above hinted at great diversity within the human microbiome, yet it left important questions unanswered such as the identity of the nondominant community members and their biological roles. the applications of shotgun techniques to the study of the human microbiome (kurokawa et al., 2007; manichanh et al., 2006; zhang et al., 2006) again highlight the extent of microbial diversity associated with the human body while revealing much more of the identity and biology of nonculturable microorganisms. as a result of reduced costs and improved sequencing technologies, it is possible to perform in-depth metagenomic surveys of the human body's microbial diversity beyond the 16s rrna surveys. metagenomics, a term introduced in 1998, describes the functional and sequence-based analysis of total microbial genomes from environmental samples (handelsman et al., 1998) . metagenomics uses techniques that resemble the "whole genome shotgun" approach of single genome sequencing, but it is not limited to a single species. human metagenomics has provided insight into the complex composition of the microbiome of these several body sites, and this information has allowed us to draw tentative conclusions about the relationship between specific microbiomes and health. the human microbiome is composed of multiple "ecological niches", including the mouth (kroes et al., 1999; paster et al., 2001) , esophagus (zhang et al., 2006) , stomach (bik et al., 2006) , intestine , skin (gao et al., 2007) , and vagina (zhou et al., 2004) . our understanding of the overlap and the degree of communication between them is rudimentary at best. perhaps the most extensively studied has been the human gut microbiome where the interaction of the gut microflora, independently or through interaction with the genetic makeup of the host plays a role in obesity, crohn's disease, and ulcerative colitis (frank et al., 2007; gophna et al., 2006; turnbaugh et al., 2006) . asthma is a complex disease characterized by chronic inflammation in the lungs and reversible narrowing of the airways. symptoms include dyspnea, coughing, wheezing, airway hyper-reactivity, chronic eosinophilic atopy, and mucus hyper secretion (busse and lemanske, 2001) . about 20 million people in the us have been diagnosed with asthma; 9 million of them are children. asthma causes 4,000 deaths per year in the us and 11 million exacerbations. asthma is caused by environmental and genetic factors (martinez, 2007) , with asthma attacks resulting from immune responses to inhaled allergens. the majority of asthma exacerbations are caused by viral infections (krishnan et al., 2006) . atypical bacterial infections have also been associated with asthma exacerbations and with chronic asthma (johnston and martin, 2005; martin et al., 2001) . in susceptible individuals, the development of asthma has been associated with bacterial colonization in neonates (bisgaard et al., 2007) and viral and bacterial infections (wu and chu, 2009 ). there is abundant evidence testifying to the importance of microbes to the development and maintenance of asthma. a recent publication using a bacterial gene sequencing method suggests a disordered microbiome in asthmatic airways (hilty et al., 2010) . in the developed world there has been an increased focus on predisposing factors for asthma due to its rapidly increasing prevalence, now affecting up to a quarter of urban children (lilly, 2005) . asthma is known to be caused by environmental and genetic factors (martinez, 2007) . these factors determine asthma severity and how easily it can be treated (martinez, 2007) . many associations with asthma have been detected including exposure to cigarette smoke (thomson et al., 2004) , caesarean section birth relative to natural birth (thavagnanam et al., 2008) , early viral respiratory infections (gold and wright, 2005; harju et al., 2006) , early in life antibiotic use (marra et al., 2006) , and living in the us (gold and wright, 2005) . one theory for the cause of the increase in asthma incidence is the hygiene hypothesis (strachan, 1989) , that the rise in prevalence of asthma is a direct consequence of the success of modern hygienic practices in preventing childhood infections. this hypothesis is supported by numerous studies that have shown that children coming from a less hygienic environment have less asthma and other allergenic diseases (ball et al., 2000; celedon et al., 1999; jarvis et al., 1997) . in addition, alterations in innate immune system genes have been shown to be associated with the inception and development of asthma. these genes include the toll-like receptors and other genes such as mbl, mylk, defb1, jun, inf-î±5, and nos2a reviewed in wu and chu (2009) . asthma exacerbations have long been associated with viral infections (pattemore et al., 1992) . more recently, the use of reverse transcriptase pcr has greatly facilitated the identification of the exacerbation-associated virus. studies using this tool have suggested that 75-80% of asthma exacerbations are caused by virus infections (wark et al., 2002) . rhinovirus (rv) infections during early childhood are associated with the development of asthma, lower respiratory tract infections, and wheezing (jackson et al., 2008; lemanske et al., 2005) . they are also associated with hospitalization for asthma in adults (venarske et al., 2006) . a separate study revealed that patients with allergic asthma infected with rv had increased admissions to hospitals and that dust mite allergen was the primary allergen when these patients were skin tested with a panel of aeroallergens (green et al., 2002) . respiratory syncytial virus (rsv) in infants causes lower respiratory infection leading to pneumonia and bronchiolitis. rsv bronchiolitis is the leading cause of wheezing in infants and young children, and children infected with rsv resulting in bronchiolitis are more likely to develop wheezing and asthma later in childhood (peebles, 2004) . similarly, the human metapneumovirus (hmpv) was first isolated from children in 2001 and has been found to be associated with asthma exacerbations in both children under 5 years of age and adults (foulongne et al., 2006; williams et al., 2004) . mycoplasma pneumoniae and chlamydia pneumoniae are bacteria that attach to airway epithelial cells and cause cell damage. infections by these bacteria have been shown to be associated with asthma exacerbations (johnston and martin, 2005; lieberman et al., 2003; martin et al., 2001) . using a pcr assay, 31 of 55 patients with asthma were positive for either of these bacteria in lung tissue or bal, suggesting that some level of colonization by these bacteria may be common in asthma patients (martin et al., 2001) . studies in a mouse model suggest that preexisting allergic inflammation impairs the ability to upregulate tlr-2 and il-6 in the lungs, leading to decreased clearance of m. pneumoniae and an increase in airway inflammation (kraft et al., 2008) . evidence is accumulating that infections are associated with the induction and development of asthma. first, long-term cohort studies on the development of asthma show that most childhood asthma begins in infancy. the first episode of wheezing begins before the age of 3 and is frequently associated with lower respiratory tract viral infections, usually rsv, but also rv (gern et al., 2000; sigurs et al., 2005) . these infectious episodes and associated wheezing are strong predictors for the development of childhood asthma and atopy (devulapalli et al., 2008; kusel et al., 2007; martinez et al., 1995; singh et al., 2007) . second, many studies have associated viral infections with asthma prevalence in children (devulapalli et al., 2008; jackson et al., 2008; kusel et al., 2007; papadopoulos and kalobatsou, 2007; sigurs et al., 2005; singh et al., 2007; williams et al., 2004) . lastly, wu et al. have provided evidence to suggest that viral infections have a causal role in asthma initiation and development where they show that viral infection during the first 4 months of age is strongly correlated with the development of asthma by age 5 (wu et al., 2008) . only one-third of children with childhood wheezing and asthma, however, will develop persistent asthma symptoms in adulthood (gerritsen, 2002; taylor et al., 2005; vonk et al., 2004) . management of the symptoms with corticosteroid therapy is effective but may not alter the asthma progression (guilbert et al., 2006) . the role of infections in asthma induction and development will likely be shown to be mediated through the effect of these infections on the chronic inflammatory response in the airways of asthmatics. microbial infections can generate either a th2-or a th1-biased response that could exacerbate or attenuate asthma, respectively. in asthmatics, a pro-inflammatory th2 response persists even in the absence of allergens involving cd4+ th2 cells, eosinophils, mast cells, and the th2 cytokines il-4, il-5, il-9, and il-13 (holgate, 2008) . bacterial infections have been shown to contribute to asthma development. in a longitudinal prospective birth cohort study of 411 infants born to mothers with current or previous asthma, neonates colonized in the hypopharyngeal regions with streptococcus pneumoniae, haemophilus influenzae, or moraxella catarrhalis or a combination of these organisms were found to be at increased risk for recurrent wheezing in early childhood and asthma at age 5 (bisgaard et al., 2007) . a protective role for some bacteria has been reported . several studies have found a protective effect of mycobacterial exposure on atopy and airway inflammation (camporota et al., 2003; shirakawa et al., 1997; yang et al., 2002) . these exposures include bacillus calmette-guerin vaccination or heat-killed mycobacterium vaccae. early exposure to bacterial endotoxins may reduce future allergies or asthma (von mutius et al., 2000) , although endotoxins associated with house dust are associated with more asthma symptoms and worse lung function (dales et al., 2006; michel et al., 1996; park et al., 2001) . thus, the role of bacteria in asthma initiation and development appears to be complex. the causative interaction is likely to prove to be the interaction of bacteria and bacterial components in modulating the th1 and th2 innate immune system responses. the characterization of these interactions will be complicated by timing, dose, anatomical site, and duration of the bacterial exposure as well as the host genetic and environmental factors influencing the immune inflammatory response (holt, 1996) . it has recently been demonstrated that patients with severe asthma who are also atopic or sensitized to environmental fungi may benefit from treatment with the antifungal azole itraconazole . this observation has raised questions about the relationships among asthma severity, fungal sensitization, and fungal exposure. the issue is complicated by more than 1.5 million species of fungi that are thought to exist (hawksworth and rossman, 1997 ) and more than 80 species of fungi that have been associated with symptoms of airway allergy (horner et al., 1995) . for one species, a. fumigatus, 20 allergens are thought to participate in human airway allergies (www.allergome.org). determining the clinical relevance of fungal allergens is confounded further by extensive cross-reactivity among fungal allergens (crameri et al., 2009) . fungal allergens can induce a number of different human bronchopulmonary disorders, each with a distinct immune pathogenesis. in allergic bronchopulmonary aspergillosis (abpa), the respiratory system is chronically colonized typically with a. fumigatus. evidence now suggests that severe asthmatics without abpa are more likely to be atopic to fungi than patients with milder disease. the diagnostic label "severe asthma with fungal sensitization (safs)" has recently been applied to this group . in these patients, the fungal sensitization is most commonly a. fumigatus, candida albicans, and penicillium notatum . the association between severe asthma and fungi has been identified in numerous studies. atopy to environmental fungi has been associated with severe asthma (o'driscoll et al., 2005) . many population studies have shown an association between local fungal spore counts and medical emergencies due to asthma exacerbations (atkinson et al., 2006) . furthermore, studies have shown that fungus exposure in fungal-sensitized individuals induces asthma symptoms (malling, 1986; matheson et al., 2005; pulimood et al., 2007; salo et al., 2006; woodcock et al., 2006) . treatment of patients with safs with antifungal drugs has generally led to improvement of asthma symptoms concurrent with improvements in several markers of atopy such as reduced ige values, reduced eosinophils counts, and reductions in the level of dose of oral and systemic steroids required (pasqualotto et al., 2009) . these findings lead to the considerations of the fungal composition of the lung microbiome in asthmatic individuals and indeed in normal individuals. environmental fungi colonize the lungs of otherwise healthy people (lass-florl et al., 1999; okudaira et al., 1977) . these studies were dependent on cultivationbased methods for the detection and identification of these fungi. as a cultivationindependent method, gas chromatography/mass spectroscopy on exhaled breath has revealed the presence of fungus specific biomarkers in patients with cf with and without fungal colonization by a. fumigatus (syhre et al., 2008) . this approach was limited to analyzing for known a. fumigatus markers. the application of sequencing-based approaches for studying the lung microbiome will be essential for revealing the role of fungi in the lung microbiome and the role of the lung microbiome on asthma. cf is the most common inherited lung disease in the world. it is a severe autosomal recessive disease with an incidence of 1:2000 at birth in populations of northwestern european origin, with a mutant gene carrier frequency of 1:23 in these populations. the genetic defect occurs in the cystic fibrosis transmembrane regulator (cftr) protein, which acts to transport chloride across cell membranes. patients with cf are the archetype population with chronic bronchial colonization. symptoms include permanent bacterial colonization of the lower airways, with a formation of a biofilm, fat maldigestion, male infertility, and elevated levels of chloride in the sweat (knowles and durie, 2002) . the thick pulmonary system mucus in cf patients minimizes the effectiveness of the mucociliary elevator in clearing the lung of mucus-trapped microorganisms and other debris. as a consequence, microbes chronically colonize these patients' lungs and they suffer bouts of infection, requiring frequent hospital admission. cultures reveal a wide range of bacteria, including p. aeruginosa, mycobacteria, a. fumigatus, and sometimes viruses. the precise contributions of different microbes to patient morbidity, and the importance of inter-specific interactions remain largely unclear [reviewed in (harrison, 2007) ]. the complexity of this ecosystem is difficult to overstate. as an example of this complexity, the lungs of cf patients contain large numbers of neutrophils that migrate to this location in response to microbial colonization. these neutrophils secrete granule antimicrobial proteins called defensins that kill microbes. by analysis of cf sputum samples, the levels of extracellular defensins are sufficiently abundant that they may damage the airway epithelium (soong et al., 1997) . as another example of this inter-specific complexity, p. aeruginosa in cf lungs produces copious amounts of a tricyclic compound pyocyanin that kills competing microbes and eukaryotic cells. this compound was shown to specifically inactivate a human lung epithelial cell line vacuolar atpase (ran et al., 2003) . a study of the microbiome of the lungs was conducted to explore the hypothesis that organisms not routinely identified by culture occur in the lungs of cf patient airways and may contribute to disease. to test this hypothesis, 16s rrna sequence analysis was performed on bal samples from 42 subjects, 28 cf patients, and 14 other disease controls (harris et al., 2007) . the findings of this analysis were that, for cf subjects, a single rrna type was dominantly represented in the clone libraries prepared from lung microbiome genomic dna. this was not found in the controls. thirteen of the cf subjects' samples contained bacteria not routinely assessed by culture. candidate pathogens were identified in four cf subjects. candidate pathogens were also identified in the controls. this study documented the power of culture-independent molecular techniques to provide a broader view of the airway bacteria than standard clinical culture methods. the cf viral metagenome was explored in a recent study using five cf individuals and five individuals without disease (willner et al., 2009) . in both cohorts, the overall viral diversity was low. the cf bacteriophage communities were highly similar to each other, whereas the non-cf individual had more distinct phage communities. cf eukaryotic viral communities were dominated by a few viruses, including human herpes viruses and retroviruses. the significance of fastidious or noncultivatable organisms in the airway of cf patients is beginning to be explored. application of specific culture conditions to favor the growth of anaerobes coupled with molecular identification techniques have focused attention in cf on bacteria not routinely detected by standard culture and biochemical identification techniques (harris et al., 2007; tunney et al., 2008; worlitzsch et al., 2009) . direct, culture-independent detection techniques have identified much larger numbers of bacterial species in cf airways and have demonstrated the ability to identify likely pathogenic bacteria occurring during exacerbations when routine cultures are negative (harris et al., 2007) . these molecular identification and detection methods have identified bacteria with different antibiotic susceptibilities relative to conventional pathogens and will undoubtedly lead to novel antimicrobial intervention trials in cf (worlitzsch et al., 2009) . similar methodology to detect anaerobes or noncultivatable bacteria has not been applied systematically to patients with idiopathic bronchiectasis. bronchiectasis is characterized by chronic dilation and inflammation of the conducting airways associated with recurring infections (barker, 2002) . it is the pathologic manifestation of several genetic disorders, including cf and primary ciliary dyskinesia (pcd). however, many patients have no identifiable causes. idiopathic bronchiectasis is estimated to affect approximately 110,000 us adults (weycker et al., 2005) . symptoms include cough and chronic sputum production, recurring airway infection, dyspnea, wheezing, and chest pain (barker, 2002) . microbial infections are central to the pathogenesis and progression of disease. much of the research characterizing the composition and significance of the lower airway microbial flora has been done in cf and relatively little is known about the microbial contribution to disease pathogenesis in idiopathic bronchiectasis. however, recent observations suggest a link between the lower airway microbial flora and host disease characteristics. for example, the prevalence of idiopathic bronchiectasis associated with nontuberculous mycobacteria (ntm) appears to be increasing (billinger et al., 2009; marras et al., 2007) . both familial clustering and a characteristic "tall asthenic" phenotype (scoliosis, pectus excavatum, mitral valve abnormalities) in postmenopausal women with bronchiectasis associated with ntm infection (colombo et al., 2009; kim et al., 2008) have been reported. it is unknown whether the age, female sex, and unique body morphotype associations are seen in idiopathic bronchiectasis unassociated with ntm. correlating disease phenotype with microbial flora is dependent upon accurately categorizing the microbial status of the patients. for environmental organisms like ntm, it is important that this categorization include both accurate speciation and determination that the organism likely represents true infection rather than contamination or transient colonization. the american thoracic society and the infectious diseases society of america (ats/idsa) microbiologic diagnostic criteria for pulmonary disease based on sputum specimens call for at least two positive sputum specimens for the same species (kim et al., 2008) . concomitant recovery of filamentous fungi from airway specimens is also common in bronchiectasis, but the pathophysiologic consequences are not known. a recent study in cf patients found that a. fumigatus, like ntm, was commonly present in older patients: 75% of patients aged 16-20 years and in 60% of patients over age 20 (valenza et al., 2008) . amin and colleagues further noted that cf patients who were chronically infected with a. fumigatus (defined as two positive cultures in a given year) had significantly worse airway obstruction as evidenced by a lower forced expiratory volume in one second (fev 1 ) and significantly higher risk of pulmonary exacerbations during subsequent follow-up than patients without a. fumigatus (amin et al., 2009) . this potential negative impact on the course of bronchiectasis and a possible benefit from antifungal treatment for chronic infection in cf have prompted initiation of a multicenter clinical trial of itraconazole in cf patients in canada (amin et al., 2009; shoseyov et al., 2006) . in non-cf bronchiectasis, a recent study suggested that aspergillus is more common in patients infected with ntm than in those without ntm, and that it is commonly associated with fungal lung disease manifestations in ntm-infected patients (kunst et al., 2006) . however, outside the relatively small numbers of idiopathic bronchiectasis patients with allergic bronchopulmonary aspergillosis (abpa) or chronic necrotizing aspergillosis, the pathologic significance of these fungi has not been systematically explored in large numbers of patients and very few data are available for aspergillus species other than fumigatus or filamentous fungi other than aspergillus (kobashi et al., 2006; kunst et al., 2006; raju et al., 2008) . abpa is well described in association with bronchiectasis occurring in asthmatics and patients with cf (malde and greenberger, 2004) . the diagnostic criteria rely on an elevated total ige as well as elevated a. fumigatus-specific ige and igg in the setting of episodic bronchial obstruction, pulmonary infiltrates, and central bronchiectasis. kunst and colleagues assessed the prevalence of positive serologic markers for a. fumigatus [ige by radioallergosorbent test (rast) and precipitins] among idiopathic bronchiectasis patients and found these markers to be commonly present especially in the setting of concomitant ntm disease (kunst et al., 2006) . patients with these serologic markers more commonly had radiographic manifestations suggesting aspergillus-associated disease. while other filamentous fungi such as scedosporium species have been commonly recovered from the airways of both cf and non-cf bronchiectasis patients, the role these fungi play in disease pathogenesis remains controversial (cooley et al., 2007) . while specific ige antibody rast and precipitin assays can be prepared using allergen prepared from the isolated species and correlated with the clinical presentation of allergic bronchopulmonary mycoses, these assays have not been commonly used to characterize the clinical significance of these fungal species recovered from the lower airway (fedorova et al., 2008; lake et al., 1991) . copd is the fourth leading cause of death in the us (petty, 2000) and is expected to rank third in the world by 2020 (lopez and murray, 1998) . despite efforts aimed at smoking cessation, little impact has been made on copd incidence, and current treatments are ineffective in slowing progression of the disease. copd has been defined by the global initiative for chronic obstructive lung disease (gold) as "a disease state characterized by airflow limitation that is not fully reversible". the diagnosis of copd can also encompass those with chronic obstructive bronchiolitis and emphysema. tissue inflammation in copd is characterized by a predominant neutrophil, cd8+ lymphocyte, and macrophage infiltration (keatings et al., 1996; lacoste et al., 1993; o'shaughnessy et al., 1997; saetta et al., 1998) . it has been proposed that the mechanism of tissue damage involves the recruitment and activation of neutrophils, macrophages, and cd8+ t cells with concomitant upregulation of several cellular proteases and inflammatory cytokines. although smoking is clearly the leading risk factor for copd, not all smokers develop disease (buist and connett, 1993) . while smoking can stimulate inflammation in the lungs, smokers with copd have an increased inflammatory response than smokers without copd, and inflammation can persist despite smoking cessation (keatings et al., 1996; lacoste et al., 1993; o'shaughnessy et al., 1997; saetta et al., 1998) . these observations suggest that some other factor or factors contribute to development and perpetuation of the inflammatory response in copd. infection might be one such factor critical in triggering and perpetuating the inflammatory response in copd. the mechanism by which infections might act to promote copd progression has been termed the "vicious circle" hypothesis (sethi, 2000a; sethi and murphy, 2008) . in this scenario, smoking causes structural remodeling that renders smokers more likely to become colonized and/or less able to clear subclinical infection. defects in mucociliary clearance and surfactant abnormalities caused by smoking also contribute to the tendency to develop chronic infection (finley and ladman, 1972; honda et al., 1996; raju et al., 2008; vastag et al., 1985; verra et al., 1995) . once colonization is established, the organism or organisms recruit white blood cells to the lungs, stimulating release of inflammatory cytokines and chemokines as well as proteases. inability to clear the inciting organism perpetuates the cycle, ultimately resulting in tissue destruction, airway thickening, and clinical copd. the most commonly implicated bacteria are h. influenzae, m. catarrhalis, s. pneumoniae, and p. aeruginosa (sethi, 2004) . viruses that seem to be important in copd include adenovirus, influenzae viruses, rhinovirus, respiratory syncytial virus, and human metapneumovirus (mallia et al., 2006; martinello et al., 2006; retamales et al., 2001; seemungal et al., 2001) . these pathogens can be found in patients with copd in the stable state and during exacerbations (sethi, 2004) . the colonization seen in patients with copd is likely playing a role in disease and is not just an innocent bystander. for example, as bacterial load increases, fev 1 falls, and colonization has been associated with greater sputum purulence, increased sputum neutrophils, and increased levels of interleukin (il)-8, tumor necrosis factor (tnf)î±, and neutrophil elastase (obrian et al., 2007; patel et al., 2002; sethi, 2000b; stockley et al., 2000) . exacerbations associated with viruses are more severe and last longer than those without a viral trigger (papi et al., 2006; seemungal et al., 2001) . in addition, exacerbations associated with both bacteria and viruses may be more severe than those associated with single organisms (obrian et al., 2007) , suggesting the usefulness of metagenomic techniques in this disease. colonization with the fungus pneumocystis jirovecii (pc, formerly pneumocystis carinii f. sp. hominis) has recently been implicated in copd pathogenesis. this organism generally causes acute pneumocystis pneumonia (pcp) in patients with immunosuppression such as those infected with hiv, but colonization with the organism occurs in both hiv + and hiv â�� individuals and may be important in copd. colonization with pc is increased in hiv patients with copd and correlates with disease severity (morris et al., 2004b; probst et al., 2000) . animal models also support the role of pc colonization in copd. christensen and colleagues recently reported that in immunocompetent mice, exposure to cigarette smoke and pc colonization resulted in pulmonary function deficits and airspace enlargement characteristic of emphysema (christensen et al., 2008) . in a model of pc colonization in simian/human-immunodeficiency virus (shiv)-infected nonhuman primates (norris et al., 2006) , pc-colonized animals developed airway obstruction and radiographic emphysema while animals infected with shiv alone did not develop these changes (shipley et al., 2010) . although pulmonary infections and neoplasms associated with hiv have decreased since the availability of highly active antiretroviral therapy (haart) (palella et al., 1998) , some pulmonary conditions may actually be increasing in persons with hiv. diseases such as copd, asthma, and bronchiectasis were reported to be increased in those with hiv before the introduction of antiretroviral therapy, and a similar decrease in these conditions as seen in the opportunistic infections has not occurred after antiretroviral treatment of hiv. in fact, in a recent study of hiv + patients, almost 4% of deaths were due to obstructive airway disease in 1998, a threefold increase from the pre-haart era (louie et al., 2002) . before the haart era, hiv + subjects were noted to have an accelerated form of emphysema with significant emphysematous disease seen in subjects less than 40 years old (diaz et al., 1992 (diaz et al., , 2000 . both emphysema and airflow obstruction have been reported in hiv infection. unlike many of the acquired immunodeficiency syndrome (aids)defining opportunistic infections, hiv-associated copd may actually be more common in the current era of hiv as it is frequently reported in those without a history of aids-related pulmonary complications and the now aging hiv + population has a longer exposure to smoking and hiv. given the immunological defects seen with hiv, it is quite possible that hiv + subjects, especially those who smoke, are more prone to develop subclinical pulmonary infections, even if successfully treated with haart. the changes that occur in the lung microbiome have not been studied in hiv, but microbial colonization is a likely factor in the accelerated copd seen in this population. the vicious circle hypothesis of copd could be further worsened in hiv + patients by upregulation of hiv levels in the lung stimulated by pulmonary colonization. several studies have shown that pulmonary infections increase lung levels of hiv. koziel and colleagues reported that hiv rna was detected in 62% of patients with active lung disease compared to 16% of asymptomatic subjects, independent of clinical stage of hiv and serum hiv rna levels (koziel et al., 1999) . the lung appears to be an independent compartment for hiv replication as drug mutations found in bal differ from those in blood (white et al., 2004) . hiv in the lungs is associated with a lymphocytic alveolitis, particularly in those subjects with cd4 cell counts between 200 and 500 cells/î¼l, suggesting that the virus might act independently to stimulate pulmonary inflammation (twigg et al., 1999) . the relationship of hiv pulmonary viral levels, infections, inflammation, and copd has not been examined. pneumocystis colonization is likely important in the pathogenesis of copd in those with hiv as well as in the hivpopulation. in hiv + subjects, the prevalence of colonization is high, particularly if subjects smoke, and colonization is seen even in patients with high cd4 cell counts receiving haart (morris et al., 2004a) . anatomic emphysema is also more common in hiv + patients with pc colonization (morris, unpublished data) . it has recently been shown that pneumocystis colonization in hiv + subjects is associated with worse airway obstruction and an increased likelihood of clinical diagnosis of copd, independent of smoking history and cd4 cell count ). in addition, the shiv-infected nonhuman primates described above serve as a model for the development of copd in the setting of pc colonization and hiv-like immunodeficiency (norris et al., 2006; shipley et al., in press ). microorganisms including bacteria, fungi, and viruses play a central role in development, exacerbation, and progress of lung diseases. even though normal lungs do not have a permanent resident microbiome, diseased lungs are acutely infected and/or chronically colonized. standard laboratory practices have not properly reflected the entirety of the microbiomes, either in health or in disease, and thus newer sequence-based technologies have begun to reveal the true complexity of the lung microbiomes. much more research still needs to be conducted in order to fully understand the microbial burden of the lungs, and how this burden relates to health and disease. it is apparent that conditions that compromise the physical and immune system barriers to lung colonization by microbes result in chronic colonization and recurrent infections. these conditions include chronic inflammation as seen in hiv, asthma, and bronchiecstasis, or physical obstruction 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cultivation-independent methods key: cord-312952-9gbb4own authors: wardzyńska, aleksandra; pawełczyk, małgorzata; głobińska, anna; makowska, joanna s.; kowalski, marek l. title: the profile of respiratory pathogens in induced sputum of elderly and non-elderly asthmatics date: 2020-01-20 journal: cent eur j immunol doi: 10.5114/ceji.2019.92790 sha: doc_id: 312952 cord_uid: 9gbb4own introduction: respiratory pathogens are thought to be involved in the pathogenesis and exacerbations of asthma at all ages; however, little is known about the airway microbiome in the elderly. aim of the study: to identify respiratory pathogens in the induced sputum (is) of elderly asthmatics, and to determine the association between pathogens and the markers of asthma activity. material and methods: twenty-nine subjects with stable asthma, 15 above 65 years of age and 14 aged 30-49 years, underwent clinical evaluation, fractional exhaled nitric oxide measurement, and sputum induction. pathogens were detected by multiplex reverse transcription polymerase chain reaction. the periostin concentration of is supernatants was measured by enzyme-linked immunosorbent assay. serum eosinophil cationic protein and total ige levels were measured by immunocap. results: elderly patients, as compared to non-elderly, had significantly higher eosinophilia in is, although other markers of eosinophilic inflammation were comparable. half of the subjects were positive for haemophilus influenzae. chlamydophila pneumoniae was found in two subjects. respiratory viruses were detected in more than 70% of patients. the detection rates and profiles of atypical bacteria and respiratory viruses were similar in both groups. only in the elderly asthmatics was influenza a positivity associated with lower predicted fvc%, rsv a positivity connected with decreased tige concentration, and rsv b positivity related to a lower percentage of lymphocytes in is. conclusions: despite the existence of differences in some clinical and inflammatory characteristics of asthma between elderly and non-elderly asthmatics, the pathogen detection rates in the is from the two groups are similar. ageing is often characterised by a progressive decline in immune response, resulting in increased susceptibility to infections and poor response to vaccination [1] . clinical observations suggest that lower respiratory tract infections may contribute to the pathogenesis of asthma and are important triggers for asthma exacerbations [2] . asthma in the elderly seems to be a distinct phenotype with higher severity and exacerbation rates [3] , which may be associated with the deterioration of immune function observed in the airways in the aged population [4] . the airway microbiome might have a profound role on the development, persistence, and clinical course of chronic inflammatory diseases like asthma and chronic obstructive pulmonary disease [5] . the presence of respiratory viruses during childhood has been identified as a significant risk factor for asthma in adolescences and adults [6] , while similar observations have been made for atypical bacteria [7] . viruses, such as rhinovirus, respiratory syncytial virus, or parainfluenza viruses, are the most common causative factors for asthma exacerbation [8] . in clinically stable periods of asthma, both viruses and bacteria are detected in the airways [9, 10] , but the significance of the persistent presence of those pathogens in the airways remains unclear. while the majority of studies indicate that the detection rate of respiratory viruses in patients with asthma and healthy subjects is similar [10] , they have been found to differ with regard to the bacterial composition of the airways [11] . information on the respiratory pathogens of the lower airways and their relationship with the nature of asthma in elderly asthmatics is limited, mostly because of the risk and inconvenience associated with direct and invasive methods of airway lumen sampling. induced sputum (is) allows for non-invasive assessment of lower airway inflammation and can be employed to detect respiratory pathogens in the lower respiratory tract. this technique was chosen for the present study, to test the hypothesis that elderly patients with asthma display a different profile of respiratory pathogens in the airways as compared to non-elderly asthmatics, and that this profile may be related to local airway and/or systemic inflammation. twenty-nine clinically stable, non-smoking patients with moderate or severe persistent asthma, 15 elderly (above 65 years of age) and 14 non-elderly (aged 30-49 years), were included to the study. none of the individuals demonstrated any symptoms of infection or had used antibiotics or oral corticosteroids for six weeks prior to the procedure. the level of asthma control was established according to global initiative for asthma (gina) 2011 guidelines [12] and assessed by the asthma control test (act) [13] . severe asthma was defined according to the american thoracic society (ats) workshop 2000 criteria [14] . spirometry was performed according to european respiratory society (ers) standards [15] , using a pneu-mo rs spirometer (abcmed artmed, kraków, poland). the panel of skin prick tests (allergopharma, reinbek, germany) included the following allergens: dermatophagoides pteronyssinus, dermatophagoides farinae, cat, dog, rabbit, hamster, guinea pig, rat, swine, birch, grass mix, mugwort, plantain, alternaria tenuis, and cladosporium herbarum. a positive result was defined as a wheal of 3 mm or more in diameter. atopy was diagnosed as the presence of at least one positive skin test. feno was measured by using the online single breath method with niox (aerocrine, solna, sweden), according to ats guidelines [16] . the measurement was performed before the sputum induction. sputum induction was performed according to pin et al. with some modifications [17, 18] . briefly, patients received 200 µg of salbutamol from a metered dose inhaler followed by inhalation of increasing doses of hypertonic saline solution (3%, 4%, 5%) using an ultrasonic nebuliser ultraneb (devilbiss health care inc., somerset, usa). patients were asked to expectorate sputum after gargling mouthwash. spirometry was performed before the procedure, 15 minutes af-ter salbutamol inhalation, and every seven minutes after the start of the saline nebulisation. when their fev1 decreased by 20% or more, the sputum induction was stopped. the sputum sample was kept on ice and processed within two hours. dithiothreitol (dtt) (sigma aldrich, st louis, usa) was added to the selected plaques of sputum and mixed for 15 min on ice. the sample was filtered using a 52-µcm nylon gauze (surtex, lodz, poland). the total cell count was measured using a haemocytometer and centrifuged. the cell pellets were resuspended with phosphate-buffered saline (pbs), and 75 µl of this cell suspension was used to perform the cytospin slides stained with rapihem solution, a variant of may-grünwald-giemsa staining (aqua-med, lodz, poland). only smears with less than 50% of non-squamous cells were considered to be adequate for the differential cell counting. on each slide, 300 cells were counted, and the macrophage, lymphocyte, neutrophil, and eosinophil values were expressed as percentages of the total number of inflammatory cells. the supernatants were stored frozen at -80° for further analysis. viral dna or rna was extracted from sputum using a qiaamp ® minelute ® virus spin kit (qiagen), according to the manufacturer's instructions. to synthesise cdna, reverse transcription was performed using a revertaid h minus first-strand cdna synthesis kit (thermo fisher scientific inc., waltham, usa). each cdna was subjected to multiplex pcr using a seeplex rv15 ace detection kit (seegene), according to the manufacturer's instructions. the multiplex pcr detected rhinoviruses (hrv) and enteroviruses (hev), parainfluenza viruses 1 (piv1), 2 (piv2), 3 (piv3), and 4 (piv4), influenza viruses a (flua) and b (flub), respiratory syncytial viruses a (rsva) and b (rsvb), coronaviruses (229e/nl63 and oc43), adenovirus (adv), human metapneumovirus (mpv), and human bocaviruses 1/2/3/4 (hbov). the multiplex pcr products were visualised by electrophoresis on 2% agarose gel. the serum concentrations of total ige (ku/l) were determined by immunocap total ige (phadia ab, uppsala, sweden), and the concentrations of ecp (µg/l) were determined using immunocap ecp (phadia ab, upsala, sweden), according to the manufacturer's instructions. periostin was measured in the is supernatants using an enzyme-linked immunoassay (uscn life science inc., wuhan, hubei, china), according to the manufacturer's instructions. comparisons between the groups were performed with the non-parametric mann-whitney u test. spearman rank correlation was used to evaluate the correlation between variables. results are expressed as median and 25 th to 75 th percentiles. the statistical analysis was performed using statistica (statsoft, usa); p values < 0.05 were accepted as statistically significant. the study was approved by the local bioethics committee, and all study subjects provided their informed consent. on average, the elderly patients with asthma had significantly lower respiratory function, as well as less current asthma control according to gina criteria and a lower act score, although both groups demonstrated similar disease severity based on the ats workshop 2000 criteria ( table 1 ). the distribution of inflammatory cells in the induced sputum varied depending on the age: older patients had a higher mean percentage of eosinophils (p < 0.05) and lymphocytes (p < 0.05), and a lower percentage of macrophages (p < 0.05) in is (table 2 ). however, the elderly and non-elderly asthmatics had similar mean feno levels and concentrations of such eosinophilic inflammation markers as periostin in is, ecp, and total ige in serum (table 1 ). there the molecular technique revealed the presence of s. pneumoniae in the is from all asthmatic patients, both elderly and non-elderly, and h. influenzae in half the patients from each group (table 3) . chlamydophila pneumoniae was detected in one subject from the elderly group and one from the non-elderly group. all sputa were negative for m. pneumoniae, legionella, and b. pertussis. respiratory viruses were detected in the induced sputum from the majority of patients in both groups: in 11 (73.3%) elderly and 10 (71.4%) non-elderly individuals. the most commonly detected virus was flu a followed by rsv a and rsv b (table 3) . no differences were observed in the detection rates of viruses between elderly and non-elderly patients. neither asthma severity according to gina or ats criteria nor current asthma control assessed by the act were found to correlate with the presence of respiratory pathogens in the is of asthmatics patients. in elderly asthmatics, but not in the non-elderly group, a few associations between the presence of specific respiratory viruses in the is and respiratory function/immunological parameters were found. flu a-positive patients had lower fvc% predicted than negative ones (81.8% pred. ±19.9 vs. 100.4 % pred. ±12,9; p < 0.05). the presence of rsv b was associated with a lower percentage of lymphocytes in the is (28.7% ±12.6 vs. 5.5 % ±9.5; p < 0.05), and the rsv a-positive patients had lower tige concentration in the serum than rsv a-negative elderly individuals (19.2 ku/l ±17.7 vs. 85.2 ku/l ±64.1; p < 0.05). this study is the first to use the is technique to compare detection rates of respiratory pathogens in the airways of elderly and non-elderly patients with asthma. the total number of positive samples and the profile of respiratory pathogens detected in the induced sputum by molecular techniques were found to be similar in elderly and non-elderly individuals. bronchial asthma, although heterogeneous, has been considered to be, on average, more severe in the elderly population and associated with increased exacerbation rates mostly related to respiratory infections [19] . our elderly patients tended to have, on average, more severe disease, as expressed by lower respiratory function, and less current asthma control over the previous four weeks, demonstrated by gina criteria and a lower mean act score. in addition, the elderly patients had higher sputum eosinophilia and lymphocytosis levels than the non-elderly patients, suggesting the presence of different types of airway inflammation in senior individuals. although a previous study documents a tendency toward neutrophilic inflammation in the is from elderly asthmatics, no correlation between neutrophilia and severity of the disease was found [20] . another study found older asthmatics with fixed obstruction to have a higher percentage of eosinophils and elevated levels of ecp in the induced sputum compared to their peers with chronic obstructive pulmonary disease (copd), despite an increased percentage of neutrophils in the sputum [21] . thus, the increased percentage of eosinophils in the is of elderly patients in our study may reflect the proposed inflammatory profile in the airway mucosa of this population of asthmatics. on the other hand, mean levels of surrogate markers of the airway eosinophilic inflammation (feno, ecp, and sputum periostin) were similar in both groups, not confirming differences in the type of inflammation between groups. ageing has been associated with several immune abnormalities in both the innate and adaptive immune systems, and consequently with deceased immune response to infections [1] . in this context, the observation of similar detection rate and profile of respiratory pathogens in the induced sputum is rather unexpected. however, our patients had stable asthma during the sputum sampling, and one cannot exclude that the difference in the microbiome between elderly and non-elderly asthmatics might be seen during the disease exacerbations although respiratory pathogens have been detected with increased frequency during asthma exacerbations, they may persist in the airways of asthmatics between exacerbation episodes, and it has been postulated that latent or persistent infection may contribute to the chronicity of the airway inflammation [22] . however, a cross-sectional study by harju et al. [9] reports similar detection rates of respiratory viruses in the is of patients with clinically stable asthma and healthy controls. similarly, in a prospective study by tucharelli et al. [23] the detection rates of 14 respiratory viruses were comparable in clinically stable asthmatics and in healthy controls at three time points. accordingly, in non-bronchoscopic bronchoalveolar lavage (bal), the percentage of viral detection did not vary between asthmatic children and controls [24] . in contrast, the presence of hrv in the lung tissue samples from stable patients was found to be higher in asthmatics than in healthy controls [25] . thus, the presence or absence of respiratory pathogens in bal or induced sputum may not reflect the persistence of infection of the airway mucosa. although the detection rate and profile of respiratory viruses in is was similar in elderly and non-elderly patients with asthma, the presence of pathogens was associated with some clinical characteristics only in older subjects. the presence of influenza a virus in the airways of stable asthma patients (without any clinical signs of infection) was associated with lower respiratory function and rsv b with a lower percentage of lymphocytes in the is. in a study by woś et al. [25] the presence of hrv was associated with lower spirometric parameters as compared to hrv-negative subjects. furthermore, in our study the presence of rsv b was associated with a lower percentage of lymphocytes in the is and the rsv a with lower total ige concentration in the serum in elderly individuals; however, the significance of this findings remains unclear. our study has several limitations. the groups were relatively small, which may have affected the variability of results. the samples were collected during late autumn and winter, which may be connected with more frequent exposure to respiratory infections. qualitative rt-pcr did not allow active replication indicating active infection to be distinguished from residuals of viral or bacterial dna or rna from past infections. the discrepancies between the positivity rates of the respiratory bacteria and viruses shown in the above-mentioned studies may be related to different methods of obtaining samples and detecting pathogens. supernatants from induced sputum were used as source material, and multiplex rt pcr assays were used for analysis. harju et al. [9] report higher detection rates of viruses in induced sputum and throat swab samples compared to gelatine-filtered expired air, ebc, or nasal swabs. however, viral identification was not consistent between these methods or during the follow-up period. in a study by falsey et al. [26] the identification of bordetella pertussis in is differed between supernatants and cells from patients with exacerbation of asthma. hence, our results should be further confirmed in studies involving larger patient populations and, if possible, more direct airway sampling techniques. in summary, our findings indicate that, despite some differences in the clinical and inflammatory characteristics of asthma between elderly and non-elderly patients, the microbial composition of is samples from stable patients is similar. inflammation & autoimmunity in human ageing: dendritic cells take a center stage respiratory infections precede adult-onset asthma asthma in the geriatric population the role of immunity and inflammation in lung senescence and susceptibility to infection in the elderly the role of the bacterial microbiome in lung disease rhinovirus illnesses during infancy predict subsequent childhood wheezing occurrence of chlamydia trachomatis and chlamydia pneumoniae in paediatric respiratory infections is asthma an infectious disease? new evidence pathogenic bacteria and viruses in induced sputum or pharyngeal secretions of adults with stable asthma asthma-associated differences in microbial composition of induced sputum disordered microbial communities in asthmatic airways global strategy for asthma management and prevention 2011 (update) development of the asthma control test: a survey for assessing asthma control proceedings of the ats workshop on refractory asthma: current understanding, recommendations, and unanswered questions standardisation of spirometry ats workshop proceedings: exhaled nitric oxide and nitric oxide oxidative metabolism in exhaled breath condensate: executive summary use of induced sputum cell counts to investigate airway inflammation in asthma wskazówki metodologiczne polskiego towarzystwa chorób płuc odnośnie do wykonywania i oceny plwociny indukowanej microbes and asthma: the missing cellular and molecular links expiratory flows and airway inflammation in elderly asthmatic patients similarity and differences in elderly patients with fixed airflow obstruction by asthma and by chronic obstructive pulmonary disease role of latent viral infections in chronic obstructive pulmonary disease and asthma repeated virus identification in the airways of patients with mild and severe asthma during prospective follow-up respiratory viral infection in lower airways of asymptomatic children the presence of rhinovirus in lower airways of patients with bronchial asthma yield of sputum for viral detection by reverse transcriptase pcr in adults hospitalized with respiratory illness the authors would like to thank mrs dorota żaromińska, mrs barbara szkudińska, and mrs marzanna jarzębska for their assistance. this study was supportthe profile of respiratory pathogens in induced sputum of elderly and non-elderly asthmatics key: cord-269554-fzu6dy4e authors: hussein, m. h.; toraih, e. a.; attia, a. s.; youssef, m.; omar, m.; burley, n.; zhang, a. d.; roos, j.; houghton, a.; aniemeka, n.; shama, m. a.; duchesne, j.; kandil, e. title: asthma in covid-19: an extra chain fitting around the neck? date: 2020-07-15 journal: nan doi: 10.1101/2020.07.13.20153130 sha: doc_id: 269554 cord_uid: fzu6dy4e introduction the novel coronavirus disease 2019 (covid-19) has rapidly spread across the globe, overwhelming healthcare systems and depleting resources. the infection has a wide spectrum of presentations, and pre-existing comorbidities have been found to have a dramatic effect on the disease course and prognosis. we sought to analyze the effect of asthma on the disease progression and outcomes of covid-19 patients. methods we conducted a multi-center retrospective study of positively confirmed covid-19 patients from multiple hospitals in louisiana. demographics, medical history, comorbidities, clinical presentation, daily laboratory values, complications, and outcomes data were collected and analyzed. the primary outcome of interest was in-hospital mortality. secondary outcomes were intensive care unit (icu) admission, risk of intubation, duration of mechanical ventilation, and length of hospital stay. results a total of 502 covid-19 patients (72 asthma and 430 non-asthma cohorts) were included in the study. the frequency of asthma in hospitalized cohorts was 14.3%, higher than the national prevalence of asthma (7.7%). univariate analysis revealed that asthma patients were more likely to be obese (75% vs 54.2%, p=0.001), with higher frequency of intubation (40.3% vs 27.8%, p = 0.036), and required longer duration of hospitalization (15.1{+/-}12.5 vs 11.5{+/-}10.6, p=0.015). after adjustment, multivariable analysis showed that asthmatic patients were not associated with higher risk of icu admission (or=1.81, 95%ci=0.98-3.09, p=0.06), endotracheal intubation (or=1.77, 95%ci=0.99-3.04, p=0.06) or complications (or=1.37, 95%ci=0.82-2.31, p=0.23). asthmatic patients were not associated with higher odds of prolonged hospital length of stay (or=1.48, 95%ci=0.82-2.66, p=0.20) or with the duration of icu stay (or=0.76, 95%ci=0.28-2.02, p=0.58). kaplan-meier curve showed no significant difference in overall survival of the two groups (p=0.65). conclusion despite the increased prevalence of hospitalization in asthmatic covid-19 patients compared to the general population, after adjustment for other variables, it was neither associated with increased severity nor worse outcomes. since its initial description in late 2019, the novel coronavirus (covid19) has become a global pandemic, overwhelming our healthcare systems and depleting resource stockpiles [1] . in some pandemic hotspots, physicians have had to make difficult decisions regarding lifesaving interventions due to a lack of supplies such as ventilators [2] . further complicating management of this disease, covid-19 has a broad clinical presentation. patients can be asymptomatic carriers or have mild non-respiratory and respiratory symptoms. on the other hand, the virus can also present with severe pneumonia or lethal respiratory failure. because of these severe outcomes, gaining an understanding of covid-19's disease course is essential to guiding treatment approaches and optimizing individual patient outcomes. preexisting comorbidities can have a dramatic impact on the course of a covid-19 infection. it is therefore crucial to identify which comorbidities most contribute to severe infections, which may influence individual patient care plans [3] . in efforts to better understand these relationships, the centers for disease control and prevention (cdc) is actively incorporating new and emerging data to update their treatment recommendations for patients with varying comorbid conditions. currently, the cdc reports that asthma is present in about 17% of hospitalized covid-19 patients, making it the fourth most prevalent comorbidity behind hypertension, obesity, and diabetes [4] . obese and diabetic patients have been categorized as high-risk, but there is still limited data regarding the impact of bronchial asthma on covid-19 outcomes [5] . because asthma is a chronic lung disease, it follows that asthmatics are at a greater risk for negative outcomes with a respiratory virus. however, there is a debate over the expected outcomes in covid-19 infected patients with asthma. some members of coronaviridiae family, that are associated with common cold, have been linked to asthma exacerbations [6] . in contrast, jackson et al. reported an observed protective relationship for asthma and atopic conditions in covid-19 patients [7] . in efforts to explain this phenomenon, it was proposed that patients with asthma and ectopic diseases may exhibit a lower concentration of respiratory tract angiotensin converting enzyme (ace) receptors in patients. as has been widely reported, ace receptors and specifically, ace2, are known to be the host receptor site for sars-cov-2 [7, 8] . considering that more than 19 million adults in the unites states have asthma [9] , it is crucial to better characterize asthma in the setting of covid-19. therefore, we retrospectively evaluated hospitalized patients with laboratory confirmed sars-cov-2, focusing on the differing outcomes between asthmatic and non-asthmatic patients. the aim of this study was help further the understanding of asthma's impact on covid-19 outcomes, hopefully enabling physicians to tailor management and resource allocation in the response to the ongoing pandemic. following institutional review board (irb) approval, data of hospitalized patients with laboratory-confirmed sars-cov-2 infection was gathered and entered into the web-based data collection platform, redcap. patients . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07. 13.20153130 doi: medrxiv preprint included in the study presented to either university medical center new orleans (umcno), tulane medical center (tmc), saint francis medical center monroe (sfmc), or our lady of the lake regional medical center (olol) during the period between march 15 to june 9, 2020. a broad range of data was recorded including but not limited to the following: demographics, medical history, comorbidities, clinical presentation, daily laboratory values, complications, and outcomes. patients were excluded if they were below 18 years of age or if they did not have recorded outcome data. obesity was defined as body mass index (bmi) ≥30 kg/m 2 [10] . for severity assessment, curb-65 score was estimated based on confusion status, respiratory rate≥30, blood pressure (systolic <90 mmhg or diastolic ≤60 mmhg), age ≥65 years, and blood urea nitrogen level >19 mg/dl (>7 mmol/l), and ranged from 0 to 5 [11] . quick sequential organ failure assessment (qsofa) score was calculated using glasgow coma score <15, respiratory rate ≥22, and systolic blood pressure ≤100, and was set to be a positive indicator for the poor outcome if ≥2 [12] . horowitz index (pao2 / fio2 ratio) was calculated as the ratio of arterial oxygen partial pressure (pao2 in mmhg) to fractional inspired oxygen to determine a patient's respiratory efficiency [13] . the neutrophil-lymphocyte ratio (nlr), an indicator for poor outcome, was also estimated [14] . a comparison between the asthmatic and non-asthmatic cohorts was performed. the primary outcome of interest was in-hospital mortality. secondary outcomes were risk of intensive care unit (icu) admission, risk of endotracheal intubation, duration of mechanical ventilation, and length of hospital stay. clinical diagnosis of complications was made using standard definitions such as the risk, injury, failure, loss of kidney function, and end-stage kidney disease (rifle) score for renal injury [15] . berlin criteria were also utilized to identify cases of acute respiratory distress syndrome (ards) [16] data management was performed in sas 9.4 (sas institute inc., sas 9.4 chi-square or fisher's exact tests were used for categorical variables, and student's t and mann-whitney u tests were applied for quantitative variables to examine the difference between asthmatic and non-asthmatics groups. shapiro-wilk test was used to test the normality of the continuous variables. kaplan-meier survival analysis and the log rank test was used to compare the in-hospital mortality in the two groups. binary logistic regression analysis was used to assess the role of asthma comorbidity in the outcomes of covid-19 disease. age, gender, and obesity were adjusted in the model. hosmer-lemeshow test was used to assess goodness-of-fit. results were reported as odds ratio (or) and 95% confidence interval (ci) and two-sided p values below 0.05 were set as significant. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20153130 doi: medrxiv preprint a total of 502 confirmed positive covid-19 patients were identified from multiple hospitals in louisiana, including 72 bronchial asthma patients and 430 non-asthmatic controls. their mean age was 60.6 ± 13.9 years and 60.8 ± 15.7 years respectively (p = 0.89). there was no observed gender difference; females accounted for 54.2% (39 patients) in the asthma group versus 52.0% (222 patients) in the non-asthma group (p = 0.79). the frequency of obesity among asthmatic patients (75%) was significantly higher than those without current asthma (54.2%), p = 0.001. on admission, asthma cohorts presented with greater respiratory rate (24.14 ± 7.03 vs 21.77 ± 7.20 breaths per minute, p = 0.015) and lower bicarbonate level (21.73 ± 5.41 vs 24.67 ± 3.57 meq/l, p = 0.022). no other significant differences were found regarding clinical and laboratory features, table 1 . univariate analysis of covid-19 outcomes revealed that asthma was significantly associated with higher rate of endotracheal intubation (40.3% vs 27.8%, p = 0.036), mechanical ventilation (both invasive and non-invasive) (70.7% vs 52.2%, p = 0.039), and longer hospital length of stay (15.14 ± 12.48 days vs 11.51 ± 10.58 days, p = 0.015). asthma was not associated with a higher rate of intensive care unit (icu) admission (22.2% vs 14.9%, p = 0.12), acute respiratory distress syndrome (37.5% vs 30.9%, p = 0.27), or death (9.7% vs 13.5%, p = 0.45) among covid-19 patients. no other clinical and laboratory findings were different between patients with and without asthma, table 2 . comparison stratified by obesity showed both asthmatic and non-asthmatic patients had overall similar demographic features, presenting manifestations, and comorbidities in each subgroup. however, clinical courses differed significantly between some groups. on comparison to non-asthmatic obese patients, obese asthmatic patients were more likely to develop sepsis (25.9% vs 14.2%, p = 0.042), had higher risk of icu admission (48.1% vs 33.2%, p = 0.042), and required prolonged intubation (2.73 ± 3.63 days vs 1.38 ± 2.07, p = 0.032).impact of asthma comorbidity on covid-19 outcomes using multivariate regression analysis, bronchial asthma was not associated with higher risk of icu admission (or as the covid-19 pandemic evolves, countries are considering policies to protect those at increased risk of severe disease. to the best of our knowledge, this is the first study evaluating the relationship between asthma and covid-. cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . this rate is higher than the national prevalence of asthma reported by the cdc (7.7%), but in line with cdc reports on the prevalence of asthma in covid-19 patients [17] . this increased prevalence of asthma in covid-19 patients may be attributable to increased disease awareness and concern to increased severity of the disease course among asthmatics. our initial univariate analysis of asthmatic patients showed significantly higher rates of endotracheal intubation and mechanical ventilation, as well as increased duration of hospital stay. patients with asthma were also more likely to be obese, a finding consistent with prior studies [18, 19] . as has been well-documented and widely reported, obesity alone has been associated with poor clinical outcomes in hospitalized covid-19 patients [4] . fittingly, in initial univariate analysis of obese asthmatic, there were significantly elevated rates of sepsis, icu admission, and prolonged intubation. however, after multivariate adjustment, asthma comorbidity did not drive poor outcomes when it came to our primary and secondary endpoints of interest -icu admission, intubation, mechanical ventilation, ards, and case fatality rate. although these results may not be expected, there is a plausible mechanism, the downregulation of ace2 receptors, that could hypothetically account for these observations [20] . early data published by jackson et al. suggested that patients with allergic asthma have decreased ace2 expression in nasal and bronchial epithelial cells [7] . the possible explanation for this observation is two-fold. first, it has been postulated that that type ii immune modulation decreases the expression of the receptor for cellular entry of covid-19 -ace2 [22] . second, individuals with chronic respiratory conditions often use inhaled corticosteroids (ics). the severe asthma research program (sarp) demonstrated that ics use in asthmatic patients leads to decreased expression of ace2 and tmprss2 -a host serine protease which primes host cells for entry via the spike protein [23] . additional in vitro studies have demonstrated that treatment with ciclesonide, an ics used for suppression of asthma attacks, demonstrated viral suppression of sars-cov-2 [24] . it must be remembered that these experimental studies occurred in non-covid-19 patients, nonetheless, the results suggest further investigation is necessary to understand the possible protective role of type 2 inflammation in asthma and covid-19. based on these studies, it may be possible that ics treatment is protective via viral suppression or ace2/tmprss2 reduction. these protective effects may explain the lack of significant difference in outcomes among asthmatic and non-asthmatic patients. the potential limitations of this study include self-reporting of asthma history and the inability to identify the severity of asthma. to prevent false reporting, each patient's home medications were reviewed to confirm the diagnosis. asthma severity may be assessed retrospectively based on symptoms or via risk assessment requiring measurement of airflow limitation using spirometry or peak flow meter. however, these aerosol generating procedures (agps) may put healthcare workers at an increased risk of coronavirus exposure. the results of the current study show that while pre-existing asthma is more prevalent in our covid-19 cohort than in the general population, after adjustment for other covariates, it was neither associated with disease severity nor negative outcomes. therefore, although a seemingly poor prognosis, asthma does not imply a worse outcome as . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20153130 doi: medrxiv preprint compared to non-asthmatics. this information can help physicians and researchers identify people with other underlying medical conditions at risk for more severe covid-19 disease. the authors declare the absence of conflict of interest. none of the authors have any funding regarding this publication. we thank numerous doctors, nurses, government, and civilians working together to fight against the sars-cov-2. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20153130 doi: medrxiv preprint 6 (85.7) seven non-asthmatic cases were still hospitalized thus was excluded from the analysis. icu: intensive care unit, los: length of stay, ards: acute respiratory distress syndrome, rf/aki: renal failure/acute kidney injury. chisquare, fisher's exact, or student's t were used. p-value at <0.05 was considered significant. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . odds ratio (or) with 95% confidence interval (ci) was reported. the vertical reference line was set at 1. p-value at <0.05 was considered significant. data were adjusted by age, gender, and obesity. ards: acute respiratory distress syndrome, aki: acute kidney injury, icu: intensive care unit, los: length of stay. (b) kaplan-meier survival curve comparing survival duration of asthma and non-asthma groups. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20153130 doi: medrxiv preprint duty to plan: health care, crisis standards of care, and novel coronavirus sars-cov-2. nam perspectives. discussion paper. national academy of medicine comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 -covid-net, 14 states covid-19): are you at higher risk for severe illness? atlanta, ga: us department of health and human services, cdc regional, age and respiratory-secretion-specific prevalence of respiratory viruses associated with asthma exacerbation: a literature review association of respiratory allergy, asthma, and expression of the sars-cov-2 receptor ace2 sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor tables a-2b, a-2c bmi classification percentile and cut off points. statpearls external validation of the qsofa score in emergency department patients with pneumonia comparison of crb-65 and quick sepsis-related organ failure assessment for predicting the need for intensive respiratory or vasopressor support in patients with covid-19 sequential oxygenation index and organ dysfunction assessment within the first 3 days of mechanical ventilation predict the outcome of adult patients with severe acute respiratory failure the diagnostic and predictive role of nlr, d-nlr and plr in covid-19 patients importance of rifle (risk, injury, failure, loss, and end-stage renal failure) and akin (acute kidney injury network) in hemodialysis initiation and intensive care unit mortality acute respiratory distress syndrome: the berlin definition a review of obesity and asthma across the life spac obesity and asthma inhaled corticosteroids downregulate the sars-cov-2 receptor ace2 in copd through suppression of type i interferon. biorxiv preprint prevalence and characterization of asthma in hospitalized and nonhospitalized patients with covid-19 angiotensin-converting enzyme 2 is a functional receptor for the sars coronavirus covid-19-related genes in sputum cells in asthma. relationship to demographic features and corticosteroids the inhaled corticosterois ciclesonide blocks coronavirus rna replication by targeting viral nsp15 key: cord-018537-t1gi76nc authors: frey, u.; gappa, m.; eber, e.; von mutius, e.; barben, j.; hammer, j.; hamelmann, e.; horak, e.; schuster, a.; hansen, g.; seidenberg, j.; modl, m. title: obstruktive atemwegserkrankungen date: 2013-10-05 journal: p&#x000e4;diatrische pneumologie doi: 10.1007/978-3-642-34827-3_27 sha: doc_id: 18537 cord_uid: t1gi76nc in den folgenden abschnitten werden die verschiedenen formen der obstruktiven atemwegserkrankungen erläutert, die je nach alter, prädisponierenden risikofaktoren und auch je nach art der auslöser verschiedenartige ausprägungen und verlaufsformen (phänotypen) annehmen können. u. frey, m. gappa, e. eber, e. von mutius in den folgenden abschnitten werden die verschiedenen formen der obstruktiven atemwegserkrankungen erläutert, die je nach alter, prädisponierenden risikofaktoren und auch je nach art der auslöser verschiedenartige ausprägungen und verlaufsformen (phänotypen) annehmen können. während im säuglingsalter häufig vor allem virale auslöser zu einmaligen obstruktiven bronchitiden oder bronchiolitiden führen, ist bei rezidivierenden formen in jedem alter, insbesondere beim vorliegen von multiplen auslösern, an ein frühkindliches asthma bronchiale zu denken. aufgrund der komplexen interaktion zwischen genetischen und umweltfaktoren sind intermediäre formen und übergänge von einem phänotyp zum anderen während der entwicklung nicht selten. eine prognose über den langzeitverlauf ist insbesondere beim sehr jungen säugling schwierig. aufgrund der klinischen erfahrung und des ansprechens auf die therapie hat kürzlich eine expertengruppe der european respiratory society (ers) versucht, die verschiedenen formen der obstruktiven atemwegserkrankungen in phänotypen einzuteilen. interessanterweise bestätigen epidemiologische studien die rein auf statistischen clusteranalysen beruhende klinische einteilung zu einem gewissen grad. für diese einteilungen sind vor allem klinische marker und symptome (7 abschn. 27.3, 7 abschn. 27.4), die über längere zeit beobachtet werden sollten, von größter bedeutung. aufgrund dieser epidemiologischen studien unterscheiden sich folgende gruppen. die episodisch auftretenden, meist transienten formen von obstruktiver, pfeifender atmung (a) viral wheeze, obstruktive bronchitis) treten bei 15-20% aller säuglinge und kleinkinder unter 2 jahren auf (. abb. 27.1). oftmals sind sie mit viralen infekten assoziiert. bei befall der kleinsten bronchiolen spricht man dagegen von bronchiolitis. das symptom »wheeze« steht bei diesen formen meist im hintergrund und atemnot, husten und pulmonale überblähung dominieren das klinische bild. bei der zweiten gruppe der hartnäckig wieder kehrenden formen (un-remitting, recurrent) gibt es verschiedene untergruppen bei ca. 2-5% aller kleinkinder treten rezidivierende obstruktive episoden vor allem spät nach dem 4. lebensjahr auf (. abb. 27.1b) late onset wheeze) und ca. 5-7% aller säuglinge zeigen persistierende formen (c) persistent wheeze) vom säuglings-bis ins schulalter. je nach verlauf werden diese formen im deutschen sprachraum als asthma bronchiale bezeichnet (. abb. 27.1). vor allem die persistierenden und spät auftretenden formen sind mit atopie vergesellschaftet. virale auslöser stehen bei allen formen im vordergrund, bei rezidivierenden formen liegen meist zusätzlich andere (z.b. allergische) trigger vor. die risikofaktoren und die langzeitverläufe für diese einzelnen phänotypen werden in den kapiteln obstruktive bronchitis (7 abschn. 27.3) und asthma bronchiale (7 abschn. 27.4) beschrieben. daneben gibt es zwischenformen. bei ca. 2-4% der kleinkinder treten die symptome immer wieder zwischen den ersten 2-4 lebensjahren auf (d) intermediate onset wheeze) und verschwinden dann wieder. oftmals kann bei einer einmaligen konsultation aufgrund der klinik und risikofaktoren keine eindeutige zuordnung zu den einzelnen phänotypen gemacht werden. die phänotypisierung ist jedoch trotzdem von größter bedeutung, da nicht alle phänotypen auf antiinflammatorische vorbeugende und auch akuttherapie gleicher maßen ansprechen. um einen besseren eindruck von einem spezifischen phänotyp zu erhalten, sind ein gutes monitoring der krankheitsverlaufs, eine beobachtung der therapieadhärenz und des ansprechens auf die therapie notwendig. ebenso ist die erfassung von komorbiditäten, differenzialdiagnosen, auslösern, lebensqualität, leistungsfähigkeit und schlafverhalten von größter bedeutung, welche sich auch während der entwicklung ändern können. wir schlagen deshalb bei unklaren rezidivierenden, obstruktiven atemwegserkrankungen beim kleinkind eine dynamische, iterative vorgehens weise vor (s. algorithmus 7 kap. 47), welche diese verlaufsbeurteilung miteinschließt, und den behandelnden arzt immer wieder dazu anhält, den phänotypen zu hinterfragen und die therapiemöglichkeiten anzupassen. wie bei jeder chronischen erkrankung ist ein mehrdimensionales monitoring-konzept entscheidend wichtig, welche die genetische prä disposition und risikofaktoren, die umweltfaktoren und mehrere klinische verlaufsparameter berücksichtigt. je nach phänotyp eignen sich einige klinische verlaufsparameter besser als andere. beispielsweise sind beim allergischen chronischen asthma marker der eosinophilen entzündung (eosinophile, feno) von größerer bedeutung als bei der episodisch auftretenden, virusassoziierten transienten obstruktiven bronchitis. das ansprechen auf die therapie und die konstante anpassung der therapiedosis sind wichtige iterative schritte zur optimalen betreuung der chronischen formen des asthma bronchiale. in vielen ländern europas sowie australien und neuseeland wird der begriff »akute bronchiolitis« für die erste virusinduzierte infektion der unteren atemwege im säuglingsalter verwendet. neben den symptomen wie tachypnoe, einziehungen und lungenüberblähung ist das vorwiegend endinspiratorische knisterrasseln (crackles, feinblasige rasselgeräusche, dem geräusch entsprechend, das beim zusammendrücken von dünnem reispapier entsteht) charakteristisch für eine akute bronchiolitis. ein pfeifen/giemen (wheezing) kann, aber muss nicht vorhanden sein. in nordamerika und einigen wenigen teilen europas hingegen wird der begriff der akuten bronchiolitis bis ins 2.-3. lebensjahr bei kleinkindern verwendet, die eine akute virale infektion der unteren atemwege mit obstruktiver symptomatik (auch wenn vorwiegend pfeifen/giemen vorliegt) erleiden, dies wird in unseren regionen als »virusinduziertes wheezing«, »wheezy bronchitis« oder eben als obstruktive bronchitis klassifiziert. diese unterschiedlichen definitionen der akuten bronchiolitis und der damit verbundene unterschiedliche altersbereich der patienten erschweren bis heute den vergleich von klinischen studien. in diesem kapitel wird für die akute bronchiolitis die in europa und australien gebräuchliche definition verwendet und auf das säuglingsalter (1. lebensjahr) beschränkt. eine akute bronchiolitis tritt in den überwiegenden fällen in den ersten 6 lebensmonaten auf, wobei auch eine zweite episode vorkommen kann. die übergänge zur obstruktiven bronchitis sind mit dem älterwerden offensichtlich fließend (7 abschn. 27 .3), wobei der begriff der obstruktiven bronchitis ab dem 1. lebensjahr verwendet wird, wenn als hauptsymptom vor allem exspiratorisches pfeifen/giemen auskultiert werden kann. für die chronische bronchiolitis bzw. bronchiolitis obliterans des kleinkindes und des jugendlichen verweisen wir auf das 7 kap. 31.11. j ätiologie und epidemiologie die akute bronchiolitis ist die häufigste virusinduzierte infektionskrankheit der unteren atemwege im 1. lebensjahr mit einer häufung zwischen dem 4. und 6. lebensmonat. die überwiegende mehrzahl der akuten bronchiolitiden werden durch das respiratory syncytial virus (rsv) verursacht (50-90%), jedoch können auch andere respiratorische viren (z.b. humanes metapneumovirus (hmpv), rhinovirus, parainfluenzavirus, adenovirus, humanes bocavirus, humanes coronavirus (hcov-nl63) etc.) das gleiche krankheitsbild bewirken. das rs-virus ist ein umhülltes virus mit einzelsträngiger minus-rna aus der familie der paramyxoviridae. zwei subtypen (a und b) und eine vielzahl von serotypen und genotypen wurden als humanpathogen identifiziert. diese zirkulieren auch gleichzeitig während der epidemien und unterscheiden sich nicht in ihrer virulenz. das hmpv wird für 4-12% aller bronchiolitiden verantwortlich gemacht und ist ebenfalls ein rna-virus aus der familie der paramyxoviridae. die infektion verläuft im vergleich zur rsv-infektion eher etwas milder und die betroffenen säuglinge sind im schnitt etwas älter. simultane infektionen mit verschiedenen viren kommen vor und führen zu schwereren verläufen. invitro-untersuchungen zeigten auch, dass die rsv-infektion die bindung von pneumokokken an das respiratorische epithel erleichtert. bakterielle superinfektionen sind mit ausnahme intubierter kinder mit rsv-induzierter ateminsuffizienz aber eine ausgesprochene rarität. die meisten säuglinge mit rsv-infektionen können ambulant behandelt werden. nur bei 2-3% der infizierten säuglinge kommt es zu einer schweren bronchiolitis, die eine hospitalisation erfordert. in den usa sind rsv-infektionen für 20% aller hospitalisationen im kleinkindesalter verantwortlich. der großteil der bronchiolitis-erkrankungen verläuft milde und heilt innerhalb weniger tage -mit oder ohne symptomatische therapie -spontan aus. die ökonomische bedeutung der akuten viralen bronchiolitis ist aber immens. in den usa wurden die kosten der rsv-infektion im jahre 2001 auf weit über 700 mio. us-dollar pro jahr geschätzt. rsv-infektionen treten überwiegend in den kalten wintermonaten auf, wobei sie vereinzelt auch im sommer vorkommen können. für die schweiz wurde eine zweijährliche periodizität kleinerer und größerer rsv-epidemien beschrieben. die übertragung des hoch kontagiösen rs-virus geschieht via tröpfchen-infektion; am häufigsten vermutlich über die hände. das rs-virus ist auf dem respiratorischen epithel für 7-10 tage nachweisbar und überlebt sehr gut in sekreten; auf kleidern und handschuhen über stunden und auf der haut >30 min. die rsv-infektion führt zu einer humoralen und zellvermittelten immunantwort, die zur überwindung der akuten erkrankung führt und auch einen kurzfristigen schutz vor weiteren rsv-infektionen des gleichen subtyps bewirkt. dieser schutz ist allerdings unvollständig und es kann zu weiteren, in der regel milder verlaufenden infektionen selbst mit demselben rsv-subtyp kommen. j pathogenese für die pathogenese der erkrankung werden vorwiegend lokale und systemische immunreaktionen der respiratorischen epithelzellen auf die rsv-infektion verantwortlich gemacht. das rs-virus hat wohl einen direkt zytopathischen effekt, doch reicht die infektion alleine nicht, um eine schwere erkrankung auszulösen. hauptverantwortlich für die pathologie sind entzündliche infiltrate in der lunge, die durch die auf die viruselimination gezielte zelluläre immunreaktion entstehen. b-zellen und humorale immunreaktionen sind für die terminierung der virusreplikation unbedeutend. dies erklärt auch den nur partiellen schutz vor reinfektion in abwesenheit von rsv-spezifischen antikörpern. hingegen ist die t-zellreaktion der hauptmediator für die pathologie der erkrankung. so scheiden rsv-infizierte, von t-zellen depletierte mäuse das virus über längere zeit aus und erkranken erst bei rekonstituierung mit cd8 + -lymphozyten. dies erklärt auch den umstand, warum die krankheitssymptome erst ihre spitze erreichen, wenn die virusreplikation bereits wieder abnimmt und die immunreaktion ihr maximum erreicht hat. es erstaunt deshalb nicht, dass antivirale therapien, wenn über-543 27.2 · akute virale bronchiolitis haupt, dann nur einen sehr geringen einfluss auf die erkrankung haben. die rsv-bronchiolitis ist das resultat eines komplexen zusammenspiels zwischen virus und der individuellen immunreaktion des wirts. polymorphismen in diversen genen, welche bei der immunreaktion eine rolle spielen (z.b. mhc-komplex, interleukin, chemokin-rezeptor-5, tnf, etc.), sind mit unterschiedlich schweren krankheitsverläufen assoziiert. die rsv-bronchiolitis verläuft besonders im sehr frühen säuglingsalter mit noch unreifem immunsystem besonders schwer. es gibt hinweise dafür, dass die anfälligkeit junger säuglinge auf ihre immunologische unreife zu einer starken antiviralen interferon-γ-antwort zurückzuführen ist. neben der möglichen rolle von unterschieden in den rsv-spezifischen immunmechanismen gibt es hinweise dafür, dass der prototypische ngf (neurotrophin growth factor), sein rezeptor (neurokinin-1-rezeptor) und der bdnf (brain-derived neurotrophic factor) während der akuten rsv-infektion hochreguliert werden. diese aktivierung führt zu einer neurogen vermittelten zellulären immunantwort mit aktivierung von lymphozyten und monozyten und einer erhöhung der vaskulären permeabilität bei stimulation der sensorischen nerven. der ngf spielt nicht nur in der genese der akuten neurogenen entzündung eine wichtige rolle, sondern ist vermutlich auch für die erhöhte bronchiale empfindlichkeit im anschluss an die rsv-infektion verantwortlich. dies wird mit einem remodeling der sensorischen innervation der luftwege erklärt, welches in einer vermehrung oder einer erhöhten empfindlichkeit des neuronalen bronchialen netzwerks resultiert. j pathophysiologie der akuten bronchiolitis liegt eine verstopfung der bronchiolen infolge ausgedehnter abschilferung nekrotischer epithel zellen und vermehrter mukussekretion zugrunde. histologisch imponieren eine ausgeprägte nekrose des respiratorischen epithels mit schwerer destruktion der zilien, ein peribronchiales lymphozytäres infiltrat sowie ein submuköses ödem. die partielle verstopfung der bronchiolen führt zur überblähung der lunge und zum ventilmechanismus, der das endinspiratorische knisterrasseln im sinne eines »knallenden« öffnens der allerkleinsten atemwege in der späten phase der inspiration erklärt. bei vollständigem verschluss der atemwege kommt es zu atelektasen ganzer lungensegmente und -lappen. beides hat ein ventilations-perfusions-missverhältnis mit intrapulmonalem recht-links-shunt und hypoxämie zur folge. infolge der überblähung ist die funktion der atemmuskulatur beeinträchtigt, was mit einem tiefstehenden zwerchfell mit palpabler leber und milz sowie einem horizontalen rippenverlauf mit ungünstigem ansatz der inspiratorischen interkostalmuskulatur einhergeht. langandauernde atemanstrengungen können bei schwerem verlauf zur respiratorischen erschöpfung führen. speziell bei frühgeborenen und sehr jungen säuglingen (<3 monate) kann es ihm rahmen von rsv-infektionen zu zentralen apnoen mit bradykardien kommen, die vermutlich als folge einer direkten störung des atemzentrums durch das virus entstehen. j klinische symptome und diagnostik die diagnose einer akuten bronchiolitis im säuglingsalter beruht in erster linie auf klinischer beobachtung. nach einem prodromalstadium mit schnupfen, laufender nase, trockenem irritablem husten und evtl. leicht erhöhter körpertemperatur präsentiert sich die akute bronchiolitis innerhalb von 24-48 h mit typischem knisterrasseln, tachypnoe, erschwerter atmung mit einziehungen, lungenüberblähung, sowieje nach schweregrad -mit trinkschwäche und zyanose. ein leichtes exspiratorisches, pfeifendes atemgeräusch (giemen) kann, muss aber nicht vorkommen. insbesondere bei frühgeborenen und sehr jungen säuglingen können auch apnoen die ersten zeichen einer rsv-infektion sein. die akute bronchiolitis ist in der regel die erste manifestation einer obstruktiven atemwegserkrankung im säuglingsalter. sie kann aber gelegentlich wiederholt auftreten. kinder, die später an rezidivierenden obstruktiven bronchitiden oder an asthma erkranken, haben häufiger im säuglingsalter eine oder gar mehrere bronchiolitiden durchgemacht. auf den zusammenhang zwischen bronchiolitis im säuglingsalter und dem auftreten rezidivierender obstruktiver bronchitiden und asthma bronchiale im kindesalter wird in 7 abschn. 27.3, obstruktive bronchitis, näher eingegangen. bei einer vielzahl von säuglingen kommt es im anschluss an eine bronchiolitis -in der regel im zusammenhang mit erneuten viralen infektionen -zum auftreten von obstruktiven bronchitiden. diese problematik bessert sich in der regel mit zunehmendem alter, insbesondere bei nicht atopischen kindern. noch ungeklärt ist die frage, ob die rsv-infektion als risiko für eine allergische sensibilisierung oder ein frühes ige-assoziertes asthma betrachtet werden muss oder ob diese bei säuglingen mit atopischer veranlagung besonders schwer verläuft. ein schnellnachweis auf rsv im nasopharyngealsekret (nps) ist insbesondere im krankenhaus sinnvoll, um die betreuung von rsv-positiven säuglingen im separaten zimmer zu ermöglichen, was bei entsprechender hygiene eine nosokomiale übertragung im spital verhindern hilft. bei nicht eindeutiger klinischer situation und negativem rsv-resultat ist der nachweis von anderen respiratorischen viren (parainfluenza-, influenza-, rhino-, adeno-sowie humane bocaviren, coronaviren oder metapneumoviren) im nps zur sicherung der diagnose in erwägung zu ziehen. insbesondere im frühen säuglingsalter ist es für wenig erfahrene ärzte bei akuter präsentation mit schwerem krankheitsbild nicht immer einfach eine bakterielle infektion auszuschließen. blutbild und crp-bestimmung sind bei der unterscheidung zur bakteriellen pneumonie oder sepsis wenig hilfreich: eine leukozytose von >15000 hat eine geringe sensitivität und spezifität (ca. 50%); ein crp von >80 mg/l hat eine sehr gute spezifität (90%), bei jedoch geringer sensitivität (35%) für eine bakterielle pneumonie. bakterielle superinfektionen sind bei akuten bronchiolitiden ausgesprochen selten und sollten primär aufgrund klinischer parameter (persistierendes hohes fieber, az-verschlechterung, septisches zustandsbild) und nicht aufgrund von laborparametern in erwägung gezogen werden. die bestimmung der elektrolyte und die blutgasanalyse helfen bei der beurteilung der respiratorischen und/oder metabolischen entgleisung des säuglings, sind aber nur bei schwereren fällen im krankenhaus notwendig. ein thorax-röntgenbild ist für die initiale therapieentscheidung bzw. unterscheidung zu einer bakteriellen pneumonie wenig hilfreich. das typische thorax-röntgenbild zeigt eine beidseitige überblähung, diskrete peribronchiale bis parenchymatöse infiltrate sowie allenfalls atelektasen, die meist die oberlappen betreffen. letztere sind für den unerfahrenen oft schwer von bakteriellen infiltraten abzugrenzen. bei einem kleineren teil der säuglinge mit sehr schweren und fulminanten verläufen kann sich die rsv-infektion auch als virale pneumonie mit großflächigen alveolären infiltraten und primär restriktiver lungenfunktionsstörung manifestieren und bis zum schweren ards fortschreiten. j prävention die prävention der rsv-infektion bei hochrisiko-säuglingen begann zuerst mit gewöhnlichem intravenösem immunoglobulin und wurde 1996 zuerst vom rsv-hyperimmunen, polyklonalen intravenösen immunglobulin (rsv-igiv, respigam) abgelöst und 1999 durch die monatliche i.m.-injektion vom humanisierten monoklonalen antikörper der igg1-subklasse -gerichtet gegen das f-protein von rs-viren -palivizumab (synagis) ersetzt. rsv-igiv war in europa aufgrund der langen intravenösen administration, dem theoretischen infektionsrisiko und den hohen kosten nie wirklich populär. aufgrund der vereinfachten i.m.-administration und der fehlenden infektionsgefahr wurde palivizumab zum standard für die prävention der rsv-infektion. seit 1999 ist palivizumab zur prophylaxe von rsv-erkrankungen bei frühgeborenen ≤35. ssw im 1. lebensjahr bzw. zusätzlich im 2. lebensjahr für behandlungsbedürftige frühgeborene mit bronchopulmonaler dysplasie (bpd) zugelassen. im jahr 2003 kam dann die zulassung für hämodynamisch relevante kongenitale herzvitien dazu. diese beiden zulassungen gründen sich im wesentlichen auf zwei amerikanische, doppelblinde, plazebokontrollierte klinische studien, welche außer einer reduktion der hospitalisationsrate aber weder einen benefit für den klinischen verlauf noch für die an sich schon sehr geringe mortalität der rsv-infektion aufzeigen konnten. zudem hatte die frühgeborenen-kohorte einen für europa ungewöhnlich hohen anteil an säuglingen mit bpd. die astronomisch hohen kosten von palivizumab und die regionale variabilität der rsv-infektion haben zu vielen debatten über die anwendung von palivizumab geführt. die meisten säuglinge, die aufgrund einer rsv-infektion hospitalisiert werden müssen, sind bei uns primär gesunde, termingeborene säuglinge, die nicht für eine rsv-prophylaxe infrage kommen. ein ökonomischer benefit konnte auch aufgrund der hohen medikamentenkosten für palivizumab nie nachgewiesen werden. das risiko einer schweren rsv-infektion ist selbst für säuglinge innerhalb der zugelassenen indikation ausgesprochen tief, sodass die kosten den potenziellen benefit einer niedrigeren hospitalisationsrate schlecht rechtfertigen. dies hat dazu geführt, dass viele länder eigene, viel restriktivere empfehlungen für die rsv-prophylaxe herausgegeben haben und diese meist auf frühgeborene kinder (≤32. gestationswoche) mit sauerstoffbedürftiger bpd bis kurz vor oder während der rsv-saison limitieren. palivizumab ist bis jetzt bei anderen hochrisiko-gruppen (z.b. immundefizienz, zystische fibrose etc.) nicht untersucht worden und auch nicht zugelassen. zur prophylaxe wird palivizumab jeweils im abstand von einem monat während der gesamten rsv-saison (ca. oktober bis mai in abhängigkeit von regionalen epidemiologischen informationen) intramuskulär appliziert. die komplexe immunpathologie des rs-virus hat bisher die entwicklung einer sicheren und wirkungsvollen impfung verhindert. j. barben, u. frey j einleitung episodisch auftretende und rezidivierende obstruktive bronchitiden (viral wheezing disorders) gehören zusammen mit dem asthma bronchiale zu den häufigsten erkrankungen im kindesalter, wobei sich deren behandlung in den letzten 5-10 jahren rasch verändert hat. diese änderungen basieren neben der einführung von neuen medikamentengruppen vorwiegend auf der erkenntnis, dass nicht alle phänotypen der obstruktiven atemwegserkrankungen in gleicher weise auf die medikamente ansprechen. die phänotypisierung ist oft schwierig, da diese verschiedenen formen oft nicht klar auseinander zu halten sind und sich häufig über die zeit verändern. die erfassung von risikofaktoren, schlüsselsymptomen (pfeifende atmung, wheezing, husten, atemnot), und die beobachtung des zeitlichen verlaufs der obstruktiven atemwegserkrankungen, differenzialdiagnostische überlegungen sowie therapiekontrolle und der informationsaustausch zwischen den behandelnden ärzten sind für die betreuung dieser patient/innen von größter bedeutung (s. algorithmus 7 kap. 47, giemen und pfeifende atmung). j definition eine obstruktive bronchitis ist eine meist virusinduzierte infektion der unteren atemwege, die neben den schlüsselsymptomen wie husten, tachypnoe, einziehungen und lungenüberblähung typischerweise zu einem (end-)exspiratorischen hochfrequenten pfeifen/giemen (wheezing) führt. obstruktive episoden mit fehlendem nachweis von pfeifender atmung kommen im alltag auch vor. bei starker überblähung werden die pfeifenden atemwegsgeräusche oft nicht bis an die thoraxwand fortgeleitet und sind nicht hörbar (s. abgrenzung: cough variant wheezing disorders). pfeifende atmung wird durch die eltern oder betreuenden arzt oft auch nicht erkannt oder falsch eingeordnet. in unklaren fällen können videoaufnahmen zur beurteilung sehr hilfreich sein. in der regel tritt eine obstruktive bronchitis ausgelöst durch virusinfekte in schüben auf, wobei zwischen den episoden typischerweise keine symptome vorhanden sind (leitsymptom). gemäß der european respiratory society (ers) task force wird dies heute international als »viral-induced wheezing« bezeichnet. die risikofaktoren, die zur vermehrten häufigkeit bzw. zu einem schweren verlauf führen, können in zwei gruppen eingeteilt werden (. abb. 27.3). es sind einerseits störungen der atemwegsentwicklung und -mechanik und andererseits eine störung der epithelialen funktion und immundysfunktion. die atemwegsentwicklung wird durch genetische variationen in lungenwachstumsfaktoren, im rahmen einer gestörten entwicklung der atemwege bei frühgeburtlichkeit oder kongenitalen atemwegsmalformationen (7 kap. 24) sowie durch externe toxische faktoren wie tabakrauch-und luftschadstoffexposition (7 kap. 6) beeinflusst. störungen der atemwegsmechanik durch adipositas und rasche überproportionale gewichtszunahme sind mit häufigeren wheezing-episoden assoziiert. störungen der epithelialen funktion und immundysfunktion sind assoziiert mit atopie/allergie, ernährung, stillen, vitamin-d-stoffwechsel und auch mit angeborenen und erworbenen immunmangelsyndromen. faktoren, die die epitheliale und immmunfunktion auch positiv beeinflussen können, sind z.b. die antigenexposition und deren diversivität im bäuerlichen umfeld (7 kap. 5.1, 7 kap. 5.2), die ernährung und das stillen. vor kurzem publizierte studien zeigen auch, dass adipositas und eine rasche überproportionale gewichtszunahme in den ersten lebensjahren zu vermehrten wheezing-episoden führen kann. obwohl die pathophysiologie dieser symptomatik (z.b. inflammatorische aspekte) nicht vollständig aufgeklärt ist, sind sicher die atemmechanische beeinflussung mit fehlender retraktion und dehnung der glatten muskulatur in den luftwegen eine wesentliche komponente für die relative obstruktion bei adipositas. früher wurde in diesem zusammenhang dafür oft der begriff »happy wheezers« verwendet. ebenso verändern pränatale tabak-und luftschadstoffexposition die lungenfunktion kurz nach geburt. letztere sind assoziiert mit vermehrten atemwegserkrankungen im ersten lebensjahr. bei älteren kindern ist es mehrfach gezeigt, dass die funktionelle entwicklung der atemwege durch luftschadstoffe behindert wird. interaktionen zwischen genen und umweltfaktoren auf das lungenwachstum sind in mehreren studien nachgewiesen. luftschadstoffe und tabakexposition können aber zusätzlich einen einfluss auf das atemwegsepithel haben und die häufigkeit und dauer von virusinfektionen im ersten lebensjahr erhöhen, pro-inflammatorische zytokine freisetzen und die immunentwicklung beeinflussen. eine störung der atemwegsentwicklung 551 27.3 · obstruktive bronchitis kann jedoch auch durch remodellierungsvorgänge nach chronischer entzündung auftreten. diese sind bei patienten mit schwerem asthma im alter von 3-4 jahren erstmals histologisch nachgewiesen worden, bei episodisch auftretenden obstruktiven bronchitiden wurden keine solchen veränderungen gefunden. typischerweise vermindert sich der einfluss der gestörten atemwegsentwicklung auf die obstruktiven atemwegsepisoden mit zunehmendem wachstum bis ins schulalter. es wird jedoch postuliert, dass diese faktoren eine bedeutung für die chronisch obstruktiven erkrankungen im alter haben. für die persistenz von obstruktiven atemwegserkrankungen ins schulalter spielen jedoch prädisponierende faktoren eine wichtige rolle, die zu einer störung der epithelialen funktion und immundysfunktion führen. als bester bekannter faktor ist die atopie beschrieben, jedoch auch andere immunologische mechanismen scheinen eine wichtige rolle zu spielen und sind z.t. genetisch prädisponiert. die umweltinteraktionen spielen hier eine bedeutende rolle. die meisten dieser phänomene werden in anderen kapiteln behandelt (7 kap. 5 bis 7), die rolle der virusinfektionen im rahmen von obstruktiven bronchitiden wird hier besonders zusammengefasst. k zusammenspiel zwischen frühen virusinfektionen und allergie-bzw. asthmaentwicklung obwohl die »huhn und ei-frage« nicht vollständig klar ist, nimmt man heute aufgrund von erkenntnissen an großen geburtskohorten an, dass frühe virusinfektionen eher nur bei kindern mit gewissen prädisponierenden faktoren eine nachfolgenden störung der immunentwicklung und allergie beeinflussen oder gar induzieren können (two hit hypothesis). mehrere geburtskohortenstudien haben gezeigt, dass einerseits rsv-infektionen in den ersten 2 lebensjahren, aber auch häufige, frühe infektionen mit rhinoviren (speziell den schwer verlaufenden typ-c-infektionen) mit der entwicklung von späterem asthma und aero-allergen spezifischen ige-titern assoziiert sind. besonders säuglinge mit früher allergisierung scheinen bei zusätzlichen frühen schweren rhinovirusinfektionen ein höheres risiko für späteres asthma zu haben. verschiedene mögliche ätiologische hypothesen für die interaktion zwischen rhinovirusinfektionen und allergie werden in der literatur beschrieben: eine mikrobiologische untersuchung auf respiratorische viren im nasensekret (kultur, pcr-testung) während einer akuten episode hat keinen einfluss auf das therapiemanagement und sollte nur für wissenschaftliche zwecke eingesetzt werden. typischerweise ist die lungenfunktion bei der einfachen, obstruktiven bronchitis während, aber nicht zwischen den episoden eingeschränkt. einige studien zeigen, dass auch im vorschulalter der nachweis von atemwegsobstruktion mit späteren persistierender eingeschränkter lungenfunktion und asthma assoziiert ist (tracking of lung function, 7 kap. 3). möglicherweise können in ausnahmefällen lungenfunktionelle abklärungen für die phänotypisierung helfen. es gibt jedoch noch zu wenige studien, die zeigen, dass lungenfunktionen bei simplen obstruktiven bronchitiden im vorschulalter im einzelfall für die klinische beurteilung und therapieentscheidung hilfreich sind. die bronchiale erregbarkeit ist in der regel bei einfachen obstruktiven bronchitiden zwischen den episoden normal. bronchiale erregbarkeitstests im vorschulalter haben in der klinischen routine für die diagnose und phänotypisierung bei der obstruktiven bronchitis keine bedeutung. nach virusinfektionen (typischerweiser nach rsv-bronchiolitis, 7 abschn. 27.2) kann jedoch einen bronchiale übererregbarkeit noch über wochen oder monate weiterbestehen. die testung der reversibilität nach β2-stimulation ist klinisch und auch mit nichtinvasiven lungenfunktionstest (fluss-volumen-kurve, interruptionstests, impedanzmessungen) auch im vorschulalter möglich. sie kann in der klinischen routine in ausnahmefällen für die abgrenzung der obstruktiven atemwegserkrankungen vom persistierenden husten oder dem so genannten cough variant asthma nützlich sein. ebenso ist eine laboruntersuchung (blutbild und crp-bestimmung) nicht routinemäßig zu empfehlen und ist auch zur unterscheidung zur bakteriellen pneumonie ohne vorliegen von entsprechenden klinischen symptomen wenig hilfreich. bakterielle superinfektionen sind bei obstruktiven bronchitiden selten und sollten primär aufgrund klinischer parameter (persistierendes hohes fieber, az-verschlechterung, septisches zustandsbild) und nicht nur aufgrund von laborparameter in erwägung gezogen werden. ein thorax-röntgenbild ist weder für die diagnostik von kindern mit erster oder wiederholter episode einer obstruktiver bronchitis noch für die initiale therapieentscheidung bzw. unterscheidung von einer bakteriellen pneumonie bei fehlenden entsprechenden klinischen parametern hilfreich. bei hospitalisationsbedürftigen, schwersten obstruktiven episoden, klinischen verdacht auf atelektasen, unerklärlich persistierenden verlauf mit langzeitigem sauerstoffgebrauch oder anamnestischen hinweisen für eine vorbestehenden chronische pneumopathie kann eine radiologische untersuchung in erwägung gezogen werden. wichtige differenzialdiagnosen beinhalten neben einer fremdkörperaspiration (die auch durch einen febrilen infekt kaschiert sein kann), das asthma bronchiale, die zystische fibrose, seltene kongenitale tracheal-bzw. bronchialveränderungen, das ziliäre immotilitätssyndrom sowie einen gastroösophagealen reflux, wobei hier die erfassung von komorbiditäten diagnostisch eine wichtige rolle spielt (. tab. 27.2). k beurteilung des schweregrades bzw. kriterien zur hospitalisation eine international gültige einteilung des schweregrades ist bei der obstruktiven bronchitis nicht vorhanden. die entscheidung, ob ein kind hospitalisiert werden soll, hängt in der regel vom sauerstoffbedarf, dem vorliegen einer ateminsuffizienz bzw. sozialen umständen ab. in den meisten kliniken werden schwere dyspnoe und das unterschreiten der o 2 -sättigung unter 90-92% als kriterium für eine hospitalisation gewertet. die erfahrung mit früheren schweren episoden, das sehr junge alter von säuglingen, eingeschränktes trinkverhalten mit beginnender dehydrierung, inadäquate inhalationstechnik und die psychosoziale belastungssituation der familie sind jedoch immer zu berücksichtigen. j therapie die therapie der rezidivierenden obstruktiven bronchitiden ohne interkurrente symptome basiert vorwiegend auf einer guten symptomatischen therapie (antipyrese, nasenpflege, feuchtluft, bei bedarf sauerstoffgabe etc). sowie dem therapieversuch mit kurzwirkenden β2-mimetika nach bedarf, wobei diese mehrmals täglich (4-bis 6-mal pro tag) inhaliert werden können. inhalative steroide haben bei den infektassoziierten, episodisch auftretenden obstruktiven bronchitiden keine vorbeugende wirkung und werden auch in der akutphase aufgrund der ungenügenden wirkung nicht mehr eingesetzt. der nutzen von systemischen steroiden bei infektassoziierten obstruktiven bronchitiden in der praxis ist nicht erwiesen, weshalb deren routinemäßiger einsatz nicht sinnvoll ist und vermieden werden sollte. einzig bei schweren exazerbationen, die zu lebensbedrohlichen situationen führen können, kann man frühzeitig systemische steroide (betnesol 0,2 mg/kg/tag bzw. prednisolon 1-2 mg/kg/tag für 3-5 tage) in erwägung ziehen. der gebrauch von steroiden im ersten lebensjahr sollte eher restriktiv gehandhabt werden. der einsatz von leukotrienrezeptorantagonisten (ltra) bei viralen episodisch auftretenden obstruktiven bronchitiden wurde in wenigen studien überprüft und zeigt keinen effekt auf die anzahl hospitalisationen, die dauer der episoden oder steroidgebrauch. einzig die anzahl der ungeplanten hausarztbesuche wurde reduziert und eine leichte verbesserung der lungenfunktion wurde nachgewiesen. die eingeschränkte evidenzlage erlaubt deshalb die routinemäßige empfehlung dieser medikamentengruppe bei viral assoziierten bronchitiden nur mit vorbehalt, der probatorische einsatz dieser medikamente (start mit einer tablette montelukast täglich bei beginn der symptome, initial für 7 tage) kann in erwägung gezogen werden, bei fehlendem ansprechen oder spätestens nach einigen wochen ist ein absetzversuch angezeigt. die daten der melbourne-studie befinden sich im einklang mit den ergebnissen anderer asthma-langzeitstudien, wonach sich die episodische infektgetriggerte »wheezy bronchitis« meist auswächst, während frühkindliches asthma, welches mit einer frühen atopischen sensibilisierung einhergeht, in der mehrzahl der fälle bis ins erwachsenalter persistiert und die lungenfunktion schon im schulalter vermindert ist und bleibt. eine geburtskohortenstudie aus england (british 1958 birth cohort study), welche im jahr 1958 begonnen wurde, umfasst daten zum langzeitverlauf von 18558 teilnehmern, davon 613 kinder mit frühkindlichem wheezing, welche mittels regelmäßiger interviews erhoben wurden. diese studie zeigt, dass frühkindliches wheezing sich zwischenzeitlich »auswachsen« kann, aber häufig im frühen erwachsenenalter wieder auftritt. eine weitere wichtige studie auf dem gebiet des langzeitverlaufs aus neuseeland, begonnen im jahr 1972 mit follow up von 9-26 jahren, kam zu denselben resultaten. zusammenfassend lässt sich also sagen, dass früher krankheitsbeginn, eine schon im kindesalter eingeschränkte lungenfunktion sowie atopie konstante risikofaktoren für später persistierendes asthma sind. wie aus oben genannten beispielen ersichtlich ist, sind geburtskohorten und longitudinalstudien ein wichtiger und spannender forschungsansatz um krankheitsverlauf, outcome und modulatoren verstehen zu lernen. ihr nachteil ist, das sie extrem aufwendig sind und ihre aussagekraft verlieren, wenn der »lost to follow up«-anteil zu groß wird. k asthma-remission in der pubertät es wird immer wieder postuliert, dass sich asthma bronchiale in der pubertät »auswächst«, was aber in wahrheit nur für eine minderheit der kinder mit asthma zutrifft. asthma-remission ist einerseits abhängig von der untersuchten pati-entengruppe (schweregrad des asthmas), andererseits vom gewählten zielparameter. bedeutet remission keine symptome und keine therapie -oder gehören eine normale lungenfunktion und eine fehlende bronchiale hyperreaktivität dazu? in abhängigkeit davon beträgt die remissionsrate für asthma bronchiale in der pubertät zwischen 10-70%. risikofaktoren für persistenz sind weibliches geschlecht, atopie, ausgeprägte bronchiale hyperreaktivität und eine eingeschränkte lungenfunktion. k ätiologie und genetik das allergische asthma ist eine multifaktorielle erkrankung, die auf einer komplexen wechselwirkung von genetischen faktoren und umweltfaktoren basiert. in linkage-analysen und genomweiten assoziationsstudien wurden verschiedene gen cluster und kandidatengene identifiziert, die mit einer erhöhten asthma suszeptibilität einhergehen (7 kap. 7). diese sind häufig mit genen für entzündungsmediatoren oder β2-adrenorezeptoren assoziiert. die besondere bedeutung der genetischen prädisposition für das asthmarisiko wird durch eine enge korrelation mit der familiären atopischen belastung deutlich. allerdings sprechen die variabilität der vererbung und die heterogenität des krankheitsbildes für ein komplexes vererbungsmuster, das verschiedene gene auf verschiedenen chromosomen mit unterschiedlichem expressionsgrad betrifft und deshalb nur schwer zu erfassen ist. die zunehmende prävalenz allergischer erkrankungen in den westlichen ländern ist nicht genetisch zu erklären und betont die bedeutung von umweltfaktoren für das allergie-und asthmarisiko. epidemiologischen studien haben u.a. einen zusammenhang zwischen einem erniedrigten asthmarisiko und einer hohen anzahl an geschwistern, der frühen aufnahme in eine kindertagesstätte sowie dem leben auf dem bauernhof mit kontakt zu vielen verschiedenen tierspezies aufgezeigt. diese beobachtungen führten zu der so genannten »hygiene-hypothese«, die besagt, dass aufgrund der zunehmenden hygiene und veränderten lebensgewohnheiten in industrialisierten ländern eine frühe »trainierende« stimulation des immunsystems durch infektionen und kontakt zu mikrobiellen bestandteilen in den letzten jahrzehnten abgenommen und dadurch das risiko einer inadäquaten reaktion des immunsystems auf an sich harmlose antigene wie allergene zugenommen hat. bereits eine intrauterine exposition mit mikrobiellen bestandteilen scheint einen präventiven effekt zu haben. virale infektionen werden ebenfalls in engem ätiologischem zusammenhang mit dem asthma bronchiale gesehen, wobei infektionen mit rhinovirus und respiratory syncytial virus (rsv) besonders stark mit dem asthmarisiko korrelieren (. abb. 27.7, daten aus jackson et al. 2008 j pathogenese und pathologie des allergischen asthma bronchiale bei einem individuum, das gegen ein oder mehrere allergene sensibilisiert ist, löst der allergenkontakt eine allergische reaktion aus, bei der eine frühe und späte reaktion unterschieden wird (. abb. 27.8). zunächst wird das allergen von einer antigenpräsentierenden zelle (antigen presenting cell, apc), wie der dendritischen zelle (dc), aufgenommen und prozessiert. die aufnahme des antigens führt zu reifung der apc und zu deren migration zu drainierenden lymphknoten (ln). hier werden die prozessierten antigenpeptide im kontext mit mhc-klasse-ii und kostimulatorischen molekülen naiven cd4 + -t klinisches leitsymptom des asthma bronchiale ist die rekurrierende obstruktion der atemwege, die mit einem überwiegend exspiratorischen giemen assoziiert und spontan oder durch therapie reversibel ist. gelegentlich äußert sich ein asthma bronchiale auch durch einen persistierenden, teils nächtlich betonten, trockenen husten. die diagnose eines asthma bronchiale ist überwiegend eine klinische diagnose. sie wird durch eine (partiell) reversible obstruktion nach inhalation eines β2-sympathomimetikums oder eine bronchiale hyperreaktivität bei der lungenfunktionstestung objektiviert. bei vorliegen einer eosinophilen entzündung ist das exhalative stickstoffmonoxid (no) typischerweise erhöht. auslöser der atemnot können allergenkontakt beim allergischen asthma bronchiale, virale oder bakterielle infektionen, körperliche aktivität und unspezifische inhalative reize wie z.b. tabakrauch, kalte, trockene luft oder stäube sein. virale infekte stehen als auslöser vor allem im säuglingsund kleinkindesalter im vordergrund. deshalb ist eine abgrenzung des frühkindlichen asthma bronchiale von der banalen virusinduzierten obstruktiven bronchitis oft schwierig (7 abschn. 27.3). spielen allergien keine rolle, handelt es sich um ein nichtatopisches asthma bronchiale. hierbei sind die schlüsselfaktoren für die entstehung der entzündungsreaktion nicht bekannt. mischformen zwischen atopischem und nichtatopischem asthma sind möglich und häufig. so kann z.b. bei einem primär allergischen asthma im laufe der zeit eine nichtallergische komponente in den vordergrund treten. treten die symptome ausschließlich bei körperlicher anstrengung auf, spricht dies für das vorliegen eines nichtatopischen belastungsabhängigen asthma bronchiale (»anstrengungsasthma« oder »exercise-induced asthma«) (7 kap. 11.4). die atemnot eines patienten mit asthma bei körperlicher anstrengung ist häufig ein zeichen einer suboptimalen therapiekontrolle und verschwindet nach optimierung der anti-inflammatorischen dauertherapie wieder. auch medikamente, wie z.b. acetylsalicylsäure (ass) oder andere nichtsteroidale antiphlogistika, können für die entstehung eines asthma bronchiale verantwortlich sein und müssen dann streng gemieden werden (so genanntes analgetika-asthma). die einnahme von ass oder anderen nicht steroidalen antiphlogistika kann zu einer dramatischen verschlechterung mit schweren, therapierefraktären asthmaanfällen führen. hierbei handelt es sich nach derzeitigem wissen um eine erworbene idiosynkrasie des arachidonsäuremetabolismus. bei kindern tritt das analgetika-asthma sehr selten auf. neben den zu beobachtenden klinischen unterschieden der verschiedenen asthma-phänotypen, die nicht direkt bezug auf die zugrunde liegende pathophysiologie der verschiedenen krankheitsbilder nehmen, wird zunehmend versucht, bei der phänotypisierung auch die zugrunde liegenden pathomechanismen einzubeziehen. hierdurch soll die grundlage für eine individualisierte therapie geschaffen werden. j epidemiologie und ätiologie anstrengungsasthma betrifft bis zu 80% aller kinder mit asthma. das auftreten hängt von der intensität, von der dauer, von den umgebungsbedingungen (allergenbelastung, temperatur, luftfeuchtigkeit) und von der art der belastung ab. intervallsportarten (z.b. ballspiele) sind leichter zu bewältigen als ausdauersportarten (z.b. joggen oder das beliebte warmlaufen am beginn der turnstunde). anstrengungsasthma tritt eher bei trockener und kalter luft auf, umgekehrt wirkt warme feuchte luft protektiv. todesfälle durch anstrengungsasthma sind extrem selten, kommen aber vor und eine analyse von 61 verstorbenen kindern und jugendlichen konnte zeigen, dass in fast allen fällen die anti-inflammatorische asthmatherapie vernachlässigt worden war. bei kindern hat anstrengungsasthma in zweierlei hinsicht eine besondere bedeutung: kinder haben einen größeren bewegungsdrang als erwachsene, werden daher eher in ihren aktivitäten behindert und kinder werden von ihren altersgenossen rasch ausgegrenzt, wenn sie nicht mithalten können. kinder, die an anstrengungsasthma leiden, werden außerdem oft fälschlicherweise als bewegungsfaul abgestempelt. j diagnostik die diagnose erfolgt mittels anamnese (husten, atemnot, engegefühl, wheezing während bzw. nach der belastung, 7 übersicht) und nachweis der belastungsinduzierten bronchialobstruktion mittels spirometrie. untersuchungen haben gezeigt, dass das ausmaß der obstruktion schlecht mit der subjektiv berichteten dyspnoe korreliert, zudem ist dyspnoe bei sport nicht immer durch anstrengungsasthma ausgelöst. alternative diagnosen wie z.b. physiologische dyspnoe, schlechte fitness, kardiale ursachen, atemwegserkrankungen anderer ursache usw. müssen ebenfalls in betracht gezogen werden. in unklaren fällen und zu wissenschaftlichen zwecken stehen indirekte und direkte provokationstests als weiterführende diagnostische methoden zur verfügung (7 kap. 11.2 bis 11.4). insbesondere respiratorische infekte spielen eine große rolle als triggerfaktor für einen akuten asthmaanfall. in der überwiegenden zahl der hospitalisierten patienten mit akuten asthmatischen beschwerden im kindes-und jugendalter können respiratorische infekte, z.b. mit rhinoviren, seltener mit rs-viren oder anderen respiratorischen viren nachgewiesen werden. seltener anzutreffen sind schwere asthmaanfälle nach pollenexposition; eine asthmatische mitreaktion bei anaphylaktischen reaktionen bei insektengift-oder nahrungsmittelallergie ist häufig und besonders gefährlich. patienten mit der diagnose asthma bronchiale und entsprechenden allergien sind daher unbedingt auf den einsatz der notfallmedikamente zu schulen (anaphylaxieschulung), ein adrenalinhaltiges notfallmedikament ist bereitzuhalten. j klinische symptome ein asthmaanfall in folge respiratorischer infekte entwickelt sich nicht schlagartig, sondern kann im laufe der zunehmenden infektion, also u.u. auch über mehrere stunden bis tage, zum vollbild gelangen. im gegensatz hierzu ist der asthmaanfall nach allergenexposition oder in folge einer starken belastung akut einsetzend. die wesentliche klinische symptomatik ergibt sich aus der generalisierten obstruktiven ventilationsstörung (7 übersicht). k besonderheiten bei kindern unter 2 jahren die klinische diagnose eines asthmaanfalls bei säuglingen und jungen kleinkindern kann erschwert sein. aufgrund der weichheit des knorpelskeletts und des verhältnismäßig größeren anteils der kleinen atemwege am gesamtatemwegswiderstand tritt eine obstruktion früher und ausgeprägter auf, insofern entwickelt sich eine obstruktive ventilationsstörung rasch progredient. in der überwiegenden anzahl der fälle ist der akute asthmaanfall in dieser altersgruppe bedingt durch eine meist virale infektion der oberen und kon sekutiv unteren atemwege. aufgrund der erschwerten anamnese und klinischen untersuchungen sind folgende differenzialdiagnosen sicher auszuschließen: bei säuglingen und kleinkindern mit in-und exspiratorischen atemgeräuschen (stridor) ist immer an eine fehlbildung (z.b. doppelter aortenbogen, tracheo-bzw. bronchomalazie) zu denken. sollten die symptome rasch progredient sein, ist ein subglottisches hämangiom auszuschließen. bei dieser art von erkrankungen hilft vor allem eine flexible bronchoskopie schnell und sicher weiter. bei jedem plötzlich auftretenden husten mit wenig oder nicht reversibler atemnot, vor allem bei einseitigen befunden, muss an eine fremdkörperaspiration gedacht werden. die anamnese kann hier helfen, ist aber bei etwa der hälfte der fremdkörperaspirationen negativ bzw. bei länger zurückliegendem ereignis oft diffus. entsprechend ist auch bei nur geringem verdacht immer eine bronchoskopie angezeigt. bei patienten mit wiederkehrenden, schwer behandelbaren, oder chronischen infektiösen atemwegserkrankungen ist ein immundefekt auszuschließen. möglicherweise lässt sich hier in der familienanamnese eine konsanguinität der eltern nachweisen; eine gedeihstörung des kindes ist ein alarmzeichen. im suchtest sollten zumindest die serumspiegel der immunglobuline und die impfantikörper sowie das blutbild untersucht werden. bei säuglingen und kleinkindern mit rezidivierenden bronchitiden muss immer eine zystische fibrose in erwägung gezogen werden. hier ist der schweißtest ein sehr sensitiver diagnostischer test, der bei positivem ergebnis zu weiterer diagnostik (genetik) führen muss. bei patienten mit chronischen oder rezidivierenden bronchitiden, insbesondere vergesellschaftet mit chronischer rhinosinusitis und gehäuften ohrentzündungen und ohrenlaufen muss eine zilienfunktionsstörung ausgeschlossen werden. hier ist die zielführende diagnostik im ersten schritt die nasale no-bestimmung und wenn möglich die videomikroskopie, die durch immunhistochemie, elektronenmikroskopie und genetik unterstützt wird (7 kap. 30). schließlich muss bei kindern und jugendlichen mit erhöhtem körpergewicht und belastungsdyspnoe mittels einer laufbandprovokation eine zugrunde liegende belastungsabhängige obstruktive ventilationsstörung ausgeschlossen bzw. konditionelle mängel nachgewiesen werden. die wichtigsten differenzialdiagnosen, ihre entsprechenden leitsymptome und die weiterführende diagnostik sind in . tab. 27.7 aufgeführt. nachdem die diagnose eines asthmas durch anamnese, körperlichen befund und lungenfunktionsdiagnostik gestellt und andere mögliche differenzialdiagnosen ausgeschlossen werden konnten, ist eine einschätzung des aktuellen schweregrades bzw. der aktuellen asthmakontrolle notwendig, um die weitere behandlung planen oder fortführen zu können. die bisherige einteilung in unterschiedliche schweregrade anhand aktueller symptome und lungenfunktionsparameter ist für das monitoring einer asthmatherapie ungeeignet und kann nur bei bislang unbehandeltem asthma angewandt werden, ausnahmsweise auch bei erstkontakt mit patienten mit bereits diagnostiziertem asthma. diese initiale beurteilung des schweregrades kann also richtungweisend nur für die initiale behandlung sein und muss dann durch die beurteilung der asthmakontrolle abgelöst werden. . tab. 27.8 zeigt die gängige einteilung der schweregrade von intermittierendem bis hin zu schwergradig persistierendem asthma anhand von asthmasymptomen und lungenfunktionswerten. die beurteilung der asthmakontrolle ist der wesentliche parameter der langfristigen verlaufskontrolle und damit grund-lage der therapeutischen entscheidungen und anpassungen. es werden drei grade der asthmakontrolle unterschieden: 4 kontrolliertes asthma 4 teilweise kontrolliertes asthma 4 unkontrolliertes asthma die tabellen zeigen die definitionen der unterschiedlichen grade der asthmakontrolle nach der nationalen versorgungsleitlinie für kinder-und jugendliche . abb. 27.13) bzw. kinder unter 5 jahren (. tab. 27.9). hierbei ist beachtenswert, dass jegliches auftreten von symptomen am tage oder während der nacht und jeglicher einsatz einer bedarfsmedikation aufgrund respiratorischer symptome bereits als eingeschränkte kontrolle gewertet werden. der grad der asthmakontrolle ist dabei nicht fest geschrieben, sondern soll in regelmäßigen abständen neu evaluiert werden, um die behandlung zu steuern und anzupassen (7 abschn. 27.4.4). bei auftreten eines asthmaanfalls ist es zunächst sinnvoll, rasch eine schweregradbestimmung vorzunehmen. in . abb. 27.14, die als beispiel der aktuellen »deutschen nationalen versorgungsleitlinie asthma bronchiale« (2011) entnommen ist, sind die geeigneten beurteilungskriterien und die sich daraus ergebenden therapiemaßnahmen übersichtlich zusammengefasst. erstmaßnahme im asthmaanfall wird immer die inhalative verabreichung eines kurzwirksamen β2-sympathomimetikums (»saba«= short-acting beta-agonist, z.b. salbutamol) sein, die mehrfach wiederholt werden kann. zumindest bei leichtem bis mittelschwerem asthmaanfall erfolgt die verabreichung bevorzugt per dosieraerosol und spacer, auch beim sehr jungen kind. bei unter inhalativer β2-sympathomimetika-therapie unzureichender besserung wird ggf. systemisch prednisolon eingesetzt (1-2 mg/kg körpergewicht als einzeldosis), wobei kein dokumentierter wirkungsvorteil einer intravenösen gegenüber einer oralen gabe existiert. zur aufrechterhaltung einer sauerstoffsättigung im blut von >92% wird ggf. sauerstoff verabreicht. bei unzureichendem ansprechen auf diese maßnahmen oder bei schon primär schwerem asthmaanfall wird eine stationäre behandlung im krankenhaus erforderlich. hier werden die bereits ambulant begonnenen maßnahmen (saba inhalativ; glukokortikosteroide/gcs systemisch; sauerstoffgabe) unter monitoring von sauerstoffsättigung und herzfrequenz fortgeführt. eine behandlungsdauer von bis zu 3 tagen mit systemischen glukokortikosteroiden ist in der regel ausreichend. gegebenenfalls kommen in der klinik zusätzlich ipratropiumbromid inhalativ (insbesondere auch bei säug lingen und kleinkindern), β2-sympathomimetika i.v., theophyllin i.v., magnesiumsulfat i.v. und weitere therapiemaßnahmen wie flüssigkeitssubstitution zum einsatz (. abb. 27.15 antibiotika oder expektoranzien. nur selten ist eine intensivmedizinische behandlung bei kindern mit asthmaanfall erforderlich; indikationen dafür wären beispielsweise respiratorische erschöpfung, bewusstseinsstörung oder azidose. im anschluss an die behandlung eines akuten asthmaanfalls gilt es auf jeden fall, die maßnahmen zur weiterbehandlung sorgfältig zu planen. ziel der asthmatherapie ist es, dem erkrankten kind ein normales leben mit teilhabe an altersgemäßen körperlichen und sozialen aktivitäten, sprich an sport, spiel und schule, zu ermöglichen. konkret kann dieses therapieziel realisiert werden, indem durch die behandlung der definierte status eines kontrollierten asthmas (7 abschn. 27.4.3) erreicht und aufrechterhalten wird. bei den meisten kindern mit asthma bronchiale ist es heute möglich, dieses ziel mit überschaubarem medikamentösem aufwand ohne wesentliche therapiebedingte unerwünschte nebenwirkungen zu erreichen. die . abb. 27.16 gibt ein stufenschema zur medikamentösen langzeittherapie des asthma bronchiale bei kindern und jugendlichen aus der aktuellen deutschen »nationalen versorgungsleitlinie asthma bronchiale« (2011) wider. auch in österreich und in der schweiz wurden nationale leitlinien erstellt (2008, 2009 ). die drei deutschsprachigen leitlinien un-terscheiden sich inhaltlich nur in detailfragen. im folgenden wird exemplarisch auf die deutsche leitlinie bezug genommen. grundsätzlich erfolgen therapieeinstellungen und -anpassungen nicht mehr wie früher je nach asthmaschweregrad, sondern je nach grad der asthmakontrolle: es gilt das leitmotto »intensiviere wenn nötig -reduziere wenn möglich«, mit dem ziel, ein kontrolliertes asthma zu erreichen und dieses auf dem individuell niedrigstmöglichen niveau der therapieintensität aufrechtzuerhalten. der grad der asthmakontrolle ist in regelmäßigen abständen zu überprüfen. bei mindestens über 3 monate bestehender guter asthmakontrolle kann eine therapiedeeskalation gemäß dem stufentherapieplan erfolgen. für jede therapiestufe ist der einsatz eines inhalativen rasch wirkenden β2-sympathomimetikums (»raba« = rapid-acting beta-agonist) mit kurzer wirkdauer ( bei allergischem asthma wird hinsichtlich des spezifischen symptomauslösenden allergens primär zu einer weitestgehenden allergenkarenz geraten. bei tierhaarallergie beispielsweise muss der behandelnde allergologe die entfernung des für die klinische symptomatik relevanten haustiers empfehlen, wobei man sich im klaren darüber sein muss, dass ins besondere katzenallergene noch sehr lange in der raumluft verbleiben. zu den empfohlenen maßnahmen bei hausstaubmilbenallergie gehören die sanierung des haushalts mit entfernung von staubfängern und anwendung so genannter encasings (für haustaubmilbenallergene undurchlässige bezüge) im bett des patienten, um das geltende therapieprinzip der allergenmeidung umzusetzen. über die allergenreduktion hinaus bietet sich bei kindern ab dem schulalter die möglichkeit einer allergenspezifischen immuntherapie (sit) an. nach sorgfältiger abwägung der indikationsstellung kann bei klarer anamnestischer oder durch provokationstestung gesicherter assoziation zwischen kontakt mit einem inhalativen allergen und allergischer symptomatik eine sit die medikamentöse asthma-langzeittherapie bei kindern sinnvoll und erfolgversprechend ergänzen, wobei eine subkutane immuntherapie (scit) zur zeit noch weniger umstritten ist als eine sublinguale immuntherapie (slit). die am häufigsten verwendeten allergene sind gräser-und baumpollen-sowie hausstaubmilbenextrakte. zu den wichtigsten maßnahmen, die die pharmakologische und allergologische asthmatherapie ergänzen, gehört eine wissenschaftlich fundierte strukturierte asthmaschulung, die sowohl die patienten als auch deren familien aktiv einbezieht. inhalte der schulung sind sowohl anschauliche, den entwicklungspsychologischen erkenntnissen rechnung tragende informationen über verschiedene aspekte der erkrankung und deren behandlung, weiterhin der aufbau einer altersgerechten, eigenverantwortlichen körperselbstwahrnehmung sowie auch ganz konkret das einüben von im bedarfsfall bei akuter symptomatik zu treffenden maßnahmen im sinne einer verbesserten fähigkeit zum selbstmanagement. günstige einflüsse der teilnahme an einer strukturierten asthmaschulung auf verschiedene verlaufsparameter wie krankenhaus-oder schulfehltage, verbunden mit einer günstigen kosten-nutzen-relation, sind nachgewiesen (7 kap. 41). kinder mit asthma bronchiale bedürfen einer langfristig angelegten regelmäßigen sachkundigen medizinischen betreuung. wie häufig kontrolluntersuchungen durch eine spe-zialisierte einrichtung erfolgen sollen, hängt von individuellen gegebenheiten ab, so dem schweregrad/der komplexität der erkrankung und auch von der infrastruktur im lebensumfeld der patienten. grundsätzlich erscheinen im sinne eines angemessenen monitoring 3-bis 6-monatliche kontrollen der spirometrie und jährliche kontrollen der bodyplethysmografie sinnvoll. gegebenenfalls sind je nach situation weiterführende untersuchungen wie unspezifische provokations-oder reversibilitätstests zielführend. darüber hinausgehende apparative diagnostik, allem voran die messung des exhalierten no (feno) als marker der eosinophilen inflammation, unterstützt ggf. den erfahrenen betreuenden kinderpneumologen in der einschätzung der klinischen situation; die datenlage zu feno-messungen ist jedoch zu heterogen, als dass diese methodik eingang in die leitlinien zum asthma-monitoring gefunden hätte. neben lungenfunktionsbefunden sind in der langzeitbetreuung natürlich die anamnestischen daten zur klinischen situation der patienten hochrelevant. einschränkend muss dem behandler dabei bewusst sein, dass die individuelle perzeption der patienten und deren familien bezüglich des krankheitsverlaufs und der therapieerfolge oftmals unzuverlässig, durch subjektive wahrnehmung nicht selten innerhalb der familie widersprüchlich, ggf. auch geprägt von sorge um therapienebenwirkungen und durch womöglich langjährig gewohntes hinnehmen von symptomen häufig nicht objektiv ist. dagegen erlaubt die regelmäßige, systematische und strukturierte erhebung der kriterien der asthmakontrolle (. abb. 27.13, . abb. 27.14 und 7 abschn. 27.4.1) im verlauf der langzeittherapie eine gute einschätzung der krankheitsspezifischen situation. therapieziele sind beschwerdefreiheit, normale lungenfunktion und normale bronchiale reagibilität, sodass dem asthmakranken kind die teilhabe an altersgemäßen aktivitäten ohne relevante einschränkungen möglich ist. wenn durch die eingeleitete therapie die erwartete asthmakontrolle und beschwerdefreiheit nicht erzielt werden, ist es ratsam, vor einer medikamentösen therapieintensivierung auch andere aspekte als die rein pharmakologischen zu berücksichtigen: bei verordnung von inhalativen medikamenten ist es sinnvoll, die inhalationstechnik der patienten zu überprüfen; oftmals findet sich der grund für das therapieversagen schon bei der vorführung der fehlerhaften inhalation durch die patienten. bei verdacht auf eine epiglottitis muss das kind ständig überwacht und möglichst ohne verzögerung zur nächsten intensivstation transportiert werden. hierzu ist eine sitzende position zu bevorzugen, um eine hypostatisch bedingte zunahme des larynxödems zu vermeiden. wenn möglich sollte die atemluft mit sauerstoff angereichert werden. jegliche zunahme des sauerstoffbedarfs, z.b. durch schmerzbedingte hyperventilation, ist zu vermeiden. eine inspektion des rachens mit anwendung eines holzspatels kann zu einem reflektorischen herz-atem-stillstand führen und ist deshalb ohne verfügbare reanimationsmöglichkeiten kontraindiziert! eine inhalationstherapie mit adrenalin oder steroiden führt nicht zu einer besserung wie beim krupp. eine rasche intubation sollte angestrebt werden. dabei kann die diagnose gesichert bzw. eine eitrige tonsillitis oder ein peritonsillarabszess ausgeschlossen werden. die nach einem rachenabstrich sofort eingeleitete therapie mit z.b. cefuroxim ermöglicht meist die extubation bereits innerhalb von 48 h. eine verschlechterung nach intubation kann auf ein lungenödem zurückzuführen sein, das aufgrund des nun weggefallenen inspirationssogs entstanden ist. eine antibiotische umgebungsprophylaxe mit rifampicin (20 mg/kg, max. 600 mg für 4 tage) sollte bei engen kontaktpersonen durchgeführt werden und auch beim patienten selbst als eradikationstherapie, sofern er aufgrund seines jungen alters von unter 2 jahren noch keine ausreichende immunantwort bilden kann. k fremdkörperaspiration fischgräten, eierschalen und spitze plastikteile verhaken sich gerne in der glottischen region und führen zu einem prolongierten inspiratorischen stridor. auch fremdkörper im oberen ösophagus können durch kompression der pars membranacea einen krupp imitieren. k infantiler larynx obwohl der zu kleine und weiche larynx durch einklappen z.b. der arytaenoidknorpel bereits in den ersten beiden lek schleimhautabschwellende α-sympathikomimetika die verneblung von adrenalin bewirkt in den meisten fällen eine deutliche besserung des stridors bereits innerhalb von 10 min für die dauer von maximal 2 h. zugelassen ist hierfür eine inhalationslösung des razemischen adrenalins (epinephrin, infekto-krupp inhal). gleichwertig, aber für diese indikation nicht zugelassen, ist das in jedem notfallkoffer verfügbare l-adrenalin in der konzentration 1:1000, welches nicht weiter verdünnt über ca. 5-10 min (0,5 ml/kg, maximal 5 ml) inhaliert werden kann. die herzfrequenz sollte kontrolliert werden, steigt aber ebenso wie der systemische blutdruck kaum an. so kann auch bei einer ausgangsherzfrequenz von 180/min mit einer adrenalin-inhalation begonnen werden, da bei abnehmender luftnot mit einem abfall der herzfrequenz gerechnet werden kann. aufgrund der nur geringen systemischen nebenwirkungen der adrenalin-inhalation kann diese auch ambulant angewendet werden, sofern die relativ kurze wirkdauer beachtet und das kind nach 2-3 h nachuntersucht wird. bei kindern mit herzrhythmusstörungen oder obstruktion des ventrikulären ausflusstrakts (z.b. hokm, fallot-tetralogie) sollte allerdings vorsichtiger dosiert werden. eine dauerinhalation mit adrenalin ist zu vermeiden, da bei konstanter vasokonstriktion mit schleimhautnekrosen gerechnet werden muss. nach abklingen der wirkung kann es durch anhäufung saurer stoffwechselprodukte in der schleimhaut zu einer reaktiven hyperämie kommen. eine verschlechterung über den ausgangszustand hinaus wird aber in der regel nicht beobachtet. gelegentlich ist eine erneute inhalation weniger wirksam. dies kündigt eine verschlechterung im spontanen krankheitsverlauf an, die zusätzliche maßnahmen erfordert. unabhängig vom ausmaß des stridors sollte mittels abschwellender nasentropfen eine freie nasenatmung gesichert werden. gerade bei säuglingen ist bereits im gesunden zustand die atemarbeit überwiegend auf den nasalen widerstand zurückzuführen. k kortikosteroide für dexamethason in einer einmaldosis von 0,6 mg/kg körpergewicht parenteral ist eine signifikante verbesserung auch beim ausgeprägten krupp nachgewiesen. bei mildem und moderatem krupp sind 0,15 mg/kg kg dexamethason oral appliziert ebenso wirksam wie 0,6 mg/kg kg. die inhalation von 2 mg budesonidlösung (z.b. pulmicort) über einen düsenvernebler führt ebenfalls zu einer signifikanten verbesserung, die sich nicht unterscheidet von der oralen oder parenteralen dexamethasongabe. bemerkenswert ist die rasche besserung bereits nach 1 h bei beiden therapieformen, sodass neben der antiinflammatorischen wirkung ein zusätzlicher vasokonstriktiver oder membranstabilisierender effekt angenommen wird. die inhalation eines dem budesonid vergleichbaren steroids (2 mg fluticasonpropionat) mittels dosieraerosol und inhalationshilfe führte nicht zu einer verbesserung bei einer kleinen gruppe von kindern mit krupp. die mit dieser inhalationstechnik im vergleich zum düsenvernebler deutlich geringere deposition des kortikosteroids im bereich der oberen atemwege ist hierfür die wahrscheinlichste erklärung. für die im deutschen sprachraum favorisierte rektale applikation von prednison/prednisolon (z.b. rectodelt, prectal, klismacort) gibt es keine gut kontrollierten daten zum wirkeintritt oder zur dosis-wirkungs-beziehung bei kindern mit krupp. bei rektaler anwendung muss mit einem verzögerten wirkeintritt (maximaler blutspiegel nach 2-5 h) und sehr variabler resorption (20-80%) gerechnet werden, sodass sehr hohe einmaldosen von 100 mg für den säugling empfohlen werden. die orale gabe von prednisolon zeigt bereits bei 1 mg/kg kg eine signifikante verbesserung. sie muss aufgrund der kurzen halbwertszeit alle 12 h wiederholt werden, während für das länger wirksame dexamethason meist eine einmalgabe ausreicht, um rückfälle effektiv zu verhindern. die orale therapie mit dexamethason wurde deshalb als mittel der wahl empfohlen (deutsche gesellschaft für pädiatrische infektiologie 2009). das ebenfalls oral verfügbare betamethason (z.b. celestamine n liquidum) ist vergleichbar in der antientzündlichen potenz und wirkdauer zu dexamethason (z.b. infectodexakrupp). k intensivtherapie die indikation zur intubation sollte beim krupp »nicht« großzügig gestellt werden aufgrund der gefahr einer später eintretenden subglottischen stenosierung. die äußere knorpelige begrenzung dieser region begünstigt eine kompressionsbedingte schädigung der ödematös entzündeten schleimhaut durch einen intubationstubus, selbst wenn dieser deutlich kleiner als üblich gewählt und scherbewegungen durch sedierung minimiert werden. zur vermeidung einer intubation kann ein kontinuierlicher positiver atemwegsdruck über eine maske appliziert werden. allerdings bleibt hierbei die gefahr einer akuten atemwegsobstruktion durch sekretverlegung der subglottischen stenose bestehen. dies trifft auch für eine helium-sauerstoff-atmung zu, die durch die geringere gasdichte den atemwegswiderstand soweit senken kann, dass die atemnot deutlich vermindert wird. bei zunehmender erschöpfung oder sekretproblemen ist die intubation durch einen geübten durchzuführen mit einem tubus, der 1-2 größen kleiner als altersentsprechend und äußerlich mit kortisonsalbe (z.b. diprogenta) bestrichen ist. zusätzlich kann täglich lokal budesonidlösung instilliert werden, wobei der additive effekt zur sytemischen kortisontherapie bisher nicht untersucht wurde. bei klinisch deutlich nachweisbarem leck um den tubus herum kann -üblicherweise nach 4-6 tagen -eine extubation geplant werden. bei erneut notwendiger intubation sollte eine tracheotomie erwogen werden, auch um den sedierungsbedarf deutlich senken zu können. wichtig ist es, nach anlegen des tracheostomas möglichst bald ein sprechventil zu verwenden, damit die exspirationsluft den subglottischen bereich weitet und somit verklebungen vermeiden hilft. endoskopisch sollten regelmäßig fibrinöse membranen entfernt und die wund fläche gespült werden bis zur regeneration der epithelialisierung. eine primäre tracheotomie anstatt einer intubation wird nicht mehr empfohlen, da in der regel trotz intubation über mehrere tage keine subglottische stenosierung auftritt. außerdem ist der postulierte präventive effekt einer primären tracheotomie nicht erwiesen, hingegen ist die gesamtkomplikationsrate einer tracheostomaanlage höher als bei der langzeitintubation. k spezielle maßnahmen rezidivierender krupp nach entsprechender allergologischer diagnostik sind spezifische allergenkarenzmaßnahmen einzuleiten. unspezifische reizfaktoren, z.b. passivrauchexposition, sollten minimiert werden. ein gastroösophagealer reflux ist besonders bei jungen kindern auszuschließen. eine inhalationstherapie mit steroiden kann im gegensatz zum asthma bronchiale effektiver sein mit einem feuchtvernebler statt einem dosieraerosol. die hierbei produzierten tröpfchen sind größer und deponieren sich vermehrt in den oberen atemwegen. diphtherie beim diphtheriekrupp muss sofort mit einer antitoxinbehandlung begonnen werden (20000-30000 einheiten i.m. oder i.v., alternativ 1000 ie/kg kg fraktioniert i.m.). dieses ist verfügbar in den notfalldepots der apotheken. eine intrakutane oder konjunktivale vortestung mit 0,1 ml der verdünnten lösung sollte aufgrund einer möglichen sensibilisierung durch früher injizierte pferdeseren (tetanusimpfstoffe) durchgeführt werden. außerdem ist mit pencillin (100000 e/kg kg/tag) oder erythromycin (50 mg/kg kg/tag) zu behandeln. j verlauf und komplikationen überwiegend verläuft die krupp-symptomatik so mild, dass eine ambulante weiterversorgung möglich ist. allerdings ist gerade am beginn der symptomatik der weitere verlauf schwer abzuschätzen, sodass bei moderaten symptomen grad 2 und 3 eine engmaschige überwachung gewährleistet sein muss. eine vorübergehende besserung nach adrenalin-in halation ist mit zu berücksichtigen und erst eine erneute untersuchung nach 2-4 h lässt abschätzen, ob der krankheitsverlauf sich durch die mittlerweile wirksam gewordene steroidtherapie stabilisiert hat und eine weitere betreuung zu hause erlaubt. hat sich die symptomatik gebessert, so ist auch mit einem abklingen des stridors innerhalb der nächsten 24-36 h zu rechnen, während die übrigen symptome wie heiserkeit und husten noch etwa eine woche länger persistieren. erneutes auffiebern lässt eine bakterielle superinfektion vermuten. nach abklingen der krupp-symptome erfolgt in etwa der hälfte der fälle eine weitere krupp-episode, sodass dann die erweiterte diagnostik für rekurrierende krupp-syndrome empfohlen wird. eine lungenfunktionsprüfung vor und nach belastung bzw. bronchospasmolyse kann hierbei die asthmatische komponente aufdecken. definition, assessment and treatment of wheezing disorders in preschool children: an evidencebased approach complexity of chronic asthma and chronic obstructive pulmonary disease: implications for risk assessment, and disease progression and control the challenge of managing wheezing in infants diagnosis and management of bronchiolitis behandlung der bronchiolitis im säuglingsalter -empfehlungen der management of acute bronchiolitis: can evidence-based guidelines alter clinical practice? acute virale bronchiolitis: to treat or not to treatthat is the question observational study of two oxygen saturation targets for discharge in bronchiolitis glucocorticoids for acute viral bronchiolitis in infants and young children bronchodilators for bronchiolitis acute respiratory distress syndrome induced by respiratory syncytial virus the burden of respiratory syncytial virus infection in young children bronchiolitis in infants respiratory syncytial virus, human bocavirus and rhinovirus bronchiolitis in infants empiric antibiotics are justified for infants with respiratory syncytial virus lower respiratory tract infection presenting with respiratory failure: a prospective study and evidence review acute viral bronchiolitis in children -a very common condition with few therapeutic options respiratory syncytial virus prevention and therapy: past, present, and future obstruktive bronchitis definition, assessment and treatment of wheezing disorders in preschool children: an evidencebased approach diagnosis of asthma in children under five preemptive use of high-dose fluticasone for virus-induced wheezing in young children the challenge of managing wheezing in infants rhinovirus infections in infancy and early childhood validation of the asthma predictive index and comparison with simpler clinical prediction rules controversies in the management of preschool viral wheeze oral prednisolone for preschool children with acute virus-induced wheezing short-course montelukast for intermittent asthma in children: a randomized controlled trial long-term studies of the natural history of asthma in childhood genetic risks and childhood-onset asthma comorbidities of asthma during childhood: possibly important, yet poorly studied exposure to environmental microorganisms and childhood asthma the development of allergic inflammation innate and adaptive immune responses in asthma wheezing rhinovirus illnesses in early life predict asthma development in high-risk children asthma mortality in the danish child population global variation in the prevalence and severity of asthma symptoms prevalence of overweight and obesity in the united states worldwide trends in the prevalence of asthma symptoms: phase iii of the international study of asthma and allergies in childhood (isaac) the melbourne asthma study: 1964-1999 overweight and changes in weight status during childhood in relation to asthma symptoms at 8 years of age asthma in smokers: challenges and opportunities untangling asthma phenotypes and endotypes how does exercise cause asthma attacks? current opinion in asthma deaths during sports: report of a 7-year experience uniform definition of asthma severity, control, and exacerbations: document presented for the world health organization consultation on severe asthma definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach role of viral respiratory infections in asthma and asthma exacerbations identifying and managing the infant and toddler at risk for asthma problematic severe asthma in children, not one problem but many: a ga2len initiative perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study the german severe asthma registry exercise-induced bronchospasm in children acute asthma attacks in childhood the common cold-principles of judicious use of antimicrobial agents diagnostik empfehlungen zur behandlung der obstruktiven atemwegserkrankungen im kindesalter (sgpp/pia 2009 schweiz) nationale versorgungsleitlinie asthma langfassung, 2. auflage, version 1.3, juli therapie global initiative for asthma (gina). the global strategy for asthma management and prevention die spezifische immuntherapie (hyposensibilisierung) bei ige-vermittelten allergischen erkrankungen, leitlinien der deutschen gesellschaft allergologie und klinische immunologie (dgaki), des ärzteverbandes deutscher allergologen (äda), der gesellschaft für pädiatrische allergologie und umweltmedizin (gpa), der österreichischen gesellschaft für allergologie und immunologie (ögai) und der schweizerischen gesellschaft für allergologie und immunologie (sgai) childhood asthma research and education (care) network of the national heart, lung, and blood institute: step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids expert panel report 3: guidelines for the diagnosis and management of asthma. full report leitlinie zur behandlung des asthma bronchiale bei kindern und jugendlichen empfehlungen zur behandlung der obstruktiven atemwegserkrankungen im kindesalter (sgpp/ pia-ch nebulized epinephrine for croup in children humidified air inhalation for treating croup: a systematic review and meta-analysis risk of asthma in children with a history of croup effect of inhaled fluticasone propionate administered with metered dose inhaler and spacer in mild to moderate croup: a negative preliminary report croup and recurrent croup: their association with asthma and allergy. an epidemiological study on 5-8-year-old children prospective randomized double-blind study comparing l-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup) durch den erhöhten intratrachealen druck während der exspiration nicht mehr auszugleichen. die dabei entstehenden turbulenzen führen zu einem exspiratorischen stridor, der meist noch etwas leiser ist als der inspiratorische stridor (. abb. 27.18c ). in-und exspirationszeiten werden dadurch verlängert und beeinträchtigen die ventilation, sodass eine hypoxie entsteht. das kind wird unruhig und ängstlich, gelegentlich auch kaltschweißig und tachykard.ausgeprägter krupp grad 4 die luftströmung ist durch die hochgradige stenose mittlerweile so weit eingeschränkt, dass kaum noch turbulenzen entstehen (= laminarer flow) und das in-und exspiratorische geräusch nur noch sehr leise ist (. abb. 27.18d). die atemarbeit ist nun erheblich angestiegen durch den zusätzlichen einsatz der bauchmuskulatur während der exspiration. die hypoxämie begünstigt die muskuläre erschöpfung mit dann sehr rasch eintretender globalinsuffizienz. neben einer zyanose führt der anstieg des pco 2 zu einer eintrübung des bewusstseins, sodass eine zügige intubation notwendig wird. infolge sehr hoher negativer intrapulmonaler drucke kann sich ein lungenödem mit konsekutiver rechtsherzbelastung entwickeln. k endoskopie bei atypischer symptomatik sollte endoskopiert werden. aller dings birgt gerade eine stenosierung der oberen atemwege besondere risiken. bereits durch eine sedierung können kompensationsmechanismen wegfallen, wie die opisthotonushaltung des kopfs oder die muskuläre anspannung des hypopharynxbereichs, und dies kann rasch zu einer obstruktiven apnoe führen, die auch mit reiner maskenbeatmung schwer beherrschbar ist. ein güdel-tubus bzw. eine larynxmaske sollten somit verfügbar sein. durch hypostase im liegen kann ein glottisches ödem zunehmen, sodass inhalierbares oder topisch aufsprühbares adrenalin bereitstehen muss. die narkose sollte die notwendige vermehrte atemanstrengung möglichst nicht beeinträchtigen. allerdings muss sie auch entzündungsbedingt überschießende reflexe, z.b. einen laryngospasmus, unterdrücken. hieraus ergibt sich die notwendigkeit eines sehr erfahrenen teams aus anästhesist und endoskopeur, der rasch die untersuchung durchführen muss möglichst ohne die entzündliche stenose zu touchieren. lässt sich dies nicht vermeiden, kann eine nachfolgende intubation notwendig werden. hierzu nimmt man stets einen etwas dünneren tubus als üblich und bestreicht ihn äußerlich mit festhaftender kortisoncreme (z.b. diprogenta). der richtig platzierte tubus muss gegen artifizielle extubation sehr gut gesichert werden. key: cord-270647-vn4kirrx authors: romero-espinoza, jose a.; moreno-valencia, yazmin; coronel-tellez, rodrigo h.; castillejos-lopez, manuel; hernandez, andres; dominguez, aaron; miliar-garcia, angel; barbachano-guerrero, arturo; perez-padilla, rogelio; alejandre-garcia, alejandro; vazquez-perez, joel a. title: virome and bacteriome characterization of children with pneumonia and asthma in mexico city during winter seasons 2014 and 2015 date: 2018-02-15 journal: plos one doi: 10.1371/journal.pone.0192878 sha: doc_id: 270647 cord_uid: vn4kirrx background: acute asthma exacerbations and pneumonia are important causes of morbidity and mortality in children and may coexist in the same children, although symptom overlap may lead to difficulties in diagnosis. microbial and viral diversity and differential abundance of either may play an important role in infection susceptibility and the development of acute and chronic respiratory diseases. objectives: to describe the virome and bacteriome present in the upper respiratory tract of hospitalized children with a clinical diagnosis of asthma and pneumonia during an acute exacerbation and an acute respiratory illness ari episode respectively. methods: during the winter seasons of 2013–2014 and 2014–2015, 134 nasopharyngeal swabs samples of children <15 years of age with ari hospitalized at a referral hospital for respiratory diseases were selected based on clinical diagnosis of asthma or pneumonia. the virome and bacteriome were characterized using whole genome sequencing (wgs) and in-house bioinformatics analysis pipeline. results: the asthma group was represented mainly by rv-c, bov-1 and rsv-b and the pneumonia group by bacteriophage ej-1 and ttmv. ttv was found in both groups with a similar amount of reads. about bacterial composition moraxella catarrhalis, propionibacterium acnes and acinetobacter were present in asthma and veillonella parvula and mycoplasma pneumoniae in pneumonia. streptococcus pneumoniae and haemophilus influenzae were mostly found with both asthma and pneumonia. conclusions: our results show a complex viral and bacterial composition in asthma and pneumonia groups with a strong association of rv-c presence in asthmatic children. we observed streptococcus pneumoniae and haemophilus influenzae concurrently in both groups. acute respiratory infection (ari), both from the upper and lower tract (urti/lrti), represent a major public health problem worldwide especially in developing countries [1, 2] . besides being one of the most common diseases, it is a leading cause for health care use, and mortality, particularly due to the presence of pneumonia [3] [4] [5] . in the clinical practice, acute asthma exacerbations and pneumonia have an overlap of symptoms, and may also coexist, leading to misdiagnosis. for example over-diagnosis of pneumonia and under-diagnosis of asthma may contribute to significantly untreated respiratory morbidity and mortality in children less than five years old in low-income countries [6] . both groups differ with respect to the associated virus and bacteria: while asthma exacerbations have been associated to a specific rhinovirus infection, pneumonia can be related to a wide range of bacterial, fungal and viral agents, with a high prevalence of respiratory syncytial virus (rsv) [2, 7] . it has been proposed that microbial composition plays an important role in infection susceptibility and the development of acute and chronic respiratory diseases [8] . recent studies describe the community of microorganisms that reside in the respiratory tract, referred to also as the microbiome, by using next generation sequencing (ngs), and in most cases by evaluating bacterial components based only for specific gene (16s) [9, 10] . on the other hand, the whole genome shotgun (wgs) approach provides enough information to identify all viral and bacterial species not only for a specific gene [11] . while bacterial composition of the microbiome is called bacteriome, the virome (or viral metagenome) refers to the viral fraction comprising viruses responsible for acute, persistent, or latent infections, and viruses integrated into the host genome such as endogenous retroviruses [12] . a limited number of studies have attempted to characterize the virome (yang et. al. [13] ; zoll et.al. [14] ; moesker et.al. [15] ; wang et.al. [16] ; bal et.al. [17] ) and bacteriome (hilty et. al. [10] ; taboada et.al. [18] ; teo et.al. [19] ) of pediatric patients with aris. a few others studies have used well-defined clinical parameters of asthma exacerbation and pneumonia (moreno-valencia et.al. [2] ; vazquez-perez et.al. [20] ). here we describe the virome and bacteriome present in the upper respiratory tract of hospitalized children clinically diagnosed with asthma and pneumonia, during an acute exacerbation and an ari episode respectively, at the national institute of respiratory diseases (iner, mexico city) during 2014 and 2015 winter seasons. the science and bioethics committee of the national institute of respiratory diseases revised and approved the protocol and the consent procedure (b2613). for all children, the corresponding legal guardians provided written informed consent. nasopharyngeal swabs (ns) were collected from children less than 15 years of age with clinical signs of aris hospitalized at the national institute of respiratory diseases (iner) in mexico city, a referral center for respiratory diseases, which primarily provided services for uninsured individuals, during the winter season 2013-2014 and 2014-2015. all subjects enrolled were classified with an asthmatic crisis (characterized by wheezing and difficult breathing especially in previously known asthmatics or with atopic symptoms) or pneumonia (with the presence of new lung opacities, with changes in the white blood count). maximum sample number for each group was defined after each season, resulting in 42 for asthma, and 78 for pneumonia (table 1) . for all samples, automated nucleic acids isolation was performed on magna pure lc 2.0 using the total nucleic acids kit (roche diagnostics). an in-house rt-qpcr respiratory viral panel (moreno-valencia et al., 2015) was used as previous screening and for virus identification (s1 table and s1 appendix). nucleic acids were isolated directly from stored samples. for each one, 250 μl of transport media was centrifuged at 5,000xg for 5min to remove cellular debris. the supernatant was filtered through 0.2 μm-pore-size disc filters (syringe filter, corning). samples were pooled in a 15ml concentrator tube (amicon ultra -15, merck millipore) and centrifuged at 4,000xg until volume was reduced to 500 μl. nucleic acids were isolated from the concentrated sample pool using the purelink viral rna/dna kit according to the manufacturer's instructions (invitrogen, waltham, ma). nucleic acids were eluted in 60 μl of nuclease free water and stored in aliquots at -80˚c. to improve viral detection, one aliquot of 20 μl for each extraction was processed for rna viruses and another aliquot for dna viruses. the aliquot for rna viruses was treated with rnase-free dnase i, (thermo scientific) for 30 min at 37˚c and immediately chilled on ice. to reduce the amount of human dna, the aliquot for dna viruses was treated with nebnext microbiome dna enrichment kit, according to the manufacturer's instructions (new england biolabs inc.). for rna viruses, reverse transcription was performed on 10 μl de rna using a m13-random hexamer primer with transcriptor first strand cdna synthesis kit (roche diagnostics) next double strand cdna (dscdna) was generated by two rounds of synthesis using m13-random hexamer primer with klenow fragment (thermo scientific). for dna viruses and bacteria, dna previously enriched was labeled using m13-random hexamer primer. dna from each process was amplified with platinum taq dna polymerase high fidelity (thermo scientific) using m13 primers and the following program: 2 min 95˚c, 30 cycles of 15 sec at 95˚c, 30 sec at 50˚c, 3 min at 68˚c and a final step of 5 min at 68˚c. dna was quantified by qubit dsdna hs assay kit (thermo scientific), and length fragment was evaluated with agilent high sensitivity dna kit (agilent technologies). a whole genome approach (shotgun) was used for both viral and bacterial genomes. libraries were built with 1 ng of amplified dna from each sample of rna viruses and dna viruses/ bacteria, and processed with nextera xt dna library preparation kit according to the manufacturer's instructions (illumina). libraries were labeled with nextera xt index kit (illumina) according the s1 table and pooled into one. the pooled library was loaded in a flow cell and sequencing was performed in a miseq desktop sequencer (illumina) to obtain paired-end reads of 250 bp in length (2x250). an in-house pipeline was developed to perform the bioinformatics analysis for all files (fig 1 step 3) . datasets of human, bacteria and virus sequences (downloaded from the ncbi ftp server in march 2015) were downloaded to build smalt, bwa index, local blastn and blastx databases. all data from miseq instrument were trimmed through a phred-like q20 < 20 using fastqc software. reads were aligned to databases described above using a standalone blastn for direct assignment of each read with an evalue of 1e-30. for viruses, blastn with an e-value of 1e-30 and blastx with an e-value of 1e-01, on trimmed reads and after human, bacterial and viral mapping, were used respectively. velvet algorithm was used for contig assembly. to reduce data complexity for bacterial detection, human sequences were removed by mapping with human smalt index before the pathogen identification process (fig 1, step 3 ). bacterial species were identified using local blastn with an e-value of 1e-30 and the first 10 hits were obtained for each sequence. megan [21] 5.2.2 software was used to assign reads to the most appropriate taxonomic level, by assigning a read to the lowest common taxonomic ancestor of the organisms corresponding to the set of significant hits. for the rhinovirus analysis, full-length genome of human rhinovirus a, b c (rv-a, rv-b, rv-c), enterovirus 68 and 71 (ev68, ev71) were retrieved from the genbank database. for phylogenetic analysis of parvovirus b19 (pvb19), bocavirus (bov) and respiratory syncytial virus b (rsv-b), full-length genomes of representative sequences of human strains were used. analyses also were performed for three different anellovirus, torque teno virus (ttv), torque teno midi virus (ttmdv) and torque teno mini virus (ttmv). alignments were created and manually edited with mega [22] 6.0. unrooted maximum likelihood tree with 1,000 bootstrap replicates was constructed using the tajima-nei model with 5-parameter gamma distributed rates. one hundred and twenty respiratory samples were grouped into seven pools: asthma 2014 (a2014), asthma 2015 (a2015), pneumonia 2014 (p2014) and pneumonia 2015 (p2015) each one with qpcr positive (qpcr+) and qpcr negative (qpcr-) results, except qpcr-for a2015 season since we did not have enough samples to analyze (s1 table) . the average amount of sequences obtained from each group after quality filtering was 2,247193 within a range of 3,634,710 to 519,470 reads. from those reads, 0.18 to 0.35% belonged to viral or bacterial sequences, and as much as 28.08% belonged to endogenous retrovirus and sequences without certain identification. to describe the virome of the two groups of children, we grouped reads from both seasons 2014 and 2015 into one. the most represented viruses were in order of number of reads rhinovirus c (rv-c), bocavirus 1 (bov-1), rsv-b and parvovirus b19 (pvb19) in patients with asthma while bacteriophage ej-1, ttmv, streptococcus phage, rsv b and rv a were in subjects with pneumonia. ttv, influenza virus and staphylococcus phage were present in similar levels for both groups of patients ( table 2 ). most of the viral reads were classified into six virus families picornaviridae, parvoviridae, paramyxoviridae, anelloviridae, orthomyxoviridae and herpesviridae (fig 2a and 2b) . bacteriopaghes also had high abundance of reads ( fig 2b) . the viral composition in samples was complex and dominated by the most common respiratory four representative viruses were used to compare the genome coverage and depth. contigs were ensembled to generate partial consensus genomes of rv-c (97% coverage, 6,824 bp) (s1 the bacterial composition in samples was also complex. streptococcus pneumoniae and haemophilus influenzae were the species with more reads in both groups. staphylococcus aureus, mycoplasma pneumoniae veillonella parvula and different streptococcus spp had more reads in the pneumonia group (fig 3a and 3b) . while moraxella catarrhalis, acinetobacter and propionibacterium acnes had more reads in the asthma group. other bacteria genus detected of clinical interest with low frequency were: pseudomonas, neisseria and prevotella. we conducted a metagenomic analysis of the virome and bacteriome of children with asthma and pneumonia. this is the first report to describe both communities in a well-defined group of pediatric patients. previously, our group reported the role of specific viral infections on asthma exacerbations in hospitalized children using rt-qpcr detection [2, 20] . although rt-qpcr is the gold standard for viral and bacterial diagnosis, it is still limited to specific target assays. by contrast, ngs is a platform that generates millions of reads without the need of previous knowledge of the sequences present in a sample. it is also a powerful tool to confirm and discover microbial etiologies in clinical samples. whole genome shotgun sequencing (wgs) provides enough information to identify microbes to the species level as a result of a more accurate alignment with genome reference sequences, not just in particular for specific genes such as 16s in bacteria [11] . in our analyses, most of the bacterial reads were classified into a species level, implying that wgs can be a useful tool to describe the microbiome in a clinical sample. in our study, 90% of reads were classified as q30, and only 5% were discarded due to low sequencing quality. after being analyzed, human reads ranged from 71 to 91% in each group despite the use of an experimental strategy to reduce human dna. these values are found in the same range for equivalent sample types previously reported by yang et al. [13] and nakamura et al. [23] : 76-95% and 90-94.6%, respectively. however, the percentage range obtained for bacterial and viral reads (0.10-0.32%) was lower than the quantities previously reported by yang et al.(1.03%) [13] , nakamura et al. (1.33-3 .48%) [23] and taboada et al. (9.4%) [18] . all viruses detected by the qpcr panel were identified through ngs except coronavirus 229e in the asthma group and coronavirus 229e and adenovirus in the pneumonia group, probably owing to a low number of reads and the dilution effect of sample-pooling. however, the ngs method combined with the bioinformatics workflow showed greater sensitivity for detection of infa h1n1, piv-1 and bov-2 compared with qpcr detection, probably as a result of the identification of less conserved sequences. moreover, other viruses such as ttv, ttmv, ttmdv and different phages like propionibacterium phage, streptococcus phage, staphylococcus phage and bacteriopage ej-1 were also detected without having knowledge of the viruses. a diverse viral community was found in the respiratory tract of children with asthma and pneumonia; rv-c and rsv-b were the predominant species. viruses found in these respiratory samples belonged to different families, mainly picornaviridae, orthomyxoviridae and paramyxoviridae. members of the anelloviridae family were found in both groups of pediatric patients; although members of this family are usually considered ubiquitous and benign, a potential role of ttmv in pneumonia pathogenesis has been suggested [24] , other studies have implicated ttv as contributing elements in lung impairment and it has been associated with asthma [25] and chronic obstructive pulmonary disease (copd) [26] . even so, more studies are needed to elucidate the role of respiratory pathogenicity of the torque teno viruses. evd68 has been associated with asthma exacerbation and pneumonia in children [20] , in this study, ev-d68 was detected in the 2014-2015 winter seasons, confirming the presence of this virus in mexico city. with respect to cmv, some studies have found evidence of its implications in asthma pathogenesis and asthmatic inflammation [27] . infa h1n1pdm09 was found in most of the studied groups, its participation and association with bacterial pneumonia [7] are well known, but a strong association with asthma exacerbation has been reported as well [28] . among other of the found viruses, adenovirus (adv) has been associated with pneumonia [29] , and bov has been deemed as a cause of sari in the absence of viral and bacterial co-infections [15] . finally, wiersbitzky et al. [30] suggested that pvb19 can cause acute respiratory diseases with obstructive ventilatory disturbances of the upper or lower airways in children with a specific endogenous predisposition. other components detected in the viruses were bacteriophages, viruses commonly excluded in the final analysis of the viral community, yet, these highly suggest the presence of their specific bacterial hosts in the sample. we compared our results to previous reports that have used metagenomics in children [17] , and shown strategies that use pooling of samples (lysholm et.al. [31] and wang et.al. [16] ), where greater diversity has been found. in our study, we detected 25 different species of viruses using this same strategy. this is most likely due to a greater ability of analyzing more samples in the same library, thereby increasing the probability to detect more viruses. in our study, we found the preferred virus associated with respiratory diseases, rhinovirus, and consistent with others reports (lysholm et.al. [31] and wylie et.al. [12] ), however in contrast with a report from wang et.al. [16] that found a higher prevalence of rsv-b. furthermore, few reports included healthy individuals as a control group (wang et.al [16] ), detecting lesser viral diversity with a high prevalence of viruses belonging to the anelloviridae family. according to this report, the torque teno virus and torque teno mini virus that we found in children with asthma and pneumonia in our study, may be otherwise normal residents in children free of respiratory disease. further data is lacking concerning the prevalence of viruses in the respiratory tracts of healthy children, which may be a limitation of our study. in performing the bacteriome analysis, we found streptococcus pneumoniae and haemophilus influenzae had the greater amount of identified reads in both groups with a significant presence of moraxella and staphylococcus aureus in asthma and pneumonia groups respectively (fig 3a and 3b ). these findings are consistent with data reported by bisgaard et al. [32] and hilty et al. [10] for children with asthma. before rendering judgment, is important to remember that the individual presence of any virus or bacteria does not determine a direct cause for disease. interactions between invaders and host commensals may offer a better understanding about respiratory diseases [33] . identifying coinfections between different microorganisms either between viruses or viruses and bacteria is essential in determining the etiology of the respiratory disease. identifying the etiologic agents present on each disease may assist in developing better treatments and thereby improving patient care. metagenomic and bioinformatic analyses are very powerful tools to describe the microbiome, which allow discerning the etiologic agents involved, and eventually may lead to the discovery of new respiratory viruses. molecular detection of human rhinoviruses in respiratory samples: a comparison of taqman probe-, sybr green i-and boxtobased real-time pcr assays detection and characterization of respiratory viruses causing acute respiratory illness and asthma exacerbation in children during three different season (2011-2014) in mexico city. influenza other respir viruses respiratory severity score separates upper versus lower respiratory tract infections and predicts measures of disease severity characterization of acute respiratory infections among 340 infants in wuxi human pharyngeal microbiome may play a protective role in respiratory tract infections simple predictors to differentiate acute asthma from ari in children: implications for refining case management in the ari control programme the role of respiratory viruses in the etiology of bacterial pneumonia: an ecological perspective host-microbiome interactions in acute and chronic respiratory infections the lung microbiome and exacerbations of copd disordered microbial communities in asthmatic airways strengths and limitations of 16s rrna gene amplicon sequencing in revealing temporal microbial community dynamics sequence analysis of the human virome in febrile and afebrile children unbiased parallel detection of viral pathogens in clinical samples by use of a metagenomic approach direct multiplexed whole genome sequencing of respiratory tract samples reveals full viral genomic information human bocavirus infection as a cause of severe acute respiratory tract infection in children metagenomic analysis of viral genetic diversity in respiratory samples from children with severe acute respiratory infection in china metagenomic analysis of the respiratory virome associated with acute respiratory illness of unknown etiology in infants is there still room for novel viral pathogens in pediatric respiratory tract infections? the infant nasopharyngeal microbiome impacts severity of lower respiratory infection and risk of asthma development ev-d68 infection in children with asthma exacerbation and pneumonia in mexico city during 2014 autumn. influenza other respir viruses microbial community analysis using megan mega: molecular evolutionary genetics analysis software for microcomputers direct metagenomic detection of viral pathogens in nasal and fecal specimens using an unbiased high-throughput sequencing approach potential implication of new torque teno mini viruses in parapneumonic empyema in children associations between nasal torquetenovirus load and spirometric indices in children with asthma the presence of torque teno virus in chronic obstructive pulmonary disease cytomegalovirus dna is highly prevalent in the blood of patients with asthma and is associated with age and asthma traits prevalence of respiratory viral infection in children hospitalized for acute lower respiratory tract diseases, and association of rhinovirus and influenza virus with asthma exacerbations characteristics of adenovirus pneumonia in korean military personnel characterization of the viral microbiome in patients with severe lower respiratory tract infections, using metagenomic sequencing childhood asthma after bacterial colonization of the airway in neonates viral and bacterial interactions in the upper respiratory tract key: cord-336562-5qmzne98 authors: auten, richard; ren, clement; yilmaz, ozge; noah, terry l. title: pediatric pulmonology year in review 2016: part 2 date: 2017-04-25 journal: pediatr pulmonol doi: 10.1002/ppul.23719 sha: doc_id: 336562 cord_uid: 5qmzne98 pediatric pulmonology continues to publish research and clinical topics related to the entire range of children's respiratory disorders. as we have done annually in recent years, we here summarize some of the past year's publications in our major topic areas, as well as selected literature in these areas from other core journals relevant to our discipline. this review (part 2) covers selected articles on neonatology, asthma, physiology and lung function testing, and infectious diseases. pediatric pulmonology continues to publish research and clinical topics related to the entire range of children's respiratory disorders. as we have done annually in recent years, we here summarize some of the past year's publications in our major topic areas, as well as selected literature in these areas from other core journals relevant to our discipline. this review (part 2) covers selected articles on neonatology, asthma, physiology and lung function testing, and infectious diseases. since mechanical ventilation inevitably exposes the developing respiratory system to unpredictable mechanical strains and stresses, clinicians have long sought safer and less invasive approaches to respiratory support, and better tools with which to monitor respiratory function during intensive care. there has been a trend to substitute high flow nasal cannulae which are able to deliver positive pressure, but this pressure is typically not regulated or monitored. in an effort to define the limitations of this approach, gerdes et al 1 identified factors affecting delivered mean airway pressure during nasal cpap delivery with the ram™ cannula, an increasingly widely used device favored by some because of its apparent toleration compared with other devices that require more complex fixation systems. using a polymer model of the upper airway and lip, ram cannulae, and corresponding standard ncpap prongs were affixed and delivered pressures measured using a pneumotachograph. as expected, complete occlusion of the nasal passage with either the ram cannula or "standard" nasal prongs delivered comparable pressures that approximated the set pressure, providing that the ram cannula was fully inserted. however, the authors point out a critical limitation to using the ram cannula, namely that nasal expiratory resistance will be quite high if the nares are occluded. for babies that must be managed with mechanical ventilation, efforts are underway to improve both delivery and accurate monitoring of therapy. the safe use of high-frequency ventilation in newborns limits the ability of the clinician to assess ventilation in realtime. minute ventilation and tidal volume cannot be measured, and capnography has been limited to transcutaneous co 2 measurements, which have been problematic in very premature newborns that may not tolerate the skin temperatures that until very recently have been required for accurate measurement. kugelman et al 2 evaluated capnography using a 2-lumen endotracheal tube and microstream capnography correlated with arterial blood gas measurements obtained from an indwelling line. although accuracy was not acceptable, capnography was able to predict very low p a co 2 < 30 torr and very high p a co 2 above 60 torr. respiratory volumes can also be assessed non-invasively using electrical impedance. van findings with their earlier reports of increased methacholine induced respiratory system resistance. 11 the evidence for human susceptibility to neonatal and early childhood pulmonary insults that affect lung function in adulthood continues to mount, as reviewed by goldizen et al. 12 impairments of small airway function were reported by verheggen et al, 13 reporting a case-control comparison of pulmonary function testing in 4-to 8-year old subjects born before 32 weeks with or without bpd. they used forced oscillometry or spirometry. they reported that pulmonary reactance, an oscillometric method used to assess small airway function, was worse in bpd subjects. although this finding is not surprising, it should be tempered by the relatively low recruitment rate they experienced from their original qualifying cohort. factors associated with bpd risk like duration of oxygen exposure and male sex were also associated with increased pulmonary reactance. the genetic basis of asthma has been investigated in many studies recently. hua et al 14 investigated the gene-gene interactions among variants of the il13, il4, il4ra, fcer1b, and adrb2 genes, which have been associated with asthma in children, and demonstrated that single nucleotide polymorphisms il13 rs20541, il4 rs2243250, adrb2 rs1042713n, and fcer1b rs569108 were associated with asthma. moreover, risk of asthma was increased more than 10 times in carriers of all four risk homozygotes (il13 rs20541 gg, il4 rs2243250 tt, adrb2 rs1042713 aa, and fcer1b rs569108 gg). these results add to the evidence for a role for epigenetic mechanisms in the relationship between environmental smoke exposure during pregnancy and pediatric asthma. gene-environment interaction is also important in the development of pediatric asthma. research done in rural and urban parts of china on 854 children revealed that physician diagnosed asthma was significantly lower in children living in rural areas. personal and family history of atopy, high consumption of milk products, and hospitalization younger than three years of age were significantly associated with asthma. similarly, being a member of a crop-farming family and dust endoxtoxin levels were negatively associated with asthma in the child. 16 lautenbacher et al 17 investigated the effects of vitamin d on pulmonary function and compared obese and non-obese asthmatic children. although the frequency of vitamin d deficiency was not different between groups, fev1 and frc were significantly worse in vitamin d deficient obese children than in normal-weight children. moreover, tnf and il-8 were higher in obese asthmatics, while the th2 cytokine il13 was higher in normal-weight asthmatics. however, these inflammatory measures were not related to the association of vitamin d deficiency with poor lung function; thus implying an independent effect of vitamin d deficiency. coexistence of obesity and poor asthma control is well known, but body mass index (bmi) may not reflect regional differences in adiposity. as part of the asthmap-2 project that is an observational study of pediatric asthma, association of neck circumference and asthma control was assessed. 18 it was demonstrated that, in boys, neck circumference combined with bmi explained the variability of asthma control test better than bmi alone. air pollution has a significant influence on respiratory health. rice et al 19 although inflammatory markers did not correlate with ahr, the degree of ahr was less in those study subjects who were receiving hyroxyurea. their results demonstrate that there is a high prevalence of ahr in scd patients and hydroxyurea may be helpful in decreasing ahr in scd. lunt et al 38 impulse oscillometry (ios) uses the forced oscillation technique to assess airway function and does not require the maximal forced expiratory maneuver needed for spirometry. 39 ios measures total respiratory impedance (z) which is a complex number that incorporates both the in and out phase elements of resistance; the former is resistance (r), and the latter is termed the reactance (x). r reflects the airway resistive properties of the respiratory system, while x reflects the visco-elastic and inertive elements of the respiratory system. potential limitations of this method include a limit on the size of the patients studied due to limitations on the volume of the washout collection bag and an inability of detect leak since there is no pnt. this system will require further study in human subjects before determining its utility in clinical research and patient care. tidal breathing analysis is a method to assess respiratory function that does not require sedation or manipulation of the infant's respiratory system. 45 respiratory inductance plethysmography has been used to obtain tidal breathing data, but it only measures chest and abdominal excursion at two points, which does not accurately reflect the true mechanics of the respiratory system. reinaux et al 46 used opto-electronic plethysmography (oep) to measure motion at 52 sites placed in the thorax and abdomen of healthy infants and compared the results obtained using this system to those obtained using a mask with pnt. they found that measurement of tidal volume using oep was in good agreement with that obtained using a pnt with a mean difference of only 0.02 ml. the ability to obtain tidal breathing measurements may lead to new insights into changes in chest and abdominal motion in pediatric respiratory disease. bronchopulmonary dysplasia (bpd) is the most common respiratory complication of preterm birth. despite advances in neonatal medicine, bpd still occurs in 30-50% of infants born before a gestational age (ga) of 29 weeks. 47 acute viral bronchiolitis, due to rsv and other pathogens, continues to have a major impact worldwide on childhood mortality and hospital admissions, 51 is associated with subsequent asthma and allergy risk, 52 and could be increasing in incidence. 53 cangiano et al 54 noted a higher incidence of acute bronchiolitis every 4 years among previously health term infants, largely due to rsv; rhinovirus was a less common cause and had less tendency to occur in seasonal clusters than rsv. while a commonly used standard definition for bronchiolitis is initial episode of wheezing in a child <12 months old, variability in how clinicians actually define bronchiolitis was highlighted in a report from fernandes et al. 55 beamer et al 56 treatment for acute bronchiolitis remains largely supportive and progress has been made in reducing widespread use of corticosteroids and bronchodilators, which have previously been shown to be ineffective. 57 flores et al 58 conducted a randomized clinical trial comparing 3% hypertonic saline to normal saline in previously healthy infants hospitalized with mild-to-moderate acute viral bronchiolitis. the median length of hospital stay, severity score, and need for supplemental oxygen did not differ significantly between groups. patients receiving hypertonic saline had significantly more cough (46% vs 20%, p = 0.025). thus, the study does not support the use of nebulized hypertonic saline over normal saline in therapy of hospitalized children with mild-to-moderate acute viral bronchiolitis. in another study with practical implications, heikkila et al 59 factors influencing delivered mean airway pressure during nasal cpap with the ram cannula diagnostic accuracy of capnography during high-frequency ventilation in neonatal intensive care units the effect of prolonged lateral positioning during routine care on regional lung volume changes in preterm infants role of electrical impedance tomography in clinical practice in pediatric respiratory medicine fgr in the setting of preterm sterile intra-uterine milieu is associated with a decrease in rds association of bnp, ntprobnp, and early postnatal pulmonary hypertension in very preterm infants bronchopulmonary dysplasia impairs l-type amino acid transporter-1 expression in human and baboon lung pulmonary ventilation and micro-structural findings in congenital diaphragmatic hernia neonatal hyperoxia increases airway reactivity and inflammation in adult mice perinatal nicotine exposure induces myogenic differentiation, but not epithelial-mesenchymal transition in rat offspring lung perinatal nicotine exposure induces asthma in second generation offspring respiratory effects of air pollution on children respiratory function and symptoms in young preterm children in the contemporary era four-locus gene interaction between il13, il4, fcer1b, and adrb2 for asthma in chinese han children dna methylation in newborns and maternal smoking in pregnancy: genome-wide consortium metaanalysis associations of early life exposures and environmental factors with asthma among children in rural and urban areas of guangdong vitamin d and pulmonary function in obese asthmatic children sex differences in the association between neck circumference and asthma lifetime exposure to ambient pollution and lung function in children association between trafficrelated air pollution and asthma in preschool children in a national japanese nested case-control study postpartum depression, a direct and mediating risk factor for preschool wheeze in girls prenatal maternal stress and atopic diseases in the child: a systematic review of observational human studies looking beyond patients: can parents' quality of life predict asthma control in children? asthma action plan receipt among children with asthma 2-17 years of age can a single dose response predict the effect of montelukast on exerciseinduced bronchoconstriction? albuterol via metered-dose inhaler in children: lower doses are effective, and higher doses are safe exhaled breath temperature measurement and asthma control in children prescribed inhaled corticosteroids: a cross sectional study infection and inflammation in induced sputum from preschool children with chronic airways diseases association between exhaled inflammatory markers and asthma control in children concordance between bronchial hyperresponsiveness, fractional exhaled nitric oxide, and asthma control in children patterns of growth and decline in lung function in persistent childhood asthma differences in pulmonary functions in various racial groups multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations pulmonary diffusing capacity in healthy african-american and caucasian children spirometric reference values for hopi native american children ages 4-13 years pulmonary complications of sickle cell disease airway hyperreactivity is frequent in non-asthmatic children with sickle cell disease longitudinal assessment of lung function in children with sickle cell disease clinical application of forced oscillation respiratory impedance in patients with duchenne muscular dystrophy evaluation of children with cystic fibrosis by impulse oscillometry when stable and at exacerbation respiratory impedance in children with cystic fibrosis using forced oscillations in clinic changes in lung function measured by spirometry and the forced oscillation technique in cystic fibrosis patients undergoing treatment for respiratory tract exacerbation accurate lung volume measurements in vitro using a novel inert gas washout method suitable for infants tidal breathing analysis tidal volume measurements in infants: opto-electronic plethysmography versus pneumotachograph prematurity and respiratory outcomes program. comparisons and limitations of current definitions of bronchopulmonary dysplasia for the prematurity and respiratory outcomes program lung function gain in preterm infants with and without bronchopulmonary dysplasia mid-childhood lung function in a cohort of children with "new bronchopulmonary dysplasia global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the global burden of disease viral bronchiolitis in children predictors of asthma following severe respiratory syncytial virus (rsv) bronchiolitis in early childhood admission to hospital for bronchiolitis in england: trends over five decades, geographical variation and association with perinatal characteristics and subsequent asthma bronchiolitis: analysis of 10 consecutive epidemic seasons acute viral bronchiolitis: physician perspectives on definition and clinically important outcomes spatial clusters of child lower respiratory illnesses associated with community-level risk factors value in inpatient pediatrics network quality collaborative for improving hospital compliance with aap bronchiolitis guideline (bqip). a multicenter collaborative to reduce unnecessary care in inpatient bronchiolitis a randomized trial of nebulized 3% hypertonic saline with salbutamol in the treatment of acute bronchiolitis in hospitalized infants high-flow oxygen therapy is more costeffective for bronchiolitis than standard treatment-a decision-tree analysis respiratory viral detection in children and adults: comparing asymptomatic controls and patients with community-acquired pneumonia beta-lactam versus betalactam/macrolide therapy in pediatric outpatient pneumonia paradoxical tuberculosisassociated immune reconstitution inflammatory syndrome in children protracted bacterial bronchitis: the last decade and the road ahead pediatric bronchiectasis: no longer an orphan disease coccidioidomycosis in infants: a retrospective case series interaction between 25-hydroxyvitamin d and variants at 17q12-21 on respiratory infections how to cite this article pediatric pulmonology year in review 2016: part 2 key: cord-021905-fjcks7w4 authors: win, patrick h.; hussain, iftikhar title: asthma triggers: what really matters? date: 2009-05-22 journal: clinical asthma doi: 10.1016/b978-032304289-5.10017-7 sha: doc_id: 21905 cord_uid: fjcks7w4 nan in the preceding chapters, authors have discussed the various important aspects of the clinical asthma assessment. as is the case with assessing level of control, severity, and inflammation, identifying triggers for asthma is an integral part of the initial evaluation of newly diagnosed asthmatic individuals. furthermore, reviewing potential asthma triggers at each follow-up visit helps educate asthma patients. this education is a preventative first step in identifying and modifying risk factors that are responsible for poor quality of life, unnecessary morbidity, and mortality. in this, the final chapter of section iii, we will review our current concepts of asthma triggers and their role in the assessment and management of asthma. we hope to organize the classification of asthma triggers, and provide quick reference tables to simplify the initial assessment and follow-up management of asthmatics. by the end of this chapter, you will be "armed" with the information to rapidly assess, educate, and intervene upon the asthma triggers that really matter. what is an asthma trigger? asthma triggers are any condition or stimuli that cause inflammation or hyperresponsiveness of the airways that result in the symptoms of asthma: wheezing, shortness of breath, chest tightness, and/or coughing. given the heterogeneity of asthma phenotypes, it is important to understand that triggers will vary among patients. so focusing on the relevant triggers for each patient is of utmost importance. while some asthmatic individuals are atopic, others are not. accordingly, while allergen avoidance may vastly help the so-called "extrinsic" asthmatic individual by preventing morbidity and exacerbations, exposure to aeroallergens may not be detrimental to the nonatopic, "intrinsic" asthmatic individual (box 17-1). furthermore, even within the group of atopic asthmatic individuals, some will be sensitized to seasonal allergens (trees, grasses, or weeds), while others will be triggered by perennial allergens (cat, dog, or dust mites). given we have little, precious time at every patient encounter, it is imperative that we have a systematic approach to assessing and intervening upon asthma triggers targeted to the individual patient (box 17-2). accordingly, asthma triggers can be conveniently placed into groups by etiology: allergens, irritants, medications, weather changes, infections, emotions, gastroesophageal reflux, foods, and exercise (table 17 -1). in genetically predisposed individuals, allergen exposure may lead to sensitization resulting in the formation of allergen-specific immunoglobulin e (ige) by b lymphocytes. this process of allergen sensitization is uncommon within the first year of life, as formation of ige to specific aeroallergens does not commonly occur before the age of 2 to 3. in these individuals, the combination of allergen sensitization to common aeroallergens (table 17 -2) and reexposure to these allergens can trigger symptoms of asthma. subsequent allergen exposure through the respiratory tract results in t h 2-type lymphocyte recruitment, mast cell activation through ige, and clinicians must take time to carefully identify potential asthma triggers at the time of initial evaluation and at each follow-up visit to minimize unnecessary morbidity from asthma. just as asthma phenotypes vary among patients, so too do their specific triggers. thus, care must be individualized and reviewed regularly as triggers can change over time. new-onset, uncontrolled asthma may be a sign of a new asthma trigger previously not identified. after asthma triggers are identified and confirmed with testing (if necessary), every effort should be made to avoid or eliminate these specific triggers of asthma symptoms (with the exception of exercise). opportunities to minimize infectious triggers must always be taken. this should include influenza and pneumococcal vaccinations. aeroallergen: any airborne substance that can result in an ige-mediated allergic response. typically these include tree, grass, and weed pollen; mold spores; and perennial allergens like cat and dog dander, dust mite, and cockroach. asthma trigger: any condition or stimuli that cause inflammation or hyperresponsiveness of the airways that results in wheezing, shortness of breath, chest tightness, and/or coughing. atopy: the genetic predisposition to develop any of the classic allergic diseases (atopic dermatitis, allergic rhinitis, and asthma). atopy involves the capacity to produce specific-ige in response to common environmental allergens such as house-dust mites, foods, and tree and grass pollen. irritant: any substance, chemical, or physical factor that triggers asthma symptoms by nonspecific mechanisms resulting in increased bronchial hyperreactivity. examples include smoke and cold air. samter's triad: a medical condition consisting of asthma, aspirin sensitivity, and nasal polyposis. this triad is typically identified in patients in their 20s and 30s and may not include other atopic diseases. it is also commonly known as aspirin-sensitive asthma, aspirin triad, and aspirin-induced asthma and rhinitis (aiar). eosinophil influx. the ensuing inflammation from this milieu of cells and cellular mediators is thought to be responsible for not only acute asthma exacerbations, but also chronic inflammation. allergen sensitivity is commonly diagnosed by a combination of history and positive epicutaneous skin ( fig. 17-1) and/or intradermal testing ( fig. 17-2) , and in some cases, in vitro testing such as allergen-specific radioallergosorbent testing or newer technologies. after the diagnosis is made, health care providers should strive to identify the allergic triggers of asthma, treat comorbid underlying disease (e.g., rhinitis) with appropriate medications, and implement environmental controls to eliminate or minimize exposure to these factors. seasonal allergens from trees, grasses, and weeds are predominantly derived from air/wind-borne pollen. even though whole pollen grains are quite large, plants can extrude allergen-containing particles that are less than 10 μm in size through the pores in their outer covering. this relatively small size likely facilitates entry into the lower airways, and results in the aforementioned allergic cascade with subsequent inflammation. the presence and time of release of these airborne allergens vary according to location and climate. generally speaking, tree pollen is released first, in the springtime; grasses come later in the spring and early summer; and weed pollen arrives in late summer and early fall lasting until the first frost. accordingly, pollen-allergic patients can have significant asthma exacerbations during their specific pollen season or seasons. exposure to seasonal pollens is classically box 17-2 assessment considered an outdoor exposure, with peak outdoor pollen concentrations occurring in the morning. unfortunately, during the grass pollen season, pollen can be found indoors at high levels in bedding, furniture, and carpeting. this is facilitated by leaving home windows open and using window and attic fans to cool the inside environment. to minimize morbidity, asthma patients should be educated about their specific pollen sensitivities and corresponding "high-risk" seasons, as avoidance is the best way for patients to reduce risk of asthma flare. decreasing exposure and, in turn, asthma exacerbations can be facilitated by remaining indoors, closing windows, avoiding the use of cooling fans, and using car and home air-conditioning as much as possible. this is particularly important in the early morning, the time of peak airborne pollen concentration. early morning outdoor exercise should be strictly avoided, as the combination of peak pollen counts and cardiovascular exercise with increased oxygen demand, increased respiratory rate, and larger tidal volumes can be a dangerous combination. recognizing that complete avoidance is not always feasible, using locally available pollen counts to help inform patients of potential high-exposure days can be quite helpful in reducing allergen exposure. perennial allergens that trigger asthma include domesticated animals, house-dust mites, and cockroaches. cat and dog exposures are among the most common causes of perennial asthma triggers; however, all warm-blooded feathered or furry animals, including hamsters, rabbits, guinea pigs, and birds can produce allergen. exposure to these allergens, in turn, may induce ige-mediated reactions and asthma exacerbations. pet allergens are ubiquitous in our environment as 30% to 40% of american homes have pets, and even trace amounts of cat or dog allergen can be found in virtually any home (>90%, even in homes without cats or dogs). acute symptoms may develop in cat-or dog-sensitive asthmatic patients within minutes after entering a home where these animals reside. cat allergen, mainly fel d 1, is a 17-kda heterodimer comprising two disulfide-linked peptide chains. fel d 1 is produced in the sebaceous glands and is typically spread via contact with cat saliva, dander, and urine. common allergens are present in all breeds of cat (including lions, tigers, and hairless cats), but males produce more allergen than females. cat allergen can be very small (<3 to 4 μm), and the distribution in the household air at any time is highly variable. cat allergen is also very light and sticky, so it becomes airborne easily and can accumulate on household furniture, carpeting, and walls. these unique characteristics allow it to remain suspended in the air for long periods and to be inhaled deeply into the lungs, possibly accounting for its greater potential to trigger asthma symptoms than other aeroallergens. the level of cat allergen that is required to induce asthma symptoms is not well defined, so strict avoidance and proper cleaning after an animal has been removed from the household are key to preventing morbidity. cat allergen levels drop slowly after animal removal, so brief trials of cat avoidance are useless. in fact, it takes approximately 5 months for cat allergen to drop to levels similar to those found in homes without cats, and 4 to 6 months after the animal has been removed for asthma patients to achieve any improvement in symptoms. unfortunately, the clothes of cat owners constitute the vehicle of passive transport of fel d 1 to cat-free environments, so recontamination to some extent is unavoidable. in contrast to cat allergen, where the major antigenic component has been identified, dog allergen appears to be more heterogeneous, containing many varied allergens (primarily can f 1 and can f 2). contrary to popular belief, it is impossible to generalize certain dog breeds as either "nonallergenic" or "hypoallergenic." in fact, all dogs have common allergens, but there may be differences in an individual's response to a particular dog breed or possibly even an individual dog of a specific breed. despite this, even though many patients claim that "my pet has never bothered me," patients are notoriously poor at perceiving asthma symptoms when they have chronic, continuous exposure to allergens to which they have become sensitized. this is likely due to, at least in part, their emotional attachment to their animal. the best "treatment" for all animal allergies is strict avoidance, including removal of the animal that is triggering symptoms of asthma from the home. when animal removal is not possible, confining the pet to carpet-free areas, outside the bedroom, may be beneficial. these measures, combined with the use of a hepa (high-efficiency particulate air) or electrostatic air filter may provide additional benefit in "light" allergen removal (e.g., cat and dog allergen). weekly or biweekly washing of pets, by a family member or individual other than the asthmatic patient, may also help to decrease allergen exposure and symptoms. interestingly, dog, but not cat, ownership during infancy has been shown to reduce the development of allergic sensitization, and absolute number of pets, and not the type of furred pet, might also reduce future risk. the two species of house-dust mite, dermatophagoides pteronyssinus and dermatophagoides farinae, are the most important mite allergens in north america. house-dust mites are microscopic (approximately 0.3 mm long), sightless, eight-legged acarids that feed on sloughed human skin. the most allergenic parts of the house-dust mite are its body parts and fecal matter. one ounce of house dust can contain approximately 40,000 dust mites. thus a bed, a common site of house dust mites, may contain approximately 2 million dust mites. in contrast to pet allergy, dust mite-sensitive asthmatic patients are rarely aware of symptoms immediately, even when levels of dust mite allergen in a home are high. studies indicate that the critical level of house-dust mites that poses a risk factor for asthma ranges from 100 to 500 mites per gram of house dust (about 2 to 10 μg of der p 1), while acutely ill mite-sensitive asthmatic patients usually reside in homes with more than 500 mites per gram of house dust (>10 μg of der p 1). house-dust mite levels vary with humidity, temperature, season, and type of home furnishings. the most important factor influencing growth of house-dust mites is humidity. asthmatic patients who are mite-sensitive and live in environments with suitable sites for mite growth (e.g., wall-to-wall or bedroom carpeting and upholstered or overstuffed furniture) are at greater risk in more humid climates. house-dust mites optimally reproduce in bedding and carpeting where the relative humidity in the home is higher than 50%. accordingly, improper setting of the central air humidifier (commonly part of a home's central heating and air-conditioning unit) may worsen asthma control; while dehumidifiers set to keep humidity levels lower than 50% may be beneficial in reducing asthma symptoms from house-dust mite exposure. although using other environmental control measures to minimize dust mite exposure are generally endorsed by allergists as a preventative first step to reduce asthma flares, studies examining their use are conflicting and have provided much controversy. some studies using relatively basic dust mite control measures have shown no effect on asthma symptoms or reduction in mite growth; whereas other studies that use methods of extensive cleaning and dust mite proofing (e.g., mattress and pillow covers) to minimize mite exposure have been associated with a reduction in asthmatic symptoms, medication use, and morbidity. furthermore, some studies have shown that patients exposed to lower levels of house-dust mites not only have decreased asthma symptoms and medication use, but also have improvement in nonspecific bronchial hyperresponsiveness. having said this, the cochrane library meta-analysis on house-dust mite control measures for asthma, including 49 trials that examined the use of physical, chemical, and combination methods to reduce house-dust mite exposure, showed no benefit/effect on frequently reported outcomes (am peak flow, asthma symptom scores, and medication use). the reviewers mention that many of the trials included in this analysis were of poor quality, making their conclusions difficult to interpret. if environmental control measures are suggested, the bedroom is the most important room to target, as most of our day in the home (approximately 8 to 10 hours during the night for sleep) is spent there. other areas of the home, such as the living or family room that contains overstuffed furniture or carpeting, must be considered as potential sites of significant house-dust mite exposure. proposed environmental controls to be considered include replacing wall-to-wall carpeting with hardwood or vinyl flooring, encasing bedding in dust-mite impermeable material, frequent dusting (with mask or by an unaffected individual), replacing upholstered/overstuffed furniture with leather furniture, replacing fabric curtains with blinds, washing bedding weekly in hot water (60° c or 130° f), washing and high-heat drying or freezing of stuffed toys, reducing humidity to less than 50%, frequent vacuuming (with hepa filter and doublethickness bags) by an individual not sensitive to dust mites (or with mask), and using acaricides and/or tannic acid to mitigate house-dust mite infestation. cockroach has also been identified as a major allergen capable of triggering asthma exacerbations. the ability of cockroach allergen to stimulate the formation of specific ige antibodies has been demonstrated by end point skin test titration and radioallergosorbent testing. furthermore, a causal relationship between bronchospasm and sensitivity to cockroach allergen has been proved in bronchial provocation studies. positive skin tests to cockroach allergen are reportedly present in 20% to 53% of allergic patients and as high as 49% to 61% of asthmatic patients. although there are about 50 species of cockroaches that live in the united states, only 3 have been shown to induce allergen-specific ige: the american, german, and asian/oriental cockroaches. cockroach allergen usually is found in kitchen cabinets and kitchen floor dust, as they usually hide out in cabinets and behind refrigerators. a study in urban asthmatic patients has shown that cockroach sensitivity may be as important a risk factor for inner-city asthmatic individuals as house-dust mite allergy. because elimination of cockroach infestation requires aggressive, repeated extermination efforts with irritant chemicals (deltamethrin powder or cypermethrin), it is best performed by professional exterminators. cockroach baits and gels (fipronil and hydramethylnon) can be purchased at local superstores. these are generally safer and relatively nontoxic to mammals (pets and children), but may not be as effective in cases of severe infestation. other partially effective measures include restricting havens by caulking and sealing cracks in plaster work and flooring, controlling dampness, reducing the availability of food, and restricting access to the dwelling (sealing sources of entry around doors). molds and fungi are aeroallergens that can trigger significant asthma symptoms in both a seasonal and perennial fashion. unlike pollens, molds have ill-defined seasonal peaks and nadirs for airborne mold spore levels. only in the northernmost areas of the united states are there consistent seasonal increases in mold counts. in this region, mold counts increase starting in may or june and decrease by october or november, having peaked in july or august. in the south, airborne molds are present throughout the winter, with a peak in summer or early fall. clinically, molds are divided into two groups: outdoor and indoor. the two most common outdoor molds are alternaria and cladosporium. other common outdoor molds include fusarium, spondylocladium, and helminthosporium. these outdoor or field molds grow in soil, on plants, and in decaying vegetation such as cut grass or raked leaves. mold levels are affected by temperature, wind, rainfall, and humidity. rain or high humidity levels will lower mold spore counts temporarily, but afterwards, counts rise rapidly. generally, a late summer-autumn peak is seen for common fungal spores. similar to the aforementioned avoidance measures for pollen-sensitive asthmatic individuals, asthma symptoms from exposure to mold spores may be minimized by staying indoors as much as possible (especially during peak spore concentrations) and keeping home and automobile windows closed. the importance of minimizing mold exposure in mold-sensitive asthmatic individuals cannot be overemphasized. it is clear, from the observation of "new orleans asthma" and other recently described cases of mold-induced asthma, that inhalation of large quantities of mold spores can produce severe, life-threatening asthma exacerbations in mold-sensitive patients. although it is unclear what etiological factors are responsible for these cases of severe mold-sensitive asthma flares, it is hypothesized that because mold spores are smaller than pollen, they are more likely to enter and inflame the lower airways. the two most important indoor molds are aspergillus and penicillium (also known as mildew). the amount of indoor mold in any dwelling depends on several important factors: age and composition of the structure, type of heating and cooling system, and use of humidifiers. dark and humid (often poorly ventilated) basements are ideal sites for mold growth. the next most common sites of mold growth are the bathroom and the kitchen. in tropical and subtropical climates, fungi may grow on the walls of the house as a result of water seepage and humidity. to avoid this, the walls can be tiled or cleaned as necessary. home heating, cooling, and humidification systems are also potential sources of fungal growth, although air-conditioning generally reduces indoor humidity and hence discourages mold growth. most fungal spores in an indoor environment are nonviable spores that will be found in house-dust reservoirs such as carpeting, bedding, and furniture. implementing the same precautions used to reduce levels of dust mites is the best way to eliminate mold spores from the home. levels of viable indoor mold spores can be reduced by removing or cleaning mold-laden objects. levels may also be reduced by use of dehumidifiers (set humidity level < 50%) in the basement and air-conditioners in the bedroom or family room. air-conditioners and dehumidifiers reduce humidity and filter large fungal spores, lowering the mold and yeast count indoors, although their benefit in reducing asthma symptoms is controversial. home humidifiers should be used with caution and cleaned frequently because of the potential for mold and actinomyces growth. bathrooms and kitchens should be well ventilated. electronic air filters also lower the level of mold spores within a dwelling. when the major source of molds within a home is a wet or damp cellar, the basement should be kept free of carpeting, immediately dried out after a rainstorm, and, whenever possible, protected with a drain tile and sump pump. nonallergenic indoor triggers (table 17 -3) of asthmatic symptoms are a heterogeneous group of irritants that affect bronchial hyperreactivity in a non-ige-dependent fashion. as with all other asthma triggers, each should be identified and meticulously eliminated or avoided. active and passive tobacco cigarette smoke, consisting of very small, light particles that remain airborne for long periods, is a high-risk trigger for all asthmatic individuals. studies have demonstrated that children may be at increased risk of developing asthma and allergic sensitization when exposed to passive smoke. other studies in children show worsening asthma symptom severity, higher medication requirements, more frequent emergency department visits, and increased airway responsiveness when exposed to passive maternal tobacco smoke. active cigarette smoking not only has direct, deleterious effects on the lung parenchyma, it also reduces the efficacy of inhaled and systemic corticosteroids. thus, smoking cessation must be a primary objective for the patient, friends, and family members of asthmatic patients. other forms of smoke, such as that of wood-burning stoves, also have negative effects on the lower respiratory tract. additional airborne irritants, fumes, and strong odors (e.g., chalk dust, talcum powder, paint fumes, insecticides, household cleaning sprays, polishes, cooking oil fumes, perfumes, and cosmetics) may initiate or exacerbate asthmatic symptoms in some patients. other indoor pollutants include carbon monoxide, formaldehyde, nitric oxide, nitrogen oxides, and bacterial endotoxin. in all of these cases, adequate ventilation plays a pivotal role in successful prevention of asthma symptoms, as air stagnation has been shown to be a surrogate marker for the accumulation of indoor pollutants. other important preventative avoidance measures include household cleaning and proper maintenance of gas appliances. nonallergic outdoor irritants (see table 17 -3) that trigger asthma are also exceedingly common and important to identify and eliminate. studies have implicated several outdoor pollutants as potential triggers of asthma symptoms. air pollutants such as ozone, nitrogen oxides, acidic aerosols, and particulate matter can lead to asthma symptoms and frank exacerbations. other important outdoor asthma triggers include exposure to vehicle traffic (especially diesel exhaust), which might exacerbate preexisting allergic conditions by enhancing airway responses to allergen, a potential compounding effect. on occasion, weather and atmospheric conditions create brief periods of intense air pollution in a defined geographic area. at these and other times and in areas of high outdoor pollution, patients with asthma should avoid unnecessary outdoor physical activity (especially exercise) and try to stay indoors in a clean environment. as with pollen and aeroallergens, air-conditioning and filters may be helpful in preventing unnecessary morbidity. when working outdoors in polluted areas is unavoidable, taking a preventative, short-acting inhaled bronchodilator beforehand may prevent acute asthma symptoms. if prolonged outdoor polluted conditions are likely to persist, it is a good idea to tell patients to leave the polluted area before mild symptoms spiral into an acute asthma flare. hundreds of substances have been identified as occupational irritants or allergens that can trigger asthma symptoms. one can access a fairly comprehensive list of potential occupational asthma triggers at http://asmanet.com. an overview of these triggers and occupational asthma is covered in chapter 42. levels of exposure above which sensitization occurs have been proposed for many chemicals, so primary prevention is possible with proper precautionary measures. however, once a patient has been sensitized, the level of exposure necessary to induce symptoms may be very low, and resulting exacerbations may become progressively severe on reexposure. attempts to reduce occupational exposure have been successful, especially in the industrial setting, where potent sensitizers have been replaced by less allergenic or sensitizing substances. for example, primary prevention of latex allergy has been very successful. this has been accomplished by producing powder-free, lower allergen-content gloves. in cases where prevention is not possible, the early identification of occupational sensitizers and the removal of affected patients from these environments are critical to the successful management of occupational asthma. numerous medications (table 17 -4) have been implicated in triggering asthma symptoms. the most common offenders include nonsteroidal anti-inflammatory drugs (nsaids) and b-blockers. approximately 5% to 10% of adult asthmatic patients will have an acute worsening of asthma symptoms after ingesting nsaids. samters triad or "the aspirin triad" can be identified in some adult asthmatic patients. the response to aspirin or other nsaids typically begins within smoke (tobacco, wood-burning stove) strong odors (perfumes and cosmetics) particulates (chalk dust, talcum powder) fumes (household cleaning products, insecticides, paints, chemicals, cooking) smoke (wood/tree, refuse and chemical fires) exhaust (diesel fumes) other (ozone, chemicals) an hour of aspirin ingestion and may be associated with profound rhinorrhea, lacrimation, and, potentially, severe bronchospasm. patients sensitive to aspirin usually are reactive to all other nsaids (e.g., ibuprofen, naproxen), and variations in the frequency and severity of adverse responses appear to depend on the potency of each drug within this class of compounds to inhibit the activity of the cox-1 enzyme. sensitivity to nsaids is not ige-mediated and involves the modulation of eicosanoid production. nsaids likely act by reducing the formation of prostaglandins that help maintain normal airway function while increasing the formation of asthma-provoking eicosanoids, including hydroxyeicosatetraenoic acids and cysteinyl leukotrienes. thus, if aspirin-sensitive asthmatic individuals require treatment with an nsaid, the use of a selective cox-2 inhibitor is a viable treatment option, especially when combined with an inhibitor of leukotriene synthesis or leukotriene receptor antagonist. in addition, there is evidence that mast cell activation occurs, and its mediators can be detected in nasal secretions during an episode of aspirin-induced asthma. this syndrome should be of concern in any asthmatic patient with nasal polyposis, chronic sinusitis, and eosinophilia, although nasal polyposis and sinusitis may precede the onset of recognized nsaid-sensitivity by years. b-blockers administered either orally or via eye drops (for hypertension or glaucoma, respectively) may exacerbate asthma symptoms via bronchospasm. as a general rule, these medications should be not be used by asthmatic individuals, as other classes of drugs may be used to successfully treat these underlying comorbidities. if b-blockers are used, close medical supervision is essential to prevent unnecessary morbidity. as is the case with all of the aforementioned asthma triggers, avoidance is the treatment of choice. weather and atmospheric changes also commonly trigger asthma symptoms. classically, cold dry air can induce bronchoconstriction in asthmatic individuals. atmospheric conditions that typically trigger asthma symptoms include changes in temperature and humidity, barometric pressure, or gusts of wind. perhaps of greater importance than these changes are the effects these atmospheric changes have on seasonal and perennial allergens. for example, pollen and mold counts have seasonal patterns and release of these allergens is highly dependent upon "proper" environmental conditions to allow successful release and plant pollination/procreation. as aforementioned, it is well recognized that exposure to molds or pollens during a particular season can induce asthmatic attacks in sensitized (allergic) individuals, so any atmospheric change (seasonal change or sudden gust of wind) that increases exposure to these allergens is potentially detrimental to allergensensitized asthmatic individuals. furthermore, with seasonal changes (particularly the fall and winter) also comes an increased exposure to viruses like rhinovirus and influenza that commonly precipitate asthma attacks. respiratory viral and bacterial infections (table 17 -5) are a major cause of morbidity and mortality in people with asthma. respiratory viruses trigger acute exacerbation of asthma in children and adults. these infections frequently result in outpatient visits and hospitalizations. additionally, these infections make asthmatic individuals more sensitive to other asthma triggers. typical respiratory tract infections that cause airway inflammation and trigger asthma include the "common cold" and flu, bronchitis, ear infections, sinusitis, and pneumonia. asthma attacks that occur in conjunction with an upper or lower respiratory tract infection may be more severe than exacerbations that occur without concomitant infection. the most common respiratory viruses are the rhinovirus ("common cold" virus), respiratory syncytial virus (rsv), and certain influenza viruses. these viruses are present in most patients hospitalized with life-threatening asthma exacerbations and acute non-life-threatening asthma flares. asthmatic individuals are not more susceptible to upper respiratory tract rhinovirus infections than healthy, nonasthmatic individuals, but they do suffer more severe consequences of lower respiratory tract infections. recent epidemiologic studies suggest that viruses provoke asthma attacks by additive or synergistic interactions with allergens or irritants like air pollutants. an impaired antiviral immunity to rhinovirus may rhinovirus (1-100+ serotypes; causes "common cold," bronchitis and bronchiolitis) coronavirus (2299e and oc43 serotypes; causes "common cold") influenza (a, b, and c serotypes; causes "common cold," pneumonia and bronchitis) parainfluenza (1, 2, 3, and 4 serotypes; causes "common cold," laryngotracheobronchitis, and bronchiolitis) respiratory syncytial virus (a and b serotypes; causes "common cold," pneumonia, bronchitis, and bronchiolitis) adenovirus (1-4 serotypes; causes "common cold," pneumonia, bronchitis and bronchiolitis) metapneumovirus (bronchiolitis) streptococcus pneumoniae (sinusitis and pneumonia) haemophilus influenzae and parainfluenzae (sinusitis and pneumonia) moraxella catarrhalis (sinusitis and pneumonia) staphylococcus aureus (pneumonia) klebsiella pneumoniae (pneumonia) atypical (chlamydia pneumoniae and mycoplasma pneumoniae causing pneumonia) lead to impaired viral clearance and, in turn, prolonged symptoms. viral respiratory tract infections exacerbate asthma by recruiting t h 2-type cells into the lungs. currently, we have no specific antiviral strategies for preventing the exacerbation of asthma by respiratory viral infection; however, clinical trials of potential antiviral agents are ongoing. indirect prevention strategies focus on reducing overall airway inflammation to reduce the severity of the host response to respiratory viral infections. although many bacterial infections are known to cause asthma exacerbations in susceptible individuals, recent attention has been focused on lower respiratory tract infections with atypical bacteria. mycoplasma pneumoniae and chlamydia pneumoniae are thought to be common triggers of asthma. whether these bacteria are the inciting agents for the onset of disease or acute exacerbations has yet to be definitively determined; however, there are also data supporting the notion that infection with atypical bacteria may be a contributing factor to difficult-to-treat asthma. strenuous physical exercise can also trigger asthma attacks. exercise can cause asthma symptoms to flare, especially when asthma is not well controlled. mouth breathing; exercising in cold, dry air; or prolonged, strenuous activities such as medium-to long-distance running can increase the likelihood of exercise-induced bronchospasm-an obstruction of transient airflow that usually occurs 5 to 15 minutes after the onset of physical exertion. although exercise can trigger asthma in certain people, it is one trigger that should not be avoided. exercise strengthens the cardiovascular system and may lessen the sensitivity to asthma triggers. to minimize the effects of this trigger, asthmatic individuals should start any new exercise regime slowly, gradually building strength and endurance, and warm up gradually at the beginning of each exercise session. avoiding exercise outdoors in extremely cold weather or during peak pollen seasons is also a prudent measure. asthma and gastroesophageal reflux disease (gerd) are common medical conditions that often coexist. studies have shown conflicting results on whether lower esophageal acidification can act as a trigger for asthma. in fact, asthma might precipitate gerd symptoms; thus, a temporal association between the two does not establish that gerd triggers asthma. randomized trials investigating different treatment modalities for gerd in asthma have been conducted to determine whether treatment of gerd improves asthma symptoms and outcomes. a meta-analysis of randomized controlled trials concluded that therapy for gerd, including acid-suppressive treatment with a proton-pump or histamine-2 receptor antagonists, does not consistently improve lung function, asthma symptoms, nocturnal asthma, or lessen the use of asthma medications. littner and colleagues showed that in adult patients with moderate-to-severe persistent asthma and symptoms of acid reflux, treatment with 30 mg of lansoprazole twice daily for 24 weeks did not improve asthma symptoms, pulmonary function, or reduce albuterol use. however, this dose significantly reduced asthma exacerbations and improved quality of life, particularly in those patients receiving more than one asthma-controller medication. with all of this being considered, untreated gerd symptoms may affect airway reactivity in patients with asthma. thus, treating patients for symptoms of gerd with concomitant asthma has become standard practice and should be considered. exposure to food allergens and additives (see fig. 17 -3) can cause a variety of symptoms. it is widely believed that allergic reactions to foods are common asthma triggers, but definitive evidence to support this concept is lacking. despite this lack of data, some asthmatic individuals report worsening asthma symptoms after ingesting specific foods and food additives. food additives that have been implicated include salicylates, food preservatives, monosodium glutamate, and some food-coloring agents. sodium metabisulfite, a preservative in many beverages (including beer and wine) and foods, is thought to release sufficient sulfur dioxide to provoke bronchoconstriction. for some people, eating a particular food (common culprits include milk, eggs, peanuts, tree nuts, soy, wheat, fish, and shellfish) can trigger asthma symptoms. this constellation of food sensitivity and worsening asthma symptoms tends to correlate with a more severe course of disease. patients with food allergies and underlying asthma experience more severe reactions to food allergens than do patients without asthma, because their reactions are more likely to involve life-threatening respiratory symptoms. allergic reactions that involve respiratory symptoms are almost always more severe than reactions that do not involve the respiratory tract. particularly susceptible food-sensitive asthmatic individuals have been reported to react to merely inhalation without ingestion; however, isolated symptoms of rhinitis or asthma without concomitant cutaneous or gastrointestinal symptoms are rare. nevertheless, if any type of food triggers an asthma attack, the best treatment is strict avoidance. although asthma is not a psychological condition, emotional or nervous stress can trigger asthma symptoms. stress alone cannot provoke asthma; however, if accompanied by anxiety, stress can cause fatigue, potentiating coughing, shortness of breath, and wheezing. a strong feeling or emotional behavior, such as laughing or crying, may trigger asthma symptoms because of the accompanying change in breathing patterns. as with any other chronic health condition, proper rest, nutrition, and exercise are important to overall wellbeing and can help in managing asthma. effective control of asthma depends on identification and alleviation of exacerbating factors. triggers of asthma frequently include ongoing exposure to allergens and irritants, medications, weather and atmospheric changes, upper and lower respiratory tract infections, uncontrolled gastroesophageal reflux disease, foods and food additives, and emotional stress and anxiety (fig. 17-3) . it is of paramount importance to recognize contributing factors early, and eliminate exposure to prevent unnecessary morbidity and mortality. a key theme to this chapter has been avoidance, which in many cases is quite difficult; but by following a systematic method for identifying and removing potential triggers from the asthmatic individual's environment, the goal of optimum asthma control can be accomplished with a combined, concerted effort on the part of the physician and patient. attaining optimal asthma control: a practice parameter global initiative for asthma (gina): global strategy for asthma management and prevention national institutes of health, national heart, lung, and blood institute house dust mite control measures for asthma asthma: factors underlying inception, exacerbation, and disease progression effects of 24 weeks of lansoprazole therapy on asthma symptoms, exacerbations, quality of life, and pulmonary function in adult asthmatic patients with acid reflux symptoms study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children practice parameter for the diagnosis and management of asthma key: cord-022050-h24f0fpd authors: naughton, matthew t.; tuxen, david v. title: acute exacerbations of chronic obstructive pulmonary disease and asthma date: 2009-05-15 journal: clinical critical care medicine doi: 10.1016/b978-0-323-02844-8.50029-9 sha: doc_id: 22050 cord_uid: h24f0fpd nan chronic obstructive pulmonary disease (copd) and asthma are conditions characterized by fixed and variable airflow obstruction, respectively. increased use of inhaled steroids and exacerbation management plans have resulted in decreased hospital and intensive care admission rates for asthma. the same is not true for copd. although both can have common overlapping clinical presentations (table 24 .1) and are responsible for significant morbidity and mortality, with a demand on intensive care services, their etiology and management differ. copd is a condition in which permanent airflow obstruction occurs, associated with alveolar destruction (emphysema) and inflammation of the airway walls (chronic bronchitis). asthma is defined by variable airflow obstruction that is reversible, completely or partially, spontaneously or with treatment, and is associated with airway inflammation and increased airway responsiveness to a variety of stimuli. worldwide, it has been estimated that 1.1 billion people have copd, a prevalence expected to increase to 1.6 billion people by 2025. in the united kingdom, 20% of men and 10% of women older than age 45 years report a chronic cough with sputum, with 4% of men and 2% of women meeting diagnostic criteria for copd. in the united states, copd is estimated to occur in up to 19% of the adult community and result in 16 million physician visits and 500,000 hospital admissions per year. copd is the fourth most common cause of death worldwide, accounting for 5% of all deaths-an age-adjusted rate that has risen from 1965 to 1995, in comparison with those for cardiovascular disease and stroke, both of which have declined. the mortality of copd patients admitted to the hospital is 15%, exceeding that for myocardial infarction. risk factors for mortality in copd are low body mass index, degree of airflow obstruction as measured by fev 1 , exercise limitation, and degree of dyspnea. survival can also be predicted by the paco 2 ( fig. 24 .1). asthma is estimated to occur in 20% of children and 8% of adults, with 5% to 10% of these having poorly controlled disease. life-threatening episodes occur in 0.5% of patients. in the united states, asthma is responsible for 1.8 million emergency department visits per year, with 1 in 4 requiring overnight admission. new zealand, australia, and the united kingdom have the greatest prevalence rates. chapter 24 matthew t. naughton and david v. tuxen • hypercapnic chronic obstructive pulmonary disease (copd) patients should be treated with noninvasive ventilation and supplemental oxygen sufficient to overcome hypoxemia but avoid hyperoxia. • intravenous or oral steroids in copd should be limited to 3 to 10 days in most cases. • in acute severe asthma, there is no proof that the intravenous administration of short-acting b-agonists has an advantage over adequate nebulized administration. • in severe asthma, dynamic pulmonary hyperinflation due to mechanical ventilation can result in hypotension, pnemothoraces, and, in very severe asthma, circulatory collapse with pulseless electrical activity (i.e., electromechanical dissociation). this can be acutely relieved with a 60-second apnea test and thereafter prevented by a slow respiratory rate and a long expiratory time with permissive hypercapnia. • following acute severe exacerbations of copd and asthma, precipitating factors should be sought and avoided or treated. patient-orientated action plans should be instituted to avoid further acute deterioration. ninety-five percent of patients with copd have tobacco smoking as a risk factor. other environmental factors include exposure to secondary tobacco smoke, air pollution, indoor fumes (e.g., indoor cooking with solid biomass fuel), and poor socioeconomic status. host factors are also important but, with the exception of a 1 -antitrypsin deficiency, are poorly understood. although there is a clear familial prevalence of asthma, and several genes have been implicated, no single gene defined could allow for meaningful genetic planning. a number of other risk factors have been proposed, including (1) inadequate exposure to allergens due to excessive antibiotic use, (2) excessively clean dust-free environment (i.e., the hygiene hypothesis), (3) excessive exposure to common allergic (e.g., house dust mite, pollen, and animal dander) or nonallergic triggers (e.g., cold air, exercise, and atmospheric pollutants), and (4) exposure to medications that modulate airway control (e.g., aspirin and beta blockers). the increasing prevalence of asthma during the past 50 years has been attributed to increasing environmental exposures. exposure to infections such as respiratory syncytial virus and parainfluenza (in children) and chlamydia (in adults) has been implicated as a risk factor. stress and socioeconomic status have also been implicated. in 30% of patients, no precipitant can be identified. reduction in expiratory airflow occurs because of increased airway resistance and reduced lung elastic recoil. airway resistance increases in the 4th-to 12th-generation airways as a result of mucosal inflammation, basement membrane thickening, edema, mucosal hypertrophy, secretions, and bronchospasm. loss of lung elastic recoil is due to destruction of lung elastin and reduction in alveolar surface tension. reduced elastic recoil decreases expiratory airflow by reducing the alveolar pressure driving expiratory airflow. forced expiration increases alveolar driving pressure but also causes dynamic airway compression, resulting in no improvement, or sometimes a reduction, in expiratory airflow. the importance of this factor is a function of the degree of emphysema in each individual patient. hypoxia and vascular wall changes lead to pulmonary vasoconstriction, pulmonary hypertension, cor pulmonale, and ventilation-to-perfusion heterogeneity. most commonly, smoking-related copd results in apical, rather than basal, disease ( fig. 24. 2), whereas a 1 antitrypsin deficiency usually causes basal emphysema. central respiratory drive may also be poorly responsive to the physiological trigger of hypercapnic acidosis, contributing to chronic hypercapnia. this may occur in the setting of sleep (i.e., obstructive sleep apnea), obesity, drugs (sedatives, antiepileptics, and alcohol), or metabolic disturbance (metabolic alkalosis). postmortem studies indicate that small airway narrowing occurs as a result of bronchial wall edema, inflammatory cell infiltrates, smooth muscle hypertrophy and hyperplasia, collagen deposition beneath the basement membrane thickening, and intraluminal secretions of eosinophilic inflammatory cells. eosinophils infiltrate the nerve bundles and release major basic protein, which antagonizes the inhibitory m 2 muscarinic receptor present on parasympathetic nerve endings. the nocturnal (or circadian) exacerbation commonly seen in asthma is due to a combination of factors, including exposure to cool dry air, inhalation of excessive allergens related to bedding, and circadian changes in airway diameter and cortisol. in copd and asthma, pulmonary hyperinflation has both static and dynamic components. the static component is the increase in functional residual capacity (frc) that exists at the end of an exhalation that is long enough for all expiratory airflow to cease (i.e., 30-120 sec). this component of hyperinflation is primarily due to airway closure that occurs throughout exhalation. dynamic hyperinflation is the further increase in hyperinflation that occurs because of failure to complete exhalation before beginning the inhalation associated with the next breath. the extent of dynamic hyperinflation depends on the severity of airflow obstruction, the amount inspired (i.e., the tidal volume), and the expiratory time. thus, the degree of hyperinflation may vary with changes in tidal volume and/or respiratory rate that occur in response to changes in co 2 production (as a function of exercise, diet, fever, or the metabolic response to illness) or changes in dead space, as well as with changes in airflow obstruction that occur during an exacerbation. chest wall hyperinflation puts the inspiratory respiratory muscles at a mechanical disadvantage, increases the work of breathing, and predisposes patients to developing respiratory muscle fatigue. chronic use of corticosteroids, electrolyte disturbances, and/or other medications may also contribute to this problem. in copd, minor reductions in lung function due to infection, cardiac failure, or atelectasis increase the work of breathing by increasing airway resistance, lung stiffness, and/or dead space. this may result in rapid decompensation with ventilatory failure, acute hypercapnia, and respiratory acidosis as the tidal volume falls as a result of the increased volume of trapped gas and diminished respiratory muscle strength. during exhalation, use their accessory respiratory muscles for inhalation, are hyperinflated, and may develop right heart failure but only late in their course. in contrast, patients with a paco 2 greater than 45 mm hg are generally more obese, have depression of their hypoxic and/or hypercarbic ventilatory drives (which can be worsened by excessive oxygen, alcohol, sedatives, or analgesics), have sleep-related hypoventilation, and are more likely to develop right heart failure early. approximately 50% of patients with an acute exacerbation of copd will be hypercapnic, a portion of them as a result of excessive oxygen administration. acute exacerbations of copd seem to result from respiratory infections (~50%) or cardiac failure (~25%). the remaining 25% may have retained secretions, air pollution, coexistent medical problems (e.g., pulmonary embolus, gastroesophageal reflux, and medication compliance or side effects) or no cause can be identified (box 24.1). the most common bacterial isolates are streptococcus pneumoniae, hemophilus influenzae, streptococcus viridans, and moraxella catarrhalis. mycobacterium pneumonia and pseudomonas aeruginosa may also be found. viruses have been isolated in 20% to 30% of exacerbations. these include rhinovirus, influenza and parainfluenza viruses, corona viruses, and, occasionally, adenovirus and respiratory syncitial virus have been isolated in 20% to 30% of exacerbations. whether these organisms are pathogens or colonizers is often unclear. pneumonia may account for 20% of those presentations requiring mechanical ventilation. left ventricular systolic failure may result from coexisting ischemic heart disease, fluid overload, or tachyarrhythmias. diastolic dysfunction may occur secondary to right ventricular dilation. many of these patients have high levels of intrinsic positive end-expiratory pressure (peep) (or auto-peep), particularly during acute exacerbations, and this may decrease cardiac output by decreasing venous return. the increased work of breathing related to copd will also contribute to heart failure because blood flow distributed to the respiratory muscles may increase by up to 10-fold. in the absence of roentgenographic evidence of pulmonary edema, left ventricular failure may be difficult to diagnose. uncontrolled oxygen administration may precipitate acute hypercapnia in patients with acute copd exacerbations as a result of relaxing hypoxic vasoconstriction, thereby allowing increased perfusion to regions with reduced alveolar ventilation. although a reduction in hypercarbic drive was previously thought to account for this problem, the contribution of abnormal drive is limited. an accurate and detailed history is needed to distinguish asthma from other causes of dyspnea. classically, asthmatic patients will have wheeze, cough, and/or dyspnea occurring with exercise, at night, or with exposure to specific triggers. when asthma is mild, there is typically a prompt resolution following inhalation of short-acting b-agonists (sabas). the assessment of asthma severity (table 24 .2) and triage is crucial. most commonly, patients with severe asthma have a history of previous hospitalizations for asthma (some that may be near fatal), low socioeconomic status, female gender, obesity, nighttime symptoms, fev 1 less than 60% with optimal treatment, continual symptoms, reduced quality of life, use of oral or systemic steroids in the past 12 months, use of more than canister of saba per month, elevated residual volume-tototal lung capacity (rv:tlc) ratio on pulmonary function testing, and a peak expiratory flow rate variability of more than 30% (i.e., variability-(bestworst)/best reading). a typical pattern is the progression over hours to days, occurring in the setting of a history of recurrent presentations. this form is associated with greater airway inflammation and generally responds poorly, or incompletely, to initial bronchodilator therapy but responds to steroid and bronchodilators over a few hours or days. less commonly, patients can present with hyperacute exacerbations, with the interval between the onset of symptoms and respiratory failure of less than 3 hours. this form of asthma occurs in younger patients, more commonly male, with intervening normal lung function but with highly sensitive bronchial reactivity to triggers, which is attributed to marked bronchial smooth muscle contraction. this form of asthma responds to saba treatment within minutes to hours. physical examination should include assessment of speech (ability to speak in sentences, phrases, or words), oxygen saturation, heart rate, pulsus paradox, use of accessory muscles, chest auscultation, conscious state, and response to immediate inhaled bronchodilators. pulse higher than 120 beats/min, respiratory rate higher than 30/min, and pulsus paradox more than 15 mm hg indicate severe asthma. auscultatory findings of a silent chest may indicate extremely severe bronchospasm or the presence of pneumothorax. the diagnosis of copd is usually established prior to patient presentation, with respiratory failure based on history, clinical examination, and investigations. patients with copd usually have a history of smoking more than 20 pack-years. in some settings, exposure to indoor solid fuel heating or cooking or a family history of a 1 -antitrypsin deficiency may be causative or contributing factors. they may have a history of chronic cough and sputum production and describe exertional dyspnea and wheeze. in patients with mild, stable disease, an expiratory wheeze on forced expiration and mild exertional dyspnea may be the only findings. in patients with moderate disease, modest to severe exertional dyspnea is associated with clinical signs of hyperinflation and increased work of breathing. in severe but stable disease, marked accessory muscle use is seen in association with tachypnea at rest, pursed lip breathing, hypoxemia, and signs of pulmonary hypertension [right ventricular heave, loud and palpable pulmonary second sound, and elevated "a" wave in jugular venous pressure (jvp)] and cor pulmonale (elevated jvp, hepatomegaly, and ankle swelling). in severe unstable copd, there is marked tachypnea at rest, hypoxemia and tachycardia, and, in some cases, signs of hypercapnia (dilated cutaneous veins, blurred vision, headaches, obtunded mentation, and confusion). clinical examination may also identify associated medical conditions precipitating the exacerbation, such as pulmonary crepitations and bronchial breathing with pneumonia, crepitations and cardiomegaly related to heart failure, or mediastinal shift related to a pneumothorax. the severity of copd is best judged by assessing pulmonary function [i.e., peak expiratory flow rate (pefr)] or fev 1 . the vital capacity (vc) is initially normal and decreases later in the course of the disease but to a lesser degree than the fev 1 . an fev 1 :vc ratio less than 70% with an fev 1 50% to 80% of predicted without a bronchodilator response usually indicates mild copd. a significant bronchodilator response (i.e., >12% or >200 ml increase in either fev 1 or vc) implies a diagnosis of asthma. an fev 1 30% to 50% predicted indicates moderately severe copd, and an fev 1 less than 30% predicted indicates severe disease. although the diagnosis may be based on spirometry alone, further lung function testing may be useful to characterize sever-ity. flow volume curves demonstrate reduced expiratory flow rates and show the characteristic "concave" expiratory flow pattern. lung volumes measured either by helium dilution or by plethysmography show elevated tlc, frc, and rv. the rv:tlc ratio is characteristically more than 40%, representing intrathoracic gas trapping. the diffusion capacity, a measurement of alveolar surface area, is usually less than 80% predicted and is reduced in proportion to the extent of emphysema. chest x-rays will commonly show hyperinflated lung fields as suggested by flattened diaphragms (best seen on lateral cxr), evidence of emphysematous bullae, and/or a paucity of lung markings. pulmonary hypertension may be suggested by the presence of enlarged proximal pulmonary arteries, attenuated distal vascular markings, and right ventricular enlargement. high-resolution computed tomography (ct) scans show emphysema and can also confirm coexistent bronciectasis. such scans are less sensitive than standard chest ct scans (1-cm slice) for detecting pulmonary lesions (e.g., neoplasms) ( fig. 24 .3). nuclear ventilation-perfusion scans show diffuse, well-matched, nonsegmental ventilation-perfusion abnormalities, with the degree of severity matching what is seen clinically. arterial blood gases are mandatory to assess the degree of hypoxia and hypercapnia and to determine the acid-base status. a serum bicarbonate level more than 30 meq/liter indicates either renal compensation for a chronic respiratory acidosis or a primary metabolic alkalosis (e.g., diuretic therapy, high-dose steroids, or high-volume gastric fluid loss). renal compensation for chronic hypercapnia will increase the serum bicarbonate by approximately 4 meq/liter for each 10 mm hg of chronic paco 2 rise above 40 mm hg in order to return ph to the low normal range. the electrocardiogram (ecg) is commonly normal but may show features of right atrial or right ventricular hypertrophy and strain, including p pulmonale, right axis deviation, dominant r waves in v1-v2, right bundle branch block, and st depression and t wave flattening or inversion in v1-v3. these changes may be chronic or may develop acutely if there is a marked increase in pulmonary vascular resistance during the illness. the ecg may also show coexistent ischemic heart disease, tachycardia, and atrial fibrillation. occasionally, continuous ecg monitoring is required to identify transient arrhythmias, which may also precipitate an acute deterioration. as with copd, the diagnosis of asthma is usually apparent from history and examination. tests of airflow obstruction are needed to assess severity. a pefr of less than 100 l/min or an fev 1 of less than 1 liter indicates a life-threatening asthma situation. these should be repeated to assess response to treatment. in mild to moderate asthma, arterial blood gases show a respiratory alkalosis as ventilation generally increases. in severe asthma, hypoxemia is present and can be easily corrected with supplemental oxygen with normal ph and paco 2 . in fulminant disease, hypercapnic respiratory acidosis develops with more severe hypoxemia. the respiratory acidosis may be compounded by lactic acidosis if intravenous sabas (salbutamol, epinephrine, or isoprenaline) are used. occasionally, continuously nebulized salbutamol can produce lactic acidosis. the chest x-ray rarely shows consolidation but should be obtained regardless, seeking evidence of pneumothorax or chapter 24 pneumomediastinum (fig. 24.4) . importantly, a chest x-ray will also assist in excluding other differential diagnoses, such as left ventricular failure and possibly inhaled foreign bodies. if pulmonary infiltrates are found, the possibility of allergic bronchopulmonary aspergillosis should be considered. serum ige and eosinophil levels can be obtained in the acute setting. if either is elevated, the diagnosis of "extrinsic" asthma is established and even more attention should be paid to seeking out a specific allergen. other causes of "asthma" should always be considered (e.g., inhaled foreign body, aspiration, left ventricular failure, pulmonary embolus, and pneumothorax). a new asthma exacerbation in an already hospitalized patient is more likely to be due to these causes than due to the asthma. oxygen given by low-flow intranasal cannulae (1-4 l/min) or 24% to 35% by venturi mask should be initiated with the goal of achieving an arterial saturation (saco 2 ) of 90 ± 2% because this will limit o 2 -induced increases in paco 2 (which occur most commonly in patients with initial paco 2 >50 mm hg and ph <7.35). if the rise in paco 2 is excessive (>10 mm hg), consider reducing the fio 2 to a sao 2 of 87% or 88% versus increasing the level of noninvasive positive pressure ventilatory support. although high levels of o 2 should be avoided (sao 2 >95%), reversal of hypoxia is important and o 2 should not be withheld in the presence of hypercapnia nor withdrawn if it worsens. inadequate improvement of hypoxia with oxygen suggests that an additional problem is present (e.g., pneumonia, pulmonary edema, pulmonary embolus, or pneumothorax) and the diagnostic investigation should be broadened. while this is occurring, however, additional o 2 should be administered to alleviate the hypoxemia. bronchodilators are routinely given in all exacerbations of copd because a small reversible component of airflow obstruction is common, and bronchodilators may also improve mucociliary clearance of secretions. anticholinergic agents have a similar or greater bronchodilator action than b-agonists in copd, and they also have fewer side effects and are not associated with the development of tachyphylaxis. anticholinergic agents should be used routinely in copd with acute respiratory failure, and many now believe them to be the agent of first choice. ipratropium bromide, 0.5 mg in 2 ml, should be given either as a metered-dose inhaler (preferentially) or nebulized initially every 2 hours and then every 4 to 6 hours. chronic use of a long-acting anticholinergic (i.e., tiotropium) reduces the incidence of exacerbations, but this agent should not be used in the intensive care setting. nebulized b-agonists are also effective bronchodilators in copd, although they may cause tachycardia, tremor, mild reductions in potassium and pao 2 (due to pulmonary vasodilatation), and tachyphylaxis. sabas (e.g., salbutamol, terbutaline, or fenoterol) should be given by metered-dose inhaler or nebulizer every 2 to 4 hours in combination with ipratropium. the combination is more effective than either agent alone. continuous inhalation is not recommended because this has been shown to increase side effects without augmenting the response to treatment. parenteral administration is also not recommended. in stable patients, long-term use of b-agonists may improve symptoms of dyspnea, particularly in the subgroup of copd with an objective bronchodilator response. long-acting b-agonists (labas) may also have a beneficial effect on symptoms, quality of life, and exercise capacity. aminophylline is a weak bronchodilator in copd. although studies suggest that it improves diaphragm contractility, stimulates respiratory drive, improves mucociliary transport and right heart function, is anti-inflammatory, and is a weak diuretic, other studies have shown no or small benefits and frequent side effects when given to patients with acute copd exacerbations. accordingly, the literature does not support including this medication in the treatment of acute exacerbations. short-term systemic corticosteroids improve the rate of airflow limitation in patients with acute copd exacerbations. current american thoracic society guidelines and cochrane reviews recommend a maximum dose equivalent to oral prednisolone at 0.5 mg/kg body weight for 3 to 10 days. steroids should be avoided if the deterioration is clearly due to bacterial pneumonia without bronchospasm. long-term oral steroids in copd are associated with a number of serious side effects (e.g., osteoporosis, diabetes, peptic ulcer, myopathy, systemic hypertension, fluid retention, and weight gain) that are likely to impair quality of life and precipitate readmission. accordingly, long-term use should be avoided whenever possible. a small group of patients (no more than 15% of the copd population) may have a more than 50% improvement in their fev 1 following 2 or 3 weeks of systemic corticosteroids. in these patients, the dose should be tapered to the lowest possible that maintains this improvement, and alternate-day dosing and/or a trial of chronic inhaled steroids can be considered. in the majority of patients, long-term inhaled steroids do not improve lung function or survival (although a trial designed and supported by the pharmaceutical industry suggests they may improve quality of life and reduce hospital admissions). antibiotics have an accepted role in the treatment of infectioninduced exacerbations of copd. amoxicillin is a suitable firstline agent against h. influenzae, s. pneumoniae, and m. catarrahalis. if a chest x-ray suggests a component of pneumonia, then community-acquired pneumonia guidelines should be followed and treatment should include a tetracycline, macrolide, or fluoroquinolone. treatment of associated medical conditions, such as fluid overload (diuretics), left heart failure (digoxin and vasodilators), pneumothorax (intercostal drainage), pulmonary embolus (anticoagulation), and electrolyte correction, should be undertaken as appropriate. respiratory stimulants (e.g., acetazolamide, medroxyprogesterone, naloxone, doxapram, and almitrine) have no role because attempts to increase minute ventilation will increase dynamic hyperinflation and reduce muscle effectiveness and thereby increase work of breathing and fatigue. narcotic-or benzodiazepine-induced respiratory depression is best managed with the appropriate antagonistnaloxone or flumazenil, respectively. excessive carbohydrate calories should be avoided because this increases co 2 production and may worsen respiratory failure. noninvasive ventilation (niv), a technique in which ventilatory support is provided via a nasal, facial, total face, or oral mask (fig. 24.5) , should be considered in hypercapnic patients. several randomized controlled trials have demonstrated improved respiratory physiology, reduced mortality, reduced iatrogenic complications, reduced need for intubation and mechanical ventilation, and reduced length of stay in hospital (table 24 .3 and fig. 24.6) . all studies have shown good tolerance of the technique (~80% of patients) with few side effects and improvements in both oxygenation and paco 2 compared with medically treated control patients. niv unloads the inspiratory respiratory muscles, thereby reducing the work of breathing and the attendant co 2 production. this immediately improves respiratory acidosis, even if alveolar ventilation is unchanged. indications for niv to treat acute exacerbations of copd are acute dyspnea, respiratory rate higher than 28 beats/min, or paco 2 higher than 45 mm hg with a ph less than 7.35 despite optimal medical treatment. although these indications include mild to moderate exacerbations, most randomized studies have used these as entry guidelines (table 24. 3). copd patients liberated from invasive ventilatory support may also benefit from niv, although studies have questioned the utility of its use in this setting. side effects of niv include discomfort, intolerance, skin necrosis (fig. 24.7) , gastric distention, barotrauma, and aspiration. choice of mask is extremely important. face masks are generally preferred in the emergency setting, but if their use is complicated by air leaks, claustrophobia, discomfort, or nasal skin damage, then a larger face (head hood) may be better tolerated or more effective. nasal masks are more suited to long-term support and usually not recommended for an acute exacerbation. invasive ventilatory support may be required if respiratory failure progresses despite the previously discussed measures or if the patient is drowsy, uncooperative, or in extremis. the decision to ventilate requires careful consideration in some patients who may have near end-stage lung disease and whose quality of life may not justify aggressive treatment. obviously, this problem is markedly attenuated if primary care or outpatient specialty physicians appropriately address end-of-life issues with these patients prior to the acute exacerbation. the goals of invasive ventilatory support in copd are to allow respiratory muscles to rest and recover without causing them to atrophy from total inactivity and to minimize dynamic hyperinflation. a variety of approaches can be used, but pressure-support ventilation is frequently employed in milder exacerbations. since auto-peep exists in virtually every patient during an acute exacerbation, however, continuous positive airway pressure (cpap) should always be applied. the level of cpap should be adjusted and readjusted empirically, observing the work of breathing associated with inspiration (or by observing the esophageal pressure trace if this is being monitored). it cannot be adjusted on the basis of the airway pressure trace. pressure support should be titrated to achieve an adequate tidal volume (250-400 ml), adequate spontaneous rate (<30 breaths/min), and patient comfort without excessive minute ventilation (<115 ml/kg/min) or excessive correction of hypercapnia. more severely affected patients need continuous ventilation or synchronized intermittent ventilation; dynamic hyperinflation should be avoided by using a low minute ventilation (115/ml/kg is a guide). this should be achieved by the use of a small tidal volume (8 ml/kg) and a ventilator rate less than 14 breaths/min. plateau airway pressure (pplat) should be measured by applying an end-inspiratory pause of 0.5 second following a single breath. this maneuver shortens expiratory time, and if it is applied to a series of breaths it will increase dynamic hyperinflation, increase the pplat level, and increase the risk of volutrauma. if pplat exceeds 25 cm h 2 o, the ventilator rate should be reduced. if a higher minute ventilation is required for excessive hypercapnic acidosis, the degree of dynamic hyperinflation and its effects should be assessed using pplat. use of a high inspiratory flow rate is recommended because it results in a shorter inspiratory time and hence a longer expiratory time for a given venfigure 24 .6. a series of arterial blood gases taken from a 51-yearold man with severe smoking-related copd (fev 1 , 500 ml) over 84 hr who demonstrates acute hyperoxic-induced hypercapnia upon a background of chronic compensated hypercapnia. a reduction in inspired oxygen concentration and noninvasive ventilation prevented intubation and mechanical ventilation. despite presenting with severe hypercapnic acidosis and altered conscious state, the patient was suitable for discharge 3 days later. tilatory rate, which in turn reduces dynamic hyperinflation and alveolar pressure and improves gas exchange. if dynamic hyperinflation is excessive (with attendant circulatory compromise and/or a risk of barotraumas), minute ventilation should be decreased, accepting the resulting hypercapnic acidosis. muscle relaxants should be avoided unless essential. normally, however, spontaneous ventilation should be encouraged to promote ongoing respiratory muscle activity and minimize wasting. flow-by, pressure support, and low-level cpap may all reduce the work of spontaneous breathing and promote a better ventilatory pattern. care must be taken with all these supports because each can increase dynamic hyperinflation by a different mechanism, leading to circulatory compromise or risk of barotrauma. flow-by increases resistance through the expiratory valve, pressure support increases tidal volume and may increase inspiratory time, and cpap increases functional residual capacity. patients who have been invasively ventilated for 7 to 10 days and have failed a trial of extubation with noninvasive ventilatory support may benefit from the insertion of a tracheotomy tube. this may be done via dilational (seldinger) or surgical techniques. generally, the former is more convenient, can be done in the icu, and heals more quickly upon removal. the advantages of a tracheostomy are that dead space is reduced; the endotracheal tube can be removed from the mouth or nose, thus reducing local irritation and sedation; and it facilitates suctioning. the disadvantages include nosocomial infection, local trauma, reduced capacity to cough effectively, and loss of natural humidification. protection of the airway from secretions that accumulate above the tracheostomy is not 100% even with the tracheostomy cuff inflated. appropriate reduction in time on ventilatory support with an awake cooperative patient, allowing for periods of some respiratory work to maintain muscle strength, is crucial before eventual cessation of ventilatory support and removal of tracheostomy. usually, tracheostomies can be safely removed if suctioning occurs less frequently than every 2 hours and patients are capable of independent ventilation and coughing (i.e., adequate muscle strength and drive) and have no anatomic abnormality that would preclude natural ventilation. response to treatment within the first 2 hours is an important predictor of outcome. the patient should be allowed to sit upright and be given humidified oxygen at flow rates that keep the oxygen saturation higher than 90%. the development of oxygen-induced hypercapnia may indicate either underlying copd with chronic hypercapnia or deteriorating progressive severe asthma. sabas (salbutamol, albuterol, tertbutaline, and isoprenaline) are the cornerstone of acute asthma management. salbutamol has b 2 selective bronchodilator properties with minimal b 1mediated cardiac toxicity and is thus the first choice b-agonist. labas such as salmeterol or eformoterol should not be used in acute asthma management. the mode of bronchodilator delivery is an important consideration. multidose inhalers with spacer devices have the greatest penetration of drug into the lungs (~30%), are inexpensive, and should be used in patients with mild to moderate severity who are cooperative. in severe asthma or in uncooperative patients, nebulizers should be used; however, only approximately 10% of the drug reaches the lungs. nebulizers require 8 to 15 liters per minute gas flow to operate, and this can be achieved with an electric air pump or with pressurized oxygen or air. nebulized particle size ranges from 1 to 3 mm. intravenous delivery of b-agonist has no advantage over the inhaled route. in severe asthma, a standard approach is to initiate nebulized 5 mg salbutamol with 8 l/min oxygen every 30 minutes in severe cases and every 2 to 4 hours in mild to moderate asthma. the volume of salbutamol should be made up to 2 to 4 ml with saline or short-acting anticholinergics. side effects of the b 2 -agonists include tachycardia, arrhythmias, hypertension, hypotension, tremor, hypokalemia, worsening of ventilation-perfusion matching, and hyperglycemia. lactic acidosis (up to 10-12 mmol/liter) is a common, doserelated consequence of intravenous saba, appearing in as many as 70% of patients approximately 2 to 4 hours after initiation of treatment. when stable, sabas should be replaced with labas in combination with inhaled steroid cover. labas should not be used as single treatments in asthma because there have been reported events of increased mortality, particularly in african americans. anticholinergics should be used as an adjunct treatment to a saba rather than a single first-line treatment. again, metered dose inhalers are preferable, but the medication can also be administered via nebulizer (usual dosages are 250-500 mg every 4-6 hr). blurred vision may occur due to local effects on the eye. anticholinergic preservative-induced bronchospasm has been reported and should be considered in patients with persistent wheeze. systemic corticosteroids reduce hospitalization rates, mortality, and length of hospital stay in patients with asthma. their mode of action is to primarily decrease the inflammatory response and the associated bronchospasm and mucus secretion, with an onset of action 6 to 12 hours after administration. hydrocortisone (2-4 mg/kg) or methylprednisolone (0.5-1 mg/kg) is given intravenously, or prednisone or prednisolone (0.5-1.0 mg/kg) is given orally every 6 hours. these high doses are usually continued for 1 to 3 days or until clear clinical improvement is observed, after which they are tapered and replaced with inhaled steroids. side effects of steroids include hyperglycemia, hypokalemia, hypertension, acute psychosis, myopathy, and gastritis. longer term steroids are associated with additional problems, such as osteoporosis, cataracts, diabetes, oral thrush, and other secondary infections. aminophylline has bronchodilatory and a variety of other antiinflammatory properties due to its ability to inhibit phosphodiesterase. the role of theophylline in acute asthma is not clear due to conflicting results from clinical trials and its narrow chapter 24 therapeutic window, and its side effects include vomiting, tachyarrhythmias, headaches, restlessness, and convulsions. it is a fourth-line agent following sabas, anticholinergics, and steroids. a usual dosage regime is a loading dose of 3 mg/kg and infusion rate of 0.5 mg/kg. serum levels need to be monitored. several alternative treatments have been proposed, such as methotrexate, intravenous g-globulin, cyclosporine, colchicines, troleandomycoin, lignocaine, and magnesium sulfate, with either no or marginal effect. helium gas mixture has been used, as has the sedative ketamine, with similar marginal degrees of success. noninvasive ventilatory support has been used infrequently for several years in acute asthma, and only in recent years have reports confirmed its safety and efficacy. in addition to expiratory airway pressure countering the effects of auto-peep, inspiratory positive airway pressure may counter the increased inspiratory resistance. potential complications with noninvasive ventilation are patient-ventilator asynchrony, gas trapping (pulmonary or gastric), and decreased cardiac output from decreased venous return. careful monitoring, similar to that of an intubated patient, is required. this should be considered in patients with severe and lifethreatening asthma (table 24 .2) who have failed medical treatments as listed previously. as in copd, the consequence of delayed expiratory airflow in asthma is that the inspired tidal volume cannot be completely exhaled to functional residual capacity and a proportion of each breath is trapped, impairing the arrival of each new breath. as lung volume increases, expiratory airflow also increases as a result of increasing small airway caliber and increasing elastic recoil pressure. this enables the lungs to inflate to an equilibrium point at which all the tidal volume is able to be exhaled during the expiratory time available. in mild airflow obstruction, this process is adaptive because it enables required minute ventilation to be achieved at a higher lung volume with only moderate loss of inspiratory muscle power. when airflow obstruction is severe, however, the equilibrium point may encroach on total lung capacity. the hyperinflation is the result of both airflow limitation and the increased minute ventilation required to provide a normal paco 2 . complaints of needing ventilatory help, clinical appearance of exhaustion, deteriorating respiratory status, or reduced conscious state are more important indicators of the need for intubation than any specific paco 2 . the first 24 hours after intubation is the period of highest risk for ventilation-induced dynamic hyperinflation because airflow obstruction is often at its worst, co 2 production and dead space are the highest, and hence the minute ventilation requirement is highest. at this time, patient respiratory distress and clinician desire to reduce hypercapnic acidosis can easily lead to a level of ventilation that results in excessive dynamic hyperinflation with risk of hypotension, pneumothoraces, and, uncommonly, circulatory collapse. as in copd, initial minute ventilation should be restricted to 115 ml/kg/min (8 liters/min for a 70-kg lean weight patient) or less, tidal volume 8 ml/kg (560 ml for a 70-kg lean weight patient) or less, and respiratory rate 14 breaths/min or less. this should be delivered with a short inspiratory time (vi ≥ 80 liters/min or ti ≤ 0.5 sec) to allow a long expiratory time (te ≤ 3.5 sec) to minimize dynamic hyperinflation. either pressure or volume control mode can be used to achieve this. volume control mode is more established, results in more reliable volume delivery, and is preferred by these authors. peep can be used to counter intrinsic peep, but the possibility of increasing lung volume further (as will occur if external peep exceeds intrinsic peep) must be kept in mind. external peep will only be necessary if the patient continues to have spontaneous ventilation and is unable to trigger the ventilation. generally, these patients receive heavy sedation to suppress their normal response to hypercarbia when their bronchospasm is so severe that sufficient alveolar ventilation cannot be accomplished. although some patients may require one or two bolus doses of neuromuscular blocking agents, these agents should be avoided if possible because of the concern for profound, long-term myopathy thought to occur more frequently in patients receiving the combination of neuromuscular blocking agents and corticosteroids. once initial ventilation is established, dynamic hyperinflation should be assessed by measuring pplat and auto-peep and observing the response of central venous pressure and blood pressure to a transient period of reduced respiratory rate or ventilator disconnection. if pplat is more than 25 cm h 2 o or circulatory improvement occurs, respiratory rate should be reduced and ventilation reassessed. if pplat is low (e.g., <20-22 cm h 2 o) and hypercapnia is present, respiratory rate may be increased. once asthma has improved, sedation may be reduced and spontaneous ventilation in cpap mode with pressure support can occur. cpap 5 to 10 cm h 2 o can be introduced to match auto-peep and reduce work of breathing. hypotension can occur as a result of sedation, ventilationinduced dynamic hyperinflation, pneumothorax, hypovolemia, or arrhythmias. pplat is commonly higher than 25 cm h 2 o, but an equally important assessment for hypotension is the response of the blood pressure and central venous pressure to 60 sec of ventilator disconnection ("apnea test"). circulatory arrest with apparent electromechanical dissociation is a recognized complication of severe asthma. it occurs usually within 10 minutes of intubation and can result in severe cerebral ischemic injury and death if not recognized and managed appropriately. most patients can tolerate mechanical ventilation with 115 ml/kg/min ventilation; however, a small number of patients with unusually severe asthma can develop life-threatening levels of dynamic hyperinflation despite this restriction in minute ventilation. in these patients, a 60-to 90second apnea test should be undertaken and ventilation resumed at the respiratory rate of 2 to 6 breaths/min. a common pitfall is the insertion of intravenous cannulae into the chest in the belief that this circulatory collapse is due to tension pneumothoraces. these procedures usually result in the complication they are seeking to relieve, and it is often difficult to know if a pneumothorax was initially present. apnea testing should precede intercostal cannulae, and, if possible, incision with blunt insertion technique should be used. pathophysiology of severe asthma. nhbli workshop the nature of small-airway obstruction in chronic obstructive pulmonary disease treatment of oxygen induced hypercapnia (correspondence) glucocorticoid for acute severe asthma in hospitalized patients global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. nhlbi/who global initiative for chronic obstructive lung disease (gold) workshop summary early use of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. cochrane database systematic rev fda safety alert sleep and sleep disordered breathing in adults with predominantly mild obstructive airway disease a pilot prospective randomized placebo controlled trial of bilevel positive airway pressure in acute asthmatic attacks chapter 24 uncontrolled oxygen administration in copd inadequate use of noninvasive ventilation in copd excessive minute ventilation during mechanical ventilation circulatory collapse soon after intubation in patients with very severe asthma early intercostal cannula insertion during circulatory collapse development of myopathy due to prolonged muscle relaxation and steroids high-resolution ct scans not contiguous and thus may miss pulmonary lesions inadequate post-icu follow-up to recognize and treat precipitating factors etiology of acute exacerbation of copd and asthma dosage and duration of corticosteroids in acute copd and asthma role of noninvasive ventilation and acute exacerbations of asthma role of intravenous short-acting b-agonists development of hyperoxic hypercapnia in copd circulatory failure and pneumothoraces with mechanical ventilation myopathy lactic acidosis micro-macroaspiration of enteral feeds during sleep/supine position acute necrotizing myopathy is characterized by muscle weakness and histological evidence of myonecrosis, muscle cell vacuolization, and type ii muscle atrophy. myopathy ranges in severity from mild limb weakness to functional quadraparesis. diagnosis is made by elevated creatine kinase levels and electromyography. muscle biopsy is usually not required. there are no specific treatments and recovery is usually complete, but in severely affected patients significant weakness may still be present at 12 months. boxes 24.2, 24.3, and 24.4 list the pitfalls, complications, and controversies. key: cord-016783-8x05oh5q authors: arruda, l. karla; solé, dirceu; naspitz, charles k. title: early interventions in allergic diseases date: 2010 journal: allergy frontiers: therapy and prevention doi: 10.1007/978-4-431-99362-9_23 sha: doc_id: 16783 cord_uid: 8x05oh5q atopy has been defined as the genetic predisposition to develop ige antibody responses to a variety of common environmental allergens. clinically, atopy is expressed by asthma, allergic rhinoconjunctivitis and atopic dermatitis. it has been recognized that the “atopic march” evolves from food allergy and atopic dermatitis in the first 2 years of life, followed by asthma and allergic rhinitis. over the past 30 years, the prevalence of allergies and asthma has increased significantly in developed countries, and asthma is one of the most common chronic diseases in children. evidence indicates that environmental factors acting early in life, including respiratory viral infections, exposure to pets and microbial products, day-care attendance, breast feeding, and exposure to allergens, tobacco smoke and other pollutants, are key events for establishment of sensitization and development of chronic, persistent symptoms of allergic diseases [1]. it is thought that gene—environment interactions play a crucial role in these processes. therefore, attempts to successfully prevent development of allergic diseases should be a priority. at present, there are no genetic markers for atopy or asthma which could be used routinely in clinical practice and family history of atopy has been used to identify children genetically at-risk of developing allergic diseases. these children from high-risk families have been the focus of most of the intervention studies. atopy has been defined as the genetic predisposition to develop ige antibody responses to a variety of common environmental allergens. clinically, atopy is expressed by asthma, allergic rhinoconjunctivitis and atopic dermatitis. it has been recognized that the "atopic march" evolves from food allergy and atopic dermatitis in the first 2 years of life, followed by asthma and allergic rhinitis. over the past 30 years, the prevalence of allergies and asthma has increased significantly in developed countries, and asthma is one of the most common chronic diseases in children. evidence indicates that environmental factors acting early in life, including respiratory viral infections, exposure to pets and microbial products, day-care attendance, breast feeding, and exposure to allergens, tobacco smoke and other pollutants, are key events for establishment of sensitization and development of chronic, persistent symptoms of allergic diseases [1] . it is thought that gene-environment interactions play a crucial role in these processes. therefore, attempts to successfully prevent development of allergic diseases should be a priority. at present, there are no genetic markers for atopy or asthma which could be used routinely in clinical practice and family history of atopy has been used to identify children genetically at-risk of developing allergic diseases. these children from high-risk families have been the focus of most of the intervention studies. in this chapter, we discuss risk factors for development of sensitization and allergic disease, focussing on preventive strategies for allergies and asthma at an early age. infections with respiratory viruses, particularly human rhinovirus (hrv) and respiratory syncytial virus (rsv) are leading causes of lower respiratory tract (ltr) illnesses associated with wheezing in children. although acute wheezing episodes may be severe enough to require hospitalization, majority of children presenting wheezing illnesses early in life will no longer wheeze by the age of 6 [2] . however, in a proportion of these children, early-life-wheezing is a clinical manifestation of asthma. respiratory viral infections have been implicated in the pathogenesis of asthma in several ways: during infancy, certain viruses have been linked to inception of the asthma phenotype; in children with established asthma, viral respiratory infections play a significant role in triggering acute exacerbations that might lead to hospitalizations and frequent outpatient visits; in children with repeated infections due to day-care attendance or contact with older siblings, respiratory viruses may have a paradoxical effect of reducing long-term risk of allergy and asthma, through alterations of cytokine response profiles. in the first 3 years of life, most lrt illnesses with wheezing are associated with infection by rsv. in the northern hemisphere, rsv accounts for 60-80% of wheezing episodes in children younger than 2 years of age [3] . it has been shown that children who wheeze with rsv infection in early life have lower level of lung function prior to infection [2] . most children have serum rsv antibody by the age of 2, yet reinfections are common. although risk of subsequent wheezing after rsv may decrease significantly with age, recurrent episodes of wheezing due to active rsv infections may occur throughout childhood. transmission requires close contact, and occurs either by large-particle aerosols or by contamination of hands and inoculation into the eye or nose, with an average incubation period of 2-8 days [4] . more recently, the role of hrvs in causing acute wheezing has been appreciated. hrvs are small, nonenveloped, positive-strand rna viruses in the family picornaviridae , with over 100 identified serotypes with minimal cross-antigenicity [5] . hrv infects only higher primates, and causes illness only in humans, with replication restricted to the respiratory epithelium [6] . in temperate climates, hrv has been estimated to cause up to 80% of autumn colds [5, 7] . in tropical countries, available evidence indicates that hrv is frequently associated with acute respiratory illnesses (ari). hrv transmission requires close exposure and occurs mainly by hand-to-hand contact, followed by self-inoculation into the eye or nose. it can also be transmitted by airborne spread. once hrv reaches the nasal cavity, infection occurs in virtually 100% of susceptible subjects; and approximately 75% of those infected develop illness after 1-2 days incubation [5] . sensitive pcr-based assays have established the importance of hrv as the cause of lrt illnesses, in addition to upper respiratory tract symptoms. a recent study with in situ hybridization applied to lower airway biopsy specimens has demonstrated presence of hrv in the ltr of 45% of a group of children 3-26 months of age with recurrent respiratory symptoms [8] . other viruses have also been associated with wheezing lrt illnesses in children at lower frequencies, including influenza, human parainfluenza viruses, human coronavirus, adenovirus, human metapneumovirus, and the recently identified human bocaviruses (hbov) -however at a lower frequency [9] . in keeping with observations made in temperate climates, it has been shown that infection with respiratory viruses and family history of allergy, were independently associated with wheezing among infants [10] . results of this case-control study carried out in ribeirão preto, a city in southeast brazil, revealed that, in the group of children under 2 years of age, respiratory viruses were detected in 60.8% of wheezing infants versus 13.3% of controls, and rsv was detected in 39% wheezing children and none of the controls. rhinovirus rna was found in 20.2 and 10% of the wheezing and control children, respectively, though this difference was not significant ( p = 0.21). the frequency of rsv was lower than that reported in temperate regions (39% versus 60-80%). however, considering the subgroup of infants 0-6 months-old, 61% tested positive for rsv antigen. rsv infections were predominantly found in the months of february to may, corresponding to late summer and early to midfall, indicating that the virus occurs in a different seasonal pattern as compared to that of the northern hemisphere. in the group of children 2-12 years of age, respiratory viruses were not significantly associated with wheezing [10] . in the united states, heymann et al have shown that viral infections, especially hrv, were the dominant risk factor for wheezing among children hospitalized before the age of 3 [11] . in their study, 84% of wheezing children p = 3 years-old were positive for virus, compared to 54% of controls ( p < 0.001); rsv was the dominant pathogen in the winter months among children 2 years-old or younger; however, rhinovirus was detected more often among wheezing children hospitalized in the other months of the year (58%) as compared to controls (26%, p < 0.04) [11] . one important issue would be whether infections with respiratory viruses particularly rsv and hrv occurring early in life could function as triggers or "adjuvants" for subsequent development of sensitization and persistent symptoms of allergic diseases. the rational for this hypothesis would be the potential of these infections to induce significant damage to the airways which might facilitate penetration of allergen(s) and/or trigger events related to airway remodeling. rsv enters the cell by fusion of the viral envelope with the cell membrane, and causes syncytia formation as a result of fusion of the infected cells to adjacent ones. replication in the bronchiolar epithelium causes necrosis of ciliated cells, peribronchiolar inflammation with abundant lymphocytes and macrophages, and impairment of secretion clearance, resulting in small airway obstruction and the hyperinflation characteristic of bronchiolitis. clinically, involvement of the lrt is characterized by tachypnea, dyspnea, cough, expiratory wheezing, air trapping, hyperaeration of the lungs on chest x-rays, and intercostal muscle retractions and cyanosis [4] .the pathogenesis of hrv infection is based on the release of cytokines, chemokines, and inflammatory mediators triggered by productive viral replication in a limited number of cells. a number of chemokines, particularly cxcl8 (il-8), ccl3 (macrophage inflammatory protein 1 a ) and ccl5 (rantes) are major mediators released during respiratory viral infections, which could recruit virus-specific t-cells as well as allergen-specific t-cells that in turn could augment any ongoing allergic response in the lung [12, 13] . it has been speculated that the contemporaneous occurrence of cycles of viral-induced and allergen-induced inflammation in the airways during the period of rapid lung growth and remodeling in infancy interacts synergistically to disrupt underlying tissue differentiation programs. this interaction could result in deleterious changes in ensuing respiratory functions, which may then manifest as persistent wheeze and/or asthma [14] . studies have shown association of rsv bronchiolitis and other early respiratory tract infections with recurrent wheezing or symptomatic asthma during the first 4-7 years of life [15, 16] . a long-term study carried out in tucson, arizona, revealed an association of ltr infection caused by rsv early in life with persistent wheezing at 3 and 6 years of age; however, this effect was lost at age 13 [17, 18] . besides rsv, hrv [19] may be potentially implicated in the subsequent development of childhood asthma. lemanske et al. have shown that, in a group of 285 children at high risk of asthma, studied during the first 3 years of life, infection with hrv in the first year was the greatest risk factor for persistent wheezing in the third year [20] . the authors showed that 63% of children who wheezed during rhinovirus season continued to wheeze in the third year, as compared to only 20% of all other infants (or = 6.6). a study in finland revealed that infants hospitalized for rhinovirus-induced wheezing presented a fourfold higher risk of asthma in school age, as compared to wheezing infants from whom no rhinovirus was identified. children with atopic dermatitis were especially likely to develop wheezing during hrv infections [21] . these studies highlight the previously unrecognized potential role of rhinovirus infection occurring in early life in the onset of asthma. follow-up of children 0-2 years of age who participated in the emergency room study in brazil [22] revealed that, after 2 years, 52% presented persistent wheezing. in contrast to studies carried out in temperate regions, viral infections were not a risk factor for persistent wheezing. on the other hand, early sensitization particularly to mites and cockroach, at 2-4 years of age, and exposure to high levels of cockroach allergen in the home in the first 2 years of life were both strong and independent risk factors for persistence of wheezing. it has been consistently shown that early allergen sensitization becomes a major risk factor for wheezing exacerbations and hospitalizations for wheezing after age 3 [17, [22] [23] [24] [25] . it is thought that ige-mediated inflammation found in most children with persistent symptoms of asthma is a key factor in causing lung function impairment and airway remodeling. previous studies in brazil have shown that day-care centers and schools, in addition to homes, are sources of significant exposure to mite and cockroach allergens, which might contribute to sensitization [26, 27] . heymann et al have demonstrated that sensitization to house dust mites and other aeroallergens was an important risk factor for hospital admissions for wheezing and adverse responses to viral infections, particularly those caused by rhinovirus, in 3-18 years old children [11] , highlighting the synergistic effect of sensitization, allergen exposure, and concomitant viral infection in augmenting inflammatory responses in the airways [28] . the possibility that viral and atopy-associated inflammation may interact synergistically to drive asthma pathogenesis has been raised recently by kusel et al. [14] . results of this community-based cohort, involving 198 children followed from birth to 5 years, revealed that acute ltr infection caused by rhinovirus or rsv in the first year of life interacted with atopy in infancy (sensitization £ 2 years-old) to promote later asthma [14] . it is well recognized that exacerbations of asthma, in patients with established disease, are often triggered by respiratory viral infections, particularly those caused by rhinovirus. in asthmatic patients, persistence of hrv up to 6 weeks following infection or exacerbation of asthma, has been reported [29, 30] , suggesting that an aberrant immune response to hrv may be involved in the development of acute exacerbations in atopic individuals with asthma. also, coexistence of atopy enhances the clinical effect of hrv infection, increasing intensity and duration of bronchial hyperreactivity [31] . finally, it has been suggested that repetitive viral infections might confer protection to development of asthma, based on their ability to skew the immune system away from the th2-type response [13, 15] . day-care attendance and/or siblings significantly increased the likelihood of occurrence of rsv or rhinovirus infections, and increased the risk of rhinovirus-induced wheezing at an early age. neonatal interferon (ifn)-g responses were lower in infants with high frequency of respiratory infections; conversely, frequent infections were associated with a smaller decline of ifn-g responses during the first year of life, indicating that preexisting immunologic factors may influence the expression of viral infections in infancy [15] . exclusive breast feeding for at least 4 months has been associated with protection against development of asthma or atopic diseases [32, 33] , but other studies have failed to demonstrate protection by breast milk [34] . bottcher et al. [35] found no relationship in levels of cytokines (il-4, il-5, il-6, il-8, il-10, il-13, il-16, ifn-g , tgf-b 1, tgf-b 2), chemokines (rantes, eotaxin) or secretory iga in breast milk, and development of sensitization or allergic symptoms, or levels of salivary iga during the first 2 years of life. endotoxin is a constituent of the outer membrane of gram-negative bacteria, found ubiquitously in nature, being present in most indoor environments as a component of house dust. endotoxin stimulates the release of potent proinflammatory cytokines. exposure to high levels of endotoxin in dust is associated with induction of asthma in sensitive patients [36, 37] . it has been demonstrated that bacterial endotoxin is capable of producing th1associated cytokines, ifn-g , and il-12 and therefore, has the potential to decrease allergen sensitization. chronic endotoxin exposure, before polarized t-cell responses are established, might be expected to protect against allergen sensitization by continuously enhancing th1-type lymphocyte development [38] . this assumption has been partially confirmed by studies in humans showing that exposure to high levels of endotoxin in early life was associated with protection against allergic sensitization [39, 40] . an experimental study with pregnant balb/c mice has shown that combined exposure to endotoxin during prenatal and postnatal phases suppressed allergenspecific sensitization (ige production), eosinophilic airway inflammation (reduced numbers of eosinophils in bronchoalveolar lavage fluids), and in vivo airway reactivity in response to methacholine. the suppression of allergen-mediated inflammatory responses was associated with increased toll-like receptor and t-bet expression by lung tissues and a shift toward predominantly th1 immune responses [41] . similar results were observed by wang and mccusker [42] . the relationship of exposure to microbial agents (endotoxin, fungal agents, and other microbial contaminants) early in life (3 months of age) and the development of atopic sensitization and physician-diagnosed asthma and wheeze in the first 4 years of life, in children of atopic mothers, was investigated in the prevention and incidence of asthma and mite allergy (piama) birth cohort study. a significant reduction in the development of asthma was associated with early exposure to these substances [43] . children who were born and raised in a farm environment and exposed to poultry and livestock were reported to have lower prevalence of asthma and/or allergic diseases in comparison to those living in urban area [44, 45] . until recently, exposure to high levels of endotoxin was associated with exposure to farm animals, presence of pets in home, number of people living in the house, and cleaning habits [46] . however, results of a study carried out on children from rural areas in europe, evaluating farm-related exposures and health outcomes, revealed that levels of endotoxin and extracellular polysaccharides were associated with health outcomes independent of farm exposures [47] . it has recently been shown by simpson et al. that the impact of endotoxin may be genetically determined [48] . in the setting of a birth cohort study, increasing endotoxin exposure was associated with reduced risk of allergic sensitization and eczema, and increased risk of nonatopic wheeze, only in children with the cc genotype at −159 of the cd14 gene [48] . several prospective birth cohort studies have raised the issue of whether keeping of pets , particularly keeping of dogs or cats, might decrease the risk of developing sensitization to those allergens and have confirm these results in part [49] [50] [51] . a systematic review of the scientific literature concerning keeping of pets within the first 2 years of life and prevalence of asthma has shown that exposure to pets was associated with increased risk of asthma and wheezing in children older than 6 years of age and a tendency for protection in those aged below 6 years [52] . in a recent study, a protective effect of early exposure to cat was documented [53] ; however it hasn't happened unanimously and some bias of selection may have accounted for the results. so, the protective effect observed might be attributable to allergen or other exposures associated with pet ownership (eg. endotoxin), but may in part be due to the prior removal of pets in families where children are sensitized or symptomatic or in families with a positive history for atopy at the time the child was born [49] . platts-mills and colleagues [54] while evaluating the immune response among 226 children, 47 of whom had asthma and airway hyperresponsiveness, have demonstrated that increasing the exposure to house dust mites was associated with an increase in frequency of sensitization to dust mite allergen. the highest category of exposure to cat allergen though was associated with decreased frequency of sensitization and higher prevalence of igg antibody to fel d 1. however, the occurrence of sensitization to dust mite or cat allergens was the strongest independent risk factor for asthma (mite or = 4.2; cat or = 6.1). maternal tobacco smoking during gestation is an important avoidable risk factor associated with elevated levels of ige in cord blood, subsequent asthma and allergic diseases in childhood [55] [56] [57] , and reduction of pulmonary function in children [58] . increased production of il-13 by cord blood cells has been found in newborns whose mothers had smoked during gestation as compared with those who never smoked [56] . macaubas et al. [59] reported a direct relationship of maternal tobacco smoking with both low concentrations of il-4 and ifn-g in cord blood and increased risk of wheezing by age 6 years. a recent experimental study on balb/c mice has shown that daily in utero exposure to maternal tobacco smoking was associated with exacerbation of subsequent adult responses to initial allergen exposure [60] . there is a strong body of evidence to support the role of exposure of children to environmental tobacco smoke (ets) in increasing the incidence of asthma, wheeze, cough, bronchitis, bronchiolitis, pneumonia, and impaired pulmonary function. ets increases both the prevalence and severity of asthma, as judged by increases in the frequency of attacks, the number of emergency room visits, and the risk of intubation [55, 57] . the risk associated with parental smoking seems to be greater at younger ages. although a dose-response relationship between ets exposure and respiratory outcomes has been demonstrated, at present there is no threshold dose of ets exposure below which an effect will not occur, and therefore active intervention measures and policies to reduce or eliminate children's exposure to ets should be strongly encouraged [55] . polymorphisms in the proinflammatory cytokine genes tumor necrosis factor-a (tnf) and lymphotoxin-a (lta) have been associated with asthma and atopy in some studies. secondhand smoke and ozone both stimulate tnf production. in a recent study, wu et al. genotyping six tagging single nucleotide polymorphisms (snps) in tnf and lta have observed that genetic variation in tnf may contribute to childhood asthma and that association may be modified by parental smoking [61] . a home-based, individualized, intervention study [62] carried out among inner city children with atopic asthma which included education and remediation for exposure to both allergens and ets, resulted in reduction of asthma associated morbidity. few specific interventions are available to reduce the impact of respiratory viruses. no vaccine is currently available for rsv prophylaxis. the disease enhancement caused by formalin-inactivated vaccine in the 1960s plus results of more recent unsuccessful trials of live-attenuated vaccines, have significantly slowed progress toward an rsv vaccine. passive immunization/immunoprophylaxis with monthly infusions of rsv immunoglobulin or monthly intramuscular injections of humanized monoclonal antibody, during the rsv season, reduced the incidence and severity of rsv infections in high-risk children including those preterm babies less than 6 months-old, children with congenital heart disease, and children less than 2 years with bronchopulmonary dysplasia [4] . the large number of hrv serotypes with minimal cross-antigenicity has hampered the development of an hrv vaccine. it may be possible to reduce exposure to hrv by washing of hands after contact with a cold sufferer or after handling objects that may have been contaminated with respiratory secretions [5] . immunization with formalin-inactivated or live-attenuated multivalent influenza virus vaccines and chemoprophylaxis for influenza virus a are the methods available for preventing influenza. influenza vaccine is used prior to the influenza season. the inactivated vaccine has an approximate 70-90% efficacy in preventing illness in healthy children and adults. in summary, there are virtually no effective strategies targeted at the respiratory viruses for treatment or prevention of viral-induced wheezing illnesses in children. however, evidence indicates that treatment of lung inflammation with inhaled corticosteroids or blocking viral-induced overproduction of leukotrienes with leukotriene-receptor antagonist montelukast may be effective in decreasing severity and frequency of viral-induced wheezing in young children with recurrent or persistent symptoms [63, 64] . a double-blind, controlled trial (previa study) investigated the effect of treatment with montelukast for 12 months in 2-5 years-old children with intermittent asthma. approximately half of these children were positive for at least one respiratory virus, including hrv, coronavirus, and rsv in their nasal aspirates during exacerbations of symptoms. the results showed that montelukast had a beneficial effect, decreasing frequency of exacerbations, increasing time between acute wheezing episodes, and reducing the need for inhaled corticosteroids during exacerbations [64] . preventive strategies have focused on manipulating the environment of high-risk individuals as an attempt to reduce the prevalence of allergies and asthma in children. at present, six primary prevention controlled studies are in progress [65] . the longest follow-up reported has been from the isle of wight study [66] . in this randomized, controlled study, a group of 120 high-risk infants was recruited prenatally, and development of allergic diseases and sensitization to common allergens was assessed at ages 1, 2, 4 and 8 years. intervention included strict elimination of common food allergens (dairy products, egg, wheat, nuts, fish, and soy) to the age of 12 months. lactating mothers followed the same restriction diet (except wheat) for the duration of breast feeding. extensively hydrolyzed formula was given as a supplement to the child from birth, or when breast feeding was discontinued before 9 months. stringent allergen avoidance measures were also instituted at birth, aimed at reducing exposure to house dust mites. repeated measurement analysis showed a sustained preventive effect of allergen avoidance on asthma, atopic dermatitis, and sensitization to allergens over the period of the first 8 years of life, and on allergic rhinitis at age 8 [67] . therefore, the conclusion was that stringent avoidance of mite and food allergens applied to high-risk children in infancy were beneficial and resulted in reduction of allergic sensitization and clinical manifestations of allergy, beyond the period of avoidance [67] . likewise, outcome of the canadian primary prevention study on high risk infants has been reported at age 7 years, showing that intervention during the first year of life, comprising avoidance of mite, pet allergens and ets, as well as dietary regimen, resulted in reduction of asthma symptoms and asthma diagnosed by a pediatric allergist in the intervention group. in the canadian study, no significant effect of intervention was observed for bronchial hyperreactivity, allergic sensitization, allergic rhinitis, or atopic dermatitis at age 7 years [68] . initial results from other cohorts look promising; however further follow-up will be necessary before any recommendations can be made [65] . results of the manchester asthma and allergy study (maas) have been reported up to the age of 3, and showed that stringent mite and pet allergen avoidance measures starting during gestation, resulted in decrease in severe wheezing and exercise induced wheezing at age 1, and improved pulmonary function in the intervention group at age 3. however sensitization to mites was increased at 3 years of age [69] . in the study of prevention of allergy in children in europe (space), environmental control measures aimed at reducing exposure to dust mite allergens at birth and education failed to prevent sensitization at age 2 [70] . another study looking at the effects of mite avoidance measures during gestation and education. the piama study, showed a modest benefit of reduction of cough apart from colds at 2 years of age [71] . the results of the childhood asthma prevention study (caps), carried out in australia, revealed that house dust mite allergen avoidance in conjunction with supplementation of diet with omega-3 fatty acids (abundant in fish and canola-based oils), applied to children with high risk of asthma, resulted in decrease in cough and sensitization to mites at 3 years of age , with no significant differences in wheeze [72] . the conclusion of these prospective studies so far is that environmental measures taken to decrease exposure to dust mite allergens, even if started during gestation, appear to have limited beneficial effects. however, dust mite avoidance in conjunction with stringent dietary avoidance measures applied to high-risk infants of highly motivated families, may result in prevention of sensitization and clinical manifestations of allergy up to 8 years. follow-up of some of the studies is still too short to allow more definitive recommendations. the prophylactic treatment with an antihistamine, ketotifen, in atopic dermatitis patients was followed by a fourfold reduction in incidence of asthma related symptoms, mainly in those with high levels of serum total ige [73] . similar results were observed among children with high risk of developing asthma. the incidence of asthma in preasthmatic patients treated with ketotifen was 9% versus 31% in the placebo group [74] . warner et al. have evaluated long-term treatment with cetirizine as a preventive tool for the onset of asthma in children aged less than 2 years with atopic dermatitis and without asthma, in a double-blind, randomized, placebo-controlled trial (the early treatment of the atopic child, etac study). at the end of 18 months of active treatment, they observed a significant reduction in the onset of asthma among grass pollen-sensitized infants and dust mite-sensitized infants. these differences were sustained only for the grass pollen-sensitized infants after 18 months of treatment interruption. they concluded that cetirizine truly delays or, in some cases, prevents the development of asthma in a subgroup of infants with atopic dermatitis sensitized to grass pollen and, to a lesser extent, to house dust mite [75] . more recently, preliminary results of the early prevention of asthma in atopic children (epaac) study, shows that the use of levocetirizine daily for 18 months was safe among atopic children 12-24 months of age [76] . on the whole, these studies indicate that the antihistamines ketotifen, cetirizine, and levocetirizine are safe for use in very young atopic children, and that they may have a role in preventing development of asthma in some of these children, particularly those with atopic dermatitis, and those allergic to house dust mite and grass pollen at an early age [76] . the hypothesis that early introduction of inhaled corticosteroids in young children at high risk of developing asthma could change the natural history of the disease has been investigated. a recent study in preschool children at high risk of asthma revealed that 2 years of treatment with inhaled corticosteroid was highly effective in reducing symptoms and asthma exacerbations, though the benefit was no longer present during a third treatment-free year, indicating that corticosteroids may not have disease modifying effects [63] . in this trial, the prevention of early asthma in kids (peak), 285 children aged 2-3 years were randomized to receive either 88 mcg fluticasone twice daily for 2 years or placebo, and at the end of the second year, treatments were interrupted. clinical and functional differences favoring the children treated with inhaled fluticasone disappeared a few weeks after discontinuation of regular treatment. recently, two other studies carried out in the united kingdom and denmark [77, 78] reached similar conclusions as the peak trial: very early treatment of asthma with inhaled corticosteroids, even before the persistent form of the disease has become evident, does not change the natural clinical course of the disease, and does not seem to affect the level of lung function attained at the end of follow-up, despite the fact that this form of treatment is very effective in controlling asthma symptoms while in use [79] . specific immunotherapy (sit) administered by the subcutaneous route is an efficient treatment for ige-mediated disease to defined allergens [80] . beneficial effects of sit in children have been demonstrated in preventing new sensitizations in children monosensitized to mites [81, 82] and in slowing the progression to asthma in those with seasonal allergic rhinitis, sensitized to pollen allergens (the pat study) [83] . follow-up of children with allergic rhinitis sensitized to birch or grass pollens, who underwent sit for 3 years [83] showed that the effect of sit in preventing development of asthma was still evident 2 years after sit was discontinued [84] . concerns regarding the use of sit in asthma include the possibility of severe anaphylaxis; however guidelines have been developed to minimize risks of reaction [80] . sublingual immunotherapy (slit) is increasingly being regarded as an efficient tool for the treatment of patients with asthma and/or rhinitis, as indicated by results of meta-analysis of studies carried out in children and adults [85] . the increased safety and ease of administration of slit makes this strategy very attractive as a form of early intervention in young children with ige-mediated disorders, which could modify the natural course of allergic diseases. studies addressing the use of slit in young children however have not been reported. issues including standardization of the vaccines, establishment of effective doses and schedules for administration, compliance, and better understanding of mechanisms of action and magnitude of efficacy need further research [85] . evidence suggests that events taking place between 2 and 3 years of age might be crucial determinants in the development of allergies and asthma [86] . strategies to prevent development of sensitization and progression to disease or to elicit long lasting remission of symptoms are strongly desirable. however, current environmental interventions and treatment modalities with pharmacotherapy do not meet these expectations. according to the recent published world allergy organization project report and guidelines on prevention of allergy and allergic asthma document [87] , some evidence-based recommendations can be highlighted (tables 1 and 2 ). acknowledgments dr. l. karla arruda's research on risk factors for asthma in children in brazil is supported by fapesp and cnpq, instituto de investigação em imunologia, l.k.a. and d.s. are recipients of cnpq scholarships. table 1 recommendations based on the world allergy organization project report and guidelines on prevention of allergy and allergic asthma -primary prevention infants without a special risk for allergic diseases exclusive breast feeding for 6 months is recommended by the who: if a supplement is needed, a conventional cow-milk-based formula is recommended (b) no special maternal diet during pregnancy or lactation (a) avoidance of solid foods until 6 [4] months of age (b) avoidance of exposure to tobacco smoke (also during pregnancy) (b) infants with a high risk for allergic diseases exclusive breast feeding for at least 6 months: if a supplement is needed, a documented hypoallergenic formula is recommended for the first 4 months of life; after the age of 4 months, high-risk children can receive the same nutrition as nonhigh-risk children (a) no special maternal diet during pregnancy or lactation (a) avoidance of solid foods until 6 [4] months of age (b) environmental measures avoidance of tobacco smoke (also during pregnancy) (b) reduction of allergen exposure early in life (house dust mites, furred pets, cockroaches) (b) avoidance of damp housing conditions (c) avoidance of pollutants (c) table 2 recommendations based on the world allergy organization project report and guidelines on prevention of allergy and allergic asthma -secondary prevention avoidance of tobacco smoke (b) patients who have perennial asthma, rhinitis, or eczema and who are allergic to house dust mites or animal dander should try to reduce their exposure to the relevant allergens (a, b). recommended measures include: removal of relevant pets reduction of indoor relative humidity below 50% if possible encasing of mattresses with documented protective coverings washing of pillows in hot water (>55°c) regularly or encasing of pillows with documented protective coverings washing of bedding in hot water (>55%) regularly (every 1-2 weeks) removal of carpets in bedroom influences in allergy: epidemiology and the environment development of wheezing disorders and asthma in preschool children the role of viral infections in the natural history of asthma respiratory syncytial virus and parainfluenza viruses clinical virology localization of human rhinovirus replication in the upper respiratory tract by in situ hybridization frequency and natural history of rhinovirus infections in adults during autumn human rhinovirus in bronchial epithelium of infants with recurrent respiratory symptoms detection of viruses identified recently in children with acute wheezing risk factors for acute wheezing among children in a subtropical environment: role of respiratory viruses, ige 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a prospective study of wheezing in young children: the independent effects of cockroach exposure, breast-feeding and allergic sensitization the relevance of allergen exposure to the development of asthma in childhood exposure to house-dust mite allergen (der p i) and the development of asthma in childhood. a prospective study relationship of indoor allergen exposure to skin test sensitivity in inner-city children with asthma exposure to indoor allergens in homes of patients with asthma and/or rhinitis in southeast brazil: effect of mattress and pillow covers on mite allergen levels daycare centers and schools as sources of exposure to mites, cockroach, and endotoxin in the city of são paulo, brazil synergism between allergens and viruses and risk of hospital admission with asthma: case-control study persistence of rhinovirus and enterovirus rna after acute respiratory illness in children persistence of rhinovirus rna after asthma exacerbations in children rhinoviruses in the 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with lps and/or allergen prevents experimental allergic airway disease: development of tolerance using environmental antigens does early indoor microbial exposure reduce the risk of asthma? the prevention and incidence of asthma and mite allergy birth cohort study to endotoxin and its relation to asthma in school-age children determinants of endotoxin levels in living environments of farmers' children and their peers from rural areas surface sampling for endotoxin assessment using eletrostatic wiping cloths not all farming environments protect against the development of asthma and wheeze in children endotoxin exposure, cd14, and allergic disease: an interaction between genes and the environment the pasture project: eu support for the improvement of knowledge about risk factors and preventive factors for atopy in europe childhood environmental and adult atopy: results from the european community respiratory health survey exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age systematic review: exposure to pets and risk of asthma-like symptoms early" cat ownership and the risk of sensitization and allergic rhinitis in ligurian children with respiratory symptoms sensitisation, asthma, and a modified th2 response in children exposed to cat allergen: a population-based cross-sectional study prenatal and postnatal environmental tobacco exposure and children's health maternal smoking in pregnancy alters neonatal cytokine responses maternal smoking during pregnancy increases the risk of recurrent wheezing during the first years of life (bamse) effects of early onset asthma and in utero exposure to maternal smoking on childhood lung function association between antenatal cytokine production and the development of atopy and asthma at age 6 years in utero exposure to environmental tobacco smoke potentiates adult responses to allergen in balb/c mice parental smoking modifies the relation between genetic variation in tumor 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prevention of asthma by the use of inhaled fluticasone propionate in wheezy infants (ifwin): double-blind, randomized, controlled study intermittent inhaled corticosteroids in infants with episodic wheezing asthma treatment and asthma prevention: a tale of 2 parallel pathways allergen immunotherapy: therapeutic vaccines for allergic diseases. world health organization. american academy of allergy immunotherapy with a standardized dermatophagoides pteronyssinus extrat. vi. specific immunotherapy prevents the onset of new sensitizations in children prevention of new sensitization in asthmatic children monosensitized to house dust mite by specific immunotherapy. a six year follow-up study pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the pat-study) five-year follow-up on the pat study: specific immunotherapy and long-term prevention of asthma in children sublingual immunotherapy: the optimism and the issues does environment mediate earlier onset of the persistent childhood asthma phenotype? preventive measures: early interventions key: cord-271790-3s8o774l authors: pinto mendes, j. title: the role of infection in asthma date: 2008-10-31 journal: revista portuguesa de pneumologia (english edition) doi: 10.1016/s2173-5115(08)70297-5 sha: doc_id: 271790 cord_uid: 3s8o774l abstract this paper reviews the impact of infections on the onset and clinical course of bronchial asthma. a just emphasis is given to the role viral infections, particularly rhinovirus infections, play in exacerbations, and that played by respiratory syncytial virus, suspected of triggering the asthmatic syndrome. the mechanisms of the immune response to virus attacks are explained, highlighting the asthmatic and allergic patient's weakened response, particularly in the perinatal period. further stressed is a potentiating effect of viral aggression on the allergic response. the hygiene hypothesis and its lack of scientific consistency is detailed, at least as far as the role it seeks to confer on an unproven antagonism of the th1 and th2 lymphocyte responses. the current importance of research not into bacteria, but into bacterial products, including endotoxins, on the modulation of asthma and allergy is noted. studies which, along these lines, show an environmental impact on genetic secretion in the phenotype are underlined. also discussed in passing are several mechanisms which go towards explaining neutrophilic asthma – for many a contradiction, given eosinophilia's stranglehold on asthmatic inflammation. hostil e ambígua a relação do homem com os agentes microbianos! apesar de ser hoje mais limitado o risco de se repetirem as epidemias que, de um só golpe, arrasaram populações inteiras, ainda hoje a memória deste passado povoa o seu imaginário e cria um subconsciente fóbico em relação às infecções. receoso, continua a usar antibióticos mal desconfie que um qualquer gérmen possa esconder -se por detrás do mais tímido sintoma, e julga estar, assim, a levar de vencida o velho inimigo! pura ilusão, porque os microrganismos aprenderam há muito a produzir antibióticos para combater as estirpes que os ameaçam e a criar mutações que os tornam resistentes a idênticas armas dos concorrentes. que as bactérias estavam bem preparadas para os antibióticos, que julgamos ter descoberto, não restam dúvidas! pareceria mais inteligente que, sem deixar de usar as suas armas à medida do risco que a infecção pro-infecção na modulaçâo da asma j pinto mendes man has always had an antagonistic and ambiguous relationship to germs. while we are at much less risk today of epidemics which wiped out entire populations in one fell swoop, we are still aware of those more dangerous times and our subconscious is riddled with phobias when it comes to infection. wary, we continue to take antibiotics as we fear a germ may lie at the root of any seemingly mild symptom and feel in this way we are defeating an age-old enemy. this is pure illusion as microorganisms learnt long ago to produce antibiotics to combat any strains threatening them and to create mutations to make them resistant to their opponent's identical weaponry. there is no doubt that bacteria were more than ready for antibiotics. an intelligent choice would be that in addition to using weapons befitting the risk the infection brings, mankind finds a way to live in har-mete, perante algumas bactérias com as quais já conta um longo convívio, o homem encontrasse formas de coabitação pacífica, como já sucede com a flora comensal das suas mucosas, que protege em troca de um importante papel regulador da resposta imune e da estabilidade funcional local que o abuso de antibióticos pode prejudicar. mas, mais, a sua intempestiva reacção de pânico perante certas agressões microbianas faz com que, por vezes, sejam tão grandes ou maiores os estragos do gesto de defesa do que os da agressão. poderá ser o caso das destruições pulmonares na presença do bacilo de koch. e isto para não falar das doenças autoimunes que, ciclicamente, são julgadas uma consequência de inadequada resposta à presença de bactérias e vírus. é dentro desta problemática do desajuste da resposta de defesa que se equaciona o papel das infecções na reacção imune/inflamatória alterada que se manifesta pelos fenótipos asma brônquica e atopia. tema que ganha cada dia novos contornos, por vezes contraditórios, e daí que temamos que, após este nosso passeio pela literatura, fiquem mais dúvidas do que certezas. de entre os agentes animados, são claramente os vírus os que reúnem provas mais concludentes de uma interferência moduladora na asma, claramente na sua evolução clínica e, presumivelmente, no seu desencadear 1,2 . sem dúvida, são eles os mais potentes e habituais desencadeantes das exacerbações da asma 3, 4 e disso é prova a detecção de vírus durante estes episódios em mais de 80% dos casos em crianças em idade escolar 3 e em mais de 60% em adultos 5 . aliás, os asmáticos que revelam a pre-infecção na modulaçâo da asma j pinto mendes mony with some long-standing bacteria. this is the case with the normal human flora of mucous. this is protected in exchange for a vital regulatory role in the immune response and local functional stability which overuse of antibiotics can harm. further, a panic response to certain bacterial action means that the damage which defensive causes can be greater than that caused by the attack. this is the case with lung damage and koch's bacillus. this is in addition to autoimmune diseases which are cyclically judged a consequence of inadequate response to bacteria and viruses. the role of infection in the changed immune/inflammatory response shown by bronchial and allergic asthma phenotypes is part of the defense overresponse situation. the situation changes on an almost daily basis, sometimes contradicting itself and, as this literature review shows, throws up more questions than answers. viruses are the agents playing a weightier role in the modulation of asthma. they impact on its clinical course and its trigger 1, 2 . they are undoubtedly the most powerful and typical triggers of asthma exacerbations 3, 4 , as shown by the fact that a virus is detected during attacks in over 80% of cases involving school-aged children 3 and in over 60% of cases involving adults 5 . asthmatics suffering exacerbation and who have a virus are more likely to be admitted to hospital 6 , and a virus attack here is clearly linked to bronchial hyperresponsiveness 7 sença de vírus no decurso das exacerbações apresentam um maior índice de hospitalização 6 e a agressão virusal tem neles clara influência no aumento da hiperreactividade brônquica 7 e na diminuição da permeabilidade das vias aéreas, com as consequentes alterações dos volumes pulmonares 8 e das trocas gasosas 9 . discute -se, ainda, a responsabilidade de infecções virusais precoces na persistência de sintomas de asma na infância tardia e na puberdade 3 ou, mesmo, na idade adulta 10 . questão não totalmente respondida é, finalmente, a de o vírus poder ser responsável pelo próprio aparecimento de asma. será ele causa suficiente ou a gota que faz extravasar a água numa situação de particular fragilidade, eventualmente com causa genética? ou será um mero marcador? o vírus sincicial respiratório (vsr) e o rinovírus (rv) são claramente os actores principais neste palco. o segundo o grande responsável pelas exacerbações, e o primeiro o mais prevalente nos três primeiros anos de vida, não se livrando da fama de poder ser capaz de instalar a asma. mas não esqueçamos a influência de vírus há muito conhecidos como os influenza, parainfluenza, enterovírus e adenovírus 2 , enquanto se procura esclarecer o papel de vírus de mais recente descoberta como o hmpv (human metapneumovirus) 11 , os coronavírus nlg 3 12 e hkv 1 13 , o bocavírus humano 14 e o vírus troqueteno 15 . mas o vsr e o rv merecem uma abordagem individualizada, e o enorme volume de publicações que a eles se referem é em grande parte consequência do importante avanço obtido com a utilização de métodos de análise molecular, como o da amplificação enzimática dos ácidos nucleicos virusais, através de pcr (polymerase chain reaction) 16 . pena é que não seja uma técnica acessível infecção na modulaçâo da asma j pinto mendes and decreased airway permeability, with its subsequent lung volume 8 and gas exchange 9 alterations. the role of early viral infections in the persistence of asthma symptoms in late childhood and adolescence 3 or even in adults 10 is also a topic of debate. the jury is still out on whether viruses are responsible for the onset of asthma. is virus on its own the culprit or is it the last straw to break the back of a particularly fragile situation, possibly genetically caused? or is it a mere marker? it is clear that respiratory syncytial virus (rsv) and rhinovirus (rv) are the main players on this stage. rv is the main cause of exacerbations and rsv more prevalent in the first three years of life and thought to promote the onset of asthma. the role played by other and more well know viruses, such as influenza, parainfluenza, enterovirus and adenovirus 2 must not be forgotten, and research is underway into the importance of more recently discovered viruses, including hmpv (human metapneumovirus) 11 , coronavirus nlg 3 12 and hkv 1 13 , human parovirus 14 and torquetenovirus 15 . rsv and rv deserve a separate approach, however. there is a huge body of published work on them, mainly stemming from the important gains brought about by molecular analysis methods, including enzymatic amplification of viral nucleic acids using pcr (polymerase chain reaction) 16 . countries with limited financial means do not have access to this technique, which is a pity. rsv is always present during early life. it infects 70% of children aged one and prac-para estudos epidemiológicos em países de escassos recursos financeiros. o inevitável vsr é presença obrigatória nos primeiros anos de vida -infecta 70% das crianças no primeiro ano e praticamente 100% ao segundo 17 , e é responsável por 70% das hospitalizações por bronquiolite 18 . a sua presença nos primeiros anos de vida acompanha -se com muita frequência de sibilâncias, que se podem arrastar, permanecendo a dúvida de se poderá ser causa de asma ou se apenas a irá precipitar em indivíduos predispostos por influências genéticas ou por imaturidade da resposta imunológica ou do desenvolvimento pulmonar 2 . o certo é que nas populações não consideradas de risco é normal reagir -se ao vsr como se de uma gripe comum se tratasse, se bem que uma minoria possa fazer bronquiolites. desta, 25 a 50% (consoante os estudos) vem a apresentar sintomas de asma intermitente (sibilâncias) aquando de infecções virusais de qualquer natureza, mas só um número muito reduzido virá a apresentar sintomas na idade adulta 19 . não faltam publicações a salientar a influência da infecção por vsr nos primeiros anos de vida na persistência de sibilâncias 15,20 -23 . mas uma grande parte não se revela convincente em atribuir -lhe um papel diferente do de outros vírus respiratórios 2,23,24 . mas uma análise atenta dos diferentes estudos 25 conclui que as bronquiolites graves, que requerem hospitalização, ou seja, as estudadas em meio hospitalar 20, 26 , mais facilmente desenvolverão sibilâncias ou asma atópica na infância tardia, enquanto os estudos populacionais 27 que, em princípio, envolvem casos menos graves, não encontra-infecção na modulaçâo da asma j pinto mendes tically 100% of two year olds 17 . it is the cause of 70% of bronchiolitis-related hospital admissions 18 . rsv in the one to three year old age range often goes hand-in-hand with wheeze, sometimes long-lived, bringing in its wake the question if this is the cause of asthma or just the trigger in patients predisposed due to genetic influences on immature immunological response or on lung development 2 . what is clear is that non-risk populations react to rsv as they do to a normal 'flu virus, although the minority can develop bronchiolitis. of these, 25-50% (it varies from study to study) develops intermittent asthma symptoms (wheeze) in response to any viral infection but only a very small number will develop symptoms at adult age 19 . while many studies underline the role played by rsv infection in early life and the persistence of wheeze 15, [20] [21] [22] [23] , the majority are not convinced it plays a different role to that of other respiratory viruses 2, 23,24 . a close scrutiny of the raft of studies 25 concluded that cases of severe bronchiolitis which needed hospital admission -that it, those studied in a hospital setting 20,26 -, showed a greater tendency to develop wheeze or allergic asthma in later childhood. this is in contrast to population studies 27 which usually involved milder cases and found fewer examples of far-reaching consequences. they sometimes found wheeze, however, which cleared up at 3-5 years and was only rarely prolonged, leading or not to asthma. animal research is difficult to extrapolate to man but suggests rsv can induce allergic sensitisation 28 , increase bronchial and interleukin (il)-13 hyperresponsiveness, and rão, na maioria dos casos, consequências remotas, embora algumas vezes descrevam sibilâncias que irão desaparecer aos 3 -5 anos e só raramente se prolongam, instalando -se ou não uma asma. a investigação animal, difícil de transpor para o homem, sugere a capacidade de o vsr induzir sensibilização atópica 28 , aumento da hiperreactividade brônquica e da interleucina (il) -13, hipereosinofilia e hiperprodução de muco 29 , com maiores probabilidades de tal suceder se a infecção for grave 26 . respostas mais concretas poderão surgir quando for possível uma vacinação anti--vsr, ou se se confirmarem as esperanças que alimentam os esforços de síntese de medicações antivirusais 30, 31 . mas os resultados díspares sobre as potencialidades de o vsr poder ser factor determinante na indução de asma e de atopia não poderão deixar ninguém indiferente à medida que se vão desvendando os mecanismos de defesa antivirusal e as suas potenciais fragilidades na infância precoce, sobretudo no período perinatal e, de um modo particular, em crianças em risco de atopia e asma. não admira que a insuficiência da resposta ao vírus possa passar despercebida em infecções ligeiras e ter consequências indesejáveis nas mais graves. a este assunto voltaremos adiante. poder -se -á dizer, com muitas probabilidades de acertar, que sempre que surge uma exacerbação de asma numa criança até à idade escolar espreita um rv. é que ele é detectado em 80% dos aspirados nasais colhidos quatro dias após os episódios de sibilâncias 3,32 , enquanto no adulto colocará o seu carimbo em 60% das exacerbações agudas de asma 33 . infecção na modulaçâo da asma j pinto mendes stimulate hypereosinophilia and hyperproduction of mucous 29 . there is high probability of this happening in cases of severe infection 26 . more concrete answers will come once an rsv vaccine is available, or if hopes of synthesising anti-virus medications are realised 30, 31 . the different results on rsv's role in inducing asthma and allergy cannot leave anyone indifferent to the way anti-viral defence mechanisms are marshalled and their limited power in early childhood, particularly the perinatal period, especially in children at risk of allergy and asthma. it is no surprise that an inadequate response to the virus can remain undetected in cases of mild infection and bring about unwished for consequences in cases of more severe infection. this subject is dwelt on hereonin. an rv is almost always at the root of an asthma exacerbation in a pre-schooler. it is seen in 80% of nasal aspirate collected four days after episodes of wheeze 3,32 , while it is seen in 60% of acute asthma exacerbations in adults 33 . a review of pcr statistics leads us to the same conclusion; rv is seen in 80% of children taken to emergency rooms with the virus isolated in 20-41% of this population 34 . there are less published studies into rsv, also the cause of childhood asthma attacks 33 . as the name of the virus indicates, rv has a propensity for installing itself in the nasal structures. it is also found in the bronchial structures, extending an influence over the epithelium 34, 35 where it does not cause much lançando mão do pcr, chegamos à mesma conclusão nas crianças que tiveram mesmo de ir a uma urgência, pois revela -se positivo em 80% dos casos, tendo o próprio vírus sido isolado em 20 a 41% desta população 34 . menos publicações a respeito do vsr que também tem sido responsabilizado por ataques de asma na infância 33 . se, como o nome indica, o rv tem uma apetência particular por se instalar nas estruturas nasais, ele também é encontrado nas brônquicas, exercendo a sua importante interacção com o epitélio 34, 35 , onde não causa grandes destruições, e vai ocupar pequenas áreas, em comparação com a vasta destruição do vsr 26 . mesmo assim, os seus efeitos pró -inflamatórios são demonstrados experimentalmente quando a sua inoculação em asmáticos ligeiros produz um aumento da hiperreactividade brônquica, que persiste pelo menos uma semana 36 , e uma diminuição da permeabilidade das vias aéreas dois dias após a sua introdução 37 . o rv pode persistir nos tecidos brônquicos durante duas semanas 24 , induzindo infecções arrastadas que vão comandando uma inflamação progressiva que pode acabar numa exacerbação asmática aguda. mantém -se actual a discussão sobre a cumplicidade da agressão virusal na constituição da atopia, nomeadamente da asma atópica, como deixámos entrever em relação ao vrs. assunto não encerrado porque, se uns defendem poderem ser os vírus determinantes da sensibilização 26 , outros negam -na 27 , e há, até, quem defenda um papel protector da agressão virusal 38 . o vrs é o mais citado, e aponta -se a sua capacidade de aumentar a expressão dos recep-infecção na modulaçâo da asma j pinto mendes damage and occupies only small spaces, unlike the swathe of destruction wreaked by rsv 26 . even so, its pro-inflammatory effects were shown in an experimental model when its inoculation in mildly asthmatic patients induced bronchial hyperresponsiveness lasting at least a week 36 and decreased airway permeability two days after it was introduced 37 . an rv can linger in the bronchial tissues for two weeks 24 , inducing long-lasting infections which give rise to progressive inflammation that can end in an acute asthma exacerbation. the role of virus attacks in building allergy, particularly allergic asthma, is still under discussion, as we can see in relation to rvs. the matter is still the topic of debate; some argue that viruses causes sensitisation 26 ; others refute this 27 , and some believe virus attacks play a protector role 38 . rvs is the most cited and its ability to increase immunoglobulin (ig) e receptor expression, a factor which could make sensitisation to allergens easier, is noted. its role is increasingly suspected by the high rate of rvs infection in early life, when transitory immune system difficulties 4 could theoretically favour a response to the virus, in line with an allergy model. it is an open question as current knowledge of anti-viral responses can provide theoretical support. longitudinal analysis in children aged below two admitted to hospital with viral infection 39 and studies into large populations 27 find no correlation between early life viral infection and onset of allergic asthma up to the age of thirteen years or later, however. tores das imunoglobulinas (ig) e, o que poderia tornar mais fácil a sensibilização perante os alergénios. e torna -se mais suspeito devido à elevada frequência da infecção por este vírus nos primeiros tempos de vida onde dificuldades transitórias do sistema imune 4 podem, em teoria, favorecer uma resposta ao vírus segundo um modelo próprio da atopia. é uma questão em aberto a que os conhecimentos actuais sobre a resposta antivirusal poderão dar suporte teórico. contudo, análises longitudinais em crianças com idades inferiores a dois anos, hospitalizadas por infecção virusal 39 , e estudos em grandes populações 27 , não conseguem encontrar correlação entre infecção virusal precoce e desenvolvimento da asma atópica até à idade de treze anos, ou mais tarde. mas do que parece não restar dúvida é do papel amplificador das infecções respiratórias virusais sobre as consequências da sensibilização, um efeito sinérgico vírus/atopia 23 . e provam -no os estudos experimentais com a concomitância, ou a sequência, de inoculação de rv e provocação alergénica -maior aumento de hiperreactividade brônquica e da infiltração eosinofílica em comparação com qualquer das agressões isolada 40 . esta verificação tem a sua correspondente experimental no animal 41 e na clínica quando se juntam a infecção virusal e a exposição alergénica 42 , mas em qualquer modelo exige--se a proximidade das duas agressões porque se o intervalo for maior do que uma semana este fenómeno já não terá lugar 43 . esta associação imprimiria uma resposta simultânea t helper (th) 1 e th 2 que se potenciariam mutuamente 44 . o vírus também poderia influenciar o processo de tolerância imunitária a agentes estranhos e aumentar a memória específica, a longo prazo, para os alergénios contactados durante a infância 10 . there seems little doubt of the amplification role respiratory viral infections play in sensitisation, a virus/allergic synergy 23 . experimental studies prove that there is a greater increase in bronchial hyperresponsiveness and eosinophilic infiltration with rv inoculation and concomitant or segmental antigen bronchoprovocation and allergenic provocation than with any isolated attack 40 . this is also seen in experimental animal models 41 and in clinical practice when virus infection is in tandem with exposure to allergens 42 . both models demand the two forms of attack in conjunction as the phenomena will not occur if the two are at an interval greater than a week 43 . this association suggests a simultaneous t helper (th) 1 and th 2 response which is mutually potentiating 44 . the virus can also influence the immune response to foreign agents and heighten specific long-term memory to allergens the patient had contact with in childhood 10 . the role of virus is the modulation of asthma and allergy cannot be downplayed. it can intervene on a grand scale in the inflammatory mechanisms which regulate asthma and allergy. it is in fact a thousand piece puzzle which is far from being assembled. we are privy only to a clutch of clues, in themselves seemingly convincing. virus is in the front line of innate immunity which is somewhat dormant, in that infection cannot be fought off quickly and lasts for some time. virus also uses the asthmatic patient's weaknesses, which developed in early life whether he/she is allergic or not 10,25 , vírus nos caminhos da asma e da atopia na modulação da asma e da atopia é difícil menosprezar o papel dos vírus, tal a sua apetência para interferir nos mecanismos inflamatórios que comandam aquelas patologias. é um puzzle de muitas peças que está muito longe de ser resolvido. ficar -nos -emos por algumas pistas que julgamos serem, por si só, convincentes. interferem, logo, na actuação da primeira tropa de choque, a da imunidade inata que é, de certo modo, adormecida para que a agressão infecciosa não possa ser combatida com rapidez e se prolongue no tempo. aproveita também as fragilidades do asmático, atópico ou não, acrescidas nos primeiros tempos de vida 10,25 e que incluem um défice da própria imunidade inata 45 . na agressão virusal às vias aéreas inferiores, o epitélio é a peça fundamental 34, 45 , e conhece--se o seu papel na libertação de moléculas pró -inflamatórias que activam e atraem células t, cd 4 + e cd 8 + , neutrófilos, eosinófilos, macrófagos e mastócitos 10 . se na asma aguda a infecção virusal, nomeadamente pelo rv, a mais bem estudada, está associada à inflamação neutrofílica, lise celular e produção de interferãos (ifn) 46 , se o meio local for rico em il -4 a regra passa a ser a produção de il -5, rantes (regulated upon activated t cell expressed and selected) e eotaxina, a infiltração eosinofílica e a produção de ige 47 . esta mutabilidade dos caminhos da inflamação faz com que não estranhemos que, sendo habitualmente de perfil th 1 a resposta aos vírus, ela possa fazer -se através de citocinas th 2 quando se reúnem as devidas circunstâncias, que o vsr parece com frequência promover. para tal, poderá contribuir uma alteração genética no cromosso-infecção na modulaçâo da asma j pinto mendes one of which is an innate immunity deficiency 45 . in virus attacks the airway below the epithelium is the vital part 34, 45 and its role in the release of pro-inflammatory molecules which activate and attract t, cd 4 + and cd 8 + , cells, neutrophils, eosinophils, macrophages and mastocytes is known 10 . if viral infection in acute asthma, particularly rv -the most studied -is associated with neutrophilic inflammation, cellular lysis and production of interferons (ifns) 46 and if the environment is rich in il-4, the production of il-5, rantes (regulated upon activated t cell expressed and selected), eotaxin, eosinophilic infiltration and ige production 47 generally occur. this change in the inflammation pathways comes as no surprise as, as is usually the case of the th 1 profile in response to virus, it can be made through th 2 cytokines under the correct circumstances, of which the rsv seems to be a frequent promoter. as such it can contribute to a genetic alteration in chromosome 5 (gene 589t il-4 genotype), associated to an hyperexpression of il-4 48 in association to rsv production of the g protein which promotes a delayed th 1 expression (with ifn deficiencies) 49 . this double inflammatory response route, which in the asthmatic can be traced singly or simultaneously, provides good clues to explain the thoroughly discussed eosinophilic and neutrophilic forms of severe asthma. the latter can respond to other stimulation which will not be listed here. one which must be cited is endotoxin inhalation (50) , which is dealt with shortly. epithelial stimulation both promotes neutrophil (through il-8) and eosinophil (il-16), recruitment and increases produc-ma 5 (polimorfismo do gene 589t il -4) que se associa a uma hiperexpressão de il--4 48 em associação com a produção pelo vsr de proteína g, que promove um atraso da expressão th 1 (com um défice de ifn) 49 . esta dupla via da resposta inflamatória, que no asmático pode ser percorrida consoante as circunstâncias ou em simultâneo, fornece boas pistas para a explicação das tão discutidas formas eosinofílica e neutrofílica da asma grave. esta última pode obedecer a outras condicionantes, que não vem a propósito enumerar, mas não poderemos deixar de citar a da inalação de endotoxinas 50 , de que nos ocuparemos adiante. a estimulação epitelial, além de promover o recrutamento de neutrófilos (através da il -8) e eosinófilos (il -16), também aumenta a produção de tumor growth factor (tgf) -β e do vascular endothelial growth factor (vegf), abrindo caminho à remodelação das vias aéreas 1, 24 . e é também a partir daqui que se dá o primeiro passo para a resposta ao vírus, a da imunidade inata, inespecífica, através dos toll -like receptors (tlr) 5,51 , em particular do tlr 3, que reconhece os ácidos nucleicos com dupla cadeia 52 . também fundamental a estimulação dos tlr de membrana dos macrófagos para a activação destes fagócitos das células infectadas. antes, porém, este "varrer da cena" dos vírus intracelulares é preparado pela actuação do tumor necrosis factor (tnf) -α que expõe os vírus intracelulares às células imunes 25 , enquanto os ifn -β dão o seu contributo inibindo a replicação virusal 35 . a prova da importância dos ifn e do tnf--α na luta antivirusal está na demonstração de que a forma de evasão que o vírus põe em infecção na modulaçâo da asma j pinto mendes tion of tumor growth factor (tgf)-β and vascular endothelial growth factor (vegf), laying the groundwork for airway remodeling 1, 24 . it is this which gives the first step towards response to virus, and innate non-specific immunity, through the toll-like receptors (tlrs) 5, 51 , in particular the tlr 3 which recognises double-stranded nucleic acids 52 . tlr stimulation of the macrophage membrane is also vital for activation of these infected cell phagocytes. in fact, this clean sweep of the intracellular viruses is prepared by actuation of the tumor necrosis factor (tnf)-α which exposes the intracellular viruses to the immune cells 25 while the ifn-β contributes by inhibiting viral replication 35 . the importance of ifns and tnf-α in the fight against viruses is shown by the form of evasion which the virus demonstrates and the production of anti-ifns and anti-tnf-α 25 . the entire anti-virus defence process is liable to be different in the asthmatic patient. an ifns deficit, a natural early life occurrence, means the patient cannot fight off a slight attack. this lack can be more deeply felt in the asthmatic patient, a fact not universally accepted, however 10, 53 . it can lead to a reduced clearance due to deficient apoptosis 54 with increased replication of the viruses which linger longer in the airway. innate immunity leads to adaptive and specific immunity, where the dendritic cells play the critical role of introducing the viral antigens to the t, cd 4 + and cd 8 + cells 55 . here too asthmatics could have significant constraints, beginning with an inefficient introduction of the viral antigens, cutting the efficacy of the specific response 1 . marcha é a da produção de anti -ifn e anti--tnf -α 25 todo este processo de defesa antivirusal pode estar alterado no asmático, que não consegue dominar uma agressão maciça pelo seu défice de ifn, natural nos primeiros tempos de vida, e que poderia ser mais acentuado no asmático, factos não aceites por todos 10, 53 . daqui resultaria uma diminuição da clearance por deficiente apoptose 54 com aumento da replicação dos vírus que permaneceriam mais tempo nas vias aéreas. da imunidade inata chega -se à adaptativa, específica, onde cabe às células dendríticas o importante papel de apresentação dos antigénios virusais às células t, cd 4 + e cd 8 +55 . aqui também poderá haver importantes constrangimentos nos asmáticos, a começar por uma ineficaz apresentação dos antigénios virusais, reduzindo a eficácia da resposta específica 1 . uma das populações das células dendríticas, as chamadas plasmacitóides, conseguem fazer a expansão das células t, mas em menor grau do que as suas parentes, designadas por mielóides. contudo, enquanto as primeiras podem induzir tolerância para alergénios, nomeadamente os inalados, as segundas são fortemente imunogénicas e favorecem o perfil th 2 da resposta imune e a atopia, atenuam o papel das plasmacitóides na secreção de tnf -α e facilitam a proliferação das células cd 8 + memória 3, 56 . a estimulação virusal pode originar uma interconversão das células plasmacitóides em mielóides, passando -se, em relação aos alergénios inalados, de um comportamento tolerogénico para o aumento da resposta, com perfil atópico 57 .um importante handicap, sobretudo para as populações em risco de atopia e de asma. one of the dendritic cell populations, the plasmacytoids, is able to make t cells expand but to a lesser degree than their parents, the myeloids. while the first can induce tolerance to allergens, particularly inhaled allergens, the second are strongly immunogenic and favour the th 2 profile in the immune response and allergy, attenuating the role of plasmacytoids in tnf-α secretion and facilitate the proliferation of memory cd 8 + cells 3, 56 . viral stimulation can cause an interconversion of the plasmacytoids cells into myeloids, passing in terms of inhaled allergens from tolerogenic behaviour to an increased response with allergy profile 57 . this is a significant handicap, particularly for the popu lations at risk of allergy and asthma. viral influence in neurogenic inflammation deserves mentioning, even if is seemingly less important or less studied. if the rupture of the epithelium can lead to the discovery of nervous fibre terminals, the virus stimulates the m 2 receptors and determines the hyperexpression of nk 1 , contributing to an increased bronchoconstrictor reflex and inflammation 29, 58 . this fragility demonstrated by the asthmatic in the face of viral attack makes it easy to understand that defences can be easily breached in severe infections, for example rsv, and the virus's persistence is a decisive influence on the phenotype and the syndrome's clinical course. we must not forget that an ineffectual antiviral response can be a determinant in the onset of allergy and asthma, especially in susceptible patients. this is theoretical and widely accepted today, but awaiting scientific confirmation and validation in clinical reality. apesar de aparentemente menos importante, ou menos bem estudada, não deixa de merecer uma palavra a influência virusal na inflamação neurogénica. se a rotura do epitélio pode colocar a descoberto os terminais das fibras nervosas, o vírus estimula os receptores m 2 e determina a hiperexpressão de nk 1 , contribuindo para aumentar o reflexo broncoconstritor e a inflamação 29, 58 . esta fragilidade do asmático perante a agressão virusal, de que apresentamos ao de leve algumas matrizes, faz compreender que em infecções graves, pelo vsr, por exemplo, as defesas possam ser facilmente ultrapassáveis e a persistência do vírus influa decisivamente no fenótipo e na evolução clínica da síndroma. e não é de excluir que, sobretudo em indivíduos predispostos, a insuficiência da resposta antivirusal possa ser determinante no aparecimento da atopia e da asma. isto em teoria, assumida hoje por muitos, que aguarda a confirmação científica da sua validade na realidade clínica. há umas décadas, as preocupações acerca da influência das infecções na modulação da asma centravam -se nas bactérias. falava--se de "asma infecciosa", a não atópica, que muitas vezes se manifestava como grave. e reinou também o conceito de "alergia bacteriana" que aconselhava a administração a longo prazo de vacinas por via subcutânea, muitas vezes preparadas a partir das próprias secreções do doente. hoje, pouca gente acredita na influência bacteriana na génese da asma brônquica, do modo como ela era descrita. mas parece evidente que a inflamação produzida pela infecção, e pela resposta imune subsequente, poderão complicar a instabilidade celular já infecção na modulaçâo da asma and what about bacterial infections? ten years ago, concern over the role played by infection in asthma revolved around bacteria. talk was of 'infectious asthma' and not allergic asthma and it often onset in a severe form. the concept of 'bacterial allergy' was also bandied about, and it advised the long-term administration of sc route vaccines, very often prepared from the patient's own secretions. very few people today believe in a bacterial influence in the genesis of bronchial asthma in the form it was then described. it seems evident, however, that the inflammation caused by infection and the subsequent immune response can complicate the already existing cellular instability. while this is not the place to ask the question, it remains to be discovered if bacteria in themselves are able like viruses to trigger exacerbations or determine the long-term course of asthma. it is not likely that the more common infections such as streptococus pneumoniae, streptococus pyogenes or haemophilus influenzae 19 could also play this role. similar questions are being asked of mycoplasma pneumoniae and clamydia pneumoniae. although there is a lack of evidence, both are believed to be responsible for chronic forms of asthma in children and adults and clamydia alone for acute forms of asthma 1, 18, 59 . faced with a lack of better options, macrolid antibiotics are deemed efficacious in clearing up symptoms, in recovering airway permeability and lowering il-5 expression only in those patients seropositive for those bacteria 1 . the design of those studies left a lot of gaps still to be filled and did not take the anti-inflammatory properties of that antibiotic group into account. instalada. contudo, não é esta a questão que aqui interessa colocar, mas a de saber se, como os vírus, poderão ser as bactérias capazes, por si só, de desencadear exacerbações ou de determinar a evolução a longo prazo da asma. parece fora de causa que tal papel possa ser atribuído às infecções mais comuns, como as do streptococus pneumoniae, do streptococus pyogenes ou do haemophilus influenzae 19 . mas já o mycoplasma pneumoniae e a clamydia pneumoniae têm estado no banco dos réus, embora com culpa mal formada. sugere -se, sem provas suficientes, a sua responsabilidade por formas arrastadas de asma na criança e no adulto e a clamídia, mas não o micoplasma, em formas agudas 1,18,59 . na falta de melhores argumentos, avança -se com a eficácia dos antibióticos macrólidos na melhoria dos sintomas, na recuperação da permeabilidade das vias aéreas e na diminuição da expressão de il -5 apenas nos seropositivos para aquelas bactérias 1 . e se o desenho destes trabalhos deixa muitas dúvidas, também se não têm em conta as potencialidades anti--inflamatórias daquele grupo de antibióticos. mas justificações não faltam, como a da interferência do processo infeccioso nos circuitos inflamatórios, com produção de mediadores ou indução de défices de ifn ou, ainda, a actuação de proteínas de choque térmico indutoras de alterações inflamatórias tendo como alvo o epitélio brônquico, macrófagos e outras células 2,25 . mais do que de afirmação, estamos em fase de pistas para investigação e, como tal, é de aguardar futuros desenvolvimentos. as nossas "amigas" bactérias comensais, com as quais ao longo do processo evolutivo, filo infecção na modulaçâo da asma j pinto mendes justifications abound, including the impact of infection on the inflammatory circuits, with production of mediators or induction of deficits in ifns, or even the performance of heat shock proteins which induce inflammatory abnormalities and whose target is the bronchial epithelium, macrophages and other cells 2,25 . this is more than a theory: it is the subject of research and so we must await future developments. our normal human bacteria with which we have been in more of a trade-off than a coexistence situation throughout the evolutionary process and the phylo-and ontogenetic development process, are now indispensable for our defence system. they give off the strongest signal for the postnatal maturation of innate immunity, with the aid of the tlrs 51 , a fundamental process for the prevention of th 1 and th 2 diseases and for stimulating memory in adaptive immunity. their non-invasive presence in mucous is vital, as a deficiency in this microbial exposure could result in a broad spectrum of immune diseases. it is calculated that in early life there are ten times more bacteria in the mucous, particularly the intestinal mucus and with a genome three times larger than that of the host than there are in the organism as a whole 60 . what has become known as the hygiene hypothesis has been cited as an explanation of the increase in the rates of asthma and allergy in industrialised countries over the last few decades. this hypothesis blames a lack of early childhood exposure to infec-e ontogenético, negociamos, mais do que uma convivência, uma verdadeira parceria, tornaram -se indispensáveis para o desenvolvimento da nossa quadrícula defensiva. delas provém o mais forte sinal para a maturação pós -natal da imunidade inata, com a colaboração dos tlr 51 , um processo fundamental para a prevenção das chamadas doenças th 1 e th 2 e para a estimulação da memória na imunidade adaptativa. a sua presença, não invasiva, nas mucosas tornou -se de tal modo vital que um défice desta exposição microbiana poderá conduzir a um largo espectro de doenças imunes. calcula -se que, nos primeiros anos de vida, existam nas mucosas, com particular relevo para a intestinal, bactérias num número dez vezes superior ao das células de todo o organismo, com um genoma três vezes superior ao do seu hospedeiro 60 . procurando uma explicação para o aumento, nas últimas décadas, da atopia e da asma nos países industrializados, a chamada hipótese higiénica pretende responsabilizar um défice de exposição microbiana nos primeiros tempos de vida pelo acréscimo no desenvolvimento da hipersensibilidade atópica e da asma. esta suspeita foi levantada pela primeira vez por strachan, em 1989 61 :" a diminuição do tamanho das famílias, a melhoria dos cuidados domésticos e os mais elevados padrões de limpeza pessoal reduziram a possibilidade de infecções nos membros mais novos das famílias. daqui pode ter resultado uma expressão mais comum das doenças atópicas". partiu, para esta hipótese, da verificação de uma correlação inversa, em famílias numerosas, entre doenças atópicas e a ordem do nascimento -os mais novos vão -se expondo às infecções dos irmãos mais velhos. infecção na modulaçâo da asma j pinto mendes tious agents for the increase in allergy and asthma. this suspicion was first raised in 1989 by strachan, 61 : '… declining family size, improvements in household amenities, and higher standards of personal cleanliness have reduced the opportunity for cross infection in young families. this may have resulted in more widespread clinical expression of atopic disease'. springboarding from this hypothesis is the verification of inverse correlation between allergic diseases and position in large families: the younger children are exposed to infection from the older. in 1998, peat 62 supported this supposition, attributing the increased rate of asthma particularly in children and teenagers in industrialised countries to our 'sterile' lifestyle. martinez 63 , liu 64 and von mutius 65 found an inverse correlation between exposure to germs and asthma onset, while calvani 38 attributed an identical role to viral infections. there are several other studies of this nature, underlining the role played by several aggressors, such as salmonellas, helicobacter pylori, hepatitis a, toxoplasma gondii and mycobacteria 1, 52, 66 ; all worth evaluating. the explanation given for these statements is that the lack of th 1 stimulation favours the th 2 arm of the immune response, with il-4 and il-13 secretion and ige synthesis, meaning that on balance, there is an unstable opposing th 2 /th 1 equilibrium; as one weakens, the other strengthens. the hygiene hypothesis is far from convincing, however, at least as it stands, but it is at least open to new horizons, which we touch on here. the greater part of these assumptions are difficult to sustain (64) and no one can affirm that in comparing family size and hy-em 1998, peat 62 vem em apoio desta suposição quando atribui ao nosso estilo de "vida esterilizada" o aumento da prevalência da asma, sobretudo em crianças e adolescentes, nos países industrializados. martinez 63 , liu 64 e, também, von mutius 65 encontram relação inversa entre a exposição microbiana e o desenvolvimento da asma, enquanto calvani 38 atribui idêntico papel às infecções virusais. sucedem -se as referências deste tipo, especificando a responsabilidade de vários agentes agressores, como salmonelas, helicobacter piloryi, hepatite a, toxoplasma gondii e micobactérias 1,52,66 , a maior parte não resistindo a um primeiro olhar de avaliação crítica. a explicação levantada para estas verificações é a de que a falta de estimulação th 1 favorece o braço th 2 da resposta imune, com secreção de il -4 e il -13 e síntese de ige. quer dizer que, como se colocadas numa balança de dois pratos, há um equilíbrio instável das vertentes th 2 e th 1 que se opõem de modo a que o enfraquecimento de uma robustece a outra. mas esta hipótese higiénica, pelo menos na explicação que lhe foi dada, está longe de ser convincente, se bem que tenha tido a virtude de ter aberto novas perspectivas que não deixaremos de desenvolver no decurso deste trabalho. na verdade, a maioria destas verificações é dificilmente sustentável 64 e ninguém pode dizer que comparando tamanho familiar e níveis de higiene estamos a medir directamente a exposição a infecções. nesta lógica, como se explica o aumento de prevalência da asma nos bairros pobres dos estados unidos 67 ? ou, em áfrica e na américa latina, em zonas endémicas de xistosomiase, promotora da secreção th 2 e da síntese de ige, que a prevalência daquela parasitose esteja na relação inversa da asma e da atopia 68 infecção na modulaçâo da asma j pinto mendes giene levels we are directly measuring exposure to infection. if we were, how would one explain the rise in the asthma rate seen in the poorer usa neighbourhoods 67 ? or how in africa and latin america, in areas rife with bilharzia, which promotes th 2 secretion and ige synthesis, is the prevalence of that parasite in an inverse correlation with asthma and allergy 68 ? and the high risk of asthma in children who attend nursery schools, with the greatest amount of infections in the lower respiratory tract 69 ? any remaining illusions should be put to rest by the failure of treatment which converts th 1 responses in asthmatics into th 2 with no clinical effect whatsoever 70 . we need new arguments as the th 1 /th 2 dichotomy is no longer accepted. how would the parallel increase in auto-immune inflammatory diseases, th 1, expression and asthma and allergy 71 or the fact that autoimmune diseases are higher in asthmatics 64 be explained on that basis? human and murine studies confirm that there may even be a synergism in both cytokine profiles that goes hand in hand-inmany types of immune response, especially allergic response 72 . this is particularly evident in allergic and viral attacks which combine th 1 and th 2 expressions 73, 74 . rsv attack, inducing th 1 response, occurs in a previously th 2 environment and does not upset the lymphocyte balance. rather it contributes to exacerbating the inflammatory type already installed 42, 43, 72 . in murine models this dual exposure results in a strong response of both cytokine profiles, suggesting that an efficient th 1 response is important for adequate th 2 73 . in 2003, holtzman 75 unveiled a theory that could be true in some cases: the asthmatic risco de asma em crianças que frequentam infantários, com maior número de infecções do tracto respiratório inferior 69 ? se restassem ilusões, bastaria assinalar o fracasso de intervenções terapêuticas que converteram respostas th 2 em th 1 em asmáticos sem qualquer eficácia clínica 70 . temos de arranjar outros argumentos, já que se não aceita hoje a relação dicotómica th 1 /th 2 . como se explicaria, naquela base, o aumento paralelo da prevalência das doenças inflamatórias autoimunes, de expressão th 1, e de asma e atopia 71 , ou o facto de as doen ças autoimunes terem elevada prevalência nos asmáticos 64 ? aliás, os estudos em modelos humanos e murinos confirmam que pode, até, haver um efeito sinérgico de ambos os perfis citocínicos que concorrem de mão dada em muitos tipos de resposta imune, nomeadamente na atópica 72 . isto é bem evidente quando se sucedem as agressões alérgica e virusal que combinam as expressões th 1 e th 2 73,74 . a agressão pelo vsr, indutora de resposta th 1 , acontecendo num ambiente previamente th 2 , não desvia o balanço linfocitário, antes contribui para a exacerbação do tipo inflamatório já instalado 42, 43, 72 . em modelos murinos, desta dupla exposição resulta uma resposta forte de ambos os perfis citocínicos, sugerindo -se, mesmo, que uma resposta eficaz th 1 pode ser importante para uma th 2 adequada 73 . em 2003, holtzman 75 expõe uma teoria que, pelo menos em algumas situações, poderá corresponder à realidade -o fenótipo asmático desenvolve -se pela activação concomitante de mecanismos atópico e antivirusal. seria uma resposta de ampliação mútua th 1 /th 2 que levaria à inflamação crónica, à hiperreactividade brônquica e à remodelação. infecção na modulaçâo da asma j pinto mendes phenotype develops via concomitant activation of allergic and anti-viral mechanisms. a mutual th 1 /th 2 amplification leads to chronic inflammation, bronchial hyperresponsiveness and remodulation. those two types of response seem to fight for the same ground. the immunology battle field is an open and interactive one, allowing multiple combinations of tactics to be selected, and weapons of choice befitting every situation. regulatory t cells stand up to choose the most fitting solutions 45, 76, 77 and as such, those seeking to understand the intricacies of the immune response should study them. romagnani 78 feels any explanation of the hygiene hypothesis has to pass through the altered immunity situation caused by alteration of the regulatory t cells. the role of these cells, whose promotion may well start in the intestinal microbial flora 79 , is becoming increasingly complex as the choices at its disposal are ever-widened by the discovery of new aids to immunology. an example is the recent discovery of the th 17 profile 80 which acts through the il-17 and will fill some gaps in knowledge of the immune/inflammatory phenomena. unlike the th 1 and th 2 profile, the th 17 profile mediates tissue inflammation, promoting neutrophil recruitment and survival and is likely to be a participant in auto-immune diseases as its netralisation prevents tissue inflammation in these types of diseases. it is another clue in severe neutrophilic asthma where suspicion is cast from time to time on auto-immune intervention. the set of variables acting in the immune response is large and complex. it is conditioned by genetic susceptibility (genotypes) definitivamente, vamos deixar de colocar aqueles dois tipos de resposta num quarto fechado, a disputar o mesmo espaço. o campo de batalha imunológico é aberto e interactivo, permitindo múltiplas combinações de escolhas tácticas, seleccionando as armas para cada situação. para gerir a escolha das melhores soluções candidatam -se as células t reguladoras 45, 76, 77 , para as quais se devem dirigir as atenções de quem pretender compreender a intrincada rede da resposta imune. romagnani 78 entende que qualquer explicação para os factos apresentados pela hipótese higiénica tem de passar por fenómenos de desvio imune por alteração das células t reguladoras. e o papel destas células, cuja promoção pode partir da flora microbiana intestinal 79 , afigura -se cada vez mais complexo, na diversidade das escolhas ao seu dispor, com a descoberta de novos braços armados da imunidade. exemplo é a recente descoberta do perfil th 17 80 que actua através da il -17 que vem preencher alguns hiatos na explicação dos fenómenos imunes/inflamatórios. ao contrário de th 1 e de th 2 , o perfil th 17 medeia a inflamação nos tecidos, promovendo o recrutamento e a sobrevivência dos neutrófilos, sendo um provável participante nas doenças autoimunes, já que a sua neutralização previne as lesões tecidulares deste tipo de doen ças. mais uma pista para as asmas graves neutrofílicas, onde se tem ciclicamente vindo a lançar a suspeita de intervenção autoimune. é grande a complexidade de todas as variáveis que intervêm no desenvolvimento da resposta imune, sujeita a factores de susceptibilidade genética (o mundo dos polimorfismos) e, no período perinatal, a muitas variáveis. a começar pelas decorrentes da gravidez, incluindo as infecções da mãe 81 , e continuando com a relação do momento da agressão infecção na modulaçâo da asma j pinto mendes and by many variables in the perinatal period. these begin with occurrences in pregnancy, such as maternal infection 81 , continue with the relationship to the moment of attack and the stage of maturity of the immunologic system and the lung structures. here there are moments when the patient comes under external attack which takes advantage of transitory vulnerabilities with results which are difficult to explain a posteriori. despite criticisms, the epidemiological effort which went into the hygiene hypothesis was extremely worthwhile in that it opened up a new perspective of asthma modulation which promises to bring forth much which is new and vital. we move from microbial infection to nonviable bacterial products such as endotoxins, able to influence the immune response so the rate of asthma and allergy is altered [82] [83] [84] [85] [86] . their performance brings about several sets of consequences, depending on when exposure occurs (important in early life), the amount and frequency of stimulation and any cross-exposure. this is all conditioned by genetic variability. the majority of epidemiological studies conclude that children which are rural born and bred, in contact with farmyards and hay in haylofts, have a lesser rate of asthma and allergy than neighbouring urban populations. this is seen more the earlier the exposure 85 . some conditioning factors are certain life styles, such as those of some hindustan peninsula communities which have a great deal of domestic contact with large animals com o estado de maturidade do sistema imunológico e das estruturas pulmonares. dentro deste contexto, surgem janelas de acessibilidade para agressões externas que exploram vulnerabilidades transitórias com resultados difíceis de explicar a posteriori. pesem, embora, todas as objecções que lhe queiramos colocar, foi de grande mérito o esforço epidemiológico que levou à teoria higiénica porque estendeu a passadeira a uma nova perspectiva da modulação da asma que promete trazer muito de novo e importante. já não se trata aqui da infecção microbiana mas de produtos bacterianos não viáveis, como as endotoxinas, que teriam a capacidade de influenciar a resposta imune de modo a alterar a prevalência da asma e da atopia 82 -86 . a sua actuação, com mais do que um tipo de consequências, dependerá da altura da exposição (importante a precoce), da dose e frequência do estímulo, de co--exposições, tudo isto dependendo de uma clara variabilidade genética. de entre as inúmeras referências a estudos epidemiológicos, avultam as que concluem que crianças, nascendo e crescendo em quintas, em contacto com currais e feno acumulado em palheiros, vêm a revelar menos asma e atopia do que populações vizinhas com estilo de vida mais próximo do urbano, efeito tanto mais nítido quanto mais precoce a exposição 85 . algumas especificidades são as de certos estilos de vida, como acontece em algumas comunidades da península hindustânica, onde é íntimo o contacto doméstico com animais, de grande porte ou gatos durante a noite, que levariam a que as crianças desen-or cats during the night, leading the children to develop less asthma, rhinitis and allergy 87, 88 . the same is seen for the habitual consumption of non-pasteurised milk 85 . while children at risk at allergic asthma have long been told to avoid contact with these animals, it is concluded that prolonged early life exposure to feld-1 induces a form of immune tolerance specific to that allergen 89 . this effect cannot be explained by an increase in the exposure to endotoxins 90 . it is evident that this does not overrule the need for avoidance in patients sensitised to these animals. here unanimous opinion states that children at risk should avoid them in early life. in addition to the lipopolysaccarides (lps) of gram negative bacteria walls (the largest component of endotoxins) other bacterial products have been responsible for this protector effect. these include muramic acid, composed of proteoglycans present in the wall of most bacteria. this influence works in proportion to the concentration, in the beds of rural houses, of lps and muramic acid 87 . explanations of this have emerged over the years but are still not totally clear. what seems clear is that they cannot reside in the now clarified th 1 /th 2 balance as children living where there is high exposure to endotoxins have a decreased secretion of both th 1 and th 2 cytokines when their leucocytes were re-stimulated with lps via the tlr 4 84 . it is natural that the regulatory t cell role emerges to the fore again, probably through a suppressor effect in the allergic response 83, 91 . repeated exposure to endotoxins and other bacterial products leads to a refractory situation in response to re-exposure. romagnani 92 argues for an effect of volvessem menos asma, rinite e atopia 87, 88 . o mesmo para o consumo habitual de leite não pasteurizado 85 . em relação aos gatos, rompendo com uma longa tradição de evicção destes animais por crianças em risco de asma atópica, concluiu--se que a elevada exposição precoce a feld -1 induz uma forma de tolerância imunitária que é específica daquele alergénio 89 , efeitos que, contudo, não podem ser explicados por um aumento da exposição a endotoxinas 90 . é evidente que tal não contraria a exigência de evicção em indivíduos tornados sensíveis a estes animais, e mesmo, aqui sem unanimidade de opiniões, em crianças de risco, passados os primeiros anos de vida. para este efeito protector, para além dos lipopolissacáridos (lps) das paredes das bactérias gram negativas (o maior componente das endotoxinas), outros produtos bacterianos também têm sido responsabilizados, como o ácido murâmico, composto de proteoglicanos presente na parede da maioria das bactérias. esta actuação moduladora exerce -se proporcionalmente à concentração, nas camas das casas rurais, de lps e ácido murâmico 87 . as explicações para este fenómeno não foram logo evidentes, nem hoje são transparentes, mas pareceu claro que não podiam estar no já desmistificado balanço th 1 /th 2 porque crianças vivendo em ambientes de elevada exposição a endotoxinas apresentavam uma secreção diminuída de citocinas, tanto th 1 como th 2 , quando os seus leucócitos eram reestimulados com lps através dos tlr 4 84 . naturalmente que o papel das células t reguladoras volta a emergir, provavelmente através de um efeito supressor na resposta atópica 83, 91 . a exposição repetida a endotoxinas e outros produtos bacterianos conduzirá a uma situação refractária na resposta às reexposições. romagnani 92 de-those cells in simultaneous suppression of th 1 and th 2 response. attention naturally returns to the cellular receptors of the bacterial products and with surprising results in the environment/genome interaction field 93, 94 . the cd14 gene is the key here. it is the gene which codifies a co-receptor for multiple tlrs which recognise in addition to the virus -as stated above -the lipopolysaccarides and proteoglycans of the bacterial membranes 95 . the white blood cells of farm born and bred children have more cd14 and tlr receptors than those of city children, in the absence of any infectious attack worth noting 96 . epidemiology studies in this field have abounded over the last few years with conclusions which are sometimes very different 97 ; different methodologies make it hard to establish cause-effect relationships. one apparent contradiction are the conclusions which in some epidemiological studies, in spite of an inverse correlation with allergy, see increased risk of wheeze 98 or non-allergic asthma 99 with exposure to endotoxins. we have known for some time of the negative impact endotoxins have on the respiratory system, particularly when exposure is occupational. this has led to the description of 'endotoxin-sensitisation asthma' 100, 101 , with neutrophil type inflammatory reaction 50 . this phenomenon has been put to the test in inhalatory challenge tests which could bring on asthma episodes or exacerbations in children and adults 82, 102 , but, to test this seeming paradox, it is not necessary to resort to these arguments as in a german study 82 , the degree of early life exposure to domestic endotoxins was in direct correla-fende um efeito daquelas células na supressão simultânea das respostas th 1 e th 2 . e a atenção voltou -se, logicamente, para os receptores celulares dos produtos bacterianos e com surpreendentes resultados no campo da interacção ambiente/genoma 93, 94 . e a chave utilizada para abrir estas portas é a do gene cd14 que codifica um co -receptor para múltiplos tlr que reconhecem, além de vírus, como já foi citado, os lipopolissacáridos e proteoglicanos das membranas bacterianas 95 . ora, os glóbulos brancos de crianças que nasceram e vivem em fazendas manifestam uma maior quantidade de receptores cd14 e tlr do que as que vivem em zonas urbanas, na ausência de agressões infecciosas dignas de registo 96 . os estudos epidemiológicos, neste campo, multiplicaram -se nestes últimos anos, com conclusões por vezes muito diferentes 97 , a que não serão estranhas vicissitudes metodológicas que tornam difícil estabelecer relações de causa -efeito. uma aparente contradição são as conclusões que, nas circunstâncias de alguns estudos epidemiológicos, apesar de uma associação inversa com a atopia, há aumento do risco de sibilâncias 98 ou de asma não atópica 99 com a exposição a endotoxinas. mas já é do nosso velho conhecimento o efeito negativo das endotoxinas sobre o aparelho respiratório, nomeadamente em meio ocupacional, que levou à descrição de uma suposta "asma por sensibilização às endotoxinas" 100,101 , com reacção inflamatórias de tipo neutrofílico 50 . este fenómeno está bem testado em provas de provocação inalatória que podem provocar episódios de asma em crianças, ou a exacerbação da síndroma, em crianças e adultos 82, 102 , mas, para testar este aparente paradoxo, não é necessário recorrer a estes argumentos de inalação de tion to the increase in the rate of respiratory and cutaneous symptoms between 6 and 12 months. another longitudinal study showed that a higher degree of exposure to endotoxins at birth was linked to a higher risk of early life asthma 103 . what is the path out of this crossroads? various research units across the world are studying endotoxin receptors and the polymorphisms of their genes. the final results of this multi-polarised scientific effort, with epidemiological studies into geographically distant populations with different ethnicities, could provide enormous advantages as it represents a wide genetic diversity. as expected, bacteria have been indicated for the polymorphisms of gene cd14 having a dominant position in the complex of lps receptors but also of rsv, particularly the tlrs, located on chromosome 5q31, a region associated with markers of asthma 84 . the relevant results in so far are particularly useful for the light they shed on this dense and vast matter which will be hard to solve and give rise to fundamentally opposing positions. mononucleotide polymorphisms of that gene are the ideal target. we will start with cd14/-260, whose c allele is associated to higher levels of total and specific ige in patients in regular contact with pets but which has an inverse correlation in patients in regular contact with farm animals 104 . another example is the tt homozygotic of cd14/-159 which correlates with a greater sensitisation to dog allergens and a lesser rate of allergic eczema 105 . another paradigmatic reference states that cd14/-1721 when in homozygotic aa, and to a lesser degree in gg, is linked to an inverse correlation between non-pasteurised doses maciças porque, num estudo alemão 82 , o grau de exposição precoce a endotoxinas no ambiente doméstico está directamente correlacionado com o aumento da prevalência de sintomas respiratórios e cutâneos entre os 6 e os 12 meses. num outro estudo longitudinal, um maior grau de exposição a endotoxinas, à nascença, estaria ligado a um maior risco de asma no primeiro ano de vida 103 . como sair desta encruzilhada? espalhados por todo o mundo, centros de investigação lançaram -se na pista dos receptores das endotoxinas e do polimorfismo dos seus genes. esta multipolarização do esforço científico, com estudos epidemiológicos em populações muito afastadas geograficamente, com distintas etnias, poderá trazer enormes vantagens quando se fizerem as contas finais, pela diversidade genética que pode representar. e, como seria de prever, as baterias foram apontadas para os polimorfismos do gene cd14 que tem uma posição dominante no complexo de receptores dos lps, mas também do vsr, com destaque para os tlr, e que está localizado no cromossoma 5q31, uma região que tem sido conotada com marcadores da asma 84 . os relevantes resultados já conseguidos valem sobretudo pelas clareiras que abrem numa densa e vasta floresta que vai custar a desbravar e que virá trazer motivos para uma infindável e salutar polémica. são alvo privilegiado os polimorfismos uninucleotídicos daquele gene e vamos apontar, como primeiro exemplo, o do cd14/ -260, cujo alelo c estará associado a níveis mais elevados de ige totais e específicas em indivíduos que têm contacto regular com animais domésticos, mas apresenta uma associação inversa nos que contactam regularmente com estábulos de animais 104 . outro exemplo é o da homozigotia tt do cd14/ -159 que milk consumption and allergic sensitisation 106 . non-treated components in milk can modify expression of cd14, at the level of position -1721. the difficulties of these genetic studies are well-known, particularly in the choice of quality phenotypes and genotypes and the impossibility of eliminating all confusing factors 107 . it is impossible to list all the studies, but mention is made of the braun-fahrlan der/von mutius and fernando martinez results. these remarkable teams have learned from the past that incongruent results often lead to the largest leaps in scientific knowledge. in 1999, the f. martinez team 108 described the existence of an oligonucleotide polymorphism at position -159 of gene cd14, located on chromosome 5q31 and to which are attributed responsibilities in asthma phenotypes. it is also of interest in that it is present in monocyte, macrophage and neutophil membrane and could be an intermediary in the performance of microbial products 109 and probably of rsv 110 . two alleles (c and t) of cd14/-159 have been studied. their homozygote could be important in allergic sensitisation ability. the early studies of the martinez team were confirmed by some but not all researchers. the braun-fahrlander team falls into the latter, with their wide-based study which cited the influence of more than a position of cd14 and various forms of environmental exposure. another example is the alex (allergy and endotoxin) study 83 . the closeness of these two groups, an example of scientific rigour in terms of protocols and the analysis of divergent results, led to understandably provisional conclusions in this thorny field 84, 104 . se correlaciona com uma menor sensibilização a alergénios de cão e uma menor prevalência de eczema atópico 105 . outra referência paradigmática reporta -se ao cd14/ -1721 que, quando em homozigotia aa, e em menor grau em gg, está ligado a uma relação inversa entre o consumo de leite não pasteurizado e a sensibilização alérgica 106 . sugere -se que componentes existentes no leite não tratado são capazes de modificar a expressão do gene cd14, a nível da posição -1721. são reconhecidas as dificuldades destes estudos genéticos, nomeadamente na escolha de fenótipos e genótipos de qualidade e na impossibilidade de eliminar todos os factores de confusão 107 , mas, na impossibilidade de citação exaustiva, ficamo -nos pela breve enunciação dos resultados dos grupos de braun -fahrlander/von mutius e de fernando martinez. estas notáveis equipas aprenderam com a história que é da incongruência dos resultados que muitas vezes se parte para as maiores conquistas científicas. em 1999, a equipa de f. martinez 108 descreve a existência de um polimorfismo oligonucleotídico na posição -159 do gene cd14, situado no cromossoma 5q31, ao qual têm sido atribuídas responsabilidades nos fenótipos da asma e igualmente interessante pelo facto de estar presente na membrana de monócitos, macrófagos e neutrófilos e poder ser intermediário da actuação dos produtos microbianos 109 e, provavelmente, do vsr 110 . para o visado cd14/ -159 estudaram -se dois alelos (c e t), cuja homozigotia pode ser relevante na capacidade de sensibilização atópica. os estudos iniciais da equipa de martinez, confirmados por alguns investigadores, não o eram por outros, nomeadamente pela equipa de braun -fahrlander no estudo de a study of peripheral leucocytes concluded that in the cc homozygote when there is a low degree of exposure to endotoxins there was a high risk of allergic sensitisation, while when there was a high degree of exposure, the risk of sensitisation was minimal. on the contrary, when there was a tt homozygote there was protection in relation to allergic sensitisation when the levels of exposure were low and a great risk when they were high. martinez 84 was the first to show a correlation between phenotypic expression and dose dependant environmental factors on gene secretion. it is believed that this type of phenomenon can have an important impact on phylogenetic evolution and the ontogenetics of the immune system 111 . we await the results of studies underway into cd14 and other gene polymorphisms which may have an influence on endotoxin receptors and other outside agents, particularly viruses, which are increasingly seen as important in the expression of allergic and asthmatic phenotypes. another strand in the argument came in a recent issue of the journal of immunology, where a korean team used a human and murine model 112 . after concluding that severe asthmas are often of neutrophilic expression, with increased ifn-γ (th 1 ) expression, they later verified in an animal model that inhalation of low endotoxin doses induces th 2 response phenotypes, bronchial hyperresponsiveness and induction of ige secretion. in contrast, high endotoxin doses induce neutrophilic inflammation and bronchial hyperresponsiveness with a th 1 profile in rats. this does not happen in animals deficient in ifn-γ. grande amplitude, incidindo sobre mais de uma posição do cd14 e vários tipos de exposição ambiental, o estudo alex (allergy and endotoxin) 83 . a aproximação destes dois grupos, um exemplo de seriedade científica no confronto de protocolos e na análise de resultados divergentes, levou a conclusões, naturalmente provisórias, neste campo de tão difícil abordagem 84, 104 . o estudo em leucócitos periféricos concluiu que, na homozigotia cc, quando havia um baixo grau de exposição a endotoxinas, era elevado o risco de sensibilização atópica, enquanto se o grau de exposição fosse elevado o risco de sensibilização era mínimo. pelo contrário, quando existia uma homozigotia tt havia uma protecção em relação à sensibilização atópica quando eram baixos os níveis de exposição e um grande risco quando esta era elevada. para martinez 84 , ter -se -á demonstrado pela primeira vez uma relação da expressão fenotípica com a influência do ambiente (dependente da dose) sobre a secreção génica. presume -se que fenómenos deste tipo poderão ter tido importante papel na evolução filogenética e na ontogenia do sistema imune 111 . aguardam -se os resultados dos estudos em curso sobre outros polimorfismos do cd14 e de outros genes que possam ter algo a ver com receptores das endotoxinas e de outros agentes externos, nomeadamente vírus, que parece estarem a ganhar grande relevância na expressão dos fenótipos atópico e asmático. uma outra acha para a fogueira foi lançada por uma publicação recente no journal of immunology por uma equipa coreana que utilizou modelos humano e murino 112 . depois de concluírem que as asmas graves são com frequência de expressão neutrofílica, com aumento da expressão de ifn -γ (th 1 ), martinez 84 stated that asthma and allergic phenotypes are only rarely purely 'genetic' or 'environmental'. he proposed that they are almost always the result of inadequate genetically determined responses to environmental situations in which, depending on the context, the latter can predispose towards disease, prevention or even neutral results in the environment/phenotype correlation. developments are eagerly awaited and will shortly cascade. there is a heavy current investment in animal research, as in addition to the difficulties in epidemiological research starting from the genome already discussed, there are important ethical barriers which will not be easily overcome. in the midst of so much confusion, is it possible to reach any conclusions on asthma and allergy prevention which are applicable to the here and now? will we have to change the way we lead our lives? it is obvious, and no one would say otherwise, that it is not possible or desirable to turn back the clock on advances in quality of life which hygiene measures have brought to populations. this is of course not a defence of those urging an obsessively sterile lifestyle, which is sometimes advocated by pressure groups with financial interests in those areas. but this is already calling into question advice to which we have all been privy, and which is sometimes taken too much to heart by parents of allergic and/or asthmatic children, or children at risk of these diseases, to keep the house clean and avoid animals in early life. can genetic studies, such as those infecção na modulaçâo da asma j pinto mendes verificam, depois, no animal, que a inalação de doses baixas de endotoxinas induzem fenótipos de resposta th 2 , hiperreactividade brônquica e indução da secreção de ige. em contraste, o uso de doses altas de endotoxinas induzem no rato inflamação neutrofílica e hiperreactividade brônquica, com um perfil th 1 , situação que não acontece no animal deficiente em ifn -γ. para martinez 84 , os fenótipos asma e atopia só raramente poderão ser "genéticos" ou "ambientais" puros. propõe que sejam, quase sempre, o resultado de respostas inadequadas, geneticamente determinadas, a situações ambienciais, onde, dependendo do contexto, estas últimas tanto podem predispor para a doença, para a prevenir, ou, ainda, para resultados neutros na correlação ambiente/fenótipo. pressente -se na literatura médica impaciência quanto aos desenvolvimentos que, neste domínio, vão surgir em catadupa e que conhecem actualmente um forte investimento na investigação animal, já que ir mais longe na avaliação de modelos humanos, para além das já referidas dificuldades na investigação epidemiológica com ponto de partida no genoma, compreende importantes obstáculos de ordem ética que dificilmente poderão ser ultrapassados. será que de tanta contradição, de que fizemos eco, é possível retirar consequências para o quotidiano na procura da prevenção da asma e da atopia? será que temos de mudar os nossos padrões de vida? é evidente, e ninguém o defende, que não é possível nem desejável voltar atrás no progresso que as medidas higiénicas trouxeram à qualidade de vida das populações. mas, claro, isto não significa apoiar certos fundamentalismos already carried out into endotoxins, provide future guidance? a somewhat logical option, part of the initial hygiene hypothesis, is the use of orally administered probiotics, something which even today provides the backbone of foodstuff industry marketing strategy. existing studies are inconclusive, however 60, 114 , and attempts to blame early life antibiotic use for the increased rate of asthma were not encouraged 115 . the synthesis of anti-viral vaccines, particularly anti-rsv and anti-rv, or anti-viruses suitable for administering in early life may be a useful way to go, and bring something to knowledge of asthma modulation by virus. while it is good in the field of asthma, as in other medical science fields, to hope for discovery of environment/genotype/phenotype correlations and easy access markers to characterise them, we are all aware that fresh scien tific knowledge does not appear at the speed we would hope. that said, hope remains of future clarification of such cloudy areas as asthma, particularly in its modulation by infections. infecção na modulaçâo da asma j pinto mendes de obsessão por uma sociedade esterilizada, com excessos normativos que, muitas vezes, não deixam de ter por detrás grupos de pressão com interesses financeiros nestas áreas. mas já são de por em causa conselhos que todos nós vimos dando, por vezes levados a um extremo de rigor pelos pais de crianças atópicas e/ou asmáticas, ou em risco de o serem, na limpeza da casa ou evicção de animais desde os primeiros meses de vida. será que os estudos genéticos, como os feitos para as endotoxinas, nos poderão orientar futuramente? uma opção mais ou menos lógica, dentro da versão inicial da hipótese higiénica, seria o uso de probióticos por via oral, visão que continua ainda hoje a orientar estratégias de marketing na indústria alimentar. mas os estudos realizados revelaram -se inconsistentes 60, 114 , nem foram encorajadoras as tentativas de responsabilizar a administração de antibióticos em idades precoces pelo aumento da prevalência da asma 115 . poderá ter interesse, e tê -lo -á por certo para o conhecimento da modulação da asma por vírus, a síntese de vacinas antivirusais, nomeadamente anti -vsr e anti -rv, ou de anti virais viáveis para administração nos primeiros tempos de vida. se bem que, no campo da asma como no de outros sectores da ciência médica, se alimentem todas as esperanças nas relações ambiente/genótipo/fenótipo e no achado de marcadores de fácil acesso para as caracterizar, todos estamos conscientes de que a passagem à prática de novos conhecimentos científicos não se faz à 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asthma: at the crossroad of the hygiene and barker hypothesis effects of an antileukin -12 on eosinophils, airway hyperresponsiveness, and the late asthmatic reaction the effect of infections on susceptibility to autoimmune and allergic diseases allergen -specific th1 cells fails to counterbalance th2 cell induced airway hyperreactivity but cause severe airway inflammation viral -induced t helper type1 responses enhance allergic disease by effects of lung dendritic cells th2 and th1 lung inflammation induced by airway allergen sensitization with low and high dose of double. stranded rna immunity, inflammation, and remodeling in the airway epithelial barrier: epithelial -viral. allergic paradigm role of regulatory t cells and foxp3 in human diseases regulatory t cells in allergy and asthma coming back to a missing immune deviation as the main exploratory mechanisms for the hygiene hypothesis icam -1 on epithelial cells in allergic subjects: a hallmark of allergic inflammation th17 cells in the big picture of immunology a reformulation of the hygiene hypothesis: maternal infectious diseases confer protection against asthma in the infant? exposure to endotoxin decreases the risk of atopic eczema in infancy: a cohort study the allergy and endotoxin study team. environmental exposure to endotoxin and its relation to asthma in school--age children actions and interactions early life exposure to farming provides protection against the development of asthma and allergy asthma and allergies in rural areas of europe asthma and indoor environment in nepal effect of animal contact and microbial exposures in the prevalence of atopy and asthma in urban vs rural children in india a role for il -10 mediated hla. dr7 -restricted t -cell -dependent events in the development of the modified th2 response to cat allergen airborne endotoxin in homes with domestic animals: implication for cat specific tolerance human cd4+ t cells express tlr5 and its ligand flagellin enhances the suppressive capacity and expression of foxp3 in cd4+ cd25+ t regulatory cells the increased prevalence of allergy and the hygiene hypothesis: missing immune deviation, reduced immune suppression, or both? endotoxin exposure, cd14, and allergic disease. an association between genes and the environment gene environment interaction in allergic disease: more questions, more answers? toll -like receptor function and signaling expression of cd14 and toll -like receptor 2 in farmers and non--farmers children not all farming environments protect against the development of asthma and wheeze in children hygiene hypothesis and endotoxin: what is the evidence? toll -like receptor 2 as a major gene for asthma in children of european farmers endotoxin exposure in allergy and asthma: reconciling a paradox endotoxin -stimulated innate immunity: a contributing factor for asthma does environmental endotoxin exposure prevents asthma? house dust endotoxin and wheeze in the first year of life the allergy and endotoxin (alex) study team. opposite effects of cd14/. 260 on serum ige levels in children raised in different environments effects of dog ownership and genotype in immune development and atopy in infancy a polymorphism in cd14 modified the effect of farm milk consumption on allergic disease and cd14 gene expression association studies in asthma genetics a polymorphism in the 5'. flanking region of the cd14 gene is associated with circulating soluble cd14 levels and total serum ige dependent mechanisms of cell stimulation by bacterial endotoxin phenotypic evolution: a reaction norm perspective airway exposure levels of lypopolysaccharide determine type 1 versus type 2 experimental asthma probiotics and prevention of atopic disease: 4 -year follow -up of a randomized placebo. controlled study lack of association between antibiotic use in the first year of life and asthma, allergic rhinitis, or eczema at age of 5 years key: cord-270834-b625s54s authors: robinson, lacey b.; fu, xiaoqing; bassett, ingrid v.; triant, virginia a.; foulkes, andrea s.; zhang, yuqing; camargo, carlos a.; blumenthal, kimberly g. title: covid-19 severity in hospitalized patients with asthma: a matched cohort study date: 2020-10-22 journal: j allergy clin immunol pract doi: 10.1016/j.jaip.2020.10.021 sha: doc_id: 270834 cord_uid: b625s54s nan institute, inc.), with a two-tailed p<0.05 considered statistically significant. 105 we matched 80 asthma inpatients with covid-19 to 323 comparators ( table i) . inpatients with 107 asthma were similar to their comparators for matching variables (age, sex), as well as 108 race/ethnicity, smoking status, and comorbid conditions. asthma patients had a higher mean 109 body mass index than their non-asthma comparators (32.9 kg/m 2 vs. 30.7 kg/m 2 , respectively). 110 asthma patients had documentation of using short-acting beta-agonist (89%), inhaled 111 corticosteroid with long-acting beta-agonist (26%), inhaled corticosteroid (25%), montelukast 112 (13%), and long-acting antimuscarinic antagonists (6%); none were on biologics. 113 114 there were 19 (24%) asthma patients and 108 (33%) comparators who required icu admission. 115 in the fully adjusted model, the risk of icu admission was lower among asthma patients than 116 comparators (adjusted hazard ratio [ahr] 0.52, 95%ci:0.30-0.90) ( table ii) . mechanical 117 ventilation was utilized in 12 (15%) asthma patients and 91 (28%) of comparators. in the fully 118 adjusted model, the risk of mechanical ventilation was lower among asthma patients than 119 comparators (ahr 0.42, 95%ci: 0.21-0.81). death occurred in 7 (9%) asthma patients and 38 120 (12%) comparators. in the fully adjusted model, risk of death did not differ between groups (ahr 121 0.64, 95%ci:0.24-1.68). the 7 asthma deaths occurred in patients aged 57-88 years, 6 (86%) 122 were male, all had at least 2 other substantial co-morbid conditions, with 4 (57%) having 123 dementia/cognitive impairment that guided prior asthma treatment and code status. 124 in this matched cohort study of mgh inpatients with covid-19, we identified that asthma 126 patients were less likely to require icu admission and mechanical ventilation but were not at 127 increased risk for death. 128 129 given that asthma exacerbations are triggered by viral respiratory infections and that asthma 130 patients have a higher risk of severe illness from other respiratory viruses, 2 asthma was 131 considered a covid-19 risk factor by the centers for disease control and prevention. 5 132 although current research specifically assessing asthma and covid-19 remains limited, recent 133 reports suggest that asthma is not overrepresented among severe covid-19 cases and may not 134 be associated with an increased risk of hospitalization or death. 6-9 however, most of these studies 135 included other pulmonary conditions (e.g. copd) with asthma cases. while patients with 136 concomitant asthma-copd may have a higher risk of severe outcomes, this risk appears driven 137 by copd. 5, 9 in this study, we uniquely used both a strict diagnosis of asthma and excluded 138 patients with additional chronic pulmonary diseases, thus isolating the association of asthma and 139 situation report 195: world health organization we would like to acknowledge all members of the mgh covid-19 registry for their work on 164 the development and data management for the registry. the key: cord-305838-i0ck2oo0 authors: kouri, andrew; gupta, samir; yadollahi, azadeh; ryan, clodagh m.; gershon, andrea s.; to, teresa; tarlo, susan m.; goldstein, roger s.; chapman, kenneth r.; chow, chung-wai title: chest reviews: addressing reduced laboratory-based pulmonary function testing during a pandemic date: 2020-07-08 journal: chest doi: 10.1016/j.chest.2020.06.065 sha: doc_id: 305838 cord_uid: i0ck2oo0 abstract to reduce the spread of sars-cov-2, many pulmonary function testing (pft) laboratories have been closed or have significantly reduced their testing capacity. as these mitigation strategies may be necessary for the next 6-18 months to prevent recurrent peaks in disease prevalence, fewer objective measurements of lung function will alter the diagnosis and care of patients with chronic respiratory diseases. pfts, which include spirometry, lung volumes, and diffusion capacity measurement, are essential to the diagnosis and management of patients with asthma, copd, and other chronic lung conditions. both traditional and innovative alternatives to conventional testing must now be explored. these may include peak expiratory flow devices, electronic portable spirometers, portable exhaled nitric oxide measurement, airwave oscillometry devices, as well as novel digital health tools such as smartphone microphone spirometers, and mobile health technologies along integration of machine learning approaches. the adoption of some novel approaches may not merely replace but could improve existing management strategies and alter common diagnostic paradigms. with these options come important technical, privacy, ethical, financial, and medicolegal barriers that must be addressed. however, the covid-19 pandemic also presents a unique opportunity to augment conventional testing by including innovative and emerging approaches to measuring lung function remotely in patients with respiratory disease. the benefits of such an approach have the potential to enhance respiratory care and empower patient self-management well beyond the current global pandemic. as of june 23nd, there are over 9.1 million confirmed cases of covid-19 globally, and many countries have implemented broad and extraordinary public health strategies in hopes of "flattening the curve". 1 one important consequence of these strategies has been the widespread suspension of non-urgent healthcare services, such as non-urgent outpatient in-person consultations and routine diagnostic testing. this has resulted in the full or partial closure of most pulmonary function testing (pft) laboratories, in keeping with guidance provided by the american thoracic society. this guidance is founded primarily on concerns that the testing performed in these laboratories, which includes spirometry, lung volume, and diffusion capacity measurement, present a higher risk of sars-cov-2 transmission compared to other diagnostic tests, given the potential for aerosol formation and coughing during the testing of patients with lung disease. 2 though these and other societal measures have resulted in some success in slowing the spread of sars-cov-2, modeling at both local and national levels has suggested that current policies will likely need to be maintained for as long as 18 months in order to prevent a deadly rebound. 3, 4 for pft laboratories, this implies continued closure versus limited reopening with strict pre-visit viral testing, personal protective equipment use, and cleaning protocols -either scenario leading to a significant reduction in testing capacity compared to historical norms. although the provisional diagnosis and management of chronic respiratory diseases with limited access to objective measures of lung function may be feasible in the short term, sustained reductions in testing will almost certainly lead to sub-optimal care for many. furthermore, the inability to diagnose new conditions objectively, for example occupational asthma, may worsen long term outcomes. 5 as such, it is important to address this issue as soon as possible. as with the decrease in in-person consultations, virtual and digital technologies may play an important role going forward, 6 but it is vital to consider the technical, administrative, ethical, and financial implications that will arise as newer technologies replace, complement or augment conventional pulmonary function testing. pulmonary function testing is essential to the care of respiratory disorders. it is used to diagnose lung disease, monitor disease course and the effect of therapeutic interventions, determine perioperative risk, and assess prognosis. 7 reduced access to pfts over the next 6-18 months would affect the nearly half a billion children and adults worldwide who live with asthma and chronic obstructive pulmonary disease (copd), the two most common chronic respiratory conditions, as well as those who will be under-and over-diagnosed during that time period due to reduced testing. 8 in both children and adults with asthma, respiratory symptoms correlate poorly with lung function measurements and cannot be used to infer underlying pulmonary function and pathophysiology. 9, 10 the results of pfts have also been shown to change physicians' treatment plans in as many as 48% of patients with asthma, 11 and are a strong independent predictor of exacerbation risk. 9 with copd, pfts are critical for diagnosis, for assessing the impact of pharmacologic and non-pharmacologic interventions, and for prognosis, as deteriorating function is associated with increased exacerbations, hospitalization, and risk of death. 12 pfts are equally vital in preventing misdiagnosis of asthma and copd, which can result in the unnecessary, potentially harmful, and costly use of respiratory medications in patients who will not benefit from them. [13] [14] [15] as many as one third of patients receiving anti-asthma therapy in canada are found not to have the disease when objective measures of lung function are used diagnostically. 13 the overdiagnosis and misdiagnosis of copd may be even worse, with estimates of overdiagnosis in primary care ranging from 31% to 60%. 14 objective measurement of lung function has also been shown to reduce the problem of gender bias in copd. 16 beyond asthma and copd, many other chronic respiratory conditions rely on the objective measurements of lung function to guide diagnosis, management, and prognostication. guidelinebased care of patients with cystic fibrosis, interstitial lung disease, and pulmonary hypertension, for example, depends on regular access to pft results. [17] [18] [19] [20] access to reliable pulmonary function data is particularly critical for lung transplant patients when weekly monitoring with spirometry is the gold standard care during the first 3 months post-transplant when the risk of acute graft rejection is highest. 21 though some respiratory sub-specialists have already provided guidance as to how care should be adjusted while deferring non-essential pfts, 22 it is not yet clear how long this new paradigm of care will be effective in avoiding negative health outcomes, especially as increasing numbers of patients have their testing postponed. to prevent undue harm to both patients and technicians in communities with high prevalence of covid-19, many healthcare facilities have restricted laboratory-based pfts to "essential" cases where results will influence immediate treatment decisions. 2 however, this has the secondary effect of further limiting the information available to clinicians who must already manage patients without physical examinations, since many have now moved almost exclusively to virtual care for outpatient visits. 23 without this information, management decisions are being made based on history alone. this may be adequate for routine follow-up of some patients with stable respiratory disease but is challenging for new patients and follow-up patients whose clinical status has changed. though pft laboratories may gradually open as covid-19 numbers plateau and begin to decrease, infection control requirements will likely still reduce testing capacity for a long time. similar concerns around infection control and testing capacity will also adversely affect traditional alternatives to in-laboratory testing such as office-based spirometry, as current international recommendations do not distinguish between healthcare settings when assessing the risks of aerosol generating procedures, and even the use of spirometer filters does not eliminate the need for enhanced infection control measures. 2, 24, 25 alternatives to laboratoryand office-based pfts may be sought in existing approaches as well as innovative technologies. home measurement of peak expiratory flow (pef) using an inexpensive portable handheld device is already a guideline-recommended option to facilitate patient self-management in asthma and in the diagnosis of occupational asthma, but its role is less well defined in copd. 9, 12, 26 many studies have investigated the potential for pef to be used as a surrogate for pfts in the diagnosis and management of patients with asthma and copd, but the results have been mixed. some research has shown that pef, in combination with other tools such as validated patient questionnaires, can be used to help diagnose copd when spirometry is not easily available, [27] [28] [29] [30] and may be helpful in copd prognostication independent of spirometry. 31 however, other work in both diseases has shown that agreement between pef (a purely effortdependent measure) and spirometry can be highly variable, and may lead to inappropriate clinical decision making if relied on exclusively, particularly in children and in cases with either very mild or severe airway obstruction. [32] [33] [34] [35] additionally, studies in children with asthma have shown that self-recorded peak flow is often inaccurate and adherence levels low, and similar concerns may extend to adults. 36 thus, while pef may continue to be used by patients with asthma already familiar with its measurement and tracking, it is unlikely to suffice as a long-term replacement for pfts across chronic respiratory diseases. given the potential for aerosol generation during the forced exhalation maneuver required for pef measurement, patients using this technique to monitor their respiratory status at home should also be counselled on measures to avoid infecting other members of their household while using their flowmeter. a more sophisticated alternative to pef measurement is the use of portable spirometers. as a home-based measurement, it minimizes the exposure risk of forceful expiratory measurements and cough in the laboratory or office setting. many of these devices are now commercially available and in addition to providing more accurate objective measurements of lung function compared to pef, most are now also designed to pair with and download results onto personal mobile devices or computers, facilitating transmission to and monitoring by healthcare professionals. 37 electronic portable spirometers have been studied and found to be comparable to conventional laboratory spirometry in several chronic respiratory conditions, such as asthma and copd, cystic fibrosis, idiopathic pulmonary fibrosis, and post-lung and hematopoietic stem cell transplant monitoring. [37] [38] [39] [40] [41] [42] [43] indeed, the ability of patients to monitor spirometry weekly, more frequently than is feasible using laboratory-based measurements, offers advantages in some settings where early detection of problems is important -pulmonary fibrosis monitoring and lung transplant surveillance are two established examples. 39, 40 limitations of these devices include cost, which can range from $99 to over a $1000 usd, lack of feedback on quality of the breathing maneuvers in many devices, variable reporting of accuracy levels (though some devices claim to meet american thoracic society standards for spirometry and include global lung function initiative reference equations), and the need to validate results against reference standards when starting them for new patients. 37 additionally, most of these devices are only able to provide spirometry readings, and cannot aid in lung volume or diffusion capacity measurement. given these limitations, clinicians considering electronic portable spirometers must select the most appropriate devices available locally, ideally balancing price, accuracy, and features that support correct and safe usage. with the correct device-patient match, portable spirometers may present a valuable in-home alternative to pfts for monitoring patients with known chronic lung conditions, augmenting virtual care with important physiologic data. their use could also offload the testing demand on pft laboratories and outpatient clinics, allowing them to focus their limited capacity on new diagnoses and more urgent testing. as with flowmeter use, patients using portable spirometers at home should be counselled on measures to avoid potentially infecting other members of their household. the fraction of exhaled nitric oxide (feno) has been studied extensively in asthma, but also in other respiratory diseases, as a non-invasive biomarker that can supplement or potentially replace conventional spirometry in diagnosis and management decisions. [44] [45] [46] [47] unlike spirometry, measurement of feno does not require forceful expiratory maneuvers and is not prone to trigger cough. 48 feno may be particularly useful in identifying asthma characterized by type 2 airway inflammation, 49 and may help guide treatment initiation decisions in these patients. 44, 50 guidelines do not currently recommend using feno alone in either the diagnosis or ongoing management of asthma across different phenotypes. 9 however, increased use of the technology could see revision of these paradigms. at present, laboratory-based measurements are used to diagnose asthma by demonstrating evidence of variable airflow obstruction. such an approach is fraught with difficulty, as patients with mild asthma seldom demonstrate bronchodilator responsiveness at times of randomly scheduled laboratory visits. in fact, operating characteristics of exhaled no measurement for asthma diagnosis were clearly superior to those of spirometry with bronchodilator testing in a recent review. 51 moreover, traditional challenge studies are not only cumbersome to carry out, but also produce variable responses in different subpopulations of patients with asthma and depending on the challenge used. 52 arguably, recognizing and managing airways inflammation is a more important treatment decision in asthma than the decision to use albuterol for symptoms, and exhaled nitric oxide has been suggested as a predictor of inhaled corticosteroid responsiveness is patients with asthma or asthma-like symptoms. 50 institutions familiar with feno testing may thus consider using this technology as a potentially safer (i.e. less likely to generate aerosols) method in inpatient and outpatient settings for diagnosing and following patients with asthma characterised by type 2 airway inflammation. portable handheld devices that can measure feno are also available, and could be a useful remote monitoring option in patients with eosinophilic asthma in the future, though strategies to ensure appropriate technique and quality standards will be required. however, the high cost of portable devices, requirement for patient coaching, and lack of validation for feno in different asthma phenotypes and across other chronic respiratory diseases means it is unlikely to provide an adequate long-term substitute for pfts. 53 oscillometry is emerging as an alternative form of pulmonary function testing that offers some advantages over conventional pfts. 54 it has been shown to be more sensitive than spirometry in early diagnosis of copd, 55, 56 to correlate better with respiratory symptoms and asthma control 57,58 as well as in identifying spirometrically silent episodes of biopsy-proven acute graft rejection following lung transplant. 59 however, there is a dearth of normal reference values for oscillometry due to its relative infancy when compared to conventional pfts, though this is anticipated to improve with recent publications of technical and interpretation guidelines. 60, 61 as oscillometry is conducted under normal tidal breathing and does not require forced expiratory efforts, it may also have infection control advantages over spirometry, being less likely generate aerosol and minimizing potential sars-cov-2 transmission. furthermore, oscillometry can be easily conducted in the very young, the elderly and those with physical or cognitive impairment. oscillometry may also be a useful endpoint in methacholine or other challenge studies, obviating the need for forceful maneuvers (although challenge-induced cough remains a potential hazard). 62 lastly, remote home monitoring with portable oscillometry is available and likely to provide more reliable readings than portable spirometry, as coaching, a crucial component for quality control in spirometry, is not needed for oscillometry. 63 one barrier to the broader use of oscillometry is the high cost of the limited portable devices available (for example, the tremoflo â® device from thorasys) , though some of this may be recouped over time given the increased volume of testing permitted by oscillometry, and staff training is considerably simpler than with traditional spirometry. 60, [64] [65] [66] novel digital health alternatives a growing body of literature is exploring the potential to turn existing mobile devices and smartphones into portable electronic spirometers using their built in microphones, supplemented with machine learning techniques. 67, 68 pilot studies of these "smartphone spirometers" in healthy subjects and patients with asthma and copd have demonstrated reasonable levels of agreement between resulting values and traditional spirometry, particularly with the fev 1 /fvc ratio. [69] [70] [71] [72] [73] though rigorous clinical evaluation and validation of these innovative approaches against laboratory-based pulmonary function testing has not been done and they cannot be considered a current alternative during the covid-19 crisis, their low cost and capacity for broad dissemination and digital integration offer considerable promise. is not a direct substitute for formal pulmonary function testing but may contribute to improved management outcomes if implemented during the covid-19 pandemic. in asthma care, mhealth applications supporting patient self-management through education, medication reminders, symptom monitoring, and action plan provision have been shown to improve asthma control, medication and action plan adherence, and quality of life. 74, 75 similar mhealth interventions for copd have been associated with decreased hospitalization risk. 76 importantly, many mhealth self-monitoring technologies are able to facilitate the transmission of clinical data to healthcare professionals, which could enhance the virtual and remote-patient monitoring and management currently taking place. 77 these types of mhealth solutions may be leveraged in patients with established respiratory diagnoses and relationships with mhealth-savvy health care professionals, but are likely less useful in new patient assessments or cases of diagnostic uncertainty. additionally, it is important to note that mhealth in asthma and copd is an emerging research field, and long-term studies of clinical effectiveness are still lacking. 74, 75 another innovative approach to enhance remote and virtual monitoring is the use of machine learning algorithms with telemonitoring data. in copd for example, machine learning techniques have been combined with sociodemographic, clinical, and physiologic telemonitoring data to predict acute exacerbations of copd with high sensitivity and specificity. [78] [79] [80] as these technologies mature, they may become particularly useful in centers with established telemonitoring programs in helping clinicians to identify which patients are at higher risk of clinical deterioration, allowing triaging of limited pft resources. however, as with all applications of machine learning with healthcare data, interpreting clinical applicability, generalizability, and the potential for algorithmic bias must be carefully addressed. 81 our present concern is to maintain the usual management standards of patients with chronic respiratory disease until conventional lung function laboratories are able to re-open. however, as new technology is developed and validated, we may find our management strategies improved. convenience is one obvious advantage of remote patient-measured pulmonary function options. patients, especially those living in underserviced areas, may be spared the need for frequent office visits and laboratory-based studies if equally useful measurements can be generated at home. more frequently monitored lung function at home or in the workplace also offers obvious advantages in the management of difficult asthma, for example. the benefits of weekly home spirometry for monitoring patients with interstitial lung disease, post-transplant patients, and those with cystic fibrosis have already been demonstrated and seems likely to replace at least some of the quarterly clinic visits now employed. 37, 39, 40, 42 additionally, many of the non-remote options reviewed such as in-laboratory feno and airwave oscillometry currently offer a lowerrisk alternative to pfts in the short-term, as they are less likely to generate aerosols, but they may also prove to be viable longer-term alternatives as more research is dedicated to their validation across respiratory conditions. one important question that remains with the proposed use of alternative and/or portable pulmonary function testing technologies is what criteria would warrant confirmation with in-laboratory testing. while some options such as feno have established cut-offs, interpretation guidelines for other options such as airwave oscillometry have only recently been published and have yet to be incorporated into computer-based interpretation algorithms. 60, 61 clinicians will have to be mindful of emerging evidence when using any pft alternative and incorporate other sources of clinical information into their decision making. however, any signals of deterioration from the options suggested could equally prove useful in the triaging of limited in-laboratory pft resources. see table 1 for a summary of reviewed alternatives and their limitations. though the covid-19 pandemic presents an opportunity to study and explore the potential alternatives to conventional pfts in managing the care of patients with chronic respiratory diseases, these alternatives are not without their own unique challenges. integrating many of the proposed remote alternatives into existing care workflows and electronic health records that are already struggling to cope with the massive shift to virtual care would be challenging. privacy and equity issues would need to be carefully addressed, particularly when dealing with interventions that interact with patients' personal digital devices as well as when considering the costs of various alternatives. technical support for both patients and healthcare workers may be needed with new technologies and devices. remuneration systems would need to be adjusted to recognize the technical and professional components involved in the introduction of new and advancing technologies, and to compensate for potential loses in hospital revenue associated with decreased laboratory testing. this is already occurring to some extent, as the us administration has enacted several regulatory changes to support expanded remuneration for remote patient monitoring and telehealth services. 82 finally, the use of novel technological solutions may herald unanticipated or new medicolegal implications which will require consideration. 67 in the face of serious limitations to the availability of conventional laboratory and office-based pulmonary function testing that are likely to persist for at least the next 6-18 months, respiratory clinicians, researchers, and administrators must begin to consider how alternatives to conventional pfts could be integrated into the care of patients with chronic respiratory diseases to provide the best possible quality of care. though no current individual alternative is sufficient to replace conventional testing in all patients, many of the options reviewed may provide acceptable and actionable physiologic information to improve clinical management. examples include the use of portable electronic spirometry and mhealth self-monitoring technologies in patients with asthma and copd, as well as portable oscillometry for monitoring patients postlung transplant. the covid-19 pandemic provides a unique opportunity for the respiratory community to implement existing alternatives to pfts and to engage in the rigorous clinical evaluation of new digital solutions and systems that may enhance the management of those with respiratory diseases, while being mindful of the importance of privacy and autonomy to our patients. table 1 . summary of evidence for pft alternatives during a pandemic peak expiratory flow measurement use in asthma 9 : -diagnosis of variable expiratory airflow limitation (diurnal variation, response to therapy, variation between visits) -diagnosis of occupational asthma and workexacerbated asthma -short-term and long-term self-monitoring (i.e. use in asthma action plans) use in copd [28] [29] [30] [31] [32] [33] : -diagnosis, in combination with validated patient questionnaires -prognostication results less reliable in children, and in patients with very mild or severe airways obstruction. may also be adherence issues, particularly in children but also in adults. remote follow-up in patients diagnosed with [37] [38] [39] [40] [41] [42] [43] an interactive web-based dashboard to track covid-19 in real time pulmonary function laboratories: advice regarding covid-19 impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand projecting the transmission dynamics of sars-cov-2 through the postpandemic period workplace interventions for treatment of occupational asthma. cochrane database syst rev covid-19 and health care's digital revolution standardization of spirometry world health organization. chronic respiratory diseases global initiative for asthma. global strategy for asthma management and prevention asthma symptoms do not predict spirometry spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and copd global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease reevaluation of diagnosis in adults with physician-diagnosed asthma factors associated with undiagnosed and overdiagnosed copd pulmonary function testing in the diagnosis of asthma: a population study gender bias in the diagnosis of copd pulmonary function testing in idiopathic interstitial pneumonias esc/ers guidelines for the diagnosis and treatment of pulmonary hypertensionthe joint task force for the diagnosis and treatment of pulmonary hypertension of the european society of cardiology (esc) and the european respiratory society (ers): endorsed by: association for european paediatric and congenital cardiology (aepc), international society for heart and lung transplantation (ishlt) cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung health british thoracic society bronchiectasis non-cf guideline group. british thoracic society guideline for non-cf bronchiectasis comprehensive care of the lung transplant patient practical considerations for the diagnosis and treatment of fibrotic 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and economic evaluation of niox mino, niox vero and nobreath calling time on spirometry: unlocking the silent zone in acute rejection post lung transplantation impulse oscillometry may be of value in detecting early manifestations of copd clinical characteristics of copd patients with tidal expiratory flow limitation ventilation heterogeneity and oscillometry predict asthma control improvement following step-up inhaled therapy in uncontrolled asthma oscillometry and pulmonary magnetic resonance imaging in asthma and copd airway oscillometry detects spirometric-silent episodes of acute cellular rejection development of quality assurance and quality control guidelines for respiratory oscillometry in clinic studies technical standards for respiratory oscillometry comparison of impulse oscillometry and spirometry for detection of airway hyperresponsiveness to methacholine, mannitol, and eucapnic voluntary hyperventilation in children home-based forced oscillation technique day-to-day variability in pediatric asthma applications of oscillometry in clinical research and practice comparison of oscillometry devices using active mechanical test loads shaping new perspectives on pulnonary function -tremoflo airwave oscillometry mobile devices and health towards reliable data collection and annotation to extract pulmonary digital biomarkers using mobile sensors spirosmart: using a microphone to measure lung function on a mobile phone determining the validity of smartphone based spirometry using machine learning remote pulmonary function test monitoring in cloud platform via smartphone built-in microphone high-resolution time-frequency spectrum-based lung function test from a smartphone microphone mobile based spirometry for detecting copd the use of mobile applications to support self-management for people with asthma: a systematic review of controlled studies to identify features associated with clinical effectiveness and adherence mobile technology interventions for asthma self-management: systematic review and meta-analysis mobile health applications in self-management of patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of their efficacy living with asthma and chronic obstructive airways disease: using technology to support self-management -an overview machine learning for copd exacerbation prediction ensemble machine learning for the early detection of copd exacerbations improving prediction of risk of hospital admission in chronic obstructive pulmonary disease: application of machine learning to telemonitoring data key challenges for delivering clinical impact with artificial intelligence trump administration makes sweeping regulatory changes to help u.s. healthcare system address covid-19 patient surge authors' contributions: an initial draft of this paper was prepared by a.k., and all authors contributed to the editing and final draft of the work. a.k acts as the guarantor of this work. key: cord-304549-e8q8mck4 authors: holgate, stephen t. title: genetic and environmental interaction in allergy and asthma()() date: 2005-11-02 journal: j allergy clin immunol doi: 10.1016/s0091-6749(99)70005-9 sha: doc_id: 304549 cord_uid: e8q8mck4 asthma is an inflammatory disorder of the airways involving coordinate up-regulation of t(h)2-type cytokines encoded in a cluster on chromosome 5q(31-33) on t cells and inflammatory cells. there is also a requirement for local airway susceptibility factors that, together with t(h)2 polarization, results in hyperresponsiveness, variable airflow obstruction, and, over time, remodeling of the airway wall. asthma has strong genetic and environmental components that interact both in the induction and subsequent expression of the disease phenotypes. multiple genes are involved and probably interact. whole genome screens are beginning to identify gene-rich regions of special relevance to asthma and atopy, although a novel disease-related gene has yet to be discovered from these. by contrast, there are a plethora of candidate genes whose function in relation to disease pathophysiologic mechanisms and response to treatment are known. two examples are polymorphisms involving il-4 receptors and the enzymes controlling cysteinyl leukotriene production. abnormal signaling between the epithelium, which is in contact with the environment, and the underlying (myo)fibroblasts and dendritic cells indicating reactivation of the epithelial mesenchymal trophic unit, which is involved in fetal lung development and branching, provide a basis for asthma that encapsulates both t(h)2 polarization and airway wall remodeling. (j allergy clin immunol 1999;104:1139-46.) asthma is a complex disorder involving a combination of genetic and environmental interactions that culminate in a specific type of inflammation involving mast cells, eosinophils, and macrophages and polarization of t cell-mediated immunity toward enhanced production of cytokines encoded in a cluster on the long arm of chromosome 5. these include il-4, il-5, il-9, il-13, and gm-csf, which orchestrate the isotype switching of b lymphocytes to produce ige, maintain the persistence of t-helper 2 (t h 2) lymphocytes with their enhanced capacity to secrete cytokines of the il-4 gene cluster and recruit and maintain the survival of mast cells, basophils, and eosinophils. 1 in contrast to the many animal models of t h 2 polar-ization in the lung, which tend to be self-limiting, asthma is a chronic disorder characterized by exacerbations and remissions and an underlying bronchial hyperresponsiveness (bhr) of the airways to a wide variety of environmental factors. 2 in established disease a major part of the bhr can be separated from the inflammatory response and most likely represents structural changes to the airways with deposition of matrix proteins throughout the airway wall and "remodeling" of the formed elements including epithelial goblet cell metaplasia, smooth muscle hypertrophy, and an increase in microvessels and nerves. 3 whether these features occur as a consequence of or in parallel with the inflammatory response is not known, but increasingly in asthma it is becoming appreciated that many of these structural elements are themselves altered to produce cytokines, growth factors, and mediators that may contribute to the sustenance of the inflammatory response. 4 although for therapeutic reasons it has become convenient to consider asthma as a single disease entity, this clearly is not the case, with many variants occurring. 5 from a clinical standpoint, a minimal subdivision includes atopic asthma, cough variant asthma, brittle asthma, intrinsic asthma, aspirin-intolerant asthma (aia), and occupational non-ige-dependent asthma. when disease severity and responsiveness to treatment are added to this categorization, the number of variations becomes very large. if these manifestations are controlled by specific genes and environmental interactions, then the true complexity of this disease becomes appreciated. atopy, the propensity to generate ige against common environmental allergens, is the strongest single risk factor that has so far been identified for asthma, increasing the risk in those affected by 10-to 20-fold. 6 although atopy and asthma interact, they are not interchangeable. thus, although a high proportion of children and young adults are atopic, even in countries with a high prevalence of atopy (eg, united kingdom, australia, and new zealand) full-blown chronic asthma will develop in only 1 in 5 atopic patients. moreover, in adults, especially at the severe end of the asthma spectrum, atopy diminishes as a risk factor. 7 the phenotype of other chronic inflammatory diseases, such as crohn's disease or psoriasis, presents little diagnostic uncertainty but, in the case of asthma, there is a lack of diagnostic precision. this has led to the use of intermediate phenotypes reflecting asthma and atopy, such as bhr, serum total and allergen-specific ige, skin prick test (spt) positivity, and circulating eosinophil counts. although these provide quantitative measures, bhr, for example, can be assessed in many different ways (eg, histamine or methacholine provocation, exercise or cold air challenge, sulfur dioxide challenge, peak expiratory flow variability, etc), each measure describing different airway characteristics. in addition, there are numerous ways in which an individual can be designated atopic. the danger in using intermediate phenotypes is the assumption that their genetic basis will be the same as that of the disease state. several large epidemiologic studies have established that the presence of asthma corresponds to high serum levels of total ige. 8, 9 however, when analyzed on a family basis, a tendency to be a high ige producer proved to be only one factor related to the inheritance of asthma susceptibility and, in itself, had a limited ability to predict asthma inheritance. 10 an alternative approach has been to pool multiple measures of asthma (eg, respiratory questionnaire, spt, specific and total ige) to generate summary scores using, for example, principal component regression analysis. 11 this method can also be used to construct a quantitative trait in the form of an asthma score in which the influence of atopy is removed 12 (fig 1) . although it has long been known that asthma and related atopic diseases cluster in families, the genetic basis for this has eluded definition. in 176 families a striking association has been shown between asthma in parent and offspring, hay fever in parent and offspring, and eczema in parent and offspring, suggesting that, in addition to genetic factors determining allergen sensitization, there are also important genetic factors that determine the end-organ in which this was expressed, a conclusion drawn from further large epidemiologic studies. 13, 14 one method that can be used to great effect in complex disorders to determine the relative contribution of genes and the environment is to study the concordance of a trait in monozygotic (mz) and dizygotic (dz) twins, in which the former have identical genotypes and the latter share on average only half their genes. thus a disease that has a strong genetic component will show a higher rate of concordance in mz than in dz twins. in a large survey of 7000 twin pairs, concordance rates for asthma, eczema, and hay fever were all substantially higher for mz than for dz twins. 15 this observation has also been shown for bhr, spt responses, and serum total and specific ige. 16, 17 in a study deliberately designed to disaggregate genetic from environmental effects, both allergic disease and partial phenotypes were compared in mz and dz twins reared together and apart. 18 whether together or separated, mz twins showed a greater concordance than dz twins, indicative of a strong genetic contribution. this has been further strengthened by the findings in a recent 11,688 danish twin pairs with use of additive and genetic and nonshared environmental modeling that 73% of asthma susceptibility was genetic and a substantial part of the variation liability of asthma was the result of environmental factors. 19 segregation analysis is a method for estimating the pattern of inheritance of a disease by observing how it is distributed through family pedigrees. several different modes of inheritance have been proposed for elevated serum total ige, including autosomal recessive, autosomal dominant, and polygenic inheritance. [20] [21] [22] application of more sophisticated segregation models to asthma and its partial phenotypes have shown that it is unlikely that any single gene predominates, 23 although for physician-diagnosed asthma in us hispanics a major autosomal codominant gene has been proposed. 24 in contrast to single-gene disorders, which are rare, subject to severe mutations and deletions, and exert a large phenotypic effect often independent of environmental factors, complex genetic traits such as asthma and related allergic disorders are common and result from mild mutations in multiple genes each of which has a small effect on the phenotype and requires subtle genegene (epistasis) or gene-environmental interactions for optimal expression. two fundamental approaches are being used to discover susceptibility genes in asthma and atopy: linkage analysis with functional cloning and association analysis for mutations of "candidate" genes thought to be involved in disease pathogenesis. linkage analysis uses family data to follow the transmission of genetic information between or across generations to enable genes to be identified by their position on the genetic map; no prior knowledge of disease pathophysiologic features is required. linkage studies require families usually enriched with the disease, which must be accurately phenotyped. depending on the approach, families can be nuclear families (ie, children and their parents), extended pedigrees, or inbred populations. linkage analysis requires the saturation of the entire human genome at regular intervals with microsatellite markers comprising variable nucleotide tandem repeats whose precise position on the genetic map are known. whole-genome screens use 300 to 500 dinucleotide, trinucleotide, or tetranucleotide markers spaced 5 to 10 cm across the genome. the proximity of a marker to a disease-related gene is estimated by measuring the number of recombination events between them; the closer 2 loci are, the less chance they will be separated at meiosis (fig 2) . the significance of linkage is measured by the "lod score" (log of the odds ratio of the likelihood of a hypothesis of linkage to the likelihood of a hypothesis of no linkage). for example, for a lod score of 3, there is a 5% chance of a false-positive linkage. a lod score of 2.2 is suggestive of linkage, 3.6 significant linkage, and 5.4 highly significant linkage. 25 this type of parametric linkage analysis requires an a priori knowledge of the mode of inheritance of the disease or its partial phenotype, which, for asthma and allied allergic disorders, is not known. under such circumstances nonparametric linkage analysis or allele sharing methods are more reliable but less powerful. affected sib-pair analysis is most commonly used, which involves studying affected relatives in a pedigree to see how often a particular copy of a chromosomal region is shared identical by descent (ie, inherited from a common ancestor within a pedigree). for example, 2 siblings can share 0 or 2 copies of any locus. if the disease or partial phenotype is linked to a certain marker, then the affected siblings will inherit identical alleles of the marker more frequently than expected by chance alone. when assessed by a chi-square test a lod score of >3.6 is considered significant. 26 association studies are case control studies based on a comparison of unrelated affected and unaffected individuals from a population. although association can be performed for any random dna polymorphisms, they are most meaningful when applied to functionally significant variations in genes having a clear biologic relationship to the trait. positive association may occur under 3 circumstances: (1) the allele is contributing to the phenotype, (2) population (racial or ethnic) admixture, and (3) when alleles at 2 loci are close together (linkage disequilibrium). an alternative type of case control is the transmission disequilibrium test, which avoids the confounding effects of an incorrectly matched control population and uses a trio design of 2 parents and 1 affected sibling. 27 a number of whole-genome scans for asthma have now been completed (table i) . [28] [29] [30] [31] [32] although there is an emerging consensus for some chromosomal regions, in different populations there exist many where linkage has not been reproduced. although this may represent true heterogeneity on the basis of racial differences, it is of concern that all the whole genome screens have been conducted on relatively small numbers of families (100-500), whereas it is predicted on statistical grounds that in excess of 1000 sibling pairs is needed to provide absolute confidence for linkage to a specific marker. 25 one possible way around this is to pool data from different studies either by meta-analysis or through establishing a voluntary network in which separate groups pool their results in a single analysis. 33 even when a chromosomal region has been narrowed down to 1-2 cm, the task of identifying which gene (or genes) within this stretch of dna is contributing to the disease phenotype is daunting. this requires the construction of physical maps of the region with use of overlapping genomic dna clones and techniques such as exon trapping and complementary dna selection to identify genes in a given section of dna. with the availability of integrated genetic and physical maps it is possible to obtain an inventory of genes mapping to the specified genetic interval and scan this for genes of known function (positional-candidate approach). once a specific gene and its mutations have been identified, their expression can be assessed in diseased tissue by a combination of pcr and in situ hybridization and functional studies undertaken by overexpressing and underexpressing the gene in appropriate human cell lines and transgenic mice. at the time of writing, no candidate genes for asthma have yet been reported that have emerged from whole genome screens. a large number of mutations have been described for candidate genes that influence functions relevant to known disease mechanisms in asthma and allied disorders. in all cases, altering the level of expression or function of a specific protein accounts for only a very small component of the disease phenotype. table ii displays candidate genes that have found widest acceptance in different populations. in many cases it is highly likely that several mutations involving a number of components of a particular metabolic or physiologic pathway are needed to fully manifest the effect of a candidate gene. for example, for il-4 a polymorphism at -589 involving a c→t substitution in the promoter region on chromosome 5q31 results in increased transcription of il-4 and therefore increased responsiveness to il-4 (eg, by enhanced ige production). 34 clearly, there may be other functionally active polymorphisms influencing il-4 secretion. moreover, at least 12 common polymorphisms have also been described in the coding region of the il-4 receptor gene on chromosome 16p12.1, 5 of which lead to amino acid changes of the gene product (fig 3) . 35 ) decrease 37 stat6 activation, whereas others appear to have no effect on il-4 signalling. 38 the role of glutamine (gln) 576 arginine (arg) is not clear. 36, 38, 39 when 2 or more il-4r polymorphisms occur together (eg, ser 503 prol and gln 576 arg, stat6 phosphorylation is reduced and irs1/2 phosphorylation is increased. 37 if the level of il-4 secretion is also increased (eg, in the -589 promoter polymorphism), then any genetic effects mediated through the il-4r or il-13 receptor are likely to be magnified. another example of gene-gene interaction may occur in the leukotriene pathway. the cysteinyl leukotrienes ltc 4 , ltd 4 , and lte 4 are critical mediators of airway narrowing, microvascular leakage, mucus secretion, and eosinophilia in bronchial asthma. 40, 41 the terminal enzyme for cysteinyl leukotriene (cyst-lt) synthesis is ltc 4 synthase encoded on chromosome 5q35. we have shown that in patients with aspirin-intolerant asthma (aia) the expression of this enzyme in mast cells and eosinophils is increased 5-fold in parallel with enhanced cyst-lt production. 42 this might explain why such patients find particular benefit from being treated with cyst-lt 1 receptor antagonists (ltras) such as montelukast. 43 an a→c polymorphism at the -444 position of the ltc 4 synthase promoter has been shown to be strongly associated with aia (odds ratio 3.89). 44 this base substitution creates an extra activator protein-2 transcription factor binding site, leading to increased enzyme transcription. we have also shown that the a/a or a/c allele is also found more commonly in patients with severe asthma and is accompanied by a greater ability to produce ltc 4 on ex vivo activation of the peripheral blood eosinophils and a tendency toward enhanced responsiveness to the antileukotriene drug zafirlukast. 45 5-lipoxygenase (5-lo) is the first committed enzyme in the biosynthesis of leukotrienes. a series of naturally occurring mutations have been discovered within the glucocorticoid-rich transcription factor binding region in the promoter of the 5-lo gene. 46 these involve deletion of 1, deletion of 2, or addition of 1 zinc finger (sp1/egr2) binding sites. when transfected, the mutant alleles result in reduced sp1/egr2 binding, and reporter gene transcription is reduced by 20% and 40% compared with the wild-type sequences. 47 in 236 patients with asthma, only those possessing mutant 5-lo alleles were relatively resistant to treatment with the 5-lo inhibitor abt-761; the mean fev 1 improved by ~5% compared with ~15% for the wild-type and heterozygotes. 48 thus, if there were mutations both of the cysteinyl lt 4 synthase and 5-lo in favor of greater ltc 4 production, then a subtype of "leukotriene-dependent" asthma can be envisaged. with the recent cloning and expression of the cyst-lt 1 receptor, 49 variation in expression, ligand binding, or transduction signaling may further the appearance of leukotriene dependence. such mechanisms may help explain the responder-nonresponder phenomenon that is emerging in clinical studies of asthma involving ltras. 43, 50 although asthma and related allergic disorders are closely linked to atopy, there are other important gene-environmental interactions that are of central importance in the clinical expression of disease. in the case of asthma, exposure to oxidant air pollutants (eg, ozone, no x , particulates, tobacco smoke) has been linked to worsening disease. 51 respiratory virus infections, especially those caused by rhinoviruses and coronaviruses, account for the majority of asthma exacerbations in children and adults. 52, 53 because both these environmental factors operate by increasing the activation of proinflammatory transcription factors in epithelial and inflammatory cells (eg, nuclear factor-κb), 54 genetic factors regulating this cascade are likely to be of considerable importance in determining susceptibility to exacerbations of continuing disease. the complex cellular events that are linked to altered stress responses at the mucosal surface on exposure to pollutants or respiratory viruses are only just being revealed, but key among them is the ability of the epithelium to protect itself from such insults by antioxidant pathways. 6, 53 these include glutathione peroxidase, glutathione synthase, and xanthine oxidase. 55 in susceptible mice genetic linkage has shown that ozone-induced lung inflammation is directed by genes encoded on chromosome 17, including the strong candidate tnf-α, a pleiotropic cytokine generated during oxidant-induced cell injury. 56 there are numerous studies linking asthma with a reduced antioxidant status. 57, 58 because antioxidants may also be provided in the diet (eg, vitamins a, e, and c), asthmatic subjects defective in endogenous antioxidant-generating capacity may be especially susceptible to dietary deficiencies. [57] [58] [59] a similar case can be made for another dietary link to asthma. both in animals and in in vitro studies in humans omega-3 polyunsaturated fatty acid (pufa)-enriched diets has been shown to reduce allergen-induced inflammatory responses and cyst-lt generation, respectively. 60, 61 on this basis, it has been suggested that supplementation of the diet with omega-3 fatty acids in the form of fish oil might protect asthmatic patients by reducing the capacity to generate cyst-lts. unfortunately, clinical trials with diet supplementation have been disappointing both with allergen provocation and in clinical asthma. [61] [62] [63] however, broughton et al 64 have recently shown that only those patients who have high urine secretions of lte 4 responded favorably to omega-3 fatty pufa dietary supplementation, whereas in those who were low excretors the asthma deteriorated or was unchanged rather than improved. because urinary lte 4 excretion is a measure of the activity of the 5-lo pathway, 39, 43 it is possible that responders and nonresponders to this dietary intervention could be determined by prior genotyping. it has been suggested that reduced exposure to bacteria or their products during early infancy is a key factor in programming the immune response toward an allergic phenotype. 65 thus children brought up in livestock farming communities have a substantially lower risk for development of allergies. 66 it is suggested that exposure to bacteria or their products (eg, endotoxin) polarizes the immune response toward a protective t h 1 phenotype by enhanced il-12 (or il-18) production by professional antigen-presenting cells such as dendritic cells, 67 thereby providing a negative signal for t h 2 polarization by enhanced ifn-γ production. the lower prevalence of allergic disease in formerly communist countries and the subsequent increase that has been observed since reunification has also been cited as supporting the "hygiene hypothesis" of allergic disease, as has the increased urban-to-rural gradient of allergic sensitization in african communities. 68 however, what is notable about the changes in prevalence being observed in the former eastern bloc countries and in africa is that allergic sensitization has increased but asthma and bhr has not. 69 this adds further evidence to the view that asthma and allergy are not equivalent or even linearly related and that local organ-derived factors are important. the recent description of a polymorphism of cd14, the endotoxin receptor that is linked to the development of atopy in children, is of great interest 70 and will encourage a search for other candidate gene polymorphisms linked to susceptibility to early life infection, including ifn-γ, natural resistance-associated macrophage protein-1, natural resistance-associated macrophage protein-2, and the mannose-binding protein. although genetic and environmental factors that operate to direct the immune response toward the t h 2 phenotype are fundamental to understanding the origin and pathogenesis of allergic diseases, genetic and the environmental factors that direct this response to selected organs are of key importance. eczema is a strong predictor of asthma persistence and, in chronic severe disease, there is evidence for gastrointestinal epithelial permeability and inflammation. therefore the epithelium may play a particularly important role in directing the inflammatory and remodeling responses in chronic allergic disease. subepithelial deposition of interstitial (repair) collagens, impaired epithelial proliferative responses to damage, enhanced inflammatory and cytokine growth factor secretion, and evidence for altered subepithelial myofibroblast function in asthma suggest a fundamental abnormality in the epithelial-mesenchymal trophic unit that is involved in fetal lung development. 71, 72 abnormal signaling between the epithelium and myofibroblast and to dendritic cells provides a basis for asthma that encapsulates both t h 2 polarization and airway wall remodeling. whether this hypothesis can be sustained will require research at the gene by environment interface and its application to disease as it occurs in humans. cytokine networks in the pathogenesis of bronchial asthma: implications for therapy the inflammation-repair cycle in asthma: the pivotal role of the airway epithelium airways remodelling: the chronicity of asthma, quaeritur focus viii cytokine production by cell cultures from bronchial subepithelial myofibroblasts difficult asthma reversing the trend: reducing the prevalence of asthma proportion of asthma attributable to sensitisation to aeroallergens association of asthma with serum ige levels and skin-test reactivity to allergens relation between airway responsiveness and serum ige in children with asthma and in apparently normal children the relationship between parental and children's serum ige and asthma genetic analysis of atopy and asthma as quantitative traits and ordered polychotomies linkage of asthma to markers on chromosome 12 in a sample of 240 families using quantitative phenotype scores the familial incidence of allergic disease genetic risk for asthma, allergic rhinitis and atopic dermatitis allergy in 7000 twin pairs total and specific ige (rast) in atopic twins bronchial reactivity pattern in non asthmatic parents of asthmatics atopic disease and immunoglobulin e in twins reared apart and together genetic and environmental influence on asthma: a population-based study of 11,688 danish twin pairs a genetic study of immunoglobulin e genetics of total serum ige levels: a regressive model approach to segregation analysis detection of a recessive major gene for high ige levels acting independently of specific response to allergens analytic options for asthma genetics evidence for mendelian inheritance of serum ige levels in hispanic and non-hispanic white families genetic dissection of complex traits: guidelines for interpreting and reporting linkage results genetic dissection of complex traits transmission test for linkage disequilibrium: the insulin gene region and insulin-dependent diabetes mellitus (iddm) a genome-wide search for quantitative trait loci underlying asthma collaborative study on the genetics of asthma. a genome-wide search for asthma susceptibility loci in ethnically diverse populations genetic influences of chromosome 5q31-q33 and 11q13 on specific ige responsiveness to common inhaled allergens among african american families: collaborative study on the genetics of asthma genome-wide search for asthma susceptibility loci in a founder population a genome-wide search for linkage to asthma: german asthma genetics group report on the working group on phenotype approaches workshop on genetics of asthma: methodological approaches promoter polymorphisms in the chromosome 5 gene cluster in asthma and atopy common polymorphisms in the coding part of the il-4-receptor gene ileu50val variant of il-4a upregulates ige synthesis and associates with atopic asthma the polymorphisms s530p and q576r in the interleukin-4 receptor * gene are associated ith atopy and influence signal transduction effect of allergy associated mutation in human il-4ra (q576r) on human il-4 induced signal transduction the association of atopy with a gain of function mutation in the * subunit of the interleukin 4 receptor leukotriene antagonists and synthesis inhibitors: new directions in asthma therapy inflammatory mechanisms in asthma over expression of leukotriene c4 synthase in bronchial biopsies from patients with aspirin-intolerant asthma drug therapy: treatment of asthma with drugs modifying the leukotriene pathway leukotriene c4 synthase promoter polymorphism and risk of aspirin-induced asthma variant ltc4 synthase gene enhance in vitro ltc4 synthesis and clinical response to zafirlukast, international symposium: aspirin intolerance and related syndromes: a multidisciplinary approach naturally occurring mutations in the human 5-lipoxygenase gene promoter that modify transcription factor binding and reporter gene transcription egr-1 and sp1 interact functionally with the 5-lipoxygenase promoter and its naturally occurring mutants pharmacogenetic association between alox5 promoter genotype and the response to anti-asthma treatment characterisation of the human cysteinyl leukotriene cys lt1 receptor oral montelukast, inhaled beclomethasone and placebo for chronic asthma: a randomised control trial panel studies for investigating the acute health effects of air pollution community study of role of viral infections in exacerbations of asthma in school children in the community respiratory viruses and exacerbations of asthma in adults is nk-kb the sensor of oxidative stress? toxicological mechanisms underlying oxidant pollutant induced airway injury linkage analysis of susceptibility to ozone-induced lugn inflammation in inbred mice dietary antioxidant vitamin intake and lung function in the general population a prospective study of diet and adult-onset asthma effect of fresh fruit consumption on lung function and wheeze in children n-3 polyunsaturated fatty acids and cytokine production in health and disease effect of dietary intake of omega-3 and omega-6 fatty acids on severity of asthma in children effect of dietary fish oil supplementation on the antigen-induced late phase response in the skin dietary fish oil effects on seasonal hay fever and asthma in pollen sensitive subjects reduced asthma symptoms with n-3 fatty acid ingestion are related to 5-series leukotriene production microbial stimulation as an aetiologic factor in atopic disease prevalence of hay fever and allergic sensitisation in farmer's children and their peers living in the same rural community: scarpol team development of t-cell memory agonist inhalant allergens: risks for the future the epidemiology of childhood asthma the rising trends in asthma and allergic disease polymorphism in the 5-flanking region of the cd14 gene is associated with circulating soluble cd14 levels and with total serum immunoglobulin e the bronchial epithelium as a key regulator of airway inflammation and remodelling in asthma the attenuated fibroblast sheath of the respiratory tract epithelial-mesenchymal trophic unit key: cord-320431-0877trhh authors: frey, andreas; lunding, lars p.; ehlers, johanna c.; weckmann, markus; zissler, ulrich m.; wegmann, michael title: more than just a barrier: the immune functions of the airway epithelium in asthma pathogenesis date: 2020-04-28 journal: front immunol doi: 10.3389/fimmu.2020.00761 sha: doc_id: 320431 cord_uid: 0877trhh allergic bronchial asthma is a chronic disease of the airways that is characterized by symptoms like respiratory distress, chest tightness, wheezing, productive cough, and acute episodes of broncho-obstruction. this symptom-complex arises on the basis of chronic allergic inflammation of the airway wall. consequently, the airway epithelium is central to the pathogenesis of this disease, because its multiple abilities directly have an impact on the inflammatory response and thus the formation of the disease. in turn, its structure and functions are markedly impaired by the inflammation. hence, the airway epithelium represents a sealed, self-cleaning barrier, that prohibits penetration of inhaled allergens, pathogens, and other noxious agents into the body. this barrier is covered with mucus that further contains antimicrobial peptides and antibodies that are either produced or specifically transported by the airway epithelium in order to trap these particles and to remove them from the body by a process called mucociliary clearance. once this first line of defense of the lung is overcome, airway epithelial cells are the first cells to get in contact with pathogens, to be damaged or infected. therefore, these cells release a plethora of chemokines and cytokines that not only induce an acute inflammatory reaction but also have an impact on the alignment of the following immune reaction. in case of asthma, all these functions are impaired by the already existing allergic immune response that per se weakens the barrier integrity and self-cleaning abilities of the airway epithelium making it more vulnerable to penetration of allergens as well as of infection by bacteria and viruses. recent studies indicate that the history of allergyand pathogen-derived insults can leave some kind of memory in these cells that can be described as imprinting or trained immunity. thus, the airway epithelium is in the center of processes that lead to formation, progression and acute exacerbation of asthma. with more than 300 million people affected bronchial asthma is one of the most common chronic inflammatory diseases worldwide (1) . actually, 1 out of 250 deaths is associated with asthma and it causes annual direct medical (drugs, care, hospitalization) and indirect economic (productivity loss, early retirement) costs of about €34 billion for the eu (2) and over 80 billion for the united states (3, 4) , making it a major burden for public healthcare systems (5) . asthma is characterized by acute broncho-obstruction, in combination with additional symptoms such as cough, chest tightness, shortness of breath, and wheezing, which vary in extent and over time. these symptoms arise on the basis of chronic airway inflammation in response to a trigger, most commonly inhaled allergen(s), that causes airway hyperresponsiveness (ahr), airway remodeling and mucus hypersecretion (6) . due to the complexity and variation of the symptoms along with its pathogenesis, asthma is nowadays described as a heterogeneous syndrome with distinct sub-or endotypes. however, the majority of asthma patients displays allergic inflammation of the airways, which can be classified by profiles of several characteristic mediators in "th2 high" or "th2 low" subtypes (7) . thus, in sensitized individuals t helper 2 (th2) cells orchestrate allergic inflammation by releasing a typical array of cytokines including interleukins (il)-4, -5, -9, and -13 and granulocyte-macrophage colony stimulating factor (gm-csf). these mediators induce the production of allergen-specific immunoglobulin (ig) e, th2 cell development, goblet cell differentiation, submucosal gland activity, as well as recruitment, maturation, and activation of eosinophils and its precursors (8) . activation of mast cells and eosinophils via ige-bound allergens results in their degranulation and, thus, in the release of a plethora of effector molecules and growth factors that on the one hand destroy airway tissue and on the other hand conduct its repair. chronic activation of these processes ultimately lead to signs of airway remodeling such as increased smooth muscle mass, subepithelial fibrosis, and epithelial desquamation, which in turn give rise to the pathological changes and clinical symptoms characteristic for asthma (9) . allergic sensitization against aeroallergens represents the strongest factor predisposing for the development of asthma, indicating a hyperreaction of the immune system to be the central event within the pathogenesis of this disease. nevertheless, structural cells and particularly airway epithelial cells also appear to be of critical importance. this is not surprising since these cells represent the barrier that first encounters environmental stress factors like air pollutants, bacterial and viral pathogens, as well as allergens, and markedly contributes to their neutralization by a mechanism called mucociliary clearance (mcc). besides these barrier and cleaning functions airway epithelial cells also exert a number of immunological tasks interweaving the role of the epithelium with that of the above-mentioned cells of the immune system. here we aim to review these immune functions of the airway epithelium against the background of asthma pathogenesis. the main purpose of mucosae is to separate the body from its environment and therefore they are essential for the maintenance of the inner homeostasis. though this task is not commonly regarded as an "active" or "typical" immune function, it is absolutely central for the defense against allergens, pathogens and other harmful environmental factors. in order to fulfill this function the airway epithelium forms a continuous, selfcleaning barrier with a considerable resistance against biological, chemical or physical stressors (10) . together with the physical barriers of the mcc and glycocalyx, this is achieved by three types of intercellular epithelial junctions that form the structural adhesion forces of the airway mucosa by linking the intracellular structures of the cytoskeleton of one epithelial cell to that of its neighbors. these junctions involve adherens junctions (ajs), hemidesmosomes, and tight junctions (tjs). ajs can appear as spots (adhesion plaques) or as bands encircling the cell (zonula adherens). in the junctional zone ajs interconnect the actin filaments of the adherent cells via homotypic transmembrane e-cadherin adhesions and anchor proteins like actinin, vinculin, and α-, β-, and p120 catenins, while adhesion plaques attach the cells to the extracellular matrix (11) . similarly, hemidesmosomes are focal structures that form adhesive bonds between the cytoskeleton of epithelial cells and the lamina lucida, which is a part of the lamina propria. hemidesmosomes utilize integrin α6β4, plectin 1a and the tetraspanin cd151 connecting laminin and fibronectin of the extracellular matrix to the intermediate filaments of the cytoskeleton (12) . in contrast, tjs form a multiprotein junctional complex called zonula occludens (zo) that in turn appears as the main regulator of the paracellular permeability. these complexes are formed by several transmembrane and cytoplasmic proteins that are attached to actin filaments of the cytoskeleton. the main components of tjs are claudins and occludins, proteins with four transmembrane domains, as well as so-called junctional adhesion molecules (jams) belonging to the immunoglobulin superfamily with only one transmembrane domain. these proteins are connected to actin filaments by cingulin and zo proteins 1, -2, and -3 (13) . in the airways of healthy individuals, the tjs of the zonula occludens and ajs of the zonula adherens constitute dense protein networks that interconnect the basolateral sides of epithelial cells in such a way that they prevent the paracellular passage of basically all molecules, including water, ions and proteins, as well as of pathogens or other inhaled particulate matter. several findings strongly indicate that in asthma patients the barrier function is impaired by epithelial disruption. for example, endobronchial biopsies revealed a fragile or even injured airway mucosa with partially or completely uncovered areas and detachment of columnar, ciliated cells (14) . epithelial desquamation is further indicated by the presence of epithelial cells in bronchoalveolar lavage (bal) and of creola bodies (epithelial cell aggregates) in sputum of asthmatics (15) . furthermore, bronchial biopsies of asthmatic subjects displayed patchy disruption of tjs (16) and the expression of a number of proteins that are essential for the formation of tjs and ajs has been shown to be markedly reduced. among these proteins are α-catenin (17), β-catenin (18), occluding (16) , zo-1 (16, 17) , and e-cadherin (17, 19) . the levels of the latter one in sputum also correlate with asthma severity (20) . these data are further supported by in vitro studies where primary bronchial epithelial cells are kept in air liquid interface (ali) culture, a method that allows the cells to differentiate and form a pseudo-stratified epithelial monolayer largely resembling the physiological structure of the airway mucosa. once this structure has been established, in vitro barrier integrity can be assessed by measuring the transepithelial electrical resistance (teer), a characteristic that is indicative of the tightness of a cell layer (21) . several studies showed that ali cultured airway epithelia from asthma patients display a decreased teer in comparison to epithelia derived from healthy controls (16, 22, 23) . to date, three different factors are discussed to have a harmful impact on the barrier integrity of the airway epithelium in asthma pathogenesis: allergens themselves, viral infection, and (allergic) inflammation. according to the "protease hypothesis" allergens with an inherent protease activity are capable of cleaving the protein components of the aforementioned intercellular epithelial junctions so that the barrier function is disrupted and allergens can penetrate the airway mucosa on the paracellular route, which eventually could result in sensitization against them. accordingly, a considerable number of allergens has been tested in vitro for proteolytic potential and for an effect on epithelial barrier integrity. several studies provided evidence for a direct cleavage of e.g., occludin and zo-1 proteins by the major allergen from house dust mites (dermatophagoides), der p 1 (24, 25) . house dust mite extracts as well as der p 1 have been shown to increase the permeability and to decrease teer of epithelial layers in vitro (23, 25, 26) . comparable effects have been shown for extracts of the allergenic fungus alternaria alternata that reduced teer of human bronchial epithelial cells in vitro (27) or the aspergillus fumigatus-derived alkaline protease 1 (alp-1) (28) . similarly, a variety of different pollen extracts has been investigated for their effect on the barrier integrity of epithelial cells in vitro. diffusates of italian cypress (cupressus sempervirens), orchard grass (dactylis glomerata), olive (olivia europaea), and scots pine (pinus sylvestris) have been shown to affect claudin-1, e-cadherin, and occludin expression and thus to disrupt epithelial junctions in ali cultures of calu-3 cells, an effect which could be suppressed by protease inhibitors (29) . japanese hop (humulus japonicus) extract also reduced expression of occludin in a comparable setting (30) . another study provided evidence for proteolytic activity of giant ragweed (ambrosia trifida), kentucky bluegrass (poa pratensis), and white birch (betula pendula) as shown by reduced expression of claudin-1, occludin, and zo-1 in calu-3 as well as in mdck cells (31) . however, an inherent protease activity appears not to be the only way, by which allergens can impair the barrier integrity of the airway epithelium. cockroach, hdm, fungus, and mold extracts have also been shown to activate the protease-activated receptor (par-) 1 and/or 2, which in turn leads to degradation of aj components (25, (32) (33) (34) . the effect of viral infections on airway barrier function is even more pronounced than that of allergens. respiratory viruses cause junction dysfunction by different mechanisms: human rhinoviruses (hrv), respiratory syncytial virus (rsv), human metapneumovirus (hmpv), influenza and parainfluenza viruses bind to their entry receptor, which are typically protein or sugar structures expressed on the cellular surface for other purposes, leading to endocytosis of the virus. once the virus has been internalized, it uncoats and initiates the viral replication process, which has certain consequences for infected cells. on the one hand, the cell starts with the production of type i interferons (ifn) in order to slow down the internal virus replication and to activate the cellular immune response against the virus. in consequence, infected airway epithelial cells are killed by virus-specific, cytotoxic cd8 + t cells. on the other hand, the virus itself also kills epithelial cells, since it induces morphological alteration of the cells summarized as cytopathic effect (cpe). for hrv and influenza viruses, the cpe manifests in rounding and detachment of airway epithelial cells that are ultimately lysed by the virus in order to release freshly produced viruses. paramyxoviruses such as rsv and hmpv induce cell fusion so that four or more cells form typical syncytia (35, 36) . additionally, at least hrv and rsv affect the barrier integrity of the airway epithelium by reducing the expression of epithelial junction proteins (37) (38) (39) (40) . it could be shown that hrv increases epithelial permeability by a reduction of occludin and zo-1 expression (41, 42) . rsv also disrupts junctional complex structures by fostering the activity of protein kinase d (pkd) (43). the antiviral immune response also includes the release of cytokines that directly affect epithelial barrier function as well. this is especially true for il-1β, ifn-γ and tumor necrosis factor (tnf). these cytokines have been shown to support epithelial permeability and to decrease expression of claudins, jam, occludin, and zo-1 in several in vitro studies (44-46). in case of asthma, these effects are even more pronounced because of the allergic inflammatory response that already exists before the viral infection of the airway epithelium. hence, th2 type cytokines like il-4 and il-13 also increase barrier permeability by inhibiting the surface expression of β-catenin, e-cadherin, occludin, and zo-1 (45, 47). in addition to cytokines, mast cell derived mediators also appear to have an effect on the barrier function of the airway mucosa. histamine for example has been shown to contribute to transient disruption of apical junctional complex integrity and thus to increase epithelial permeability in vitro (48). allergens, viruses, and the inflammatory response to their exposure represent extrinsic factors that impair the barrier integrity of the airway epithelium. however, some studies suggest that epithelial cells of asthma patients inherently predispose for an increased permeability. as already mentioned above, airway epithelial cells that have been isolated from asthmatics and propagated in vitro to form an epithelial monolayer under ali culture conditions, display a decreased teer as compared to cells from healthy donors (23, 45) . this observation indicates that the cellular properties leading to an increased barrier permeability are somehow imprinted within the cells. whether this is a matter of genetic predisposition encoded in epithelial stem cells or whether epithelial cells from asthma patients "remember" previous insults by epigenetic modifications that predispose for asthma development in later life remains elusive. besides the barrier function of the epithelium provided by the mere presence of the sealed cell layer itself, two additional barrier structures are "exported" onto the luminal surface by the airway epithelium, a static one dubbed glycocalyx or periciliary layer (pcl) and a mobile one termed mucus. the glycocalyx or pcl is a sponge/fleece-like, cell membraneanchored layer of glycolipids and glycoproteins -mainly mucins (see below) -that vertically stick out of the apical epithelial cell membrane. although mainly attributed to the gut epithelium where it can extend up to 1500 nm (49) and to the vascular endothelium (50, 51) a glycocalyx/pcl is also present throughout the airway epithelium even down to the alveoli (52), again with heights up to 1500 nm in certain areas (53) (figure 1 ). this static glycoprotein and glycolipid coat stores water to control mucus hydration but also serves as a protective zone against the compression of the mucus lying above in order to allow persistent cilia beating for ongoing functionality of the mucociliary clearance (mcc; see below) (53, 54). beyond that, the glycocalyx/pcl regulates receptor specificity by architectural means and prevents the progression of viruses through the occasionally patchy mucus layer. it has been shown that the height and density of the epithelial glycocalyx can determine whether a ligand-equipped nanoparticle may attach to its membrane receptor or not (49, 55). in line with this, the inefficiency of adenovirus-mediated gene transfer into the airway epithelium was found to be caused by the membranetethered glycocalyx/pcl proteins that put a halt to the advance of the viral vectors (56, 57). consequently, the susceptibility of the airway epithelium toward infection is at least to some extent controlled by the glycocalyx/pcl. very small viruses such as bocavirus (hbov1) and hrv, which are 20-30 nm in size (58, 59) should readily advance through the pcl to the epithelial plasma membrane as has been observed with nanoparticles of the respective size (53). consequently, those viruses should be able to luminally infect airway epithelial cells as long as their receptor is present on the apical side. little is known about receptor distribution in vivo but at least on cultured airway epithelial cells apical receptor expression and/or infectivity has been demonstrated for both viruses (60-63). larger particles of about 100 nm and above, on the other hand, are efficiently blocked by the pcl (53). hence, viruses such as rsv, hmpv, influenza and parainfluenza viruses, adenovirus or coronavirus, which are in this size range (64) (65) (66) (67) , should be hindered efficiently by the pcl to infect the host. yet, those viruses often are associated with respiratory infections and asthma exacerbations (68, 69) . one possibility for them to infect the airway epithelium may be the presence of the viral receptor on structures that extend from the pcl such as the tips of the cilia. an example for this is chemokine receptor cx3cr1 via which rsv can infect its host. in differentiated human airway epithelial cells this molecule is highly abundant on cilia (70, 71) . another possibility is the preceding action of a door-opener such as hbov1 which may pave the way for further viral infections. hbov1 was shown to persist for several months in the human airway epithelium (72) and causes pyroptotic cell death, epithelial cell hypertrophy, loss of cilia and disruption of the tight junction barrier (60, 61). such a predamaged epithelial barrier may then readily fall victim to an influenza, parainfluenza or hpmv infection. with up to 13% of asthma exacerbations in small children found to be associated with hbov1 infection (73) it may be worthwhile to further investigate possible coinfections with hbov1 in asthma exacerbation cases. in this context, it may also be of interest that the treatment of chronic inflammatory diseases of the airways such as asthma with corticosteroids (cs) seems to reduce the glycocalyx/pcl height on the alveolar epithelium (74) thereby rendering the lung more susceptible to e.g., pneumocystis carinii infection. consequently, alleviating chronic inflammation in asthma with cs may make the patient more susceptible to certain infections, which in turn may enhance inflammation again, clearly a two-edged outcome of cs therapy in asthma. although the glycocalyx appears to be static on the architectural level, it may not be invariant in terms of its molecular composition. it was shown that lipopolysaccharide exposure could lead to heparan sulfate shedding from the airway epithelium thereby causing increased lung permeability (52). allergen exposure of experimental animals resulted in different glycosylation patterns of the glycocalyx (75), which may result in a deviant presentation of viral and bacterial receptors on the cell surface. in light of the above, the airway epithelial glycocalyx seems to play a so far underestimated but possibly important role in airway epithelial defense. whether or not the molecular composition figure 1 | protection of epithelial surfaces by physical barriers. in the healthy state, ciliated cells (cc) form a tight epithelial layer where paracellular passage is prevented by sealing of lateral intercellular spaces with tight junctions (tj). the apical epithelial cell surface, including the cilia, is covered by a layer of membrane-anchored glycoproteins and glycolipids, the glycocalyx. the dense meshwork of glycostructures restricts access of luminal matter to the apical cell surface; depending on their size, larger pathogens can be cut off from their receptor if it is not present on cilia (inset). goblet cells (gc) secrete mucus, consisting of highly glycosylated mucins which absorb large quantities of water to form a viscous gel. the mucus -and any matter trapped within -is transported upward in the airway lumen by the coordinated beating of the cilia. bc, basal cells. in the asthmatic state, barrier functions can be compromised by partial disruption of tight junctions and gaps in the pcl/glycocalyx meshwork due to loss of cilia. mucus clearance is impeded by increased mucus viscosity and swelling of the gel matrix, and by disturbance of ciliar beating due to disorganization and dykinesia of cilia. of this static cell coat is different in asthma, remains to be investigated. while the role of the glycocalyx/pcl is still subject of debate, the importance of mucus in airway luminal defense is unchallenged. mucus is an unstirred discontinuous sheet of secreted mucous hydrogel which floats on top of the epithelium and is transported toward the oral cavity like the cargo on a conveyor due to the constant and coordinated beating of underlying ciliated cells (76) . the mucus carried upward by this mucociliary clearance (mcc) mechanism can be swallowed or expectorated. as the mucus layer separates the airway lumen from the epithelium only objects that diffuse faster "vertically" toward the epithelial surface than the mucus is transported "horizontally" toward the oral cavity can reach the epithelial cell membranes. thus, only nanoscalar objects and smaller, like gases, water, salts and nutrients are able to reach the epithelial cells (77, 78) . this way the mucus carpet provides a protective line of defense against pathogens, dust and other harmful objects that might be inhaled by an individual. in addition to that, the sticky texture of the mucus slows down airborne objects and further prevents their advance to the epithelial cell layer. in order to exert these functions properly, mucus requires a specific composition. mucus consists mainly of water, further components are salts, lipids and proteins. among those, antimicrobial proteins like lysozyme, immunoglobulins and antimicrobial peptides are major molecular scavengers distributed within the mucus layer (79) (80) (81) . the characteristic viscous, elastic and sticky properties of the mucus are provided by a group of macromolecules named mucins (82, 83) . to date, 21 genes coding for mucins have been described (84) . their protein products are secreted either to form mucus or remain immobile on the apical membranes of the airway epithelial cells where they become part of the glycocalyx/pcl. muc5ac and muc5b are the major secreted mucins in the airways. in addition, muc2 and muc19 are also part of airway mucus, albeit to a considerably smaller proportion, and thus belong to the family of secreted mucins (83) . in contrast, muc1, muc4 and muc16 are tethered to the cells of the airway epithelium (figure 1 ) thereby contributing to the static luminal epithelial barrier, which resides underneath the mobile mucus layer (85, 86) . the viscous and elastic properties of the mucous gel are primarily given by the secreted polymeric mucins muc5ac and muc5b (83) . these mucins are highly o-glycosylated proteins enriched with amino acids like proline, serine or threonine (87) . although both have a similar structure, muc5b and muc5ac differ in charge due to differential glycosylations (88) . their production depends on cell type and site of production. in the upper airways, muc5ac is produced by epithelial goblet cells while muc5b is secreted from mucous cells in submucosal glands from secretory cells in the tracheal and bronchial epithelium. in the distal airways, muc5b is also produced by secretory cells of the epithelium and seems to be the major mucin of this airway region (83, 89, 90) . before secretion, polymeric proteins are stored in secretory granules in a compacted, dehydrated state. upon release, they switch to a hydrated form, which is necessary for the mucous gellike properties (91, 92) . whether the two different mucins have different functions restricted to their site of production or whether the two mucins mingle to create a novel type of barrier structure is not clear yet. at least some studies analyzing airways of piglets have shown that muc5b strands are becoming coated with muc5ac to some extent after release at the epithelial surface (93, 94) . a possible role of muc2 and muc19 has not been identified yet. howsoever, under healthy conditions, the viscous mucus traps noxious substances, which are then removed from the airway via cilial beating by the mcc (95) . in asthma, the mcc is impaired leading to mucus plug formation which in turn results in the characteristic obstruction observed in asthmatics. this is already a feature of mild stable asthma and the dysfunction worsens during aggravation of asthma and in asthma exacerbations (96) (97) (98) . one reason is an increased mucin content of the mucus thereby disturbing its regular composition. normally, the airways' mucus consists of ∼98% water and only ∼2% solid factors mainly mucins. in obstructive diseases, the amounts of mucins rise up to 8-15% (54, 86). due to its hygroscopic nature, this leads to acquisition of water from the underlying pcl/glycocalyx and shrinking of this static layer. the now protruding cilia either project into the mucus or get bend (54). both effects impede passing on of the mucus to the next cell. loss and/or disorientation of cilia as it is typical for asthmatics will further disturb the "bucket chain"-like transport process (99) . on the cargo side enhanced intermolecular crosslinking of mucus constituents by oxidative processes may further complicate forwarding. it will also increase mucus viscosity eventually leading to plug formation. oxidative intramolecular crosslinking of biomolecules is predominantly caused by cysteines whose thiol side chains can form disulfide bridges. all mucins are rich in cysteines, especially in their less glycosylated carboxy-and amino terminal regions. in the "normal" mucous gel of healthy individuals these cysteines are believed to be only moderately crosslinked, forming a lightly entangled network. in asthma, however, the degree of crosslinking and the density of the mucin network increases considerably (100, 101) (figure 1 ). increased oxidative stress appears to play an important role in this respect with eosinophils being the main suspects for oxidant production. the abnormally high levels of eosinophil peroxidase detected in the sputum of asthma patients may form an oxidative milieu. this would also bring the widely observed correlation between airway eosinophilia and airway obstruction into a causative relationship (102) . lastly, the muc5ac of asthmatics tends to tether to the epithelium, which also complicates mucus forwarding (103) . in asthmatics not only the amount but also the composition of the mucus changes, especially the ratio of muc5ac to muc5b as well as the posttranslational modification of muc5b. mucus from healthy individuals contains predominantly muc5b, which is essential for the mcc and protection against pathogens (104) (105) (106) . in asthma, the proportion of muc5b relative to muc5ac often decreased (104, 105) along with the expression of a lowcharge form of muc5b. consequently, there was a changed ratio between the two differently glycosylated forms of muc5b (104, 107) . the importance of muc5b is indicated by muc5bdeficient mice, which showed an accumulation of undesired substances e.g., bacteria, resulting in severe inflammation and airway obstruction (106) . the ratio between muc5b and muc5ac changes dramatically in asthma because muc5ac expression and protein production are substantially upregulated in asthmatic patients (104, 105, 107) . especially patients with an eosinophilic type 2 asthmatic phenotype showed a shifted ratio toward higher muc5ac concentrations (105, 108) . this is in line with the assumption that muc5ac seems to be important for the defense against enteric nematodal and influenza infections (109, 110) . the increased expression of muc5ac seems to depend on substantially increased levels of il-13. the il-13 signaling pathway activates the signal transducer and activator of transcription 6 (stat6), which induces the expression of muc5ac via various regulators (111) and appears to be involved in ahr development (112, 113) . several studies using in vitro systems with human epithelial cells or murine models validated this mechanism (114) (115) (116) (117) . furthermore, egfr, which is also overexpressed in asthma, also induces the expression of muc5ac (118) (119) (120) (121) . this excessive production of mucins in the asthmatic airway epithelium leads to an increased volume of intracellular stored mucins, a mucus metaplasia (122) . thus, a higher number of goblet cells compared to the healthy situation appears in case of asthma (122) . it is not exactly understood, whether this switch from a muco-ciliary phenotype to a mucous metaplastic phenotype develops from goblet cell hyperplasia, metaplasia or both as reviewed before (123) . in animal models, goblet cell metaplasia/hyperplasia arises from an increased expression of primarily il-13, but also of il-4 and il-9 (124) (125) (126) (127) . these cytokines are highly upregulated in asthmatic individuals (128) (129) (130) (131) . one important factor for the development of the goblet cell metaplasia is notch2 regulated by il-13 (132) . studies analyzing the function of sam-pointed domain containing ets transcription factor (spdef) highlighted its essential role in the development of goblet cell differentiation, hyperplasia and mucous metaplasia (133) (134) (135) . therefore, spdef seems to inhibit the expression of forkhead box protein a2 (foxa2) which is an important negative regulator of genes associated with mucous metaplasia and goblet cell hyperplasia (111, 121, 133, 136, 137) . thus, the physical barriers provided by the airway epithelial layer seem to be deeply disturbed in asthmatic individuals. although mucin is one of the most important barrier molecules in the airways its unbalanced overproduction is clearly detrimental to the desired outcome. mucus plugging impedes egress of the active luminal defense molecules necessary to eliminate invaders. although strong walls (tight junctionally sealed epithelial cell layer) surrounded by a glacis (pericilial layer/glycocalyx) and a moat filled with flowing liquid (mcc) are crucial to prevent invaders from entering a castle, active defenses are necessary to end the siege. this is of particular importance when the besieger can replicate and thus may increase continuously by number, as is the case when pathogenic bacteria colonize the luminal side of the airway epithelium. in order to get rid of a potential invader the airway epithelium possesses a battery of defense molecules, with which a potential microbial enemy can be attacked, destroyed or removed out of the airway lumen. prominent innate molecular scavengers are lysozyme, transferrin and antimicrobial peptides. lysozyme is produced in large amounts (20 mg/day) by serous cells of the upper human airway epithelium (138) and is able to destroy the polysaccharide capsules of many bacterial species. it has been shown that the production of lysozyme by serous cells residing in the serous glands of the upper airways is crucial for defending against bacterial airway invaders (139) . once the polysaccharide capsule is destroyed or damaged, so called defensins or antimicrobial peptides may exert the lethal hit to the invader. defensins can form holes or pores into a bacterial cell membrane thereby killing a pathogen that aims to enter the body (79, 140, 141) . in addition, lactoferrin is produced and secreted by serous cells (142) , and transferrin is expressed by alveolar type i cells (143) . these ferrins are iron-binding proteins, which deplete their environment from iron ions that are essential for the growth of a self-replicating organism (143, 144) . consequently, the pathogen is starved out. besides this innate "rapid response team, " the polarized epithelium of the human airways is also able to transport and apically release immunoglobulins that carry a j-chain (joining chain) by using its poly ig receptor (pigr) (145) (146) (147) that is expressed by all non-stratified epithelial cells (figure 2) . only igm and multimeric iga are equipped with j-chains (148, 149) . these two immunoglobulin classes not only circulate in the bloodstream but are also produced directly underneath the airway epithelium by b cells, given those lymphocytes express the j-chain (150, 151) . functionally, igm can substitute for multimeric iga. for that reason iga-deficient individuals do not show a strong phenotype concerning susceptibility to infection. nevertheless, secreted iga (siga) outperforms igm in terms of mucosal protection as it usually displays a higher affinity toward its antigen and, more importantly, is able to crosslink with mucins upon target binding (152, 153) . this way an incoming viral or bacterial pathogen becomes trapped in mucus and is removed from the airway surface via the mcc. the protective function of secreted iga has been demonstrated with various model systems, both for the gastrointestinal mucosa as well as for the airways, using passively administered monoclonal iga (154) (155) (156) (157) , injected hybridoma cells whose target specific, dimeric igas are then transported across the mucosae ("backpack tumor model") (158) (159) (160) and by neutralization of preexisting mucosal iga immunity with mucosally administered anti-iga immunoglobulins (80) . although adaptive multivalent target binding via its hypervariable regions is probably the main mode of protection in those models, siga is also able to bind in an innate manner to luminal pathogens via its carbohydrate components by presenting decoy structures that mimic target cell surface receptors (161) . if both modes of repelling fail and a pathogen has nonetheless invaded an epithelial cell, dimeric iga may still be able to protect the infected cell, this time from inside. this is possible whenever the respective pathogen does not directly infect the cytosol of its target cell or inject its nucleic acids directly into the cytosol but rather uses an initial endocytosis step for infection. depending on the infected organelle, vesicles, which concurrently translocate iga toward the apical site, may fuse with the infected organelle, bind to the invader and carry it away into the lumen. in addition to this removal activity, mucus crosslinking and the tricking of pathogens by offering decoy receptors, siga also scavenges il-8 and thereby inhibits il-8-driven neutrophil chemotaxis (162) . in addition to these molecular interactions with a pathogenic target, iga also binds to numerous cell types that patrol at the airway epithelium. the most important cellular partner seems to be the eosinophil as this cell possesses a total of five different receptors for iga: fcαri (cd89), transferrin receptor (tfr) (cd71), pigr, asialoglycoprotein receptor (asgpr) and a receptor for secretory component (scr) with the integrin mac-1 (cd11b/cd18) serving as a coreceptor for fcαri (163, 164) . depending on the receptor addressed and the form of iga offered, i.e., soluble versus target-bound and cross-linked, eosinophils are either calmed down or activated (165) (166) (167) . yet, eosinophils are not only manipulated by iga, they also influence iga production themselves (168, 169) . thus, immunoglobulin a and eosinophils share a really intimate relationship. equipped with less receptors but still responsive to iga are neutrophils, dendritic cells, macrophages, basophils and even epithelial lining cells that express the transferrin receptor such as alveolar-type 2 cells (170) . an additional, so far unidentified receptor is present on m cells (microfold cells) (171, 172) . m cells are a specialized epithelial lining cell type that is responsible for antigen sampling at mucosal surfaces and predominantly occurs in the epithelium above organized mucosa-associated lymphoid tissue (173, 174) . this receptor senses the distance between two heavy chain domains in iga. thus, it is not able to bind iga1, an iga subclass present only in primates. iga1 is different from iga2 in that it contains a mucin-like, highly glycosylated extension of its hinge region. it is believed that this hinge region also serves as a ligand for yet other iga receptors (163) . if this holds true, subclass switching may be another adjusting wheel for iga function. the class switch from iga1 to iga2 depends on the presence of the cytokines april and baff which were shown to be produced by the epithelial layer itself, at least in case of the gut, upon bacterial stimulation (175) . this way the microbiome as sparring partner of the epithelium comes into play as the true master of this adjusting wheel. in contrast to the gut where iga2 prevails, iga1 is the predominant iga subclass in the airways (176) . this, however, does not imply that iga2 is of less importance for airway defense. iga1 simply may be the first class formed after pathogen challenge. those initial secretory iga (siga) responses are believed to be not very mature. upon pathogen challenge the human body apparently rapidly switches its current igm repertoire to iga even if most of such "first line of defense" iga are of low affinity (177) . this can be regarded as just a "better than nothing" attempt; yet it creates a window of opportunity for the body to develop more powerful siga via affinity maturation. such optimized immunological scavengers are then able to block and eventually clear a microbial infection. thus, the iga system in which the transporting epithelium plays a key role is a complex defense machinery that combines innate with adaptive immune responses. it is therefore not surprising that the role of secretory iga attracted attention in asthma research in recent years. the role of siga in chronic inflammatory lung diseases is still ambiguous. some studies show that siga is necessary to maintain immune homeostasis, other reports claim that siga may play a detrimental role in asthma. a harmful effect of iga in asthma may be explained by its ability to activate eosinophils and neutrophils because both cell types play a central role in the pathogenesis and persistence of asthma (178) . when iga is able to activate those cell types, this would readily lead to the hypothesis that in case of allergic asthma, allergen-specific iga is responsible for this activation upon allergen exposure. this assumption is supported by the finding that increased levels of both, allergen-specific ige and iga were observed in the airway mucosa of patients with atopic asthma and/or rhinitis (179) (180) (181) (182) (183) , and it was shown that allergen-specific iga levels were positively correlated to eosinophil activation marker release after segmental lung challenge of asthmatic patients (166) . yet, coincidence and correlation do not necessarily imply a causative relationship. in the abovementioned study, where a positive correlation of allergen-specific iga and eosinophil activation was observed, the non-allergic control patients also displayed allergen-specific iga in their airways; but in contrast, they did not have any allergen-specific ige as was the case for asthmatics. either so the allergen-specific ige was responsible for eosinophil activation in asthmatics or the eosinophils of asthmatics underwent some kind of imprinting or immune training that rendered them more sensitive to allergen-specific iga. with the expression of five different iga receptors on the eosinophil described so far (163) , locked-in differences in iga receptor expression in eosinophils of asthmatics versus healthy individuals are not impossible. on the other hand, a coincidence of allergen-specific iga and ige does not necessarily imply a pathological role of iga either. it may still be the case that iga are beneficial to chronic airway inflammation, and the concomitant production of allergenspecific iga can also be interpreted as a rescue attempt of the body to counteract the allergen-specific ige. in fact, more evidence points toward a beneficial role of iga in asthma and other chronic airway inflammations. it was shown for instance that upon aging iga knockout mice tend to develop chronic airway inflammation that resembles chronic obstructive pulmonary disease (copd) in humans (184) . a copd-like phenotype also develops in pigr knockout mice upon exogenous bacterial challenge (185) , and it has been shown in the past that copd patients have an impaired pigr expression (186) and reduced siga levels on the airway epithelium (187) . recently a similar phenomenon was reported for asthma (188) and rhinosinusitis (189) . in the study of ladjemi et al., asthmatics show a reduced immunostaining of pigr in airway epithelia, with il-4 and il-13 being the suppressors of pigr formation in the airway epithelium. notably, there were no significant differences in the pigr gene expression rate among asthmatics and healthy individuals (188) . thus, a posttranslational event such as proteolytic degradation of pigr in the epithelium may be responsible for the observed differences. a beneficial effect of allergen-specific iga in the airway lumen was highlighted by schwarze et al. (190) . they showed that local application of a human monoclonal iga antibody directed against the ragweed allergen amb a attenuated the proinflammatory response to allergen inhalation in mice sensitized to amb a i, whereas a control iga against ovalbumin did not. notably, the instilled anti-ragweed iga induced the formation of amb a i-specific igg2a in the animals upon allergen challenge which indicates a shift toward th1. thus, iga residing in the airways may have an anti-allergic/anti-asthmatic immunomodulatory activity. this effect may be explained by the iga feedback loop, via which a secretory iga response is adjusted to current needs. in order to provide an optimal defense against luminal noxa luminal iga are continuously sampled at the epithelium and transported to the basolateral side, where it is inspected by immune cells whether it is loaded with antigen or not. if this is the case, an immune response is mounted or boosted (191) . although this type of transcytotic event has been attributed primarily to m cells, the set-up of the ragweed-study rather precludes that route in this specific case in as much as a human iga1 against amb a i was used and this type of iga does not bind to murine m cells (172) . however, with a plethora of iga receptors known, other epithelial cell types may have taken over the task. the iga-binding transferrin receptor, for instance, is expressed by type ii pneumocytes and was shown to transport transferrin conjugates to the basolateral site (192) . in addition, similar to the gut, airway dendritic cells, which also carry iga receptors, send protrusions to the epithelial layer via which luminal antigen can be sampled (193, 194) . yet, sampling antigen-loaded iga from the airway lumen and driving the airway immune response toward th1 requires the presence of iga in the lumen, which is reduced by the th2 micro-milieu in allergic asthma. this results in a vicious circle of a locked-in th2 environment where a lack of iga causes a further lack of iga. this is in line with clinical observations on asthmatic patients that suggests a critical role for iga in asthma pathogenesis. patients with selective iga deficiency tend to bronchial hyperresponsiveness (195) and children that show a delay in maturation of iga production display atopic manifestations more often (196) . moreover, immunotherapy against the respective aeroallergen result in higher specific mucosal iga levels along with lower skin prick test sensitivity (197) or lower airway hyperreactivity (198) . nevertheless, most of the above suggests a prominent role of siga or, more precisely, the lack thereof in the pathogenesis and chronicity of atopic asthma. whether a lack of siga also plays a prominent role in asthma exacerbations remains to be elucidated. in addition to all the homeostatic defense functions like the maintenance of barrier integrity, transcytosis, and the mucosal clearance the airway epithelium also plays a major role against inhaled materials by producing several defense proteins such as mucins, defensins, antimicrobial peptides, cytokines, and chemokines (199) . thus, it contributes to local acute inflammatory reactions by regulating early inflammatory events via transcription and secretion of antimicrobial and pro-inflammatory proteins and by activating of mucin production (200, 201) . consequently, it is also a critical player during sensitization processes, asthma pathogenesis and acute exacerbations of the established disease (figure 3 ). inhaled pathogens that are not cleared by mcc are recognized by airway epithelial cells (202) . equipped with a large number of prrs such as cytoplasmic nod like receptors (nlr) and transmembrane toll like receptors (tlr) that can respond to figure 3 | inflammatory response of the airway epithelium during stable allergic asthma and exacerbation. during stable allergic asthma airway epithelial cells (aecs) release il-25, il-33 and tslp supporting differentiation of t helper (th) 2 cells that are activated by dendritic cells (dcs). th2 cells in turn secrete il-5 and gm-csf that together with aec-derived eotaxins, rantes and mcps regulate the production, maturation, recruitment and activation of eosinophils. local degranulation of eosinophils in the lung eventually leads to damage of the airway epithelium. in parallel, the th2-type cytokines il-9 and il-13 induce goblet cell (gc) metaplasia in airway epithelium. during viral induced asthma exacerbations, several other additional factors lead to an aggravation of this inflammatory response. viral infection can be detected by the airway epithelium via pattern recognition receptors (prr). subsequently, aecs secrete on the one hand tarc, the main chemokine for the recruitment of th17 cells that amplifies the proinflammatory effects of th2 cells via release of il-17, and on the other hand il-8, which leads to the recruitment of neutrophils. local degranulation of neutrophils in the lung eventually leads to additional damage of the airway epithelium. viral infection of aecs also directly leads to damage of the airway epithelium. in summary, these conditions result in a markedly increased damage of the airway epithelium compared to the stable disease, which further impairs barrier integrity and leads to release of matrikines further amplifying the ongoing inflammation. damps and pamps aecs represent the first line of cells, which can respond to pathogens and other danger signals like cell stress and cell death in the lung (203) . damps are molecules that are release from injured cells. their presence is a clear sign for the loss of homeostatic integrity of specific cell compartments or even whole cells. hence, they originate from the cytoplasm (s100 proteins, heat shock proteins, defensins, galectins, uric acid), the nucleus (high-mobility-group-protein (hmgb1)), the endoplasmic reticulum (calreticulin), mitochondria (atp, mitochondrial dna, n-formylated peptides) or from the extracellular matrix (fibronectin, hyaluronan, versican) (204) . airway epithelial cells are both, responder to and producer of damps (205, 206) . the dna binding protein hmgb1 for example, set free during necrosis of one cell can be detected from nearby cells by binding to their receptor age (rage), which leads to activation of nuclear factor kappa b (nfκb) and thereby to the production of pro-inflammatory mediators and consequently the recruitment of immune cells. in turn, pamps are preserved molecules and structures from pathogens and toxins. they can originate from such different sources as bacteria, mycobacteria, viruses, fungi and parasites (207) . pamps and damps activate signaling pathways resulting in the transcription and production of cytokines and chemokines. in brief, signal transduction through myd88 and myd88independent mechanisms leads to the activation of nfκb, mitogen-activated protein (map) kinases, and interferon regulatory factor (irf) 3 (203) . based on the nature of the triggering pamps and damps and a possible preexisting inflammatory environment in the lung its signals can result in protective effects or pathological effects for the host organism (208) . repeated cell stress and exposure to pathogens trigger chronic activation of prr pathways in airway epithelial cells that are highly active and play an important role in chronic airways diseases (204) . activation of prrs by damps leads to a massive secretion of proinflammatory mediators like il-6, cxcl8, tnf that consequently entail infiltration of activated immune cells. some of these cells like dendritic cells (dc), lymphocytes and mast cells are also involved in the pathogenesis of asthma (204, 209, 210) . after contact for example with hdm extracts, representing a major source of asthma associated allergens, tlr4 dependent activation of nfκb and protease induced injuries in airway epithelial cells lead to secretion of chemokines and cytokines like thymic stromal lymphopoietin (tslp), gm-csf, il-25, and il-33 (211) (212) (213) (214) (215) . this results in the activation and infiltration of dcs, innate lymphoid cells type 2 (ilc2) and th2 cells (216) (217) (218) . during infection with bacterial pathogens airway epithelial cells can sense bacterial cell wall components via tlr2 (recognizing e.g., lta), tlr4 (recognizing e.g., lps), nucleotidebinding oligomerization domain-containing protein 1 (nod1) and nod2 (recognizing peptidoglycans) leading to activation of nfκb and subsequent immune responses and consequently to regulation of bacterial clearance (219, 220) . nucleic acid patterns arising during viral infection can be sensed via tlr3, tlr7/8, retinoic acid inducible gene i (rig-1), and melanoma differentiation-associated protein 5 (mda-5) (221) (222) (223) (224) (225) . in response to tlr activation airway epithelial cells can also produce antimicrobial peptides such as human β-defensin 2 (hbd-2) after tlr2 activation (201, 226) . the signals of different prrs like tlrs, nlrs, and rage cooperate to regulate cellular immune responses to cell stress, infection and inflammation, which can amplify or dampen their effects (227) . airway epithelial cells are very potent producers of cytokines and chemokines. the presence of aggressors like toxins and pathogens leads to production and fast and early secretion of il-1β, il-6, tnf, cxcl8, ccl11, and ccl20 (202, (228) (229) (230) . thereby, airway epithelial cells regulate and orchestrate local immunity by interacting with the recruitment of dcs, t-cells, and b-cells (ccl20), eosinophils (ccl11), and neutrophils (cxcl8). during viral infections they constitutively produce ifnβ to reduce viral replication and to support epithelial apoptosis (231) . thereby, airway epithelial cells represent the frontline of antiviral defense mechanisms. as mentioned earlier, increased concentrations of proinflammatory cytokines like il-1β, il-4, il-13, and tnf can directly lead to damage of the barrier function of the airway epithelium (44-47, 232, 233) . in allergic asthma airway epithelial cells are one of the main producers of proinflammatory cytokines and chemokines like il-13, il-33, tslp, ccl5 (rantes), ccl7 (mcp-3), ccl17 (tarc), ccl22, and several eotaxins. all of these cytokines strongly direct or support the development of a th2 polarized inflammation (234) . the chemokines ccl17 and ccl22 play a prominent role in the recruitment of th2 cells by binding to the ccr4 receptor, since activation of it is a key event for th2 cell specific chemoattraction (235, 236) . as a highly potent producer of tslp the airway epithelium can create a local micro-milieu that supports and maintains a th2 polarized inflammation (234, 237) . in response to different epithelial injuries, airway epithelial cells secrete so-called alarmins like tslp, il-25, and il-33 that direct t helper cell differentiation toward an th2 phenotype (238) . additionally, secreted gm-csf from airway epithelial cells leads to maturation and survival of eosinophils (239) (240) (241) . both effects are supporting allergic inflammation in asthma. taken together the airway epithelium plays a major role for the recognition of pamps and damps in the lung. binding of these molecules to their respective receptors enables the airway epithelium to regulate pathways important for barrier function, mcc and local immune responses. functional disorders of the airway epithelium in the ability to answer the presence of pamps and damps favor the development of chronic airways diseases. viral infections and exposure to bacteria in early life modulate the acquisition of th1 and th2 immunity during further development and influence the responses to following exposures. these effects could play an even greater role in patients with asthma since they show disrupted mcc that could amplify the disease morbidity (242, 243) . a cytokine induced th2 polarization of the epithelium in combination with a barrier dysfunction induced by the same cytokines augments barrier impairment, further infiltration of proinflammatory cells, and enhanced penetration of inhaled allergens, which can be described as a self-reinforcing mechanism that predisposes for the development and perpetuation of allergic asthma (244) (245) (246) . consequently, it has been suggested that an abnormal programming of the airway epithelium in general paired with an impaired capability to produce anti-inflammatory mediators such as il-37 or α melanocyte stimulating hormone (α-msh) may be the origin of chronic inflammatory airway diseases (247, 248) . viral infections of the airways is of critical importance for the pathogenesis of allergic bronchial asthma: on the one hand recurrent respiratory viral infections during early childhood represent one of the strongest factors increasing the risk for the development of asthma in later life (249) (250) (251) (252) (253) . on the other hand such infections are by far the most common cause for acute exacerbation of already established asthma leading to acute aggravation of disease symptoms and necessitating increased medication, gp visits, and can lead to hospitalization and critical care measures under certain conditions (254) . indeed, the airway epithelium is in the center of action during such an exacerbation, since it is not only the barrier that first comes into contact with viral pathogens, but its cells are also the target for their infection and the site of their replication. thus, viral infection of the airway epithelium does not only impair the barrier integrity as already mentioned before, but also triggers the release of chemokines, cytokines, alarmins, and matrikines of the epithelial layer that affect the pre-existing inflammatory response in the asthmatic airway, which largely contributes to the formation of an acute exacerbation. the viruses that have been implicated in asthma pathogenesis and especially the formation of acute exacerbation are hrv, rsv, influenza and parainfluenza viruses, human metapneumovirus, corona and adenoviruses, however, hrv infections appear to be the most common cause (255, 256) . hrv is a non-enveloped, icosahedral virus, which belongs to the family of picornaviridae (genus enterovirus) and is subdivided into three clades (a, b, and c). the single-stranded positive rna genome of hrv is constituted of ca. 7200 nucleotides (257, 258) . clades a and b, which comprise the 100 most common serotypes, are further subdivided into a major and minor group. the major group utilizes the intracellular adhesion molecule-1 (icam-1) to bind to and transfect the host cell (259) (260) (261) . the minor group hrv bind to the low density lipoprotein (ldl) receptor (262) (263) (264) (265) and are considered to be more infectious. clade c consists of 50 serotypes (266) , which all bind to the cadherin-related family member 3 (cdhr3). all species of hrv have been shown to infect and replicate in airway epithelial cells (267) . viral engagement with the specific receptor leads to transfection of the host cell (e.g., bronchial epithelial cells) and subsequently to a multitude of cellular responses. it is this cellular response that is believed to facilitate acute asthma exacerbation. the cellular response to the virus is initiated by the detection of single-stranded rna via tlrs -3, -7, and -8, mad5, and rig-i (221, 268) . activation of these receptors ultimately leads to the secretion of cytokines such as il-1, il-6, il-8, il-11, chemokines like cxcl10, ccl11 (eotaxin), ccl5 and anti-viral interferons of type i and iii (268) (269) (270) (271) (272) (273) (274) . the interferons have not only innate but also adaptive immune-system functionality to keep the viral infection locally at bay by mobilizing the adaptive immune response for effective viral clearance (275) . furthermore, proinflammatory cytokines like il-1β and il-6 are not specific for special types of immune response and thus, not only support the immune response against the invading virus but also promote the allergic immune response already established in the airways. consequently, augmentation of the allergic immune response results in acute amplification of tissue damage, mucus production, and mediator release, and therefore in acute symptom aggravation. especially, the interferon response is thought to be an early post-infection event. in asthmatics epithelial interferon responses are believed to be hampered and as a consequence antiviral responses lack sufficient clearance (275) . not only interferons seem to be differently expressed in epithelial cells from asthmatics but also tslp, which promotes th2 responses (276) . another critical cytokine elevated in humans after hrv infections is il-33, which also augments th2 cell development (277) . it is of note that viral infections not only initiate an immune response but also drive remodeling of the epithelial barrier and the subepithelial extracellular matrix (ecm). hence, hrv16 induces perlecan, collagen v, tenascin c and matrix-associated (ma-) vegf expression in an either tlr-3 or tlr-3/-7 associated manner in vitro (278, 279) . elevated expression of ma-vegf and tenascin c was replicated in a mouse model of hrv infection, in which also collagen i and fibronectin was found to be increased (278, 279) . in addition, our group found human nasal epithelial cells infected with rv-16 in vitro to significantly downregulated genes associated with ecm receptor interaction and focal adhesion (280) . after infection and viral replication, the release of a vast array of mediators is among the earliest responses. in tissue culture a pneumocyte cell line expresses large amounts of il-8 and ccl20 readily after 6 h post-infection (281) . also, the interferon response is thought to be an early post-infection event. in asthmatics epithelial interferon responses have been suggested to be hampered and as a consequence antiviral responses lack sufficient clearance (275) . but not only interferons seem to be differently expressed in epithelial cells from asthmatics but also tslp, which promotes th2 responses (276) . another critical cytokine elevated in humans after hrv infections is il-33. in line with that, jackson et al. impressively showed, that the release of il-33 by bronchial epithelial cells induces il-4, il-5, il-13, and gata3 expression in th0 cells. an effect, which could be entirely blocked by an antibody against the il-33 receptor (277) . recently, active fragments from epithelial deposited ecm molecules have gained some recognition in asthma and asthma exacerbation. matrikines are a class of molecules derived from ecm proteins (e.g., via proteolysis) with different properties from the parent molecule (282) (283) (284) . in 2010, burgess et al. reported diminished levels of the collagen iv isoform alpha 3 (col4a3) in airways from asthmatic subjects. the non-collagenous domain of col4a3 is referred to as tumstatin and a biologically active matrikine. treatment of mice with experimental allergic asthma with human recombinant tumstatin let to a significant reduction of hallmark disease features (e.g., airway hyperresponsiveness, ma-vegf, eosinophil influx, il13) (285) . in another study, van der velden et al. identified an anti-angiogenic effect of tumstatin in a sheep model of asthma (286) . further investigations revealed a novel active region in tumstatin (cp17), which significantly reduced neutrophil influx, mucus production in a mouse model of viral asthma exacerbation and reduced migrational speed and production of reactive oxygen species of neutrophils in vitro (287, 288) . while the matrikine tumstatin conveys protection from experimental features of asthma and asthma exacerbation, a collagen i derived matrikine (pgp, acetylated-(ac) pgp) has been shown to be a more potent inducer of neutrophil chemotaxis then il-8 and is found to be increased in severe asthmatics, a group of patients prone to develop exacerbations (283, 289) . albeit ecm derived matrikines follow a different kinetical pathway (deposited first, released during inflammation) as compared to cytokines and chemokines (de novo production after viral infection), they can serve as protective or aggravating factors in asthma exacerbations. in addition, the notion of epigenetic modification due to hrv infection in epithelial cells in asthma has gained attraction. mcerlean et al. infected nasal epithelial cells from asthmatics and found evidence of reproducible changes to the methylome (290) . we confirmed these results, which may unriddle how asthmatic airway epithelial cells may be able to respond differently to the same stimuli as compared to healthy epithelial cells (280) . first studies to investigate this effect in vivo are underway (291, 292) . infection associated stimuli appear not to be the only factors that imprint mucosal immune reactions of the airway epithelium. in addition, the interaction between epithelial cells and leukocytes can lead to sustained alteration of respiratory epithelial cell biology. even though these cells are definitely not able to constitute an immunological memory, it becomes more and more obvious that especially epithelial cells somehow memorize their exposure to certain environmental factors and the following insults and thereby develop some kind of trained immunity. we are just at the beginning to understand these processes and questions of which parts of the epithelium are trained and of how long the training effects sustain in the mucosa remain to be answered. thus, respiratory epithelial cells are constantly exposed to many types of challenges, including pathogens, allergens and environmental pollutants. consequently, they are able to respond quickly and effectively to cellular damage such as the local cytokine production, lateral transport by ion exchanges, wide arrays of mucus compositions, secretion of antimicrobial peptides, and epithelial shedding. to date, it appears possible that different inflammatory environments as originated by for example typical th1-or th2-directed immune responses have a different impact on the biology of the respiratory epithelium and lead to some kind of e1-or e2-polarization of the respective epithelial cells (293) (figure 4) . there is in vivo evidence for the inhibitory role of ifnγ on asthma pathogenesis at the epithelial level indicating that type-1 responses counteract allergy (294, 295) . the direct implication of airway epithelial cells was demonstrated by selective transgenic expression of the ifn-γ receptor on the airway epithelium and showed that ifn-γ inhibits mucus secretion, release of chitinases and eosinophilia independent of the activation of th2 cells (296) . in turn, gata-3 inhibition causes an increase of t-bet und ifn-γ expression levels, leading to a dampened allergic phenotype (297) . in addition, an increase in dna-methylation of ifn-γ was observed during allergic sensitization (298) , while perinatal prevention of allergy mediated by acinetobacter does not show the anticipated drop in h4 acetylation in the ifn-γ promoter (299) . the immunological consequence of epithelial differentiation becomes increasingly interesting, as sensitization, but also recovery processes and airway remodeling could open new options for intervention and prevention of lung damage. increasing evidence of mechanisms involving epithelial cytokine production such as ccl-26, and the epithelium-derived alarmins tslp and il-33 are substantiating the current focus on the cross talk between airway epithelium and immune cells in allergy research. the role of tissue cells in the early phase of disease is largely unknown, but could provide important information about the pathologic development and could help to identify the causal relationships. however, bronchial epithelial cells are pre-committed to a type-2 (e2) or type-1 (e1) like phenotype. e2 epithelial cell activation by allergens takes place and their pro-inflammatory cytokines and chemokines induce inflammation and contribute to an epithelial type-2 response, so called "e2 response" with epithelial alarmins tslp, il-31, ccl-26, il-25, and il-33. local type-2 responses involve multiple cytokines such as il-4, il-5, il-9, il-13, il-25, il-33, and increase of eosinophils. a series of chemokines are produced and migration of inflammatory cells to the allergic tissues takes place. the activation of e.g., smooth muscle cells by adam33 lead to remodeling. bronchial hyperreactivity takes place leading to an enhanced susceptibility to bronchoconstriction. e1 epithelial cells respond to an infection releasing cxcl2, cxcl8, il12 and ccl20, thus stimulating the local synthesis of ifn-γ, il-2, il-12, il-18, il-36, and tnf-α that present a wide range of antiviral activities, inducing up-regulation of mhc-i molecules and antiviral resistance in uninfected cells. neutrophils respond to the infection signals il-12 and ifn-γ by releasing pro-inflammatory cytokines, leading to the containment of the infection, rise of body temperature and to the recruitment of further phagocytic cells. however, it is unknown whether epithelial cells are influenced by il-4 prior or with entry into terminal differentiation. this early influence could imprint the offspring cells that populate the epithelial surface and therefore have major consequences for the physiology of the airways. il-4 was shown to have a major effect on the epithelium, as mice overexpressing this cytokine under the club cell-secretory protein 10 (cc10) promoter show increased cellular infiltration, epithelial hypertrophy, mucus cell hyperplasia, secretion of gastric mucins and surfactant proteins (sp) a and b (300) . while this model effectively demonstrated all hallmarks of experimental allergic asthma, it did not demonstrate whether il-4 itself is inducing differentiation of basal cells or whether secondary effects trigger epithelial differentiation. however, the differentiation effects could also be observed in human primary epithelial cells of the nose, where il-13 modulates the differentiation toward less ciliated and more secretory cells (114) . to date, it is controversially discussed, whether il-4 and il-13 can also affect fully differentiated epithelial cells in air liquid-interphase cultures or whether this is only possible in immature submerged cultures (301, 302) . however, during the epithelial differentiation process induced by air-liquid exposure, the addition of il-4 enhances expression of certain antimicrobial peptides (303) and eicosanoids (304) . furthermore, it was demonstrated that il-4 and il-13, through inhibition of tlr3 expression and signaling (irf3), impair immune responses to hrv infection (305) . this is in line with the finding that chronic house dust mite exposure in the airways not only causes a strong th2-directed inflammation but also diminishes anti-rhinovirus responses and local ifn expression, particularly of epithelial ifn-λ (306) . in line with this, transgenic il-4 expression in the lungs reduces cytotoxic t cell responses against influenza viruses (307) . on the level of secreted factors, it was shown that cytokines such as wnt5a (wingless-type mmtv integration site family, member 5a) or il-24 are expressed as response to il-4 stimulation only, while proteins with known pathological roles such as the il-4 induced protein ccl-26 or periostin were shown to be upregulated by il-4 and down-regulated in ifn-γ environment. these results were consistent when comparing upper and lower airway secretions, thus confirming nasal lining fluids as a proxy for the lower respiratory tract, particularly for epithelial type-2 biomarker like ccl-26 and il24 (308, 309) . the e2-related transcription factor network contained the e2 hub-transcription factors gata3, nfe2, meis1, hey2, and ahr: gata3 is well known as the master transcription factor of type-2 response in immune cells, however it was also shown to be expressed in airway epithelial cells. nfe2 was demonstrated to have a cytoprotective activity against epithelial cell injury by cigarette smoke, which could hint on a protective role in an il-4 dominated micromilieu (310) . for meis1, it has been demonstrated that its inactivation produces an increase in airway smooth muscle mass and a corresponding decrease in cartilage and suggesting an important role in allergic airway diseases. a loss of hox gene function, however, does not preclude airway repair, but regenerated epithelium displays goblet cell metaplasia and less scgb1a1-positive cells, demonstrating the essential role of hoxa5 for correct differentiation. this goblet cell metaplasia is further associated with increased notch signaling activity. consistent with these findings, expression levels of activated notch1 and the effector gene hey2 are in turn enhanced in patients with allergic disease (293, 311, 312) . taken together, e2polarization has a marked impact on the barrier and especially immune functions of the airway epithelium and at least supports impairment of the mcc and antiviral responses, both factors that are critical in asthma pathogenesis. in summary, the airway epithelium exerts a broad variety of immune functions that range from passive barrier over mcc, active production and transport of pathogen-neutralizing molecules to pathogen recognition and targeting as well as cytokine and chemokine release. the airway epithelium is usually the first tissue that is exposed to inhaled allergens, pathogens or pollutants. since it is able to react on this contact by inducing local inflammatory reactions, it is clearly a central part of the local immune response and bridges innate and adaptive immune functions against all types of harmful intruders entering the respiratory system. therefore, the airway epithelium is a key factor in asthma pathogenesis and plays a critical role in the development as well as in the progression and exacerbation of the disease: hence, a disturbed cellular barrier enables allergens to enter the body and to induce a sensitization reaction, which is widely regarded as the starting point of an asthma career. down the line, the protective mucus and pcl layers provided by the epithelium as physical barriers are compromised and the release of pathogen deterring molecules such as secretory iimmunoglobulins becomes impaired. as a consequence, this frontline toward invading pathogens can be breached and airway epithelial cells are infected and even destroyed by respiratory pathogens. a vicious cycle is started where barrier disturbance and infection promote each other. the latter, in particular with certain viruses, is also one of the strongest factors predisposing toward asthma development in early childhood. once asthma has been established, the airway epithelium responds to further viral infection with the release of manifold factors promoting not only the antiviral response but also augmenting the 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dysfunction and ultrastructural abnormalities are features of severe asthma ex vivo sputum analysis reveals impairment of protease-dependent mucus degradation by plasma proteins in acute asthma oxidation increases mucin polymer cross-links to stiffen airway mucus gels mucus plugs in patients with asthma linked to eosinophilia and airflow obstruction epithelial tethering of muc5ac-rich mucus impairs mucociliary transport in asthma muc5ac and a glycosylated variant of muc5b alter mucin composition in children with acute asthma abnormalities in muc5ac and muc5b protein in airway mucus in asthma muc5b is required for airway defence heterogeneity of airways mucus: variations in the amounts and glycoforms of the major oligomeric mucins muc5ac and muc5b helper type 2-driven inflammation defines major subphenotypes of asthma muc5ac: a critical component mediating the rejection of enteric nematodes overexpressing mouse model demonstrates the protective role of muc5ac in the lungs the cell biology of asthma the failure of stat6-deficient mice to develop airway eosinophilia and airway hyperresponsiveness is overcome by interleukin-5 stat6-mediated signaling in th2-dependent allergic asthma: critical role for the development of eosinophilia, airway hyper-responsiveness and mucus hypersecretion, distinct from its role in th2 differentiation il-13 alters mucociliary differentiation and ciliary beating of human respiratory epithelial cells direct effects of interleukin-13 on epithelial cells cause airway hyperreactivity and mucus overproduction in asthma interleukin-13 mediates a fundamental pathway for airway epithelial mucus induced by cd4 t cells and interleukin-9 dissecting asthma using focused transgenic modeling and functional genomics expression of epidermal growth factor and epidermal growth factor receptor immunoreactivity in the asthmatic human airway epidermal growth factor system regulates mucin production in airways van seuningen i. induction of muc2 and muc5ac mucins by factors of the epidermal growth factor (egf) family is mediated by egf receptor/ras/raf/extracellular signalregulated kinase cascade and sp1 13 and epidermal growth factor receptor have critical but distinct roles in epithelial cell mucin production mild and moderate asthma is associated with airway goblet cell hyperplasia and abnormalities in mucin gene expression cellular and molecular mechanisms of goblet cell metaplasia in the respiratory airways novel role for murine il-4 in vivo: induction of muc5ac gene expression and mucin hypersecretion requirement for il-13 independently of il-4 in experimental asthma expression of interleukin 9 in the lungs of transgenic mice causes airway inflammation, mast cell hyperplasia, and bronchial hyperresponsiveness nadel jail-. 4 induces mucin gene expression and goblet cell metaplasia in vitro and in vivo increased sputum and bronchial biopsy il-13 expression in severe asthma elevated expression of messenger ribonucleic acid encoding il-13 in the bronchial mucosa of atopic and nonatopic subjects with asthma allergen-induced cytokine production in atopic disease and its relationship to disease severity il-9 and its receptor in allergic and nonallergic lung disease: increased expression in asthma notch2 is required for inflammatory cytokine-driven goblet cell metaplasia in the lung spdef is required for mouse pulmonary goblet cell differentiation and regulates a network of genes associated with mucus production spdef regulates goblet cell hyperplasia in the airway epithelium airway epithelial spdef integrates goblet cell differentiation and pulmonary th2 inflammation foxa2 regulates alveolarization and goblet cell hyperplasia distal airways are protected from goblet cell metaplasia by diminished expression of il-13 signalling components cftr and lysozyme secretion in human airway epithelial cells lysozyme secretion by submucosal glands protects the airway from bacterial infection antimicrobial peptides in lung inflammation defensins in lung host defense the serous cell alveolar type i cells protect rat lung epithelium from oxidative injury protein transport across the lung epithelial barrier transepithelial transport of immunoglobulins the j chain is essential for polymeric ig receptor-mediated epithelial transport of iga the role of the polymeric immunoglobulin receptor and secretory immunoglobulins during mucosal infection and immunity immunoglobulin m and secretory immunoglobulin a: presence of a common polypeptide chain different from light chains role of j chain in secretory immunoglobulin formation mucosal b cells: phenotypic characteristics, transcriptional regulation, and homing properties putting j chain back on the map: how might its expression define plasma cell development? siga binding to mucosal surfaces is mediated by mucin-mucin interactions secretory component: a new role in secretory iga-mediated immune exclusion in vivo intranasal monoclonal iga antibody to respiratory syncytial virus protects rhesus monkeys against upper and lower respiratory tract infection urease-specific monoclonal antibodies prevent helicobacter felis infection in mice intranasal monoclonal immunoglobulin a against respiratory syncytial virus protects against upper and lower respiratory tract infections in mice immunoglobulin a monoclonal antibodies protect against sendai virus new model for analysis of mucosal immunity: intestinal secretion of specific monoclonal immunoglobulin a from hybridoma tumors protects against vibrio cholerae infection monoclonal secretory immunoglobulin a protects mice against oral challenge with the invasive pathogen salmonella typhimurium analysis of the roles of antilipopolysaccharide and anti-cholera toxin immunoglobulin a (iga) antibodies in protection against vibrio cholerae and cholera toxin by use of monoclonal iga antibodies in vivo secretory iga n-and o-glycans provide a link between the innate and adaptive immune systems il-. 8 released constitutively by primary bronchial epithelial cells in culture forms an inactive complex with secretory component iga receptors in health and disease mac-1 (cd11b/cd18) as accessory molecule for fc alpha r (cd89) binding of iga secretory iga induces antigenindependent eosinophil survival and cytokine production without inducing effector functions ragweed-specific antibodies in bronchoalveolar lavage fluids and serum before and after segmental lung challenge: ige and iga associated with eosinophil degranulation iga-induced eosinophil degranulation eosinophils promote generation and maintenance of immunoglobulin-a-expressing plasma cells and contribute to gut immune homeostasis il-1β in eosinophil-mediated small intestinal homeostasis and iga production secretory iga accumulated in the airspaces of idiopathic pulmonary fibrosis and promoted vegf, tgf-β and il-8 production by a549 cells binding and transepithelial transport of immunoglobulins by intestinal m cells: demonstration using monoclonal iga antibodies against enteric viral proteins selective adherence of iga to murine peyer's patch m cells: evidence for a novel iga receptor antigen sampling across epithelial barriers and induction of mucosal immune responses molecular insights into the mechanisms of m-cell differentiation and transcytosis in the mucosa-associated lymphoid tissues intestinal bacteria trigger t cell-independent immunoglobulin a(2) class switching by inducing epithelial-cell secretion of the cytokine april cells containing iga subclasses in bronchi of subjects with and without chronic obstructive lung disease rat salivary gland reveals a more restricted iga repertoire than ileum eosinophilic and neutrophilic inflammation in asthma: insights from clinical studies antigen-specific ige and iga antibodies in bronchoalveolar lavage fluid are associated with stronger antigen-induced late phase reactions dissociation of allergen-specific ige and iga responses in sera and tears of pollen-allergic patients: a study performed with purified recombinant pollen allergens elevation of specific immunoglobulin a antibodies to both allergen and bacterial antigen in induced sputum from asthmatics specific iga and igg antibodies to house dust mite dermatophagoides farinae in nasal secretions ragweed-specific iga in nasal lavage fluid of ragweed-sensitive allergic rhinitis patients: increase during the pollen season airway bacteria drive a progressive copd-like phenotype in mice with polymeric immunoglobulin receptor deficiency bacterial-derived neutrophilic inflammation drives lung remodeling in a mouse model of chronic obstructive pulmonary disease bronchial secretory immunoglobulin a deficiency correlates with airway inflammation and progression of chronic obstructive pulmonary disease secretory iga deficiency in individual small airways is associated with persistent inflammation and remodeling bronchial epithelial iga secretion is impaired in asthma. role of il-4/il-13 downregulation of polymeric immunoglobulin receptor and secretory iga antibodies in eosinophilic upper airway diseases antigen-specific immunoglobulin-a prevents increased airway responsiveness and lung eosinophilia after airway challenge in sensitized mice delivery of antigen to nasal-associated lymphoid tissue microfold cells through secretory iga targeting local dendritic cells confers protective immunity transcytosis of gcsf-transferrin across rat alveolar epithelial cell monolayers dendritic cells express tight junction proteins and penetrate gut epithelial monolayers to sample bacteria accelerated antigen sampling and transport by airway mucosal dendritic cells following inhalation of a bacterial stimulus bronchial hyper-responsiveness in selective iga deficiency correlation between serum immunoglobulin a concentrations and allergic manifestations in infants sublingual immunotherapy alters salivary iga and systemic immune mediators in timothy allergic children production of salivary immunoglobulin a and suppression of dermatophagoides pteronyssinus-induced airway inflammation by local nasal immunotherapy chronic inflammatory airway diseases: the central role of the epithelium revisited innate immunity in the lung: how epithelial cells fight against respiratory pathogens innate immunity in the respiratory epithelium airway epithelial regulation of pulmonary immune homeostasis and inflammation the airway epithelium in asthma damps activating innate and adaptive immune responses in copd s100a8, s100a9 and s100a12 activate airway epithelial cells to produce muc5ac via extracellular signal-regulated kinase and nuclear factor-κb pathways dangerassociated molecular patterns and danger signals in idiopathic pulmonary fibrosis toll-like receptors and their crosstalk with other innate receptors in infection and immunity type i interferon response to extracellular bacteria in the airway epithelium the danger within: endogenous danger signals, atopy and asthma innate and adaptive immune responses in asthma house dust mite allergen induces asthma via toll-like receptor 4 triggering of airway structural cells transcription of interleukin-25 and extracellular release of the protein is regulated by allergen proteases in airway epithelial cells tlr4 signaling in stromal cells is critical for the initiation of allergic th2 responses to inhaled antigen interleukin-1α controls allergic sensitization to inhaled house dust mite via the epithelial release of gm-csf and il-33 proteases induce production of thymic stromal lymphopoietin by airway epithelial cells through proteaseactivated receptor-2 allergens and the airway epithelium response: gateway to allergic sensitization commensal bacteria-derived signals regulate basophil hematopoiesis and allergic inflammation innate lymphoid cells: critical regulators of allergic inflammation and tissue repair in the lung klebsiella pneumoniae increases the levels of toll-like receptors 2 and 4 in human airway epithelial cells various human epithelial cells express functional toll-like receptors, nod1 and nod2 to produce antimicrobial peptides, but not proinflammatory cytokines role of double-stranded rna pattern recognition receptors in rhinovirus-induced airway epithelial cell responses dynamic cross talk model of the epithelial innate immune response to double-stranded rna stimulation: coordinated dynamics emerging from cell-level noise respiratory syncytial virus induces tlr3 protein and protein kinase r, leading to increased double-stranded rna responsiveness in airway epithelial cells cutting edge: influenza a virus activates tlr3-dependent inflammatory and rig-i-dependent antiviral responses in human lung epithelial cells airway epithelial versus immune cell stat1 function for innate defense against respiratory viral infection activation of toll-like receptor 2 on human tracheobronchial epithelial cells induces the antimicrobial peptide human beta defensin-2 rage and tlrs: relatives, friends or neighbours? bronchial epithelial cells: the key effector cells in the pathogenesis of chronic obstructive pulmonary disease? preferential recruitment of ccr6-expressing th17 cells to inflamed joints via ccl20 in rheumatoid arthritis and its animal model the nucleotide-binding domain, leucine-rich repeat protein 3 inflammasome/il-1 receptor i axis mediates innate, but not adaptive, immune responses after exposure to particulate matter under 10 µm critical role of constitutive type i interferon response in bronchial epithelial cell to influenza infection chronic il9 and il-13 exposure leads to an altered differentiation of ciliated cells in a well-differentiated paediatric bronchial epithelial cell model cytokines induce tight junction disassembly in airway cells via an egfr-dependent mapk/erk1/2-pathway sensing the outside world: tslp regulates barrier immunity blockade of ccr4 in a humanized model of asthma reveals a critical role for dc-derived ccl17 and ccl22 in attracting th2 cells and inducing airway inflammation tlr3-and th2 cytokinedependent production of thymic stromal lymphopoietin in human airway epithelial cells bronchial epithelium as a target for innovative treatments in asthma effect of interleukin-5 and granulocyte-macrophage colony stimulating factor on in vitro eosinophil function: comparison with airway eosinophils group 2 innate lymphoid cells facilitate sensitization to local, but not systemic. th2-inducing allergen exposures lung natural helper cells are a critical source of th2 cell-type cytokines in protease allergen-induced airway inflammation the lung tissue microbiome in chronic obstructive pulmonary disease microbes and mucosal immune responses in asthma epithelial barrier function: at the front line of asthma immunology and allergic airway inflammation role of viral respiratory infections in asthma and asthma exacerbations gabriela transregio 22 study group. exposure to environmental microorganisms and childhood asthma 37 requires il-18rα and sigirr/il-1r8 to diminish allergic airway inflammation in mice the alpha-melanocyte-stimulating hormone acts as a local immune homeostasis factor in experimental allergic asthma respiratory syncytial virus in early life and risk of wheeze and allergy by age 13 years respiratory syncytial virus bronchiolitis in infancy is an important risk factor for asthma and allergy at age 7 rhinovirus illnesses during infancy predict subsequent childhood wheezing early-life respiratory viral infections, atopic sensitization, and risk of subsequent development of persistent asthma wheezing rhinovirus illnesses in early life predict asthma development in high-risk children costs of asthma in the united states: 2002-2007 asthma exacerbations: origin, effect, and prevention the role of rhinovirus in asthma exacerbations sequencing and analyses of all known human rhinovirus genomes reveal structure and evolution cdna cloning reveals that the major group rhinovirus receptor on hela cells is intercellular adhesion molecule 1 the major human rhinovirus receptor is icam-1 evidence for the direct involvement of the rhinovirus canyon in receptor binding type 2 rhinovirus infection of cultured human tracheal epithelial cells: role of ldl receptor similar frequency of rhinovirus-infectible cells in upper and lower airway epithelium structure of a human rhinovirus complexed with its receptor molecule the minor receptor group of human rhinovirus (hrv) includes hrv23 and hrv25, but the presence of a lysine in the vp1 hi loop is not sufficient for receptor binding cadherin-related family member 3, a childhood asthma susceptibility gene product, mediates rhinovirus c binding and replication rhinoviruses infect the lower airways co-ordinated role of tlr3, rig-i and mda5 in the innate response to rhinovirus in bronchial epithelium rhinovirus replication causes rantes production in primary bronchial epithelial cells interleukin-11: stimulation in vivo and in vitro by respiratory viruses and induction of airways hyperresponsiveness rhinovirus infection of primary cultures of human tracheal epithelium: role of icam-1 and il-1beta role of p38 mitogen-activated protein kinase in rhinovirus-induced cytokine production by bronchial epithelial cells human rhinovirus recognition in non-immune cells is mediated by toll-like receptors and mda-5, which trigger a synergetic pro-inflammatory immune response poly(inosinic-cytidylic) acid-triggered exacerbation of experimental asthma depends on il-17a produced by nk cells airway epithelial orchestration of innate immune function in response to virus infection. a focus on asthma double-stranded rna induces disproportionate expression of thymic stromal lymphopoietin versus interferon-beta in bronchial epithelial cells from donors with asthma il-33-dependent type 2 inflammation during rhinovirusinduced asthma exacerbations in vivo rhinovirus infection induces extracellular matrix protein deposition in asthmatic and nonasthmatic airway smooth muscle cells airway epithelial cells generate pro-inflammatory tenascin-c and small extracellular vesicles in response to tlr3 stimuli and rhinovirus infection rhinovirus infections change dna methylation and mrna expression in children with asthma gene expression patterns induced at different stages of rhinovirus infection in human alveolar epithelial cells matrikines and the lungs an extracellular matrix fragment drives epithelial remodeling and airway hyperresponsiveness bioactive extracellular matrix fragments in lung health and disease reduction of tumstatin in asthmatic airways contributes to angiogenesis, inflammation, and hyperresponsiveness the effects of tumstatin on vascularity, airway inflammation and lung function in an experimental sheep model of chronic asthma lamstatin-a novel inhibitor of lymphangiogenesis derived from collagen iv tumstatin fragment selectively inhibits neutrophil infiltration in experimental asthma exacerbation novel proteolytic cascade generates an extracellular matrix-derived chemoattractant in chronic neutrophilic inflammation human rhinovirus infection causes different dna methylation changes in nasal epithelial cells from healthy and asthmatic subjects atopic asthma after rhinovirus-induced wheezing is associated with dna methylation change in the smad3 gene promoter dna methylation in nasal epithelium, atopy, and atopic asthma in children: a genome-wide study interleukin-4 and interferon-γ orchestrate an epithelial polarization in the airways helper 1 cells and interferon gamma regulate allergic airway inflammation and mucus production allergen-specific th1 cells counteract efferent th2 cell-dependent bronchial hyperresponsiveness and eosinophilic inflammation partly via ifn-gamma ifn. -γ acts on the airway epithelium to inhibit local and systemic pathology in allergic airway disease effective prevention and therapy of experimental allergic asthma using a gata-3-specific dnazyme dna methylation of th1/th2 cytokine genes affects sensitization and progress of experimental asthma epigenetic regulation in murine offspring as a novel mechanism for transmaternal asthma protection induced by microbes interleukin-4 alters epithelial cell differentiation and surfactant homeostasis in the postnatal mouse lung epithelial differentiation is a determinant in the production of eotaxin-2 and -3 by bronchial epithelial cells in response to il-4 and il-13 differentiationdependent responsiveness of bronchial epithelial cells to il-4/13 stimulation il-4 and il-13 exposure during mucociliary differentiation of bronchial epithelial cells increases antimicrobial activity and expression of antimicrobial peptides eicosanoid biosynthesis during mucociliary and mucous metaplastic differentiation of bronchial epithelial cells th2 cytokines impair innate immune responses to rhinovirus in respiratory epithelial cells no exacerbation but impaired anti-viral mechanisms in a rhinovirus-chronic allergic asthma mouse model local il-4 expression in the lung reduces pulmonary influenza-virus-specific secondary cytotoxic t cell responses biomatrix for upper and lower airway biomarkers in patients with allergic asthma early il-10 producing b-cells and coinciding th/tr17 shifts during three year grass-pollen ait the cytoprotective role of dj-1 and p45 nfe2 against human primary alveolar type ii cell injury and emphysema the loss of hoxa5 function promotes notch-dependent goblet cell metaplasia in lung airways current and future biomarkers in allergic asthma all authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. this work was supported by the german center for lung reearch (dzl). key: cord-283870-b9hvcrd1 authors: castillo, jamee r.; peters, stephen p.; busse, william w. title: asthma exacerbations: pathogenesis, prevention, and treatment date: 2017-08-31 journal: the journal of allergy and clinical immunology: in practice doi: 10.1016/j.jaip.2017.05.001 sha: doc_id: 283870 cord_uid: b9hvcrd1 guideline-based management of asthma focuses on disease severity and choosing the appropriate medical therapy to control symptoms and reduce the risk of exacerbations. however, irrespective of asthma severity and often despite optimal medical therapy, patients may experience acute exacerbations of symptoms and a loss of disease control. asthma exacerbations are most commonly triggered by viral respiratory infections, particularly with human rhinovirus. given the importance of these events to asthma morbidity and health care costs, we will review common inciting factors for asthma exacerbations and approaches to prevent and treat these events. despite optimal guideline-directed treatment, and irrespective of underlying disease severity, patients with asthma experience exacerbations, which are caused by an accentuation of existing inflammatory processes and a loss of disease control. asthma exacerbations are a major cause of disease morbidity, increases in health care costs, and, in some patients, a greater progressive loss of lung function. 1 the frequency of exacerbations can be reduced, but not always fully prevented, with adequate inhaled corticosteroid (ics) treatment or combination ics/long-acting b-agonists (laba). 2 because asthma exacerbations can break through standard treatment regimens, identifying at-risk patients and having a plan of management can improve disease control and patient well-being. asthma exacerbations remain a major reason for health care utilization and a significant financial burden to patients and society. patients with asthma exacerbations have significantly higher total health care costs, $9223 versus $5011 (2007 dollars) per person per year, and asthma-specific costs, $1740 versus $847 per person per year, compared with matched patients without exacerbations. 3 in 2007, total expenditures for asthma were estimated to be $56 billion per year with productivity losses due to morbidity and mortality of $3.8 and $2.1 billion, respectively. 4 moreover, patients requiring an emergency department (ed) visit or hospitalization for asthma are at significantly increased risk for future exacerbations independent of demographic and clinical factors, asthma severity, and asthma control, 5 collectively reflecting an ongoing need to develop better strategies to prevent and treat these events. the most common triggers for an exacerbation are viral respiratory infections with human rhinovirus (rv), particularly subtypes a and c, 6, 7 most frequent. in school-age children, hospital admission rates for asthma exacerbations correlate with the seasonal increase of rv infections in september through december and again in the spring. 8 similar asthma hospitalization peaks are observed in adults. 9 other respiratory viruses also may cause exacerbations. during the 2009 h1n1 influenza a pandemic, mortality and admissions to the intensive care unit with h1n1 infections were frequently associated with asthma. [10] [11] [12] respiratory syncytial virus, a frequent cause of wheezing in infants and young children, may also trigger acute asthma in adults, particularly, patients older than 65 years. 13 coronaviruses, human metapneumoviruses, parainfluenza viruses, adenoviruses, and bocaviruses have all been detected in asthma exacerbations, but in low frequencies. 14 there are a number of susceptibility, or risk, factors that help to determine whether a viral respiratory infection causes an exacerbation ( figure 1 ). allergy and defective anti-viral immunity allergic sensitization is a risk factor for wheezing with rv infection, particularly in children. whether allergic inflammation often found with sensitization increases the susceptibility for viral infections or enhances their ability to provoke further inflammation is not entirely clear. 16 type i interferons are important innate antiviral responses to respiratory viruses. 14, 17 there is evidence that virus-induced interferon generation from peripheral blood mononuclear cells, [18] [19] [20] plasmacytoid dendritic cells, 21 and bronchial epithelial cells 22, 23 is reduced in some patients with allergic asthma (figure 2 ). it has been show that ige occupancy of their membrane receptors inhibits antiviral generation of ifn-a from plasmacytoid dendritic cells and may increase susceptibility to rv-induced wheezing and asthma exacerbations ( figure 3 ). deficient immune responses to viral infections may be present in type 2 inflammatory conditions with interferon production being inversely correlated with increasing airway eosinophilia, il-4 levels, and total serum ige. 23 finally, the use of inhaled ifn-b at the time of an upper respiratory infection reduces the airway viral load and improves clinical symptoms in patients with asthma. 24 bacterial infections may impair mucociliary clearance and increase mucus production in the lung and may cause chronic lower airway inflammation. evidence linking bacterial infections to acute asthma exacerbations has been limited. 25, 26 however, respiratory viruses may impair the antibacterial defenses by human alveolar macrophages and thereby facilitate emergence of bacterial infections or change in the microbiome. 27 how these interrelationships contribute to exacerbations is not established, but they may be of potential therapeutic importance 28 to prevent acute asthma. environmental allergens can provoke asthma. 29 furthermore, more than 80% of children with asthma are sensitized to environmental allergens, with indoor allergens being especially important to underlying asthma. 30, 31 mast cell activation by allergens releases 32,33 histamine, prostaglandin d2, and cysteinyl leukotriene generation to cause airway smooth muscle constriction, increased microvascular permeability, mucus secretion, and enhanced inflammation. allergic sensitization is also associated with diminished innate immune responses and may be a susceptibility factor to viral-induced wheezing. this allergen associated inflammation also increases airway responsiveness to rv 34 to further enhance a loss of asthma control. mold sensitization and their seasonal increase parallel greater asthma severity and seasonal exacerbations. patients sensitized to alternaria alternata were approximately 5 times more likely to have asthma 35 and increased airway responsiveness, wheeze, and bronchodilator use. 36 emergency visits for asthma exacerbations correlate with high airborne concentrations of mold. 37 finally, alternaria sensitization was found to be associated with an approximate 200-fold increase in the risk of respiratory arrest in children and adults. 28, 38 other contributing causes pollutants such as tobacco smoke, ozone, and particulate matter, along with occupational exposures, provoke asthma exacerbations. tobacco smoke has also been implicated in the development of persistent wheezing 39 and greater asthma severity. 40 hospitalizations and ed visits for asthma occur more frequently among cigarette smokers. 41 particulate matter, ozone, nitrogen dioxide, sulfur dioxide, and diesel exhaust can increase airway inflammation and airway responsiveness. 32, 33, 42 airway pollutants, together with a viral infection, may act synergistically to cause asthma exacerbations. the severity of lower respiratory tract symptoms increased and peak expiratory flow measurements fell with rising exposure to nitrogen dioxide in the week before a respiratory infection. 33 four essential components of asthma management include patient education, monitoring of symptoms and lung function, control of triggering factors and comorbid conditions, and pharmacologic therapy. patient education on asthma decreases exacerbations and improves control. 43, 44 however, because asthma severity varies and differs among individuals and age groups, it is essential to regularly monitor the effectiveness of asthma control to guide necessary treatment adjustments. the expert panel report 3 and global initiative for asthma describe a stepwise treatment approach and strategy to reduce impairments and prevent future risks like asthma exacerbations. 45, 46 treatments inhaled corticosteroids ics improve disease control and reduce asthma exacerbations. [47] [48] [49] in new onset, untreated persistent, asthma, low-dose inhaled budesonide reduces asthma exacerbations by almost 50%. 50 ics but under poor control, 50 pauwels et al showed that highdose budesonide further reduced severe asthma exacerbations, that is, need for systemic corticosteroids, by nearly 50% compared with treatment with low-dose ics in adults. 50 however, as found by o'byrne et al, 51 a doubling of the budesonide dose in patients poorly controlled on low-dose ics also reduced exacerbation rates by 30%, but the degree of protection was less than those patients who recently started ics. these findings indicate that dose-response benefits with ics are relatively flat. 52 overall, compared with placebo or a short-acting b 2 -agonist, ics reduce clinically relevant exacerbations by nearly 55%. 53 ics also reduce exacerbations in children 54 and are superior to a leukotriene antagonist, montelukast. 55 for patients with diminishing asthma control, quadrupling the recommended dose of ics decreases the likelihood of an asthma exacerbation. 56 this protection does not occur with a doubling of the ics maintenance. 57, 58 however, the benefit of using an increase in ics is time dependent to increased symptoms and need to be started early in the course of a cold. if higher doses of ics are used pre-emptively at the onset of a respiratory tract infection and continued for 10 days, the need for oral corticosteroids is reduced. 59 the mechanisms by which ics prevent virus-induced exacerbations, beyond anti-inflammatory activity, are poorly understood. ics can reduce the number of airway eosinophils that presumably reflect enhanced inflammation with a respiratory infection. 60, 61 as approximately 50% of asthma exacerbations are associated with an increase in airway eosinophils, these cells are a reasonable target. 62 this concept is substantiated by studies showing that a reduction in airway eosinophils significantly diminishes exacerbations (figure 4) , 63, 64 but this approach does not eliminate all exacerbations, particularly for patients with more severe asthma. 65, 66 furthermore, as airway neutrophils increase early in asthma exacerbations, 67 ics treatment has no effect on these cells and alternative approaches will be needed. 68 in patients with poorly controlled asthma and a history of prior asthma exacerbations, the combination of budesonide and formoterol significantly reduces asthma exacerbations compared with ics alone. 50 ics/laba have consistently been shown to prevent exacerbations. [69] [70] [71] the benefit of ics/laba to prevent exacerbations versus ics alone is primarily seen in patients requiring higher doses of ics, thus suggesting that combination therapy to prevent exacerbations should be reserved for patients with more severe disease. asthma control can vary even in the face of ongoing ics/ laba treatment. consequently, the use of ics/laba combinations both for maintenance and symptom relief has been investigated and shown to reduce exacerbations. 72-74 these benefits are also seen in children with a prior history of severe asthma exacerbations and poorly controlled moderate-to-severe persistent asthma despite the use of moderate doses of ics. 75 the use of ics/laba as maintenance and reliever treatment should be restricted to formoterol because of its quick onset of action, 76 safety profile, 77 and dose-response effect. 78 how the addition of laba to ics reduces asthma exacerbations remains unclear as laba do not affect inflammation. ics/laba, however, attenuate allergen-induced airway eosinophilia and lung function changes to a greater extent than ics alone. 79 edwards et al 80 demonstrated that combination treatment synergistically suppressed induction of rhinovirusgenerated chemokines in bronchial epithelial cells. thus, the synergistic benefits of both ics and laba on airway eosinophilic inflammation might explain a greater reduction in exacerbations. alternatively, an early use of ics/laba for relief of symptoms might simply deliver additional ics to the airway early in the course of an emerging exacerbation. antileukotrienes reduce asthma exacerbations in children 72, 81 and adults. 82, 83 montelukast reduced asthma exacerbations to rv infections that occurred on return to school in september. 81, 84 in a systematic review and meta-analysis, compared with placebo, leukotriene modifiers/receptor antagonists lowered exacerbation rates by 41% but were inferior to ics. 53 adding montelukast to inhaled budesonide was as effective as doubling the dose of inhaled budesonide, with no difference in exacerbation rates and asthma free days. 85 the anticholinergic tiotropium reduces the frequency of asthma exacerbations and is fda-approved for long-term, maintenance treatment for patients 6 years of age and older with persistent asthma, that is uncontrolled with ics plus one or more controllers. in 2 replicate trials with a total of 912 adult patients with severe asthma and using ics/laba, adding tiotropium, 5 mcg, increased the time to first exacerbation by 56 days over placebo, and reduced exacerbations by 21% ( figure 5 ). 86 in a systematic review of 13 randomized placebocontrolled trials, 87 tiotropium decreased rates of exacerbations and improved asthma control in patients with moderate symptomatic asthma already receiving medium-to-high doses of ics or ics/laba. studies in children aged 6 to 11 years demonstrate improvements in forced expiratory volume in 1 second (fev 1 ) but not reductions in exacerbations, likely due to the short duration of the study. 88 however, given that decreases in the fev 1 /forced vital capacity ratio are associated with an increased risk of exacerbations, 89 improvements in fev 1 with tiotropium may be associated with reduced exacerbations in children. the benefit from environmental control measures to prevent exacerbations is limited. perhaps, this is because environmental interventions usually focus on a single allergen, such as dust mites, 90 or environmental tobacco smoke, 91 and with this limited approach, no effect was seen on asthma morbidity. however, an inner-city asthma study evaluated the effectiveness of a multifaceted, home-based, environmental intervention that used remediation of exposure to dust mites, passive smoking, cockroaches, pets, rodents, and mold 92 and was tailored to each child's skin-test sensitization profile and environmental exposures. the intervention group reported significantly fewer symptoms of asthma during both the intervention year and, interestingly, the follow-up year as well ( figure 6) , with significantly fewer unscheduled asthma-related visits to the ed or clinic for the intervention group (p ¼ .04). the correlation between the reduction in levels of cockroach allergen on the bedroom floor and asthma-related morbidity was particularly strong during the active intervention. although it is difficult to generalize these results to all children with asthma, a reduction in continuous exposure to environmental allergens and irritants, like those present in the homes of inner-city patients with there was a 21% risk reduction in asthma exacerbations (hazard ratio, 0.79; p ¼ .03 in pooled analysis) for the tiotropium group. reproduced with permission from kerstjens et al. 86 j allergy clin immunol pract volume 5, number 4 asthma, may indicate the need for a more comprehensive intervention. omalizumab is approved for use in patients 6 years of age and older with allergies and uncontrolled, persistent asthma despite moderate-to-high dose ics. omalizumab is a humanized monoclonal antibody directed against ige and reduces the risk for asthma exacerbations in allergic asthmatic patients. [93] [94] [95] [96] [97] omalizumab reduces asthma exacerbations when given with ics 97 and shortens the duration of exacerbations 98 in adults and children. [99] [100] [101] some patients with asthma and allergy have a diminished interferon response to an in vitro challenge with respiratory viruses, and this reduction is related to ige. in a study of inner-city children, 99 omalizumab reduced seasonal exacerbations in the fall and spring, without altering the rates of infections with respiratory viruses, suggesting that omalizumab may not prevent viral infections, but rather modify the consequences of the infection. teach et al 20 showed that omalizumab improved antiviral defenses by increasing release of ifn-a from peripheral blood mononuclear cells to rv stimulation; in those subjects with a greater restoration of ifn responses, fewer exacerbations occurred (figure 7) . thus, in addition to anti-inflammatory effects of omalizumab, a restoration of antiviral activity may prevent exacerbations. selecting patients most likely to benefit from omalizumab has been difficult. in a post hoc analysis, patients with elevated levels of fractional exhaled nitric oxide, blood eosinophils, and serum periostin, likely reflecting greater t2 inflammation, had a greater likelihood of benefitting from omalizumab. 102, 103 anti-il-5 two anti-il-5 monoclonal antibodies, mepolizumab and reslizumab, are approved as maintenance therapy for patients with uncontrolled, persistent eosinophilic asthma with an exacerbation phenotype despite high-dose ics. il-5 contributes to airway eosinophilic inflammation. approximately 40% to 50% of patients with difficult-to-control asthma have persistent airway eosinophilia despite treatment with high-dose ics. although elevated sputum eosinophil counts predict the risk for asthma exacerbations, the use of sputum for routine measurements is impractical in clinical practice. price et al 104 found a relationship between the intensity of peripheral blood eosinophilia and asthma-related outcomes; patients with asthma with blood eosinophil counts greater than 400 cells/ml experience more frequent severe exacerbations, and serves as a convenient biomarker for anti-il-5 therapy. mepolizumab, given subcutaneously, reduces exacerbations by approximately 50% in patients with severe asthma who have blood eosinophil counts 150 cells/ml or greater ( figure 8) . 65, 66, 105, 106 it has been fda-approved for add-on maintenance treatment of severe asthma in patients 12 years of age or older. although clinical trial data suggest that efficacy requires an absolute eosinophil count of at least 150 cells/ml, 107 the national institute for health and care excellence recommends a threshold of 300 cells/ml. reslizumab is also fdaapproved for add-on maintenance therapy of severe asthma in patients 18 years or older who have an eosinophil count of 400 cells/ml or higher. in clinical trials, intravenous reslizumab reduced asthma exacerbations by approximately 50%. 108, 109 rv infections lead to the generation of il-5 and an increase in airway eosinophils, which correlate with exacerbation probability. 110 these relationships provide a probable explanation for why anti-il-5 mab treatment reduces asthma exacerbations. other biologics to prevent asthma exacerbations are under study. despite optimal maintenance therapy and asthma control, exacerbations occur. therefore, early recognition and intervention are important to successfully stabilize asthma. a limited number of treatments are currently available to alleviate asthma exacerbations, and the evidence supporting their use has limits. inhaled or nebulized short-acting b 2 -agonists (sabas), such as albuterol or levalbuterol, resolve acute symptoms of asthma and can initially be used every 15 to 20 minutes for the first hour during acute asthma. 107 levalbuterol, the r-enantiomer of albuterol, and albuterol are equivalent. [111] [112] [113] data are conflicting whether continuous nebulization with a saba is superior to intermittent nebulization. 114, 115 in very severe asthma exacerbations, continuous nebulization should be considered based on evidence of reduced admissions and improved pulmonary function. 114, [116] [117] [118] sabas provide symptomatic relief but have no effect on airway inflammation or sustained benefit. adding ipratropium bromide to an inhaled saba in severe exacerbations decreases rates of hospitalizations and shortens ed stays for patients with severe or moderate-to-severe asthma exacerbations. [119] [120] [121] the benefit of ipratropium bromide to saba therapy is seen primarily in more severe asthma exacerbations. 120, 122 corticosteroids an underlying component of exacerbations is an increase in airway inflammation. 103 numerous studies evaluated ics and oral corticosteroids (ocs) in asthma exacerbations, but the evidence for their efficacy remains limited. moreover, because ics often do not prevent exacerbations, it is unlikely that an increase in inflammation with an exacerbation will be fully responsive to corticosteroids. nonetheless, their use is a reasonable and expected first step. inhaled corticosteroids. the administration of high-dose ics for asthma exacerbations should be reserved for patients with mild or intermittent asthma and those unable to tolerate ocs because of side effects such as diabetes or psychiatric effects. a systematic review analyzed 8 studies comparing the efficacy of ics with placebo in acute asthma exacerbations and found that ics appeared superior to placebo, especially when given at high doses, that is, >1 mg of budesonide or fluticasone. 123 however, patients in these studies were heterogeneous in severity, ics dose and administration frequency, and outcomes measured. the role of ics for asthma exacerbations remains to be established. comparisons between ics and systemic corticosteroids have also been conflicting. ocs were superior to ics in reducing hospital admission rates in some studies [124] [125] [126] and others showed superiority of ics. 127 a systematic review of 12 trials concluded that there was no benefit to the addition of ics to systemic corticosteroids in reducing the relapse rate of acute asthma. 128 at present, insufficient evidence exists to support using ics rather than ocs for exacerbations. systemic corticosteroids. early administration of systemic corticosteroids for the treatment of acute exacerbations is standard guideline management with beneficial effects of systemic corticosteroids usually delayed for approximately 4 hours. 129 systemic glucocorticoids accelerate the rate of improvement when persistent airflow obstruction exists despite bronchodilator treatment. 130 however, an evidence-based evaluation reported neither an improvement in airflow obstruction nor reduction in hospitalization rates with systemic corticosteroids. 112 in contrast, a systematic review by rowe et al 113 concluded that the use of systemic corticosteroids in adults and children reduces the rate of hospital admission in ed treatment settings, especially in patients with severe asthma and those not currently receiving corticosteroids. the optimal dose for systemic corticosteroids in asthma exacerbations also remains to be convincingly established. doses above 2 mg/kg, or 60-80 mg/day, do not add benefit to improving pulmonary function, rates of hospital admission, or length of hospital stay. 131, 132 furthermore, no differences are found between oral and intravenous administration of comparable doses. 133, 134 prescribing a short course of oral corticosteroids after ed treatment of acute asthma exacerbations reduces the rate of relapse. 113 although the duration of therapy is not fully established, courses longer than 5 days did not provide additional benefit. 135, 136 there is also no benefit from using a dose taper over a fixed-dose regimen and stopping. 122 difficulties, however, arise in assessing approaches to treating exacerbations in patients already taking systemic corticosteroids. optimal exacerbation treatment strategies for this patient population remain undefined and reflect the need for more targeted therapy. a single dose of benralizumab, an anti-il-5 receptor monoclonal antibody, reduces the rate and severity of subsequent exacerbations when given at the time of an initial exacerbation. 137 thus, biologic therapy may also be beneficial in the acute treatment of asthma exacerbations to prevent subsequent events. asthma exacerbations can be prevented with ics, ics/laba, and biologics in some patients. exacerbations are more frequent in patients with severe disease and preventative strategies with biologics, such as anti-ige and anti-il-5, are seen. when exacerbations occur, systemic corticosteroids remain the primary intervention when bronchodilator therapy is not effective, but the evidence for their benefit has limitations. prevention of exacerbations remains a major unmet need in asthma management. an improved understanding of the pathogenesis of asthma exacerbations will likely lead to new strategies to prevent and treat asthma exacerbations. severe exacerbations predict excess lung function decline in asthma severe exacerbations and decline in lung function in asthma effect of asthma exacerbations on health care costs among asthmatic patients with moderate and severe persistent asthma costs of asthma in the united states: 2002-2007 recent asthma exacerbations: a key predictor of future exacerbations community study of role of viral 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an umbrella review: corticosteroid therapy for adults with acute asthma rapid effects of inhaled corticosteroids in acute asthma: an evidence-based evaluation a comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma comparison of high-dose inhaled flunisolide to systemic corticosteroids in severe adult asthma comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care comparison of inhaled fluticasone with intravenous hydrocortisone in the treatment of adult acute asthma inhaled steroids for acute asthma following emergency department discharge corticosteroid therapy for acute asthma glucocorticoids in acute asthma. a critical controlled trial corticosteroids for acute severe asthma in hospitalised patients highdose and low-dose systemic corticosteroids are equally efficient in acute severe asthma oral versus intravenous corticosteroids in children hospitalized with asthma are intravenous corticosteroids required in status asthmaticus? prospective, placebo-controlled trial of 5 vs 10 days of oral prednisolone in acute adult asthma single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma a randomized trial of benralizumab, an antiinterleukin 5 receptor alpha monoclonal antibody, after acute asthma key: cord-272742-q37xxkja authors: mei‐zahav, meir; amirav, israel title: aerosol treatments for childhood asthma in the era of covid‐19 date: 2020-06-08 journal: pediatr pulmonol doi: 10.1002/ppul.24849 sha: doc_id: 272742 cord_uid: q37xxkja nan to the editor, about 10% of children in the united states have asthma and aerosols are the cornerstone of treatment of asthma. nebulizers (wet or jet) are one of the commonly used aerosol-generating medical devices and generate small particles that can spread to a larger distance than a normal breath. 1 the particles can also stimulate the patient's or any by-stander's cough mechanisms, which increase the risk of disease spread. this risk is linked not only to patients in medical facilities (offices, emergency departments, etc) who proved infected but to any patient with respiratory symptoms regardless of their infectious status. in conclusion, given that mdi/vhc has been shown to be as effective in numerous clinical situations, switching from nebulization to mdi/vhc treatment should be another important step that pediatricians can take in reducing covid-19 spread, particularly among health caregivers. meir mei-zahav md 1, 2 israel amirav md 2,3,4 1 factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises prevention and control of influenza during a pandemic for all healthcare settings aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 n holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma the canadian paediatric society practice point. paediatric asthma and covid-19 key: cord-321824-zbo75ki3 authors: coverstone, andrea m.; wang, leyao; sumino, kaharu title: beyond respiratory syncytial virus and rhinovirus in the pathogenesis and exacerbation of asthma: the role of metapneumovirus, bocavirus and influenza virus date: 2019-05-16 journal: immunol allergy clin north am doi: 10.1016/j.iac.2019.03.007 sha: doc_id: 321824 cord_uid: zbo75ki3 respiratory viruses other than rhinovirus or respiratory syncytial virus, including human metapneumovirus, influenza virus, and human bocavirus, are important pathogens in acute wheezing illness and asthma exacerbations in young children. whether infection with these viruses in early life is associated with recurrent wheezing and/or asthma is not fully investigated, although there are data to suggest children with human metapneumovirus lower respiratory tract infection may have a higher likelihood of subsequent and recurrent wheezing several years after initial infection. viruses are associated with acute wheezing illness, including rhinovirus (rv), respiratory syncytial virus (rsv), human metapneumovirus (hmpv), influenza virus, parainfluenza virus, adenovirus, human bocavirus (hbov), 1 coronavirus, and enterovirus ( table 1) . these viruses have also been shown to be associated with asthma exacerbations. 4, 5 rv and rsv are the most frequently detected pathogens (see table 1 ), with rsv more prevalent in younger children in winter months and rv more prevalent in older children. 2 there is a large body of evidence implicating the association of rv [6] [7] [8] and rsv 9,10 with the subsequent development of recurrent wheezing and/or asthma. viruses other than rv or rsv can be detected in 50% of wheezing illnesses, 1, 11, 12 but there are limited data regarding the association of these other viruses and asthma. conducting studies to evaluate the long-term consequences of these other viruses has been challenging for several reasons. first, the detection rate of these viruses is often lower compared with rv and rsv, so a much larger cohort is required to perform a study with adequate representation of patients infected with these other viruses. the prospective study that investigated the role of hmpv infection in the development of wheezing and asthma required screening of more than 400 children infected with hmpv over a 5-year period of recruitment. 13 second, establishing appropriate animal models has been challenging and existing models may not adequately model human infection to evaluate long-term outcomes. third, it is difficult to tease out the specific contribution of other viruses because the association of rv and rsv can confound the analysis given the high rate of coinfection with these viruses. for instance, in a community cohort of 147 children with high atopic risk, wheezy, febrile lower respiratory tract infection (lrti) during the first year of life was associated with a higher risk of persistent wheezing (odds ratio [or], 3.5) and asthma (or, 4.9) at age 10 years if they were atopic by age 2 years. 3 respiratory virus was detected in 62% of these patients with febrile lrti with a large proportion (60%-70%) of the detected viruses being rv or rsv, so this observed association may be primarily caused by the effect of rv or rsv infection. however, there are data suggesting that viral infection in early life with any cause may be important in increasing the risk of asthma. in a high-risk birth cohort study in demark, the number of respiratory episodes in the first year of life was associated with the development of asthma at age 7 years regardless of virus type. 14 this article focuses on 3 viruses (hmpv, hbov, and influenza virus) in which an association with wheezing illness has been most studied. it provides an aggregate of available data reviewing the current research investigating the role of these viruses in acute and chronic respiratory disease. hmpv is a paramyxovirus first discovered by van den hoogen and colleagues 15 in 2001. similar to rsv, hmpv is a single-stranded rna virus belonging to the pneumoviridae subfamily, and causes many of the same symptoms as rsv. typical symptoms of hmpv infection include mild, self-limiting, acute upper respiratory tract infections to more severe lrtis, with wheezing and pneumonia. it is a frequent cause of bronchiolitis in young children. 16 cough, rhinorrhea, wheeze, and fever are commonly reported symptoms in children infected with hmpv. [17] [18] [19] [20] [21] [22] virtually all children have evidence of exposure to hmpv by age 5 years. 15 hmpv is responsible for a significant portion (2%-12%) of respiratory tract infections 16, 17, 19, [23] [24] [25] [26] and is associated with a large burden of hospitalizations and outpatient visits in younger children. 18, 20 it tends to peak during the late winter and spring seasons, typically between december and april, 16, 19, 22, 24 often peaking in february and march. compared with infection with other viruses, there have been conflicting data on whether hmpv infections result in greater hypoxemia or duration of hospitalization or intensive care unit (icu) stays. 23, 24 the severity of illness is worse in those with a history of extreme prematurity. 25 although hmpv causes wheezing and lower respiratory tract symptoms, the contribution of hmpv to asthma exacerbations varies among different populations. in those with asthma exacerbations, the detection rate of hmpv is approximately 5% worldwide, 4 whereas in those with hmpv lrti a much higher proportion have a diagnosis of asthma. in a study of children with hmpv lrtis in the united states, 14% to 33% carried a diagnosis of asthma or history of wheezing. 16, 19 in a study of children with hmpv in spain, 60.7% of those infected with hmpv alone carried a diagnosis of recurrent wheeze or asthma, which was higher than rates in rsv or adenovirus but similar to that of rv or hbov. children with rsv were more likely to have a diagnosis of bronchiolitis than children with hmpv. 24 hmpv can cause an illness consistent with bronchiolitis, but children may be diagnosed less often with this term, given that it often is synonymous with rsv infections in young children. nonetheless, hmpv causes wheezing in young children; can often precipitate episodes of wheezing in those prone to do so, such as asthmatics; and is an important cause of viralinduced asthma exacerbations. in children with asthma, studies have shown synergistic effects of allergic characteristics of the host (ie, immunoglobulin e level, house dust sensitization) and the severity of asthma exacerbation by rv, 27,28 but the interaction of allergy of the host and hmpv infection has not been well studied. in contrast with the large number of studies reporting the association of hmpv in early childhood with acute wheezing illnesses or asthma at the time of illness, 16, 23 there are sparse data on the long-term consequences after the acute infection. one study from garcia-garcia and colleagues 26 retrospectively identified children 2 to 5 years of age who were hospitalized with hmpv or rsv bronchiolitis in their first 24 months of life and contacted them to assess their diagnosis of asthma at the time of the study. of 101 children with hmpv-positive bronchiolitis (without coinfection) over the course of the prior 5 years (october 2000 to june 2005), they were able to obtain follow-up on 23 children with no prior history of wheezing. they then selected a random sample of children in that same time period with rsv bronchiolitis and obtained follow-up on 32 of those children. a diagnosis of recurrent wheezing and asthma was more frequent in children with a history of hmpv bronchiolitis or rsv bronchiolitis compared with control children who were hospitalized around the same time because of rotavirus. hmpv bronchiolitis was the strongest independent risk factor for asthma (or, 15.9; confidence interval [ci], 3.6, 70.5), followed by rsv bronchiolitis (or, 10.1; ci, 2.5, 40.1) and allergic rhinitis (or, 4.9; ci, 1.2, 40.1) at age 3 to 5 years. another study prospectively followed premature infants with viral lrti and, although it did not track wheezing or asthma status, found that airway resistance measures were increased at 1 year of age, although this study included only 4 infants with hmpv. 29 stronger evidence for the long-term effect of hmpv ltri was found in a recent prospective study that evaluated the effects of hmpv infection on wheezing and asthma outcomes. children less than 5 years of age hospitalized or treated in the emergency room with hmpv lrti and no prior history of wheezing were prospectively followed along with a control group, with outcome assessment every 3 to 6 months for up to 3 years, and a final follow-up as late as 6.5 years. 13 this prospective study design enabled the investigators to obtain the child's wheezing history and capture the outcome securely in a longitudinal fashion. follow-up data were collected on 29 children with hpmv lrti and 27 controls. children with hmpv lrti had a higher likelihood of wheezing episodes during the follow-up period (hazard ratio [hr], 2.8; ci, 1.4, 5.8) than controls. in addition, children with hmpv lrti had earlier onset of recurrent wheezing, both with and without colds, than the control children (fig. 1) . the association with the development of asthma was not statistically significant (hr, 2.5; ci, 0.8, 8.1; p 5 .12), although the number of children diagnosed with asthma was larger in the hmpv group (9 of 29) than the control group (4 of 27). there is more to learn, but these studies suggest an increased risk of asthma development following hmpv infection early in life. the mechanism of short-term and long-term pathologic effects of hmpv infection is not well studied compared with that of rsv. infection with hmpv in mice was shown to lead to persistence of viral rna, pulmonary inflammation, and airway hyperresponsiveness several months after the infection, 30 suggesting long-term pathologic changes can occur after hmpv infection. studies in both mice and humans have suggested several different molecular mechanisms of hmpv affect airway inflammation and function at the time of acute infection, often comparing these mechanisms with those of other viral causes. alveolar macrophage activity may be augmented in hmpv infection, leading to detrimental effects on the airway, whereas alveolar macrophage depletion was seen in rsv and may provide protection against the harmful effects of the virus. 31 the chemokine profile of nasal secretions was also shown to differ in hmpv, with high concentrations of interleukin (il)-8 (neutrophil chemotactic factor) and low concentrations of rantes (regulated on activation, normal t-cell expressed and secreted) (eosinophil chemotactic factor) in individuals infected with hmpv compared with the increased rantes concentrations seen in rsv. 17 in another study of children 1 to 14 years of age with hmpv infection, differences in measures of cell-mediated immunity distinguished hmpv from other respiratory viruses, such as rsv and influenza. 22 thymic stromal lymphopoietin (tslp) as well as il-4 plasma levels were higher in children with wheezing and hmpv than in those without wheezing and hmpv or without wheezing and another respiratory virus. tslp has been implicated as a mediator in the pathway of pediatric asthma, with higher plasma tslp levels correlating with poor asthma control. 32 tslp promotes basophil production and type 2 inflammation. 33 infection of human airway epithelial cells with hmpv induced expression of tslp, as well as leading to upregulation of il-8 and il-33, whereas tslp blockade led to reduced lung inflammation, 34 indicating activation of the tslp pathway initiating airway inflammation by hmpv acute infection. these studies may suggest the involvement of the tslp pathway as a molecular mechanism for how hmpv leads to a recurrent wheezing and asthma phenotype, although further investigation is warranted. hbov is a parvovirus that was discovered in 2005 from pooled nasopharyngeal samples by molecular screening. 35 subsequent studies have shown that hbov genotype 1 is commonly detected in respiratory samples from children with acute wheezing. 1, 12 in children with acute wheezing for the first time, hbov was detected in 18%. 12 however, it is also known that the coinfection rate of hbov with other viruses is very high (15%-100%). in addition, detection in asymptomatic individuals is also frequent. hbov was found to be present in 17% of healthy controls admitted to the hospital for elective surgery, 36 and in participants in a household study in which symptoms and nasal samples were prospectively collected for 12 months, 50% of hbov detection occurred in those without symptoms. 37 viral persistence is thought to be responsible for the high frequency of coinfection. 37, 38 hbov 1 is implicated to be an important respiratory pathogen by many, 39, 40 but the precise pathologic contribution of hbov in acute respiratory disease is still not accurately defined and hbov may be both a passenger and a causative pathogen. 36, 41 hbov may interfere with rv-induced immune responses during acute wheezing. lukkarinen and colleagues 42 compared the t-helper (th) 1, th2, proinflammatory cytokine response profile in young children with rv, hbov, and rv-hbov coinfection with acute wheezing illness. unlike rv, hbov infection was not associated with systemic proinflammatory or th2-type responses and the rv-hbov coinfection resulted in a non-th2-type immune response. although bocavirus is frequently detected and seems to be associated with acute wheezing episodes, the data on long-term consequences after the acute infection are sparse. one retrospective study from spain identified children who were previously hospitalized with hbov (n 5 10) or rsv bronchiolitis (n 5 80) in their first 24 months of life and evaluated them to assess clinical outcomes, including a diagnosis of asthma and presence of atopy at age 5 to 7 years. 43 all children in the hbov group developed recurrent wheezing. fifty percent in the hbov group and 23% in the rsv group had a diagnosis of asthma at age 5 to 7 years. the proportion of those with atopy was similar among those with hbov and rsv. another study in children hospitalized for acute viral wheezing showed that 13 children with hbovassociated bronchiolitis had recurrent wheezing 2 years after the initial hospitalization less often than children with rv-associated bronchiolitis (hbov 40% vs rv 60%). 42 the association of hbov lrti in early life and asthma is inconclusive and larger prospective studies are required to confirm these findings. influenza viruses are responsible for an average of 3.1 million annual hospitalized days, and 31.4 million outpatient visits, 44 and is one of the frequently detected viruses during asthma exacerbations. it has long been identified as a precipitant of asthma exacerbations in all age groups. 2, 4, 45 in people with asthma exacerbations, the detection rate of influenza virus is approximately 10% worldwide, 4 but, during a flu season, the prevalence of influenza viruses can be as high as 20% in wheezing infants and 20% to 25% in adults with acute asthma exacerbations. 2, 46, 47 although involvement of influenza virus is common in asthma exacerbation, influenza virus is an infrequent cause of acute wheezing illness in younger children. [1] [2] [3] the authors are not aware of any studies evaluating the role of influenza virus lrti on the development of recurrent wheezing and/or asthma later in life. the cytokine il-33 is implicated as an important driver for influenza-induced asthma exacerbations in animal studies. 48, 49 in the influenza-infected mouse models, il-33 expression is upregulated, shifting the balance of th1/th2 immunity. 48, 50 a recent study has shown that il-33 is produced by ciliated bronchial cells and type ii alveolar cells on viral-induced exacerbation in human and mice and dampened innate and adaptive th1-like and cytotoxic responses, which subsequently results in increased viral loads and enhanced airway inflammation underlying the influenza-induced asthma exacerbation. 49 meanwhile, heightened il-33 production induces substantial il-13 production in type 2 innate lymphoid cells (ilc-2), th2 cytokine-producing cells that promote allergic inflammation in mouse models of asthma and atopic dermatitis. 51 in another study, influenza a infection induced acute airway hyperreactivity that was medicated by ilc-2, suggesting the importance of the il-33-il-13 axis in influenza-induced acute asthma exacerbations. 52 whether asthmatics are more frequently infected by influenza virus is still a matter of debate. it has been shown that patients with asthma have reduced type 1 interferon (ifn) responses on rv infection, 53,54 but a few studies did not confirm this observation. 55, 56 human bronchial epithelial cells from patients with asthma show increased ifn-lambda 1 levels and preserved ifn-beta levels when infected with influenza a virus, although viral levels were higher in asthmatics compared with nonasthmatics. 56 in a us study, children with asthma were found to be infected twice as often as nonasthmatics by h1n1 influenza when monitored by weekly nasal samples and symptoms scores during the 2009 to 2010 season. 57 regardless, it has been accepted that asthma is a risk factor of severe disease with influenza once acquired, and patients with asthma have been listed as a priority population for vaccination. 58 the population studies in the 2009 h1n1 pandemic have provided interesting observations regarding this susceptibility. having asthma was found to be a risk factor for hospitalization for h1n1 59, 60 and was found in 10% to 20% of the hospitalized patients worldwide. 61 nonetheless, an observation has also been made that having asthma may be protective once patients are hospitalized from influenza. patients with asthma had decreased risk of icu stay, mechanical ventilation, and death from h1n1, compared with other chronic conditions, such as cardiovascular diseases and obesity. [62] [63] [64] the observed protective effect may be in part explained by early hospital admission and/or a favorable response to steroids. 65 in mouse models, this protective effect of allergic asthma on influenza infection has been recapitulated and the increased eosinophil levels in asthmatic airways may be one of the mechanisms. 66 with putative antigen-presenting functions, eosinophils enhanced influenza-specific cd81 t cells after infection, mediating the viral clearance of influenza virus in a mouse asthma model. 66 rapid induction of type iii ifns, natural killer cells, and tgf-beta was also observed in asthmatic mice on influenza infection, indicating a potential mechanism for enhanced antiviral immunity against influenza in asthmatics. [66] [67] [68] influenza vaccine is recommended for patients with asthma in many countries, but there has not been clear evidence showing a protective benefit. the most recent cochrane review, in 2013, which included 18 trials across the world, concluded that inactivated influenza vaccine did not provide significant reduction in the number or duration of influenza-related asthma exacerbations. 69 safety concern was raised in an earlier study that showed a decrease in peak flow following the administration of the inactivated influenza vaccine. 70 a subsequent study in the netherlands 71 and a large study in the united states 72 enrolling more than 2000 patients with asthma confirmed that there is no increase in risk for adverse events including asthma exacerbation within 2 weeks following the injection. this cochran review also conducted a systematic review in 3 trials comparing intranasal vaccine with intramuscular infection in infants and older children and concluded that event rates for asthma exacerbation and wheezing were similar in both vaccine types. 69 a more recent study in the united kingdom evaluated the safety of intranasal live attenuated influenza vaccine in atopic children with well-defined allergy to eggs. sixty-seven percent of children had asthma in addition to their egg allergies. there was no systemic reaction following the injections and 8 mild self-limiting symptoms after 433 doses given in 282 children, which also ensured safety. 73 respiratory viruses other than rv or rsv, especially hmpv, influenza virus, and hbov, can be detected frequently in acute wheezing illness. the interaction of these other viruses with an allergic host, and their contribution in the development of asthma after acute infection, are not well understood, although there is evidence to suggest that children with hmpv lrti have a higher likelihood of subsequent and recurrent wheezing over the several years after initial infection. human bocavirus and acute wheezing in children viral infections in relation to age, atopy, and season of admission among children hospitalized for wheezing febrile respiratory illnesses in infancy and atopy are risk factors for persistent asthma and wheeze regional, age and respiratory-secretionspecific prevalence of respiratory viruses associated with asthma exacerbation: a literature review viruses in asthma exacerbations early life rhinovirus wheezing, allergic sensitization, and asthma risk at adolescence wheezing rhinovirus illnesses in early life predict asthma development in high-risk children assessment of wheezing frequency and viral etiology on childhood and adolescent asthma risk determinants of asthma after severe respiratory syncytial virus bronchiolitis asthma and allergy patterns over 18 years after severe rsv bronchiolitis in the first year of life early-life respiratory viral infections, atopic sensitization, and risk of subsequent development of persistent asthma the first wheezing episode: respiratory virus etiology, atopic characteristics, and illness severity recurrent wheezing in children following human metapneumovirus infection association between respiratory infections in early life and later asthma is independent of virus type a newly discovered human pneumovirus isolated from young children with respiratory tract disease human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children metapneumovirus and acute wheezing in children human metapneumovirus infections in hospitalized children genetic variability of human metapneumovirus infection: evidence of a shift in viral genotype without a change in illness clinical features of different genotypes/genogroups of human metapneumovirus in hospitalized children epidemiological and clinical features of human metapneumovirus in hospitalised paediatric patients with acute respiratory illness: a cross-sectional study in southern china elevated serum levels of thymic stromal lymphopoietin in wheezing children infected with human metapneumovirus burden of human metapneumovirus infection in young children human metapnuemovirus infections in hospitalized children and comparison with other respiratory viruses. 2005-2014 prospective study human metapneumovirus infection is associated with severe respiratory disease in preschool children with history of prematurity human metapneumovirus bronchiolitis in infancy is an important risk factor for asthma at age 5 weekly monitoring of children with asthma for infections and illness during common cold seasons rhinovirus and serum ige are associated with acute asthma exacerbation severity in children lung function in prematurely born infants after viral lower respiratory tract infections human metapneumovirus infection induces long-term pulmonary inflammation associated with airway obstruction and hyperresponsiveness in mice alveolar macrophages contribute to the pathogenesis of human metapneumovirus infection while protecting against respiratory syncytial virus infection correlation of tslp, il-33, and cd4 1 cd25 1 foxp3 1 t regulatory (treg) in pediatric asthma tslp promotes interleukin-3-independent basophil haematopoiesis and type 2 inflammation human metapneumovirus infection activates the tslp pathway that drives excessive pulmonary inflammation and viral replication in mice cloning of a human parvovirus by molecular screening of respiratory tract samples human bocavirus in children: monodetection, high viral load and viraemia are associated with respiratory tract infection community surveillance of respiratory viruses among families in the utah better identification of germs-longitudinal viral epidemiology (big-love) study human bocavirus 1 primary infection and shedding in infants human bocavirus-the first 5 years human bocavirus: passenger or pathogen in acute respiratory tract infections? human bocavirus: current knowledge and future challenges human bocavirus 1 may suppress rhinovirus-associated immune response in wheezing children recurrent wheezing and asthma after bocavirus bronchiolitis the annual impact of seasonal influenza in the us: measuring disease burden and costs prevalence of viral respiratory tract infections in children with asthma epidemiology of respiratory viruses in patients hospitalized with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease the incidence of respiratory tract infection in adults requiring hospitalization for asthma pandemic influenza virus, ph1n1, induces asthmatic symptoms via activation of innate lymphoid cells il-33 drives influenza-induced asthma exacerbations by halting innate and adaptive antiviral immunity an early innate response underlies severe influenza-induced exacerbations of asthma in a novel steroidinsensitive and anti-il-5-responsive mouse model type 2 innate lymphoid cells in allergic disease innate lymphoid cells mediate influenzainduced airway hyper-reactivity independently of adaptive immunity role of deficient type iii interferonlambda production in asthma exacerbations impaired type i and iii interferon response to rhinovirus infection during pregnancy and asthma rhinovirus-induced interferon production is not deficient in well controlled asthma interferon response and respiratory virus control are preserved in bronchial epithelial cells in asthma increased h1n1 infection rate in children with asthma prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices-united states surveillance of the first 205 confirmed hospitalised cases of pandemic h1n1 influenza in ireland asthma and severity of 2009 novel h1n1 influenza: a population-based case-control study influenza in asthmatics: for better or for worse? risk factors for severe outcomes following 2009 influenza a (h1n1) infection: a global pooled analysis factors associated with death or hospitalization due to pandemic 2009 influenza a(h1n1) infection in california predictors of clinical outcome in a national hospitalised cohort across both waves of the influenza a/h1n1 pandemic 2009-2010 in the uk differences between asthmatics and nonasthmatics hospitalised with influenza a infection eosinophils promote antiviral immunity in mice infected with influenza a virus initial influenza virus replication can be limited in allergic asthma through rapid induction of type iii interferons in respiratory epithelium mice with asthma are more resistant to influenza virus infection and nk cells activated by the induction of asthma have potentially protective effects vaccines for preventing influenza in people with asthma. cochrane randomised placebocontrolled crossover trial on effect of inactivated influenza vaccine on pulmonary function in asthma does influenza vaccination exacerbate asthma in children? the american lung association asthma clinical research centers. the safety of inactivated influenza vaccine in adults and children with asthma safety of live attenuated influenza vaccine in atopic children with egg allergy key: cord-293678-jfjc7wjb authors: haroun-díaz, elisa; de la torre, maría vázquez; ruano, francisco javier; somoza álvarez, maria luisa; alzate, diana pérez; gonzález, paula lópez; prieto-moreno, ana; rojas, isabel torres; cervera garcía, maría desamparados; blanca-lópez, natalia; díez, gabriela canto title: severe asthma during the covid-19 pandemic: clinical observations date: 2020-06-27 journal: j allergy clin immunol pract doi: 10.1016/j.jaip.2020.06.033 sha: doc_id: 293678 cord_uid: jfjc7wjb nan in spain, 2% of public health expenditures are devoted to asthma-related care (4). it is 110 estimated that the global economic burden of asthma is between 1.5 and 3 billion euros 111 annually, and higher costs are associated with greater disease severity (5). severe asthma affects 3.9% of asthmatic patients (5). it is defined as an inflammatory 113 chronic respiratory disease that remains uncontrolled despite optimal therapy and 114 treatment of contributing factors, or which worsens when high-dose treatment is 115 decreased (6). around 50% of patients with severe asthma experience uncontrolled or 116 partially controlled symptoms despite maximal treatment (5). these patients pose a 117 special challenge for care providers because of the extensive diagnostic testing and care 118 resources they require. the aim of this study is to determine the prevalence and characterization of covid-19 120 infection among patients with severe asthma according to ers/ats criteria who 121 presented to our allergy department during the covid-19 pandemic. epidemiological and 206 clinical characteristics of 99 cases of china: a descriptive study risk factors for severity and 210 mortality in adult covid-19 inpatients in wuhan guía española para el manejo del asma 4.4 ats guidelines on definition, evaluation and treatment of 219 severe asthma the 221 inhaled corticosteroid ciclesonide blocks coronavirus rna replication by 222 targeting viral nsp15 abbreviations: cv risk factor, cardiovacular risk factor; nsaids, nonsteroidal anti-inflammatory drugs; bmi, body mass index; rf, respiratory frequency on admission (rpm: respiration per minute); o sat (oxigen saturation) on admission; polymerase chain reaction; crp, c-reactive protein; ldh, lactate dehydrogenase; n/a, non applicable. key: cord-258093-6fn8ei9f authors: hanania, nicola a.; king, monroe j.; braman, sidney s.; saltoun, carol; wise, robert a.; enright, paul; falsey, ann r.; mathur, sameer k.; ramsdell, joe w.; rogers, linda; stempel, david a.; lima, john j.; fish, james e.; wilson, sandra r.; boyd, cynthia; patel, kushang v.; irvin, charles g.; yawn, barbara p.; halm, ethan a.; wasserman, stephen i.; sands, mark f.; ershler, william b.; ledford, dennis k. title: asthma in the elderly: current understanding and future research needs—a report of a national institute on aging (nia) workshop date: 2011-08-25 journal: j allergy clin immunol doi: 10.1016/j.jaci.2011.06.048 sha: doc_id: 258093 cord_uid: 6fn8ei9f asthma in the elderly is underdiagnosed and undertreated, and there is a paucity of knowledge on the subject. the national institute on aging convened this workshop to identify what is known and what gaps in knowledge remain and suggest research directions needed to improve the understanding and care of asthma in the elderly. asthma presenting at an advanced age often has similar clinical and physiologic consequences as seen with younger patients, but comorbid illnesses and the psychosocial effects of aging might affect the diagnosis, clinical presentation, and care of asthma in this population. at least 2 phenotypes exist among elderly patients with asthma; those with longstanding asthma have more severe airflow limitation and less complete reversibility than those with late-onset asthma. many challenges exist in the recognition and treatment of asthma in the elderly. furthermore, the pathophysiologic mechanisms of asthma in the elderly are likely to be different from those seen in young asthmatic patients, and these differences might influence the clinical course and outcomes of asthma in this population. states is currently about 13% but is projected to grow from about 40 million in 2005 to more than 86 million by 2050, accounting for 25% of the population. the age group with the largest growth will be those older than 85 years, which is estimated to be more than 1 million by 2050. 1, 2 in 2004, the us prevalence of asthma for those 65 years or older was 7%, with 1,088,000 reporting an asthma attack in the previous 12 months. 3 older asthmatic patients are more likely to be underdiagnosed, undertreated, 4,5 and hospitalized than younger asthmatic patients. 3 they also have the highest death rate (51.3 per million persons) of any other age group. 6 older women are hospitalized more than twice as often as older men. asthma in older adults is superimposed on a background of aging-related changes in respiratory and immune physiology and often on multiple diseases and conditions common in older age. recognizing the paucity of research, the many challenges that exist in the recognition and treatment of asthma in older adults, and the opportunity to bridge geriatrics and the clinical specialties that focus on asthma, the national institute on aging (nia) sponsored a workshop on asthma in the elderly in herndon, virginia, on september 8 and 9, 2008. the workshop was planned by a committee of 6 physician-scientists from us academic institutions or from the division of geriatrics and clinical gerontology in the nia. the planning committee selected speakers and participants for their expertise in asthma, pulmonology, allergy/immunology, primary care, emergency medicine, geriatrics, and/or gerontologic science (see the list of participants in appendix 1). the immediate goals of this workshop were to summarize the current understanding of the mechanisms of asthma in older persons and to identify knowledge gaps and research opportunities leading to improved medical care and health outcomes for older persons with asthma. these research opportunities are discussed in the body of this report and summarized in table i . [7] [8] [9] in addition, the nia, in collaboration with the national heart, lung, and blood institute and the national institute of allergy and infectious diseases, recently issued a set of program announcements inviting research proposals on asthma in older adults (http:// grants.nih.gov/grants/guide/pa-files/pa-10-263.html, http://grants. nih.gov/grants/guide/pa-files/pa-10-264.html, and http://grants. nih.gov/grants/guide/pa-files/pa-10-265.html). it is a central principle of gerontology that aging itself is not a disease. 10 yet there are physiological changes within organs, tissues, and cells that result in diminished functional reserve and thereby increased susceptibility to stressors, disease, or both. a second principle is that these aging changes are highly variable and account for the great constitutional heterogeneity among older persons from very ''fit'' to very ''frail.'' in fact, the concept of frailty, both its causes and consequences, has become a focus of concentrated gerontologic investigation. at the root of age-associated physiological changes are a number of genetic, epigenetic, and environmental factors. 11 molecular damage accumulates over time, and the capacity for dna repair decreases. 12 cellular senescence, which is believed to be the consequence of accumulated dna and protein damage and reduced proliferative capacity, is becoming increasingly understood at the molecular level. 13 however, just how this correlates with the phenotypic changes of advanced age remains incompletely understood. 14 there has been much written about cellular senescence and the events that lead to cell death. [15] [16] [17] after a finite number of divisions, normal somatic cells invariably enter a state of irreversibly arrested growth, a process termed replicative senescence. 18 in fact, it has been proposed that escape from the regulators of senescence is the antecedent of malignant transformation. however, the role of replicative senescence as an explanation of organismal aging remains the subject of vigorous debate. the controversy relates, in part, to the fact that certain organisms (eg, drosophila species and caenorhabditis elegans) undergo an aging process, yet all of their adult cells are postreplicative. what is clear is that the loss of the proliferative capacity of human cells in culture is intrinsic to the cells and not dependent on environmental factors or even culture conditions. 18 unless transformation occurs, cells age with each successive division. the number of divisions turns out to be more important than the actual amount of time passed. thus cells held in a quiescent state for months, when allowed back into a proliferative environment, will continue approximately the same number of divisions as those that were allowed to proliferate without a quiescent period. 19 the question remains whether this in vitro phenomenon is relevant to animal aging. one suggestive observation is that fibroblasts cultured from samples of old skin undergo fewer cycles of replication than those from young skin. 20 furthermore, when various species are compared, replicative potential is directly and significantly related to lifespan. 21 an unusual b-galactosidase with activity peaks at ph 6 has proved to be a useful biomarker of in vitro senescence because it is expressed by senescent but not presenescent or quiescent fibroblasts. 22 this particular b-galactosidase isoform was found to have the predicted pattern of expression in skin from young and old donors, with measurably increased levels in dermal fibroblasts and epidermal keratinocytes with advancing age. 22 the nature of the expression of this in vivo biomarker of aging in other tissues will be important to discern. for clinical investigators, frailty has proved hard to define primarily because of the seemingly insurmountable heterogeneity inherent in geriatric populations on the basis of these variable rates of organ system decrease and the presence or absence of 1 or more diseases. 9 yet, regardless of the pathway taken to frailty, the clinical picture has common features, including a reduction in lean body mass (sarcopenia), loss of bone mass (osteopenia), cognitive impairment, functional decline, and anemia. on the basis of data derived from large cohorts of elderly patients, fried et al 23 have offered an operational definition of frailty incorporating an assessment of 5 specific characteristics to ascribe a frailty index. on this 5-point scale, a score of 3 or more has been shown to be independently predictive of a range of adverse clinical outcomes, including acute illness, falls, hospitalization, nursing home placement, and early mortality. [23] [24] [25] furthermore, simple performance measures, such as the assessment of walking speed, are predictive of important outcomes, including survival. 26 with the phenotype better defined, attention has shifted to pathophysiology. although frailty can occur in the absence of a diagnosable illness, the fact that some become frail and others do not suggests an inherent or acquired variability in homeostatic pathways. recent evidence from observational studies has raised suspicion that dysregulated inflammatory processes are involved in, if not central to, the variable patterns of aging. increased serum levels of certain proinflammatory cytokines, most notably il-6, are increasingly present with advancing age and to a greater extent with frailty. 27, 28 furthermore, the appearance of this and other inflammatory markers has been associated with a number of adverse clinical outcomes, including decreased strength and mobility, falls, dementia, and mortality. 27 life expectancy, lifespan, and maximum survival from the perspective of those who study aging, there is an important distinction made between median (life expectancy) and maximum lifespan. over the past several decades, with the advent of modern sanitation, refrigeration, and other public health measures, including vaccination and antibiotics, there has been a dramatic increase in median survival. 29 early deaths have been diminished, and more patients are reaching old age. in the united states today, life expectancy now approaches 80 years. 30 median survival is what concerns public health officials and health care providers, but for those studying the biology of aging, it is maximum survival that is the focus of greatest attention. it is worthwhile to note that it has been estimated that if atherosclerosis and cancer were eliminated from the population as a cause of death, about 10 years would be added to the average lifespan, yet there would be no change in maximum lifespan. 31 although several theories have been proposed, none suffice to account for the complexities of aging. lifespan is finite and varies generally from species to species and much less so within species. mice live, on average, 2½ years, monkeys 30 years, and human subjects about 90 years. among species, larger animals generally live longer than smaller animals, but within species, smaller animals are likely to live longer. it is clear that aging is not entirely explained by dna sequence. for example, mice and bats have only 0.25% difference in their primary dna sequence, but bats live for 25 years, 10 times longer than mice. a commonly held notion is that regulation of gene expression accounts for a longevity difference between species. the aging lung large, longitudinal, and more complete studies to determine the effects of aging on the function of the respiratory system improved knowledge about lung structure-function relationships in older age using techniques of imaging and measures of lung function not requiring effort (eg, high-resolution computed tomographic scanning and forced oscillation) improved assessment of lung processes underlying airflow limitation attributable to aging versus copd or asthma, especially in asthmatic patients who smoke studies to examine the effects of aging in ethnic groups and the role of gender epidemiology, effect, diagnosis, and management determine the true prevalence and cost of asthma in the older population develop a uniform definition of asthma to be applied to health care records that will distinguish asthma from copd and mixed asthma/copd evaluate evidence-based treatment algorithms for older asthmatic patients, such as those developed by the national heart, lung, and blood institute and global initiative for asthma guidelines 7 assess the effect of asthma treatment, including direct medical costs of care, indirect costs of care, and value of treatment in improving quality of life 8, 9 assess the effect of comorbid conditions, especially copd and congestive heart failure, on asthma 9 characterize phenotypes of elderly asthma with regard to responses to therapy and long-term outcomes based on age of onset, duration of disease, and environmental triggers develop algorithms for electronic medical record systems that are asthma-specific evaluate effects of current asthma medications in older patients compared with younger patients identify pharmacogenetic determinants of response to asthma medications in older adults identify simpler and safer drug delivery systems and schedules for older adults develop simple methods to differentiate copd from asthma exacerbations in older adults understand how environmental or aging-related factors affect epigenetic changes in asthma in older adults identify differences between older and younger asthmatic patients or between lsa and loa with regard to inflammation, remodeling, intracellular mechanisms, responses to environmental pollutants, and allergy sensitization and their effects on the metabolism and action of asthma drugs identify naturally occurring age-related changes in airway cellular patterns develop animal models of age-related airway inflammation understand the significance of allergy sensitization associated with asthma in older adults (eg, through larger prospective studies) identify the utility of allergy tests, either skin tests or serum specific ige measurement, in reflecting allergy sensitization in older adults identify the role of the microbiome in patients with loa understand the role of non-ige mechanisms in older adults' inflammatory responses to inhalant allergens or pollutants (eg, t h 17 lymphocytes producing il-17 or protease receptor responses to molds and dust mites) determine the roles of adaptive versus innate immune mechanisms on asthma development, progression, and response to treatment in older adults determine whether there are environmental pollutants peculiar to institutional settings identify viruses and other microbiological agents responsible for, and the mechanisms by which they cause, asthma exacerbations in older adults, which might lead to the development of vaccine-or antiviral drug-based interventions determine effects of asthma medications, viral or bacterial load, or allergy status on susceptibility to exacerbations in older patients define rates of infection and specific pathogens in older asthmatic patients distinguish roles of innate immunity in eosinophilic versus neutrophilic asthma it is now clearly established that certain specific genes can alter lifespan, at least in lower animals, but whether these same genes regulate ''aging'' is still in question. for example, transgenic drosophila species expressing increased copies of the free radical scavenging enzymes superoxide dismutase and catalase live on average a third longer than the appropriate controls. 32 in even lower species (eg, yeast and nematodes) the identification of specific genes that influence lifespan 33, 34 has led to the optimistic impression that analogous genes in higher organisms will lead greater insights into the aging process. yet the identification and functional analysis of analogous genes in human subjects remains elusive. the oldest human being alive today is approximately 120 years old. what is intriguing is that the record has remained stable and unchanged by the public health initiatives mentioned above. in fact, there has been some recent data presented that the maximum survival is actually decreasing in the united states. 35, 36 what is interesting is that, unlike the public health initiatives in human subjects in which median but not maximum survival has been enhanced, experimental interventions in lower species have resulted in prolongation of maximum survival. as mentioned above, transgenic drosophila species producing extra copies of superoxide dismutase and catalase survived about 33% longer than controls, 32 and similarly, the maximum survival in c57bl/6 mice fed a calorically restricted diet enhanced by 50% or more. 37, 38 the true mechanisms of aging might well be uncovered with a better understanding of how these interventions affect longer survival. future research in aging should attempt to improve our understanding of the basic biology of aging and interventions that retard the aging process. there is a need for the development and application of a standardized definition of frailty for future clinical investigation. investigations directed at the role of comorbidities in accelerating the aging process are important. furthermore, future research should focus on the development of cellular and animal models of typical, delayed, and accelerated aging and of large collaborative networks in which populations and resources can be shared to study aging and frailty. leveraging on well-characterized existing cohorts, when possible, is recommended. the lungs, like other organs, age and exhibit continued loss of function as a person grows old. lung function is traditionally assessed by means of a number of standardized methods. the most common measurement used is spirometry with the determination of fev 1 and forced vital capacity (fvc). fev 1 and fvc both show continuous decreases of between 25 and 30 ml with each year of life after about age 20 years. 39 the cause of this decrease is usually attributed to the loss of the driving forces for airflow as a result of reduced respiratory muscle performance, loss of static elastic recoil, or both. 39, 40 the decrease in fev 1 in asthmatic patients is largely a function of the decrease in fvc because of the increase in residual volume. 41 stiffening of the chest wall and reduced respiratory muscle performance result in a decrease in total lung capacity and an increase in residual volume because of ever-increasing closing volume. 42 accordingly, these aging processes lead to airflow limitation that might be hard to distinguish from an active disease process. not all older persons are able to perform spirometry, especially those with decreased cognition, coordination, and frailty. in addition, spirometry is effort dependent, and the very old can tire quickly. techniques of imaging and measures of lung function not requiring effort (ie, forced oscillation) should be used in future studies to extend our knowledge about lung structure-function relationships at the very end of life. bronchodilator responses are known to be less marked in the elderly, perhaps as a consequence of the aging effects attributed to the emphysema-like state of the senile lung 43 ; however, this would not explain the slow temporal response to bronchodilators. other studies do not find such age-related bronchodilator differences. furthermore, although methacholine responsiveness has been reported to increase with aging, the exact mechanism for this is not apparent. increased incidence and prevalence of many lung diseases occur with age. alterations in immune function increase the risk of many of these diseases. studies of systemic immunity suggest that sustained antigenic stress over a lifetime leads to a decrease in naive t-cell numbers, an accumulation of memory t cells, and a decrease in t-cell repertoire and b-cell functions but a lesser decrease in innate immunity. 43, 44 little is known about what happens to the immune/inflammatory pathways in older asthmatic patients. the immune system changes seen with aging will be discussed in more detail in the section on pathophysiology. in the united states the national health interview survey asks questions regarding lifetime history of asthma, current asthma prevalence, and asthma attacks in the last 12 months. 3 for all age groups, asthma prevalence has been steadily increasing since 1980. for the 65 years and older age group, asthma is consistently more prevalent in female than male subjects. 3 the national center for health statistics tracks data on physician encounters for asthma. the national ambulatory medical care survey reported that those 65 years or older have the second-highest rate of outpatient office visits after those aged 0 to 4 years. those 65 years and older did not have significantly different emergency department visits than the other adult groups. the 65 years and older age group accounts for a greater proportion of hospitalizations (23%) than the size of its population (13%) would indicate. not surprisingly, the elderly population is a high user of medical resources for the treatment of asthma. hospitalizations and emergency department visits are more common for these patients than for other adult cohorts. some of the increased costs are related to comorbid disease. for example, the presence of comorbid chronic obstructive pulmonary disease (copd) increases the risk of an asthma-related hospitalization in medicare patients 3.6-fold, respiratory medical costs almost 6-fold, and total medical costs 2-fold. elderly female subjects appear at greater risk than elderly male subjects. [45] [46] [47] [48] asthma mortality increased steadily from 1980 until it peaked in 1998. the highest mortality rates for asthma occur in the 65 years and older group. in fact, the increase in asthma mortality between 1979 and 1989 was primarily driven by the 65 years and older group. in addition, the decrease in asthma mortality between 1999 and 2005 was most evident in this age group. elderly women with asthma tend to have higher mortality rates than elderly men with asthma. one reason for the increasing prevalence of asthma in the elderly might be the improved longevity of the population. also, increased office visits for asthma in the elderly might be responsible for fewer attacks. increasing hospital admissions might account for decreased mortality. by continuing to gather surveillance data on asthma, reasons for these trends could become clearer. in addition, surveillance data help to focus intervention efforts in areas of greatest need. in the cardiovascular health study, a large community-based cohort of subjects older than 65 years, questions were asked that were relevant to asthma and provided more insight into the prevalence and effect of asthma in this population. 5, 49, 50 definite asthma was defined as a positive response to the questions indicating that the patient had current asthma and that a physician confirmed the diagnosis. probable asthma was defined as a history of wheezing in the past year associated with chest tightness or breathlessness. excluding smokers and those with a diagnosis of congestive heart failure, 4% of subjects had definite asthma, and 4% had probable asthma. among those who smoked, 11% had definite asthma, and 14% had probable asthma. among nonsmokers, 185 subjects were identified who had definite or probable asthma; 76% were women, and 20% were older than 80 years. the age of asthma onset was spread approximately evenly among decades. twenty-seven percent had late onset of disease after age 60 years, and 25% had onset of disease before age 20 years. as expected, respiratory symptoms in the older asthmatic subjects were more prevalent, with a 2-to 5-fold increase in cough, phlegm, wheezing, and dyspnea. dyspnea on exertion was 1.6-fold more likely to be present in asthmatic patients than in those without the diagnosis. lung function was reduced in those with a diagnosis of asthma. mean fev 1 was 77% of predicted value in those with definite asthma and 89% of predicted value in those with probable asthma compared with 96% in those who did not have asthma. forty-one percent of those with a diagnosis of asthma had airflow obstruction below the fifth percentile for the age group, and peak flow lability was increased. elderly asthmatic patients reported the most common trigger was a viral infection in 58% compared with animal allergies in 30%. two thirds reported seasonal worsening. asthma had a significant effect on quality of life, with 35% of patients with definite or probable asthma reporting a fair or poor health status compared with 17% of elderly patients without asthma. sixty percent of patients with definite asthma reported seasonal allergic rhinitis compared with only 30% in the nonasthma group. despite the high prevalence and morbidity of asthma in this population, inadequate treatment was common. only 40% of those with definite asthma had a rescue albuterol inhaler, and only 30% had inhaled corticosteroid use. 5, 49, 51, 52 the pathophysiology of asthma in the older adult is poorly understood and understudied. many questions about this issue remain: is asthma the same disease in older adults as it is in children and younger adults? is late-onset asthma (loa; asthma that starts in middle age or older) different from longstanding asthma (lsa; asthma of early onset that has persisted into older adulthood)? if loa and lsa are the same disease, then the diagnosis and treatment should be similar. however, if loa and lsa are different phenotypes or at least have a different cause and pathophysiology, then the diagnosis and treatment might differ (table ii) . the traditional view of disease susceptibility has been expanded to include epigenetics to account for the influence of environmental factors and aging on the genomic blueprint. epigenetics is defined as heritable changes in gene expression that occur without alterations in dna sequence. it is the process by which genotype interacts with environment to produce a phenotype and explains differences between cells, tissues, and organs despite identical genetic information. genes function in a milieu determined by the developmental and environmental history of the cell, which constitutes the epigenotype. 53, 54 epigenetic changes or marks can play a major role in human disease. 55, 56 the most common examples of epigenetic marks are dna methylation of cpg islands by dna methyltransferases and chromatin modification of histone proteins, particularly acetylation by histone acetyltransferases and histone deacetylases. 57, 58 the function of epigenetic changes is to regulate gene expression. epigenetic changes are known to contribute to cancer and autoimmune disease and are thought to contribute to common diseases, including cardiovascular disease, diabetes, and the loss of response to stress caused by aging. 59 asthma is a markedly heterogeneous disease, and recent evidence suggests that environmentally induced epigenetic changes contribute to asthma phenotypes and that airway inflammation in patients with asthma and copd might involve epigenetic regulation. 57, 58, 60 methylation patterns and chromatin structure change with age and are thought to contribute to the increase in the incidence of common diseases that begin in middle age. 55, 61 the incidence of asthma in the elderly resembles the incidence of common diseases. moreover, characteristics and asthma drug response in the elderly asthmatic patient differ from those seen in childhood asthma. compared with younger cohorts, elderly asthmatic patients have a higher prevalence, higher rates of bronchial hyperreactivity, more severe asthma, and a lower prevalence of atopy. the symptoms of elderly asthmatic patients are more difficult to control with drug therapy, and these patients have steroid resistance and might respond better to leukotriene receptor antagonists compared with inhaled corticosteroids. [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] the contribution of epigenetics to differences observed between elderly asthmatic patients and younger cohorts is unknown. unlike genetic variants that contribute to disease, epigenetic changes can be reversed and therefore represent potential drug targets. 72 older asthmatic patients are less responsive to albuterol treatments given in the emergency department and are more frequently admitted for hospitalization. 73 thus it appears that the responsiveness to treatment is diminished and the severity of asthma exacerbations is greater. the exact reason for these disparities is not known. immune cell function decreases with aging, a property often termed immunosenescence. 74 one often-confusing aspect of immunosenescence is the observation that aging might be associated with opposing immunologic effects. for example, t-cell secretion of il-2, il-4, or ifn-g has been shown to be both decreased with aging and also increased with aging. 75 it is likely that both phenomena are correct but are dependent on the context of the immune function. thus the effect of aging on t-cell function in the context of allergen stimulation might be different than the effects of aging on t-cell function in the context of viral infection. given that asthma is an inflammatory disorder of the airway, it is of interest to determine whether asthmatic airway inflammation of the elderly might differ from that of younger asthmatic patients and thus represent a distinct phenotype of asthma. these changes might have implications for susceptibility to exacerbations because of viruses or other pathogens, as well as response to treatment. the aging process has been shown to exhibit changes in airway inflammation. an examination of the cellular composition of bronchoalveolar lavage fluid from 19-to 83-year-old subjects without a history of allergies, pulmonary disease, or gastroesophageal reflux showed increased airway neutrophilia, as well as increased numbers of cd4 1 t cells. 76, 77 the t cells also appeared to be more activated in the elderly, with increased expression of hla-dr and cd69. the increase in airway neutrophils with aging has also been observed in asthmatic patients. 78 because there is a phenotype of severe asthma characterized by a predominantly neutrophilic airway inflammation, 79 the question arises as to whether the increased presence of neutrophils contributes to greater asthma severity in the elderly. some of the prominent inflammatory cells recruited into the airway in asthmatic patients are eosinophils, neutrophils, and t cells, which are capable of secreting numerous inflammatory mediators, including leukotrienes and cytokines. it is not known whether immunosenescence affects the production of these mediators in elderly asthmatic patients, either at baseline or during an exacerbation of symptoms. furthermore, it is not known whether age-related changes in their production would have any implication for the clinical presentation or management of asthma in the elderly. peripheral blood eosinophils were isolated from younger (20-40 years old) and older (55-80 years old) subjects for in vitro functional assays. the eosinophil effector functions of degranulation and superoxide production were diminished in the older compared with the younger asthmatic patients. 78 in another study examining the expression of neutrophil mediators in younger and older asthmatic patients, there was decreased baseline expression of leukotriene b 4 in the sputum of older asthmatic patients despite greater numbers of neutrophils. 80 whether these findings have implications during an asthma exacerbation has yet to be determined. nevertheless, the results demonstrate agerelated changes in the function of an inflammatory cell considered pathognomonic for allergic asthma and raise the question of whether additional effects of immunosenescence are relevant to airway inflammation in asthmatic patients. there have been several studies of animal models to address age-related changes in the airway inflammation induced by allergen challenge of sensitized aged animals (see experimental approaches section below). these studies yielded conflicting results, and there is concern that the animal models do not accurately represent the chronic features of human asthma with seasonal allergen exposure and intermittent exacerbations. the aged animals were both sensitized and challenged at old age, which is in contrast to the typical elderly human asthmatic patient who might be exposed to allergens for several decades. typically, nasal and ocular symptoms on exposure to allergens diminish with age. allergen-triggered asthma symptoms also diminish with age. the epidemiology and natural history of asthma (tenor) study examined the natural history of asthma in older (>65 years old) compared with younger patients and found that older asthmatic patients had lower total ige levels, fewer positive skin prick test responses, and less concomitant allergic rhinitis or atopic dermatitis. 81 several studies have demonstrated age-related decreases in total ige and allergen-specific ige levels, [82] [83] [84] [85] [86] [87] suggesting that this might be the explanation for the decrease in allergy symptoms. there is also evidence for an age-related decrease in skin prick test responses to allergens. 88 however, the relationship between total ige levels and allergic disease persists in the elderly, such that subjects with greater ige levels remain more likely to have allergic rhinitis or asthma. 89, 90 given the changes in allergic inflammation with aging, one might conclude that asthma in the elderly should be milder. however, there are several other common triggers for exacerbations of asthma, including irritants (eg, cold air) and respiratory tract infections. estimates suggest that up to 80% of asthma exacerbations in adults are caused by viral upper respiratory tract infections. 91 the role of environmental exposures and allergy in older asthmatic patients is largely unknown. in the general population, evidence regarding the effect of indoor pollution on asthma is summarized in ''clearing the air: asthma and indoor air exposure'' by the institute of medicine for the environmental protection agency published in 2000. 92 evidence was reported for asthma development related to house dust mites and for asthma development associated with environmental tobacco smoke in preschool children. the report also showed evidence for causation of asthma exacerbations for house dust mite, environmental tobacco smoke (in preschool children), cat, and cockroach; an association with exacerbations was found for dogs, fungi, formaldehyde, and rhinovirus. in addition, evidence associating exacerbation of asthma-related symptoms with self-reported damp air was reported in a review of damp indoor spaces and health. 93, 94 there are only a few studies that have evaluated the role of atopy in elderly patients with asthma. one large national study of allergy skin tests that included older adults 95 and several small studies of allergy skin tests in older adults with asthma 81,96-103 j allergy clin immunol volume 128, number 3 were reviewed. allergy skin test results were positive in 8% to 12% of all older adults. the prevalence of positive skin test results or specific ige levels to at least 1 allergen in older adults with asthma ranged from 0% to 75%. those whose asthma had an unknown age of onset ranged from 27% to 60%, those with onset before age 41 years ranged from 56% to 62%, and those with onset greater than age 41 years ranged from 0% to 24% (table iii) . 97, 101, 102 although there were no studies of allergen room exposure or bronchial challenge in older adults, neither prick-puncture skin test results nor specific ige levels predicted the nasal challenge response to dust mites. 104 safety concerns for allergen challenges in older adults are unresolved. technical limitations of allergens, environmental measurements, and age-specific norms and cutoff levels for laboratory and physiologic tests are needed. a few epidemiologic studies suggest an association between outdoor environmental exposures and emergency department or hospital admissions in older adults. 105, 106 in summary, studies of the general population suggest a causation or association between indoor air pollutants and allergy exposure and asthma. there are several small studies suggesting higher levels of positive allergy test results in older adults with asthma than in the general population of older adults. when age of onset is considered, asthma with an early onset (<41 years of age) has a much higher association with positive allergy test results than late-onset asthma. viral respiratory tract infections are common precipitants of asthma exacerbations during childhood. in approximately 80% of children with acute asthma exacerbations, a respiratory tract virus can be detected, with rhinovirus being the most frequent pathogen identified. 107 although it is likely that viruses also lead to exacerbations of asthma in older adults, comprehensive studies regarding the rates and specific pathogens are lacking. several issues have made defining the role of viruses in adult asthmatic patients problematic and include difficulty distinguishing copd from asthma, lack of sensitive diagnostic tests, and issues with asymptomatic infection. a number of investigators have explored the incidence of viral infection in adult asthmatic patients. 91, 108, 109 older studies using viral culture and serology for diagnosis demonstrated infection rates of 10% to 29%. 109 in contrast, more recent studies, which include rt-pcr, have shown significantly higher infection rates of 44% to 55%. 91, 108 similar to results found in children, rhinoviruses are the most frequently detected pathogen. few older persons were included in these studies, in which the mean ages of subjects were 30 to 39 years. the incidence of acute respiratory tract infections decreases steadily with advancing age, and rates of viral infection in older adults are influenced by place of residence. 110 among community-dwelling older adults, rates of acute respiratory tract infections are roughly 1% to 2% per year, whereas rates in senior day care centers and long-term care facilities are substantially higher at 6% to 11%. 111 in addition, the epidemiology of respiratory tract infections can be quite complex in these semiclosed populations, with multiple pathogens circulating simultaneously. 112 influenza a, respiratory syncytial virus (rsv), and human metapneumovirus (hmpv) are the most commonly identified viruses among older persons hospitalized with acute cardiopulmonary conditions. 113, 114 most patients who require hospitalization during a viral respiratory tract infection have underlying heart and lung conditions. although studies to date have largely focused on the role of viruses in copd exacerbations, it is reasonable to extrapolate infection rates and specific pathogens from these studies to older adults with asthma. johnston, 115 in ontario, canada, found a seasonal peak in emergency department visits for all acute respiratory tract infections, as well as exacerbations of both copd and asthma, for persons younger and older than 50 years. all the common respiratory tract viruses have been associated with copd exacerbations, and depending on the methodology and season of study, the specific rates of influenza, rsv, parainfluenza viruses, coronaviruses, hmpv, and rhinoviruses vary. 116, 117 wheezing appears to be a common symptom in older adults infected with any of the respiratory tract viruses, particularly rsv and hmpv, and 7% of adults hospitalized with rsv will have a discharge diagnosis of asthma. 114, 118 because most adult infections represent reinfection, the viral load in respiratory secretions tends to be low, making detection with conventional techniques difficult. viral culture and rapid antigen testing, which can be used successfully in children, have poor sensitivity in older adults. the use of molecular diagnostics has vastly improved the ability to detect a number of viruses, such as rsv, parainfluenza, and rhinoviruses, and allows the detection of hitherto uncultivable agents, such as hmpv and coronaviruses. viral infections appear to aggravate reactive airway disease through a number of different mechanisms. it has been postulated that viral infection disrupts the negative feedback loop of acetylcholine on the m2 receptor, leading to increased levels of acetylcholine and increased constriction of bronchiolar smooth muscle. 119 infection of the respiratory epithelium also induces chemokines, cytokines, and immune and growth factors, which result in a proinflammatory state. 120, 121 immunosenescence might affect the ability of older adults to clear viruses efficiently, and thus greater and more prolonged inflammation can result. in summary, respiratory viral tract infections are common among older adults and are likely precipitants of acute asthma exacerbations. furthermore, viral respiratory tract infections might likely precipitate the onset of loa, although this needs to be further examined. 122 comprehensive studies regarding the rates and specific pathogens are lacking in older adults. distinguishing copd from asthma, lack of sensitive diagnostic tests, and issues with asymptomatic infections make it difficult to define the role of infections in older adults. classic symptoms of asthma in the elderly are mostly similar to those seen in younger asthmatic patients. 4, 96 data on the clinical features of asthma in the elderly have been derived from both longitudinal community surveys and case studies. 5, 64, 97, 98, [122] [123] [124] most patients complain of episodic wheezing, shortness of breath, and chest tightness. these symptoms are often worse at night and with exertion and, like those in younger asthmatic patients, are often precipitated by an upper respiratory tract infection. in fact, the majority of elderly patients who have asthma after age 65 years have their first asthmatic symptom preceded immediately by or concomitant with an upper respiratory tract infection. 122 asthma can often be triggered by environmental exposures, such as aeroallergens, irritants (cigarette smoke, household aerosols, and paints), strong odors (perfumes), and inhalation of metabisulfites (found in beer, wine, and food preservatives). asthmatic symptoms can also be triggered by medications, such as aspirin, nonsteroidal anti-inflammatory agents, angiotensin-converting enzyme inhibitors, or b-blockers, which are commonly used by this patient population. this emphasizes the need for the physician to perform a comprehensive review of medications taken by the older asthmatic patient. studies have consistently shown that elderly patients and their physicians frequently overlook symptoms caused by asthma. 5, 73, 125 several factors contribute to the underdiagnosis and misdiagnosis of asthma. one reason, as shown in large community studies, is that most patients first have asthma in childhood or adolescence, and many physicians have had the misconception that asthma is a childhood disease. another important reason is that the symptoms of asthma are more commonly associated with other diseases seen in this age group. the symptoms of asthma in the elderly are therefore nonspecific and might be caused by conditions that mimic asthma. the differential diagnosis of asthma in the elderly is greater than seen in younger asthmatic patients and includes congestive heart failure, emphysema and chronic bronchitis (copd), chronic aspiration, gastroesophageal reflux disease (gerd), and tracheobronchial tumors. comorbid illnesses and the psychosocial effects of aging might also profoundly affect the diagnosis, clinical presentation, and care of asthma in the elderly. one particular diagnosis that is often difficult to detect and frequently overlooked by the patient and physician until the condition is advanced is upper airway obstruction, including the extrathoracic and intrathoracic central airways. common causes of upper airway obstruction include malignancy, infection, inflammatory disorders, trauma, and extrinsic compression related to enlargement of adjacent structures (eg, an enlarged thyroid gland). it appears that malignancy and benign strictures related to airway instrumentation (eg, endotracheal intubation and tracheostomy) are becoming increasingly more prevalent in the older age group. distinguishing chronic asthma from copd can be very challenging, and in some patients asthma cannot be distinguished from copd with widely available diagnostic tests. the management of these patients might have similarities to that of asthma. the distinction between loa and copd can be difficult to define precisely. the lung health study showed that methacholine-induced airways reactivity is present in many patients with mild-to-moderate copd (ie, 63% of men and 87% of women). approximately 85% of patients with tobacco-related copd demonstrate bronchodilator reversibility at least once on repeated testing sessions. the distinction between copd and asthma can be confounded by either the coexistence of the 2 common disease entities, the progression of common pathobiologic mechanisms induced by different environmental agents, or different disease mechanisms leading to an overlapping clinical syndrome. it has been known for more than a century that early-morning wheezing is a prominent symptom of congestive heart failure. it has been called cardiac asthma because it can mimic the clinical picture of typical asthma. the usual symptoms of gastroesophageal reflux in the elderly, such as vomiting and heartburn, might be absent. in a study of elderly patients with esophageal reflux proved by means of intraesophageal ph monitoring, chronic cough, hoarseness, and wheezing were present in 57% of patients. 126 in addition to causing asthma-like symptoms, there is also evidence that gerd might be a cause of worsening asthma. shortness of breath is a common symptom in the elderly and is most commonly caused by heart or lung diseases. it is usually experienced during exertion. shortness of breath at rest is not typical of heart disease or lung diseases, such as copd or interstitial lung disease, except in advanced stages. when present, it should prompt an investigation for asthma because sudden bronchospasm can cause respiratory distress at rest or exercise. paroxysmal nocturnal dyspnea, which is typical of congestive heart failure, is found in a smaller number of elderly patients with asthma. many elderly patients limit their activity to avoid experiencing dyspnea, and others assume that their dyspnea results from their aging process and thus avoid seeking medical attention early in their disease process. however, aging per se does not cause dyspnea, and a cause needs to be always pursued in assessing an elderly patient who complains of breathlessness. there are several other reasons why the diagnosis of asthma in the elderly might be delayed or not made at all. elderly patients have been shown to have a reduced perception of bronchoconstriction, 127 and this might delay medical intervention. many elderly patients are fearful of having an illness and dying and are reluctant to admit they are having symptoms. underreporting of symptoms in the elderly might have many causes, including depression, cognitive impairment, social isolation, denial, and confusing symptoms with those of other comorbid illnesses. cough is a very prominent symptom and might occasionally be the only presenting symptom. wheezing, on the other hand, might not be as prominent, and its presence is not very specific and does not correlate with severity of obstruction. physical examination in elderly patients with asthma is usually nonspecific and might misguide the diagnosis: a negative examination result does not rule out asthma, and wheezing can be found in a number of conditions, such as copd, recurrent aspiration, and ''cardiac asthma'' (congestive heart failure). two distinct clinical presentations have been described for asthma in the elderly. these are based on the onset and duration of the disease state. 97, 124, 128 patients with loa start having asthma symptoms for the first time when they are 65 years of age or older (some studies have suggested middle age or older). some studies of elderly asthmatic patients have shown that, as a group, as many as 40% will have their first attack after the age of 40 years. 97 patients belonging to this group tend to have fewer atopic manifestations, higher baseline fev 1 , and a more pronounced bronchodilator response than those with lsa. patients with lsa start having asthma symptoms early in life. patients belonging to this group tend to have a higher incidence of atopic diseases, more severe and irreversible or partially reversible airway obstruction, and more hyperinflation. the duration of the disease in this group is an important determinant of severity and of the development of irreversible airflow obstruction. 128 longitudinal studies of asthmatic populations, whether new onset or long standing, have shown that remission from asthma is uncommon in older groups, occurring in less than 20% of patients. 130 this contrasts with asthma in children and adolescents, in whom remission of asthma symptoms is common, especially in the second decade of life, and might be seen in as many as 60% to 70% of patients. objective measures to confirm the diagnosis of asthma are uncommonly performed in primary care settings. inhalers are prescribed for patients who are evaluated for asthma-like symptoms, and during a follow-up visit, the patient is asked whether the controller inhaler reduced the frequency of asthma symptoms or whether the albuterol inhaler quickly relieved the symptoms. such an empiric approach might work most of the time for young patients with mild asthma but is more likely to result in an incorrect diagnosis, poorly efficacious treatment, or unnecessary medication side effects in older patients. the onset of wheezing, shortness of breath, and cough in an elderly patient is likely to cause concern. although the adage ''all that wheezes is not asthma'' is true at any age, it is especially true in the elderly. diagnosis based on objective measures is essential. moreover, lung function testing, even in the presence of minimal symptoms, is especially important in this age group because there is thought to be an age-related reduction in the perception of exertional dyspnea in the elderly. 125 an older patient with chronic, untreated, severe airway obstruction caused by asthma might reduce activity to avoid dyspnea and stoically deny impairment of activity. this might reflect either neurocognitive function or changes in lifestyle that favor sedentary activities. there exist some barriers to lung function testing in the elderly. spirometry might be difficult to perform in some situations because of physical or cognitive impairments. however, 80% to 90% of elderly persons are able to perform goodquality spirometry when tested by skilled technologists. [129] [130] [131] [132] [133] the global initiative for obstructive lung disease guidelines for diagnosing the airway obstruction of copd by using a fixed fev 1 /fvc ratio of less than 0.70 caused a high misclassification rate in older persons. 134 however, almost all computerized spirometers automatically calculate the appropriate lower limit of the normal range for fev 1 /fvc ratio and for fev 1 by using race-specific national health and nutrition examination survey iii reference equations. in addition, it is hard to define the lower limits of predicted normal values in this age group. although complete reversibility of airflow obstruction is frequently seen with young asthmatic patients, most elderly asthmatic patients show incomplete reversibility despite continuous intense therapy, and many show fixed airflow obstruction as if they have copd. however, objective measures of lung function, such as spirometric and peak flow measurements, are generally underused in elderly patients, and this also contributes to the delay or absence of diagnosis. 134, 135 lung function testing is especially important in this age group because of the age-related reduction in the perception of dyspnea seen in the elderly. 127 spirometry is easily performed to determine that fev 1 and fev 1 /fvc ratio are demonstrated with the timed vital capacity maneuver. the flow-volume loop, which also measures inspiratory flow, is especially useful when the cause of respiratory tract symptoms is not known and an upper airway obstruction is in the differential diagnosis. although it might be difficult to perform spirometry in the elderly in some situations because of physical and poor cognitive impairment, studies have demonstrated that between 82% and 93% of elderly patients are able to perform the test properly. [131] [132] [133] [134] [135] on the other hand, it might be more difficult to define the lower limits of predicted normal values in this age group. traditionally, an fev 1 /fvc ratio of less than 70% increases the probability of asthma in an elderly patient with asthma symptoms, but this ratio normally decreases with age because of a decrease in elastic recoil, and a ratio lower that 70% might be a normal finding. 136 a brisk response to a short-acting bronchodilator might demonstrate the second cardinal feature of asthma: reversible airflow obstruction (ie, ''a responder''). when airflow obstruction is found in an elderly patient, attempts should be made to demonstrate reversibility after the inhalation of a short-acting b-adrenergic agent, such as albuterol. evidence of reversibility (postbronchodilator fev 1 or fvc increases of >12% and 200 ml) increases the probability of a diagnosis of asthma. elderly asthmatic patients, however, might have an impaired b-agonist bronchodilator response because the number of b-adrenergic receptors on smooth airway muscles is decreased with aging. 137 although the bronchodilator response to inhaled b-agonists decreases with age, 138 this is not the case with anticholinergic agents. 139 airway obstruction might be absent at the time of testing, and further testing might be needed to facilitate the diagnosis. bronchoprovocation testing with a methacholine challenge can be useful, and it is a safe and effective method to uncover asthma in older adults. 140, 141 a negative test result will rule out asthma; a positive test result must be interpreted and include an assessment of pretest probability. 142 in addition, some studies have shown that bronchial responsiveness is heightened in older adults, and therefore aging might be an independent factor that influences airway responsiveness. 143 there is a relationship between the degree of bronchial hyperresponsiveness and prechallenge pulmonary function; a low fev 1 predicts heightened responsiveness. 144 other factors that might contribute to heightened airway responsiveness in the older population are atopy and current or previous smoking history. peak expiratory flow variability might be helpful in the diagnosis and follow-up of younger patients with asthma, but poor coordination and muscle weakness in some elderly patients might lead to an inaccurate reading. 52, 145 a prospective study did not demonstrate any advantage of peak flow monitoring over symptom monitoring as an asthma management strategy for older adults with moderate-to-severe asthma when used in a comprehensive asthma management program. 146 other tests, such as measuring the carbon monoxide diffusing capacity of the lung, have been advocated to distinguish between asthma and copd because the diffusing capacity of the lung is reduced by parenchymal destruction found with emphysema. however, studies have shown that differences in lung function tests, although statistically significant, cannot be used clinically to separate the 2 groups of subjects because of a large overlap. 147 there is growing evidence that the airway function of young and middle-aged asthmatic patients decreases at a greater rate than that of healthy subjects. [148] [149] [150] the rate of decrease increases with increasing age and in those who smoke cigarettes. 149, 151 in patients with loa, there is evidence that lung function is reduced even before a diagnosis is made and decreases rapidly shortly after diagnosis. 98, 152 thereafter, it remains fairly stable. although the effect on older asthmatic patients with lsa is variable, in a random survey of 1200 elderly asthmatic patients older than 65 years, only 1 in 5 patients had normal pulmonary function (fev 1 >80% of predicted value), whereas a similar number showed moderate-to-severe airflow obstruction (fev 1 <50% of predicted value) after an inhaled short-acting bronchodilator. 153 because structural changes of emphysema are minimal in elderly asthmatic patients, except if they are previous smokers, airway remodeling is thought to be the main cause of fixed airflow obstruction. nitric oxide (no) is a gas generated by the action of no synthase from the substrates molecular oxygen and arginine. it was originally identified as a biologically important signaling molecule with the properties of an activity previously described as endothelial-derived relaxing factor. this molecule is important in regulating vascular integrity and blood flow and is thought to be a regulator of vascular smooth muscle relaxation. more recently, it has been found that no can be generated by a variety of inflammatory cells, including polymorphonuclear leukocytes, mononuclear cells, and, importantly, eosinophils. this finding led to the identification of no as a molecule present in exhaled breath. studies of no exhalation have found that it is increased in infection and inflammation of the airway. although high levels of no are found in nasally expired air, studies in pulmonary inflammation have avoided this by redirecting airflow through the oral airway. it has been found that exhaled no reflects airways inflammation and particularly eosinophilic inflammation. exhaled no levels are increased during the allergy season in atopic subjects. inhaled glucocorticoids promptly suppress exhaled no and do so in conjunction with suppression of eosinophilic inflammatory infiltrates. studies have demonstrated that monitoring exhaled no might permit better regulation of asthmatic symptoms, exacerbations, and total steroid use than treatments based on guidelines or symptoms. furthermore, increases in exhaled no levels might predict asthma exacerbations. 154 it is of interest that no levels in expired air decrease after bronchoconstrictive stimulation of asthmatic airways. little is known of the effects of age on no levels in the expired air. it appears that no production and vascular responses to no might be diminished in the elderly, but that effect might be overcome by exercise to increase fitness. an unanswered question in airways biology is whether no is causative of airways dysfunction, a marker for this dysfunction, or an ineffective homeostatic response to airways constriction. [155] [156] [157] [158] [159] challenges in defining asthma in the elderly there is agreement that asthma is both a common and underrecognized health problem for the elderly that leads to impairments of lung function and quality of health and life. the first question that needs to be addressed is why we need to make such a diagnosis rather than just treat the symptoms. there are reasons that physicians must strive to assign a diagnosis to a patient with a symptom complex. the patient is given relief by letting him or her know what is wrong by giving the illness a name, which implies a cause, establishes a prognosis, and initiates a treatment plan. moreover, advancement of the understanding of epidemiology, natural history, pathobiology, and treatment require a definable disease entity. whether the threshold for diagnostic criteria is set at a high level of sensitivity, a high level of specificity, or a high level of accuracy depends entirely on the costs and benefits of an incorrect diagnosis versus a missed diagnosis. for example, enumeration of a disease might require a high level of accuracy, whereas diagnosis of an uncommon and difficult-to-treat disease (eg, metastatic cancer) ought to be highly specific. the diagnosis of a common and easily treatable disease (eg, vitamin deficiency) ought to be highly sensitive, even if there is a risk of overdiagnosis. asthma tends to be one of those disorders that is relatively easy (although not inexpensive) to treat and has morbid consequences if left untreated, suggesting that the diagnostic criteria ought to be highly sensitive. although medical students are taught the rigorous discipline of data collection, differential diagnosis, and test confirmation, most physicians do not practice this way. in practice, physicians typically rely on a constellation of signs and symptoms along with demographic characteristics and recent experiences to establish diagnoses through the process of pattern recognition. there are no shortages of official definitions of asthma, and modifications seem to be added every year. most of these definitions involve the definition of a clinical syndrome (episodic cough, wheezing, and dyspnea), an underlying pathophysiology (airway hyperresponsiveness, variable, and reversible airflow obstruction), an underlying biological process (chronic eosinophilic or neutrophilic inflammation of the airways), and an associated morbid anatomy (basement membrane thickening, smooth muscle hypertrophy, and mucus cell metaplasia). given this, why is it so challenging to diagnose asthma in the elderly? first, the syndrome of asthma is often confused with other common diseases in the elderly, such as copd, congestive heart failure, paroxysmal arrhythmias, pulmonary emboli, recurrent aspiration, and gerd. second, asthma can often coexist with these other conditions, and it can be impossible to determine which of the 2 conditions is responsible for the patient's ill health. this diagnostic confusion can be amplified by the different manifestations of asthma in the elderly. elderly asthmatic patients can be insensitive to exertional dyspnea because of a sedentary lifestyle. they tend to be less atopic and have an incomplete response to bronchodilators. the elderly without asthma tend to show some signs suggestive of asthma: slower emptying of the lung during forced expiration, decreased lung elastic recoil, and a higher prevalence of nonspecific airways reactivity. the hope that formal testing of airways reactivity would prove useful in diagnosing asthma has led to disappointment. in young adults a history of asthma, wheeze, or treatment for asthma plus a positive methacholine challenge test result is highly specific for asthma (99%) but misses about half of the asthmatic population. 160 in epidemiologic studies that have examined various criteria for diagnosing asthma, it turns out that the solution is relatively j allergy clin immunol volume 128, number 3 simple. patients who answer yes to the question ''have you ever had asthma?'' have nearly 100% specificity and 48% to 100% sensitivity when compared with those receiving an independent expert's diagnosis. 161, 162 the problem of diagnosing asthma in the elderly is more complicated because of the overlap with copd. asthma is typically considered a disease of onset in youth driven by atopy and eosinophilic inflammation causing reversible airflow limitation. copd, in contrast, is considered to be a disease of onset in middle age driven by cigarette smoking and neutrophilic inflammation and leading to irreversible airflow limitation. as evidence presented in this workshop has shown, asthma in the elderly displays many of the features of copd. the disease can have its symptomatic onset late in life, often is only partially reversible, and is associated with neutrophilic inflammation. moreover, the current cohort of elderly patients has a high prevalence of past smoking, reflecting the health habits in the united states in the 1940s and 1950s. the failure to deal with the population of elderly patients who have overlapping signs of asthma and copd is not just a matter of classification of disease. it has significant health consequences in that such patients are systematically eliminated from clinical trials and are not covered by treatment guidelines. little is known about how best to treat the elderly patient with asthma who smokes or the elderly patient with copd who has reversible airflow limitation. this confusion is manifest by diagnostic coding in older medicaid patients. of those who were hospitalized with an initial diagnosis of copd, 43% had an asthma diagnosis within 3 years. of those who had an initial hospital diagnosis of asthma, 46% had a diagnosis of copd within 3 years. price et al 161 attempted to develop a discriminant function using clinical and demographic information that would separate patients with copd from those with asthma by using strict physiologic criteria. although several discriminating characteristics were found, the best diagnostic criteria were only 78% sensitive and only 75% specific. we need to ask whether it really is important to make the distinction between asthma and copd in the elderly in terms of prognosis or treatment. one study by hansen et al 136 suggests that regardless of whether a person is given a diagnosis of asthma or copd, the prognosis is mostly determined by the impairment in fev 1 . there are a number of ways to measure the effect of asthma in both young and elderly patients. assessments of symptoms, functional limitations, quality-of-life measures, and risk of adverse events are several that have been suggested by current asthma guidelines. 163 in addition, measuring a patient's satisfaction with his or her asthma symptom control and overall asthma care has been advocated. the use of objective measures of asthma control and satisfaction can be especially important in the elderly because the perception of symptoms might be impaired with advancing age. in addition, many elderly patients unconsciously accommodate to their symptoms or assume that the symptoms are a function of the aging process itself. because the number of unscheduled ambulatory visits, emergency department visits, and hospitalizations are high in elderly asthmatic patients, 164 ,165 and quality-of-life scores are low in elderly patients with persistent asthma when compared with those with mild asthma or no asthma at all, 5 careful assessment of asthma control is essential in this age group. despite severe symptoms and physiologic impairment, most elderly patients with asthma can lead active productive lives if their asthma is appropriately managed. in fact, when elderly patients with severe or difficult-to-treat asthma have been identified by a physician's assessment, they appear to do better than younger patients. in the tenor study, despite lower lung function, older asthmatic patients (mean age, 72 years) had lower rates of unscheduled office visits, emergency department visits, and corticosteroid bursts. 81 patients reported in the tenor study received more aggressive care than younger adults, including higher use of inhaled and oral corticosteroids, and this undoubtedly had an effect on outcomes. the tools to measure asthma outcomes include questionnaires and other self-report tools, such as diaries and standardized medical history forms. standardized questionnaires that assess asthma impairment include the asthma control test, 166, 167 the asthma control questionnaire, 168,169 the asthma therapy assessment questionnaire, 170, 171 and others. [172] [173] [174] [175] there are many tools available to clinicians to assess the quality of life of asthmatic patients. [176] [177] [178] [179] [180] [181] [182] [183] unfortunately, these psychometric instruments that claim to measure the same outcomes might produce disparate results, and none have been targeted for the elderly. in general, results that measure several domains are more accurate when a composite score is derived rather than when subscores of specific domains are compared. medical, administrative, and pharmacy records have also been used, especially to study larger asthmatic populations; these have proved useful for the assessment of a patient's change over time and to measure group differences. clinical trials of asthma therapy and educational, selfmanagement, and health services interventions have used psychometric instruments to assess elderly patients with asthma. in most of these studies, however, the majority of subjects are younger. there are no studies that have specifically determined the reliability and validity of these instruments in elderly persons. this is true of patient-satisfaction measures that have been used to assess asthma care. [184] [185] [186] this is much needed because using lung function testing to measure outcomes has potential limitations in this age group. there are difficulties in defining normal predicted values at a very advanced age, and many patients with physical or cognitive impairment cannot reliably perform these tests. it is hopeful that newer biomarkers of lung inflammation have a particular role to play in the assessment of asthma control in the elderly. tools assessing physical function: self-reported and objective a major goal of geriatric and gerontologic research is to reduce the decrease in cognitive and physical function and prevent disability among older adults. accordingly, many functional status measures have been developed and used to understand the disabling process, as well as to evaluate interventions to prevent functional decline. it is useful to identify instruments that measure functional limitations and disability to investigate the functional consequences of asthma in older adults and to understand the pathway from asthma to disability. functional limitations are restrictions in performing basic physical and mental actions at the whole-person level (eg, walking or climbing stairs), whereas disability refers to limitations or difficulty in performing socially defined roles or tasks of everyday living in a given environmental context (eg, grocery shopping or bathing). 187, 188 both self-reported and objective measures can be used to measure these different stages of disablement. 189 self-reported measures can provide an indication of how well a patient is functioning in daily life and provide an assessment of care needs. these measures incorporate self-perception of function and can assess adaptations made to compensate for decrements in function. 190 for disability assessment, self-reported difficulty or inability to perform basic activities of daily living (adl) is commonly used. for example, a composite score of 8 adl items has been used as an outcome to evaluate the efficacy of a program to prevent functional decline in frail older adults. 191 other composite scores assessing difficulty in ambulation, stair climbing, transferring, upper extremity function, and basic and instrumental adls have been developed. 192 these comprehensive instruments of function and disability are amenable to computer adaptive testing. 193 several objective measures of physical performance are used in studies of older adults and in disease-specific patient populations. tests of physical performance eliminate subjective attitudinal differences in the patient's reporting of physical function limitations. they have the advantage of providing an objective measure for comparisons across populations. 194 these tests are sensitive to change over time and can detect decrements in function that might not be observed with self-reported instruments. many studies in older adults have used physical performance tests as predictors of adverse health events, as well as outcomes. for example, the short physical performance battery, which consists of timed balance, walking, and chair-rise tasks, is a powerful predictor of disability, nursing home admission, and mortality. 195, 196 the short physical performance battery was also used as a screening instrument to identify functionally limited older adults and as an outcome in a randomized controlled trial of exercise. 197 increasingly, objective measures of physical function are used to summarize the effect of total disease burden, including subclinical conditions and impairments, and to identify physiologic reserve that might help some older adults cope with disease burden. clinically meaningful differences have been established for commonly used performance measures. 198 the goals of asthma therapy in elderly patients are not different from those for younger asthmatic patients. 96 they are to treat acute symptoms, prevent chronic symptoms, decrease emergency department visits and hospitalizations, preserve normal activity level, and optimize pulmonary function with a minimal adverse effect from medications. 163, 199, 200 optimal management should also focus on improving health status (quality of life) in these patients, which is often complicated by depressive symptoms and side effects from the drugs commonly used for asthma. 201 unlike many younger adults who might require no medication or just asneeded b-agonist therapy for occasional symptoms, most older asthmatic patients need continuous treatment programs to control their disease. at a time when memory loss is common and financial resources are often limited, many older patients require complicated and frequent dosing with multiple expensive drugs. unfortunately, this has led to a significant rate of noncompliance among the elderly population in general. 45 sex, socioeconomic factors, educational level, marital status, and severity of disease do not seem to be good predictors of compliance in elderly asthmatic patients. in summary, there are many challenges in the treatment of asthma in the elderly, which include a greater propensity to experience adverse events from medication use, as well as potential drug interactions with medications used for the treatment of comorbidities, 4,96 and thus it is particularly important to treat any disease in the elderly, including asthma, with a minimum of therapy while attaining maximum efficacy. a thorough understanding is required regarding which medications will be most effective in the treatment of asthma in the elderly to achieve this balance. because many current therapeutic options and those in development for asthma focus on specific inflammatory cells and mediators, any age-related changes in the airway inflammatory milieu will likely affect their therapeutic efficacy. therefore a rigorous characterization of age-related changes in airway inflammation will facilitate the management of asthma in the elderly. the therapeutic approach to asthma in elderly patients does not differ from what is recommended for young patients. statements on the standard of care for treating asthma have been published by the national institutes of health and are widely used as guidelines. 163, 199 treatment protocols use step-care pharmacologic therapy based on the intensity of asthma symptoms and the clinical response to these interventions. as symptoms and lung function worsen, step-up or add-on therapy is given. as symptoms improve, therapy can be stepped down. in this age group special attention should also be given to the potential adverse effects of commonly used medications. corticosteroids are capable of reducing airway inflammation, thereby improving lung function, decreasing bronchial hyperreactivity, reducing symptoms, and improving overall quality of life. oral corticosteroids should be avoided if possible because they place the patient at risk for bone fracture and increased likelihood of cataracts, muscle weakness, back pain, bruising, and oral candidiasis. 202 many studies have shown that inhaled corticosteroids are safe and effective treatment for persistent asthma, but none have specifically targeted the elderly population. long-term use of inhaled corticosteroids has been associated with a good safety profile, but higher doses of inhaled steroids (eg, >1000 mg/d) are capable of causing hypothalamicpituitary-adrenal axis suppression. local adverse effects, such as hoarseness, dysphonia, cough, and oral candidiasis, do occur but can usually be avoided by the use of a spacer or holding chamber with the metered-dose inhaler and by rinsing the mouth after each use. despite the pivotal role of inhaled corticosteroids in asthma, many elderly patients are undertreated with this group of medications. 5, 203 leukotriene-modifying agents (ltms) are also asthma controllers. these agents have been shown to be effective in preventing allergen-induced asthma, exercise-induced asthma, and aspirin-induced bronchospasm. studies on their use in the elderly are limited. when compared with ltms, low-dose inhaled corticosteroids have favored the latter. the ltms might also reduce asthma exacerbation rates and the need for steroid bursts. the ltms are generally very safe. 66, 204 b-adrenergic agents are important medications in the acute and chronic management of asthma. elderly patients with asthma j allergy clin immunol volume 128, number 3 might be less responsive to certain bronchodilators compared with younger patients. 73, 138 inhaled short-acting b 2 -adrenergic agonists are the treatment of choice for the acute exacerbation of asthma symptoms. despite the minimal systemic absorption seen with these agents, slight tachycardia might be observed. this is presumably because of vasodilatation, which results from the stimulation of b 2 -receptors in vascular smooth muscle. tremor can also occur and is especially troublesome in the geriatric patient. tremor is thought to be caused by stimulation of b 2 -receptors in skeletal muscle. in general, they have been proven to be safe and effective in all age groups. 205 however, b-agonists can cause (1) a dose-dependent decrease in serum potassium levels and (2) a dose-dependent increase in the qt interval on electrocardiography. because sudden death from ventricular arrhythmia can be caused by both of these mechanisms, as well as being a complication of ischemic heart disease, the use of b-agonists in the elderly should be closely monitored. short-acting b 2 -agonists should be used for rescue of symptoms, whereas long-acting agents should be used as maintenance medications only as an add-on to inhaled corticosteroids and never as stand-alone therapy. anticholinergics, such as inhaled ipratropium, a short-acting bronchodilator, and tiotropium, a bronchodilator with 24-hour action, have an excellent safety profile in the elderly. they should be considered when additional bronchodilator therapy is necessary; however, their role in long-term maintenance of asthma in the elderly has not been established. theophylline is an effective bronchodilator and has some antiinflammatory properties. however, its use has been greatly reduced over the past decade because of safety concerns, especially in the elderly. the narrow therapeutic range of theophylline, the frequency of concomitant illnesses that alter theophylline kinetics, and many drug interactions that affect the clearance of theophylline make it essential to closely monitor blood theophylline levels in older asthmatic patients. theophylline toxicity can cause seizures and cardiac arrhythmias, such as atrial fibrillation, supraventricular tachycardia, ventricular ectopy, and ventricular tachycardia. the most common cause for theophylline toxicity is a self-administered increase in medication. controlling triggers. measures should be taken to avoid triggers that can cause worsening of symptoms. as with asthma at any age, education concerning avoidance of aggravating factors that can lead to severe bronchospasm is very useful. although aeroallergens are less important in provoking symptoms in the elderly than in young patients, a program implementing environmental control measures, such as avoiding or minimizing aeroallergen exposure, should be instituted in patients with documented sensitivity to specific allergens. however, such programs might not be successful in all cases, especially because lifestyle changes in the elderly population might be difficult. the most important provocative factors include viral respiratory tract infections and irritants, such as cigarette smoke, paints, varnish, and household aerosols. pharmacologic agents that are often prescribed for concomitant illnesses (ischemic heart disease and hypertension), such as b-adrenoreceptor antagonists (b-blockers), can also provoke bronchospasm. 206 this includes both noncardioselective agents (propranolol, pindolol, and timolol) and, to a lesser extent, cardioselective agents (metoprolol and acebutolol). topical b-blockers are also widely used in the elderly to reduce intraocular pressure in wide-angle glaucoma. with such treatment, sufficient systemic absorption might cause fatal status asthmaticus. 207 the severity of b-blocker-induced bronchoconstriction correlates with the severity of underlying airflow obstruction and the degree of bronchial reactivity and might be reduced by the use of a cardioselective topical b-blocking agent, such as betaxolol. 208 aspirin and nonsteroidal anti-inflammatory agents might precipitate acute bronchospasm in certain asthmatic patients, and angiotensin-converting enzyme inhibitors might cause dry cough in some, worsening the symptoms of asthma. gerd should also be considered a cause of worsening asthma symptoms. asthma education. the complexity of the prescription regimen (number and frequency of medications), coupled with the memory loss and cognitive dysfunction that might be present in this group of patients, contribute partially to poor compliance with therapy. 4, 96 patient education is an effective tool and should be an integral part in the management of asthma. 209 active participation by a patient and family members in monitoring lung function, avoidance of provocative agents, and decisions regarding medications provide asthma management skills that give that patient the confidence to control his or her own disease. mastering the technique of an inhaled medication delivery device is a challenging problem in elderly patients, and the great majority of elderly patients are unable to properly use the metered-dose inhaler, even after proper instruction. [210] [211] [212] [213] use of dry powder devices, although simpler, requires the generation of an adequate inspiratory flow that might be suboptimal in frail patients and those with severe airway obstruction. in such situations the use of spacer devices or nebulizers might be beneficial. patients should recognize the rationale behind using the different medications, the correct way to use them, and their side effects, and polypharmacy should also be avoided. asthma in the elderly can be effectively managed, and despite severe symptoms and physiologic impairment, most patients can lead active and productive lives. a demographic study of 380 low-income elderly persons in chicago found that 26 (10%) without a previous diagnosis of asthma or emphysema had symptoms compatible with those of obstructive lung disease. 214 of patients with a previous diagnosis, only 18% were compliant with medications, and this was largely due to the cost of medications. in addition, health care use was high in this population. telephone intervention offers a simple option in the management of elderly patients with asthma. it has been shown that asthma care by means of telephone triage of adult asthmatic patients can lead to a higher percentage of asthmatic patients being reviewed at less cost per patient and without loss of asthma control when compared with usual routine care in the outpatient clinic. 215 however, it has not been determined whether such an intervention could improve asthma care specifically in persons aged 65 years or older. the following study was designed to evaluate this question. fifty-two elderly asthmatic patients who used their rescue inhalers more than twice a week and had at least 1 emergency department or urgent care visit in the previous year were randomized to an intervention or control group. 216 all patients received 2 telephone calls over a 12-month period. the intervention group received an asthma-specific questionnaire, and the control group received a general health questionnaire. medication use and health care use were evaluated at the beginning and end of a 12-month period. the study was completed by 23 control and 25 intervention subjects. baseline data were similar in both groups. after 12 months, 72% (n 5 18) of the intervention group was taking an inhaled corticosteroid compared with 40% (n 5 10) of the control group. the intervention group had fewer emergency department visits when compared with the control group. sixtyfour percent (n 5 16) of the intervention group had an asthma action plan compared with 26% (n 5 6) of the control group. this study provides evidence that using a simple telephone questionnaire can successfully improve asthma care in the elderly. by empowering the elderly with the appropriate knowledge regarding their asthma, an appropriate discussion about their asthma care can be initiated with their primary care physicians. pulmonary rehabilitation. although pulmonary rehabilitation is recommended as the standard of care for patients with copd, there are only a few studies that evaluate the benefit of rehabilitation for asthmatic patients, and none of these consider elderly asthmatic patients. one study looked at the effects of a 10-week outpatient rehabilitation program for 58 asthmatic patients after 3 years. [217] [218] [219] they found that 39 of 58 subjects continued to exercise regularly all 3 years; there was a decreased number of emergency department visits and a decrease in asthma symptoms. further studies are needed to assess empowerment strategies for elderly patients with asthma, as well as the potential benefits of pulmonary rehabilitation on morbidity and mortality. asthma pathogenesis is complex and incompletely understood. research into the pathophysiologic mechanisms is made more difficult by multiple factors, including the heterogeneity of the disease itself, variable presentations in different stages of life, and the lack of highly relevant animal models. [220] [221] [222] [223] [224] in the last decade, increasing interest in asthma in the elderly has triggered more intensive investigation in both human and animal systems by using ever more sophisticated immunologic methodologies. early investigation with rats revealed a lack of total and allergenspecific ige in response to ovalbumin. 225 this was born out by several later in vivo studies. [226] [227] [228] igg subset analysis (igg 1 vs igg 2 ) provided further support for this phenomenon. igg 1 , correlating in the mouse to a t h 2 response (vs igg 2 [t h 1]) was shown to follow a similar pattern. 227, 228 recent studies [226] [227] [228] of cytokine profiles in aged rodents compared with young control animals enhanced the paradigm that age resulted in less robust t h 2 cytokines, particularly il-4, il-5, and il-13, in favor of t h 1 gene and protein expression. 227, 228 this pattern was not fully supported in a recent chronic murine asthma model 229 wherein il-5 was greater in aged sensitized mice, making the picture more complex. ifn-g, a key t h 1 cytokine, has been consistently overexpressed in aged versus young rodents. [226] [227] [228] [229] eosinophilia, which is considered a key component of (allergic) asthma, was more pronounced in younger versus older animals (bronchoalveolar lavage fluid, lung tissue, or both) after most, [226] [227] [228] 230 although not all, 229 sensitization paradigms. molecular genetics and t-cell subset analysis has allowed further insight into possible mechanisms underlying the waning t h 2 response observed in most models. [227] [228] [229] specifically, elderly mice appear to have more memory t cells, less activated cd4 1 t h 2 cells, and less activated monocytes. 227, 228 resident goblet cells also appear to express upregulation of mucin and mucin gene expression. 229 a key to the impaired t h 2 response was recently found in the gata3 pathway. 228 elderly mice do not phosphorylate components of the extracellular signal-regulated protein kinase/mitogen-activated protein kinase pathway, resulting in lack of downstream signaling with gata3, with subsequent impairment of promoter regions for key t h 2 cytokines, including il-4. this could be an overarching explanation for many findings in the elderly asthmatic patient, including less ige (il-4 and il-13 are needed for opening switch regions for ige production); il-4 and il-13 are highly associated with airway hyperreactivity, and il-5 is associated with eosinophil activation, survival, and, to a lesser extent, trafficking. finally, airway hyperreactivity has been universally found to be greater in young versus aged animals. [226] [227] [228] [229] 231 the mechanisms might be complex, including both an altered key cytokine milieu and alterations in muscle function at the muscarinic receptor level. [231] [232] [233] clinical and translational research research into the pathogenesis of asthma in recent years has led to the discovery of a number of novel, potentially important targets for the development of new treatment options. much of this research has focused on t h 2 lymphocyte-driven processes underlying allergic asthma and its characteristic eosinophilic airway inflammation. abundant information supporting this research has been derived from bronchial biopsy and bronchoalveolar lavage studies largely carried out in a young adult population. it is recognized, however, that the role of allergy and allergic triggers in asthma diminishes with age. 69, 234 in addition, loa is often less reversible, more severe, and frequently occurs in response to a viral respiratory tract infection. 153 a distinct asthma phenotype characterized by normal airway eosinophil numbers has been described. 235 moreover, normal airway eosinophilia might also be associated with abnormal sputum neutrophilia. 236, 237 recent studies have shown that neutrophilic asthma might be associated with activation of innate immune pathways in contrast to the adaptive immune response associated with t h 2-mediated allergic asthma. 238 thus alternative immune pathways involving natural killer t or t h 17 lymphocyte subtypes have been hypothesized as being potentially important in the pathogenesis of asthma, particularly in adult-onset asthma. 239, 240 just as the discovery of t h 2-related pathways has led to important leads in drug discovery for allergic asthma, further clinical research into these alternative pathways should be carried out with the goal of identifying new and exciting targets for future drug discovery. this research should focus not only on the discovery of new molecular targets but also on the identification of noninvasive biomarkers that will help predict the success of any new therapy in an individual patient. asthma is an important disease in the older adult, affecting 7% of the population older than 65 years, which is understudied and frequently underdiagnosed. there are data to suggest that asthma in older adults is phenotypically different from that in young patients, with a potential effect on the diagnosis, assessment, and management in this population. this workshop brought together many disciplines to further our current understanding, resolve gaps in knowledge, and explore future areas of research and education. table i lists specific areas in need of research and study. the coming acceleration of global population ageing the census bureau on prospects for us population growth in the twenty-first century. population and development review national surveillance for asthma-united states asthma in the elderly: current knowledge and future directions underdiagnosis and undertreatment of asthma in the elderly. cardiovascular health study research group increasing u.s. asthma mortality rates: who is really dying? quality of care for older adults with chronic obstructive pulmonary disease and asthma based on comparisons to practice guidelines and smoking status economic burden in direct costs of concomitant chronic obstructive pulmonary disease and asthma in a medicare advantage population report of the national institute on aging task force on comorbidity a painful interface between normal aging and disease epidemiology of aging correlation between deoxyribonucleic acid excision-repair and life-span in a number of mammalian species executing cell senescence a systematic look at an old problem overview of biological mechanism of aging molecular biology of aging replicative senescence: a critical review the limited in vitro lifetime of human diploid cell strains cell culture aging: insights for cell aging in vivo? the relationship between in vitro cellular aging and in vivo human age evidence for a relationship between longevity of mammalian species and life spans of normal fibroblasts in vitro and erythrocytes in vivo a biomarker that identifies senescent human cells in culture and in aging skin in vivo frailty in older adults: evidence for a phenotype phenotype of frailty: characterization in the women's health and aging studies from bedside to bench: research agenda for frailty gait speed and survival in older adults age-associated increased interleukin-6 gene expression, late-life diseases, and frailty decreased cell proliferation and altered cytokine production in frail older adults determinants of longevity: genetic, environmental and medical factors united states life tables gains in life expectancy after elimination of major causes of death: revised estimates taking into account the effect of competing causes extension of life-span by overexpression of superoxide dismutase and catalase in drosophila melanogaster a genetic pathway conferring life extension and resistance to uv stress in caenorhabditis elegans divergent roles of ras1 and ras2 in yeast longevity can an improved environment cause maximum lifespan to decrease? comments on lifespan criteria and longitudinal gompertzian analysis longitudinal gompertzian analysis of stroke mortality in the u.s., 1951-1986: declining stroke mortality is the natural consequence of competitive deterministic mortality dynamics nutritional interventions in aging and ageassociated diseases caloric restriction and aging physiological changes in respiratory function associated with ageing sex and age differences in pulmonary mechanics in normal nonsmoking subjects elasticity of human lungs in relation to age flow and age dependence of airway closure and dynamic compliance human immunosenescence: the prevailing of innate immunity, the failing of clonotypic immunity, and the filling of immunological space inflamm-aging. an evolutionary perspective on immunosenescence patient factors and medication guideline adherence among older women with asthma refill adherence by the elderly for asthma/chronic obstructive pulmonary disease drugs dispensed over a 10-year period deaths: final data for asthma costs and utilization in a managed care organization asthma and its association with cardiovascular disease in the elderly. the cardiovascular health study research group the cardiovascular health study: design and rationale prevalence and correlates of respiratory symptoms and disease in the elderly. cardiovascular health study correlates of peak expiratory flow lability in elderly persons intra-individual change over time in dna methylation with familial clustering epigenetic reprogramming and imprinting in origins of disease aging by epigenetics-a consequence of chromatin damage? epigenetics at the epicenter of modern medicine the role of histone deacetylases in asthma and allergic diseases environmental epigenetics and asthma: current concepts and call for studies epigenetics, disease, and therapeutic interventions epigenetic regulation of airway inflammation epigenetic differences arise during the lifetime of monozygotic twins predictors of loss of lung function in the elderly: the cardiovascular health study overcoming gaps in the management of asthma in older patients: new insights allergic respiratory disease in the elderly the diagnosis and management of asthma is much tougher in older patients effect of age on response to zafirlukast in patients with asthma in the accolate clinical experience and pharmacoepidemiology trial (accept) is asthma in the elderly really different? diagnosis and severity of asthma in the elderly: results of a large survey in 1,485 asthmatics recruited by lung specialists asthma in the elderly asthma medications and their potential adverse effects in the elderly: recommendations for prescribing interleukin 1 genetics, inflammatory mechanisms, and nutrigenetic opportunities to modulate diseases of aging trichostatin a attenuates airway inflammation in mouse asthma model prospective multicenter study of acute asthma in younger versus older adults presenting to the emergency department immunosenescence: emerging challenges for an ageing population pathways to a robust immune response in the elderly variation of bronchoalveolar lymphocyte phenotypes with age in the physiologically normal human lung neutrophils and low-grade inflammation in the seemingly normal aging human lung age-related changes in eosinophil function in human subjects asthma: defining of the persistent adult phenotypes characterization of leukotrienes in a pilot study of older asthma subjects asthma in older adults: observations from the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) study ige mediated hypersensitivity in ageing influence of ageing on ige-mediated reactions in allergic patients the association of age, gender and smoking with total ige and specific ige total and specific serum ige levels in adults: relationship to sex, age and environmental factors aging and serum immunoglobulin e levels, immediate skin tests, rast age-related serum immunoglobulin e levels in healthy subjects and in patients with allergic disease longitudinal changes in allergen skin test reactivity in a community population sample chronic respiratory symptoms and airway responsiveness to methacholine are associated with eosinophilia in older men: the normative aging study serum total ige and specific ige to dermatophagoides pteronyssinus, but not eosinophil cationic protein, are more likely to be elevated in elderly asthmatic patients respiratory viruses and exacerbations of asthma in adults clearing the air: asthma and indoor air exposures meta-analyses of the associations of respiratory health effects with dampness and mold in homes damp indoor spaces /media/files/report%20files/2004/damp-indoor-spaces-and-health/dampin door2pagerforpdf.pdf. accessed is allergen skin test reactivity a predictor of mortality? findings from a national cohort asthma in older adults asthma in the elderly. a comparison between patients with recently acquired and long-standing disease characteristics of asthma among elderly adults in a sample of the general population asthma severity, atopic status, allergen exposure, and quality of life in elderly persons asthma in the elderly sensitization to cat allergen is associated with asthma in older men and predicts newonset airway hyperresponsiveness. the normative aging study the role of allergy and airway inflammation asthma in the elderly: cockroach sensitization and severity of airway obstruction in elderly nonsmokers prick puncture skin tests and serum specific ige as predictors of nasal challenge response to dermatophagoides pteronyssinus in older adults particulate air pollution and hospital admissions for cardiorespiratory diseases: are the elderly at greater risk? traffic and outdoor air pollution levels near residences and poorly controlled asthma in adults community study of role of viral infections in exacerbations of asthma in 9-11 year old children respiratory tract viral infections in inner-city asthmatic adults the incidence of respiratory tract infection in adults requiring hospitalization for asthma acute respiratory illness in an american community. the tecumseh study acute respiratory tract infection in daycare centers for older persons long-term care facilities: a cornucopia of viral pathogens respiratory syncytial virus infection in elderly and high-risk adults human metapneumovirus infections in adults: another piece of the puzzle the similarities and differences of epidemic cycles of chronic obstructive pulmonary disease and asthma exacerbations a community-based, time-matched, case-control study of respiratory viruses and exacerbations of copd viral infections in patients with chronic obstructive pulmonary disease respiratory syncytial virus infection in elderly adults virus-induced asthma attacks how viral infections cause exacerbation of airway diseases role of viral infections in asthma and chronic obstructive pulmonary disease incidence and outcomes of asthma in the elderly. a population-based study in rochester, minnesota the clinical outcome of asthma in the elderly: a 7-year follow-up study characteristics of asthma in the elderly asthma in the elderly: underperceived, underdiagnosed and undertreated; a community survey determinants of symptoms suggestive of gastroesophageal reflux disease in the elderly reduced subjective awareness of bronchoconstriction provoked by methacholine in elderly asthmatic and normal subjects as measured on a simple awareness scale duration of asthma and physiologic outcomes in elderly nonsmokers asthma in the elderly features of asthma in the elderly factors determining performance of bronchodilator reversibility tests in middle-aged and elderly quality of spirometric performance in older people study of respiratory function in the elderly with different nutritional and cognitive status and functional ability assessed by plethysmographic and spirometric parameters quality control of spirometry in the 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direct and indirect stimuli in asthma height, age, and atopy are associated with fraction of exhaled nitric oxide in a large adult general population sample use of exhaled nitric oxide measurements to guide treatment in chronic asthma exhaled nitric oxide: the effects of age, gender and body size defining asthma in epidemiological studies symptom-based questionnaire for identifying copd in smokers asthma and asthma-like symptoms in adults assessed by questionnaires. a literature review national heart, lung and blood institute national institute of health. national asthma education and prevention program: expert panel report 2-guidelines for the diagnosis and management of asthma. bethesda: national heart, lung, and blood institute asthma in older patients: factors associated with hospitalization asthma exacerbations in north american adults: who are the ''frequent fliers'' in the emergency department? development of the asthma control test: a survey for assessing asthma control 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preclinical mobility disability predicts incident mobility disability in older women a program to prevent functional decline in physically frail, elderly persons who live at home a randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. the fitness arthritis and seniors trial (fast) creating a computer adaptive test version of the late-life function and disability instrument variation in thresholds for reporting mobility disability between national population subgroups and studies a short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability effects of a physical activity intervention on measures of physical performance: results of the lifestyle interventions and independence for elders pilot (life-p) study meaningful change and responsiveness in common physical performance measures in older adults naepp working group: consideration for diagnosing and managing asthma in the elderly. bethesda: national institutes of health asthma: a six-part strategy for managing older patients drug treatment of asthma in the elderly adverse effects of oral corticosteroids in relation to dose in patients with lung disease underuse of inhaled steroid therapy in elderly patients with asthma loss of response to treatment with leukotriene receptor antagonists but not inhaled corticosteroids in patients over 50 years of age are there any detrimental effects of the use of inhaled long-acting beta 2-agonists in the treatment of asthma? beta-adrenergic-blocking agents in bronchospastic diseases: a therapeutic dilemma respiratory arrest following first dose of timolol ophthalmic solution the effect of topical ophthalmic instillation of timolol and betaxolol on lung function in asthmatic subjects asthma in the elderly: the importance of patient education a comparison of breath-actuated and conventional metered-dose inhaler inhalation techniques in elderly subjects acquisition and short-term retention of inhaler techniques require intact executive function in elderly subjects what determines whether an elderly patient can use a metered dose inhaler correctly? asthma in the elderly. a diagnostic and management challenge prevalence of obstructive airways disease in the disadvantaged elderly of chicago targeted routine asthma care in general practice using telephone triage improving asthma care for the elderly: a randomized controlled trial using a simple telephone intervention asthmatic patients' views of a comprehensive asthma rehabilitation programme: a three-year follow-up a 3-year follow-up of asthmatic patients participating in a 10-week rehabilitation program with emphasis on physical training high-intensity physical training in adults with asthma. a 10-week rehabilitation program animal models of asthma usefulness and optimization of mouse models of allergic airway disease murine models of asthma modeling allergic asthma in mice: pitfalls and opportunities promise and pitfalls in animal-based asthma research: building a better mousetrap van der straeten m. the effect of age on ige production in rats decreased expression of th2 type cytokine mrna contributes to the lack of allergic bronchial inflammation in aged rats induction and maintenance of airway responsiveness to allergen challenge are determined at the age of initial sensitization impaired gata3-dependent chromatin remodeling and th2 cell differentiation leading to attenuated allergic airway inflammation in aging mice effect of ageing on pulmonary inflammation, airway hyperresponsiveness and t and b cell responses in antigen-sensitized and -challenged mice failure of aged rats to accumulate eosinophils in allergic inflammation of the airway age differences in cholinergic airway responsiveness in relation with muscarinic receptor subtypes effect of ageing on nicotine-induced contraction of guinea-pig bronchial preparation effects of age on muscarinic agonist-induced contraction and ip accumulation in airway smooth muscle total serum ige is associated with asthma independently of specific ige levels. the spanish group of the european study of asthma analysis of induced sputum in adults with asthma: identification of subgroup with isolated sputum neutrophilia and poor response to inhaled corticosteroids evidence that severe asthma can be divided pathologically into two inflammatory subtypes with distinct physiologic and clinical characteristics heterogeneity of airway inflammation in persistent asthma: evidence of neutrophilic inflammation and increased sputum interleukin-8 innate immune activation in neutrophilic asthma and bronchiectasis persistent activation of an innate immune response translates respiratory viral infection into chronic lung disease il-17 is increased in asthmatic airways and induces human bronchial fibroblasts to produce cytokines fla co-chair: nicola a. hanania, md, ms section of pulmonary and critical care medicine asthma clinical research center baylor college of medicine houston, tex members sidney s. braman, md warren alpert medical school, brown university division of pulmonary, critical care, and sleep medicine rhode island hospital providence, ri carol saltoun we thank the nia for recognizing the need for this workshop, especially susan nayfield, md, who convened the workshop and provided tremendous support in moving this research field forward; evan hadley, md, the director of the division of geriatrics and clinical gerontology; and basil eldadah, md, who continued the work of dr nayfield and contributed valuable advice and encouragement to the authors in completing these proceedings. key: cord-280210-6xivdgvt authors: eichner, e. randy title: writing on sports medicine in pandemic times date: 2020-07-08 journal: curr sports med rep doi: 10.1249/jsr.0000000000000731 sha: doc_id: 280210 cord_uid: 6xivdgvt nan it is humbling to write on sports medicine during a raging pandemic. but as a young man, long ago, i spent 2 years as a medical epidemiologist. so i try to keep up with epidemiology, even though at this writing, in may 2020, more than 10,000 scientific or medical articles have already appeared on this novel coronavirus, sars-cov-2, that causes the disease covid-19. even more challenging is that one third of these articles are not peer-reviewed; they appear on "preprint servers" that, for a price, publish verbatim anything you send them. so, against all odds, i will start with thoughts on infections and epidemics, on our primal fear of contagion, and on quarantine or "social distancing." then, i will address four questions i have received that are relevant to athletes. bear in mind the fast pace of this pandemic and our race to learn and cope. we have much more to learn about covid-19 than we have yet learned. so when this column appears in july, part of what i write now will prove to be wrong then. but i do not know which part. anyway, here i go. it is said that nothing in history has killed more people than infectious disease (id). several stellar nonfiction or popular science books agree that id has been a primary shaper of history. now is the time to read john barry's "the great influenza," on the deadliest plague in history, the influenza pandemic from early 1918 to early 1920 that killed up to 100 million people worldwide. it killed more people in 1 year, 1918, than the black death killed in a century. it killed 650,000 americans; during the "second wave" in 1918, as many as 200,000 americans died in a single month, october. three other books come to mind. the polymath jared diamond wrote "guns, germs, and steel" in 1996. he covers id as a shaper of why eurasian peoples conquered or displaced native americans, australians, and africans. but his theme is: human history follows geography. esteemed historian william mcneill wrote "plagues and peoples" in 1976. he aims to help explain human history by the ravages of id and epidemics. he credits smallpox for helping cortez conquer the aztecs and pizarro conquer the incas. he covers epidemics from ancient to modern times, including black death (bubonic plague) in the 14 th century and cholera in the 19 th century. his book, if speculative and eurocentric, is a novel look at history. my favorite is "rats, lice and history," by hans zinsser (1935). zinsser, a harvard microbiologist with a classical education, also traces epidemics throughout history, but he keys on typhus. he writes like none other, except maybe kurt vonnegut. he is cynical of humanity yet full of humanity. he shows sardonic wit and whimsical humor. he bounces all over, but it is fun to follow the bounces. he covers the sex life of the louse. he compares rats to man, saying "neither is of the slightest earthly use to any other species." he recounts an episode in the thirty years' war where typhus, "singlehanded," killed so many soldiers that it "defeated both armies before they could join battle." he also writes the best footnote ever, on the word saprophyte: "if the reader does not understand this word, it is too bad." our new quarantine is "social distancing." the key partto prevent spread of the virusis physical distancing, but it also is social distancing, until the extroverts come banging on the internet doors of the introverts via zoom. distancingor quarantineis a default measure to quell our primal fear of contagion when we lack other means to fight the dreaded id. early in the acquired immune deficiency syndrome panic, a boston neurosurgeon called for massachusetts to quarantine "irresponsible" carriers of human immunodeficiency virus on penikese island. penikese, a small, barren, windswept island 14 miles off new bedford, had a leper colony from 1905 to 1921. the boston doctor, frank parker, who moved to penikese (with his wife and a small staff) to care for the lepersfighting for them; always reminding them of their value, humanity, and dignitywas later ostracized by the good people of boston. he died fighting diphtheria in montana in 1926. frank parker was not honored by massachusetts until 1996 (1). quarantine began with leprosy, the great blight that shadowed medieval life. medicine had nothing to offer, so the church applied old testament principles to isolate lepers. the lepers wore shrouds, heard the mass for the dead, had earth thrown on them, and were led to huts outside the community. they were "quarantined" for life. quarantine came into its own when the black death exploded in europe in the mid-14th century. every house with a plague victim was placed under a ban. the duke of milan ordered all plague patients to be moved to a field outside the city to recover or die. venice isolated incoming ships in the lagoon. soon all travelers from plague-stricken areas were isolated for 40 dhence the term "quarantine," from quarantenaria, the latin word for 40 d (2) . today, nearly 700 years later, we face another dreaded scourge, a killing pandemic, and so far, quarantine is again our only friend. as kurt vonnegut would say: so it goes… now to the four questions i have received from sports medicine colleagues: question 1: is asthma a risk factor for severe covid-19? the early answer is: yes, then no, but we need more research. health organizations cautioned that those with asthma may be at higher risk, but they based this on questionnaires with an "umbrella" box (to check or not) that included asthma, chronic obstructive pulmonary disease, or emphysema. now, with clinical articles flooding in, asthma is "falling out." asthma was not named as a risk factor in a large case series from china. in new york, asthma is not even in the top 10 co-morbidities, and state officials say only 5% who died from covid-19 had asthma. a recent comment by european researchers also notes that asthma is "underrepresented" in those with covid-19. a study from seattle hospitals notes that 3 (12.5%) of 24 patients with severe covid-19 had asthma, but this is not significantly more than expected by chance. two pediatric studies apply. among 48 children in intensive care units (in the united states and canada) with covid-19, asthma was not prominent. among 177 children and young adults in the washington, dc area with covid-19, although 20% had asthma, it was not more common in those critically ill, and the authors judge that although asthma commonly flares from viral infections, with covid-19, asthma is not the primary determinant of severe disease. a laboratory study even suggests that allergic asthma may fend off severe covid-19. so yes, we need more research. question 2: are athletes with sickle cell trait prone to covid-19 or problems therefrom? the answer for now is no. african-americans and other minorities are hit harder by covid-19, but sickle cell trait (sct) has not been singled out. diverse clotting complications are increasingly being reported with covid-19, not just the expected deep venous thrombosis (dvt) and pulmonary emboli (pe) in some after weeks on ventilators, or the typical disseminated intravascular coagulation in those gravely ill, but also large vessel strokes in the young and even aortic occlusion just above the iliac arteries. some of these patients may prove to have inherited thrombophilias. along these lines, four epidemiologic studies of adults in various populations find that, over the years, when all else is equal, sct carriers have about a two-fold higher risk of pe, often without clearcut underlying dvt. why this should be is unclear; here too we need more research. question 3: if athletes test positive for the antibody, are they immune to this coronavirus? maybe. but no one yet seems to know how immune, or for how long. let me ask a question: say your antibody test is 99% reliable, but only 1% of your population of concern has the antibody. if a random person in that population tests positive, what is the chance he or she actually has the antibody? the intuitive answer is 99%. the correct answer is 50%. it is statistics, the bayes theorem. even doctors tend to answer wrong; they fall for the "base-rate neglect fallacy" (3) . even when the antibody-carrying rate rises to 5%, as it may be now in the nondense county in california where i live, 16% of the positives will be false positives. pitfall: antibody testing for this novel coronavirus is not yet failsafe. do not blame me; i was an english major. blame bayes. question 4: we tell our players to sit in the front row in classrooms, to feign interest in what the teacher has to say. this fall, in light of covid-19, should we tell them to sit in the back row? college classrooms full of students may be risky this fall. one person infected nine others in a small restaurant in china; one person infected 96 others in a call center in south korea; and one person infected 52 others (and two died) in a choir practice in skagit county, washington. a recent study finds that tiny respiratory droplets from normal speech can remain in the air for 8 minutes or longer. as the saying goes: "hope floats." alas, so does this coronavirus. bottom line: yes, tell them to sit in the back row, far from the teacherand 6 ft away from all others in the room. everyone should wear a mask. and pray that this fall is not like that of 1918. the tragic story of massachusetts' leper colony and the "lights of penikese island quarantine: the once and future shield? comparing risks of alternative medical diagnosis using bayesian arguments key: cord-022658-mq91h15t authors: nan title: executive summary date: 2008-12-30 journal: allergy doi: 10.1111/j.1398-9995.1998.tb04885.x sha: doc_id: 22658 cord_uid: mq91h15t allergic rhinitis is now recognized as a major cause of morbidity that significantly impairs function and quality of life. moreover, it is now widely held that the pathophysiologic mechanisms causing nasal allergy contribute, or predispose many individuals, to the development of other airway diseases, including asthma. allergic rhinitis may well be a factor in 24% of children with otitis media with effusion (ome), and perhaps 28% of cases of chronic sinusitis. as many as 78% of persons with asthma aged 15 to 30 years have elevated serum ige antibodies to five common aeroallergens. in many instances, nasal allergy signals the presence of more severe disease. considerable evidence now suggests that early and appropriate intervention can improve the quality of life and productivity of patients with allergic rhinitis, enhance the academic performance of children, and reduce the prevalence of airway complications. the goal of treatment has shifted from mere symptom alleviation to blocking the pathophysiologic mechanisms that cause chronic allergic inflammation and leave patients vulnerable to airway infections. the earlier in a patient's life that this can be accomplished, the better the anticipated consequences. a panel of experts was convened in amsterdam, the netherlands, on 2 september 1996, to explore these issues and their impact on allergy prevention and treatment in primary care. their undertaking was supported by an unrestricted educational grant from schering‐plough pharmaceuticals. allergic inflammation appears to be the first and primary occurrence in the chain of events leading to asthma and other airway disorders. chemical mediators released during hypersensitivity reactions give rise to the symptoms of allergic rhinitis, and induce the cell infiltration and activation that results in chronic inflammation. a key event in this process is the upregulation of specific intercellular adhesion molecules, including members of the immunoglobulin superfamily intercellular adhesion molecule-1 (icam-l), that permits inflammatory cells to migrate into nasal, sinus, and lung tissue. in certain conditions, inflammatory mediators stimulate the expression of icam-1, which is also a receptor for the subtype of human rhinoviruses that accounts for 90% of human rhinovirus infections. it is currently under investigation that allergen exposure and viral infection in the first 3 years of life may alter pulmonary and immune function irreversibly in genetically predisposed children. * moreover, these same mechanisms may contribute to other respiratory problems associated with eosinophilic inflammation, lymphoid hyperplasia, mucosal edema, and viral infection. therapies that downregulate icam-1 are being investigated as a means of preventing or minimizing allergic inflammation. treatments presently known to downregulate icam-1 include antihistamines (loratadine, terfenadine, cetirizine, and azelastine). allergic rhinitis is associated with impairments in how patients function physically, emotionally, socially, and at work or school. adults may complain of role and activity limitations, frustration, sleep disturbance, irritability, embarrassment over symptoms, cognitive impairment, decreased alertness, and performance deficits. in children, chronic nasal allergies are associated with learning deficits. unfortunately, sedating antihistamines can exacerbate these effects by hampering performance and cognition even when subjects have no sense of being impaired. at least one of the newer nonsedating agents, by contrast, can partially reverse allergic rhinitis' effect on cognition and performance. nasal allergy may usually be differentiated from other forms of rhinitis by an allergy diagnosis. this includes personal history of symptoms, the timing of their expression, triggers, and physical examination. skin prick tests and eventually in vitro diagnosis of specific ige are important. imaging studies are usually indicated only if the diagnosis is in doubt, if related airway disorders complicate the presentation (e.g., nasal polyps), or when occupational rhinitis is suspected. the the impact of allergic rhinitis temporal association of nasal or ocular symptoms with the workplace strongly suggests occupational rhinitis. treatment of chronic rhinitis and nasal allergies should be individualized, with therapeutic measures aimed at the underlying etiology, likely pathophysiology, and dominant symptoms. medication is best taken prophylactically for seasonal symptoms before the anticipated onset of symptoms in seasonal rhinitis or for episodic exposures to specific ailergensand regularly, rather than as needed. such usage of antihistamines and intranasal steroids has been found to alleviate exacerbations in patients with both nasal allergy and seasonally induced asthma. avoidance of inciting factors (e.g., allergens, irritants) can reduce the expression of nasal symptoms and minimize the need for medications. the avoidance measures that are easiest to implement are the ones most likely to be used and therefore to be successful. antihistamines. although traditional agents have some benefits (e.g., low cost), they can no longer be recommended due to their potential for causing cns impairment. nonsedating anthstamines are the preferred option. oral decongestants. although topical steroids are the first-line treatments for nasal blockage, a-adrenergic agonists such as pseudoephedrine, phenylpropanolamine, or phenylephrine also ameliorate nasal congestion. this symptom is a major factor in perennial rhinitis. careful dosing of agonists is required to avoid aggravating hypertension. moreover, these agents generally should be avoided in patients with cardiovascular disease, thyrotoxicosis, glaucoma, or diabetes. oral corticosteroids. a brief course is indicated only to relieve severe nasal blockage so that topical therapy can proceed. in such cases, patients should be referred to an allergist. intranasal corticosteroids are highly effective in reducing inflammation, rhinorrhea, itch, and nasal blockage. they are the first choice for treating nasal blockage and largely reduce, but may not eliminate, the need for other medications to treat ocular symptoms. they may be used safely in children, though youngsters often have difficuity with sprays. in addition to treating nasal allergies, these medications can be used to treat nonallergic rhinitis with eosinophilia syndrome (nares) and to shrink small nasal polyps or prevent their recurrence after surgery. the onset of action of topical corticosteroids is slow compared to antihistamines. topical nasal decongestants may be used to open nasal passages in preparation for the use of other agents, such as intranasal steroids. to prevent rebound congestion, they should be used for 2 to 3 days and no more than 7 to 10 days. mast-cell stabilizers include intranasal cromolyn and nedocromil sodium. cromolyn may be used for the prophylaxis of allergic symptoms, and is considered especially safe for elderly patients, children, and pregnant women. the need for frequent administration can raise compliance issues. nedocromd sodium, unlike cromolyn, can both prevent an allergic reaction and control a reaction in progress. topical antihistamines allay allergen-induced itching, sneezing, rhinorrhea, and ocular symptoms but are less useful for nasal blockage. intranasal anticholinergics such as ipratropium bromide are effective in controlling the excessive watery rhinorrhea associated with neurogenic stimuli (e.g., cold air, spicy foods) or the common cold. however, they have no effect on nasal blockage, sneezing or itching, or ocular symptoms. patients with rhinitis or asthma caused by allergens for which the clinical efficacy and safety of sit have been documented by placebo-controlled, doubleblind studies, and those requiring daily pharmacotherapy for longer periods (e.g., preventive treatment during a pollen season or perennially) are candidates for sit. sit is most effective if a single allergen is identified, rather than multiple allergens. injections should be prescribed by specialists and given by physicians only if a specific allergen has been identified. sit should never be initiated in pregnant women, though the continuation of maintenance therapy is safe. considerable care must be taken if allergic rhinitis coexists with moderate or severe asthma. local immunotherapy offers improved safety and equivalent effectiveness. when patients respond poorly to standard medical care, clinicians should a) ascertain whether compliance has been poor, b) adjust drug doses, c) consider combination therapy, d) reconsider the diagnosis, e) reassess the patient for a nasal structural defect or a complication of allergic rhinitis, or f) refer the patient to a specialist. referral can be helpful under the following circumstances: in most cases when significant airway comorbidity is present (asthma, chronic sinusitis, nasal polyps, or otitis media with effusion) when the diagnosis is in question or special diagnostic testing is required when occupational rhinitis is suspected, to distinguish between clear-cut allergic reactions and toxic or nonallergic reactions when poor symptom control necessitates a consultation for environmental control measures, pharmacotherapy, or specific immunotherapy when medication side-effects are intolerable when rhinitis is only part of a complex series of mucosal allergies. allergic rhinitis is a seasonal or perennial disorder characterized by mild to severe upper respiratory symptoms such as nasal congestion, rhinorrhea, sneezing, and itching. these symptoms arise from an underlying inflammatory process initiated by a reaction between the allergen and immunoglobulin e (ige), neurogenic stimuli, and other complex cellular processes. a panel of experts was convened in amsterdam, the netherlands, on 2 september 1996, to explore these issues and their impact on allergy prevention and treatment in primary care. their undertaking was supported by an unrestricted educational grant from schering-plough pharmaceuticals. conclusions and recommendations from that meeting are summarized subsequently and presented in expanded form later in this monograph. allergens are primarily responsible for provoking chronic inflammatory processes; viral infections underlie acute exacerbations of asthma, chronic sinusitis, and otitis media with effusion. there is a growing awareness of how allergic rhinitisand some of the medications used to treat itcan affect patients' quality of life, work or school performance, and emotional well-being. besides physical symptoms, patients may exhibit fatigue, psychomotor sluggishness, irritability, and mood and cognitive disturbances (1 -5). learning is impaired in children (6), while some adults may report reduced productivity and concentration (7). this combination of physical, emotional, and functional problems may diminish quality of life in both adults (7) and adolescents (8). moderate to severe perennial allergic rhinitis has been found to affect quality of life significantly compared to healthy subjects in eight of the nine dimensions of the medical outcomes study short-form health survey 36 (sf-36) (9). the prevalence of allergic respiratory disorders is high and is a burden on the health-care system: one study of patients in a london general practice found that nearly one in seven adults had allergic rhinitis (10). by the age of 6 years, 42% of 747 children followed from birth in the tucson children's respiratory study had physician-diagnosed allergic rhinitis (11). those who developed rhinitis before the age of 1 were more likely to have asthma by age 6 (11). as many as 78% of persons with asthma aged 15 to 30 years have been shown to exhibit high levels of ige antibodies to five common aeroallergens (12). of 200 patients with chronic sinusitis, 27.5% also had allergy in one study (13). about 24-50% of children with ome had allergic rhinitis (14) or nasal allergy (15). for comparison, about one-third of the general population has chronic sinusitis or ome. in general, the prognosis for patients with asthma or allergic rhinitis is mixed: only 10% of patients are cured, about 50% improve, 30% show no change, and 10% deteriorate over time (16). medicine has begun to revise its traditional therapeutic approach to allergic rhinitis. it is now acknowledged that impeding the natural course of airway allergies by interfering with the pathophysiologic mechanisms that cause mediator release and chronic inflammation may help prevent related airway disorders. this would reduce overall morbidity and improve patients' quality of life. it also should help make patients less vulnerable to the consequences of viral infection, as well as to environmental factors such as pollution. recent advances in allergy treatmentsmost notably the introduction of nonsedating selective histamine hiantagonists and intranasal corticosteroid sprayshold the promise of achieving these goals. of particular interest are the studies showing that tgeatment of allergic rhinitis reduces the incidence and severity of asthma (17) (18) (19) . the purpose of this monograph is to introduce new ways of thinking about and managing allergic rhinitis in the hope that physicians will look for related airway disorders and individualize therapeutic programs, considering tbe special needs of populations such as pregnant women, children, and the elderly. persons with allergic rhinitis have ige antibodies bound to high-affinity receptors on mast cells and basophils, and to low-affinity receptors on other cells, such as eosinophils, monocytes, and platelets. allergic inflammation is initiated when allergens deposited in the airway bind to ige molecules, causing cellular degranulation and releasing a number of inflammation mediators (20) . this process entails both an early-and a late-phase rqsponse (fig. 1) . the interaction of antigen with specific ige antibodies leads to the degranulation of mast cells and basophils and the prompt release of preformed and newly generated mediators, such as histamine, neutral proteases, leukotriene c,, prostaglandin d,, cytokines, and kinins (21). the interaction of these chemical messengers with blood vessels, mucous glands, and nerves produces the symptoms of allergic rhinitis, such as sneezing, rhinorrhea, and itching. histamine is one of the most important mediators of the early-phase allergic response in the nasal mucosa. its release stimulates sensory nerves, this reaction, manifested by some patients, entails a process of cell infiltration and activation occurring over 4-24 h. late-phase allergic reactions begin when autocoid mediators and cytokines released from mast cells during the early-phase response upregulate the expression of leukocyte endothelial adhesion molecules in the postcapillary venules of the nose. especially sensitive to histamine, postcapillary venules are also the site of blood cell extravasation. once adherent to the endothelium, these cells pass between adjacent cells to the perivascular space. various chemoattractants, essentially il-5 and the chemokines, draw primed leukocytes (eosinophils, basophils, neutrophils, and mononuclear cells) into the submucosal tissue. once there, by interacting with additional stimuli by matrix proteins, they release their own mediators. this perpetuates the inflammatory response and augments aspects of the immediate hypersensitivity reaction, such as mucosal congestion and mucus secretion. although pruritus the impact af allergic rhinitis and sneezing occur, the major symptoms in latephase reactions are hypersecretion and congestion. the chronic inflammation caused by repeated allergen exposure lowers the threshold for other provocative stimuli reactions (22) . as a result, allergic individuals react more strongly to a) low levels of the primary allergen, b) other allergens to which they are only mildly sensitive, or c) nonspecific "triggers", such as cold air, cigarette smoke, spicy foods, and strong chemical odors. a key event in chronic respiratory allergy is the upregulation of specific adhesion molecules that permit inflammatory cells (e.g., eosinophils) to migrate into nasal, sinus, and lung tissue. the first step is the experience of such molecules on endothelial cells and on activated circulating inflammatory cells. the accumulation of eosinophils in these tissues is injurious, and contributes to the pathogenesis of allergic rhinitis, sinusitis, and asthma (23 -26) . in certain conditions, histamine is known to stimulate the expression of adhesion molecules on nasal epithelial cells of normal subjects (27) . an important adhesion molecule required for effective cell recruitment in allergic disease is intercellular adhesion molecule 1 (icam-2) (28) . vascular inflammation induced in a primate madel of allergic sensitization and exposure (29) ; b) on bronchial epithelial and on vascular endothelial cells in symptom-free asthmatics (30) ; c) on epithelial cells of the nose and conjunctiva in patients with perennial and seasonal (31) allergic r~n i t i s (fig. 2) ; and d) on the nasal and conjunctival epithelium of patients with asymptomatic perennigl rhinitis when exposed to allergen, though not in cohabiting relatives or heqltby volunteers (32) . besides its role in allergic inflammation, icam-1 serves as a receptor for the major subtype of humqn rhinoviruses; this subtype accounts for 90% of all human rhinoviruses (33, 34) . rhinoviruses are a major cause of the common cold. evidence of minimal, persistent inflammation in asymptomatic allergic patients suggests that by inducing icam-1, subclinical allergen exposure may incregse the susceptibility of allergic patients to rhinovirus infection, and thereby explain the greater frequency of colds in asthmatic children (30) . in short, it now appears that both icam-1 and viral infection play a role in the patbophysiology of asthma (fin. 3 ) . the epidemiologic link between viral respiratpry infection and asthma is. strong. researchers have shown that such viral infections are associated with: 86% of wheezing episodes that last longer than 48 h in noqhospitalized children (35) 80% to 85% of asthqa exacerbations in 9 to 12-year-old children (36) . among the viruses associated with childhood asthma exacerbations are rhinoviruses, respiratory syncytial virus (rsv), adenovirus, and coronaviruses (36) . rhinovirus infection has been implicated in 50% of acute asthmatic episodes in schoolchildren, followed by coronaviruses in 13'%0 of cases (36) . levels of eosinophil, a major basic protein in children with asthma, have been shown to be higher during exacerbations associated with rhinovirus infection than during asymptomatic periods adults with allergic rhinitis exhibit bronchial hyperresponsiveness to histamine and antigen following rhinovirus infection. rhinovirus infection also predisposes the allergic patient to allergenprovoked late asthmatic reactions (38) . in asthmatics, but not in nonasthmatics, eosinophilia in the bronchial mucosa is still evident at 6-10 weeks after rhinovirus infection, probably due to ongoing secretions initiated by the virus in the allergenprimed mucosa (39) . (37) . rhinitis can be divided into three categories: allergici.e., acute or chronic conditions characterized by seasonal or perennial symptoms, or both infectiousi.e., nasal disorders caused by viral, bacterial, or fungal agents nonallergichoninfectiousi.e., a heterogeneous group of disorders comprising eosinophilic conditions, such as aspirin idiosyncracy; or noneosinophihc conditions, such as gustatory rhinitis, rhinitis of pregnancy, and vasomotor rhinitis. table 1 catalogues the characteristic features of the various forms of chronic rhinitis (10, [40] [41] [42] [43] [44] [45] [46] [47] [48] . despite the considerable overlap, it is usually possible to diagnose the disorder by skin prick test and the patient's symptoms, history (including relevant behavioral practices, such as smoking), and physical examination. the elements of a diagnosis include elicitation of a detailed patient history and physical examination of the nose, eyes, ears, and lungs. among the many factors that must be explored are patterns of symptom expression, environmental triggers, medication use, family history, and exposure to workplace allergens or irritants. it is important to determine the severity of symptoms and to uncover possible complications such as asthma, sinusitis, otitis media, or nasal polyps. questions related to psychosocial or quality-of-life problemssuch as fatigue or cognitive impairmentalso should not be overlooked. the differential diagnosis of rhinitis primarily depends on use of an allergy skin prick test. pharmacologic agents that may affect results should be withdrawn for a sufficient time before testing ( table 2) . because of its long duration of action (approximately 7-9 days), the antihistamine astemizole can suppress skin test reactivity for 8-12 weeks after its discontinuation (40) . by contrast, this effect lasts only 2-4 days with most other antihistamines. most patients who present with rhinitis exhibit clusters of symptoms that define them as either "sneezers and runners" or "blockers". those with seasonal allergic rhinitis are usually sneezers and runners. some patients with rhinitis have only a single symptom or many nonnasal complaints, such as headache, sore throat, postnasal drip, a "full" or a "stuffy" head, recurrent head colds, chronic "sinusitis", chronic cough, plugged ears, hyposmia, loss of the sense of taste, fatigue, or poor concentration. often, patients use the term "sinuses" or "sinusitis" to describe symptoms caused by nasal pathology. a thorough patient history yields information needed to classify nasal symptoms, determine their cause, and make appropriate therapeutic decisions. family studies indicate that environment generally influences the expression of allergic disease (ll), but genetics determines the severity and specificity of the symptoms (49) . genetics also is an important component of atopy as a general predisposition, involving multiple as yet unidentified genes. children not only inherit a tendency to atopy from their parents, but are likely to develop the same allergic disorders (50, 51) . consequently, the following information should be sought: symptom type, occurrence, and frequency symptom duration and severity aggravating factors current medications illicit drugs. the age at which symptoms began (episodic, seasonal, or perennial) allergen exposure in home or work environment although the physical examination of patients with chronic rhinitis centers on the nose, eyes, and throat, clinicians also should evaluate the ears, sinuses, and lungs to identlfy any related airway disorders, which often are present. general signs of an atopic predisposition, such as eczema, also are helpful. imaging studies are usually indicated only in specific circumstancesmost commonly, when the diagnosis is in doubt, when symptoms persis despite appropriate therapy, or when related airway disorders complicate the diagnosis. persistent symptoms or airway complications may be factors in perennial allergic rhinitis. plese.g., limiting outdoor activities during the height of the pollen season, shielding young children from passive tobacco smoke and gas heating or wood-burning stoves. they also may entail fairly complex undertakings aimed at specific allergens; e.g., cat dander. as people spend increasing amounts of time indoors, environmental control is focused largely on containing exposure to house dust, animal dander, mold, and cockroaches. as a rule, measures to avoid allergens are effective when they are likely to be usede.g., simple to follow and inexpensive to implement. patients should be informed that even partial compliance can help control symptoms and lessen the need for medicalion. they should be encouraged to persevere, as it may lake weeks or months of avolddnce before an improvement in sympfoms is noticeable. (see appendix for a patient information sheet about allergen-control measures.) the selection of an appropriate and effective medication for the treatment of chronic rhinitis entails consideration of several factors: although impaired olfaction is frequently overlooked in cases of nasal allergy, it is relatively easy to assess by olfactory threshold tests. patients who require more sophisticated testingsuch as assessment of mucociliary function or nasal airway patencyshould be referred to a specialist. underlying eriology. especially in patients for whom immunotherapy is being considered, this requires careful diagnosis of the allergen (s), primarily through skin prick testing. a likely parhophysiology. symptoms due to inflammatory processes (as in nasal allergy) require differed1 medications than those caused treatment options consist of allergen avoidance, pharmacologic therapy, or allergen-specific immunotherapy. efforts aimed at environmental control may involve relatively simple activities based on general princi-by-noninflammatory neurogenic mechanisms (as in gustatory, idiopathic, or atrophic rhiniiis). dominant symptoms. medications should address the patient's most prominent complaints. combination therapy may be warranted for patients with a mix of moderately severe lo severe symptoms. safety. it is important 10 determine whelher medication side-effects may impede a patient's perfarmance at work or scho61, diminish quality of life, or enhance risk of sustairiing personal the impact of allergic rhinitis table 2 withdrawal of pharmacologic agents that affect skin test reactions (38) individuals. regular antihistamine use over weeks or months has been found to reduce asthma symptoms significantly in allergic rhinitis patients with seasonal and chronic rhinitis (55) (56) (57) . injury or significant morbidity. the potential for drug interactions also must be considered when patients are taking multiple medications. patient age and other special considerations. the needs of special populationspediatric patients, the elderly, pregnant women, and competitive athletes must be evaluated. coexistence of related airway disorders. in patients with coexisting airway disease, the treatment of nasal allergy is important to prevent exacerbation of sinusitis or asthma. patient preferences and compliance historv. in some countries, patients prefer oral medications to sprays (52) . additionally, individuals differ greatly in their capacity to adhere to therapeutic regimens. consequently, an attempt should be made to determine each patient's understanding of abd willingness to comply with a specific treatment program. factors that may adversely affect compliance include poor symptom relief, the nature or severity of the side-effects, and the inconvenience or complexity of the therapeutic rkgimen (53,54). as a rule, it is best for patients to start therapy before the anticipated onset of symptoms, to suppress those immunologic and mediator mechanisms that cause inflammatory reactions and to minimize the priming effect. prophylactic therapy is usually possible in seasonal allergic rhinitis, when the onset of symptoms is relatively easy to predict, or for episodic exposures to specific allergens (e.g., before visiting the home of someone with pets). as a rule, patients with seasonal or perennial rhinitis should take their medication regularly, rather thhn as needed, because consistent use best controls mucosal inflammation. in turn, this helps lessen the risk of related airway complications in susceptible in its 1994 consensus statement, the international rhinitis management working group advocated a stepwise approach to therapy that took into account specific diagnoses and patient characteristics (40) . this approach is summarized in table 3 . stepwise management certainly represents a reasonable starting point for therapeutic decisions in cases of chronic rhinitis. nonetheless, the complexity and interrelationship of these disorders suggest that, while taking account of the guidelines, a case-by-case approach provides added value. what follows is a review of the benefits and limitations of various medications used to treat chronic rhinitis. among the agents considered are topical and oral antihistamines, topical and oral corticosteroids, topical and oral decongestants, crornolyn sodium, nedocromil, sodium intranasal anticholinergic agents, and saline sprays. the discussion concludes with a review of combination drug therapy and the ihdications for immunotherapy. there are at least three classes of histamine receptors, designated hi, h,, and h,. histamine can exert local or widespread effects on smooth muscles and glands. bronchoconstriction and contrktion of the intestine are mediated by h,-receptors, while gastric secretion results from h,-receptor activation (58) . h,-receptors appear to exist predominantly in the central nervous system (cns) and at presynaptic nerve endings (58) . histamine causes capillary dilation; hi-receptor stimulation leads to a rapid, brief dilator response, while h,-receptors mediate a response that is slowkr to develop and more sustained (58) . it also plays a role in extravascular smooth-muscle contraction and (more rarely) relaxation, with h,receptor activation responsible for contraction and h,-receptor stimulation usually resulting in relaxation (58) . the class of agents known as hi-receptor antagonists comprises drugs that act rapidly to antagonize the histamine activity of hi-receptors, thereby relieving the maiq symptoms of allergic rhinitis (sneezing, watery rdnorrhea, and itching of the ndse, eyes, and palate). in addition, some of the hewer agents have been shown to possess antiallergy properties that may contribute to diagnosis and treatment. these properties include the ability to: inhibit histamine release from human basophils block histamine, and partly block prostaglandin d, release, in the nasal secretions of highly allergic subjects (61) directly inhibit eosinophil activation (62, 63) block histamine activation of airway epithelial cells by suppressing the expression of surface markers, such as icam-1, and the major histocompatibility complex class i1 antigen hla-dr, involved in antigen presentation (27) . the ability both to inhibit histamine release and downregulate icam-1 makes certain anthistamines (e.g., terfenadine [65, 66] , loratadine [27] , cetirizine [65] , azelastine [65] , oxatomide [65] , and levocabastine [65] particularly suitable for treating allergic inflammation, because icam-1 is a marker of allergen-induced inflammation as well as a receptor for human rhinoviruses (33, 65) . (59, 601 reduce vascular permeability (64) sedating vs nonsedating antihistamines. "sedating" agents are distinguished from "nonsedating" ones by the higher incidence of drowsiness associated with the former at the doses used to control allergic ,symptoms. in part, this difference is due to the speed with which antihistamines cross the bloodbrain barrieri.e., rapidly in the case of the sedating agents and slowly in the case of the nonsedating agents. the sedative potential of the newer agents is limited further by their specificity for binding to peripheral hi-receptors. sedating antihistamines, in contrast, affect central hi-receptors and receptors of other types (e.g., muscarinic cholinergic, a-adrenergic, and tryptaminergic) (67) . this may contribute to their sedative and other side-effects (67) . sedating agents' effect on central hi-receptors may be especially relevant, as hstaminergic transmission originating from the posterior hypothalamus sustains waking arousal (68) . in short, by having a reduced capacity to cross the blood-brain barrier and specifically blocking hireceptors, the nonsedating agents are less able to cause cns effects and associated adverse reactions. (see subsequent discussion of cns effects.) efficacy. table 4 presents selection criteria for 10 of the antihistamines most commonly used in europe. studies have shown that the newer nonsedating antihistamines produce moderate to the impact of allergic rhinitis excellent symptom response in up to 67% of patients with seasonal allergic rhinitis (691, making them as effective as, if not more effective than, the older (i.e., sedating) agents (70, 71) . as a group, the newer agents demonstrate comparable efficacy (72, 73) . a comparison of loratadine and astemizole in patients with seasonal rhinitis found equivalent efficacy in the two (72) . cetirizine has been shown to lessen nasal blockages (74) . although the use of antihistamines in asthma is still controversial, the new nonsedating agents seem to offer some benefit for allergic patients with concomitant asthma. data indicate that terfenadine (75, 76) and loratadine alone (77) , and combined with pseudoephedrine ( 5 5 ) , astemizole (78), certirizine (79) , and azelastine (80) exhibit modest bronchodilating effects (75), reduce bronchial sensitivity to histamine (55) , and guard against exercise-(78) and antigen-induced bronchospasm. such effects may require higher than currently recommended doses, however. loratadine (5.9, cetirizine (56), and terfenadine (57) have been shown to reduce asthma symptoms in rhinitic patients with seasonally induced asthma when taken over weeks or months, though this evidence is disputed. together, such findings suggest that timely and appropriate use of antiallergy therapy may help prevent lower airway symptoms in susceptible patients if used in an adjunctive manner. moreover, they dispel the fallacy that antihistamines are contraindicated in asthmatic patients. cns effects. sedating antihistamines can exacerbate the cognitive and functional problems caused by untreated allergic rhinitis (81) . among their most troubling cns effects are fatigue, sedation, and performance impairment (81) . patient reports of unusual daytime drowsiness have been noted in 25-50% of users of sedating antihistamines (82) -e.g., diphenhydramine, pyrilamine, brompheniramine, chlorpheniramine, triprolidine, hydroxyzine, promethazine, and cyproheptadine. by contrast, when given at the recommended doses, the "nonsedating" antihistaminesastemizole, ebastine, fexofenadine, loratadine, and terfenadinecause no more drowsiness than placebo. confusion exists as to the sedating properties of two new agents, acrivastine and cetirizine. both medications have been associated with significantly more reports of daytime drowsiness than placebo at recommended doses: acrivastine, 8 mg, 11% versus 6% (82); cetirizine, 10 mg, 9% to 25% versus 6% (83) . although the lower dose ( 5 mg) of cetirizine is no more sedating than placebo (83) , it has been shown that, if allowed, more than 80% of cetirizine users will titrate the dose upward, to achieve symptom relief (84). after repeated dosing, some patients may become tolerant of the sedating effects of antihistamines (85) . however, it is unwise to depend upon tolerance to abolish the antihistamineinduced sedation and performance impairment that commonly occurs for at least 1 week after the medication is started (86) . it is generally agreed that tolerance is a highly idiosyncratic phenomenon that is not universal, complete, or predictable. virtually all antihistamines are equally effective in relieving allergy symptoms (see "efficacy" section). consequently, before recommending a particular antihistamine, physicians must weigh the benefits of that agent against its drawbacks. the lower cost of the older "sedating" antihistamines, and their general availability without prescription, may argue in their favor, but their use can no longer be recommended. the nonsedating agents offer the potential long-term benefits of safety and improved performance at work or in school compared to sedating antihistamines, and greater therapeutic compliance owing to their longer half-life and the need for less frequent dosing (81, 82) . ' consequences of cns effects. unfortunately, one's subjective sense of sleepiness or impairment is an unreliable gauge of whether it is safe to operate heavy machinery while taking sedating antihistamines. this is because impairment can occur without the patient's awareness (87, 88) . these factors have important safety implications in areas such as building consltuct ion, manufacturing, pub1 ic transpottation, and automobile driving. simulated and real-life driving studies verify that these agents carl impair performance significantly (87, 89, 90) . in one study, lane weaving by drivers given triprolidine 10 mg (emtamed release), was comparable to that ib pers6hs with a blood alcohol level of 0.05%; moreover. at 3-4 h after drug use, the drivers stopped feporting any sense of being impaired (87) (fig. 4) . another study found that the effects of a single 10-mg dose of cetirizine resembled those of alcohol (72 g/kg lean body mass), and that the impairment appeared to be greater when alcohol and cetirizine were taken together (91) (fig. 5) . by contrast, no psychomotor deficits have been observed in drivers given loratadine (87, 91) , or in individuals tested while taking astemizole (92); nor does the use of alcohol with these agents produce an additive effect. studies have also shown that terfenadine did not impait psychomotor performance or reaction time (65) , and that ebastine at 10, 20, or 30 mg given for 5 days did not impair driving performance compared to triprolidine 10 mg (93). besides causing psychomotor problems, sedating antihistamines also adversely affect cognition and functional performance (6, 88, 94, 101), compromising sustained attention and cerebral processing speed in adults (97) and children (95) . the effects of nonsedating agents on somnolence, cognition, and performance, by contrast, are comparable to those of placebo (70, 95, 96, 102) . specific findings to date include the following: performance on a digit symbol substitution test impaired by diphenhydramine (50 mg t.i.d.), but not by loratadine (10 mg q.d. and 40 mg visuavmotor coordinationimpaired by promethazine, chlorpheniramine, and clemastine, but not by terfenadine (101,115) clerical skills -8112 skills impaired by diphenhydramine; none by loratadine (96) learning in children with seasonal rhinitisimpaired by diphenhydramine (50 mg) compared to nonallergic, unmedicated children, with the impairment in allergic children offset partly by loratadine (10 mg) (6). nonallergic, unmedicated children performed significantly better on tests of learning ability than atopic children given placebo, diphenhydramine, or loratadine; performance among atopic children was q.d.) (99) the impact of allergic rhinitis best among subjects receiving loratadine and worst among those receiving diphenhydramine. this suggests that the learning problems associated with allergy are augmented by sedating antihistamines and offset somewhat by nonsedating agents. cardiovascular effects. two nonsedating agentsterfenadine and astemizolehave been found to cause malignant ventricular arrhythmias, such as torsades de pointes (103, 104), when patient factors or drug interactions result in greatly elevated serum drug levels (105, 106). although rare, these phenomena can delay cardiac repolarization and prolong the qt interval through blockage of a k rectifier channel, resulting in possible sudden death. at least 11 case reports involving 20 patients have been published in which patients taking astemizole experienced torsades de pointes, qt prolongation, and sometimes other cardiac effects (67) . eight such reports affecting 22 patients have appeared for terfenadine (67) . acrivastine, cetirizine, fexofenadine and loratadine appear to be the least likely of the newer antihistamines to be arrhythmogenic (67) . the risk of cardiac arrhythmias can be minimized by reviewing the medical and pharmacologic risk factors for torsades de pointes before prescribing terfenadine or astemizole for any individual. drug interactions associated with the potential for cardiotoxicity are a major concern of clinicians, as patients frequently fail to report all of the medications they are tdking. concomitant administration of certain antifungal agents (especially ketoconazole and itraconazole) or macrolide antibiotics (patticularly erythromycin), along with terfenadine or astemizole, inhibit metabolism of these two antihistamines through competition for hepatic p450 enzymes. this results in increased plasma cohcentrations of these antihistamines. coadministratiori of terfenadine or adtemiztde in users of such medications is thus sttictly contraindicated. hepatic dysfunction and preexisting cardlovascular disease also ate risk factors for cardiovascblar complication$ with these ztrltihfstamines. because the causes of qt prolongation are additive (106), patients with more risk factors have a potentially greater chance of developing ventricular arrhythmias while taking either terfenadine or astemizole. the use of these drugs at recommended doses without the aforemefitioned concomitant medications by patiedts lacking known rtsk factors carries a low risk of ah adverse catdiac event. still, such low-risk patients taking terfenadine or &temizble should be warned not to inmease antihistamine doses without 6!dnsulting their physician. cytochrome p450 enzymes are responsible for the metabolism of many drugs. all of the currently available nonsedating antihistamines are metabolized by the cytochrome p450 hepatic enzyme system. cytochrome p450 3a4 is involved in the metabolism of terfenadine, and erthromycin attenuates the metabolic effect of cyp3a4. loratadine is metabolized primarily by cyp3a4 and secondarily by cyp2d6. other considerations. side-effects involving the digestive tract (e.g., loss of appetite, nausea, vomiting, epigastric distress, and constipation or diarrhea) are among the most common for all antihistamines. many of the older agents are associated with significant anticholinergic or antimuscarinic sideeffects, such as dryness of the mouth and respiratory passages, urinary retention or frequency, palpitation, blurred vision, hypotension, headache, and tingling or weakness of the hands (58) . use of astemizole can cause weight gain. in a comparative trial with loratadine, weight gain was significantly greater with astemizole (pco.012) (72) . this sideeffect may argue against astemizole's use in selected individuals. nasal blockage is a major factor in perennial rhinitis, and a possible incitement to related airway disorders such as ome and chrohic sinusitis. topical steroids are the agents of choice for nasal blockdge (see subsequent section, "intranasal steroids"); however, leukotriene antagonists or oral decongestants also control this symptom. examples of the last class of agents include pseudoephedrine, phenylpt-opanolamine, and phenylephrine. these a-adrenergic agonists constrict blood vessels supplying the nasal mucosa, thereby decreasing congestion; they do not control the itchihg, sneezing, or rhinorrhea associated with upper-respiratory allergies. when such syifiptoni6 coexist with significant blockage, optimal rhariagement requires the use of intranasal steroids. another option is a combination decongestant/antihistamine medication (see next section). a-adrenoreceptor agonists are stimulatory agents that constrict vascular beds throughout the body, not just in the nose. this raises the potential for significant systemic side -effectse.g., hypertensibn, palpitations, tachycardia, and extrasystole, as well as restlessness, insomnia, and headache. as side-effects are dose-related, clirliciahs must choose the ptescribed dosage carefully to prevent aggravating or "unmasking" hypertension. patiefits shobld the impact of allergic rhinitis be cautioned against increasing dosages on their own. as a rule, oral decongestants should be avoided in patients who have cardiovascular disease, thyrotoxicosis, glaucoma, or diabetes. medications that combine an antihistamine with a long-acting oral decongestant offer another option for managing nasal blockage. the value of this practice has been proven in trials using formulations containing pseudoephedrine and either loratadine (107), acrivastine (108), or chlorpheniramine (109) . such combinations may be especially beneficial for patients at risk of chronic, allergen-induced eustachian tube obstruction, a condition that may favor the development of ome (109) . combined antihistamine/ decongestants can provide greater overall symptom relief than possible with either agent alone (107, 108), though the tradeoff may be a higher incidence of adverse events (110) . nevertheless, combination agents decrease the number of drugs patients must take, a fact which may facilitate therapeutic compliance in selected individuals. oral corticosteroids and systemic injected depot preparations carry a high risk of systemic sideeffects. consequently, the only justification for their use in chronic rhinitis is to improve nasal patency in patients with severe or urgent blockage, so that topical therapy can proceed. even then, systemic steroids should be given only by a specialist, and only to patients who lack contraindications to their use. these agents generally should not be used in children or pregnant women. a course of systemic steroids may be needed to gain control of nasal polyps, after which the patient can be managed with topical steroids (44) . in addition, oral corticosteroids can rapidly relieve anosmia associated with polyps and, by opening the nasal passages, facilitate the access of locally acting nasal corticosteroids. alternate-day dosing may improve the riskbenefit ratio of oral corticosteroids, but studies proving this point have yet to be undertaken. various topical agents are now available for relieving the symptoms and, in some cases, addressing the underlying pathology, of chronic rhinitis. the benefits, appropriate usage, and drawbacks of specific agents are discussed in this section. general limitations of topical treatments are reviewed in table 5 . the value of any topical agent in the treatment of allergic or nonallergic rhinitis syndrome may be limited by several factors. physical anomalies. severe septal deviation or enlarged turbinates may impede direct delivery of topical agents to the nasal mucosa. poor therapeutic compliance. compliance studies have shown that patients generally prefer taking pills to using medicinal sprays 150) slow therapeuric onset. in the case of intranasal steroids and crornolyn sodium. a slower onset of action may leave some patients frustrated and noncompliant. par!ent handicaps in particular. children and elderly persons may find it difficult to aim sprays or manipulate inhalers. intranasal steroids can relieve most of the symptoms of seasonal and perennial allergic rhinitis (112) (113) (114) (115) (116) (117) . they are more effective than cromolyn sodium (17). intranasal steroids are probably the most effective drug for all symptoms but they are particularly effective on nasal blockage topical steroids are the agents of choice for relieving nasal blockage. they permit direct delivery to the nasal mucosa, thus minimizing systemic sideeffects. the following specific actions are noteworthy: inhibition of both the early and late hypersensitivity response to allergens (111) reduction of the number of eosinophils in the nasal mucosa (112, 113) substantial inhibition of the nasal secretory response (1 14) reduction of mast cells and t cells desensitization of nasal irritant receptors (114). (1 17 -1 19) . appropriate use. intranasal steroids may be used to: relieve seasonal or perennial allergic rhinitis, when the main complaint is moderate to severe nasal blockage treat nares (only effective therapy at present) shrink small nasal polyps, or manage patients with polyps once control is gained through a course of oral steroids (44) prevent polyp recurrence after surgery reduce the risk of chronic sinusitis, ome, or bronchial asthma in allergic patients with a history of these complications. drawbacks. side-effects of intranasal steroids are generally minor and local, e.g., irritation, burning, and reactive sneezing, which usually disappear after several days; and nasal dryness followed by blood-stained crusts (124). in rare cases, treatment has to be stopped due to epistaxis. a few reports of septal perforation following intranasal steroid use have been published (124,125). some adverse effects (e.g., mucosal drying) can be avoided by using sprays with an aqueous base. the risk of systemic side-effects is very small, with one published report of a posterior cataract after intranasal steroid use and one report of children's growth being inhibited while taking an adult dose of budesonide (124). it is prudent to use the lowest efficacious dose in children and pregnant women (124). once-daily usage probably is sufficient for all glucocorticoids if the nose is patent and dry when the spray is used (124). some patients or agents may require multiple daily dosing, however, or multiple sprays per nostril. patients should be informed that onset of action is delayed compared with that of antihistamines and decongestants, and requires a few days for patients with seasonal allergic rhinitis (124). many patients are reluctant to use steroids in any form, and parents may be especially hesitant to sanction their use in children. individuals should be reassured that intranasal steroids are much safer than oral corticosteroids and that the former should not be equated with the latter. this anti-inflammatory agent has been proved safe and effective for the treatment of allergic rhinitis (126,127), although in one comparative study (17) it proved less effective than intranasal corticosteroids. owing to its control of both early-and late-phase hypersensitivity responses, cromolyn can relieve nasal itching, sneezing, hypersecretion, and nasal blockage. its need for frequent administration (four to six times daily [126], with possible reduction to two to three times daily in periods of low antigen load [127]), may impede therapeutic compliance. appropriate use. cromolyn sodium is best used for the prevention of allergic symptoms. given its wide safety margin, it often is prescribed for elderly patients, children, and pregnant women with seasonal or perennial allergies. it has virtually no utility in nonallergic rhinitis syndromes. the ocular formulation of cromoglycate is very effective in controlling eye symptoms. like cromolyn, nedocromil sodium controls both the early-and late-phase allergic reaction. unlike cromolyn, nedocromil can both prevent an allergic reaction and control a reaction in progress (126). nedocromil has significantly improved symptoms of rhinorrhea, congestion, itching, and sneezing (126). it is about 10 times more potent than cromolyn sodium. recommended dosing is two to four times daily (126). appropriate use. like cromolyn, nedocromil sodium is very effective at blocking symptoms when used immediately prior to an anticipated allergen exposure (126). both nasal challenge studies (128, 129) and those involving seasonal exposures (130) indicate that topical antihistamines can inhibit allergen-induced nasal symptoms, including sneezing and rhinorrhea. side-effects are locale.g., stinging and itching in the nose and, occasionally, the throatwith the incidence ranging from 7% to 30% of patients (128-131). azelastine has been shown to lessen nasal blockage, although reported side-effects include burning in the nose and altered taste (132) . the lack of major improvement in nasal blockage (128, 129) in some other studies, however, suggests that congestion entails more than the direct effect of histamine on receptors on the capacitance vessels of the nasal mucosa. levocabastine is a potent antihistamine available as nasal spray and eye-drops. minute amounts applied topically are sufficient to result in an antiallergic effect. appropriate use. on the basis of their safety profile, topical antihistamines may be used to relieve ocular or nasal symptoms in patients with mild to moderate seasonal allergies. when patients have severe ocular symptoms, specific topical preparations for ocular application should be used. azelastine (133) and levocabastine (134, 135) , for example, have been found to be nonsedating. topical nasal decongestants constrict the smaller arterioles of the nasal passages, thus reducing blood flow and relieving mucosal edema. these agents can relieve nasal congestion rapidly and effectively, and generally are available without a prescription. this probably explains their popularity among patients with perennial forms of allergic or nonallergic rhinitis. unfortunately, the overuse of decongestant sprays can cause rebound nasal congestion and rhinitis medicamentosa. moreover, like oral sympathomimetics, topical sprays are associated with systemic side-effects such as cardiac arrhythmias and exacerbation of hypertension (136) . thus, the impact of allergic rhinitis patients who overuse decongesting nose-drops should be assessed for hidden allergic nasal disease. appropriate use. the primary use for topical decongestants in chronic rhinitis is to open severely blocked nasal passages, so that slower acting drugs (e.g., cromolyn or intranasal steroids) can reach the necessary nasal passages to provide ongoing symptom control. their potential for causing rebound congestion is such, however, that these agents should never he used for inore than 3 consccurive days. ipratropium bromide, an anticholinergic drug, acts on the glandular cholinergic receptors in the nose to control excessive watery rhinorrhea (137) . rhinorrhea generally improves within 30 min, and remains in check for s-12 h. "here is no improvement, however, in nasal blockage, sneezing, or itching. nasal dryness, the main local side-effect of topical anticholinergics, may be alleviated by adjusting the dose. although rarely required, high doses of these agents may cause systemic side-effects. appropriate use. intranasal anticholinergics may be used to relieve the excessive rhinorrhea associated with allergic or nonallergic rhinitis syndromes e.g., gustatory or idiopathic rhinitis ("skier's nose"). the latter, perennial form of rhinitis entqils little if any nasal blockage, and tends not to respond to other treatments. intranasal anticholinergics also may help relieve the rhinorrhea associated with common colds (138) . various symptoms of perennial rhinitise g , nasal stuffiness, sneezing, rhinorrhea, and nose-blowing may improve with the use of saline or propyleneand-polyethylene glycol sprays. in one trial, patients also showed decreased eosinophil counts with propylene-and-polyethylene glycol spray (139) . symptom amelioration also may be accompanied by an improvement in nasal airway resistance and nasal biopsy findings (139) . although wetting agents act slowly, their lack of side-effects makes them attractive therapeutic options for some patients. appropriate use. wetting agents are indicated for the relief of mucosal irritation or dryness, the prevention of mucosal atrophy, and the removal of encrusted or thickened mucus. they also may be used immediately before intranasal steroid dosing, to prevent or mitigate drug-induced local side-effects. when the use of any of these medications results in poor control of chronic rhinitis, physicians have several options: determine whether there has been therapeutic noncompliance. if so, try to ascertain the reason e.g., poor symptom control, inconvenient dosing schedule, high medication cost. once the cause is known, engage the patient in therapeutic decision-making, as this may enhance treatment satisfaction and compliance. two or more antiallergy medications may be prescribed if a single agent fails to relieve adequately a patient's symptoms. combination therapy generally is indicated in the following situations. w h e n syrnptonis are moderately severe, severe, or diverse patients with severe nasal symptoms often benefit from taking both an antihistamine/decongestant and a topical nasal steroid. when patients have severe ocular symptoms, specific topical preparations for ocular application should be used. in a study comparing solo and combined drug use in patients with seasonal rhinoconjunctivitis, juniper et al. found that a ) nasal symptoms responded better to beclomethasone alone than to astemizole monotherapy, b) ocular symptoms were relieved more effectively by asteniiznle alone than by beclomethasone monotherapy, and c) the combination provided the best relief of ocular symptoms (121). when symptoms are intense or long-lasting patients who suffer from perennial rhinitis with seasonal exacerbations may benefit from using intranasal steroids on a continual basis and employing "rescue" antihistamines as needed. persons with allergic rhinitis and asthma might require a nasal corticosteroid and a bronchodilator to control their upper and lower airway problems. reliance on specific immunotherapy (sit) varies from country to country. physicians in the south of europe are more inclined to offer sit, while a decreasing number of patients receive this therapy in scandinavia and the uk (141) . immunotherapy used to be viewed as indicated only for patients responding inadequately to, or developing side-effects from, drug therapy (141) . current recommendations are to consider sit for a broader range of patients (see table 6 ). sit, unlike pharmacotherapy, modifies the immune system and plays a preventive role in asthma development. it is used in conjunction with drug therapy but should reduce the need for symptomatic pharmacotherapy. the efficacy of sit for table 6 specific immunotherapy for allergic rhinitis 1142) grass pollen, ragweed pollen, and house-dust mites is very well established (141, 142) . results are best when the patient has a single allergic sensitivity rather than allergies to multiple substances. it must be stressed, however, that sit should be undertaken only by physicians working in facilities equipped to handle possible adverse reactions (urticaria, laryngeal edema, bronchospasm, and anaphylaxis). although its safety under these conditions is good, a careful riskhenefit analysis is required for each patient before injections commence. some experts believe that children may be especially responsive to sit (142) . although childhood allergies show a strong tendency toward spontaneous improvement, sit may hasten this effect in a greater percentage of case% disagreement exists, however, about the age at which sit may be started (141, 142) . noninjective immunotherapy is another option to consider. nasal, sublingual, and oral immunotherapy have been demonstrated to be safe and effective (143) . perhaps the most enmuraging thing about sit is that it holds out the possibility at present, more than conventional pharmawlogic therapyof "curing" seasonal allergies and even preventing the progression to asthma (141, 142). children a variety of genetic and environmental factors favor the development of respiratory allergies in children (table 7) . allergy should be considered in the differential diagnosis when children have asthma, ige levels exceeding 100 iu/ml at age 6, or a maternal history of allergy (11). these were found on logistic regression to be risk factors for development of allergic rhinitis by age 6 in the tucson children's respiratory study, which followed 747 healthy children from birth to age 6 (11). presence of dogs as household pets and serum ige exceeding 100 iu/ml were significant risk factors for development of atopic (vs nonatopic) allergic rhinitis (1 1). wheezing in infancy usually implies no increased risk of asthma or allergies, but for the minority (14%) of children in whom wheezing persists at age 6, this symptom may signal a predisposition to asthma (144) . a prospective study following 826 children from birth to age 6 years found that risk factors for persistent wheezing were elevated serum ige at 9 months old and a maternal history of asthma (144) . preventive therapy may be especially relevant for these children. special concern is also indicated for those with severe or persistent nasal polyps. such children should be referred to a specialist, as polyps in the very young may be associated with cystic fibrosis or primary ciliary dyskinesia. environmental control assumes particular importance in children with allergic rhinitis, as considerable evidence shows that chronic respiratory symptoms are associated with significant early exposure to allergens (11, 145). the tucson children's respiratory study of 747 6-year-olds found that 42% had allergic rhinitis, and half of them had been diagnosed with this condition in their first year of life (11). accordingly, it is important to instruct parents about environmental control measures and the need to.implement them early in the course of their child's disease. early avoidance not only improves symptoms, but also may affect the natural history of nasal allergy and related disorders such as ome. moreover, if implemented aggressively at home, it has the added benefit of possibly preventing similar allergies in any siblings that the patient may have. when drug therapy is needed, a conservative approach to selection is warranted. nonsedating oral antihistamines are a good choice for children, owing to their lack of cns side-effects and ease of use. moreover, once-or twice-daily administration elunnates the need for dosing during school hours. pediatric formulations of the nonsedating antihistamines generally are available throughout europe. cromolyn sodium, nedocromil, or intranasal steroid sprays, although safe and effective, may be difficult for small children to use. this can lead to compliance problems. moreover, cromolyn must be dosed at least four times a day, whereas nedocromil is used twice a day. intranasal steroids usually are given at half the adult dose, once daily in the morning. as a rule, systemic steroids and topical vasoconstrictors should be avoided in very young children. perennial rhinitis in the elderly is generally idiopathic in nature (42) , with the underlying cause being autonomic imbalance, alteration in muscarinic receptors, or the sequelae of previously treated nasal disorders. almost invariably, the only symptom of nasal hyperresponsiveness in older persons is profuse rhinorrhea. treatment with ipratropium bromide, an anticholinergic drug, has been shown to be effective in some cases (146) . for elderly persons with true allergic rhinitis, treatment plans must take into account age, concomitant illnesses, and the use of other pharmacologic agents. nonsedating topical or oral antihistamines are a reasonable choice for this population. older antihistamines are best avoided, not only because of their sedative properties, but also because of the potential for urinary retention, problems with visual accommodation, and cns impairment. because of their sympathomimetic effects, oral vasoconstrictors (e.g., phenylephrine, phenylpropanolamine, or pseudoephednne) are generally contraindicated or need to be used with considerable caution in patients with diseases that frequently occur in the elderly such as hypertension, the impact of allergic rhinitis coronary artery disease, diabetes, glaucoma, or prostate hypertrophy. finally, elderly patients may require lower doses of certain antihistamines owing to slowed hepatic metabolism. moreover, because they often take multiple prescription and nonprescription medications, the elderly also run a greater risk of drug interactions than most other patients. pregnancy-associated hormones affect the nasal mucosa, and may indirectly affect the nose through increasing circulating blood volume (146) . as a result, some women with allergic rhinitis experience an exacerbation of symptoms, especially congestion, during pregnancy. this phenomenon generally starts toward the end of the first trimester and resolves rapidly after parturition. other women experience the apparent onset of allergic rhinitis during pregnancy (147) . although pharmacologic agents may help control nasal symptoms in pregnant women, chicians should prescribe them cautiously, bearing the following facts in mind: despite its probable safety in pregnant women, clinical experience with loratadine is still relatively limited. the safety of diphenhydramine remains uncertain (148) . all oral antihistamines are excreted in breast milk. in the usa, pseudoephedrine is approved for use in pregnancy at recommended dosages, and is widely prescribed in this population. owing to their overall safety, saline wetting agents and cromolyn sodium may be used to relieve congestion during pregnancy. in some european countries, topical antihistamines are recommended for the treatment of allergic rhinitis during pregnancy (149) . if cromolyn proves ineffective, intranasal steroids may be tried. their use at recommended doses has not been associated with teratogenicity or other adverse effects in pregnant women (38) . unfortunately, nasal congestion in pregnant women is often refractory to medical therapy. in such cases, patients may obtain some relief by using an external nasal dilator and saline douches. under no circumstances should immunotherapy be started during pregnancy, though continuation of maintenance doses is safe (38) . physical exercise causes vasoconstriction that lasts for about 1 h after exertion stops. however, endurance athletes (e.g., long-distance runners or cyclists) may experience long-lasting rebound congestion after a brief period of improved nasal patency. this rebound effect may impair athletic performance. when managing allergic rhinitis in competitive athletes, physicians must be careful to avoid prescribing medications with doping properties or therapy that may adversely affect performance. nonsedating antihistamines and topical steroids are generally the best choices for serious athletes. the international olympic committee and other international regulatory authorities prohibit sympathomimetic decongestants (e.g., phenylpropanolamine and pseudoephedrine). in large enough quantities, these agents can act as psychostimulants as strong as d-amphetamine. immunotherapy is recommended for athletes who wish to avoid being dependent on anti-allergy medications, though discomfort at the injection site may impede physical performance for several days at a time. the successful management of chronic rhinitis depends greatly on how well patients cooperate with the therapeutic program. educating patients about their disease and its management can promote that cooperation. it has been shown, for example, that allergic symptoms can be well controlled and a reasonable quality of life maintained when patients are given the appropriate medications, education, and written instructions before the pollen season commences (150) . specifically, patients benefit from knowing or understanding the following: h o w and why rhinitis develops. simple avoidance measures that can minimize exposure to allergens or rhinitis triggers. the appendix provides a handout about allergen control measures for patients in primary care. complications and related airway diseases that can develop f r o m poor allergy control. patients who understand the scope of their disease are apt to take it seriously and thus comply better with therapy. this, in turn, may help minimize their risk of developing related airway diseases. how specific medications work, and how to use nasal sprays correctly. patients must understand that antihistamines and intranasal steroids are most effective when taken on a regular basis and not as needed. for those who require two or more medications, an explanation of how each drug works provides a rationale for their use and may aid compliance. the necessity for prophylactic medication. patients should be informed that early use of medication can prevent the onset of severe symptoms. individuals with seasonal symptoms should start treatment at the outset of the spring or autumn seasons or in late summer. those with perennial allergies need to take medication in advance of specific exposuresfor example, before visiting a relative who keeps indoor pets. the side-effects associated with prescribed medications. patients should be told about common side-eff ects of particular pharmacologic agents, and what to do in the event of their occurrence. possible drug interactions. patients should understand the importance of informing their physician of all the medications they are taking, both prescription and nonprescription. because of the risk of torsades de pointes, this is especially vital for users of terfenadine or astemizole. for the same reason, patients taking either of the latter two agents should also be instructed not to increase the dosage without consulting their physician. the appropriate use of topical decongestants. the risks and consequences of overuse should be discussed. simply written instructions help to reinforce key messages. still, clinicians should ascertain whether patients truly understand what they have been told. consider having patients repeat instructions rather than merely asking whether everything is clear. reviewing key points with patients during subsequent office visits is advisable, especially when therapeutic goals are not being met. building a trusting alliance with patients is important in gaining their cooperation with therapy. in part, trust is established by attending to patients' concerns and preferences. specifically, patients should be asked the following types of questions: how does rhinitis affect you daily? what medications or measures have you tried to reduce your symptoms? what do you expect from anti-allergy therapy? do you anticipate any problems from treatment? do you have any preferences in medications? asking patients about their opinions and experiences in these matters fosters empathy and trust, and so encourages compliance. other pathways to improved compliance include the following: prescribing drugs with a longer half-life, so that less frequent dosing is possible. choosing combination agents when more than one medication is needed to control symptoms. selecting pharmacologic agents with few sideeffects. educating patients about their disease and its management (see prior section about patient education). for example, allergic patients who appreciate that poor compliance may increase the risk of asthma may be more motivated to follow pharmacologic and avoidance protocols. selecting medications that target what the patient considers to be his or her most troubling symptoms. impressing upon patients that compliance improves disease control and quality of life. allergists and immunologists find that compliance can be good, even when patients are not symptomatic, because failure to take medications or practice avoidance guarantees the return of symptoms. in conclusion, iherapeutic intervention in allergic rhinitis aims to relieve symptoms, improve longterm outcome and quality of life, and encourage patient satisfaction with medical management. patients who are compliant with therapy generally obtain better symptom relief and feel more satisfied with their care. allergy and depression: a neurochemical threshold model of the relation between the finesses effects of allergy season on mood and cognitive function allergic diseases from infancy to adulthood the allergic irritability syndrome: four case reports and a position statement from the neuroallergy committee of the american college of allergy assessment of quality of life in adolescents with allergic 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common cold: current therapy and national history beneficial effects of propylene and polyethylene glycol and saline in the treatment of perennial rhinitis a novel therapy concept for the treatment of allergic rhinitis eaaci position papers report of bsaci working party alternative routes of immunotherapy: a review asthma and wheezing in the first six years of life the effect of genetic and environmental factors on the prevalence of allergic disorders at the age of two years ipratropium (atrovent) in the treatment of vasomotor rhinitis of elderly patients the course and management of asthma and allergic diseases during pregnancy drugs in pregnancy and lactation pharmacotherapy of allergic rhinitis aqueous beclomethasone dipropionate nasal spray in treatment of seasonal (ragweed) rhinitis key: cord-281844-c0uhcatg authors: costa, lusmaia d.c.; costa, paulo sucasas; camargos, paulo a.m. title: exacerbation of asthma and airway infection: is the virus the villain? date: 2014-12-31 journal: jornal de pediatria doi: 10.1016/j.jped.2014.07.001 sha: doc_id: 281844 cord_uid: c0uhcatg abstract objective to review the available literature on the association between acute viral respiratory tract infection and the onset of asthma exacerbations, identifying the most prevalent viruses, detection methods, as well as preventive and therapeutic aspects. sources a search was conducted in pubmed, lilacs, and scielo databases, between the years 2002 and 2013, using the following descriptors: asthma exacerbation, virus, child, and acute respiratory infection. summary of the findings a total of 42 original articles addressing the identification of respiratory viruses during episodes of asthma exacerbation were selected, mostly cross-sectional studies. there was a wide variation in the methodology of the assessed studies, particularly in relation to the children's age and methods of collection and viral detection. the results indicate that, in up to 92.2% of exacerbations, a viral agent was potentially the main triggering factor, and human rhinovirus was the most frequently identified factor. the pattern of viral circulation may have been responsible for the seasonality of exacerbations. the association between viral infections and allergic inflammation appears to be crucial for the clinical and functional uncontrolled asthma, but few studies have evaluated other triggering factors in association with viral infection. conclusions respiratory viruses are present in the majority of asthmatic children during episodes of exacerbation. the involved physiopathological mechanisms are yet to be fully established, and the synergism between allergic inflammation and viral infection appears to determine uncontrolled disease. the role of other triggering and protective agents is yet to be clearly determined. asthma is a chronic, genetically-determined disease, whose prevalence in the pediatric population ranges between 19 .0% and 24.3% among brazilian adolescents and schoolchildren, respectively. 1 from the physiopathological viewpoint, it is characterized by chronic inflammation with the involvement of several cell types, associated with airway hyperresponsiveness, with episodes of reversible airflow limitation. it is clinically manifested by recurrent exacerbations, also called ''asthma attacks'' or, more appropriately, acute asthma, characterized by progressive worsening of dyspnea, coughing, wheezing, chest tightness, or a combination of these. 2 the loss of clinical and functional asthma control usually occurs gradually, but it can occur abruptly in a subgroup of patients. 2 it is one of the main causes of emergency consultations, having been responsible, in 2007, for 195 deaths in children younger than 19 years in brazil. 3 public policies have been developed to promote both scientific knowledge about the disease and its management, as well as to organize assistance programs in public health, which include, among others, the dispensing of medications. however, exacerbations continue to represent a significant number in statistics, with great impact on public and private healthcare systems. 2 the multifactorial origin of the clinical-functional lack of disease control is well known; since the early 1970s, respiratory viruses have been associated with the triggering of asthma exacerbations in adults and children. 3 in the 1990s, the development of more sensitive and specific molecular techniques allowed for the increase in respiratory virus detection and therefore, ways to better explain this association. studies using reverse transcriptase polymerase chain reaction (rt-pcr) as the detection technique, isolated or combined with traditional methods, observed positivity for respiratory viruses in up to 92.2% of episodes of acute asthma exacerbation in children. 4 considering the possibility of a causal relationship between respiratory virus infection and the triggering of asthma attacks in children, the implications of this association, as well as the possibility of specific prophylaxis and therapy for these agents, special attention to this subject is justified. therefore, this literature review aimed to analyze articles, published between 2002 and 2013, assessing the association between asthma exacerbation and acute viral airway infection. a search was conducted in the pubmed, lilacs and scielo databases, using the descriptors: ''asthma exacerbation'', ''viral infection'', and ''child'', resulting in a total of 283 references for that period. after selecting the articles published in portuguese, english, spanish, or french, 195 articles remained. after reading the titles and abstracts, 42 original articles that assessed respiratory tract viral infection in asthmatic children during exacerbation were selected. some articles of historical importance or review articles that included the three descriptors were added to generate the bibliography of this review. the list of references was inserted into endnote x6 (thompson corp., ca, usa), a bibliographic citation management software. the most frequently identified respiratory viruses in association with asthma exacerbation were human rhinovirus (hrv), respiratory syncytial virus (rsv), human adenovirus (hadv), influenza (flu), parainfluenza (pflu), human metapneumovirus (hmpv), and human coronavirus (hcov). of the listed viruses, most have rna as the nucleic acid; their biological characteristics and taxonomy 5 are described in table 1 . the main transmission methods for these viruses are through contaminated fomites, droplets, aerosols, or direct contamination. by infecting the nasal epithelium cells, these agents trigger an immune response, which involves mainly the dendritic cells and natural killer (nk) cells, inducing the release of a number of pro-inflammatory cytokines and chemokines by the infected epithelial cells, such as interferon (ifn-1) and tumor necrosis factor alpha (tnf␣), among others ( fig. 1) . in asthma patients, the viral infection causes an imbalance in the immune homeostasis of the respiratory system. several mechanisms related to viral infection and allergic inflammation, as well as their role in triggering acute asthma, have been proposed; among them, the deficient function of the epithelial barrier caused by the virus, which has been implicated as a predisposing factor by some. 6 however, both asthma and atopy are associated with epithelial damage, which may contribute to increased susceptibility to infections, including viral diseases and sensitization by aeroallergens. 7 another evaluated factor was mucus production as an airway defense mechanism; in mice studies, it was demonstrated that allergic inflammation and viral infection act synergistically increasing mucus production, which can lead to airway impaction and obstruction in asthma patients. 8 virus-induced alterations in interferon production have also been observed. for instance, in vivo and in vitro studies in epithelial cells from healthy adults and asthma patients infected with hrv demonstrated a decreased production of type i interferon (␣ and ␤) in the latter, making them more susceptible to infection associated with viral exacerbation. 6, 9 similar results were obtained in studies performed with children, where the production of interferon and th2 cytokines by bronchial epithelial cells was assessed after hrv-16 infection. lower interferon production and higher concentrations of viral rna have been demonstrated in children with asthma, regardless of their atopic status, and in atopic children without asthma, suggesting that an impaired immune response to viral infection occurs not only in asthma patients, but in children with other disorders associated with th2 lymphocytes. 10 however, other studies failed to demonstrate the same reduction in interferon production; others even found an increase in its production in exacerbated asthma. 11, 12 the bronchial epithelium produces some cytokines, including interleukin 25 and 33, as well as thymic stromal lymphopoietin, which promotes the differentiation of innate lymphoid cells into th2. the latter can be induced by viral infection, and its production can be increased by interleukin-4 (il-4), suggesting that the interaction between viruses and allergic airway inflammation may enhance the inflammatory th2 response and potentially reduce the antiviral response. 11, 13 collection and viral detection methods viral detection is highly dependent on the quality of the collected sample, on the time of symptom onset to the time of collection (ideally within 72 hours), and on transportation and storage of the sample before testing. the analysis for respiratory viruses should be performed in material from the airways. upper airway secretion is used in most cases, and several methods are employed for this collection, such as nasopharyngeal aspirate (npa), nasopharyngeal swab (nps), nasopharyngeal lavage, and the combined nasal-oral swab; the first technique is considered the gold standard. 14 recently, new flocked swabs (copan, brescia, italy) were developed, and presented better performance during data collection. recent studies using this type of swab presented a sensitivity comparable to that of npa when the detection is performed by pcr, suggesting that this swab can be used in epidemiological research and surveillance studies, due to its greater technical simplicity. 15, 16 there are few data to support the use of combined oralnasal swabs for virus detection, and its sensitivity is lower than that of the nasopharyngeal swab or aspirate, which can be explained by the lower viral load in the oropharynx than in the nasopharynx. the collection can also be performed on material from the lower airways, such as induced sputum and bronchial lavage. 17 the methods for detection of respiratory viruses are varied and include rapid tests for antigen detection, culture, direct and indirect immunofluorescence, and nucleic acid amplification reactions, such as rt-pcr, which can detect a single agent (monoplex) or perform multiple detections (multiplex). the sensitivity of the latter is higher, and it was used in most recent studies. 18, 19 immunofluorescence reactions have lower cost, are faster to perform, and are also able to detect multiple viruses. a panel of seven viruses (iflu a and b, pflu 1 to 3, hadv, and rsv) is generally used. some viruses, such as hrv and bocavirus, can only be detected through nucleic acid amplification reactions. 17 several authors have performed studies aiming to detect viruses in respiratory secretions of exacerbated asthma patients, showing a prevalence of viral identification that varies with several factors, such as patient age, time of the year, method of sample collection, and method of viral detection. table 2 presents the original articles that demonstrate results of viral testing in children with exacerbated asthma. most studies found prevalence rates between 36.0% 20 and 92.2%; 5 in these cases, the most frequently identified virus was hrv. an investigation of respiratory viruses in 209 children aged between three and 16 years hospitalized for asthma exacerbation was performed over a period of 12 months in buenos aires, argentina. due to the possibility of other diagnoses for wheezing episodes in infants, the definition immune process involved in response to respiratory viruses and their association to allergic inflammation. respiratory viruses infect bronchial epithelial cells (becs) through tool-like receptors (tlrs). during replication, they trigger an inflammatory process with induction of cytokine and chemokine production by becs, among them interferon (ifn-1), tumor necrosis factor alpha (tnf-␣), interleukins (il-33, il-25), and thymic stromal lymphopoietin (tslp). the dendritic cells (dcs), components of the innate immunity, are directed to secondary lymphoid organs after capturing viral antigens, where they stimulate the lymphoid cells, the protagonists of the specific immune response. in asthma patients, the production of ifns is reduced, allowing for greater viral replication and under stimulation of tslp, there is a deviation from lymphoid profile to helper t lymphocyte 2 (th2), promoting lower antiviral response and increased allergic inflammation, with bronchial hyperreactivity and increased production of mucus, causing bronchial obstruction and asthma exacerbation. of asthma was based on the criteria of castro-rodriguez for children younger than 3 years, and on the global initiative for asthma (gina) criteria for those older than 3. immunofluorescence and pcr were performed in nasopharyngeal secretions of the children and showed a positive rate of 78.0% for viruses in general; hrv and hrsv were the most frequently identified types. there was also 20.0% of dual detection, with the involvement of all analyzed viruses. 21 in méxico, the frequency of the viral positivity at the immunofluorescence was higher in children with asthma (75.0%) than in a control group of wheezing children without asthma (44.0%). hrv was not included in that study, and iflu, pflu, and hadv were the most frequently identified virus in the group of asthma patients. 22 in japan, respiratory viruses were detected by multiplex pcr in 86.1% of 115 children with exacerbated asthma, with a mean age of 20.8 months. the hrsv was related to a single episode of wheezing (p < 0.05). 23 hrv was more frequently observed in patients with a history of asthma (p < 0.05). a group of 82 french children with exacerbation treated at home was compared to 27 stable asthmatic children. immunofluorescence, pcr, and serology for viruses (mycoplasma pneumoniae and chlamydophila pneumoniae) detected a pathogen in 45.0% of samples, with significantly higher frequency in cases than in controls (3.7%). viral detection tests were positive in 38% of cases, and hrv was the most common (12.0%). in 10.0% of cases, the serologic tests were positive for both atypical pathogens. 24 another series of 104 children with exacerbation, compared to 31 stable children, was studied by turkish authors and showed positivity of 53.8% in the cases and 22.6% in controls, through rt-pcr reaction. hrv was the most commonly found virus in 35.6% of the samples. 25 in japan, 174 children with acute asthma were compared to 79 stable asthmatic children and 14 children without asthma. using an antigen detection kit and rt-pcr, respiratory viruses were detected in 79.0% of nasal aspirate samples in exacerbated asthmatic children, and hrv was the most common (33.9%). in parallel, the assessment of inflammatory markers showed a significant elevation (p < 0.01) of interleukins il-1, 5, 6, and 10 in serum and in the nasal aspirates of patients in exacerbation, as well as an increase in serum eosinophilic cationic protein (ecp) levels (p < 0.01). 26 flu, although less frequently associated with these episodes, appears to be responsible for increased morbidity in patients with an underlying chronic disease, including asthma. of 2,165 children aged 2 to 17 years admitted with a diagnosis of infections by fluv-a and b between 2003 and 2009 in the united states, 44.0% were asthma patients, and complications were more significantly associated with fluv-a (p < 0.01). other viruses were not assessed in that population. 27 another study compared exacerbated children treated in hospitals (n = 232) with those treated at home (n = 107). immunofluorescence for flu, hadv, hrsv, and piv was performed, as well as pcr for bocavirus. a 36.0% rate of viral detection was obtained, but no difference was observed regarding the viral profile between inpatients and outpatients. the most frequently observed viruses were rsv (15.0%) and bocavirus (12.0%), but hrv was not included in the viral panel of this study. 20 a group of 179 australian children aged up to 16 years had their nasal secretions collected in three periods between 2000 and 2002, and were compared with a control group of non-asthmatic children with upper respiratory tract infection (urti) in the same period and another group of 28 children with controlled asthma, assessed during routine consultations. hrv and hmpv were screened by rt-pcr and a panel of seven viruses (fluv-a and b, piv-1 to 3, hadv, and hrsv) was studied by immunofluorescence. hrv infection accounted for 50.0% of the urti of non-asthmatic children, and co-infection was common, especially with the hrsv, especially in children younger than 2 years. children with symptomatic asthma had the highest rates of hrv infection (79.0% vs. 52.0% among all children). finally, children with controlled asthma had the lowest rates of hrv identification (17.0% vs. 79.0%). 19 studies conducted in 2007 28 and 2009 29 aimed to the identification of hrv in exacerbated asthmatic patients through rt-pcr, found an overall frequency of viral identification of 37.0% and 15.9%, respectively. the first study used a group of comparison consisting of stable asthma patients, in which the identification rate was lower (18.0%) than in the case group (60.0%). both studies found a greater association between exacerbations and the presence of hrv c. another important issue in the complex association between viruses and asthma is related to the intensity of the association of exacerbations with viral infection. in this sense, several studies 4,30---34 presented inconclusive results, although hrv was associated with increased severity or worse response to treatment. 30, 33, 34 the association between viral infection and acute asthma severity was evaluated in 128 children aged 2 to 16 years. a positivity rate of 92.2% for the presence of virus was observed by direct immunofluorescence (dif) and multiplex pcr; hrv was detected in 87.5% of cases, and type c was observed in half the cases and was associated with greater severity. 4 fifty-eight asthmatic children aged 6 to 8 years were monitored for a period of five weeks between april and september of 2009. they had nasal lavage samples collected weekly for multiplex pcr analysis, in addition to a symptom diary, peak expiratory flow, and notes on rescue medication use. a virus was detected in 36.0% to 50.0% of the specimens; hrv was identified in 72.0% to 99.0% of the positive samples, and was associated with greater symptom severity. 30 nonetheless, viral testing by multiplex pcr for 20 pathogens in 209 children with exacerbated asthma compared with 77 controlled asthma patients, performed in hong kong between 2007 and 2008, showed no association between the presence of the virus and exacerbation severity. one virus was identified in 51.0% of cases, and this detection was, in general, more associated with exacerbations (or 2.77; 95% ci: 1:51 to 5:11; p < 0.01). when analyzed individually, no virus was associated with exacerbation, although hrv was the most frequent, being identified in 26.2% of exacerbated and in 13.0% of controlled asthma patients, but with no significant difference (p = 0.27). 31 nasopharyngeal aspirate samples of 201 asthmatic children aged between 2and 15 years collected during episodes of exacerbation were referred for viral identification by pcr. the positivity rate was 53.8%;the most frequently observed were hrv (41.0%), followed by hrsv (9.0%). there was no association with exacerbation severity. 32 a study compared the response to treatment with bronchodilators between exacerbated children with viral respiratory infection symptoms (n = 168) and a group without such symptoms (n = 50). the mean age was 6.6 years, and exacerbation severity did not differ between groups. children with viral symptoms had poor response to bronchodilators, requiring more doses of beta-agonists after 6, 12, and 24 hours. the viral screening was conducted in 77.0% of cases; hrv was the most frequently found virus (61.4%). 33 in another study, 78 exacerbated children were treated at the hospital and compared to 78 asymptomatic adults. multiplex pcr reactions for eight respiratory viruses and monoplex pct for enterovirus, hrv, and bocavirus detected the presence of respiratory viruses in 65.4% of cases; hrv was once again the most frequently observed virus (52.6%). genotyping showed a higher frequency (56.0%) of type c hrv and association with type a showed a worse clinical outcome. 34 asthma exacerbations have seasonal distribution, occurring cyclically in both adults and children, and can be explained by the viral circulation pattern or change in the level of pollutants and aeroallergens. one example is what occurs in temperate countries, where a higher rate of occurrence is more likely to be observed in the fall and spring among schoolchildren. 35 a combination of factors may explain this phenomenon, such as increased circulation of hrv in late summer and early autumn, increased circulation of pollutants and aeroallergens, and the return to school after the summer vacations. the influence of the return to school activities may be explained by lower adherence to maintenance treatment during the vacation period. the circulation of other viruses has been reported in other countries in the northern hemisphere, especially hrsv during autumnwinter, flu in winter, piv-1 and 2 in the fall, and piv-3 in the spring. 36, 37 in brazil, data on viral circulation were collected from the brazilian system of epidemiological surveillance on flu viruses and their counterparts in the period between 2000 and 2010. samples obtained from nasopharyngeal swabs of patients in different sentinel units distributed throughout the country were analyzed by immunofluorescence. they showed a predominance of fluv and hrsv, with circulation throughout the year, with peaks for the latter between march and june, and between may and august for fluv. 38 no data were located concerning the movement of hrv in brazil. few published data regarding the seasonality of exacerbations were found. to make a parallel to virus circulation and the occurrence of exacerbations, the authors analyzed data obtained in some studies, such as the study conducted in the federal district, which observed a higher frequency in the month of march. 39 still in the midwest region, in the state of goiás, an increased frequency of respiratory symptoms, not specified as asthma, was observed in winter. 40 an observation regarding the distribution of the occurrence of asthma in the state of minas gerais also showed higher concentrations in fall-winter, between may and july, 41 indicating a predominance of respiratory and/or asthma symptoms in the brazilian fall-winter seasons. in addition to the seasonal variation of the virus, other factors involved in the genesis of asthma exacerbation may explain this variation, such as aeroallergens and pollutants, which also vary throughout the different seasons. it is likely that the combination of these and other factors result in the observed seasonal peaks in exacerbations. in the month of april of the years 2006 and 2008, a study was conducted in korea aiming to monitor viral infection and to identify sensitization to aeroallergens in 58 children with acute asthma or diagnosis of a cold, whose mean age was 6.5 years. children with allergic sensitization presented the same number of viral infections, but with more symptoms than those nonsensitized. 30 in another study, conducted in manchester, england, 84 children hospitalized for exacerbation were compared to children with stable asthma and children hospitalized for non-respiratory disease. the authors concluded that the association between viral infection and allergen exposure increased the risk of hospital admission by 19.4-fold. 42 in brazil, camara et al. 43 investigated the role of viral infections, sensitization, and exposure to aeroallergens as risk factors for wheezing in children aged up to 12 years. in those younger than 2 years, the frequency of viral positivity was significantly higher in cases (60.8%) than in controls (13.3%). in older children, there was no significant difference: 69.7% of cases and 43.4% of the positive controls. they concluded that in children younger than 2 years, the risk factors associated with wheezing were viral infection and a family history of atopy; among older children, sensitization to inhalant allergens was the most important event for the onset of crises. the effect of air pollutants is usually disregarded in the presence of viruses or allergens. however, there is evidence that acute exposure to specific pollutants may contribute to the symptoms and severity of exacerbations. for instance, cigarette smoke induces a model of non-eosinophilic inflammation with relative resistance to corticosteroids. 44 passive smoking is quite common in homes of asthmatic children, causing a negative impact on disease control. in scotland, the 2006 legislation that banned smoking in public places reduced hospitalizations for asthma by 18.2%. 45 other pollutants appear to contribute to asthma exacerbations, such as those resulting from the combustion of natural gas and engine oil, such as nitrogen dioxide (no 2 ). children spend most of their time outside and breathe in a greater amount of pollutants per kilogram of weight when compared to adults, and the increased levels of no 2 are associated with the severity of virus-induced exacerbations. this emphasizes a potential synergism between these two inflammatory stimuli. 44 moreover, controlled exposure in asthma patients demonstrated that no 2 increases the response to inhaled allergens. a cohort of 114 asthmatic children aged between 8 and 11 years were monitored for symptoms, measurement of peak expiratory flow, measurement of exposure to no 2 , and presence of virus in nasal secretion during a period of 13 months. one or more viruses were detected in 78% of the reported episodes of respiratory symptoms; it was demonstrated that exposure to high concentrations of no 2 in the week before the onset of a viral respiratory infection was related to the exacerbation severity. 46 a longitudinal study conducted in the united states measured exposure to cigarette smoke in 1,444 children with asthma and no 2 in a subset of 663 of them, over a period of nine months. they demonstrated increased symptoms in those exposed to no 2 , but only among non-atopic children, with a relative risk of 1.8 (95% ci: 1.1 to 2.8). there was no association between symptoms and increased cigarette smoke exposure. 47 two cross-sectional studies compared children exposed to different levels of cigarette smoke and showed that those exposed to high levels had higher symptom scores (p < 0.01), nocturnal symptoms (or 3.4; 95% ci: 1.3 to 8.8), and need for relief (p = 0.03) and control (p = 0.02) medications. 48 a study in which 937 children aged between 5 and 11 years were randomized to intervention with environmental education guidelines aimed at reducing exposure, showed a reduction in exposure in the group that received instructions for a period of 14 months. the intervention group had fewer days with symptoms (p < 0.01) after one year of followup, in addition to a decrease in the levels of dust mites (dermatophagoides pteronyssinus and dermatophagoides farinae) and cockroach antigens in the home environment. 49 fungal sensitization is prevalent in children with asthma, although few studies have addressed this issue, compared to studies related to dust mites. one study demonstrated that children with a positive skin test for fungi had more days of symptoms when compared to those with negative tests (6.3 vs. 5.7 for two weeks, p = 0.04). during the study period, fungi were grown from the intra-and extra-domestic environment; increased exposure to fungi was associated with increased days of symptoms and unscheduled physician visits for asthma. 44 the preponderance of virus participation among the infectious agents in exacerbations makes the indiscriminate prescription of antibiotics in this situation pointless in most cases. previous studies suggest that chest radiography is improperly and unnecessarily used in children and adults with acute asthma treated in emergency rooms. 50 due to the alterations that are usually found in patients during asthmatic crises, such as hyperinsufflation, fluid extravasation, and atelectasis associated with hypoxemia, 51 the misinterpretation of these findings as a sign of pneumonia is common and, consequently, unnecessary prescription of antibiotics. a multicenter study of 734 asthmatic patients treated in emergency rooms evaluated the request for additional tests, in this case, chest radiography and blood tests. severely ill patients, those under 1 year, and those with a comorbidity were excluded. a total of 302 (41.0%) children underwent additional tests, such as chest radiography (27.0%) and blood tests (14.0%). after excluding febrile or hypoxic patients, 32.0% were still subjected to at least one of the exams. 50 despite the lack of brazilian data, the routine of pediatric emergency care services in the country appears to adhere to this rule. in order to prevent the dissemination of viral agents, due to the high capacity of viral spread through droplets and fomites, hand washing, and the use of respiratory masks are simple strategies that have been proven to be effective. 52 staying away from situations that favor clusters of people during periods of increased viral circulation has been recommended, although there are no studies that proved the effectiveness of this strategy. 52, 53 the use of substances such as herbal preparations including echinacea and vitamin c has been evaluated, but double-blind, placebo-controlled studies failed to demonstrate their benefit. 54 the prevention of viral infections through vaccines has been the most effective way to control diseases caused by viruses. in the case of respiratory viruses, the only vaccine available is for flu, although there are ongoing studies for the development of vaccines for other respiratory viruses, especially hrv. however, their great antigenic diversity hinders research success; recent studies have tried to establish a more adequate antigenic target in the viral structure. 54, 55 specific rsv immunoglobulin has been successfully used in reducing hospitalizations for viral bronchiolitis, and new perspectives for the treatment of exacerbations triggered by viral infections have emerged from studies directed to synthetic agonists of tlr3 receptor, ifn-␤ agonist, and il33and il25-antagonists, among others. 56, 57 there is no specific treatment for most respiratory viruses. some antivirals have been successfully used, as in the case of flu infection, such as amantadine, rimantadine, oseltamivir phosphate, and zanamivir; the latter is not indicated for patients with asthma. ribavirin is indicated for the treatment of severe infections caused by rsv. other antiviral agents are being studied and have not yet been approved for clinical use, such as pleconaril, vapendavir, pirodavir, and rupintrivir. 54 glucocorticoids have potent anti-inflammatory effects and have been successfully used in maintenance treatment in patients with persistent asthma, controlling inflammation and preventing exacerbations. some studies have assessed its effect on virus-induced asthma. the suppression of the release of pro-inflammatory mediators induced by hrv infection in vitro in bronchial epithelial cells, such as ccl5, ccl10, cxcl8, and il6, as well as the reduction of factors associated with remodeling, was achieved after the use of budesonide. 58 other in vitro studies documented the action of other corticosteroids alone or in combination with bronchodilators or leukotriene antagonists in reducing the release of several inflammatory molecules, with potential modulation of the deleterious effects of viruses on the asthmatic population. 51, 59 despite the proven benefits of inhaled corticosteroids in the control of asthma triggered by multiple factors, their action on virus-induced exacerbations is unclear. the use of low-to-moderate doses of inhaled corticosteroids as maintenance therapy cannot prevent intermittent viral-induced wheezing. 60, 61 however, better results have been obtained with the intermittent use of inhaled corticosteroids at high doses. 62 the use of viral detection techniques with high sensitivity and specificity has increased the identification of some respiratory viruses in children with asthma exacerbation. the direct or indirect immunofluorescence reactions still have great practical importance, as they can detect a panel of seven viruses (fluv-a and b, piv-1-3, hadv and hrsv), being an affordable and fast method, with good sensitivity, especially in children. 18 it is currently used by the brazilian ministry of health for the screening of respiratory viruses in the diagnosis of severe acute flu-like illness and flu-like illness in sentinel units. the techniques for nucleic acid amplification (rt-pcr) are more expensive, but more sensitive; thus, they are used in research and by the brazilian ministry of health for the identification and genotyping of flu. 38 furthermore, it allows for the identification of some viruses with significant clinical and epidemiological importance, such as hrv and bocavirus, not identified by immunofluorescence. 17, 54 as for the method used to obtain the sample, it is worth mentioning the controversial issue of nasopharyngeal swab in viral research. although its use has been consolidated for bacterial infections (s. pneumoniae and s. aureus), its role in viral infections still deserves some consideration. the authors agree that, from the practical point of view, it is more feasible, eliminating the use of suction systems, probes, and more specialized training, when compared to aspirate or lavage samples. however, only those with more advanced technology (flocked swab), which provides best capture and release of cells and, therefore, of the virus, are equivalent to the aspirate in terms of sample quality. nevertheless, this swab is not routinely used in services and researches in brazil. 38 regarding the association between viral infection and asthma exacerbation, a wide variation was observed concerning the methods of studies that assessed viral infection in exacerbated asthmatic children in the studies included in this review. for instance, sample size varied from 58 to 1,052 cases and the age ranged from 0 to 17 years. this finding is important, given the difficulty in defining asthma in children younger than 3 years, which should be considered in case selection. 2, 21 moreover, it is known that there is a considerable difference between the age groups and the most prevalent viruses, such as the hrsv. 60 regarding the methods of respiratory secretion collection in the included studies, there was no uniform means of collection; the aspirate was used in 43.8% of studies, the swab in 31.6%, both in 25%, and the flocked swab was not used. there was a wide variation regarding the detection methods and in relation to some outcomes. in addition to the differences in sample collections, all these studies were cross-sectional, which does not allow for the establishment of a cause-effect association between viral infection and the onset of exacerbation, but suggest such an association. in relation to other factors known to be associated with uncontrolled asthma, such as allergens and irritants, most studies did not include these variables in the evaluation. when the inflammatory process typical of asthma is associated with a viral respiratory infection, there is a tendency to greater severity and duration, as well as a poorer response to conventional treatment of the acute episode. 32, 33 the involved mechanisms still need to be fully elucidated, evidencing the synergistic effect between viral infection and allergic airway inflammation in the pathogenesis of exacerbations. 30, 43 another pertinent issue is the role of inhaled corticosteroids in attenuating the inflammation triggered by the virus, also seldom mentioned in these studies. its action in the control and reduction of morbidity associated with asthma is well established, 2 but it is still a controversial subject regarding the prevention of viral-induced wheezing. its effectiveness in the inflammatory process triggered by a virus has been demonstrated in in vitro studies, 51, 58, 59 but studies evaluating its clinical benefit have yet to reach conclusive results. 61, 62 regardless of the direction of virus-allergen interaction, the present findings strongly suggest that an adequate strategy to prevent virus-induced exacerbations should focus on two courses, namely the improvement of antiviral response and the reduction of allergic sensitization or inflammation. the latter can be achieved with appropriate treatment of the asthma patient at risk with medications that reduce airway inflammation. conversely, the preventive measures for viral infection acquisition and its timely diagnosis allow for a proper management of exacerbations, and reduction of the number of hospitalizations and unnecessary additional tests, especially in children who are febrile at the time of assessment. the association between viral infection and asthma in childhood still has several points that need clarification, especially the actual role of viruses in triggering exacerbations and that of inhaled corticosteroids in its attenuation. fundação de amparo à pesquisa do estado de goiás (n • 20120267001128). the authors declare no conflicts of interest. prevalência de sintomas de asma, rinite e eczema atópico entre crianças e adolescentes brasileiros identificados pelo international study of asthma and allergies (isaac): fase 3 global strategy for asthma management and prevention. global initiative for asthma (gina) 2012 proceedings: the role of viral infection in asthma and bronchitis association between human 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tobacco smoke exposure and nocturnal symptoms among inner-city children with asthma results of a home-based environmental intervention among urban children with asthma guidelines reduce x-ray and blood gas utilization in acute asthma basic research on virus-induced asthma exacerbation: inhibition of inflammatory chemokine expression by fluticasone propionate respiratory viral infections in children with asthma: do they matter and can we prevent them? the impact of infection control upon hospital-acquired influenza and respiratory syncytial virus human rhinoviruses rhinovirus vaccination: the case against asthma exacerbations: origin, effect, and prevention use of toll-like receptor 3 agonists against respiratory viral infections budesonide and formoterol inhibit inflammatory mediator production by bronchial epithelial cells infected with rhinovirus budesonide and formoterol effects on rhinovirus replication and epithelial cell cytokine responses epidemiological and genetic characteristics associated with the severity of acute viral bronchiolitis by respiratory syncytial virus effect of continuous treatment with topical corticosteroid on episodic viral wheeze in preschool children preemptive use of high-dose fluticasone for virusinduced wheezing in young children to the laboratory of virology of the instituto de patologia tropical e saúde pública of the universidade federal de goiás. key: cord-017789-rhoisec4 authors: stockert, karin title: lipidmediatoren und ihre rolle bei entzündungen und allergien date: 2020-03-25 journal: allergiepr&#x000e4;vention doi: 10.1007/978-3-662-58140-7_6 sha: doc_id: 17789 cord_uid: rhoisec4 lipidmediatoren sind als lokal agierende lipide nach dem eindringen eines krankheitserregers oder nach gewebsverletzung im zusammenspiel mit interleukinen und chemokinen zunächst für die sinnvollen proinflammatorischen prozesse wie calor, rubor, dolor, tumor verantwortlich. nach erfolgreich abgewehrter infektion sind es wieder lipidmediatoren, die mithelfen, die unschädlich gemachten viren und bakterien sowie nekrotisches material aus dem gewebe zu eliminieren, die entzündungsreaktion zu stoppen und geschädigtes oder zerstörtes gewebe zu regenerieren. mit den lipidmediatoren hat die evolution wunderbare molekulare netzwerke für kontrollierte immunantworten auf infektionen und verletzungen geschaffen, die perfekt koordiniert zu einer restitutio ad integrum führen und die die homöostase im gewebe wiederherstellen. lange zeit konzentrierte man sich auf die wissenschaftliche beobachtung der entzündungsauslösenden wirkung der prostaglandine und leukotriene. in letzter zeit fokussiert die forschung jedoch immer mehr auch die antiinflammatorischen und entzündungsauflösenden, schützenden und die regeneration mediierenden effekte der lipidmediatoren, weil diese vor der pathogenese von chronischen erkrankungen, wie zum beispiel allergien, schützen können. lipidmediatoren sind als lokal agierende lipide nach dem eindringen eines krankheitserregers oder nach gewebsverletzung im zusammenspiel mit interleukinen und chemokinen zunächst für die sinnvollen proinflammatorischen prozesse wie calor, rubor, dolor, tumor verantwortlich. nach erfolgreich abgewehrter infektion sind es wieder lipidmediatoren, die mithelfen, die unschädlich gemachten viren und bakterien sowie nekrotisches material aus dem gewebe zu eliminieren, die entzündungsreaktion zu stoppen und geschädigtes oder zerstörtes gewebe zu regenerieren. mit den lipidmediatoren hat die evolution wunderbare molekulare netzwerke für kontrollierte immunantworten auf infektionen und verletzungen geschaffen, die perfekt koordiniert zu einer restitutio ad integrum führen und die die homöostase im gewebe wiederherstellen. lange zeit konzentrierte man sich auf die wissenschaftliche beobachtung der entzündungsauslösenden wirkung der prostaglandine und leukotriene. in letzter zeit fokussiert die forschung jedoch immer mehr auch die antiinflammatorischen und entzündungsauflösenden, schützenden und die regeneration mediierenden effekte der lipidmediatoren, weil diese vor der pathogenese von chronischen erkrankungen, wie zum beispiel allergien, schützen können. lipidmediatoren sind "gewebshormone", die in den verschiedenen zellen des menschlichen körpers als katalysator für eine große zahl an stoffwechselvorgängen, wie ca 2+ ein-/ausstrom, regulation von zytokinen und hormonen, kontraktion und dilatation, zellteilung und wachstum sowie hemmung und förderung der blutgerinnung dienen. ausgangsstoffe für die verschiedene lipidmediatoren sind die mehrfach ungesättigte fettsäuren arachidonsäure (20:6, n-6), docosahexaensäure (22:6, n-3) und eicosapentaensäure (20:5, n-3). unter eicosanoiden fasst man jene gruppe von lipidmediatoren zusammen, die 20 kohlenstoffatome (20-c) enthalten: prostaglandine, leukotriene und lipoxine 5 prostaglandine und leukotriene sind lipide aus plasma und zellmembranen, die stark vermehrt nach inflammatorischen stimuli in der anfangsphase der entzündung gebildet werden. sie aktivieren das komplementsystem, induzieren über postkapilläre venolen lokale ödeme und locken leukozyten an den ort der entzündung. 5 zusätzlich entdeckte man in letzter zeit über massenspektrometrische bestimmung (lipidomics oder eicosadomics) auch verschiedenste andere pufas ("poly unsaturated fatty acids") oder lipidmediatoren, wie lipoxine, die neue einblicke in die entzündungsauflösende wirkung der eicosanoide geben. z eicosanoid-biosynthese der ausgangsstoff der eicosanoide ist die arachidonsäure, die in veresterter form gespeichert und durch die phospholipase (pl)a2 aktiviert wird. die kalzium-unabhängige ("independent") pla2 (ipla2) wird im rahmen von alltäglichen membranhomöostase-erhaltenden prozessen aktiviert. bei infektionen und entzündlichen prozessen aktivieren die stimulierten toll-like-rezeptoren (tlr), die purinergen und andere rezeptoren besonders die kalzium-abhängige pla2 (cpla2), die daraufhin in die perinukleären membranen und die membranen des endoplasmatischen retikulums gelangt, um dort die arachidonsäure-haltigen phospholipide in proinflammatorische eicosanoide zu hydrolisieren, aber auch die verwandten n-3-pufas -epa, dpa und dha -zu transformieren, die als vorstufe für resolvine und protektine antiinflammatorische eigenschaften haben (dennis und norris 2015; norris und dennis 2012 ) -dazu aber später (s. 7 abschn. 6.4). die arachidonsäure stellt, als 20-cmehrfach ungesättigte fettsäure, die wichtigste vorstufe der eicosanoide dar, und wird über 3 verschiedene enzymatische vorgänge metabolisiert (. abb. 6.1): 1. über die cyclooxygenasen (cox-1, in prostaglandine und thromboxan 2. über die lipoxygenasen (5-lox, 12-lox, 15-lox) in leukotriene und lipoxine 3. über die cytochrom-p450-enzyme (cyp) in epoxide und dihydroxy pufas (folco und murphy 2006) . als metabolite entstehen dann epoxyeicosantrien-säuren (eets) und n-hetes (hydroxy-eicosatetraen-säuren), die antiinflammatorische wirkung haben dürften, sowie dihete, die wahrscheinlich proinflammatorisch wirken. einige epoxide scheinen essenziell für die bildung von speziellen pro-resolving-mediatoren (spms) zu sein, die für die auflösung von entzündlichen prozessen und die eliminierung von abgestorbenen zellen durch makrophagen sowie die hemmung von proinflammatorischen zytokinen verantwortlich sind (buczynski et al. 2009 ). ausgangsstoff für prostaglandine ist die arachidonsäure (. abb. 6.2). diese wird von den beiden cyclooxygenasen (cox-1 und cox-2) metabolisiert: 5 cox-1 hat eine dominierende rolle für die metabolisierung jener physiologischen prostanoide, die die homöostase lenken (kang et al. 2007 )und wird von fast allen zellen des körpers im endoplasmatischen retikulum und in der kernhülle gebildet (morita et al. 1995) . jedoch auch das bronchokonstriktorische prostaglandin d2 und prostaglandin e2 entstehen zumindest teilweise durch die enzymatische aktivität von cox-1. 5 cox-2 wird als antwort auf inflammatorische stimuli im rahmen von entzündlichen prozessen aktiviert und ist für die bildung der prostanoide bei inflammatorischen und proliferativen erkrankungen verantwortlich (ricciotti und fitzgerald 2011) . induziert wird die cox-2-expression von den zytokinen il-1, il-2, tnf-α und von lipopolysacchariden (kang et al. 2007 ). cox-2 kommt in höherer menge in der hülle des zellkerns vor (morita et al. 1995) seit dem jahr 1982, in dem der medizin-nobelpreis für die prostaglandinund cox-erforschung vergeben wurde, entwickelte man zur analgesie und fiebersenkung selektive cox-2-hemmer, weil man erkannt hatte, dass hemmung der cox-1 zu unerwünschten nebenwirkungen, wie gastrointestinale ulzera und verzögerte plättchenaggregation führte (kang et al. 2007 ). wegen schwerster kardiovaskulären nebenwirkungen nach selektiver cox-2-hemmung musste jedoch ein selektiver cox-2-hemmer, rofecoxib, 2004 wieder vom markt genommen werden (rainsford 2007) . während cox-1 hauptsächlich die arachidonsäure oxygeniert, kann cox-2 auch sehr effizient andere fettsäuren wie die eicosapentaensäure und linolensäure oxygenieren (laneuville et al. 1995; vecchio et al. 2010 vecchio et al. , 2012 . in letzter zeit erkannte man, dass die cox-2 nicht nur proinflammatorische prostanoide erzeugt, sondern besonders in bronchialen und alveolären epithelzellen auch konstitutiv exprimiert wird und gerade in der lunge auch eine schützende funktion zu haben scheint, indem ihre substrate wie pge2 z. b. die proliferation der fibroblasten hemmen können (ermert et al. 1998; simon 1999; lama et al. 2002) . heute differenziert man unterschiedliche prostaglandine, deren funktionen besonders in den letzten jahren besser erforscht wurden, weil man knockout-mausmodelle entwickelte, bei denen gentechnisch prostaglandin-rezeptorgene oder synthetasen durch eine gezielte mutation ausgeschaltet oder überexprimiert werden können. prostaglandin d2 wird von mastzellen und eosinophilen als antwort auf ige-aktivierung gebildet und wird daher bei allergischem asthma, rhinitis und rhinokonjunktivitis vermehrt sezerniert. außerdem wirkt es bronchokonstriktorisch und gefäßerweiternd (johnston et al. 1995) . gebildet wird es vornehmlich durch cox-1 (daham et al. 2011) . pgd2 erhöht die vaskuläre durchlässigkeit und den eosinophilen einstrom in die konjunktiva, trachea sowie bronchien und spielt daher eine wichtige rolle bei der pathogenese allergischer erkrankungen (doyle et al. 1990 ). pgd2 wirkt über 2 verschiedene g-proteingekoppelte rezeptoren: der dp1-rezeptor wird von becherzellen der nasen-und kolonmukosa, vaskulären endothelzellen, th2-zellen, dcs, basophilen und eosinophilen exprimiert, aktiviert die adenylcyclase und erhöht das camp. dagegen reduzieren die dp2-rezeptoren das intrazelluläre camp. man findet sie in eosinophilen, basophilen und th2-zellen. dp2-signale in eosinophilen erhöhen die freisetzung von eosinophilen im knochenmark, bewirken deren anhäufung und chemotaxis im respirationstrakt und erhöhen die mikrovaskuläre permeabilität und die irritation von becherzellen (smith et al. 2011) . inhalation von allergen führt bei asthmatikern zu vermehrung von pgd2 in der bal (murray et al. 1992 ). auch bei allergischer konjunktivitis (proud et al. 1990 ) und allergischer rhinitis (naclerio et al. 1983 ) wurde in der tränenflüssigkeit und im nasensekret vermehrt pgd2 nachgewiesen. gabe von aerosolisierten pgd2 an mäuse erhöht die pulmonalen th2-antworten (honda et al. 2003) . besonders die signalgebung über den dp2-rezeptor dürfte die allergische inflammation verstärken. erste versuche mit dp2-antagonisten am menschen verbesserten bei asthma die symptomen-scores und senkten die eosinophilen im sputum (barnes et al. 2012 ) und im tierversuch die antigen-induzierte bronchiale hyperreaktivität (gervais et al. 2011 ). pgj2 und 15-deoxy-pgj2 sind natürlich vorkommende abbauprodukte von prostaglandin d2, die ganz im gegensatz zu deren vorstufe (pgd2) antiinflammatorische wirkung haben. diskutiert wird eine direkte hemmung der nf-kb-abhängigen genexpression und damit hemmung der cox-2-aktivierung (straus et al. 2000) . neuere studien zeigen, dass 15-d-pgj2 direkt die prostaglandin-e-synthase 1 (s. 7 abschn. 6.1.3) hemmt und dadurch entzündungen und fieber antiinflammatorisch beenden kann (prage et al. 2012) . hier eröffnet sich dem beobachter wieder eine evolutionär vorgesehene feedback-schleife, die über eine negative rückkoppelung der prostaglandin-biosynthese eine antiinflammatorische wirkung entfacht und dadurch die entzündungsauflösung initiiert. als eines der hauptprodukte des arachidonsäurestoffwechsels kann pge2 pleiotrope wirkungen entfalten: pge2 war lange zeit dafür bekannt, dass es schmerzen und entzündungen auslöst. aufgrund seiner stark proinflammatorischen wirkung wird es mit verschiedensten entzündlichen erkrankungen wie rheumatoider arthritis in verbindung gebracht (mccoy et al. 2002) . pge2 ist auch an der fieberentstehung beteiligt, indem es über signalwege in neuronen an die entsprechenden rezeptoren koppelt. wie schon im 7 abschn. 5.4.1 erwähnt, bewirkt der kontakt von pyrogenen mit lipopolysacchariden (lps), dass die coxund die pge-synthetase in endothelialen und perivaskulären zellen der mikrozirkulation des gehirns aktiviert werden und in folge pge2 freisetzen (murakami und kudo 2004) . beim vergleich der pge2-mengen in den unterschiedlichen organen offenbart sich, dass kolon, lunge und magen wesentlich mehr an pge2 enthalten als andere organe (chinen et al. 2011) . als eines der am reichlichsten in der lunge vorkommenden cox-produkte wird pge2 auch in den atemwegsepithelzellen, makrophagen und in der glatten muskulatur der atemwege gebildet, wo es sowohl bronchokonstiktorisch als auch bronchodilatorisch wirken kann. in letzter zeit erhärten erkenntnisse über die wirkung von pge2 auf die lunge die theorie, > dass pge2 das wichtigste prostaglandin zur erhaltung der homöostase im rahmen von entzündlichen antworten der atemwege ist und einen starken bronchoprotektiven und antiinflammatorischen effekt haben dürfte. die vorstufe pgh2 wird von mikrosomalen und zytosolischen pge2-synthetasen (mpges, cpges) zu pge2 isomerisiert (smith et al. 2011) . die bildung von pge2 ist sowohl cox-1-als auch cox-2-abhängig. die zytosolische pge2-synthetase (cpges) koppelt an cox-1, aber auch cox-2, und fördert in folge eher die bildung jenes basalen pge2, das für die zelluläre homöostase wichtig ist (park et al. 2006) . diese cpges-aktivierung wird durch dexamethason reduziert (park et al. 2006) . die mikrosomale pge2-synthetase-1 (mpges-1) bindet eher an cox-2 und kann binnen kürzester zeit bei entzündungsvorgängen die menge von pge2 erhöhen (claar et al. 2015) . schon kurz vor der jahrtausendwende hatte man beobachtet, dass inhalation von pge2 die allergen-induzierte bronchokonstriktion hemmt (pavord und tattersfield 1995) . inhaliertes pge2 reduzierte signifikant den fev1-abfall nach allergen-challenge bei allergischem asthma im vergleich zu placebo (pavord et al. 1993) . auch nach künstlicher überexpression der pge2-synthetase reagierten mäuse mit erhöhten pge2-werten und einer reduzierten metacholin-induzierten bronchokonstriktion (hartney et al. 2006) . auch gegen die aspirin-induzierte bronchokonstriktion wirkt inhaliertes pge2 protektiv (sestini et al. 1996) . später mehrten sich studien, die zeigten, dass pge2 auch vor atemwegseosinophilie schützt. man beobachtete 5 dass bei asthmatikern eine inverse relation zwischen der menge des pge2 und den eosinophilen im sputum besteht (aggarwal et al. 2010) , 5 dass pge2 die eosinophile migration hemmt (sturm et al. 2008) , 5 dass pge2 die allergen-induzierte eosinophile akkumulation unterdrückt (gauvreau et al. 1999) . vom atemwegsepithel produziertes pge2 hemmt auch die aktivität der dcs und dämpft dadurch die sekretion von proinflammatorischen zytokinen (schmidt et al. 2011) . pge2 ist auch das wichtigste prostaglandin, das von lungenfibroblasten gebildet wird (korn et al. 1983 ) und übt dort diverse antifibrotische wirkungen aus: pge2 hemmt 5 die migration der fibroblasten (white et al. 2005) , 5 die proliferation der fibroblasten und reduziert tgf-β (elias et al. 1985) , 5 die differenzierung vom fibroblasten zum myofibroblasten (bozyk und moore 2011), 5 die kollagenakkumulation im lungenfibroblasten (kolodsick et al. 2003) . pge2 fördert 5 die apoptose der fibroblasten (huang et al. 2009 ). dysregulation der pge2-synthese bzw. pge2-antworten wurden bei lungenfibrosen am menschen beobachtet (scotton und chambers 2007) . fibroblasten von patienten mit idiopathischer lungenfibrose (ipf) zeigten als antwort auf diverse stimuli eine reduzierte synthese von pge2 und eine reduzierte cox-2-produktion (wilborn et al. 1995 (stumm et al. 2011) . spannenderweise zeigten die fibroblasten von den asthmatischen tieren -im vergleich zu gesunden tieren -auch nach diversen allergenchallenges per se keinen defekt in der fähigkeit von pge2, die proliferation von fibroblasten und die bildung von kollagen-1 zu hemmen. trotzdem nahm das remodeling mit vermehrung der allergen-challenges bei asthmatischen tieren progressiv zu. messungen ergaben, dass die zytokin-induzierte hochregulierung von pge2 sowie die expression von cox-2 und der mikrosomalen pge-synthetase-1 mit steigender anzahl der antigen-challenges abnahm. die gabe eines selektiven cox-2-hemmers potenzierte das ausmaß der remodeling-effekte nach wiederholter challenge. somit wurde bestätigt, dass durch endogene cox-2 gebildetes pge2 wie eine "bremse" dem atemwegsremodeling entgegenwirkt. die ursache dafür scheint in der unfähigkeit der fibroblasten zu liegen, die pge2-produktion über cox-2 hochzuregulieren. (zhang et al. 2015) . heute weiß man, dass sowohl die entzündungsfördernden als auch entzündungshemmenden wirkungen von pge2 von deren bindung an 4 verschiedene g-proteinrezeptoren abhängen: ep1, ep2, ep3, ep4. alle 4 rezeptoren befinden sich in neutrophilen, makrophagen, epithel-und endothelzellen der lunge und auch anderer organe (smith et al. 2011 ). ep1-rezeptoren: befinden sich in mastzellen, in den pulmonalvenen, im myometrium und in der kolonmuskulatur. aktivierung der ep1-rezeptoren führt zu kontraktion der glatten muskulatur in jenen organen (woodward et al. 2011) über erhöhung des intrazellulären ca 2+ (regan 2003) . ep2-rezeptoren werden besonders in der lunge, aber auch in der milz und im uterus exprimiert. über erhöhung von intrazellulärem camp bewirken aktivierte ep2-rezeptoren eine entspannung der glatten muskulatur in den bronchien und wirken antiinflammatorisch. die bronchiendilatation durch pge2 wird über den ep2-rezeptor durch hemmung der mastzellendegranulation verursacht (kay et al. 2006; peachell et al. 1988) . diese erkenntnis wurde durch eine aktuelle studie bestätigt. erstmals konnte 2015 in einer in-vitro-studie auch an menschlichen zellen der kleinen atemwege mit einem inneren durchmesser von maximal 1 mm, die für die obstruktion der atemwege beim asthmatiker von besonderer bedeutung sind, gezeigt werden, dass pge2 über ep2-rezeptoren eine hemmung der igeund mastzell-mediierten bronchokonstriktion bewirkte und daher eine starke bronchoprotektive aktivität entfaltete (säfholm et al. 2015) . nachdem molekularbiologische methoden mittlerweile die herstellung von agonisten und antagonisten der verschiedenen rezepto-ren ermöglichen, bekommt man neue einsichten über die wirkungsweisen und das zusammenspiel der einzelnen strukturen: die pge2-ep2-achse scheint auch eine hemmende wirkung auf die allergische sensibilisierung zu haben. mäuse ohne ep2-rezeptoren (knockout-ep2 -/-mäuse) zeigten in einem ova-induzierten modell von allergischen asthma, zeichen verstärkter allergischer inflammation mit höheren werten von eosinophilen und th2-zytokinen il-4, il-5 und il-13 in der balf sowie verstärkte th2-antworten mit erhöhter il-13-produktion von pulmonalen lymphozyten und splenozyten während der sensibilisierungsphase im vergleich zu mäusen mit intakten ep2 (ep2+/+)-rezeptoren (zaslona et al. 2014 ). in-vitro-gabe von pge2 reduzierte die ova-induzierte il-13-produktion um 85 % bei splenozyten von ep2 +/+ mäusen, jedoch nicht bei ep2-knockout-mäusen wurde das pge2 analog misoprostol in vivo 2 h vor und 10 h nach ova-sensibilisierung verabreicht, beobachtete man nach zwei folgenden inhalativen allergen-challenges eine woche später, bei den mäusen mit intakten ep2-rezeptoren eine reduzierte eosinophile, niedrigere il-5-und il-13-werte in der balf sowie reduzierte ige-werte im serum, im vergleich zum effekt von misoprostol bei ep2-knockout-mäusen. somit wurde klar, dass pge2 hauptsächlich über ep2-rezeptoren die immunologischen effekte während der allergischen sensibilisierung hemmt und dass diese effekte stark genug sind, um die allergische inflammation nach inhalativer challenge auch noch eine woche später abzuschwächen. die achse pge2-ep2 stellt offensichtliche eine immunologische "bremse" für die entwicklung der adaptiven th2-immunantwort dar. die tatsache, dass sowohl endogenes als auch exogenes pge2 5 die sensibilisierung unterdrücken, 5 aber auch die th2-antworten nach inhalativer challenge reduzieren 5 und damit auch die th1/th2-balance verbessern, lässt den wichtigen stellenwert von pge2 zur aufrechterhaltung des homöostatischen gleichgewichts in der mukosa der atemwege erkennen. bei der fragestellung, welche zellen des lymphatischen gewebes am ehesten durch pge2 gehemmt werden, untersuchte man die wirkung von pge2 auf die cd4 + -t-zellen (vorstufen der th2-zellen) und auf die dcs, weil frühere studien auch eine hemmende wirkung von pge2 auf die dcs nachgewiesen hatten (yang et al. 2003) . in der vorliegenden studie (zaslona et al. 2014 ) wurde an ova-sensibilierten zellen eine merkliche il-13-erhöhung nur an den ep2 -/-cd4 + -t-zellen, jedoch nicht an den ep2-/-dcs gefunden, woraus man schloss, dass eher die ep2-rezeptoren an den cd4 + -t-zellen als an den dendritschen zellen für die beobachtete hemmung der sensibilisierung verantwortlich sind. als beweis dafür wiesen cd4 + -t-zellen von ova-sensibilisierten mäusen mit intakten ep2-rezeptoren nach gabe von ep2-agonisten und pge2-agonisten eine 75 % reduktion der il-13-werte auf. diese studie wies auch nach, dass die effekte höchstwahrscheinlich über eine hemmung der phosphorylierung von stat6, einem transkriptionsfaktor der th2-differenzierung, ausgelöst werden. nachdem th2-zellen (neben den ilc2-zellen) als hauptverantwortlich für die bildung von th2-zytokinen angesehen werden, ist es sehr wahrscheinlich, dass der pge2-ep2-signalweg eine hemmende wirkung auf die th2-zellproliferation hat und dadurch die allergische sensibilisierung unterdrücken kann. die protektive, antiallergische rolle von pge2 auf die schleimhäute des atemtrakts wurde von studien an patienten mit chronischer rhinosinusitis bestätigt, die nach oraler gabe von pge2-analoga ebenfalls eine reduzierte il-13-produktion in der mukosa von nasenpolypen (okano et al. 2009 ) sowie eine unterdrückung der il-4-produktion mit folgender reduktion von ige zeigten (parker et al. 1995 ebenfalls über den ep2-rezeptor dämpft pge2 die soeben beschriebene proliferation der fibroblasten und deren kollagenproduktion (huang et al. 2008) . die reaktion des cox-metabolismus auf entzündliche signale und die auswirkung auf die pge2-ep2-achse wurde in einem weiteren versuch getestet: dazu wurde nasenschleimhaut von gesunden sowie nasenschleimhaut mit polyposis von aspirin-toleranten und aspirin-intoleranten mit il-1β stimuliert und die cox-mengen sowie die menge an pge2 und ep2 gemessen: in zellkulturen gesunder nasenmukosa stimulierte il-1β die fibroblasten dazu, vermehrt ep2 und pge2 zu exprimieren. im gegensatz dazu produzierte nasenmukosa mit polypen sowohl von aspirin-toleranten als auch von aspirin-intoleranten nach il-1β-stimulation kein "schützendes" pge2 und ep2. exposition der fibroblasten mit il-1β induzierte bei gesunden eine vermehrte pge2-synthese über gesteigerte cox-1-und cox-2-expression. bei fibroblasten von nasenpolypen bei aspirin-toleranten beobachtete man eine wesentlich geringere vermehrung der cox-1-und cox-2-ausschüttung, und bei aspirin-intoleranten kam es zu fast keiner vermehrten expression von cox-1 und cox-2 (roca-ferrer et al. 2011) . somit zeigt sich wiederum (wie bei den untersuchungen bezüglich remodeling), dass eine mangelnde hochregulierung von cox-1 und cox-2 sowie fehlende vermehrung von pge2 unter inflammatorischen bedingungen an der entwicklung einer chronischen eosinophilen rhinosinusitis mit polypen sowohl mit als auch ohne aspirin-intoleranz beteiligt sind. dieses experiment versuchte eine "künstliche" inflammatorische situation über stimulation von il-1β zu erzeugen. wie schon im 7 abschn. 5.4.1 beschrieben, wird il-1β auf natürlichem weg durch lipopolysaccharide aus bakterienwänden oder andere endogene pyrogene aktiviert und stellt als entzündungsmediator einen wichtigen baustein zur fieberauslösung dar. die brisanz dieser studie ergibt sich aus der tatsache, dass sich hier zeigt, dass beim gesun-den die il-1β-aktivierung mit folgender vermehrung von cox-1 und cox-2 und daraus resultierendem erhöhten pge2 eine schutzwirkung auf die nasenmukosa auszuüben scheint. (luo et al. 2005) . dieser rezeptor hat eine kontraktile funktion auf die lunge und pulmonalarterie (qian et al. 1994 ) und wird mit entzündung, schmerz (woodward et al. 2011 ) und mit der entwicklung von fieber (s. 7 abschn. 5.4.1) in verbindung gebracht. auch pge2-induzierter husten wird über den ep3-rezeptor mediiert und kann durch gabe von ep3-antagonisten gehemmt werden (maher et al. 2009 ). eine andere arbeit zeigte jedoch interessanterweise, dass die aktivierung des ep3-rezeptors durch pge2 die allergische inflammation unterdrücken kann (kunikata et al. 2005 ) (s. 7 abschn. 7.2.3). diese teilweise widersprüchlichen ergebnisse machen deutlich, wie vielfältig das zusammenspiel der pleiotropen wirkungen von pge2 und seiner rezeptoren sein dürfte und mit welch komplexen wirkungen man bei der verabreichung von cox-hemmern rechnen muss. ep4-rezeptor: er befindet sich in lunge und thymus, aber auch in der niere und den peripheren leukozyten. ep4-rezeptoren arbeiten genauso wie ep2-rezeptoren über aktivierung von camp und bewirken entzündungshemmung (takayama et al. 2002) . ep4 ist der wichtigste bonchodilatierende rezeptor. ep4-rezeptoragonisten wirken stärker direkt bronchienerweiternd als ep2-rezeptoragonisten (säfholm et al. 2015 aber auch unabhängig von camp hemmt ep4 die nf-κb-aktivierung in menschlichen makrophagen (takayama et al. 2006 ) und die eosinophile migration (luschnig-schratl et al. 2011) . topaktuell im mai 2018 publizierte eine schwedisch/österreichische gruppe eine studie, die eine zusätzliche antiallergische wirkung von pge2 aufzeigt. pge2 hemmt an menschlichen zellen auch die ilc2-aktivierung! nach stimulation menschlicher ilc2-zellen mittels einer kombination aus il-25, il-33. tslp und il-2 konnte die proliferation dieser ilc2-zellen mittels pge2 über hemmung der ga-ta-3-expression blockiert werden. gata 3 ist ein transkriptionsfaktor, der für die entwicklung von ilc2-zellen und th2-zellen benötigt wird. gata 3 aktiviert in den ilc2-zellen die sekretion von il-5 und il-13. in den gehemmten ilc2-zellen wurde daraufhin eine reduzierte sekretion von il-5 und il-13 beobachtet. . abb. 6.4 verdeutlicht, dass diese effekte über die ep2-und ep4-rezeptoren mediiert wurden, die von ilc2-zellen besonders stark exprimiert werden (maric et al. 2018) . somit offenbart auch diese studie, dass pge2 eine protektive wirkung auf die lunge hat und als endogener mediator die überschießende ilc2-aktivierung der allergischen inflammation "beruhigen" und gegensteuern kann. dadurch ist es sehr wahrscheinlich, dass die pge2-ep2/ep4-achse eine entscheidende bedeutung sowohl bei der prävention der allergischen sensibilisierung als auch bei der auflösung der allergischen inflammation haben dürfte. dies erscheint besonders wichtig, wenn man bedenkt, dass viele protease-bildende allergene (z. b. hausstaubmilbe, hopfenpollen) bzw. auch bakterien (z. b. staphylococcus aureus) (s. 7 abschn. 7.3) il-33 aktivieren und dadurch eine erhöhte sensibilisierungsbereitschaft auslösen. hemmung der il-33-impulse auf die ilc2-zellen hätte somit eine starke präventive funktion. eine vermehrte il-10-produktion durch pge2 von makrophagen zeigte auch ein murines modell, bei dem zunächst künstlich eine sepsis induziert wurde, die dann durch zugabe von mesenchymalen stammzellen erfolgreich gehemmt wurde. gabe von il-10-antikörper blockierte die hemmung der sepsis, was die bedeutung von il-10 bei der umprogrammierung der makrophagen deutlich macht. die reprogrammierung der makrophagen durch stammzellen erfolgte über pge2, das an den makrophagen über die prostaglandin-ep2-und -ep4-rezeptoren agierte (nemeth et al. 2009 ). interessanterweise sind die komplexen erkenntnisse über die schützende wirkung von prostaglandin e2 auf die atemwege in der ärzteschaft relativ unbekannt. obwohl sie bei der verschreibung von cox-hemmern von größter relevanz wären. prostaglandin f2α hat größere bedeutung bei der reproduktion und für die nierenphysiologie, als für immunologische und inflammatorische prozesse und weist im corpus luteum des ovars die größte konzentration auf (hata und breyer 2004) . dennoch führte inhalation von pg f2α bei asthmatikern innerhalb weniger minuten zu giemen und husten (smith et al. 1975) . die bedeutung von pg f2α in bezug auf allergische er-krankungen dürfte jedoch im vergleich zu den anderen prostaglandinen eher gering sein. prostaglandin i2 ist ein cox-2-induziertes prostaglandin, das im mausversuch die dc-aktivierung von th2-zellen und die th2-zelldifferenzierung hemmt sowie die eosinophile migration beeinflusst (idzko et al. 2007 ). pgi2 kann auch die antigenaufnahme der dcs reduzieren (toki et al. 2013) . ebenso wie pge2 bewirkt es eine hemmung von tnf-α sowie eine aktivierung von il-10 und wirkt dadurch einerseits antiinflammatorisch. andererseits kann es aber auch zusätzlich die entzündungsauflösende phase des infekts initiieren (shinomiya et al. 2001) . prostaglandin i2 scheint einen bronchoprotektiven, antiinflammatorischen und antiallergischen effekt zu haben, der durch cox-hemmer aufgehoben wird (zhou et al. 2014 ) (s. 7 abschn. 7.2.3). außerdem wird pgi2 in den endothelzellen produziert, hemmt die thrombozytenaggregation und fördert die vasoldilatation (dennis und norris 2015) , weshalb pgi2-analoga aktuell zur behandlung der pulmonalen arteriellen hypertension eingesetzt werden (demerouti et al. 2013) . für den einsatz in der allergologie gelten pgi2-analoga derzeit als entwicklungsfähige therapieoption. thromboxan a2 ist ein cox-1-produkt und stellt eines der hauptprodukte des arachidonsäurestoffwechsels dar. es wird vom lungenparenchym, thrombozyten, monozyten, makrophagen, und neutrophilen gebildet. tx a2 ist ein potenter plättchen-aggregator, wirkt jedoch auch als stark bronchokonstriktorischer und inflammatorischer mediator beim asthma (whittle und moncada 1983) . der thromboxanrezeptor (tp) gilt als der stärkste bronchokonstriktorische prostanoidrezeptor. als be-weis dafür wurde kürzlich nachgewiesen, dass ein tp-rezeptorantagonist sämtliche bronchienverengenden wirkungen der pge2-rezeptoren ep1 und ep3 aufhob (säfholm et al. 2015) . bereits 1989 hatte man beobachtet, dass pge2 auch über thromboxanrezeptoren kontraktionen der menschlichen atemwege auslösen kann, was die komplexität der funktionen von pge2 nochmals erhöht (coleman et al. 1989) . tx a2-synthetasehemmer und antagonisten der tp-rezeptoren stellen aufgrund verfügbarer daten aus mausexperimenten interessante ziele in der forschung für neue asthmatherapien dar (shi et al. 1998) . diese tatsachen haben auswirkungen auf die nebenwirkungen der diversen cox-hemmer: nach selektiver hemmung der cox-2 beobachtete man ein erhöhtes risiko an kardiovaskulären ereignissen, die wahrscheinlich über eine hemmung der pgi2 hervorgerufen wurden, während das cox-1-produkt thromboxan a2 nicht beeinflusst wurde. der stärkste cox-2-hemmer rofecoxib musste deshalb wegen erhöhter raten von myokardinfarkten und insulten 2004 vom markt genommen werden (fitzgerald 2004) . umgekehrt wirkt niedrig dosiertes aspirin kardioprotektiv, indem es über eine cox-1-hemmung die bildung von thromboxan a2 und die plättchenaggregation hemmt, jedoch die pgi2-bildung nicht beeinflusst. leukotriene sind lipidmediatoren, die bei infekten zunächst physiologisch proinflammatorisch wirken und schleimbildung, ödeme, aber auch bronchokonstriktion auslösen. bei überproduktion haben sie jedoch eine wichtige bedeutung bei der entstehung von asthma und allergischer inflammation. in eosinophi-len, mastzellen, makrophagen und myeloiden dendritischen zellen bildet sich nach aktivierung über umwandlung von arachidonsäure durch die 5-lipooxygenase zunächst das instabile leukotrien (lt) a4, das zu lt b4 sowie durch weitere konjugation mittels der lt-c4-synthetase in lt c4 transformiert wird (s. . abb. 6.6). dieses wird aus der zelle exportiert und zu lt d4, sowie schließlich enzymatisch in den stabilen endmetaboliten lt e4 metabolisiert (laidlaw und boyce 2012) . als cysteinyl-leukotriene (cys-lt) bezeichnet man lt c4, lt d4 und lt e4, die eine klar definierte rolle beim asthma haben, indem sie die pulmonale inflammation aufrecht erhalten und eine atemwegsobstruktion durch vermehrte schleimbildung, ödeme, konstriktion der bronchialmuskulatur sowie ein remodeling auslösen. das stabile endprodukt lt e4 erhöht auch die migration von eosinophilen in die asthmatischen atemwege (gauvreau et al. 2001 ) schon vor 25 jahren konnten erhöhte menge von leukotrienen im rahmen von asthmaexazerbationen im harn gemessen werden, was auf die beteiligung der cys-lte an asthmatischen krankheitsprozessen hinwies (drazen et al. 1992; christie et al. 1991) . auch nach aspirin-challenge bei aerd beobachtete man erhöhte lt e4-werte im harn. anders als viele andere mediatoren, die schon vorgeformt sind, werden leukotriene nach aktivierung de novo gebildet. die 5-lipoxygenase wird im rahmen von infektionen, aber auch durch allergische inflammation aktiviert (montuschi et al. 2007) . hemmung der 5-lipoxygenase und folglich auch der synthese sämtlicher leuktriene mit dem 5-lox-hemmer zileuton verbessert die asthmakontrolle und die lungenfunktion im vergleich zu placebo signifikant (israel et al. 1996) . die leukotrien-signalkaskaden werden über verschiedene g-protein-gekoppelte rezeptoren aktiviert: der cys-lt1-rezeptor mediiert viele pathophysiologischen effekte der cys-lte beim asthma und wird in der bronchialen mukosa von asthmatikern verstärkt exprimiert (zhu et al. 2005) . für diesen rezeptor, der besonders lt d4 bindet, werden bereits seit jahren antagonisten (montelukast, pranlukast und zafirlukast) mit gutem erfolg therapeutisch eingesetzt und haben in den gi-na-guidelines einen festen platz. hingegen spielt der cys-lt2-rezeptor eine rolle bei pulmonaler fibrose sowie gefäßverletzungen (beller et al. 2004 ) und hat eine affinität zu lt c4 und lt d4. in letzter zeit erkannte man, dass hemmung dieser beiden rezeptoren lt e4 mit der längsten halbwertszeit nicht blockieren konnte. daraufhin entdeckte man noch zusätzliche rezeptoren: p2y12 , cys-lte und gpr99, die besonders an lt e4 binden und die atemwegseosinophilie und becherzellmetaplasie verstärken (paruchuri et al. 2009 ). clodiprogel ist ein p2y12-antagonist, der zur antikoagulation eingesetzt wird und der bei der häufig auftretenden aerd als ersatz für aspirin zur antikoagulation sinnvoll verwendet werden kann. die derzeit in den gina-guidelines für die asthmatherapie angewandten leukotrien-rezeptorantagonisten sind in klinischen studien den inhalativen steroiden unterlegen. dies liegt auch daran, dass diese rezeptorantagonisten nur an den cys-lt1-rezeptor binden, jedoch andere rezeptoren der leukotriene nicht antagonisiert werden (holgate et al. 2003) . lt d4 verstärkt die proliferation der atemwegsmuskulatur über induktion von "epidermal growth factor" (panettieri et al. 1998) . lt c4 erhöht die expression der kollagenase und die synthese von lungenfibroblasten (medina et al. 1994) . anhand 29 asthmatischer kinder beobachtete man, dass die menge der cysteinyl-leukotriene der ausatemluft mit dem ausmaß der basalmembranverdickung korrelierte (lex et al. 2006) . umgekehrt konnte durch den cys-lt1-rezeptorantagonisten montelukast in einem mausmodell mit chronischem asthma die becherzellmetaplasie, die bronchialmuskelmasse und die subepitheliale kollageneinlagerung reduziert werden (henderson et al. 2006) . leukotriene spielen eine schlüsselrolle beim "exercise-induced" asthma, wo sie bis zu 6 stunden nach der belastung noch verstärkt nachweisbar sind (hallstrand et al. 2005) (buchheit et al. 2016) . somit sind die zentralen ursachen der aerd-pathogenese die hemmung des bronchoprotektiven und antiinflammatorischen pge2 sowie eine überproduktion von proinflammatorischen und bronchokonstriktorischen cysteinyl-leukotrienen. die dysbalance dieser lipidmediatoren führt wahrscheinlich zu erhöhten eosinophilen im respirationstrakt (diamant et al. 1997) . typisches merkmal für die aerd ist die abhängigkeit von cox-produkten. pge2-analoga und ep2 rezeptoren-analoga sind in der lage, die aspirin-induzierte überproduktion von cys-lts zu 90 % zu blockieren. . bei aerd-patienten findet man in den schleimhäuten deutlich verringerte mengen der enzyme cox-2-und pge2-synthetase, die dort auch indirekt proportional zur menge der leukotriene sind, und eine überproduktion von pgd2 (yoshimura et al. 2008) . so beobachtete man im gewebe von nasenpolypen von aerd-patienten im vergleich zu polypen von aspirin-toleranten eine reduzierte expression von cox-2 und eine hypermethylierung des pge2-synthetase-gens. während entzündlicher prozesse scheint die verfügbarkeit von pge2 bei aerd-patienten durch eine reduzierte expression von cox-2 und hypermethylierung des pge2-synthetase-gens reduziert zu sein und wird dann nach cox-1-hemmung durch aspirin oder nsar noch weiter vermindert, wodurch es zur exazerbation mit den charakteristischen symptomen kommt (cheong et al. 2011 ). mangelndes pge2 spielt somit eine wichtige rolle bei der aerd. epithelzellen der nasenpolypen von aerd-patienten produzierten signifikant weniger pge2, aber umgekehrt signifikant mehr lt-c4-synthase und cysteinyl-leukotriene (perez-novo et al. 2005; kowalski et al. 2000) . dieselben veränderungen sieht man beim vergleich von atemwegsfibroblasten von aerd-patienten mit gesunden, die viel weniger pge2-produzieren als aspirin-tolerante und gesunde (pierzchalska et al. 2003) . umgekehrt blockiert die inhalation von pge2-agonisten die bronchokonstriktion und hemmt den anstieg der lt e4 nach aspirin-challenge bei aerd-patienten (sestini et al. 1996) . mit der reduzierten pge2-produktion geht auch eine geringere expression von ep2-rezeptoren in mastzellen, makrophagen und t-zellen der nasalen und bronchialen mukosa von aerd-patienten im vergleich zu aspirin-toleranten kontrollen einher (adamusiak et al. 2012; corrigan et al. 2012) . ursache für pathogenese der aerd können auch polymorphismen der ep2-gene sein (jinnai et al. 2004 ). zusätzlich zeigen aerd-patienten eine erhöhte end organ-reaktivität zu leukotrienen, weil spezielle lt e4-rezeptoren verstärkt exprimiert werden, ein mechanismus, der ebenfalls über polymorphismen gewisser gene ausgelöst sein könnte (sousa et al. 2002) . diese beobachtungen bekräftigen, dass aerd zum teil auch von genetischen mustern veränderter pge2-und leukotrien-expression verursacht sein dürfte. somit scheint bei aerd-patienten auch eine "abhängigkeit" von der bronchoprotektiven wirkung der ep2-rezeptoren zu bestehen. normalerweise entsteht im atemwegsepithel -über cox-katalysierte prozesse -pge2, das die ep2-rezeptoren aktiviert und eine hemmung der mastzellaktivierung bewirkt. nsars führen zu einem mangel an schützendem pge2, wodurch die hemmung der mastzellaktivierung verhindert wird (säfholm et al. 2015) . in den folgenden kapiteln wird die gruppe der neu entdeckten entzündungsauflösenden lipidmediatoren, die in der literatur als specialized pro-resolving mediators (spms) bezeichnet werden, vorgestellt: lipoxine, resolvine, protektine und maresine. über viele jahrzehnte war unser verständnis für entzündungen limitiert auf die proentzündlichen mediatoren. therapeutisches ziel war es, die inflammatorischen prostaglandine und leukotriene zu hemmen. erst vor kurzem erkannte man, dass auf die proinflammatorische phase ein genau gesteuerter abklingprozess der entzündung folgt. entzündungsauflösung ist somit kein passiver prozess, wie man lange vermutet hatte, sondern findet durch einen evolutionär perfekt generierten wechsel der lipidmediatorenklassen statt. man entdeckte entzündungsauflösende lipidmediatoren, die als endogene agonisten agieren, um die beendigung der inflammation zu aktivieren und die auflösung der entzündung zu stimulieren. die erforschung der spms gelang durch neue techniken upcl/ms-ms ("ultraperformance liquid chromatographic separation and mass spectrometric analysis"), mit denen man heute über 150 verschiedene lipidmediatoren mit nur 50 μl plasma innerhalb weniger minuten analysieren kann. spms sind lipide mit sowohl antiinflammatorischem als auch proentzündungsauflösendem potenzial. einerseits beenden sie die im rahmen der infektion vermehrte infiltration von neutrophilen, basophilen, eosinophilen und mastzellen an den orten der infektion, andererseits erhöhen sie die bakterielle und die apoptotische neutrophile clearance. dieser prozess wird als efferozytose bezeichnet und kommt aus dem lateinischen efferre -deutsch: hinaustragen, zu grabe tragen. gemeint ist somit die phagozytäre clearance, bevor die sekundäre nekrose oder gewebsschädigung einsetzt (chiang et al. 2012) . entzündungsauflösende lipdmediatoren besitzen auch die fähigkeit, proinflammatorische zytokine zu drosseln und die antiinflammatorischen zytokine zu aktivieren (serhan und chiang 2013; maderna und godson 2009 ). folglich gelten spms als schlüsselmediatoren zur beendigung von infekten und zur vermeidung einer chronifizierung von entzündungen, die zu chronischen krankheiten wie allergien, asthma bronchiale, copd, aber auch zu arteriosklerose, pcp, adipositas, krebs und multipler sklerose führen können (nathan und ding 2010). lipoxine sind eine familie aus tri-hydroxy-eicosanoiden, die in form von lx a4, lx b4 sowie als aspirin-getriggerte epi-lipoxine (15 epi-lx a4 und 15 epi-lx b4) vorkommen. sie unterscheiden sich in funktion und form deutlich von den proinflammatorischen eicosanoiden. lipoxine entstehen ebenfalls aus der arachidonsäure und haben die aufgabe, die inflammatorischen exsudate und proinflammatorischen mediatoren, die primär zur neutralisierung von pathogenen und lokaler gewebsverletzung gebildet wurden, wieder abzubauen. ohne deren auflösung würden diese das gewebe zu sehr schädigen und die entzündung zu lange hintanhalten. in einem natürlich gesteuerten zusammenspiel des zeitlichen und räumlichen auftretens der verschiedenen eicosanoide haben lipoxine wichtige aufgaben im rahmen der entzündungslösung und scheinen durch "stopp"-signale die fähigkeit zu besitzen, die chronifizierung von entzündungen zu vermeiden und diese zu beenden . gebildet werden die lipoxine in interaktion mit der 5-lipoxygenase (5-lox)), die auch die bildung von proinflammatorischen leukotrienen auslöst (. abb. 6.7). chiang et al. 2006) neutrophile, eosinophile, basophile leukozyten sowie mastzellen) aufgenommen wird und über 5-lox in lipoxin umgewandelt wird. dieser vorgang fördert nicht nur die biosynthese von lipoxinen, sondern hemmt auch die entstehung von leukotrienen (serhan 1997) . neben der direkten aktivierung der lipoxinbildung kann die 15-lox aber auch leukotrien a4 in lipoxine umwandeln aspirin kann daher in klinisch relevanten dosen (81, 325 und 650 mg täglich) sowohl thromboxan blockieren als auch die antiinflammatorischen at-lipoxin-spiegel erhöhen (chiang et al. 2004 . abb. 6.9 lipoxinsynthese. aus arachidonsäure entstehen über cox die prostaglandine, und über 5-lox die leukotriene sowie über 5-lox plus 12-lox oder 15-lox die lipoxine. 15 epi-lipoxin (oder aspirin-getriggertes lipoxin) entsteht über 15r-epimere, die nach irreversibler acetylierung der cox-2 durch aspirin aus der arachidonsäure gebildet werden und danach über 5-lox in 15 epi-lipoxine umgewandelt werden (grüne pfeile) steuerung einer relativ erhöhten menge an bronchokonstriktiven substanzen, wie leukotrienen, ausgesetzt sein (sanak et al. 2000) . 15r-hete kann aber auch in abwesenheit von aspirin über cytochrom-p450-enzyme gebildet werden (claria et al. 1996) . wie schon im 7 abschn. 5.4.2 beschrieben, wurde in nature reviews publiziert, dass bereits in der anfangsphase des infekts innerhalb einer einzelnen zelle über die aktivierung von oberflächenrezeptoren (toll-like rezeptor 4, purinerger rezeptor p2x7) sowohl die proinflammatorische kaskade als auch die antiinflammatorische kaskade mit der lipoxinsynthese aktiviert wird (dennis und norris 2015) . zunächst wird beim akuten infekt durch lipopolysaccharide der tlr4-rezeptor im makrophagen stimuliert und dieser induziert sequenziell über aktivierung von nf-κb die bildung von pro-il-1β. daraufhin initiiert der rezeptor p2x7, ein purinerger rezeptor für extrazelluläres atp, die aktivierung von caspase-1 über atp, die pro-il-1β in die aktive form il-1β umwandelt, welches proinflammatorisch wirkt. parallel dazu wird bereits der prozess der entzündungsauflösung gestartet: ebenfalls über den tlr4-rezeptor wird die cpla2 (zytosolische phospholipase a2) aktiviert und die cox-2-produktion über nf-κb initiiert. . abb. 6.10 aufrechterhaltung der homöostase im rahmen einer entzündungsantwort: die pro-inflammatorische il-1ß aktivierung findet parallel zur anti-inflammatorischen lipoxinbildung über aktivierung derselben rezeptoren statt (mod. nach dennis und norris (2015) . beim infekt induziert die tlr 4-aktivierung durch lipopolysaccharide eine pro-il-1β-sekretion, vermittelt über aktivierung von nf-κb. zusätzlich wird der p2x7-rezeptor über atp aktiviert und triggert nach inflammasom-aktivierung die caspase-1-bildung. caspase 1 hat daraufhin die fähigkeit die vorstufe pro-il-1β zu aktivem il-1β umzuwandeln, das die inflamma-torische kaskade in gang setzt. parallel aktiviert der tlr4 die cpla2 dazu, aus den membranphospholipiden arachidonsäure zu bilden und induziert die cox-2-produktion, ebenfalls über aktivierung von nf-κb. cox-2 bewirkt die umwandlung der arachidonsäure in prostaglandine und veresterte 15-hete, die als vorstufe gespeichert wird. parallel dazu werden über aktivierung des purinergen p2x7-rezeptors ebenfalls cpla2, aber auch 5-lox gebildet, die die gespeicherte 15-hete hydrolysieren, aus den membranphospholipiden freisetzen und danach in entzündungsauflösendes lipoxin umwandeln. schließlich zum abheilungsprozess bei (godson et al. 2000) ; 5 den nf-κb mit den damit verbundenen proinflammatorischen signalen hemmen und die antiinflammatorischen zytokine il-10 und tgf-β erhöhen sowie die phagozytäre aktivität z. b. auch der mikrogliazellen bei m. alzheimer verstärken (medeiros et al. 2013) . in der hippokampusregion bei m. alzheimer fand man reduzierte werte von il-10, die auf eine fehlende entzündungsauflösung hindeuten, gekoppelt mit einer reduktion von lipoxin a4 (wang et al. 2015) . gabe von lx a4-analoga vermehrte den antiinflammatorischen mediator il-10. il-10 ist auch bekannt für seine protektive wirkung auf neurone (spera et al. 1998 ). somit wird spekuliert, dass eine verringerte produktion von il-10 durch den mangel an hemmenden signalen auf die entzündung zu pathologien im nervensystem beitragen könnten. außerdem koppelt der alx/fpr2 rezeptorliganden verschiedenster peptide sowohl pro-als auch antiinflammatorischer natur. bei asthmatikern ist die alx-oberflächenexpression sowohl in den neutrophilen, als auch in den eosinophilen und monozyten, im vergleich zu gesunden, reduziert (planaguma et al. 2008) . mittlerweise weiß man, dass auch ein endogenes glukokortikoid-reguliertes protein namens annexin a1 (anxa1) -auch lipocortin-1 genannt -an diese lipoxinrezeptoren (alx/ fpr2) bindet. anxa1 unterdrückt die aktivierung von proinflammatorischen m1-makrophagen, indem es die expression von il-6, il-1β und tnf-α hemmt (li et al. 2011 ) und bewirkt dadurch eine reduktion der akkumulation der neutrophilen. außerdem fördert anxa1 auch die clearance der apoptotischen leukozyten durch makrophagen über eine vermehrte expression von il-10, wodurch die bildung von antiinflammatorischen, proentzündungsauflösenden m2-makrophagen stimuliert wird (cooray et al. 2013 ). daher ist es auch nicht verwunderlich, dass eine relativ aktuelle studie bei giemenden kindern im vergleich zu gesunden eine reduzierte menge von lipoxinen, aber auch weniger annexin a1 nachwies (eke gungor et al. 2014) . somit sind lipoxine und annexin a1 für das "feintuning" am ort der entzündung verantwortlich, das für eine ordentliche entzündungsauflösung notwendig ist und zur kompletten restitutio ad integrum führt, und gelten als vielversprechende substanzen für die entwicklung neuer therapeutischer strategien bei entzündlichen erkrankungen. auch von den lungenepithelien werden lipoxine gebildet, die dort eine vielzahl von zellspezifischen antworten zur auflösung eines akuten infekts sowie einer akuten exazerbation bei asthma triggern. lipoxin a4 und aspirin getriggerte lipoxine (at-lx-analoga) modulieren die inflammatorischen antworten an den leukozyten über hemmung des aktivatorprotein-1 und hemmung des nf-κb. sie blockieren die il-8-mrna-expression und die il-8-freisetzung um 50-65 %. il-8 fördert chemotaktisch die rekrutierung von neutrophilen granulozyten am ort der entzündung und gilt daher als stark proinflammatorisches zytokin in menschlichen leukozyten (jozsef et al. 2002) . lipoxin a4 bewirkt daher eine hemmung der chemotaxis und adhäsion sowie die hemmung der transepithelialen und transendothelialen migration der neutrophilen. weiters hemmt lipoxin die neutrophil-epithelialen interaktionen (serhan et al. 1995; papayianni et al. 1996) . da schweres steroidrefraktäres asthma oft mit einer neutrophilie verbunden ist, haben lipoxine hier eine entscheidende gegenregulatorische bedeutung. lipoxine und at-lx a4 reduzieren die inhalation mit lx a4 bei asthmatikern zeigt positive effekte auf die lungenfunktion und antagonisiert eine durch leukotrien-c4-inhalation ausgelöste atemwegsobstruktion (christie et al. 1992) . stabile lx a4-analoga blockierten die hyperreaktivität der bronchien und die allergische entzündung der atemwege im mausmodell (levy et al. 2002) . folglich ist es wenig überraschend, dass bei schweren asthmatikern signifikant niedrigere werte von lipoxin a4 im respirationstrakt und in den granulozyten des peripheren blutes gemessen wurden. zellen der bronchoalveolären lavage zeigten einen fünffach erniedrigten wert von 15-lox. auch die cox-2 ist bei schweren asthmatikern in der gesamten lunge vermindert (planaguma et al. 2008) . die unterproduktion von lipoxinen mit reduzierten enzymen und rezeptoren, die für die biosynthese von lipoxinen verantwortlich sind, scheinen ein wichtiger mechanismus zu sein, der der pathologischen immunologischen antwort beim schweren asthma zugrunde liegt. schweres asthma dürfte somit, zumindest teilweise, durch eine defekte synthese von entzündungsauflösenden lipoxinen gekennzeichnet sein, die allergische immunantworten gegenregulieren könnten. ebenfalls deutlich niedrigere werte des 15-lox-produkts 15-hete (vorstufe von lipoxin) und von lx a4 beobachtete eine weitere studie bei schweren asthmatikern, wohingegen in dieser gruppe die durch die 5-lox alternativ metabolisierten produkte 5-hete, lt b4 und cys-lt deutlich erhöht waren . mehr noch, die lungenfunktionswerte von asthmatikern korrelieren mit der höhe der lipoxinwerte: auf . abb. 6.11 ist deutlich zu sehen, dass die meisten patienten mit schwerem asthma und einer fev1 <80 % nur ganz niedrige lx a4-werte aufweisen. steigende lipoxinwerte sind mit einer besseren fev1 verbunden. dagegen sind die cys-lt-werte bei levy et al. 2005) schweren asthmatikern deutlich erhöht und assoziiert mit stark erniedrigter fev1 und somit schlechterer lungenfunktion als bei patienten mit moderatem asthma. cys-lte sind wie in 7 abschn. 6.2.1 beschrieben bekannt als starke bronchokonstriktoren. dieser versuch untermauert ergebnisse aus früheren studien (samuelsson et al. 1987) , die zeigten, dass lipoxine die cys-lt-mediierte bronchiale hyperreaktivität beim asthma blockieren bzw. gegenregulieren können. lx a4 scheint somit bei allergischer inflammation der lunge positive einflüsse zu haben. diese annahme wurde anhand von in-vivo-versuchen bestätigt: verabreichung eines stabilen lx a4-analogs während einer allergen-challenge im mausmodell mit allergischem asthma blockierte die hyperreaktivität der bronchien und die pulmonale inflammation mit reduktion von leukozyten sowie der mediatoren il-13, il-5, eotaxin und cys-lt. auch die bildung von ige und die eosinophile wanderung konnten verringert werden (levy et al. 2002) . auch nach induktion einer transgenen expression von lipoxinrezeptoren beobachtete man eine signifikante hemmung der pulmonalen inflammation und der einwanderung von eosinophilen ins gewebe (levy et al. 2002) . auch dieser versuch bekräftigt die schützende, gegenregulatorische wirkung von lx a4 bei asthma und allergien. lipoxine stimulieren die nicht-phlogistische phagozytose von apoptotischen neutrophilen durch makrophagen (godson et al. 2000) . nachdem auch alveoläre makrophagen lipoxine erzeugen können, fand man heraus, dass die biosynthese von lipoxinen in makrophagen von schweren asthmatikern wesentlich geringer ist als von nicht-schweren asthmatikern und gesunden. nach beobachtung der basalen ausschüttung benützte man zur stimulation der makrophagen lipopolysacharide (lps). makrophagen von schweren asth-matikern erzeugten nach stimulation signifikant weniger lipoxine als makrophagen von gesunden. umgekehrt induzierte lps reizung in makrophagen schwerer asthmatiker signifikant höhere werte an leukotrienen (lt b4) als von leichten asthmatikern und damit zeigte sich eine höhere leukotrien/lipoxin-ratio (bhavsar et al. 2010) . nachfolgende orale gabe von dexamethason hemmte interessanterweise nicht nur -wie gewünscht -die leukotriene, sondern auch die lipoxine. die ratio proinflammatorische leukotriene/antiinflammatorische lipoxine nach dexamethasongabe war bei schweren asthmatikern am höchsten. zusätzlich konnte auch in dieser studie eine signifkant positive korrelation zwischen der höhe der lipoxine und der fev1 gezeigt werden. diese dysbalance der arachidonsäureprodukte, nämlich verstärkte bildung von leukotrienen und mangelnde biosynthese von lipoxinen und somit fehlende gegenregulation der proinflammatorischen leukotriene von den antiinflammatorischen lipoxinen, könnte bei schwerem, steroidresistenten asthma zur persistierender eosinophiler und neutrophiler inflammation führen. dies begünstigt häufige exazerbationen beim asthma trotz kortisontherapie, bei denen mangelnde lipoxinsynthese die durch leukotriene induzierte chemotaxis, adhäsion und transmigration der neutrophilen/ eosinophilen granulozyten im rahmen eines akuten infekts, nicht hemmen kann ). in fibroblasten hemmt lipoxin a4 die synthese von proinflammatorischen zytokinen, wie z. b. il-6, il-8, und die synthese der matrix-metalloproteinase-3 (mmp-3). lx a4 verstärkt jedoch die timp ("tissue inhibitor of metalloproteinase" = hemmer der matrix-metalloproteinase), wodurch schon im jahr 2000 gezeigt wurde, dass lx a4 in eine negative feedback-schleife gegenüber der entzünd-lichen zytokinaktivierung in fibroblasten involviert ist (sodin-semrl et al. 2000) . matrix-metalloproteinasen aktivieren das extrazelluläre matrix-turn-over und die gewebsreparatur, können aber, wenn sie im rahmen von entzündungen außer kontrolle geraten, zu destruktiven prozessen mit verzögerter wundheilung, aber auch zu remodeling im respirationstrakt führen (sampsonas et al. 2007 natürlich sind deshalb mittlerweile metalloproteinasen-inhibitoren auch zum interessanten forschungsthema für die pharmaindustrie geworden, das jedoch nach anfänglichem hype in letzter zeit wegen zahlreicher fehlschläge an attraktivität eingebüßt hat. deshalb wird deren erforschung aktuell mit einem ritt auf der "achterbahn" verglichen (murphy 2017) . nachdem mangelnde auflösung der primären inflammatorischen antwort zur vermehrung von leukotrienen sowie zu chronifizierten entzündlichen prozessen und fibrose führt, versucht man bereits im tierversuch, mit lipoxin-anloga die lungenfibrose zu behandeln. exogenes aspirin-getriggertes lipoxin reduzierte im mausversuch die pulmonale fibrose (martins et al. 2009 ), aber auch die renale fibrose (borgeson et al. 2011 ). lipoxin a4 beeinflusst auch über "innate lymphoid cells" (ilcs), inklusive "natural-killer (nk)-zellen und typ-2-innate lymphoid cells" (ilc2) (s. 7 abschn. 3.5) die regulation des allergischen asthmas und besonders die eosinophile entzündung der atemwegsmukosa (barnig et al. 2013): ilc2s sind dafür bekannt, dass sie nach aktivierung durch die atemwegsepithel-zytokine il-25, il-33 und tslp die zytokine il-13 und il-5 freisetzen, aber auch antigenunabhängig als antwort auf das mastzellenprodukt prostaglandin d2 (pgd2) und dadurch bei der pathogenese von allergischen erkrankungen eine schlüsselrolle einnehmen. nk-zellen mediieren die eosinophile apoptose. koinkubation von nk-zellen mit granulozyten initiierte bei nk-zellen von gesunden und milden asthmatikern eine vermehrte apoptose von eosinophilen und neutrophilen, im vergleich zu nk-zellen von schweren asthmatikern. sowohl nk-zellen als auch ilc2 exprimieren alx/fpr2-rezeptoren, mit denen auch lipoxin a4 interagiert. zugabe von lipoxin a4 erhöhte die nk-zellmediierte eosinophile apoptose und reduzierte die il-13-sekretion von ilc2-zellen. blockade mit einem alx/fpr2-rezeptorantagonisten hob die wirkung wieder auf. somit untermauert dieses experiment, dass die ilc-rezeptoren alx/fpr2 angriffspunkte für lipoxin a4 darstellen. demzufolge wirkt lipoxin a4 als physiologischer gegenregulator zu der von den ilc2s ausgelösten atemwegsinflammation und eosinophilie. reduzierte lipoxin-a4-synthese bei schwerem asthma führt zur ungehemmten ilc2-aktivierung. all diese ergebnisse bewirken, dass die pharmaindustrie auf hochtouren versucht, lipoxinanaloga künstlich herzustellen. derzeit kämpft man jedoch noch mit der schwierigkeit, synthetische, stabile lipoxinanaloga in kleinsten mengen genau an jene stellen zu bringen, wo sie wirken sollen. die absolut erste publizierte randomisierte klinische studie mit spms am menschen verglich topisches lx a4 mit topischen kortikosteroiden und verbesserte den schweregrad und die abheilung des kindlichen ekzems ohne nebenwirkungen, genauso wie die kortisontherapie (wu et al. 2013 ). in der entzündungsphase erhöhen akuteine weitere studie demonstrierte, dass hemmung der cox-2 und damit verbundene hemmung von pge2 die bildung der lipoxine unterdrückt (fukunaga et al. 2005) . auch diese studie unterstreicht die wichtige bedeutung der cox-2 und ihrer produkte, die die stimulation der lipoxinausschüttung bewirken und eine schützende wirkung auf das asthma haben (s. 7 abschn. 7.2.1). zusammenfassend lässt sich sagen, dass die entzündungsauflösenden mechanismen im rahmen eines infekts beim schweren asthma reduziert sind. lipoxine modulieren als endogene agonisten antiinflammatorisch und proentzündungsauflösend die pathologie des asthmas. außerdem geht klar hervor, dass hemmer der cox und lox den entzündungsauflösenden prozess beeinträchtigen können, weil diese enzyme für die endogene bildung der lipoxine und anderer pro-resolving-mediatoren benötigt werden. resolvine sind endogene lipidmediatoren, die nicht aus der arachidonsäure, sondern durch enzymatische spaltung aus den von omega-3-fettsäuren stammenden, mehrfach ungesättigten fettsäuren epa (eicosapentaensäure) und die dha (docosahexaensäure) entstehen. wie der name explizit ausdrückt, handelt es sich bei resolvinen um lipidmediatoren, die als agonisten an spezifischen rezeptoren die entzündungsauflösung (resolving) fördern, indem sie die leukozytenzahl am ort der entzündung hinunterregulieren und das gewebe für eine gründliche, zeitgerechte abheilung vorbereiten (schwab et al. 2007; serhan et al. 2006) . beendingung der unkontrollierten aktivierung und akkumulation von leukozyten an den orten der entzündung ist eine wichtige verletzungs-limitierende komponente in der natürlichen abklingphase einer entzündung. findet diese entzündungsauflösung nicht zeitgerecht statt, entstehen unerwünschte gewebsverletzungen, die das risiko für entzündliche erkrankungen wie asthmaentwicklung und copd erhöhen (weiss 1989) . auch bei zystischer fibrose (saba et al. 2002) und beim akuten respiratory-distress-syndrom (ards) liegt eine exzessive neutrophilie mit mangelnder phagozytose der apoptotischen leukozyten vor (matute-bello et al. 1997) . in anderen organen kann die chronifizierte entzündung zu arteriosklerose, kardiovaskulären erkrankungen, morbus alzheimer und pcp führen (tabas und glass 2013) . . abb. 6.13). 5 aspirin-getriggerte (at)-resolvine werden aus dha durch aspirin-acetylierte cox-2 und danach über 5-lox in at-rvd1-4 transformiert. aspirin ermöglicht die bildung von r-varianten der resolvine. durch acetylsalicylsäure (asa) wird dha über asa-acetylierte cox-2 an entzündungsorten in verschiedene 17-r-hpdha und at-resolvine umgewandelt, die eine noch besser entzündungslösende wirkung haben dürften als natürlich entstandene resolvine und die zytokinproduktion in leukozyten, aber auch in der mikroglia, hemmen, wodurch die weitere leukozytenrekrutierung blockiert wird . 5 aus epa (c20:5) stammende rve1, rve2, rve3. 5 wie . abb. 6.14 und 6.15 zeigen, entsteht rve1 im menschlichen körper aus epa, die über cytochrom-p450-enzyme in 18r-hepe und dann mittels 5-lox in rve1 umgewandelt wird (arita et al. 2005; capdevila et al. 1996) . aspirin über die transformation von epa in 18r-hepe, mit hilfe der aspirinacetylierten cox-2 in den endothelzellen. danach wird 18r-hepe durch 5-lox von leukozyten in rve1 umgewandelt. rve1-werte sind bei menschen, die aspirin und/oder epa als nahrungsergänzung einnehmen, erhöht (arita et al. 2005 ). diese neue gruppe von resolvinen wurde erst vor kurzem entdeckt und dürfte eine wesentliche rolle bei der auflösung von bakteriell getriggerten infektionen und entzündungen spielen . rvts bestehen aus einer 22-kohlenstoffatom-kette mit 5 doppelbindungen und tragen typischerweise eine alkohol-gruppe am c13-atom, weshalb sie auch 13-serie-resolvine genannt werden. » rvt1, rvt2, rvt3 und rvt4 haben folgende strukturformeln: 7,13,20-trihydroxy-docosapentaensäure 7,12,13-trihydroxy-docosapentaensäure 7,8,13-trihydroxy-docosapentaensäure 7,13-dihydroxy-docosapentaensäure ausgehend von der n-3-docosapentaensäure (dpa), einem zwischenprodukt bei der umwandlung von epa in dha, erfolgt die biosynthese in 2 schritten: 5 zuerst wird dpa im endothel mithilfe der endothelialialer cox-2 in 13-hydroxy-docosapentaensäure (13-hdpa) umgewandelt. 5 nach transzellulärer wanderung zu angrenzenden neutrophilen wird 13-hdpa über 5-lox in rvts transformiert. rvts regulieren besonders die bakterielle phagozytose und inflammasom-komponenten: während die bisher besprochenen resolvine, aber auch die protektine und maresine erst 4-12 stunden nach infektion die entzündungsauflösung regulieren, dürften die rvts bereits innerhalb der ersten 4 stunden nach infektion geformt werden und somit bereits in der initialen phase der entzündung deren auflösung steuern. anhand von experimentell mit e. coli infizierten mäusen wurde die zeitliche abfolge der lipidmediatorenproduktion beobachtet : die anzahl der eingewanderten pmns ist 12 stunden nach der experimentellen e.-coliinfektion maximal hoch und verringert sich danach wieder, was als typisches zeichen einer intakten entzündungsauflösenden antwort interpretiert werden kann. rvts wurden bereits frühzeitig in der anfangsphase der entzündung gebildet und erreichten nach 4 stunden ihr maximum, woraufhin sie wieder absanken. ganz zum unterschied von arachidonsäure-, dha-und epa-abstammenden lipidmediatoren, die auch nach 4 stunden anstiegen, jedoch erst nach 12 stunden ihr maximum erreichten (z.b. rvd2 und lxb4). deutlich reduzierte mengen von rvt (um 60 % niedriger) waren gekoppelt mit klinisch verstärkten infektionszeichen und verspäteter entzündungsauflösung und wurden bei mäusen mit einer höheren e.-coli-last beobachtet. zusätzlich konnte in diesem versuch die wirkung der endothelialen cox-2-expression auf die bildung der rvts nachgewiesen werden. nachdem man bereits wusste, dass in der anfangsphase des infekts il-1β und tnf-α die endotheliale cox-2 aktivieren, um dha in 13-hdha umzuwandeln , beobachtete man, dass auch n-3-dpa über die cox-2 in 13-hdpa transformiert wurde. in diese studie weist damit auch auf den nachteiligen effekt der cox-2-hemmer bei der akuten infektion hin, weil die cox-2 für die umwandlung von dpa in 13-hdpa benötigt wird! zusammenfassend untermauern die versuche von dalli, dass rvts bei infektionen spontan vermehrt gebildet werden und die abheilung von bakteriellen infekten beschleunigen können bzw. bei verzögerter heilung reduziert sind. resolvine hemmen die neutrophile migration entlang der epithelialen barrieren und des endothels, indem sie die expression von neutrophilen adhäsionsmolekülen hemmen und beugen dadurch einer neutrophilie der epithelien vor. an der apikalen epithelialen oberfläche verstärkt rve1 die transepitheliale migration der makrophagen in das innere der mukosa und erhöht dadurch die neutrophile, nicht-entzündliche, apoptotische clearance (campbell et al. 2007; schwab et al. 2007 ). rve1 unterdrückt auch die neutrophile akkumulation im rahmen von pneumonien und künstlich ausgelösten verletzungen der lunge (seki et al. 2010 ). rvd1 blockiert die neutrophilen immunantworten, indem es die il-8 induzierte chemotaxis (s. 7 3.7.2.1) (kasuga et al. 2008 ) und die transendotheliale migration von neutrophilen hemmt . rvd2 blockiert ebenfalls die neutrophile akkumulation an orten der infektion über direkte modulation der leukozytären adhäsionsrezeptor-expression und antagonisiert die mikrobielle sepsis, indem die bakterienzahl und die systemische entzündung reduziert sowie das überleben bei mikrobieller sepsis gesteigert wird (spite et al. 2009 in einem mäuseversuch, bei dem eine künstliche peritonitis ausgelöst wurde, testete man verschiedene substanzen auf deren entzündungsauflösende fähigkeit. "testsieger" bei der il-10-aktivierung im makrophagen ex vivo war rve1. der cox-hemmer ibuprofen hingegen dämpfte die il-10-produktion am stärksten, triggerte jedoch die tnf-α-aktivierung am meisten der getesteten substanzen. 15-epi-lipoxin a4, dexamethason und azithromycin hatten ebenfalls antiinflammatorische wirkungen, indem sie die neutrophilen reduzierten (navarro-xavier et al. 2010) . auch rvd1 triggert die differenzierung von m1-zu m2-makrophagen: nach behandlung von mäusen mit rvd1 gemeinsam mit zigarettenrauchexposition, reduzierte rvd1 die neutrophile inflammation und die produktion von proinflammatorischen zytokinen, die typisch für neutrophiles asthma oder copd sind. zigarettenexposition ist mit mangelnder auflösung von proinflammatorischer antworten, deutlicher vermehrung von leukotrienen, m1-makrophagen sowie daraus resultierender neutrophiler inflammation gekennzeichnet. rvd1 bewirkte eine vermehrung von il-10 sowie eine verstärkte differenzierung der m1-makrophagen zu m2-makrophagen mit darauffolgender efferozytose und beschleunigter auflösung der lungeninflammation nach der letzten zigarettenrauchexposition (hsiao et al. 2013) . rvd1, rvd5 (aber auch pd1, siehe später) können in makrophagen auch die phagozytose von mikroorganismen (z. b. e. coli, staphylococcus aureus) erhöhen und die wirkung von antibiotika verstärken sowie den antibiotikaverbrauch reduzieren (chiang et al. 2012) : der deutsche oliver werz publizierte im jänner 2018 in nature eine studie (werz et al. 2018) , die er gemeinsam mit der gruppe von charles serhan durchführte, in der er nachwies, dass m1-und m2-makrophagen nach exposition mit pathogenen bakterien wie e. coli unterschiedliche lipidmediatoren produzierten. diese ergebnisse stehen im einklang mit der proinflammatorischen phase, in der die m1-makrophagen aktiviert werden und der sich mit verzögerung entwickelnden entzündungsauflösenden phase, für die die m2-makrophagen verantwortlich sind. oliver werz wollte danach auch wissen, ob auch nicht-pathogene e. coli dieselben reaktionen in m1-und m2-makrophagen auslösen. dabei fand er zwar eine moderate prostaglandinsekretion in den m1-makrophagen, jedoch keinerlei lox-metabolisierte spms oder leukotrien-ausschüttungen. dies lässt auf unterschiedliche aktivierungsmechanismen der lox durch die verschiedenen bakterienarten schließen. diese studie zeigt, dass der körper mit den m1-und m2-makrophagen mechanismen entwickelt hat, pathogene bakterien nicht nur unschädlich zu machen, sondern diese auch aus dem gewebe zu beseitigen und die entzündung zu stoppen. bei nicht-pathogenen bakterien werden diese mechanismen nicht aktiviert. diese "selbstheilung" zu fördern könnte vielleicht gerade im hinblick auf resistente keime, aber auch zur reduktion des antibiotikaverbrauchs, eine große bedeutung bekommen. rve1 reduziert bei asthmatischen mäusen die bronchiale eosinophilie sowie das th2-zytokin il-13 und die hyperreagibilität der bronchien (aoki et al. 2008) . rvd1-verabreichung vor allergen-challenge hemmt bei ova-sensibilisierten mäusen ebenfalls die eosinophilie und die il-4-, il-5und il-13-werte der bal und verbessert die mukosale metaplasie, verbunden mit reduzierter aktivierung des nf κb (levy 2012) . at-rvd1-und rvd1-gabe war verbunden mit einer verminderten akkumulation der eosinophilen sowie einer reduktion von lt b4 und eotaxin (levy 2012). t-zellen: rve1 drosselt th17-zellantworten, indem die il-17a-produktion gedämpft wird und ermöglicht dadurch die entzündungsauflösung ). b-zellen: rvd1 erhöht die b-zell-abhängige antikörperproduktion, was man erst vor kurzem in einem mausmodell mit h1n1-influenza-vakzination entdeckte. somit wurde eine neuer, bisher unbekannter zusammenhang zwischen den n-3-abstammenden spms und dem adaptiven immunsystem erkannt und könnte für die therapie von infektionen, aber auch für die entwicklung neuer impfadjuvantien hilfreich sein (ramon et al. 2014 ). rve1 agiert über mindestens zwei g-proteingekoppelte rezeptoren: cmklr1 (chemokinelike-rezeptor 1) und blt1. cmklr1 ist als rezeptor für das chemotaktische peptid chemerin bekannt, wird besonders von makrophagen und dcs exprimiert und kontrolliert die zellmigration ). dieser rezeptor ähnelt dem lipoxinrezeptor und den neutrophilen chemotaxin-rezeptoren c3ar und c5ar (krishnamoorthy et al. 2010) . über diesen rezeptor kann rve1 die entzündungsauflösung bei chronischen lungenerkrankungen aktivieren und beschleunigen. um die bindung am blt1-rezeptor konkurriert rve1 sehr effizient auch mit lt b4 und kann daher die leukotrien-b4-wirkung antagonisieren uddin und levy 2011) . somit dürfte die hemmung der lt b4-aktivierung ein weiterer wichtiger mechanismus von rve1 sein, um die akute inflammation zu blockieren (aoki et al. 2008) . rvd1 wiederum kann direkt den alx/ frp2-rezeptor aktivieren und gilt als äquivalent zu lx a4. dieser rezeptor wird bei atemwegsentzündungen physiologisch hochreguliert (christie et al. 1992 ) und vermittelt die entzündungsauflösung der atemwege. alx/ frp2 ist in den eosinophilen und neutrophilen bei schweren asthmatikern reduziert vorhanden (planaguma et al. 2008) . außerdem interagieren rvd1, at-rvd1 und rvd3 mit dem g-proteinrezeptor 32, gpr-32, der ein potenter agonist für signale der entzündungsauflösung sein dürfte (krishnamoorthy et al. 2010). rve1 blockiert die tnf-α-induzierte aktivierung von nf-κb (uddin und levy 2011) . nachdem nf-κb proinflammtorischen zytokine, chemokine und adhäsionsmoleküle reguliert, wirkt die unterdrückung der nf-κb-signale antiinflammatorisch und gilt als wesentlicher faktor für das abklingen von entzündungen bei chronisch entzündlichen erkrankungen der lunge wie asthma und copd. ebenfalls über reduzierte aktivierung von nf-κb hemmt rve1 die proinflammatorische lt b4-mediierte blt1-signalgebung ) und ermöglicht dadurch zusätzlich die entzündungsauflösung. erst vor kurzem wurde entdeckt, dass schmerz, der von entzündungen (wie arthritis) ausgelöst wird, an sensorischen neuronen über trp-kanäle: trpv1 (transient receptor potential subtype vanilloid 1) und trpa1 (trp ankyryn 1) übertragen wird und dass diese trp-kanäle durch die endogenen lipidmediatoren rvd2, rve1, rvd1, neuroprotektin d1 und maresin r1 auf natürliche weise gehemmt werden können. dies erklärt die schmerzstillende wirkung der resolvine und anderer lipidmediatoren . in der lunge sind jene trp-kanäle der sensorische neurone für die hustenauslösung und bronchokonstriktion verantwortlich. diese trp-kanäle an sensorischen neuronen können aber auch an der entwicklung einer allergischen atemwegsentzündung beteiligt sein, indem sie die stimulation von ilc2-zellen und th2-zellen initiieren. man erkannte, dass il-5, jenes zytokin, das durch aktivierte immunzellen produziert wird, direkt mit den trp-rezeptoren interagiert und die freisetzung von vasoaktivem intestinalem peptid (vip) induziert. vip stimuliert daraufhin die th2-zellen und ilc2-zellen, und erzeugt dadurch eine aktivierung der allergischen inflammation (talbot et al. 2015) . nachdem jene trp-rezeptoren durch die lipidmediatoren rvd1, rvd2, rve1, neuroprotektin d1 und maresin r1 gehemmt bzw. "beruhigt" werden, könnten die spms auch hier eine entscheidende bedeutung bei der vermeidung bzw. evtl. auch als mögliche therapie von asthma und allergischer inflammation haben (basil und levy 2016) . das atemwegsepithel reguliert als physische barriere alle physiologischen prozesse, inklusive den einstrom der leukozyten bei jeglichem antigenkontakt. eine gestörte interaktion zwischen dem atemwegsepithel und den inflammatorischen leukozyten führt zur pathogenese von chronischen entzündungen wie asthma und copd. mit großem interesse wird heute beobachtet, dass resolvine proentzündungsauflösend wirken und die heftigkeit und dauer von infekten reduzieren, indem sie die re-epithelialisierung, wundheilung und gewebsregeneration stimulieren und verstärken. bakterielle infektionen: bei mäusen mit künstlich erworbener pneumonie mit e. coli führte die gabe von rve1, über hemmung des nf-κb, zu erhöhter bakterieller clearance, reduzierter menge von proinflammatorischen chemokinen und zytokinen, wie il-1β, il-6, hmgb-1, mip ("macrophage inflammatory protein")-1α, mip-1β, und mcp-1 ("monocyte chemoattractant protein 1"), sowie zu besseren überlebensraten (campbell et al. 2007 ). mip-1α und mip-1β sind chemokine, die auch ccl3 und ccl4 genannt werden. sie werden von makrophagen, aber auch dcs und lymphozyten nach stimulation mit bakteriellem endotoxin produziert und induzieren die synthese von proinflamma-torischen zytokinen wie il-1, il-6 und tnf-α und wirken chemotaktisch, indem sie die einwanderung von granulozyten aktivieren und neutrophile inflammation induzieren. diese ergebnisse mit rve1 offenbaren die natürlichen gegenantworten des wirtsorganismus auf die pathogen-mediierte entzündung, die die schwere der pneumonie positiv beeinflussen. man überlegt bereits, wie diese ergebnisse in therapeutische strategien umgesetzt werden können. mechanismen könnte eine reduktion des antibiotikaverbrauches möglich machen. virale infektionen: sowohl rve1 als auch lipoxin a4 haben bei viralen infekten, wie z. b. bei der rsv-virusinfektion schützende eigenschaften, indem der bei rsv-infektionen typisch verzögerte switch von m1-zu entzündungsauflösenden m2-makrophagen beschleunigt wird (shirey et al. 2014 ). auch bei allergischen atemwegsentzündungen agiert resolvin rve1 als antiinflammatorischer und proentzündungsauflösender lipidmediator, sowohl präventiv als auch bei bereits bestehender allergie: präventiv: die sensibilierung auf antigene kann durch rve1 im mausversuch gehemmt werden. eine in nature immunology veröffentlichte studie ) beobachtete an gesunden mäusen, während einer ova-antigensensibilisierung und aerosol-challenge eine natürliche und spontane auflösung der inflammation, die jedoch durch gabe von rve1 (200 ng/tag, 30 minuten vor challenge i.v.) massiv verstärkt werden konnte und mit einer signifikant (um 80 %) reduzierten leukozytenzahl in der balf und deutlicher reduktion von eosinophilen, makrophagen und lymphozyten einherging. asthma kann signifikant beschleunigt werden, wenn eine rve1-gabe 2 und 8 stunden nach antigen-challenge erfolgt. rve1 unterdrückte auch signifikant die zytokinproduktion der pulmonären makrophagen über unterdrückung der nukleären translokation von nf-κb in diesen zellen (flesher et al. 2014) . verabreichte man asthmatischen mäusen rve1 (intraperitoneal) vor einer allergen-challenge, so beobachtete man eine reduktion von eosinophilen der atemwege, von il 13 sowie von allergenspezifischem ige und eine verbesserung der bronchialen hyperreaktivität. außerdem konnte die schleimproduktion der becherzellen signifikant reduziert werden (aoki et al. 2008) . rvd1 wirkt antiinflammatorisch, indem es die il-1β-produktion hemmt (calder 2010 ) sowie die bronchiale eosinophilie und die muköse metaplasie reduziert. rvd1 verstärkt auch die phagozytose von allergenen aus den atemwegen und reguliert die nf-κb-aktivität (levy 2012) . at-rvd1 moduliert die il-4-induzierte aktivierung von bronchialen epithelzellen und kann die darauffolgende neutrophile und eosinophile atemwegsinflammation über hemmung des nf-κb und stat6 reduzieren sowie über chemokine die th17-funktion regulieren. auch hier scheint die wirkung über den alx/frp2-rezeptor vermittelt zu werden (de oliveira et al. 2015) . obwohl asthma und copd unterschiedliche strukturelle veränderungen und entzündliche zellprofile aufweisen, kann bei beiden erkrankungen im fortgeschrittenem stadium eine neutrophil dominierte inflammation (jeffery 2004) mit vermehrten akuten exazerbationen vorkommen. mehr als 30 % der schweren asthmatiker (neutrophiler phänotyp) weisen diese stark vermehrte neutrophilie auf und sprechen klassischerweise sehr schlecht auf kortikosteroide an. aus sicht der neuesten erkenntnisse der inflammation scheint in diesen krankheitsbildern die nicht rechtzeitig gestoppte unange-messene akkumulation der neutrophilen am beginn der akuten exazerbation und fehlende phagozytose und clearance der apoptotischen granulozyten zu einer dauerhaften vermehrung zu führen. wie schon oben erwähnt interagiert rve1 mit dem blt1-rezeptor, jenem rezeptor, an den auch der proinflammatorische lipidmediator lt b4 andockt, der die neutrophile aktivierung und chemotaxis fördert. der rezeptor blt1 befindet sich besonders gehäuft auf neutrophilen, aber auch auf speziellen t-lymphozyten (cd8 + -zellen). cd8 + -zellen von asthmatikern exprimieren wesentlich mehr blt1-rezeptoren als cd8 + -zellen von nicht-asthmatikern. steroidresistente asthmatiker weisen die höchsten dichte an blt1 exprimierenden, aktivierten cd8 + -zellen auf. interessanterweise produzieren die cd4 + -t-zellen bei steroidresistenten asthmatikern die niedrigsten werte des antiinflammatorischen zytokins il-10 und von ifn-γ (chung et al. 2014 ). cd8 + -t-lymphozyten durch lt b4. somit dürfte die hemmung der leukotrienaktivierung eine wichtige funktion von rve1 sein, um die akute inflammation zu blockieren und in kombination mit dem cmklr1-rezeptor an den makrophagen, die entzündungsauflösung bei chronischen lungenerkrankungen zu aktivieren und zu beschleunigen . nachdem lt b4 auch im bronchialsekret von copd-patienten vermehrt gefunden wird, kann rve1 wahrscheinlich auch bei copd die neutrophile aktivierung bremsen. bei atopischer dermatitis reduziert rve1 die il-4-expression von aktivierten cd4 + -t-zellen, die ige-serumwerte sowie die entzündliche infiltration der betroffenen hautareale und kann dadurch die entwicklung einer atopischen dermatitis unterdrücken (kim et al. 2012 ). verabreichung von resolvin e1 (rve1) nach okulärer herpes-simplex-infektion im mausversuch reduzierte am ort der entzündung den einstrom von neutrophilen und pathogenen cd4 + -t-zellen sowie die proinflammatorischen zytokine il-6, ifn-γ, il-17 und stimulierte die produktion von antiinflammatorischem il-10 ( rajasagi et al. 2011 ). unaufgelöste inflammation und dadurch initiierte chronische entzündung könnte auch der schlüssel für die entwicklung eines diabetes typ 2 sein, bei dem eine dysregulation der rezeptoren an neutrophilen deren phagozytose beeinträchtigt und rve1 für die aktivierung braucht. nach therapeutischer gabe von rve1 kann die tnf-α-überproduktion gegenreguliert und die phagozytose mit den dafür erforderlichen entzündungsauflösenden signalen aktiviert werden. die notwendige dosis von rve1 zur entzündungsauflösung ist bei diabetischen neutrophilen signifikant höher als bei neutrophilen von gesunden (freire et al. 2017 ). resolvine erfüllen sämtliche kriterien der immunologischen infektionsauflösung: expurgatio reliquiorum: beseitigung der debris expurgatio contagionem agentis: beseitigung der infektionerreger doloris absentia: analgesie muneris lucrum: wiedergewinnung der funktion (serhan 2014) aufgrund der großen fläche des vaskulärendothelialen systems und der menge von neutrophilen innerhalb des blutkreislaufes hat der menschliche organismus vielerorts die möglichkeit, resolvine zur auflösung von infekten zu bilden. nachdem asthma und allergien durch ekzessive entwicklung von proinflammatorischen zytokinen, chemokinen, wachstumsfaktoren und eicosanoiden entstehen, die als kompliziert verwobenes netzwerk in gegenseitiger rückkoppelung mit diversen zelltypen interagieren, ist es eher unwahrscheinlich, dass eine einzige antiinflammatorische therapeutische strategie (z. b. mittels selektiver, neutralisierender antikörper), die nur auf einen einzelnen proentzündlichen mediator abzielt, auf dauer erfolg bringt. derzeit gibt es noch keine einzige therapie, die selektiv die entzündungsauflösung fördert. aktivierung der entzündungsauflösenden kreisläufe könnte einen neuen, zusätzlichen zugang für eine wirksame kontrolle chronischer neutrophiler und eosinophiler entzündungen ermöglichen. deshalb versucht man nun für die aktive auflösung der entzündung spm-agonisten zu entwicklen und diese therapeutisch zu nutzen. heute weiß man, dass spms nicht nur antiinflammatorisch den weiteren einstrom von inflammatorischen zellen hemmen, sondern proentzündungsauflösend die heftigkeit und dauer von infekten reduzieren können, indem sie die re-epithelialisierung, wundheilung und gewebsregeneration stimulieren und verstärken. protektin d1 (pd1) wird ebenfalls aus dha mittels enzymatischer 15-lox-aktivität über 17s-hpdha gebildet. wie der name deutlich macht, wirken diese lipidmediatoren schützend und protektiv auf immunfunktionen und neurales gewebe. » pd1 hat folgende strukturformel: 10r,17s-dihydroxy-docosa-4z,7z,11e, 13e,15z,19z-hexaensäure pd1 wird auch neuroprotektin d1 (np d1) genannt, weil es besonders im gehirn neuro-protektive eigenschaften entwickelt . bei morbus alzheimer wurde np d1 in reduzierter menge beobachtet (lukiw et al. 2005) . man weiß aber auch, dass np d1 pigmentepithelzellen der retina vor oxidativem stress schützt (bazan et al. 2010) . es gibt auch eine aspirin-getriggerte form der protektine, bei denen acetylierte cox-2 zur biosynthese von 17r-pd1 aus dha führt (marcheselli et al. 2003) . sowohl protektine als auch die aspirin getriggerten protektine reduzieren die neutrophile transmigration und erhöhen die efferozytose von apoptotischen neutrophilen durch die makrophagen in vivo (schwab et al. 2007; serhan et al. 2011) . protektine werden in der lunge auch von eosinophilen synthetisiert (levy et al. 2007) und hemmen die, durch eotaxin-1/ccl11 induzierte, chemotaxis von eosinophilen. die pd1 synthesekapazität von eosinophilen zellen schwerer asthmatiker ist im vergleich zu eosinophilen gesunder stark eingeschränkt (miyata et al. 2013) . somit stellen aktivierte menschliche eosinophile eine wichtige quelle für die synthese von pd1 dar, das in einem selbstregulativen prozess die fähigkeit hat, die eosinophile inflammation zu reduzieren. protektin d1 hemmt auch die tnf-α-sekretion (ariel et al. 2005) . wurde beim allergischen asthma protektin d1 im mausmodell vor der aeroallergenen challenge i.v. appliziert, beobachtete man eine reduzierte atemwegseosinophilie, eine reduzierte t-zell-rekrutierung, weniger muköses atemwegssekret und weniger proinflammatorische il-13, il-5, cysteinyl-leukotriene und pgd2 sowie eine reduzierte hyperreaktivität der bronchien nach metacholin-provokation (levy et al. 2007 ). verabreichte man man protektin d1 erst nach der aeroallergen challenge, war die entzündungsauflösende phase deutlich beschleunigt. bei akuter, schwerer influenza-h5n1-infektion hat protektin d1 das potenzial, die virusreplikation zu hemmen und das überleben und den verlauf der infektion zu verbessern: morita et al. zeigten im mausversuch (morita et al. 2013) , dass bei schwerer influenza-infektion die produktion von pd1 unterdrückt ist und die pd1-werte mit der pathogenität des h5n1-virus indirekt korrelieren. je höher die pathogenität des virus und virulenter der virenstamm, desto niedriger ist der pd1-wert. behandlung mit pd1 verbesserte das überleben und die pathologie bei schwerer influenza-infektion. diese studie lässt erkennen, dass der endogene lipidmediator pd1 die influenza-virusreplikation unterdrückt und vor tödlichen influenza-virusinfektionen schützen könnte. der stimulus zur bildung von maresinen wird im makrophagen nach apoptose von neutrophilen induziert. makrophagen generieren neben anderen spms auch 14s-hydroxyperoxy-dha (14s-hpdha), das über 12-lox in mar1 umgewandelt wird (dalli et al. 2013) . die verschiedenen subtypen der makrophagen sind -wie schon in 7 abschn. 5.1.4.2 beschrieben -regulatoren bei entzündungsantworten: die m1-makrophagen oder "klassische" makrophagen wirken proinflammatorisch, während die m2-makrophagen zur wiederherstellung der homöostase, gewebsregeneration und wundheilung dienen (ariel und serhan 2012) . beide subpopulationen exprimieren 12-lox. im laufe einer normalen infektantwort kommt es zu einem switch des makrophagentyps von proentzündlichen m1zur entzündungslösenden m2-klasse. dieser prozess verhindert die entstehung einer unkontrollierten, chronifizierten entzündungs-situation und wird von resolvinen -wie vorher beschrieben -aber auch von maresinen getriggert. in menschlichen m2-makrophagen fand man kürzlich erhöhte mengen an mar1, die mit den homöostase-wiederherstellenden eigenschaften der maresine gut im einklang stehen (dalli und serhan 2012) : maresine hemmen die weitere neutrophile akkumulation und stimulieren die efferozytose der makrophagen ). maresine sind somit schlüsselregulatoren für die entzündungsantwort und verhindern gemeinsam mit anderen entzündungsauflösenden mediatoren gewebszerstörung und fibrose . in einem rezenten mausversuch konnte durch endogenes maresin die allergische entwicklung vermieden und durch exogenes maresin die auflösung der allergischen inflammation der lunge beschleunigt werden. maresine blockierten die allergische inflammation der lunge, indem sie, wie auch die lipoxine (s. 7 abschn. 6 .3) die sekretion von il-5 und il-13 der ilc2-zellen, aber auch der th2-zellen hemmten. zusätzlich aktivierten maresine in der entzündungsauflösenden phase eine vermehrte differenzierung von treg-zellen aus naiven cd4 + -zellen und induzierten über diese treg-zellen eine hemmung der ilc2-effektorfunktionen und der th2-aktivierung. somit deutet diese studie auf eine ganz entscheidende rolle der treg-zellen bei der pathogenese des asthmas hin, die offensichtlich die ilc2-funktion kontrollieren und hemmen können, nachdem sie über maresine aktiv induziert wurden (krishnamoorthy et al. 2015) . in einem mausmodell mit ards ("acute respiratory distress syndrom") wurde ebenfalls eine schützende wirkung von maresinen auf die lunge nachgewiesen. maresine reduzierten auch in dieser studie die neutrophile migration, inflammatorische mediatoren, das lungenödem und die gewebshypoxie (abdulnour et al. 2014 bis dahin muss man versuchen, den hemmenden einfluss auf enzyme, die die bildung von spms triggern, z. b. verabreichung von cox-hemmern so restriktiv wie möglich zu halten. es sieht auch so aus, als hätte die wissenschaft die "selbstheilungskräfte" entdeckt, jene protektiven immunantworten des wirts, die bei infekten und entzündungen vom körper selbst gebildet werden und zu einer restitutio ad integrum führen. die brandneuen erkenntnisse über die enzündungsauflösenden lipidmediatoren könnten im 21. jahrhundert für die behandlung von infekten, die heute als ein möglicher trigger für die allergische sensibilisierung gelten, eine völlig neue denkweise etablieren: nämlich beim infekt -nicht wie in den letzten 70 jahren -ausschließlich das pathogen zu fokussieren, sondern die angeborene immunantwort des wirts zu stärken und auf diese weise die mikrobielle clearance zu beschleunigen. dies könnte ermöglichen, ungebremste entzündungen zu limitieren, daraus resultierende gewebsschäden zu vermeiden und die endogene entzündungsauf-lösung mit rückkehr zur homöostase zu stimulieren. genau dies ist auch das prinzip, welches die tcm bzw. traditionelle chinesische medizin bei infekten seit jahrhunderten verfolgt: nicht nur den keim zu behandeln (den man im alten china gar nicht kannte bzw. als pathogenen faktor bezeichnete), sondern vielmehr die konstitution des patienten und die "selbstheilungskräfte" zu stärken, um protektive immunantworten zu aktivieren. übersetzt in die heutige sprache würde dies bedeuten, die lipoxine, resolvine, protektine und maresine zu aktivieren bzw. diese keinesfalls durch cox-hemmer zu schwächen. findet die entzündungsauflösung wegen gehemmter lipoxin-, resolvin-und maresinsynthese nicht statt, ist die ausbildung von eosinophilen und neutrophilen entzündungen vorprogrammiert und kann den körper anfällig für allergien, chronisch-rezidivierende infekte und autoimmunerkrankungen machen. obwohl die erforschung der therapeutischen umsetzung erst ganz am beginn steht, wird es über neue strategien vielleicht bald möglich sein, die infektabheilung und die rückkehr zur homöostase zu beschleunigen. dies könnte besonders in zeiten der weltweit zunehmenden antibiotika-resistenzen, aber auch für die allergologie einen völlig neuen therapieansatz darstellen. die tcm verwendet dazu das wissen aus dem berühmten klassiker shānghán zábìng lùn 傷寒雜病論, das von zhāng zhòng jĭng ca. 200 n. chr. verfasst wurde. dieses buch ist weltweit das älteste buch der medizin, das sich systematisch mit dem ursprung und behandlungsmöglichkeiten von infektionskrankheiten auseinandersetzt. es beschreibt das eindringen eines "kälte-pathogens" (womit nach heutigem verständnis viren gemeint sind) in den körper und dessen fortschreiten und mögliche transformationen entlang der 6 schichten innerhalb des körpers. dieses betrachtungsmodell entspricht genau dem heutigen bild der nicht-gestoppten entzündung, die vielfältige formen und krankheitsmuster annehmen kann. diese krankheitsmuster wurden von zhāng zhòng jĭng in einer einzigartigen systematik geordnet, analysiert und mittels chinesischen kräuterrezepturen therapiert. somit ist heute, nach über 1800 jahren, dieses wissen aktueller denn je und soll deshalb auch im letzten kapitel genau erklärt werden (s. 7 abschn. 8.1). spannend ist es daher auch, mittels lipidomics-messungen zu erforschen, ob und wie sehr heilpflanzen, akupunktur und andere komplementärmedizinischen methoden die lipidmediatoren beeinflussen. das wissen über die lipidmediatoren gibt uns nun messbare parameter, um die "selbstheilungskräfte", jenen begriff, der in der komplentärmedizin so gerne verwendet wird, zu quantifizieren und dadurch zu entmystifizieren. diesbezügliche studien werden derzeit von uns an der sigmund freud universität in wien durchgeführt. zur bildung der resolvine, protektine und maresine benötigt der körper mehrfach ungesättigte fettsäuren, pufas ("polyunsaturated fatty acids"), die vom körper nur in minimalen mengen selbst produziert werden können und deshalb über die nahrung aufgenommen werden müssen. die verschiedenen pufas haben unterschiedlich lange kohlenstoffketten und werden nach der lokalisation der ersten doppelbindung klassifiziert. die omega-3-klasse hat die erste doppelbindung zwischen dem kohlenstoff (c)-3 und c-4, die omega-6-klasse zwischen c-6 und c-7. omega-3-fettsäuren (s. . abb. 6.17) sind in fischen, pflanzen und algen enthalten. pflanzen beinhalten fast ausschließlich α-linolensäure, langkettige omega (n)-3-pufas und deren metabolite epa und dha sind wichtige bestandteile der phospholipide der zellmembranen. phospholipide aus blutzellen (neutrophilen, monozyten und lymphozyten) von menschen mit typischer westlicher ernährungsweise beinhalten 10-20 % fettsäuren aus arachidonsäure und 0.5-1 % epa sowie 2-4 % dha (calder 2010) . epa bildet auch das substrat für die produktion von geringgradig inflammatorischen eicosanoid-derivaten, wie prostaglandinen der serie 3 (pge3) und leukotriene der serie 5 (lt b5) (s. . abb. 6.18). omega-6-fettsäuren wie sonnenblumenöl oder distelöl bestehen zu einem großteil aus linolsäure (18:2 n-6), die über die y-linolensäure und dihomo-y-linolensäure in arachidonsäure metabolisiert wird. die n-6-fettsäuren werden in die zellmembranen und zelluläre phospholipide eingebaut und können nach aktivierung durch phospholipase a2 in arachidonsäure und weiter in hauptsächlich proinflammatorische mediatoren wie prostaglandine, thromboxane und leukotriene, aber auch in entzündungsauflösende lipoxine und prostaglandine umgewandelt werden. (calder 2006) . omega-3-pufas (z. b. epa und dha) unterdrücken zusätzlich die cd4+-t-zelldifferenzierung in th17-zellen über die il-6-gp-130-stat3-signal-achse (bettelli et al. 2006 ). all diese faktoren haben mit einer hohen wahrscheinlichkeit einen schützenden effekt auf die entstehung von asthma (fogarty et al. 2000) . folglich ist das verhältnis von n-3-pufas zu n-6-pufas in der nahrung von großer bedeutung. in den letzten jahrzehnten nahm die relative einnahme von n-3 fettsäuren zugunsten von n -6 fettsäuren ab (simopoulos 2002 unter pflanzlichen ölen enthält leinöl den mit abstand höchsten relativen anteil an n-3-fettsäuren mit einem verhältnis von n-6 zu n-3 von etwa 1:3. es beinhaltet als eines der wenigen speiseöle -neben leindotteröl, chiaöl und perillaöl -mehr n-3-fettsäuren (in form von α-linolensäure) als n-6-fettsäuren. weitere speiseöle mit relativ gutem n-6/n-3-verhältnis sind raps-(2:1), hanf-(3:1), walnuss-, weizenkeim-und sojaöl (6:1) sowie olivenöl (8:1). maiskeimöl weist hingegen ein verhältnis von ca. 50:1, sonnenblumenöl 120:1 und distelöl 150:1 auf. pflanzensamen enthalten oft hohe konzentrationen an linolsäure, der häufigst vorkommenden n-6-fettsäure. manche niedere pflanzen, wie moose, farne und algen, können aus der linolsäure α-linolensäure synthetisieren. deshalb findet man bei tieren, die sich von diesen pflanzen ernähren, wie kaltwasserfischen, aber auch bei wild und rindern aus weidehaltung höhere konzentrationen an n-3-fettsäuren bzw. ein besseres n-6/ n-3-fettsäuren-verhältnis als bei konventioneller tierhaltung (7 http://www.black-angusgold.ch/archive/ rindfleischlabel_aus_tagungsband_2003. pdf). während fischöle epa und dha direkt enthalten, finden sich dagegen im rindfleisch deutlich weniger n-3-fettsäuren, sowohl in form von α-linolensäure als auch als epa und dha. die zusammensetzung der fettsäuren im menschlichen körper kann durch verstärkte aufnahme von fischölen verändert werden, wobei die erhöhte konzentration an n-3-fettsäuren zulasten der n-6-fettsäuren (besonders der ara. abb. 6.18 entstehung der lipidmediatoren aus arachidonsäure, epa und dha. epa bildet mithilfe von cox prostaglandine der 3er-serie, die schwächer inflammatorisch wirken und die wirkung der pg 2er-serie antagonisieren. epa bildet mithilfe von lox leuktriene der 5er-serie, die die wirkung der leukotriene der 4er-serie abschwächen können (mod. nach calder 2010) 6.8 · mehrfach ungesättigte fettsäuren (pufas) chidonsäure) geht (yaqoob et al. 2000) . nach ungefähr 4 wochen stellt sich eine stabile konzentrationserhöhung ein. die konzentration von n-3-pufas nach diätetischer aufnahme erhöht sich sowohl in den komplexen lipiden des blutes (triglyceriden, cholesterylester, phospholipiden) als auch in den phospholipiden der zellmembranen und der gewebe, die in inflammatorische antworten eingebunden sind. somit befinden sich die mit n-3-pufa angereicherten zellen bei möglicher inflammation auch in einer n-3-pufa reichen umgebung (blutplasma) und können dadurch stärker entzündungsauflösend wirken (calder 2010) . omega-3-substitution hemmt die cox-1 stärker als cox-2 und ist mit einer reduzierten plättchenaggregation assoziiert (norris und dennis 2012) . wie auf . abb. 6.18 dargestellt, konkurriert epa mit der arachidonsäure um die cox-1-und cox-2-enzyme. während die cox aus der arachidonsäure prostagandin d2 und pge2 erzeugt, entstehen in anwesenheit von epa die alternative eicosanoid-serien pgd3 und pge3, die die wirkungen der prostaglandine der 2er-serie antagonisieren können. pgd3 antagonisiert die migration der leukozyten, indem sie an die pgd2-rezeptoren bindet. folglich hat die gabe von n-3-fettsäuren einen zusätzlichen antiinflammatorischen effekt (tull et al. 2009 ). ebenfalls aus epa entstehen die leukotriene(lt) b5, die 10bis 100-fach weniger stark neutrophile anziehen können als die aus arachidonsäure entstandenen lt b4 (goldman et al. 1983) . epa und dha sind auch die substrate für die entstehung von resolvinen, protektinen und maresinen, die durch cox und lox enzymatisch gebildet werden (. abb. 6.18). studien mit fischöl als nahrungsergänzungsmittel zeigten eine reduktion der chemotaxis von neutrophilen, mit reduzierter anzahl von migrierenden zellen und geringerer migrationsdistanz (sperling et al. 1993) , wobei in einer dosis/wirkungsstudie 1,3 g epa/dha als optimal für die hemmung der chemotaxis angesehen wird (schmidt et al. 1991) . geringere dosen (bis 0,65 g) bewirkten keinen effekt (schmidt et al. 1996) . manche studien weisen darauf hin, dass epa eine stärkere antichemotaktische wirkung haben könnte als dha (hill et al. 2007) . gabe von 1,5 g epa/dha pro tag resultierte in niedrigerer expression von adhäsionsmolekülen icam-1 und vcam-1 an makrophagen, monozyten, lymphozyten und endothelzellen (miles et al. 2001) . epa und dha hemmen die endotoxinstimulierte produktion von il-6 und il-8 (khalfoun et al. 1997 ) und die endotoxin-induzierte aktivierung von nfκb (novak et al. 2003) . dadurch erklärt sich auch die reduzierte produktion von tnf-α, il-1β und il-6 von endotoxin-stimulierten monozyten nach fischöl substitution bei gesunden freiwilligen (abbate et al. 1996) . nachdem die n-3-pufas bereits gut dokumentierte, antiinflammatorische eigenschaften besitzen (yates et al. 2014) , haben sie ein interessantes therapeutisches potenzial für die behandlung von chronisch entzündlichen erkrankungen. studien zur behandlung der pcp zeigen, von allen bisher untersuchten diagnosen die beste evidenz (calder 2010) , die durch meta-analysen bestätigt wurde (goldberg und katz 2007) . bei asthma und atopien sind die daten weniger robust. die meisten studien bei erwachsenen ergaben keine positiven resultate, jedoch existieren bereits einige positive studien bei kindern und jugendlichen. besonders wirkungsvoll dürfte die n-3-substitution während der schwangerschaft sein. ein systematisches review (kremmyda et al. 2011 ) zeigt die aktuelle datenlage sehr gut auf: bei schwangeren gibt es bereits evidenz bezüglich fischkonsum und schutz für das kind vor atopie und allergischen erkrankungen. an-hand von mehreren epidemiologischen studien konnte eine protektive wirkung von fischölkonsum auf die entstehung von allergischen erkrankungen der kinder nachgewiesen werden. fischölsubstitution in der schwangerschaft ist mit erhöhung der n-3-pufa-werte und immunologischen veränderungen (reduktion von il-5, il-13) zum zeitpunkt der geburt verbunden, die auch nach der geburt erhalten bleiben (dunstan et al. 2003) . fischölsupplementierung in der schwangerschaft kann auch die sensibilisierung gegenüber nahrungsmittelallergenen und die prävalenz von atopischer dermatitis im ersten lebensjahr reduzieren. dieser schutz bleibt möglicherweise bis zur adoleszenz erhalten und äußert sich auch in einer reduktion von asthma und heuschnupfen (kremmyda et al. 2011) . spannende details liefert eine ganz aktuelle publikation, die bereits im jahr 1990 533 frauen während der schwangerschaft 2,7 g/tag n-3-pufa verabreichte, und nun in einem follow-up bei den mittlerweile 18-bis 19-jährigen zeigte, dass im vergleich zu n-6-olivenölsubstitution die jugendlichen der fischölgruppe signifikant seltener asthmamedikamente (hazard ratio, 0.54, 95 % ci, 0.32-0.90; p = 0.02) und weniger medikamente gegen allergische rhinitis (hazard ratio, 0.70, 95 % ci, 0.47-1.05; p = 0.09) brauchten (hansen et al. 2017) . somit erkennt man das hohe prophylaktische potenzial zur allergieprävention der fischölgruppe. im dezember 2016 publizierte das new england journal of medicine eine studie, bei der nahrungsergänzung mit 2,4 g n-3-pufa pro tag bei 736 schwangeren ab der 24. schwangerschaftswoche das absolute risiko von persistierendem giemen und asthma sowie infektionen des unteren respirationstrakts um ein drittel reduzierte, nachdem die kinder mit 3 jahren nachbeobachtet worden waren (bisgaard et al. 2016) . weil entzündungsauflösende lipidmediatoren bzw. n-3-pufa sowohl in der plazenta und im nabelschnurblut (keelan et al. 2015) als auch in der muttermilch (sherry et al. 2015) nachweisbar sind, und resolvine und protektine die atemwegsinflammation, muköse metaplasie und hyperreaktivität der bronchien reduzieren sowie schutz vor respiratorischen infektionen bieten können, erweist sich diese studie als klinische bestätigung des bisherigen hauptsächlich experimentellen wissens über die oben beschriebenen lipidmediatoren. ein cochrane-review aus 2015 fand nach n-3-pufa-supplementierung in der schwangerschaft und/oder stillzeit eine reduktion von medizinisch diagnostizierten, ige-mediierten allergien bei kindern zwischen 12 und 36 monaten, aber nicht nach 36 monaten, und weniger ige-mediierte nahrungsmittelallergien im ersten lebensjahr, jedoch nicht zu einem späteren zeitpunkt, sowie weniger atopisches ekzem zwischen dem 12. und 36. lebensmonat. auch sensibilisierungen gegen jedwedes allergen zwischen dem 12. und 36. lebensmonat beobachtete man bei kindern von den in schwangerschaft bzw. stillzeit substituierten müttern deutlich seltener (gunaratne et al. 2015) . die omega-3-substitution in der kindheit zeigte inkonsistente ergebnisse: eine prospektiven geburtskohorte von über 4000 kindern (kull et al. 2006) , die bis zum 4. lebensjahr beobachtet wurde, belegte, dass regelmäßiger fischkonsum im ersten lebensjahr das auftreten von allergischen erkrankungen [or(adj) 0.76 (95 % ci 0.61-0.94)] und die sensibilisierung gegenüber nahrungs-und pollenallergenen [or(adj) 0.76 (0.58-1.0)] reduzierte. in einer anderen studie erhielten 420 kinder (d' vaz et al. 2012 ) mit hohem allergierisiko täglich fischöl (280 mg dha und 110 mg epa) oder kontrolle (olivenöl) von der geburt an bis zum 6. lebensmonat. ziel dieser studie war es herauszufinden, ob postnatale fischölsupplementierung in den ersten 6 lebensmonaten ebenso allergieprotektiv wirksam ist wie die n-3-pufa-substitution in der schwangerschaft. die ergebnisse sind spannend: während die dha-und epa-werte mit 6 monaten in der fischölgruppe signifikant höher und die arachidonsäurewerte signifikant niedriger als in der olivenölgruppe waren, hatten kinder mit hohen n-3-pufa-werten (gemessen in erythrozyten und plasma) (egal welcher gruppenzuordnung) nach 6 monaten ein niedrigeres risiko für ige-assoziierte erkrankungen wie ekzem und ein niedrigeres risiko für rezidivierendes giemen im ersten lebensjahr. dies deutet auf einen möglichen präventiven effekt in bezug auf atemwegsallergien hin, der bei geplanten follow-ups nach 2.5 und 5 jahren ersichtlich werden könnte. die assoziationen zwischen n-3-pufa-werten und nachfolgendem ekzem waren jedoch nach justierung der gruppengehörigkeit nicht mehr signifikant, was dafür spricht, dass fischölsubstitution in der frühesten kindheit möglicherweise nicht effektiv genug war und der protektive effekt von fischöl schon vor der geburt stattfindet. am ende des ersten lebensjahres konnte kein unterschied bei der allergischen sensibilisierungsrate zwischen den beiden gruppen gefunden werden (d' vaz et al. 2012) . regelmäßiger verzehr von fettreichem fisch und omega-3-fettsäuren in der kindheit reduzierte in einer weiteren untersuchung das risiko, an einer allergischen rhinitis, aber auch an nicht-allergischer rhinitis zwischen dem 8. und 16. lebensjahr zu erkranken (magnusson et al. 2015) . jenes bereits erwähnte systematisches review von kremmyda (kremmyda et al. 2011) fand bei der mehrheit (9 von 14) der studien, die omega-3-fettsäuren in der kindheit verabreicht hatten, schützende effekte bezüglich der entwicklung einer atopie. hier sind die ergebnisse bisheriger studien eher enttäuschend. ein cochrane-review fand keine verbesserung von bestehendem asthma bei erwachsenen und kindern, nur bei einer studie an kindern wurde ein verbesserter peakflow und ein reduzierter verbrauch von asthmamedikamenten nachgewiesen (woods et al. 2002) . alle bisherigen daten lassen deutlich erkennen, dass allergische immunantworten, die sich bereits manifestiert haben, für eine therapie mit n-3-pufas wesentlich schlechter zugänglich sind als eine modifikation der immunantworten durch n-3-pufas, bevor sich die krankheit etabliert hat, nämlich bereits präpartal und/oder ganz kurz nach der geburt im "early window of opportunity", in dem sich die immunantworten entwickeln. nachdem viele interventionsstudien mit n-3-fettsäuren bei asthmatischen kindern divergierende ergebnisse zeigen, nimmt man heute an, dass auch genpolymorphismen, die asthma begleiten, für diese unterschiedlichen ergebnisse verantwortlich sein könnten. deshalb wäre die genauere analyse einiger schlüsselgenvarianten in zukünftigen studien interessant, um die wirkung der n-3-fettsäuren beim asthma besser verstehen zu können. obwohl noch keine definitive evidenz besteht bzw. keine eindeutige aussagen über positive wirkungen von n-3-pufas auf bestehende allergien und asthma im kindesalter gemacht werden können, gibt es trotzdem genug evidenz, die zumindest diese möglichkeit bekräftigen. daher gibt es einen dringenden bedarf an studien, die diesen ansatz näher verfolgen und die umsetzbarkeit in bezug auf prävention während der schwangerschaft, stillzeit und kindheit und/oder therapie von allergischen erkrankungen und asthma prüfen. wenn dieser ansatz erfolgreich dokumentiert sein wird, auch wenn nur einer empfänglichen kohorte geholfen werden kann, erscheint es aus einer volksmedizinischen (public health) perspektive jedenfalls sinnvoll, n-3-pufas über diätetische maßnahmen zuzuführen. dies deshalb, weil die substitution von n-3-pufas wenig risiko birgt und besser toleriert wird als herkömmliche asthmatherapien und, langfristig gesehen, wesentlich billiger ist (d' auria et al. 2014) . im tierversuch zeigte eine substitution mit n-3-pufa-reichem fischöl bei ova-sensibilisierten mäusen eine reduktion der eosinophi-len infiltration, schleimproduktion und ova-ige (gonçalves de matos et al. 2012) . fütterung von dha an ratten während der stillzeit hatte einen nützlichen effekt auf die fähigkeit der immunzellen ifn-γ und il-10 (um 40-60 % mehr als ohne dha-substitution) nach stimulation mit lps oder ovalbumin zu produzieren. jungtiere ohne dha hatten 70 % höhere plasmakonzentrationen von ova-spezifischem ige. somit förderte die supplementierung von dha in der stillperiode die orale toleranzentwicklung (richard et al. 2016) . zusammenfassend lässt sich sagen, dass n-3-fettsäuren essenziell für ein gesundes leben sein dürften und mit der nahrung zugeführt werden sollten, nachdem sie der körper selbst nicht in ausreichendem ausmaß produzieren kann. die food and drug administration and the environmental protection agency hat 2017 empfohlen, dass frauen im gebärfähigen alter (zwischen 16 und 49 jahren), aber besonders schwangere und stillende frauen zwei bis drei fischmahlzeiten mit niedrigem quecksilbergehalt pro woche zu sich nehmen sollten (200 bis 300 g pro woche). auch kinder sollten ab dem alter von 2 jahren mindestens 1-2 fischmahlzeiten pro woche erhalten. fische mit hohem quecksilbergehalt wie königsmakrele, hai, schwertfisch, großaugen-thunfisch, marlin und granatbarsch sollten vermieden werden (fda). und der kreis schließt sich: die zufuhr von omega-3-fettsäuren bewirkt auch eine erhöhte diversität des mikrobioms! eine vielbeachtete studie (menni et al. 2017 ) präsentierte im dezember 2017, dass sowohl die omega-3-als auch die dha-werte im serum von 867 eher älteren frauen mit der diversität des mikrobioms korrelierten. 35 verschiedene bakterienarten, aber besonders bakterien der lachnospiraceae-familie wurden mit hohen dha-und gesamt-omega-3-werten assoziiert. die lachnospiraceae-familie ist dafür bekannt, dass sie komplexe polysaccharide in scfas wie acetat, butyrat und propionat abbauen kann. scfas sind das endprodukt der fermentierung von ballaststoffreicher ernährung und werden für die energiegewinnung im körper, aber auch für die physiologische funktion der "tight junctions" benötigt (s. 7 abschn. 4.1). somit könnte die substitution von omega-3-fettsäuren, neben der bildung von spms, auch über die positiven auswirkungen auf das mikrobiom zur allergieprävention beitragen. der vollständigkeit halber sei noch auf die einfach ungesättigten omega-9-fettsäuren eingegangen, deren hauptvertreter das olivenöl ist. olivenöl besteht zu 75 % aus der omega-9 (18:1)-ölsäure, 7,5 % aus omega-6-pufas und zu minimalen anteilen (nur ca. 1 %) aus omega-3-pufas. trotzdem hat olivenöl nachgewiesene antiinflammatorische und antioxidative eigenschaften (cicerale et al. 2012) . einnahme von olivenöl in der schwangerschaft konnte das kindliche risiko, innerhalb des ersten lebensjahres zu giemen, reduzieren (castro-rodriguez et al. 2010 ). olivenöl ist auch der hauptbestandteil der "mediterranen diät", die mit einem reduzierten risiko für asthma assoziiert wird (garcia-marcos et al. 2013) . wenn man diese ergebnisse beobachtet, muss man sich fragen, ob die vorher 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signaling of prostaglandin receptors: multiple roles in inflammation and immune modulation resolvin e1 regulates interleukin 23, interferon-gamma and lipoxin a4 to promote the resolution of allergic airway inflammation reversal of allergen-induced airway remodeling by cyslt1 receptor blockade n-3 fatty acid supplementation and regular moderate exercise: differential effects of a combined intervention on neutrophil function roles of cysteinyl leukotrienes in airway inflammation, smooth muscle function, and remodeling prostaglandin d2 reinforces th2 type inflammatory responses of airways to low-dose antigen through bronchial expression of macrophage-derived chemokine a novel anti-inflammatory and pro-resolving role for resolvin d1 in acute cigarette smoke-induced lung inflammation variable prostaglandin e2 resistance in fibroblasts from patients with usual interstitial pneumonia prostaglandin e(2) induces fibroblast apoptosis by modulating multiple survival pathways inhaled iloprost suppresses the cardinal features of asthma via inhibition of airway dendritic cell function effect of treatment with zileuton, a 5-lipoxygenase inhibitor, in patients with asthma. a randomized controlled trial remodeling and inflammation of bronchi in asthma and chronic obstructive pulmonary disease polymorphisms in the prostaglandin e2 receptor subtype 2 gene confer susceptibility to aspirin-intolerant asthma: a candidate gene approach prostaglandin d2-induced bronchoconstriction is mediated only in part by the thromboxane prostanoid receptor lipoxin a 4 and aspirin-triggered 15-epi-lipoxin a 4 inhibit peroxynitrite formation, nf-κb and ap-1 activation, and il-8 gene expression in human leukocytes regulation of intracellular cyclooxygenase levels by gene transcription and protein degradation rapid appearance of resolvin precursors in inflammatory exudates: novel mechanisms in resolution prostaglandin e2 activates ep2 receptors to inhibit human lung mast cell degranulation effects of maternal n-3 fatty acid supplementation on placental cytokines, pro-resolving lipid mediators and their precursors docosahexaenoic and eicosapentaenoic acids inhibit in vitro human endothelial cell production of interleukin-6 omega-3 fatty acid-derived mediator, resolvin e1, ameliorates 2,4-dinitrofluorobenzene-induced atopic dermatitis in nc/nga mice prostaglandin e2 inhibits fibroblast to myofibroblast transition via e prostanoid receptor 2 signaling and cyclic adenosine monophosphate elevation fibroblast prostaglandin e2 synthesis. persistence of an abnormal phenotype after short-term exposure to mononuclear cell products differential metabolism of arachidonic acid in nasal polyp epithelial cells cultured from aspirin-sensitive and aspirin-tolerant patients atopy risk in infants and children in relation to early exposure to fish, oily fish, or long-chain omega-3 fatty acids: a systematic review resolvin d1 binds human phagocytes with evidence for proresolving receptors cutting edge: maresin-1 engages regulatory t cells to limit type 2 innate lymphoid cell activation and promote resolution of lung inflammation fish consumption during the first year of life and development of allergic diseases during childhood suppression of allergic inflammation by the prostaglandin e receptor subtype ep3 cysteinyl leukotriene receptors, old and new; implications for asthma prostaglandin e 2 synthesis and suppression of fibroblast proliferation by alveolar epithelial cells is cyclooxygenase-2 dependent neutrophil swarms require ltb4 and integrins at sites of cell death in vivo fatty acid substrate specificities of human prostaglandin-endoperoxide h synthase-1 and -2. formation of 12-hydroxy-(9z, 13e/z, 15z)-octadecatrienoic acids from alphalinolenic acid resolvin d1 and resolvin e1 promote the resolution af allergic airway inflammation via shared and distinct molecular counter-regulatory pathways lipid mediator class switching during acute inflammation: signals in resolution multi-pronged inhibition of airway hyperresponsiveness and inflammation by lipoxin a(4) severe asthma research program nhl. diminished lipoxin biosynthesis in severe asthma protectin d1 is generated in asthma and dampens airway inflammation and hyperresponsiveness exhaled breath condensate cysteinyl leukotrienes and airway remodeling in childhood asthma: a pilot study pleiotropic regulation of macrophage polarization and tumorigenesis by formyl peptide receptor-2 prostaglandin e2 deficiency causes a phenotype of aspirin sensitivity that depends on platelets and cysteinyl leukotrienes pge 2 production at sites of tissue injury promotes an anti-inflammatory neutrophil phenotype and determines the outcome of inflammation resolution in vivo a role for docosahexaenoic acidderived neuroprotectin d1 in neural cell survival and alzheimer disease phosphorylation by protein kinase a inhibits nuclear import of 5-lipoxygenase ep4 receptor stimulation down-regulates human eosinophil function lipoxins: resolutionary road fish and polyunsaturated fat intake and development of allergic and nonallergic rhinitis prostaglandn e2 mediates cough via the ep3 receptor. implications for future disease therapy novel docosanoids inhibit brain ischemia-reperfusion-mediated leukocyte infiltration and pro-inflammatory gene expression prostaglandin e 2 suppresses human group 2 innate lymphoid cell function atla, an aspirin-triggered lipoxin a 4 synthetic analog, prevents the inflammatory and fibrotic effects of bleomycin-induced pulmonary fibrosis neutrophil apoptosis in the acute respiratory distress syndrome the role of prostaglandin e2 receptors in the pathogenesis of rheumatoid arthritis aspirintriggered lipoxin a4 stimulates alternative activation of microglia and reduces alzheimer disease-like pathology in mice leukotriene c4 upregulates collagenase expression and synthesis in human lung fibroblasts omega-3 fatty acids correlate with gut microbiome diversity and production of n-carbamylglutamate in middle aged and elderly women influence of age and dietary fish oil on plasma soluble adhesion molecule concentrations dysregulated synthesis of protectin d1 in eosinophils from patients with severe asthma pharmacological modulation of the leukotriene pathway in allergic airway disease different intracellular locations for prostaglandin endoperoxide h synthase-1 and -2 the lipid mediator protectin d1 inhibits influenza virus replication and improves severe influenza recent advances in molecular biology and physiology of the prostaglandin e2-biosynthetic pathway riding the metalloproteinase roller coaster respiratory status and allergy after bronchiolitis mediator release after nasal airway challenge with allergen nonresolving inflammation a new strategy for the identification of novel molecules with targeted proresolution of inflammation properties bone marrow stromal cells attenuate sepsis via prostaglandin e(2)-dependent reprogramming of host macrophages to increase their interleukin-10 production omega-3 fatty acids cause dramatic changes in tlr4 and purinergic eicosanoid signaling phospholipase a2 regulates eicosanoid class switching during inflammasome activation nf-kappa b inhibition by omega -3 fatty acids modulates lps-stimulated macrophage tnfalpha transcription prostaglandin e(2) suppresses staphylococcal enterotoxininduced eosinophilia-associated cellular responses dominantly through an e-prostanoid 2-mediated pathway in nasal polyps at-rvd1 modulates ccl-2 and cxcl-8 production and nf-κb, stat-6, socs1, and socs3 expression on bronchial epithelial cells stimulated with il-4 effects of lt d4 on human airway smooth muscle cell proliferation, matrix expression, and contraction in vitro: differential sensitivity to cysteinyl leukotriene receptor antagonists lipoxin a4 and b4 inhibit leukotriene-stimulated interactions of human neutrophils and endothelial cells modulation of human airway smooth muscle migration by lipid mediators and th-2 cytokines prostaglandin e2 synthesis and secretion: the role of pge2 synthases resolvin d2 is a potent endogenous inhibitor for transient receptor potential subtype v1/a1, inflammatory pain, and spinal cord synaptic plasticity in mice: distinct roles of resolvin d1, d2, and e1 suppression of il-4 production in murine lymphocytes by orally effective prostaglandin e(1) analogs leukotriene e 4 -induced pulmonary inflammation is mediated by the p2y12 receptor bronchoprotective role for endogenous prostaglandin e2 effect of inhaled prostaglandin e2 on allergeninduced asthma regulation of human basophil and lung mast cell function by cyclic adenosine monophosphate onset and duration of protection against exerciseinduced bronchoconstriction by a single oral dose of montelukast prostaglandin, leukotriene, and lipoxin balance in chronic rhinosinusitis with and without nasal polyposis deficient prostaglandin e2 production by bronchial fibroblasts of asthmatic patients, with special reference to aspirin-induced asthma airway lipoxin a4 generation and lipoxin a4 receptor expression are decreased in severe asthma observation of two modes of inhibition of human microsomal prostaglandin e synthase 1 by the cyclopentenone 15-deoxy-δ(12,14)-prostaglandin j(2) inflammatory mediator release on conjunctival provocation of allergic subjects with allergen potent contractile actions of prostanoid ep3-receptor agonists on human isolated pulmonary artery anti-inflammatory drugs in the 21st century controlling herpes simplex virus-induced ocular inflammatory lesions with the lipid-derived mediator resolvin e1 the specialized proresolving mediator 17-hdha enhances the antibody-mediated immune response against influenza virus: a new class of adjuvant? ep2 and ep4 prostanoid receptor signaling prostaglandins and inflammation a dietary supply of docosahexaenoic acid early in life is essential for immune development and the establishment of oral tolerance in female rat offspring reduced expression of coxs and production of prostaglandin e(2) in patients with nasal polyps with or without aspirin-intolerant asthma bacterial stimulation of epithelial g-csf and gm-csf expression promotes pmn survival in cf airways prostaglandin e2 inhibits mast cell-dependent bronchoconstriction in human small airways through the e prostanoid subtype 2 receptor dna sequence variations of metalloproteinases: their role in asthma and copd leukotrienes and lipoxins: structures, biosynthesis, and biological effects aspirintolerant asthmatics generate more lipoxins than aspirin-intolerant asthmatics n-3 fatty acids and leukocyte chemotaxis: effects in hyperlipidemia, and dose-response studies in healthy males no effect of a very low dose of n-3 fatty acids on monocyte function in healthy humans bronchial epithelial cell-derived prostaglandin e2 dampens the reactivity of dendritic cells resolvin e1 and protectin d1 activate inflammationresolution programmes molecular targets in pulmonary fibrosis: the myofibroblast in focus the anti-inflammatory and proresolving mediator resolvin e1 protects mice from bacterial pneumonia and acute lung injury lipoxins and novel aspirin-triggered 15-epi-lipoxins (atl): a jungle of cell-cell interactions or a therapeutic opportunity lipoxins and aspirin-triggered 15-epi-lipoxin biosynthesis: an update and role in anti-inflammation and pro-resolution novel pro-resolving lipid mediators are leads for resolution physiology resolution phase lipid mediators of inflammation: agonists of resolution design of lipoxin a4 stable analogs that block transmigration and adhesion of human neutrophils resolvins: a family of bioactive products of omega-3 fatty acid transformation circuits initiated by aspirin treatment that counter proinflammation signals lipid mediator informatics-lipidomics: novel pathways in mapping resolution resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways maresins: novel macrophage mediators with potent antiinflammatory and proresolving actions novel pro-resolving aspirintriggered dha pathway macrophage proresolving mediator maresin 1 stimulates tissue regeneration and controls pain inhaled pge2 prevents aspirin-induced bronchoconstriction and urinary lte4 excretion in aspirin-sensitive asthma docosahexaenoic acid supplementation in lactating women increases breast milk and plasma docosahexaenoic acid concentrations and alters infant omega 6:3 fatty acid ratio effect of thromboxane a2 inhibitors on allergic pulmonary inflammation in mice regulation of tnfalpha and interleukin-10 production by prostaglandins i(2) and e(2): studies with prostaglandin receptordeficient mice and prostaglandin e-receptor subtype-selective synthetic agonists role of the lipoxygenase pathway in rsv-induced alternatively activated macrophages leading to resolution of lung pathology role and regulation of cyclooxygenase-2 during inflammation the importance of the ratio of omega-6/omega-3 essential fatty acids effects of inhaled prostaglandins e1, e2, and f2alpha on the airway resistance of healthy and asthmatic man enzymes of the cyclooxygenase pathways of prostanoid biosynthesis lipoxin a4 inhibits il-1ß-induced il-6, il-8, and matrix metalloproteinase-3 production in human synovialfibroblasts and enhances synthesis of tissueinhibitors of metalloproteinases leukotrienereceptor expression on nasal mucosal inflammatory cells in aspirin-sensitive rhinosinusitis il-10 reduces rat brain injury following focal stroke dietary ω-3 polyunsaturated fatty acids inhibit phosphoinositide formation and chemotaxis in neutrophils resolvin d2 is a potent regulator of leukocytes and controls microbial sepsis lipoxin a4 counterregulates gm-csf signaling in eosinophilic granulocytes 15-deoxy-d12,14-prostaglandin j2 inhibits multiple steps in the nf-kb signaling pathway airway remodeling in murine asthma correlates with a defect in pge2 synthesis by lung fibroblasts prostaglandin e2 inhibits eosinophil trafficking through e-prostanoid 2 receptors anti-inflammatory therapy in chronic disease: challenges and opportunities prostaglandin e2 suppresses chemokine production in human macrophages through the ep4 receptor a novel prostaglandin e receptor 4-associated protein participates in antiinflammatory signaling silencing nociceptor neurons reduces allergic airway inflammation pgi2 signaling inhibits antigen uptake and increases migration of immature dendritic cells omega-3 fatty acids and inflammation: novel interactions reveal a new step in neutrophil recruitment resolvins: natural agonists for resolution of pulmonary inflammation structural basis of fatty acid substrate binding to cyclooxygenase-2 investigating substrate promiscuity in cyclooxygenase-2: the role of arg-120 and residues lining the hydrophobic groove resolution of inflammation is altered in alzheimer's disease tissue destruction by neutrophils human macrophages differentially produce specific resolvin or leukotriene signals that depend on bacterial pathogenicity prostaglandin e(2) inhibits fibroblast migration by e-prostanoid 2 receptormediated increase in pten activity pharmacological interactions between prostacyclin and thromboxanes cultured lung fibroblasts isolated from patients with idiopathic pulmonary fibrosis have a diminished capacity to synthesize prostaglandin e2 and to express cyclooxygenase-2 dietary marine fatty acids (fish oil) for asthma in adults and children international union of basic and clinical pharmacology: lxxxiii: classification of prostanoid receptors, updating 15 years of progress efficacy and safety of 15(r/s)-methyl-lipoxin a4 in topical treatment of infantile eczema cancerassociated immunodeficiency and dendritic cell abnormalities mediated by the prostaglandin ep2 receptor encapsulated fish oil enriched in α-tocopherol alters plasma phospholipid and mononuclear cell fatty acid compositions but not mononuclear cell functions pharmacology and therapeutics of omega-3 polyunsaturated fatty acids in chronic inflammatory disease correlation between the prostaglandin d(2)/e(2) ratio in nasal polyps and the recalcitrant pathophysiology of chronic rhinosinusitis associated with bronchial asthma prostaglandin e 2 suppresses allergic sensitization and lung inflammation by targeting the e prostanoid 2 receptor on t cells regulation of cyclooxygenase-2 (cox-2) in rat renal cortex by adrenal glucocorticoids and mineralocorticoids glucocorticoids sensitize rat placental inflammatory responses via inhibiting lipoxin a4 biosynthesis tissue regeneration. inhibition of the prostaglandin-degrading enzyme 15-pgdh potentiates tissue regeneration cyclooxygenase inhibition abrogates aeroallergen-induced immune tolerance by suppressing prostaglandin i2 receptor signaling localization and upregulation of cysteinyl leukotriene-1 receptor in asthmatic bronchial mucosa key: cord-312613-1nl7q6cy authors: luz garcia-garcia, m.; calvo rey, cristina; del rosal rabes, teresa title: pediatric asthma and viral infection() date: 2016-03-26 journal: arch bronconeumol doi: 10.1016/j.arbr.2016.03.010 sha: doc_id: 312613 cord_uid: 1nl7q6cy respiratory viral infections, particularly respiratory syncytial virus (rsv) and rhinovirus, are the most importance risk factors for the onset of wheezing in infants and small children. bronchiolitis is the most common acute respiratory infection in children under 1 year of age, and the most common cause of hospitalization in this age group. rsv accounts for approximately 70% of all these cases, followed by rhinovirus, adenovirus, metapneumovirus and bocavirus. the association between bronchiolitis caused by rsv and the development of recurrent wheezing and/or asthma was first described more than 40 years ago, but it is still unclear whether bronchiolitis causes chronic respiratory symptoms, or if it is a marker for children with a genetic predisposition for developing asthma in the medium or long term. in any case, sufficient evidence is available to corroborate the existence of this association, which is particularly strong when the causative agent of bronchiolitis is rhinovirus. the pathogenic role of respiratory viruses as triggers for exacerbations in asthmatic patients has not been fully characterized. however, it is clear that respiratory viruses, and in particular rhinovirus, are the most common causes of exacerbation in children, and some type of respiratory virus has been identified in over 90% of children hospitalized for an episode of wheezing. changes in the immune response to viral infections in genetically predisposed individuals are very likely to be the main factors involved in the association between viral infection and asthma. r e s u m e n las infecciones por virus respiratorios, especialmente virus respiratorio sincitial (vrs) y rinovirus, suponen el mayor factor de riesgo para la aparición de episodios de sibilancias en lactantes y niños pequeños. la bronquiolitis es la infección respiratoria aguda de vías respiratorias inferiores más común en menores de un año y constituye la causa más frecuente de hospitalización en este grupo de edad. el vrs causa aproximadamente el 70% de todas ellas, seguido por rinovirus, adenovirus, metapneumovirus o bocavirus. la asociación entre bronquiolitis por vrs y desarrollo de sibilancias recurrentes y/o asma ha sido descrita hace más de 4 décadas, aunque en la actualidad se desconoce con exactitud si la bronquiolitis es la causa de los síntomas respiratorios crónicos o si, más bien, es un marcador que señala a los niños con predisposición genética a desarrollar asma a medio o largo plazo. en cualquier caso, existe evidencia suficiente como para afirmar que esta asociación existe y que es especialmente intensa si el agente asociado a la bronquiolitis es el rinovirus. el papel patogénico de los virus respiratorios como desencadenantes de exacerbaciones en el paciente asmático no está totalmente aclarado, pero sin duda los virus respiratorios, y en especial el rinovirus, son el desencadenante más frecuente de exacerbaciones asmáticas en los niños, llegando a identificarse algún virus respiratorio hasta en el 90% de los niños hospitalizados por un episodio de sibilancias. muy probablemente, las alteraciones en la respuesta inmune frente a las infecciones virales en sujetos genéticamente predispuestos sean los principales implicados en la asociación virus-asma. asthma is a chronic inflammatory disease of the airways characterized by bronchial hyperresponsiveness to a wide variety of stimuli, recurrent episodes of wheezing, respiratory distress, and cough, associated with reversible airway obstruction. asthma is one of the most prevalent chronic diseases worldwide, affecting more than 155 million individuals, so the impact of asthma is severe, and incidence is growing, particularly in developed countries. 1, 2 respiratory viruses are one of the most common causes of asthma exacerbations in both adults and children. [3] [4] [5] [6] furthermore, increasing evidence is emerging to suggest that viral respiratory infections in early life are related with the medium and long-term development of asthma. 7, 8 this article aims first to review the role of viruses as precipitating factors for asthma, and then to summarize the current state of knowledge on their role in asthma exacerbations. viral bronchiolitis is a common feature in the clinical histories of children who go on to develop wheezing and asthma during childhood. the term bronchiolitis has been in use since 1940, but it has several different interpretations, and there is no general agreement on its definition. in this review, we will use the standard criteria of mcconnochie, who describes bronchiolitis as the first acute episode of wheezing, preceded by a respiratory syndrome of rhinorrhea, cough, and tachypnea, occurring with or without fever, in children younger than 2 years of age. 9 bronchiolitis is the most common acute lower respiratory tract infection in children younger than 1 year, and accounts for 18% of all pediatric admissions. 10 respiratory syncytial virus (rsv) is the causative agent in approximately 70%-80% of cases, followed by rhinovirus, adenovirus, human metapneumovirus (hmpv), and human bocavirus (hbov). 11, 12 the most common respiratory viruses are listed in table 1 . studies reporting global analyses of all patients with a history of bronchiolitis, irrespective of the causative agent, reveal a prevalence of recurrent wheezing that ranges from 75% in the first 2 years of life, 47%-59% between the ages of 2 and 4, and 25%-43% between 4 and 6 years, [13] [14] [15] [16] showing a clear trend to diminish with age. only 2 prospective studies included a long-term follow-up of children hospitalized for bronchiolitis, irrespective of the causative virus. they found a prevalence of asthma at the age of 17-20 years of 41%-43% in patients with a history of bronchiolitis, compared to a rate of 11%-15% in controls; between 25 and 30 years of age, prevalence was 35%, with significant impact on health-related quality of life. 17, 18 these data suggest that recurrent wheezing occurs frequently in children after an episode of bronchiolitis, and also that respiratory symptoms frequently recur in young adults after a long symptom-free period during childhood and adolescence. this changes the previously held notion of a relatively good prognosis for early childhood wheezing, and indicates that the risk of asthma and lung function changes can persist until adulthood. 19, 20 rsv was the first virus to be associated with the development of asthma in children, although in recent years, other viruses, such as rhinovirus or the more recently described hmpb and hbov, have also been studied in this context. rsv is an rna virus from the paramyxoviridae family that often causes lower respiratory tract infections in infants and small children. 21 in 1959, wittig and glaser 22 first described the epidemiological association between viral bronchiolitis in childhood and the subsequent development of recurrent wheezing and/or asthma. since then, numerous studies have evaluated this relationship, although the different methodologies employed made it difficult to draw conclusions that definitively proved this association. however, more recently, several prospective studies, now considered seminal, [23] [24] [25] [26] [27] showed that a history of bronchiolitis caused by rsv is an independent risk factor for the development of recurrent wheezing and medically-diagnosed asthma. of these authors, sigurs et al. 27 performed the longest follow-up to date, with subjects reaching the age of 18 years in the last follow-up time point. the initial cohort consisted of 47 infants aged <1 year hospitalized with severe rsv bronchiolitis and 93 age-and gender-matched controls. children who had been admitted for bronchiolitis had a higher prevalence of asthma/recurrent wheezing and allergic sensitizations at the ages of 3, 7 and 13 years, compared to the control group. at the age of 18, the bronchiolitis group maintained a significantly higher prevalence of asthma (39% vs 9%), allergic rhinoconjunctivitis (43% vs 17%), and perennial allergen sensitization (41% vs 14%). moreover, at the age of 18, the bronchiolitis group had poorer lung function (fev 1 , fev 1 /fvc) than the control group, irrespective of whether they had concomitant asthma or not. they also had more prevalent bronchial hyperresponsiveness and bronchodilator response. finally, the authors reported that the only 2 risk factors independently related with the diagnosis of asthma at 18 years of age were a history of severe rsv bronchiolitis and presence of allergic rhinoconjunctivitis. these results show that severe rsv bronchiolitis in the early months of life is associated with the development of asthma, bronchial hyperresponsiveness and allergic sensitization, and suggest that this association continues until adulthood. the results of another reference follow-up study, tucson children's respiratory study, show that rsv bronchiolitis is an independent risk factor for the development of asthma up to the age of 11 years, but the association disappears after the age of 13. 24 this difference in the long-term prognosis may be related with varying severity of the acute episode, since in the sigurs study, all patients needed to be hospitalized, while the tucson cohort included mostly outpatients. the authors also observed a greater risk of asthma among children who used more healthcare resources during the acute bronchiolitis episode. 28 the rsv bronchiolitis in early life (rbel) study also supports the association between severe rsv bronchiolitis and subsequent development of asthma 29 : of the 206 infants admitted for rsv bronchiolitis, approximately 50% had been diagnosed with asthma by the age of 7 years. although rsv is without doubt the most common virus in the etiology of acute infantile bronchiolitis, the use of molecular diagnostic techniques -primarily polymerase chain reaction (pcr) -has established that other respiratory viruses, such as rhinovirus, are also associated with bronchiolitis, and probably with the development of asthma. 30, 31 indeed, several recent studies have shown that the risk of children hospitalized for bronchiolitis presenting asthma at 6 and 11 years is higher among those who were rsv-negative than those who were rsv-positive. 32, 33 rhinovirus is an rna virus from the picornaviridae family, first isolated in 1950. it comprises a large rna family of more than 100 serotypes, originally divided into 2 species, a and b, and now with the recent addition of the c type. 34 studies published in recent years suggest that rhinovirus infections involve a greater risk for the development of asthma than rsv-associated infections. in the childhood origins of asthma (coast) study, which followed a cohort of 289 newborns with high risk of developing asthma, lower respiratory tract infection associated with rhinovirus was the main risk factor for presenting recurrent wheezing at 3 and 6 years of life, with an odds ratio of 10 for rhinovirus bronchiolitis compared to 2.6 for rsv bronchiolitis. 35, 36 moreover, children with rhinovirus-associated wheezing in the first 3 years of life had worse lung function values (fev 1 , fev 0.5 , fef ) than those with other viruses or those who never presented wheezing. 37 midulla et al. 38 confirmed the role of rhinovirus bronchiolitis as one of the main risk factors for the development of asthma at the age of 6 years. the coast study also showed that, in the case of rhinovirus, the risk of developing asthma is not limited to severe infection. in fact, only 1% of children with rhinovirus bronchiolitis included in the study needed to be hospitalized, demonstrating that even mild rhinovirus infections are associated with a greater long-term risk of asthma. finally, another cohort study with a follow-up of 15-18 years showed that the risk of asthma in adolescence is greater in children hospitalized due to rhinovirus bronchiolitis, compared to rsv bronchiolitis. this study also found that the risk of asthma is greater in children whose initial episode of bronchiolitis occurred in seasons other than winter, when the predominant virus is not rsv. 39 hmpv is a paramyxovirus, discovered in 2001 and identified throughout the world as a common cause of acute respiratory infection, particularly in infants and small children. 40 the clinical features of acute hmpv infection are similar to those caused by rsv, and can manifest as mild upper respiratory tract infections, pneumonia or severe bronchiolitis requiring hospital admission. the similarity of the clinical symptoms with those of rsv has led to speculation that hmpv infections may also be associated with the development of asthma in the long term. to date, the mediumterm progress of children admitted for hmpv bronchiolitis has been examined in only 1 study that reported a similar rate of recurrent wheezing to that seen in children admitted for rsv bronchiolitis: 5-fold the rate of the control group in both cases. 41 hbov is a dna virus belonging to the parvoviridae family. it was first identified in 2005 in respiratory samples from children with lower respiratory tract infections. 42 since then, numerous studies have investigated its prevalence and its role in respiratory infections, but to date, only 1 has examined its possible role in the development of asthma: the study in question reported that 50% of children admitted for hbov bronchiolitis had asthma by the age of 5-7 years. 43 the high rate of hbov co-infection with other respiratory viruses, and its tendency to infect older children confounds the study of the real role of early hbov infections in the development of asthma. the bronchiolitis-asthma relationship: cause or coincidence? as discussed above, a wide body of evidence relates viral respiratory infections with the subsequent development of asthma, but it remains unclear if severe bronchiolitis is the real cause of asthma, or if it is a marker of susceptibility, identifying children with a predisposition for developing asthma. a prospective, multicenter study recently conducted in europe, the united states, and canada, 44 appears to support the causative role of rsv, after an 80% reduction was observed in recurrent wheezing in the medium term among premature babies with a family history of asthma and/or atopy who received prophylaxis with palivizumab, a monoclonal antibody used for preventing rsv infection. curiously, the protective effect was only observed in children with a history of atopy, suggesting that rsv may have a causative role in the pathogenesis of recurrent wheezing, but only in patients with no genetic predisposition for atopy. the possible causative role of viral bronchiolitis was questioned by an epidemiological study performed in monozygotic twins, discordant for severe rsv bronchiolitis in infancy. the authors found no difference in the frequency of asthma, lung function or nitric oxide levels at the age of 7 years between twin siblings with a history or no history of hospitalization due to bronchiolitis. 45 finally, another 2 recent studies support the hypothesis that early viral infections are markers of atopic predisposition, rather than the cause of asthma. one of these was the danish copenhagen prospective study of asthma in childhood, which followed a cohort of newborns with asthmatic mothers. investigators measured lung function and response to methacholine of infants at 1 month of life, before any respiratory symptom had been observed. they found at this time point that children who subsequently developed severe bronchiolitis already had bronchial hyperresponsiveness as a precursor to bronchiolitis. 46 these results are supported by the recent coast study, which identified allergic sensitization in the first year of life as a significant risk factor for virus-associated wheezing, while wheezing associated with respiratory infection does not increase the risk of developing allergic sensitization. 47 it seems likely that the 2 hypotheses -bronchiolitis as a cause or as a marker of asthma -are not mutually exclusive, and that the pathogenic mechanisms of rhinovirus and rsv infections differ. rsv characteristically produces a cytopathic effect in the airway, affecting children younger than 3 months, frequently requires hospitalization and occurs in epidemic outbreaks during the winter months. 48 in contrast, rhinovirus outbreaks occur throughout the year and affect older children who are generally treated as outpatients, and who often have a family history of asthma or atopy. 7, 49 these differences have led to the hypothesis of 2 different mechanisms: rhinovirus bronchiolitis may be more a marker of predisposition to asthma and atopy, while rsv bronchiolitis may have a greater causative role, particularly in severe cases requiring hospitalization. 50, 51 the role of respiratory viruses as precipitants of asthma attacks in adults and children was identified over 30 years ago. in the early studies, in which viral diagnosis was not based on molecular methods, some viral activity was detected in between 10% and 25% of asthma attacks. 52 in contrast, in recent years, the use of pcr techniques has revealed that the proportion of asthma exacerbations associated with viruses is much higher, up to 63%, according to khetsuriani et al., 53 up to 80%, according to johnston et al., 3 or even up to 95%, according to allander et al. 54 at least 1 respiratory virus was identified in 71% of patients included in a spanish study of children hospitalized for an asthma exacerbation. 5 although practically all respiratory viruses, including the newly identified hmpv and hbov, have been associated with asthma exacerbations, the agents most commonly detected in infants and schoolchildren are rhinovirus and rsv. 5, 55 in fact, a recent cohort study in 263 infants suggests that rhinovirus is the most common pathogen in the first year of life and the most important precipitant of wheezing in infants. 56 in children of school age, johnston et al. 3 found that 80% of asthma exacerbations in asthmatic children aged 9-11 years were associated with viral respiratory infection, of which two thirds were caused by rhinovirus. asthma exacerbations among pre-schooland school-age children tend to follow a seasonal pattern, and in temperate climates, the maximum incidence occurs in the month of september, coinciding with the beginning of the school year, and in spring. 57 this pattern coincides almost exactly with the peaks of maximum circulation of rhinovirus in the community, suggesting a causal relationship between this virus and asthma exacerbations. the frequency of detecting respiratory viruses in adults with asthma exacerbations ranges between 41% and 78%, according to the results of a recent meta-analysis. 58 although rhinovirus is also most common in this age group, 59 other viruses, such as rsv, hmpv, or influenza virus appear to play an important role in asthma exacerbations in adults in clinical practice. 60 moreover, viral infections can act in synergy with other stimuli, such as exposure to allergens in allergic individuals 61, 62 or exposure to high levels of environmental contaminants, 63 increasing the risk of asthma exacerbations. viral respiratory infections affect the lung in many ways, acting on epithelial cells and antigen-presenting cells. after it recognizes the viral infection, the immune system stimulates the production of cytokines, such as interleukins (il) il-25 and il-33 and thymic stromal lymphopoietin (tslp), in the epithelial cells of the airway. these cytokines induce the th2 immune response to airborne allergens in the lungs. the production of certain cytokines, such as il4, il5, and il13, by the th2 cells subsequently increases eosinophil and mast cell recruitment, causing inflammation of the airway, cell metaplasia, and bronchoconstriction. 64 however, not all individuals who contract a respiratory virus infection suffer an asthma exacerbation, so the possibility that certain risk factors increase susceptibility to present wheezing after viral infection has been explored. studies conducted by wark et al. 65 and contoli et al. 66 suggest that the absence of an efficient innate immune response, manifested by low interferon levels in the epithelial cells of asthma patients, may assist viral replication, leading to an exaggerated asthmatic response. it seems highly likely that an altered immune response to viral infections in genetically predisposed subjects are the major factors involved in the virus-asthma relationship. asthma in the united states: burden and current theories epidemiology of asthma: prevalence and burden of disease community study of role of viral infections in exacerbations of asthma in 9-11 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infections associated with adult asthma exacerbations in clinical practice high titers of ige antibody to dust mite allergen and risk for wheezing among asthmatic children infected with rhinovirus study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children synergism between rhinovirus infection and oxidant pollutant exposure enhances airway epithelial cell cytokine production viral respiratory tract infections and asthma in early life: cause and effect? asthmatic bronchial epithelial cells have a deficient innate immune response to infection with rhinovirus role of deficient type iii interferon-lambda production in asthma exacerbations the authors declare that they have no conflict of interests. key: cord-327610-cm3vkpcn authors: fukuda, yosuke; akimoto, kaho; homma, tetsuya; baker, jonathan r; ito, kazuhiro; barnes, peter j; sagara, hironori title: virus-induced asthma exacerbations: sirt1 targeted approach date: 2020-08-13 journal: j clin med doi: 10.3390/jcm9082623 sha: doc_id: 327610 cord_uid: cm3vkpcn the prevalence of asthma has increased worldwide. asthma exacerbations triggered by upper respiratory tract viral infections remain a major clinical problem and account for hospital admissions and time lost from work. virus-induced asthma exacerbations cause airway inflammation, resulting in worsening asthma and deterioration in the patients’ quality of life, which may require systemic corticosteroid therapy. despite recent advances in understanding the cellular and molecular mechanisms underlying asthma exacerbations, current therapeutic modalities are inadequate for complete prevention and treatment of these episodes. the pathological role of cellular senescence, especially that involving the silent information regulator 2 homolog sirtuin (sirt) protein family, has recently been demonstrated in stable and exacerbated chronic respiratory disease states. this review discusses the role of sirt1 in the pathogenesis of bronchial asthma. it also discusses the role of sirt1 in inflammatory cells that play an important role in virus-induced asthma exacerbations. recent studies have hypothesized that sirt1 is one of major contributors to cellular senescence. sirt1 levels decrease in th2 and non-th2-related airway inflammation, indicating the role of sirt1 in several endotypes and phenotypes of asthma. moreover, several models have demonstrated relationships between viral infection and sirt1. therefore, targeting sirt1 is a novel strategy that may be effective for treating virus-induced asthma exacerbations in the future. asthma is the most common chronic respiratory disease, as over 300 million individuals suffer from asthma worldwide [1] . although the rate of asthma-related mortality has declined for decades due to the advancement in treatment strategies, the prevalence of asthma has gradually increased from 1990 to 2005, and death rates have plateaued in some countries with aging populations [2] . among all asthma patients, it is thought that about 5-10% of patients have severe refractory asthma. this is due to inaccurate inhalation techniques, poor treatment adherence, and inadequate management of comorbidities [3] . however, even when these factors are excluded, asthma is often still poorly controlled in the population. patients still have to grapple with various issues associated with the condition; asthma exacerbation is one of the challenges that requires a more effective solution. among multiple causes, infectious diseases are the most important cause of asthma exacerbations. various microorganisms, such as bacteria, fungi, and viruses, can cause acute exacerbations of asthma [4] [5] [6] , and viral infection is the most common trigger. human rhinovirus (hrv) is one of the major pathogens of virus-induced asthma exacerbations. in a review of 670 samples of hrv infection detected in the nasal mucosa of infants, hrv caused severe symptoms in winter, and hrv-a and hrv-c caused moderate to severe illnesses [7] . a previous study confirmed elevated expression of interferon (ifn) and type 2 cytokines analyzed from bronchosorption and nasosorption in asthma patients infected with hrv [8] . in the presence of hrv infection, it was suggested that airway infections of streptococcus pneumoniae and moraxella catarrhalis might increase the risk of experiencing the severity and symptoms of asthma exacerbations [9] . respiratory syncytial virus (rsv) is also an important pathogen for asthma exacerbations. rsv is known to infect almost all children by the age of 2 years [10] , and childhood rsv infection puts adults at risk of developing asthma [11] . in addition, the annual incidence of rsv infection is 3-7% in healthy older adults, and 7.2% of patients hospitalized for asthma have comorbid rsv infection [12] . thus, it is an essential pathogen for all generations. type 2 and non-type 2 airway inflammation are the two major immune phenotypes of asthma [13] . these phenotypes and endotypes are defined by a variety of factors, including genetic predisposition and environmental factors such as antigen exposure, inflammatory biomarkers, tight junctions in the airway epithelium, and viral infections [14] [15] [16] . in addition to the viral infections themselves, it has been suggested that viral infections can reduce the species, numbers, and diversity of microbiota, so-called dysbiosis [17] , indicating that asthma is a very complex disease. viral infection, which can affect patients with both phenotypes, induces the formation of a wide range of cytokines and chemokines in the airway [18] [19] [20] [21] [22] . eosinophils, t helper-2 (th2) lymphocytes, type 2 innate lymphoid cells (ilc2), th17 cells, and neutrophils are involved in epithelial chemokine production in virus-induced asthma exacerbation [18] [19] [20] [21] [22] (figure 1 ). inhaled corticosteroids (ics), which have been used widely for treating asthma over the past few decades, inhibit the expression of inflammatory cytokines in the airway during virus-induced asthma exacerbations, especially th2-airway inflammation [23] . although ics ameliorate asthma exacerbation by limiting neutrophilic and non-th2 inflammation [24] , it is also known that viral infection induces steroid resistance by inducing mainly neutrophilic airway inflammation [25] . virus-induced asthma exacerbation overburdens healthcare systems, and it elevates the rates of morbidity and mortality [26] . moreover, a few patients, described as severe, do not respond to current therapies, and few prophylactic strategies are available for treating such refractory cases. therefore, new therapeutic targets and approaches are the need of the hour. cellular senescence is characterized by irreversible cell-cycle arrest and release of inflammatory mediators known as the senescence-associated secreted phenotype (sasp), which can exert paracrine and autocrine effects on naïve cells [27] . the silent information regulator 2 homolog 1 (sirt1), which is a nicotinamide adenine dinucleotide (nad+)-dependent class iii deacetylase, is one of the essential proteins that regulates aging, metabolism, dna repair, immunity, and inflammation, and it protects against cellular senescence [28, 29] . in recent years, age-related diseases such as heart disease, neurological diseases, cancer, and diabetes have been found to be closely related to sirt1 [28] , and similarly, sirt1 has garnered considerable attention because of its role in the pathogenesis of asthma [30] [31] [32] . an sirt1-targeted treatment strategy may be effective in patients with virus-induced asthma exacerbation, who respond inadequately to existing therapies. in this review, we discuss the function of sirt1 in inflammatory cells that play a role in virus-induced asthma exacerbations and examine the possibility of using sirt1 as a target for treating virus-induced asthma exacerbations in the future. activation of sirt1 induces sasp in t cells through deacetylation of several transcription factors, such as p53, nf-κb, forkhead box o (foxo)3, pi3k, hif-1α, and pgc1α [32, 33] , regulating autophagy, dna repair, mitochondrial function, and cellular senescence [34] . it was suggested that the mechanism for this was an enhanced glycolysis in helper t cells, which might lead to immune dysfunction [35] . on the other hand, the details of b cells involved in the humoral immune response are not yet well known [36] . in 2003, a screen for mammalian sirt1 activators identified sirt1 activators, including resveratrol, piceatannol, and quercetin, called sirtuin activating compounds (stacs). among them, resveratrol was shown to be the most potent activator of sirt1 [37] . in a clinical trial of sirt1 activators in mild to moderate ulcerative colitis, srt2104, a sirt1 activator, was well tolerated [38] . adverse events of srt2104 was reported to include upper abdominal pain, fatigue, photophobia, diarrhea, and headache [38] . it is considered to be a relatively safe drug to use. on the other hand, selisistat (ex527), a sirt1 inhibitor, has been studied in healthy individuals and patients with huntington's disease, and has also been shown to be safe [39, 40] . the association between sirt inhibitors and respiratory illness is not well reported. based on these previous reports, we will discuss about the impact of sirt1 on virus-induced asthma exacerbations below. neutrophilic inflammation occurs in the airway during virus-induced asthma exacerbation. cxcl8 is a crucial cytokine of the neutrophilic airway inflammatory process, which is also involved in virus-induced asthma exacerbation [41] . hrv infection increases cxcl8 and il-1β levels in the nasal lavage fluid of patients with asthma [42] . smoking is an important factor in the worsening of the disease in asthmatic patients. stimulating human airway epithelial cells with hrv infection and cigarette smoking extract (cse) enhances cxcl8 expression [43] . increased production of cxcl8 is one of the mechanisms of corticosteroid resistance [44, 45] . the antimicrobial drug azithromycin may be effective in asthmatics with a predominance of cxcl-8 and other neutrophilic cytokines [46, 47] . in a clinical trial of children with rsv-infected bronchitis, azithromycin significantly reduced the expression of cxcl8 in nasal lavage and reduced respiratory symptoms one-year post-use compared to a placebo [46] . azithromycin may exert its effects by inducing ifn-β and ifn2/3, but the clinical benefits of using antimicrobials, including azithromycin, in patients with asthma are still unclear [48, 49] . mmp-9, a type of matrix metalloprotease, has been found to be increased during viral infections [50] . mmp-9 also causes airway remodeling through neutrophilic airway inflammation [50, 51] . airway remodeling is associated with decreased respiratory function and disease severity [52] . despite the fact that both cxcl8 and mmp-9 are important factors associated with neutrophilic airway inflammation, there are few therapeutic agents for these factors involved in neutrophilic airway inflammation. furthermore, it may lead to severe virus-induced asthma, and effective treatment strategies are needed. several reports suggest that sirt1 regulates neutrophilic airway inflammation related to cxcl8 [53] [54] [55] [56] . cse-induced cxcl8 elevation in mature mononuclear cells was attenuated by the overexpression of sirt1 in vitro [55] . these studies showed that activation of nf-κb signaling and deacetylation of foxo 3a protein as mechanisms by which sirt1 regulates neutrophilic airway inflammation [55] . a previous study confirmed that foxo3a expression was upregulated by rsv infection [57] . thus, sirt1 activators, including resveratrol, may be effective in targeting cxcl8-induced neutrophilic airway inflammation in virus-induced and steroid-resistant asthma exacerbations [58, 59] . interestingly, in basic experiments with macrophages isolated from bronchoalveolar lavages of copd patients, resveratrol inhibited the release of nearly all cytokines from alveolar macrophages. in contrast, dexamethasone, a type of systemic corticosteroid commonly used in the treatment of asthma exacerbations, only partially inhibited the release of cxcl8 [60] . these lines of evidence suggest that activation of sirt1 may lead to suppression of neutrophilic inflammation, possibly through suppression of cxcl8 and may be an effective therapeutic strategy, especially for steroid-resistant virus-induced asthma exacerbations. suzuki et al. investigated the relationship between viral infections and mmp-9 expression using human nasal epithelial cells [51] . notably, they found that the expression of mmp-9, which was enhanced by poly(i:c), was attenuated by resveratrol. furthermore, in the presence of the sirt1 inhibitor splitomicin, poly(i:c) significantly enhanced the expression of mmp-9 [51] . another study showed that the increased mmp-9 was attenuated by not only the sirt1 activator resveratrol, but also by the diabetes drug metformin in a mouse model exposed to uv light [61] . these results indicated that sirt1 activation could be a novel therapeutic strategy for virus-induced asthma exacerbations by regulating mmp-9 expression and suppressing airway neutrophilic inflammation and remodeling. however, additional studies will be necessary to determine whether mmp-9 is a good biomarker for sirt1-targeted therapy. eosinophils play an essential role in virus-induced asthma exacerbation. ccl5 and ccl11, which are chemokines associated with eosinophils, may be upregulated and recruit eosinophils when a virus infects the airway epithelium [62] . eosinophil cationic protein (ecp), an inflammatory mediator, is released by eosinophils and correlates with airway hyperreactivity [63] . in addition to these, cytokines such as interleukin (il)-4, il-5, and il-13 are thought to be involved in a complex. calhoun et al. investigated whether hrv could trigger an allergic response in the airway [64] since it is a significant viral pathogen that exacerbates asthma in adults and children [65] . bronchoalveolar lavage was performed for both healthy and allergic participants with or without hrv infection, and they concluded that eosinophil recruitment in the airway occurred during or after hrv infection in allergic participants, but not in healthy participants [65] . kato et al. studied childhood asthma and reported that serum il-5 and ecp levels were significantly higher in the virus-induced asthma group than those in the control group [66] . they also showed that the profile of those cytokines and chemokines differed with age [67] . fractional exhaled nitric oxide is a good indicator of eosinophilic airway inflammation [68] . bjerregaard and colleagues reported that feno in virus-induced asthma exacerbation was higher than in the follow-up period [69] . they demonstrated that patients with higher feno levels had significantly shorter time to arrive at asthma exacerbation than those patients with lower feno [69] . activation of toll-like receptor 3 (tlr3), a virus receptor within the airway epithelial cells, led to the induction of eosinophil-attracting chemokines (ccl11, eotaxin) in the cellular bases [18] [19] [20] [21] [22] . these findings suggested that eosinophilic airway inflammation is an important aspect of virus-induced asthma exacerbation. several studies have demonstrated the importance of sirt1 in eosinophilic airway inflammation. wang et al., using an ovalbumin-induced asthma mouse model, found that sirt1 was associated with eosinophilic airway inflammation [70] . while they reported that serum sirt1 levels were increased in ova-sensitized and challenged mice model, sirt1 levels were decreased in lung tissue, and more il-4, il-5, and il-13 in balf were found in the ovalbumin-induced asthma mouse model compared to the controls [70] . they also showed that respiratory function (forced expiratory volume in 1 s/forced vital capacity) was negatively correlated with serum sirt1 in asthmatic human samples [70] . based on these results, they believed that the elevated serum sirt1 levels were due to the release of sirt1 from the tissues following airway inflammation. in another study, sirt1 activator (sirt1720) treatment decreased the eosinophil count and il-5 and il-13 levels, but not il-4 levels in the bronchoalveolar fluid and lung tissue in the ovalbumin-induced asthma mouse model [71] . they also reported that sirt1 activation significantly inhibited inflammatory cell infiltration in the airways, but it did not significantly affect goblet cell hyperplasia, and they attributed this to the possibility that sirt1 activation might be inadequate to control airway inflammation. resveratrol, a known sirt1 activator, also attenuated il-5 and il-13 as well as eosinophil accumulation in ovalbumin-induced allergic rhinitis in mice [72] . this may be attributed to the differential effect of sirt1 on transcription factors, including gata3, which is a transcriptional factor that regulates th2 differentiation and the expression of the t2 cytokines il-4, il-5, and il-13 [73] . sirt1 is a key regulator of gata3 via its deacetylation, and in t-lymphocytes from patients with severe asthma, a decrease in sirt1 has been linked to increased expression of il-4 via increased gata3 activation [73] . these findings supported the fact that sirt1 activation might suppress eosinophilic inflammation in the airway during acute asthma exacerbations. controlling eosinophilic inflammation is a key approach for predicting and treating virus-induced asthma exacerbations [68, 74, 75] . anti-il-5 therapies, such as mepolizumab and benralizumab, are effective against eosinophilic airway inflammation and markedly reduce virus-induced asthma exacerbations [76, 77] . although these biologics produce marked effects in patients with refractory asthma, their efficacy was limited in patients with non-th2-asthma [78, 79] . activation of sirt1 may facilitate control of eosinophilic inflammation and refractory eosinophilic asthma. ige is an important therapeutic target for virus-induced asthma exacerbation, which is mainly produced by plasma cells. the position of omalizumab, which is a humanized anti-ige monoclonal antibody, has been confirmed as an important therapeutic agent [80] . the prose study revealed a lower asthma exacerbation frequency in the omalizumab group than that in the placebo group [81] . in this study, they conducted a subgroup analysis of patients with hrv infection and found a significant increase in ifn-α in the group of patients treated with omalizumab, which may be a protective mechanism for viral-induced asthma exacerbations [81] . another clinical study showed that omalizumab decreased the frequency and duration of hrv infection in patients with childhood asthma [82] . despite the efficacy of omalizumab in patients with asthma with viral infection, it was reported that some patients, especially geriatric patients, responded poorly to anti-ige. this observation may be attributed to immunosenescence, which includes impaired mucociliary clearance, changes within the inflammatory cells in the airway, and decreased antigen response [83] . hence, there is a demand for other treatment options besides anti-ige therapy for patients who are unresponsive to anti-ige therapy. lipid profiling is thought to be important for understanding viral infections [84, 85] . when the virus reacts with airway epithelium, mast cells are activated in an ige-dependent or independent manner, and degranulation occurs [86] . this results in the production of lipid mediators such as prostaglandin (pg) and cysteinyl leukotriene (cyslts), which induce an immediate response in the airways and other target organs [86] . currently, drugs targeting lipid mediators in asthma are mainly the cyslt 1 receptor antagonists pranlukast and montelukast [87, 88] . it is known that obesity, a factor in refractory asthma, results in steroid resistance due to decreased adipokines. although leukotriene receptor antagonists are useful in such patients [89] , they are still not well controlled. a better understanding of the pathogenesis of refractory asthma by further approaches to lipid mediators is an important issue. resveratrol, a polyphenol found in grapes, berries, red wine, and peanuts [90] , can activate sirt1 [91] . lee et al. examined the possible anti-inflammatory effects of resveratrol in an ovalbumin-induced asthma mouse model [92] . resveratrol significantly reduced total ige and ovalbumin-specific ige levels and increased serum igg2a, which is associated with th1 response, in serum [92] . moreover, it reduced airway hyperresponsiveness and mucus hypersecretion compared to a placebo [92] . yet another study found that sirt1 regulated the pathways, amp-activated protein kinase (ampk), and protein tyrosine phosphatase 1b. modulation of these pathways via resveratrol attenuated signals from the ige receptor, fcεri, and inhibited the release of lipid mediators, leukotriene c 4 (ltc 4 ) and pgd2, and the inflammatory cytokines, tumor necrosis factor (tnf)-α and il-6 [93] . in a mouse model of ova-induced allergic rhinitis, sirt1 administration reduced symptoms such as sneezing and nasal rubbing events, and it led to a significant reduction in serum ige [94] . it is known that when ige antibodies bind to the antigen, intracellular secretory granules are transported to the cell surface, and chemicals, such as histamine, contained in the granules are released. previous reports demonstrated that sirt1 inhibited degranulation [95] . the study noted that inhibition of degranulation by sirt1 may be mediated through inhibition of the response mechanisms of the phosphorylation of protein kinase c (pkc) isomer, pkcµ and pkcθ. these data suggested that sirt1 activation may ameliorate ige-mediated airway inflammation in viral-induced asthma exacerbations, whereas the detailed mechanism by which omalizumab blocks ige is unclear and requires further study. some studies on the association between sirt1 and lipid mediators have been reported. tan et al. demonstrated in basic experiments using eosinophils isolated from whole human blood that trans-resveratrol suppressed the expression of ltc 4 [96] . another study showed that resveratrol reduced the expression levels of ltc 4 and pgd in a mouse model of eosinophilic sinusitis [97] . these results might be attributed to inhibition of the phospholipasea2 (pla2) and lipoxygenase (lox) pathways, which play an important role in the arachidonic acid cascade [96, 97] . as mentioned above, sirt1 is closely related to metabolism. it was reported that fisetin and licochalcone, which are polyphenols, improve hepatic lipid metabolism via the sirt1/ampk pathway in a mouse model [98, 99] . in a clinical trial on asthma and diet, a healthier diet correlated with better asthma control [100] . these evidences suggest that drug treatment and diet modification may be one of the lipid mediator-mediated sirt targeted treatment strategies for virus-induced asthma exacerbations. ilcs are a novel type of lymphocyte, which have been recently identified as playing an important role in immune diseases. th2-type cytokines were initially found to be produced solely by th2 cells, but recent findings show that ilc2 cells, although less numerous than th2 cells, are more efficient in producing th2-type cytokines [101] . moreover, ilc2 has been shown to play an essential role in virus-induced asthma [102, 103] . studies have confirmed that the expression of the upstream cytokines il-25, il-33, and tslp that regulate ilc2 is enhanced in rhinovirus infections [104] [105] [106] [107] . current knowledge suggests that airway epithelial damage triggered by viral infections promotes the production of il-25, il-33, and thymic stromal lymphopoietin (tslp), which in turn leads to the activation of ilc2 and exacerbation of asthma [102] . we showed that the late addition of budesonide attenuates the increase in tslp caused by viral infection [19] . although tezepermab, a biologic that targets tslp for treatment, was reported to reduce the frequency of asthma exacerbations [108] , the role of ilcs2, including il25 and il-33, is not fully understood, and we need to elucidate the full mechanism of its production and develop new treatment options. little is currently known about the association between airway inflammation, sirt1, and ilc2. basic experiments using mouse models of allergic diseases demonstrated that resveratrol inhibited the expression of il-25, il-33, and tslp in airway epithelial cells [109] . resveratrol also reduces caspase-3, an indicator of apoptosis [109] . in basic experiments using a mouse model of hdm-induced asthma, resveratrol reduced cell apoptosis and suppressed the expression of the γh2ax gene, which is associated with dna damage [110] . activation of sirt1 suppresses epithelial damage, which may inhibit apoptosis and control viral-induced asthma exacerbations. leptin is one of the adipokines secreted by adipocytes and is involved in increased energy metabolism and appetite suppression via hypothalamic receptors [111] . an increase in sirt1 led to an increase in the sensitivity of leptin [111] . it was suggested that elevated leptin could cause exacerbation of allergic diseases via ilc2 [112, 113] . zeng et al. tested the relationship between leptin and ilc2 in patients with allergic rhinitis [113] . the results showed that leptin expression correlated with the percentage of ilc2 in peripheral blood mononuclear cells. mapk signaling and pi3k signaling were thought to be the possible pathways involved in this response [112, 113] . it was reported that sirt1 was inhibited by p38 mapk and pi3k signaling via micro-rna (mirna) 34-a and mirna570 expression, if the airway epithelial cells were subjected to oxidative stress [114, 115] . the possible mechanisms by which sirt1 regulates allergic airway inflammation through ilc2, such as cellular apoptosis and lipid metabolic pathways, as well as the presence of mirnas, require further investigation. th17 cells also play an important part in virus-induced asthma, mediated by the role of il-17 family cytokines [116] [117] [118] . in basic experiments in which an ova mouse model was infected with rsv, il-17a regulated the airway hyperreactivity [116] . niwa et al. demonstrated in vitro experiments using normal human bronchial epithelium that the increase in ifn-λ, which plays a protective role in viral infection, was attenuated by the presence of il-17a [118] . increased il-17 is thought to be one of the mechanisms of steroid resistance in asthmatic patients [118] , and il-17 may be a novel therapeutic target for patients with viral-induced asthma who are refractory to treatment. il-6 and transforming growth factor (tgf)-β are required for th17 differentiation. viral infection, including hrv infection, increases il-6 levels in the respiratory tract [119, 120] , which correlates with airway remodeling and the severity of asthma [121, 122] . at present, the anti-il-6 antibody tocilizumab, which is used to treat rheumatoid arthritis, is not indicated for asthma, but basic experiments suggested that il-6 may be an important marker of asthma [123, 124] . tgf-β is an essential factor affecting airway remodeling along with mmp-9, amphiregulin, vascular endothelial growth factor (vegf), and fibroblast growth factor (fgf) [125] . repeated rv infection in mice not sensitized to allergens activated tgf-β in lung tissue, but neutralizing tgf-β reduced airway smooth muscle thickening [125] . tgf-β-deficient mice showed an earlier increase in ifn-β in lung tissue compared to that in controls [126] . collectively, tgf-β was found to contribute strongly to remodeling during virus-induced asthma exacerbations. one therapeutic candidate targeting th17 cells is brodalumab, a monoclonal antibody against the il-17 receptor, which has failed to show efficacy in the clinical trial [127] . further elucidation of their mechanisms and development of therapeutic agents are required to control the pathogenesis of virus-induced asthma exacerbations. it was reported that loss of sirt1 further induced mrna expression of il-17 in an animal model of rsv infection [128] . according to their considerations, sirt1-deficient bone marrow dendritic cells elevated acetyl coa carboxylase 1 (acc1), which is associated with fatty acid synthesis, resulting in the activation of an abnormal metabolic process, which in turn preceded an excessive virus-induced immune response [128] . in other words, sirt1 may regulate the th17 immune response from virus-infected dendritic cells by regulating their metabolic pathways [128] . the relationship between sirt1 and il-17 has been well studied in other diseases. previous studies investigated the effect of sirt1 activation in patients with psoriasis [129, 130] . they found a significant histological improvement in the sirt activator group compared to that in the placebo group, which was attributed to the inhibition of il-17 and tnf-α [129] . moreover, resveratrol, a sirt1 activator, suppressed the expression of ccl6, a chemokine that is essential chemokine for the production of il-17 [130] . the involvement of th17 cells was demonstrated in patients with diabetic ophthalmopathy [130, 131] . other studies reported that the sirt1 activator might inhibit the elevation in serum il-17 levels, and regulation of il-17 through sirt1 probably leads to a reduction in the development of diabetic ophthalmopathy [132] . by applying the proven relationship between sirt1 and il-17 in these other diseases to viral-induced asthma, sirt1 could become a new therapeutic target in the future. sirt1 regulated il-6 expression in the ovalbumin-induced asthma mouse model [17, 133, 134] . these studies confirmed that the activation of the pi3k-akt pathway led to an increase in il-6, and this response was attenuated by sirt1 inhibitors [133, 134] . ichikawa et al. showed that a sirt1 activator suppressed il-6 and tnf-α production by splenocytes in ovalbumin-challenged mice [17] . these indicate that the akt-sirt1 signaling is a crucial pathway to the control of il-6. interestingly, another study reported that metformin, a pharmacotherapeutic agent used to treat diabetes, reduced il-6, il-17, il-1β, and tnf-α levels in a mouse model of acute respiratory distress syndrome [135] . one possibility was that the low expression of mirna138 might suppress the mitogen-activated protein kinase (mapk) pathway upstream of sirt1 [135] . moreover, metformin, like resveratrol, was reported to inhibit hif-1α expression, but through a different pathway [136] . in clinical practice, oral metformin reduced asthma-related hospitalizations and asthma exacerbations [137] . metformin may be one of the treatment options in patients with virus-induced asthma exacerbations by regulating th17 cells. the relationship between sirt1 and tgf-β has often been studied in idiopathic pulmonary fibrosis (ipf). zeng et al. used a bleomycin-induced mouse model to explore the role of sirt1 in pulmonary fibrosis [138] . they demonstrated that activation of sirt1 by resveratrol and srt1720 inhibited myofibroblast differentiation induced by tgf-β1. overexpression of sirt6, a member of the sirt family, reduced e-cadherin, a marker of emt, through the tgf-β pathway [139] . this result might involve p21, a protein that regulates cell cycle progression [140] . another study showed that resveratrol inhibits airway remodeling through transforming growth factor (tgf)-β1/smad signaling [141] . the relationship between sirt1 and tgf-β, which was identified in ipf, has potential applications in virus-induced asthma exacerbations, but the mechanisms of this relationship are still unclear. therefore, the findings of these studies suggest that future treatments against cellular senescence, especially sirt1, may regulate th17 airway inflammation. we believe that metformin is an attractive treatment option because it is already used in many patients with few adverse events, but further research is needed to determine whether it is useful in patients with virus-induced asthma exacerbations who do not have diabetes mellitus. protein acetylation plays a crucial role in host response to viral infection. histone deacetylases (hdac) are enzymes that define chromatin structure and are closely associated with chronic respiratory diseases [142] . adenovirus infection resulted in reduced activation of hdac in ova sensitization mice [143] . experiments using human blood samples also showed reduced activation of hdac in asthmatics compared to that in healthy subjects [144] . nf-e2-related factor2 (nrf2) is a transcription factor that has a protective effect on cells from oxidative stress caused by reactive oxygen species. rsv, which frequently causes asthma exacerbations, induces deacetylation of nrf2 [145] . in vitro models of rhinovirus infection showed that inhibition of s-nitrosoglutathione reductase was reported to increase sqstm1, an nrf2-dependent gene, and suppress viral growth, with an effect on airway hypersensitivity [146] . although these viral proteins are important factors in the pathogenesis of virus-induced asthma exacerbations, there remain unanswered questions concerning established treatment. theophylline, a drug for asthma and copd, activates hdac and exerts an anti-inflammatory effect. when the activity of hdac was investigated in lps-stimulated macrophages, hdacs were activated by the combination of theophylline compared to dexamethasone alone [147] . in a clinical trial examining the effects of low volume theophylline, the addition of theophylline to inhaled steroids improved respiratory function [148] . in patients with acute exacerbations of copd, theophylline also improved hdac activity during the stable phase [149] . interestingly, steroid resistance correlated with a decrease in sirt, and a combination of steroid, theophylline, curcumin, or resveratrol treatment resulted in an increase in sirt1 as well as an increase in glucocorticoid receptors [150] . doxophylline, which is considered to have fewer side effects than conventional theophylline preparations, improved the protein expression of sirt1, which was reduced by lps stimulation [151] . as a treatment option for targeting sirt1, theophylline is very effective for patients with inadequate response to steroids. sirt1 regulates the expression of various genes by deacetylating histones and transcription factors, such as nf-kb, stat1, and stat3 [152] [153] [154] [155] . sirt1 deacetylates induced nf-kb activation in monocytes [152] . sirt1 inhibits growth hormone-stimulated stat3 activation in mouse embryonic cells via the deacetylation of stat3 [153] . treatment with sirt1 agonists deacetylates stat3, which inhibits t-cell differentiation into th7 and th17 cells [154] . a recent study reported that the activation of sirt1 by viral infection further affected stat1 activation [155] . these studies indicated that transcription factors, including stat1 and stat3, may be potential biomarkers in virus-induced asthma with sirt1-targeted therapy. sirt1 also regulates antioxidant genes, which are important antiaging genes, via deacetylation of foxo3 and nrf2. resveratrol increased the expression of nrf2 in obese rat models and paraquat-induced lung injury mouse models [156, 157] . apios americana medikus is an edible tuberous legume native to eastern north america. chu and colleagues showed that apios americana medikus leaf extract increased the expression of nrf2 in mouse macrophages stimulated with lps [158] . at present, there is no specific treatment for nrf2, and further studies are needed. roflumilast, a selective inhibitor of phosphodiesterase 4 (pde4), was reported to reduce exacerbations and hospitalization rates as a treatment for copd [159] . roflumilast is highlighted by the fact that it increased the sirt1 expression along with nrf2 expression in copd patients [160] . in vitro, rsv infection increased the nrf2 expression and its increase was attenuated by roflumilast [161] . the proinflammatory cytokines il-6, il-8, and tnf-α were also reduced in a capacity-dependent manner. these results suggest that nrf2 may be a potential therapeutic target for viral asthma exacerbations. middle east respiratory syndrome coronavirus (mers-cov) pp1ab protein is potentially regulated by sirt1 [162] . sars-cov-2 might have a similar motif, but further study is required. sirt1 and other sirtuins were also reported to have antiviral roles against several dna and rna viruses, including hcmv, hsv-1, adenovirus, and influenza a [163] . although resveratrol was found to inhibit hrv replication in nasal epithelial cells [164] , it is unclear whether this is due to intercellular adhesion molecule-1 (icam-1) as the hrv receptor, or reduction or deacetylation on potential viral protein acetylation, as the acetylation of hrv or rsv proteins remains unclear. caspase 3 cleavage levels, indicators of apoptosis, are known to elevate in mers-cov infection [165] , and resveratrol was found to reduce caspase 3 cleavage levels with less cytotoxicity [166] . activation of sirt1 may reduce apoptosis through deacetylation of viral proteins. in another report using airway epithelial cells, kim and colleagues examined the relationship between cellular senescence and the replication efficiency of influenza virus [167] . senescent cells infected with influenza virus had reduced expression of ifn-β, which plays an essential role in the immune response compared to nonsenescent cells. they also examined whether sirt1, an essential factor in cellular senescence, affected viral replication. interestingly, sirt1-knockdown cells showed enhanced expression of proteins associated with influenza virus and reduced cell viability [167] . collectively, with further research, therapies targeting sirt1 may control asthma exacerbations through acetylation of the viral protein. we reviewed the cellular interactions between sirt1 and inflammatory cells involved in virus-induced asthma exacerbations (table 1 ). viral infection is a common health problem for children and adults with asthma. especially with the recent rampant covid-19 pandemic, treating and preventing viral infections is becoming an area of focus. while the role of various respiratory viruses in inducing the exacerbation of asthma is well established, the pathophysiological mechanisms underlying virus-induced asthma exacerbation and its treatment remain controversial. existing drugs such as ics and biologics are among the best treatment options for asthma exacerbation triggered by viral infection, but they may be partially ineffective due to unknown 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authors: yang, xiaoyu; huang, junjun; hu, yan; guo, cuiyan; wang, xi; yang, zhao; zhou, tianyu; wang, guangfa title: the rescue intervention strategy for asthma patients under severe air pollution: a protocol for a single-centre prospective randomized controlled trial date: 2020-11-04 journal: trials doi: 10.1186/s13063-020-04830-0 sha: doc_id: 288344 cord_uid: 8dar2p3j background: asthma is a common chronic airway inflammatory disease. exacerbations of asthma not only accelerate the progression of the disease but also increase the incidence of hospitalization and death. studies have shown that air pollution is a high-risk factor for asthma exacerbations. however, few treatment strategies have been recommended to reduce the risk of severe air pollution-related asthma exacerbations. methods/design: this is a single-centre, prospective, randomized and standard treatment parallel control clinical trial. seventy-two asthma patients in the nonexacerbation stage according to gina guidelines 2017 will be recruited and randomized into the rescue intervention strategy (ris) group and control group. original treatments for the participants will include no use of inhaled medicine, the use of short-acting β-agonists (saba) on demand or the use of budesonide/formoterol (160 μg/4.5 μg/dose, 1–2 dose/time, b.i.d.). the rescue intervention strategy for the ris group will be budesonide/formoterol plus the original treatment until the severe pollution ends (air quality index, aqi < 200). the control group will maintain the original treatment. the follow-up observation period will last 1 year. the primary outcome is the frequency of asthma exacerbations per year. secondary outcomes include the mean number of unplanned outpatient visits, emergency visits, hospitalizations, medical costs and mortality caused by asthma exacerbations per patient per year. discussion: the results of this trial will provide a novel strategy to guide clinical practice in decreasing the risk of asthma exacerbations under severe air pollution. trial registration: chictr chictr1900026757. registered on 20 october 2019—retrospectively registered recently, increasing attention has been drawn to air pollution and its serious consequences, especially in china and other developing countries. the evidence has demonstrated that air pollution could cause critical public health problems. a retrospective study of 80,515 deaths in beijing during 2004-2008 found that the reduction in life expectancy was associated with increased air pollution. more specifically, an interquartile range increase in particulate matter with aerodynamic diameter < 2.5 μm (pm 2.5 ), pm 10 , so 2 and no 2 was associated with 15.8, 15.8, 16.2 and 15.1 years of life lost, respectively [1] . asthma is a common chronic airway inflammatory disease, with more than 45 million adults suffering from asthma in china [2] . exacerbations of asthma not only accelerate the progression of the disease but also increase the incidence of hospitalization and death. it has already been proven that air pollution can cause asthma exacerbations [3] . unfortunately, few treatment strategies have been recommended to reduce severe air pollution-related asthma exacerbations. inhaled corticosteroids (ics)/long-acting β-agonists (laba) with single maintenance and relief therapy (smart) are well known for significantly reducing asthma exacerbations [4] . however, only when patients have symptoms will smart be applied, meaning that the airways have already been damaged by atmospheric pollutants and the subsequent inflammatory response. some treatments with ics/laba (such as budesonide/formoterol) might stop these inflammatory responses with rapid action [5] . therefore, we hypothesize that the rescue intervention strategy of budesonide/formoterol plus original treatments under severe pollution may reduce the risk of asthma exacerbations caused by air pollution before patients have symptoms. we will undergo a 1.5-year single-centre prospective randomized controlled clinical trial to compare the frequency of asthma exacerbations per year and asthma exacerbation-related visits, hospitalizations, mortality, medical costs etc. between the rescue intervention strategy (ris) group and the control group. this study is a single-centre, prospective, randomized and standard treatment parallel control clinical trial (see fig. 1 ). we followed the standardized programme intervention: standard protocol item recommendations for interventional trials (spirit) 2013. we followed similar methods of zhou et al. 2019 [6] , especially in the 'intervention' and 'outcomes' sections. patients who meet the inclusion criteria (details are shown in the 'inclusion criteria' section) and do not meet the exclusion criteria (details are shown in the 'exclusion criteria' section) will be recruited from peking university first hospital. advertising strategies such as posters, social media and popular community websites will be used to increase recruitment. when screening, the purposes, procedures, potential benefits and risks of the study will be explained carefully by the investigators. after explaining the trial, the investigators will answer any questions that the participants may have about the study. participants will then make the final decision on whether to participate and sign the informed consent form. then, written informed consent will be obtained, and each participant visit will be overseen by a trained clinician. at the baseline visit (v0), basic data will be collected, including sex, age, education, income, type of medical insurance, workplace/home addresses, the air pollution monitoring station for the study (which is defined as the nearest air pollution monitoring station from the workplace for employees or from home for nonemployees), medical/surgical history, suspected allergen contact history (such as pets), therapeutic scheme for asthma and any exacerbations experienced within the past 3 months. physical examinations will also be performed (height, weight, body mass index (bmi), heart rate and blood pressure), along with the chinese version of asthma assessment scales, which have shown good validity [7] (the mini asthma quality of life questionnaire 7 (mini-aqlq 7), the numerical control questionnaire (acq) and asthma control test (act)), lung function testing (bronchodilator reversibility test) and fraction of exhaled nitric oxide (feno) measurement, which will be interpreted with the use of cut points. several interventions, such as no use of inhaled medication, the use of saba on demand or the use of budesonide/formoterol (160 μg/4.5 μg/dose, 1-2 dose/time, b.i.d.), are acceptable as the original treatment in our study. participants receiving other treatments must enter a washout period (see table 1 ). thereafter, they will be fig. 1 the study design flowchart (*ris group, rescue intervention strategy group) randomly divided into two groups: the ris group and the control group. exacerbation situations within the past 3 months, physical examinations, asthma assessment scales, lung function tests (bronchodilator reversibility tests) and feno measurements will be repeated on the randomization day (v1). when the air quality index (aqi) reported by the air pollution monitoring station for the study is no less than 200, participants in the ris group will receive budesonide/formoterol (160 μg/4.5 μg/dose, 1 dose/time, b.i.d.) plus original treatments until the end of severe pollution (aqi < 200). at the same time, participants in the control group will continue to receive the original treatment. participants will visit peking university first hospital every 3 months and will be followed up for 1 year (v2-v5). at each visit, exacerbations within the past 3 months, physical examinations, asthma assessment scales and lung function tests (bronchodilator reversibility tests) will be repeated. feno measurements will be repeated only at the final visit (v5). the inclusion criteria were as follows: (1) age between 18 and 80 years old (male or female), (2) asthma patients at the nonexacerbation stage (according to gina guidelines 2017), (3) smoking cessation for more than or equal to 6 months or no smoking history, (4) no restrictions in performing daily activities, (5) a resident of beijing (employees should make sure that there are air pollution monitoring stations within 5 km of their workplace, and nonemployees should make sure that there are air pollution monitoring stations within 5 km of their home), (6) a smartphone available at their disposal, (7) willing to provide written informed consent and (8) willing to follow the research programme. the exclusion criteria were as follows: (1) diagnosis of another chronic respiratory diseases, such as chronic obstructive pulmonary disease, lung cancer, tuberculosis, bronchiectasis and diffuse lung disease (interstitial pneumonia, occupational lung disease, sarcoidosis etc.); (2) a history of lobectomy, lung transplantation or pleural disease; (3) severe underlying disease (including severe psychiatric disorders, dysgnosia, nervous system disease, other malignant tumour, chronic liver disease, heart failure, autoimmune disease and chronic kidney disease); (4) life expectancy of less than 3 years; (5) no participation in outdoor activities; (6) expecting to move out of beijing within 2 years; (7) planning to decorate home or workplace during the research period; (8) alcohol or substance abuse; (9) allergy history or other contraindication against the medicine used in this trial; (10) participating in other clinical trials; (11) poor compliance; (12) unwilling to provide written informed consent; (13) diagnosis of osteoporosis or diabetes due to the risk of adverse effects related to the use of budesonide/formoterol; and (14) cigarette smoking more than or equal to 10 pack-years. to estimate compliance before the start of the study, investigators will describe the process of our study in detail and emphasize the long-term follow-up when screening. patients will answer three questions with 'yes' or 'no'. the questions are 'over the past two weeks, were there any days when you forgot to take your asthma medicine?', 'taking medication every day is a real inconvenience for some people. do you ever feel hassled about sticking to your asthma treatment plan?' and 'do you have difficulty remembering to take all your asthma medication?'. if the answers are all 'yes', the patient's compliance will be assessed as poor. block randomization will be used to generate random codes. the random codes will be designed in a 1:1 ratio (ris group or control group) using the sas 9.2 software package (sas institute, cary, nc). a researcher who is not participating in this study will generate random codes and make random grouping envelopes based on the generated results. the envelopes will be sealed and handed to the researcher responsible for grouping. after screening, participants will be identified by subject numbers according to the sequence in which they enter this trial. when grouping, the envelope with the corresponding number for the subject number of the participant for 4 weeks saba short-acting β-agonists, laba long-acting β-agonists, ics inhaled corticosteroids will be opened. the participant will be assigned to the ris group or the control group according to the randomization result in the envelope. the randomization result will be just told to the participant and researchers responsible for grouping and intervention, then it will be resealed in the same envelope until the end of the study. after randomization and grouping, all participants will be asked to add wechat (a popular social app provided by tencent company, china) friends with the intervention clinician. the communications between participants and the intervention clinician will be mainly through the wechat app. the data in this app will be saved and backed up. the real-time aqi will be collected from the beijing air pollution app (provided by the beijing municipal environmental monitoring center, china). the intervention clinician will send the real-time aqi from the air pollution monitoring station for the study to each participant via wechat between 9 am and 10 am every day. when the aqi is no less than 200, the intervention clinician will ask the participants in the ris group to take budesonide/formoterol (160 μg/4.5 μg/dose, 1 dose/ time, b.i.d.) plus the original treatment until severe pollution ends (aqi < 200), as indicated by wechat. these participants will reply to the intervention message as a confirmation via wechat. at the same time, the control group will be asked to focus on protective strategies (avoid outdoor activities, for example) and maintain their original treatments. the follow-up observation period will last 1 year. daily aqi and whether the intervention is successfully accomplished during every intervention period will be recorded by wechat, and investigators will have a backup copy of these data. when participants need to visit the hospital to receive medicine for asthma or due to respiratory symptoms, they will be asked to visit with the intervention clinician. then, the intervention clinician will assign a clinician from our study who is working at peking university first hospital that day to provide medical services to the participants. medical records will be completed and saved in the medical record system of peking university first hospital. the completed medical records will be printed immediately to preserve the data. if the participants visit another hospital for an emergency, the medical records of this visited hospital will be photographed or scanned by the intervention clinician to preserve the data. participants will be requested to visit peking university first hospital every 3 months for 1 year (v2-v5). at each visit, exacerbations within the past 3 months, physical examinations, asthma assessment scales and lung function tests (bronchodilator reversibility tests) will be repeated. feno measurement will be repeated only at the final visit (v5). exacerbation situations will include moderate exacerbations (which are defined as the use of relief therapy for more than 2 days) and severe exacerbations (which are defined as the occurrence of unplanned outpatient visits, emergency visits and hospitalizations). the exacerbation situation will be verified by medical records from peking university first hospital and other hospitals. all these visits (v0-v5) and data will be recorded in the case report form (crf). details of the follow-up visits are shown in table 2 . the crf is designed by the study staff. double data entry and periodic auditing will improve data quality and integrity. personal information and related documents of all participants will be kept strictly confidential. every participant will be identified by a subject number and a name acronym in the crf. all researchers taking part in this clinical study will receive systemic training before patient enrolment. throughout the study, the researchers responsible for the interventions and for randomization and grouping will be separated from the other researchers. as a result, the others (who will be responsible for providing medical service and measuring asthma assessment scales, for example) will be blinded to the study grouping. data analysts will also be blinded. the data will be labelled 'group a' or 'group b' when data analysis is performed. the primary outcome is the frequency of asthma exacerbations per year, which is defined as the mean number of asthma exacerbations per patient per year at the end of the 1-year follow-up period. asthma exacerbation situations include moderate exacerbations (defined as the use of relief therapy for more than 2 days) and severe exacerbations (defined as the occurrence of unplanned outpatient visits, emergency visits and hospitalizations). the secondary outcomes include the mean number of unplanned outpatient visits, emergency visits, hospitalizations, medical costs and mortality caused by asthma exacerbations per patient per year at the end of the 1year follow-up period. adverse events are unforeseeable and unfortunate events that occur during a study, either occurring with or without the intervention. although the medicine used in our study is within the recommended dosage, adverse events may still occur during daily use. nonsystematically via spontaneous self-report will be used to collect adverse events. all adverse events will be carefully monitored, managed and tracked in a timely manner until they are properly resolved, stabilized or returned to normal. the occurrence of adverse events will be recorded from the beginning to the end of the study. there will be supervisors who come from the administrators of peking university first hospital. all adverse events will be reported to these supervisors. if there are any severe adverse events, they will be reported immediately to the peking university first hospital institutional review board (irb). severe adverse events will be analysed every 3 months during the study by supervisors and the irb. if there is a definite benefit (p < 0.01) or an obvious disadvantage (p ≤ 0.05), the study will be stopped after the discussion of the centre and the approval of the ethics committee. according to a previous study, every increase in pm 2.5 of 10 μg/m 3 increased asthma-related outpatient visits by 0.65% and emergency visits by 0.49% in beijing [8] . every increase in pm 10 of 10 μg/m 3 increased the incidence of asthma exacerbations by 3-6% [9] . the beijing environmental statement published in 2016 by the beijing environmental protection agency showed that the monthly mean concentration grew from approximately 70 to 150 μg/ m 3 of pm 10 and 52 to 150 μg/m 3 of pm 2.5 [10] . this means that the risk of asthma exacerbations increases by at least 30% as air pollution changes. assuming an exacerbation frequency rate ratio (rr) of 0.85 in the ris group compared to the control group, a total of 60 subjects (30 in each group) are required to detect a 75% reduction in air pollution-related exacerbation at 90% power with a two-sided significance level of 0.05. we recruited a total of 72 subjects considering a dropout rate of 20%. statistical analysis will be carried out using spss 14.0 software (international business machines corp., new york, usa). all statistical analyses will be performed by the two-sided test. p values < 0.05 will be considered statistically significant (unless otherwise specified). the poisson regression model will be used to calculate the 95% confidence interval and the rr of exacerbation frequency. numeric variables will be presented as the mean (standard deviation) or median (minimum, maximum; or interquartile range), and categorical variables will be presented as the number of cases (percentage). the data will be analysed by the independent sample t test, the wilcoxon rank sum test, the chi-square test, the continuity corrected chi-square test or fisher's exact test. the characteristics of the baseline will be summarized by the equilibrium test. unplanned outpatient visits, emergency visits, hospitalizations, medical costs and mortality caused by asthma exacerbations per year will be compared between the two groups. we have no imputation plans for missing data. the population of intention-to-treat analysis is defined as participants who have completed randomization. the population of perprotocol analysis is defined as participants who have strictly observed the intervention protocol and completed the follow-up. the population of safe set analysis is defined as participants who have completed randomization. we have no plans to conduct a modified intention-to-treat analysis. this study proposes a rescue intervention strategy for asthma patients under severe air pollution. this singlecentre, prospective, randomized and standard treatment parallel control clinical trial aimed to determine whether the rescue intervention strategy will reduce the risk of air pollution-related asthma exacerbations. ics and laba are highly recommended by gina for asthma patients [11] . ics is regarded as the most important and effective drug for asthma control, although a high dose of ics may increase the risk of pneumonia. compared with salmeterol/fluticasone, a recent study showed that budesonide/formoterol had a lower risk of adverse events [12] . jenkins et al. demonstrated that high-dose budesonide/formoterol (1280 μg/36 μg/day) was effective and well tolerated in asthma patients [13] . in our study, the rescue intervention strategy used is budesonide/formoterol (160 μg/4.5 μg/dose, 1 dose/time, b.i.d.) plus the original treatment until severe pollution ends (aqi < 200). the maximal dosage of budesonide/ formoterol per day in our study is less than the dosage used in jenkins' research. budesonide/formoterol shows rapid-acting effects in asthma and can be used in single inhalers for maintenance and relief therapy [14] . the smart study reported that receiving budesonide/formoterol might significantly reduce the risk of asthma exacerbations [4] . as a result, budesonide/formoterol is believed to be an ideal rescue intervention drug and might be safe as an addition to the original treatment. to decrease the effects of different inhaled drugs, the original treatment for the participants in our study will be selected from the following: no use of inhaled medication, the use of saba on demand or the use of budesonide/formoterol (160 μg/4.5 μg/dose, 1-2 dose/time, b.i.d.). in our study, the rescue intervention strategy is to be administered until the end of severe pollution (aqi < 200). however, an aqi of 151-200 is moderate air pollution, and an aqi of 101-150 is slight air pollution. in 2018, the number of days with an aqi ≥ 100 was 138 days (37.8%), and the number of days with an aqi ≥ 200 was 15 days (4.1%) in beijing [15] . if we take the aqi as < 100, there will be more than 100 intervention days. a recent study suggested a possible association between respiratory tract infection and the use of ics in asthma patients [16] . as a result, the strategy we used will decrease the dosage of ics to reduce the infection risk. the article by zhou et al. 2019 [6] is a protocol for a chronic obstructive pulmonary disease (copd)-associated study that is being led by our department (department of respiratory and critical care medicine, peking university first hospital). these two studies share some of the same research members, such as guangfa wang and tianyu zhou. however, the assessment scales, therapeutic replacement schemes for the washout period, inclusion and exclusion criteria, randomization, grouping etc. are suitable for asthma and single-centre studies but not for copd and multicentre studies. moreover, there are several differences between these two studies in terms of the intervention used. first, our study uses real-time aqi instead of 24-h mean aqi, and the rescue intervention strategy of our study will be performed until the end of severe pollution (aqi < 200) instead of the third day after the end. the heart study found that air pollution led to a delayed inflammatory burst in the lung that lasted almost 3 days, and airway inflammation in copd patients worsened after exposure to severe air pollution [17] [18] [19] . nevertheless, our study uses real-time aqi, and the intervention programme may be started within the first few hours of when severe air pollution begins. this strategy might stop the inflammatory responses in an early stage to protect airways against damage from atmospheric pollutants. moreover, a possible association between respiratory tract infection and the use of ics in asthma patients has been reported [16] . our strategy will decrease the dosage of ics to reduce the risk of respiratory infection. second, communication between the participants and intervention researchers will mainly occur through wechat. wechat is the most popular social app in china [20] . the use of wechat is both customary (to improve the compliance of participants) and objective (to ensure the authenticity of the data). the limitations of our study are as follows. first, the study does not follow a double-blind design because participants in the control group will not be administered a placebo. to decrease the potential bias, there are independent groups of researchers responsible for the intervention and for randomization and grouping. the other researchers (who are responsible for providing medical service and measuring asthma assessment scales at the follow-up visits, for example) will be blinded to the grouping results. second, the study was not a multicentre design and was performed only in beijing. thus, selection bias cannot be avoided. this is a single-centre, prospective, randomized and standard treatment parallel control study aimed at decreasing the risk of asthma exacerbations under severe air pollution with a novel rescue intervention strategy. this document is based on version 1.2 (11 november 2018) of the study protocol. the recruitment has finished (from 1 january 2019 to 30 june 2019), and the trial is currently at the stage of participant follow-up visits and data collection (from 1 january 2019 to 30 june 2020). the burden of air pollution on years of life lost in beijing, china, 2004-08: retrospective regression analysis of daily deaths prevalence, risk factors, and management of asthma in china: a national cross-sectional study association between air pollution and asthma exacerbations in badalona association of inhale corticosteroids and long-acting β-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma a systematic review and meta-analysis understanding how long-acting β2-adrenoceptor agonists enhance the clinical efficacy of inhaled corticosteroids in asthmaan update a prospective study of salvational intervention with ics/laba for reducing chronic obstructive pulmonary disease exacerbation under severe air pollution (sircap) in beijing: protocol of a multi-center randomized controlled trial validity of a chinese version of the mini asthma quality of life questionnaire (miniaqlq) and a comparison of completion by patients and relatives fine particulate air pollution and hospital visits for asthma in beijing short-term effects of pm 10 and no2 on respiratory health among children with asthma or asthma-like symptoms: a systematic review and meta-analysis beijing environmental statement global initiative for asthma. from the global strategy for asthma management and prevention (gina pneumonia and pneumonia related mortality in patients with copd treated with fixed combinations of inhaled corticosteroid and long acting beta2 agonist: observational matched cohort study (pathos) efficacy and safety of high-dose budesonide/formoterol (symbicort) compared with budesonide administered either concomitantly with formoterol or alone in patients with persistent symptomatic asthma single-inhaler combination therapy for maintenance and relief of asthma: a new strategy in disease management ambient air quality of beijing in december inhaled corticosteroids and risk of upper respiratory tract infection in patients with asthma: a meta-analysis inflammatory and oxidative stress responses of healthy young adults to changes in air quality during the beijing olympics association between exposure to ambient particulate matter and chronic obstructive pulmonary disease: results from a cross-sectional study in china copd exacerbations: defining their cause and prevention development report on china's wechat in publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions xy is a joint first author. jh obtained funding. gw and jh are the joint corresponding authors. gw and jh conceived and designed the study. jh, xy, yh and tz drafted the protocol. jh, xy and yh collected the data. jh, xy, cg and xw were responsible for data management and performed the statistical analysis. zy was responsible for administrative management. all authors read and approved the final manuscript and are responsible for their contributions. this study is supported by grant 2018cr02 from the youth clinical research project of peking university first hospital. the funding bodies do not participate in the design of the study or in the collection, analysis and interpretation of data. in addition, the funding bodies do not participate in writing the manuscript. data sharing is not applicable to this article, as no datasets were generated or analysed during the current study. when the trial is completed, we plan to publish the results in a peer-reviewed journal article. the data from the trial will be available by request with privacy protection (contact with junjun huang, jaglpc@126.com). the first version of the study protocol was approved by the peking university first hospital institutional review board (irb) (2018[268]) in december of 2018. any protocol modifications will be submitted for the irb review and approval. to reduce the risk of infected covid-19, the follow-up visits were changed to online visits by wechat during the pandemic period. for each online visit, data regarding any exacerbations experienced during the past 3 months will still be collected, and the asthma assessment scales will still be conducted. however, the data from the physical examinations, lung function tests (bronchodilator reversibility tests) and feno measurements will be missed. these modifications to the protocol have been approved by the peking university first hospital irb. the study will be conducted in accordance with good clinical practice (gcp) requirements and ethical principles outlined in the declaration of helsinki. the purposes, procedures, and potential benefits and risks of the study will be explained carefully by investigators with written informed consent. written informed consent will be obtained from each participant. personal information and related documents of all participants will be kept strictly confidential. every participant will be identified by a subject number and a name acronym in the case report form. not applicable. the authors declare that they have no competing interests. key: cord-351565-ryjxbqno authors: johnston, s. l. title: bronchial hyperresponsiveness and cytokines in virus‐induced asthma exacerbations date: 2006-04-27 journal: clin exp allergy doi: 10.1111/j.1365-2222.1997.tb00666.x sha: doc_id: 351565 cord_uid: ryjxbqno nan in recent years studies employing new sensitive molecular methods of identification for the most common upper respiratory tract viruses (coronavirus and rhinovirus) have demonstrated that viral infections are associated with the majority of asthma exacerbations in children and adults in the community [1, 2] . these data are supported by other recent studies demonstrating that virus infections are associated with more severe exacerbations of asthma requiring hospital admission in both adults and children [3] and also in asthma mortality where winter peaks of asthma deaths in adults suggest a viral aetiology [4] . these studies and many previous studies on the same subject (reviewed by pattemore et al. [5] ) have over recent years stimulated a great"deal of research to elucidate the mechanisms by which upper respiratory virus infections induce exacerbations of asthma. many of these studies have involved wild type infections occurring in vivo and have led to the identification of a number of possible pro-inflammatory mechanisms. the use of experimental infections, however, allows a more invasive approach to be taken, which in recent years has included bronchoscopy with bronchial lavage and biopsy. these studies have demonstrated that an experimental rhinovirus cold in both normal and asthmatic subjects is associated with a bronchial mucosal cds"^, cd4'' and cds'" lymphocyte infiltrate, as well as eosinophiha, which in asthmatic subjects was persistent [6] . the addition of allergen challenge to experimental infection results in conversion of early asthmatic reactors to late asthmatic reactors [7] , with increased bronchoalveolar lavage eosinophilia and histamine levels [8] . two of the areas that have provoked a great deal of interest over recent years are the roles of bronchial hyperresponsiveness in virus-induced asthma and the possible role that pro-inflammatory cytokine release plays, not only in the induction of bronchial hyperresponsiveness but also in the inflammatory response in general. in this issue of the journal a further detailed study employing experimental rhinovirus infection reports on both these aspects, demonstrating that bronchial hyperreactivity is induced and that il-8 may play a role in the induction of bronchial hyperreactivity and therefore possibly in exacerbations of asthma [9] . in this study atopic asthmatic subjects were challenged with rhinovirus 16 or placebo and the severity of the cold and asthma symptoms monitored along with bronchial hyperreactivity, pulmonary function, nasal lavage il-8 levels and peripheral blood lymphocyte and neutrophil counts. of the rhinovirus-inoculated subjects, eight developed severe colds and the other 11 developed mild colds. there was no significant change in pulmonary function in either group, though there was a trend in both severe and mild groups for a decrease in fev| of about 5% on the third day after inoculation. there were significant increases in bronchial hyperreactivity in both groups and increases in nasal lavage il-8 levels on day 2 and day 9. in accordance with previous observations there was also a peripheral blood lymphopenia and neutrophilia. correlations were observed between the increase in il-8 level at day 2 and the severity of cold symptoms, the change in pc20 and neutrophil and lymphocyte counts. the authors concluded that the severity of a cold induced by experimental rhinovirus infection is related to the increase in airway hypersensitivity to histamine and that release of chemokines such as il-8 may play a role in this process. there were a number of interesting features to this study which differ from many previously conducted studies. first is that the method of virus inoculation differed from previous similar studies in that subjects received not only nasal spray and nasal drops as is commonplace but also inhalation via the nasal passages of a nebulized solution of virus. the total dose of virus given was similar to that in previous studies but the changes in histamine reactivity and also the fact that an exacerbation of asthma was induced in the one subject with the most reactive airways suggest that this model may be getting somewhat closer to virus-induced exacerbations of asthma in real life. the discrepancy between the severity of illness induced by experimental colds and that observed in real life has been a source of criticism of studies such as these and the authors may have pointed the way to try and mimic the real life situation more closely. clearly the danger is that one does not wish to induce real life exacerbations of asthma in such studies but a demonstrable decrease in airway function and an increase in asthma symptoms is clearly desirable. the authors have achieved a non-significant trend in the former case and a significant increase in asthma symptoms in the latter. i would recommend that any future studies wishing to investigate the mechanisms of virus-induced asthma should employ similar methods to those used in this study. it may be profitable in future studies to monitor small airway function rather than simply pef or fev, which are rather crude measures of large airway function. this study [9] , along with that of cheung et al. [10] and s. l. johnston others [6, 8] , clearly demonstrates that increases in bronchial reactivity can be demonstrated in atopic or asthmatic subjects and also that they may be prolonged [10] . there is now little doubt that bronchial hyperreactivity can be reliably induced by both experimental and wild type virus infections in atopic and asthmatic subjects, though the role of bronchial hyperreactivity in relation to asthma itself is more complex [11] . bronchial hyperreactivity can also be induced in normal subjects, though less reliably and of lesser severity [12] . the role of cytokine release in virus-induced asthma has been a subject of much study recently and a wide variety of cytokines including il-li3, il-6 [13] , il-8 [14] , il-11 [15] , tnf« [13] , interferon-a and -7 [13] , rantes and mlpl-a [16] have been found in association with viral infection. much more difficult, however, is to determine the possible pathological role of these cytokines. this study goes a little way towards achieving that end in demonstrating that the amount of il-8 induced by the experimental colds correlates not only with cold and asthma symptoms, but also with the changes in pc20 and in peripheral blood cell counts. these data are in accordance with our own observations, which have demonstrated increased il-8 levels in wild type virus infections during exacerbations of asthma in school children (the majority of these infections were rhinovirus infections [14] ). there were also increased levels of the neutrophil product myeloperoxidase, a correlation between the levels of myeloperoxidase and the severity of nasal symptoms, and the il-8 purified from these samples was biologically active in neutrophil chemotaxis assays, suggesting that il-8 was playing an active role in recruiting and activating neutrophiis [14] . these observations, taken with those of grunberg et al. [9] , are consistent with the hypothesis that il-8 may be playing a pathological role, though it is equally possible that it is protective and/or simply a marker of the severity of virus infection. in order to determine whether il-8 and other cytokines are playing a pathological role, studies similar to those cited above will need to be carried out, and an assessment of the severity of viral infections made using virus titrations. it is also desirable to study asthmatic subjects suffering colds but no exacerbation of their asthma, and exacerbations of asthma induced by the same virus types. most importantly, comparisons between normal subjects undergoing colds and asthmatic subjects undergoing virus-induced exacerbations of asthma will also need to be performed before the true importance of these potential mediators in virus-induced asthma can be assessed. a further interesting finding of this study, although not one of its primary aims, was confirmation of previous observations that neutralizing antibodies to rhinovirus are less protective in asthmatic subjects than in normal subjects where they do appear to have some protective function [12] . this question is intriguing as although it has long been known that local antibody responses are more protective than systemic, systemic antibodies have long been thought to play an important protective role, particularly iggi and igg4 [17] . this aspect of the difference between the normal and asthmatic response to vims infections is clearly a subject that would merit further study. the authors of the present study are to be congratulated on the thoroughness of the methods they employed, as a result of which they have made a number of important and interesting observations. this study by no means answers all the questions that the role of viruses in asthma have provoked but it provides a very good example of how these questions may be answered in further similar studies in the future. respiratory viruses and exacerbations of asthma in adults community study of role of viral infections in exacerbations of asthma in 9-11 year old children the relationship between upper respiratory infections and hospital admissions for asthma: a time-trend analysis agespecific trends in asthma mortality in england and wales viruses as preeipitants of asthma symptoms. part i. epidemiology lower airways inflammation during rhinovirus colds in normal and asthmatic subjects rhinovirus upper respiratory tract infection increases airway hyperractivity and late asthmatic reactions a common cold virus, rhinovirus 16, potentiates airway inflammation after segmental antigen bronchoprovocation in allergic subjects effect of experimental rhinovirus 16 colds on airway hyperresponsiveness to histamine and interleukin-8 in nasal lavage in asthmatic subjects in vivo rhinovirus inhalation causes long-lasting excessive airway narrowing in response to methacholine in asthmatic subjects in vivo a longitudinal study to examine the relationship between bronchial responsiveness and baseline fev| in patients with asthma amplified rhinovirus colds in atopic subjects nasal cytokines in common cold relationship of interleukin-8 to neutrophil influx in naturally occurring colds in asthmatic children asthma-associated viruses specifically induce lung stromal cells to produce interleukin-11, a mediator of airways hyperreactivity immunoreactive rantes and mlp-la are increased in the nasal aspirates of children with virus-associated asthma the specificity of antibodies induced by infection with rhinovirus type 2 key: cord-299672-dq1y1gkc authors: leung, ting fan; to, man yin; yeung, apple c.m.; wong, yun sze; wong, gary w.k.; chan, paul k.s. title: multiplex molecular detection of respiratory pathogens in children with asthma exacerbation date: 2010-02-28 journal: chest doi: 10.1378/chest.09-1250 sha: doc_id: 299672 cord_uid: dq1y1gkc background up to 80% of asthma exacerbations in white children are associated with viral upper respiratory infections. the relative importance of different respiratory pathogens and relevant microbiological data in asian children are unclear. this study elucidated the epidemiology of respiratory infections in hong kong children with asthma exacerbation. methods a total of 209 children aged 3-18 years with asthma exacerbations and 77 controls with stable asthma were recruited. the severity of asthma exacerbations was assessed according to global initiative for asthma guideline, and subjects aged 6 years or older performed exhaled nitric oxide and spirometric measurements. nested multiplex polymerase chain reaction was used to detect 20 different respiratory pathogens. results respiratory pathogens were detected in 105 (51.0%) subjects. the presence of any respiratory pathogen was associated with asthma exacerbation (odds ratio [or], 2.77; 95% ci, 1.51–5.11; p < .001). specifically, human rhinovirus (hrv) infection was more common among children with asthma exacerbation (or, 2.38; 95% ci, 1.09–5.32; p = .018). all other pathogens or coinfections were not associated with asthmatic attacks. none of these respiratory infections was associated with the severity of asthma exacerbation (p > .15 for all). during peak hrv season in the winter of 2007 to 2008, this virus was detected in 46.4% of children with asthma exacerbations. conclusions respiratory viral infections are commonly found in children with asthma exacerbation, with hrv being the most important pathogen in our patients. respiratory viral infection is a triggering factor for asthma exacerbation but does not correlate with its severity. 3 years with a defi nitive diagnosis of asthma because it may be diffi cult to differentiate acute bronchiolitis from asthma in the younger children. 16 patients who received antimicrobial agents (eg, neuraminidase inhibitors, ribavirin, and macrolides) within 2 weeks before study were also excluded. the severity of asthma exacerbation was classifi ed according to global initiative for asthma guidelines. 17 infection was defi ned as the detection of respiratory pathogens by our nested multiplex pcr assays. our primary outcome was the difference in detection rate for any respiratory pathogen between children with asthma with acute exacerbation and controls (ie, stable asthma). secondary outcomes consisted of differences in the clinical severity of asthma exacerbation, lung function parameters, and fractional exhaled nitric oxide concentration (feno) in relation to patients with different respiratory pathogens. the clinical research ethics committee of our university approved this study. following informed written consent, subjects had clinical assessment followed by feno and spirometric measurements. subjects 6 years of age and older underwent online feno measurement using a chemiluminescence analyzer (sievers; boulder, co) according to international guidelines. 18 the mean feno of three no plateau values was recorded. feno was measured within 48 h of hospitalization for children with acute asthma and at the clinic visit for stable patients. the former group was allowed to commence systemic corticosteroids as clinically indicated prior to feno because it would be unethical to withhold such treatment until this study. following feno, they performed spirometry (compact ii; vitalograph; buckingham, uk ) to measure fev 1 , fvc, and fev 1 /fvc. in accordance with local infection control policy, nasopharyngeal aspirates (npas) were collected in negative-pressure isolation rooms. deep nasal swabs were obtained as an alternative in situation where an isolation facility was unavailable. 19 these specimens were put immediately in viral transport medium and kept at 4°c during transportation. both viral rna and dna were extracted on the same day of collection by purelink viral rna/ dna mini kit (invitrogen; carlsbad, ca). rna extracted was converted to cdna by reverse transcriptase (superscript iii reverse transcriptase; invitrogen). all dna and cdna were used immediately for nested multiplex pcr for 20 respiratory pathogens as described previously. 20 tables 1a and 1b in the online supplement summarize sequences and amplicon sizes of the outer and inner sets of pcr primers. briefl y, each nested multiplex pcr assay detected four pathogens. group 1 comprised infl uenza a and b group-specifi c and subtypes h1n1, h3n2, h5n1specifi c primers; group 2 comprised parainfl uenza viruses (piv-1, piv-2, piv-3, piv-4a, and piv-4b); group 3 comprised rsv a and b, hrv, and enterovirus; group 4 comprised hcov-oc43, hcov-229e, sars-cov, and hmpv; and group 5 comprised m pneumoniae , c pneumoniae , hbov, and adenovirus. both the fi rst and second rounds of pcr were conducted in 20-m l reaction mixtures using fast thermal cycler (applied biosystems; foster city, ca). two microliters of cdna was used as the template for the fi rst round of pcr for groups 1 to 4, whereas 8 m l of the extracted preparation was used for group 5. in the second round of pcr, a 0.2-m l aliquot of the fi rst-round pcr product was used as a template. table 1c in the online supplement summarizes the pcr conditions of fi ve multiplex nested pcr assays. the pcr products were stained by sybr safe (invitrogen) and visualized by electrophoresis in 1.5% agarose gels. four corresponding positive controls and one negative control (sterile water) sample were respiratory viruses, such as human coronavirus (hcov)-229e, hcov-oc43, and human metapneumovirus (hmpv), are common causes of upper rti, [6] [7] [8] but their relation to asthma exacerbation remains u nclear. allander et al 9 developed a system for largescale molecular virus screening of clinical samples based on host dna depletion, random polymerase chain reaction (pcr) amplifi cation, large-scale sequencing, and bioinformatics. a more recently described parvovirus called human bocavirus (hbov) was identifi ed in children with lower rtis, 9 but its relation to asthma exacerbation is uncertain at present. asthma exacerbation may also be caused by atypical bacteria. chlamydophila pneumoniae , an obligate intracellular respiratory pathogen, was linked to asthma exacerbation in children. 10 among children hospitalized for wheezing, johnston 11 detected respiratory viruses in 18% of patients aged less than 3 months and 58% in those aged more than 5 years. asthma-related symptoms resolved or signifi cantly improved in half of adult patients with asthma seropositive for c pneumoniae who were treated with macrolides or doxycycline. 12 mycoplasma pneumoniae is detected by pcr in more than 50% of patients with asthma, 13 but it was also found in 11% of upper airway secretions from patients with stable asthma. 14 it is important to understand the roles different respiratory pathogens play in precipitating asthmatic attacks in order to determine ways to reduce the health-care burden associated with asthma-related hospitalization. the objectives of this study were: (1) to investigate the importance of different respiratory patho gens in childhood asthma exacerbation, and (2) to delineate the epidemiology of respiratory pathogens causing asthma exacerbation in hong kong children. this study recruited children with asthma aged 3-18 years with disease exacerbation who received treatments either in pediatric wards or outpatient clinics of a university teaching hospital between january 2007 and february 2008. inpatients hospitalized for asthma exacerbation were assessed within 48 h of hospitalization. age-and sex-matched children with asthma who were free from rtis for 4 weeks or longer and were seen in our allergy clinic within the same week as the above children with acute asthma were recruited as controls. asthma diagnosis was made according to british thoracic society criteria. 15 briefl y, older patients were either hyperresponsive to methacholine or showed reversible airfl ow limitation, whereas young children with asthma had three or more episodes of cough, shortness of breath, and wheezing during the 12 months before the study. these young patients also showed good response to bronchodilator. this study selected only children older than included for each group simultaneously. in order to prevent pcr contamination, reagent preparation, sample processing, and nested pcr assays were performed in separate rooms away from where amplifi ed products were analyzed. aerosol-resistant pipette tips were used throughout the experiments. as rtis are age-dependent, we tried to match one control per patient with respect to their age and sex. however, we failed to recruit this target number of controls because many children with stable asthma had rti symptoms during winter. the detection rates for respiratory pathogens between cases and controls were analyzed by x 2 or fisher exact test. the severity of asthma exacerbation, feno, and spirometric parameters were analyzed between subgroups with different pathogens by x 2 or student t test. multivariate logistic regression was used to identify respiratory pathogens associated with asthma exacerbation, adjusted for age, inhaled corticosteroid (ics) treatment, and domestic tobacco smoke exposure as covariates. all analyses were performed twotailed using spss v.14 (spss inc.; chicago, il), with the level of signifi cance set at .05. two hundred nine children with asthma exacerbation, including 203 patients hospitalized in our pediatric wards and six who attended our outpatient clinics, and 77 controls with stable asthma were recruited. table 1 shows the characteristics of these patients. children with asthma exacerbation were younger than the controls, mainly because of our inability to recruit one age-matched control for each child with asthma exacerbation. similar proportions of patients in the two groups received regular ics treatment. suffi cient respiratory samples were collected from 206 (98.6%) cases and all controls; these consisted of 236 npa samples and 47 nasal swabs. respiratory pathogens were detected in 105 (51.0%) subjects. table 2 summarizes the distributions of respiratory pathogens in two groups of patients. the presence of any virus with or without atypical bacteria was associated with asthma exacerbation ( p , .001 for both). specifi cally, hrv infection was more common among children with asthma exacerbation (odds ratio [or], 2.38; 95% ci, 1.09-5.32; p 5 .018). on logistic regression, asthma exacerbation was associated with the detection of hrv (or, 2.36; 95% ci, 1.11-5.00; p 5 .025), any respiratory virus (or, 2.19; 95% ci, 1.17-4.08; p 5 .014), or any respiratory pathogen (or, 2.15; 95% ci, 1.16-4.00; p 5 .015). none of the respiratory pathogens or their coinfection was associated with the severity of asthma exacerbation ( p . .15 for all). age, gender, and ics treatment did not affect the detection of respiratory pathogens in patients with asthma exacerbation ( p . .1 for all). table 3 summarizes the clinical features of patients with asthma exacerbation in relation to hrv infections. 21 respiratory pathogens were detected in 47% of these patients, and hrv peaked in winter and early spring. these multiplex nested pcr assays were specifi c and 100-to 1,000-fold more sensitive than conventional methods in detecting the viruses. our assays detected յ 10 nucleic acid copies for all viruses (except enteroviruses), which were comparable to those reported in widely quoted highthroughput multiplex pcr assays. 21 specifi cally, our nested pcr was able to detect one cdna copy of hrv. the present study used the same method, except for legionella pneumophila being replaced by hbov, to investigate the infective causes of asthma exacerbation in hong kong children. hrv infections also peaked in winter of 2007/2008 in children with asthma exacerbation ( fig 1 ) . our detection rate (51%) was similar to previous local studies 20,22 but lower than those published in white populations. 23 it is uncertain whether our low hrv detection rate was due to limitations of the pcr technique, which is less likely in view of our previously noted in vitro results, or a genuinely low incidence of hrv infection in hong kong children. further studies in other asian populations are needed to confi rm our fi ndings. hrv infection was associated with asthma exacerbation in the children, which is consistent with feno was the only parameter that differed between patients with and without hrv, being signifi cantly lower in the former group ( p 5 .018). ten controls were hrv positive, and mean (sd) feno of those with and without hrv were 38.6 (17.9) ppb and 82.2 (61.3) ppb, respectively ( p , .001). table 4 summarizes the relationship between age and different respiratory pathogens in patients with asthma exacerbation. patients with asthma exacerbation caused by respiratory viruses were younger than those without identifi able viral infections ( p , .05). this fi nding was attributed mainly to rsv ( p , .005) and infl uenza a and hmpv infections ( p , .05 for both). age did not differ between the case and control groups with infections by other organisms, including hrv, or with coinfections. figure 1 illustrates the seasonal pattern of hrv, which was found in patients throughout the study period ( ն 10%) and peaked in winter (november-december) of 2007 to 2008. similarly, 28.6% of controls had hrv in autumn-winter (september-october), but none of them were hrv positive in spring-summer (march-august). the low positive rates for other respiratory pathogens in our subjects preclude our analysis of their seasonality patterns. b. on the other hand, hrv infection was detected in 13% of our subjects with stable asthma who did not experience any symptom or sign of disease exacerbation. in a longitudinal study of healthy children, 20.6% of all hrv infections were asymptomatic. 29 future studies should delineate the pathogenic linkage between hrv and worsened asthma. during the past few years, there has been impressive advance in our understanding of the interactions between hrv and host immunity. 30 hrv infects human cells via ligation with its major group receptor intercellular adhesion molecule 1. infected respiratory epithelial cells, and possibly macrophages, produce a variety of proinfl ammatory cytokines, chemokines, and leukotrienes. these mediators in turn attract different infl ammatory cells to the airway, resulting in worsened immunopathology and increased bronchial hyperresponsiveness observed in patients with asthma. in addition, airway epithelium from patients with asthma is defi cient in mounting adequate antiviral responses to hrv. 31, 32 hbov was detected in 5.0% of 1,906 local children hospitalized for acute rtis, 33 and seasonal distribution was noted from september to february. despite this, the detection of hbov in 2.4% of cases and 2.6% of controls was not associated with asthma exacerbation in the present study. this fi nding might be explained by our exclusion of infants and young children, who were at increased risk of hbov infection. 9, 33 three-fi fths of adults with asthma exacerbation had m pneumoniae and/or c pneumoniae , 34 and telithromycin was shown to be a useful treatment in these patients. m pneumoniae was detected in more than half of patients with asthma, 11 and also in upper airway secretions from 11% of patients with chronic stable asthma. 14 hahn 12 claimed oral macrolides to be effi cacious for patients with acute asthma. on the other hand, cunningham et al 10 failed to show any relation between m pneumoniae and childhood asthma exacerbation. m pneumoniae and c pneumoniae were detected only in 2.4% of our children with asthma exacerbations, which was similar to that observed in patients with stable asthma. our fi ndings do not support atypical bacteria to be important pathogens for asthma exacerbations in children or the usefulness of macrolides in treating these patients. the major limitation of this project relates to its study power. the number of controls was much lower than that of our recruited cases, mainly because casecontrol matching within 1 week was not possible on many occasions when stable and especially younger patients also complained of nonspecifi c upper respiratory symptoms (eg, rhinorrhea, blocked nose, sore throat) during change of weather. our sample size had a power of 97% for detecting any difference in the detection of any virus between cases and controls, published data about the importance of hrv in white populations. in the childhood origins of asthma birth cohort, a total of 259 children were followed prospectively from birth to 6 years of age. 24 hrv-associated wheezing in years 1 and 3 were the strongest predictor for asthma diagnosis at the age of 6 years. nearly 90% of children who wheezed with hrv in year 3 subsequently developed asthma. two other studies found hrv to be the most important microbiological risk factors for asthma diagnosis and disease exacerbation. [25] [26] [27] more recently, miller et al 28 reported that childhood asthma exacerbations were associated with the novel group c of hrv rather than the two previously known phylogenetic groups a and results expressed in mean (sd) and only included data for pathogens that were detected in fi ve or more patients. a p , .05 for between-group comparisons. b p , .005 for between-group comparisons. c p , .01 for between-group comparisons. dr g. w. k. wong: contributed to subject recruitment and manuscript preparation. dr chan: contributed to designing and supervising virologic investigations and participated in manuscript preparation. financial/nonfi nancial disclosures: the authors have reported to chest that no potential confl icts of interest exist with any companies/organizations whose products or services may be discussed in this article. but had a marginal power of 70% for hrv infection (graphpad statmate; san diego, ca) and , 50% for the detection of other respiratory pathogens because of their rarity. thus, larger studies are needed to delineate the possible association between asthma exacerbation and rtis by these organisms. the lack of standardization on the methodology of hrv detection would also pose a problem. a recent study revealed that hrvs consist of . 100 distinct serotypes. 35 in view of this degree of phylogenetic heterogeneity, the pcr primers designed for our multiplex assays were not able to detect all hrvs. despite the use of sensitive multiplex assays as discussed previously, our molecular approach for detecting viruses would miss some hrvs that were not covered by our pcr primers. future studies need to adopt multiple pcr primers that specifi cally target as many hrv serotypes as possible. another weakness is that npa samples were collected from 236 (83.4%) subjects, whereas nasal swabs were collected from the remaining subjects. as we previously reported, the overall sensitivity of detecting infl uenza, parainfl uenza, rsv, and adenovirus in npa was higher than that obtained by nasal swabs in local children. 36 on the other hand, we did not have relevant data for hrv. although more than 80% of subjects had npa samples, it is possible that we might have missed some organisms in those with only nasal swabs. we also observed that only 30% of patients hospitalized for asthma exacerbation had successfully performed feno measurement according to guideline (table 1) . 18 as patients with severe bronchospasm were probably too breathless for the procedure, only patients with milder attacks would contribute to feno readings in this group. in addition, a substantial proportion of these patients were treated with systemic corticosteroids prior to feno. these reasons explain the lower feno in these patients when compared with patients with stable asthma. in conclusion, respiratory viruses and atypical bacteria are detected in more than half of hong kong children with asthma exacerbation. hrv infection is the most important risk factor for asthma exacerbation in these patients. nonetheless, none of these pathogens is associated with severity of asthma exacerbation. prevalence of respiratory and atopic disorders in chinese schoolchildren assessing disease burden of respiratory disorders in hong kong children with hospital discharge data and linked laboratory data community study of role of viral infections in exacerbations of asthma in 9-11 year old children role of viruses and atypical bacteria in exacerbations of asthma in hospitalized children: a prospective study in the nord-pas de calais region (france) the burden of infl uenza illness in children with asthma and other chronic medical conditions a novel pancoronavirus rt-pcr assay: frequent detection of human coronavirus nl63 in children hospitalized with respiratory tract infections in belgium human metapneumovirus detection in patients with severe acute respiratory syndrome children with respiratory disease associated with metapneumovirus in hong kong cloning of a human parvovirus by molecular screening of respiratory tract samples chronic chlamydia pneumoniae infection and asthma exacerbations in children infl uence of viral and bacterial respiratory infections on exacerbations and symptom severity in childhood asthma treatment of chlamydia pneumoniae infection in adult asthma: a before-after trial detection of mycoplasma pneumoniae in the airways of adults with chronic asthma a link between chronic asthma and chronic infection scottish intercollegiate guidelines network (sign) the group health medical associates . asthma and wheezing in the fi rst six years of life global initiative for asthma . bethesda, md : national heart, lung, and blood institute measurement of exhaled nitric oxide in children comparative study of nasopharyngeal aspirate and nasal swab specimens for detection of infl uenza rapid multiplex nested pcr for detection of respiratory viruses high-throughput, sensitive, and accurate multiplex pcr-microsphere fl ow cytometry system for large-scale comprehensive detection of respiratory viruses identifi cation of viral and atypical bacterial pathogens in children hospitalized with acute respiratory infections in hong kong by multiplex pcr assays asthma exacerbations. 2: aetiology wheezing rhinovirus illnesses in early life predict asthma development in high-risk children prevalence of viral respiratory tract infections in children with asthma rhinovirus infection preferentially increases lower airway responsiveness in allergic subjects the relationship of rhinovirus-associated asthma hospitalizations with inhaled corticosteroids and smoking new vaccine surveillance network . a novel group of rhinoviruses is associated with asthma hospitalizations picornavirus infections in children diagnosed by rt-pcr during longitudinal surveillance with weekly sampling: association with symptomatic illness and effect of season host immune responses to rhinovirus: mechanisms in asthma asthmatic bronchial epithelial cells have a defi cient innate immune response to infection with rhinovirus role of deficient type iii interferon-lambda production in asthma exacerbations pediatric hospitalization of acute respiratory tract infections with human bocavirus in hong kong the effect of telithromycin in acute exacerbations of asthma sequencing and analyses of all known human rhinovirus genomes reveal structure and evolution comparative study of nasopharyngeal aspirate and nasal swab specimens for diagnosis of acute viral respiratory infection key: cord-286328-ap0wfjhq authors: lewis, toby c.; henderson, tiffany a.; carpenter, ashley r.; ramirez, ixsy a.; mchenry, christina l.; goldsmith, adam m.; ren, xiaodan; mentz, graciela b.; mukherjee, bhramar; robins, thomas g.; joiner, terence a.; mohammad, layla s.; nguyen, emily r.; burns, mark a.; burke, david t.; hershenson, marc b. title: nasal cytokine responses to natural colds in asthmatic children date: 2012-11-26 journal: clinical & experimental allergy doi: 10.1111/cea.12005 sha: doc_id: 286328 cord_uid: ap0wfjhq background: the mechanisms by which viruses induce asthma exacerbations are not well-understood. objective: we characterized fluctuations in nasal aspirate cytokines during naturally-occurring respiratory viral infections in children with asthma. methods: sixteen children underwent home collections of nasal aspirates when they were without cold symptoms and again during self-reported respiratory illnesses. the presence of viral infection was ascertained by multiplex pcr. cytokines were measured by multiplex immune assay. mrna expression for selected markers of viral infection was measured by rt-pcr. a cumulative respiratory symptom score was calculated for each day of measurement. generalized estimated equations were used to evaluate associations between viral infection and marker elevation, and between marker elevation and symptom score. results: the 16 patients completed a total of 37 weeks of assessment (15 “well” weeks; 22 self-assessed “sick” weeks). viral infections were detected in three of the “well” weeks and 17 of the “sick” weeks (10 rhinovirus, 3 coronavirus, 2 influenza a, 2 influenza b, 2 respiratory syncytial virus, 1 parainfluenza). compared to virus-negative well weeks, nasal aspirate ifn-γ, cxcl8/il-8, cxcl10/ip-10, ccl5/rantes, ccl11/eotaxin-1, ccl2/mcp-1, ccl4/mip-1β, ccl7/mcp-3 and ccl20/mip3α protein levels increased during virus-positive sick weeks. only a subset of cytokines (ifn-γ, cxcl8, ccl2, ccl4, ccl5 and ccl20) correlated with self-reported respiratory tract symptoms. while many aspirates were dilute and showed no mrna signal, viral infection significantly increased the number of samples that were positive for ifn-λ1, ifn-λ2/3, tlr3, rig-i and irf7 mrna. conclusions & clinical relevance: we conclude that, in children with asthma, naturally-occurring viral infections apparently induce a robust innate immune response including expression of specific chemokines, ifns and ifn-responsive genes. epidemiological studies have uncovered a strong association between viral infections, especially those caused by rhinovirus, and exacerbations of asthma attacks [1] [2] [3] . however, the mechanisms by which viruses induce exacerbations of chronic airways disease are not well understood. in response to viral infection, the airway epithelium, and to a lesser extent immune cells such as monocytes, macrophages, and dendritic cells [4] [5] [6] [7] , release pro-inflammatory cytokines, interferons (ifns), and antimicrobial substances, which in turn, promote clearance of microorganisms, and activation of the adaptive immune system. however, in patients with chronic respiratory illnesses, the innate immune response may also be responsible for disease exacerbation [8] . although the inflammatory response to experimental rhinovirus infection has been monitored [9] [10] [11] [12] [13] [14] , few studies have examined the innate immune response of patients with asthma to natural colds. increases in respiratory tract cxcl8/il-8, ccl5/rantes, ccl19/ mip-1a, il-10, ccl7/mcp-3, and ccl13/mcp-4 have been detected [15] [16] [17] [18] . to further examine the innate immune response to viral infection in children with asthma, we measured nasal aspirate cytokine levels in 16 asthmatic children before and after upper respiratory tract infections. in contrast to the previous studies, we examined at least three time points before and in association with symptomatic illness. we evaluated the associations between viral infection and cytokine expression, and between cytokine expression and symptom score. we also examined the effects of upper respiratory tract infection on mrna levels of selected markers of viral infection, including ifns. finally, we evaluated a new method of virus detection using a single polymerase chain reaction-ligation detection reaction (pcr-ldr) multiplex assay. we hypothesized that respiratory viral infection of children with asthma causes robust elaboration of pro-inflammatory cytokines and ifns, and that the level of pro-inflammatory cytokines correlates with symptom severity. we conducted an observational cohort study of 16 children with asthma. children were eligible for the study if they received care from a university of michigan physician for asthma, were aged 6-18 years, and lived within a 30 mile radius of ann arbor. outpatients were enrolled for 3-6 months, with the goal of assessing cytokines at baseline and in association with at least one viral-induced exacerbation during that period. initial consent and first evaluation was conducted at the university of michigan, but all subsequent evaluations were performed in the participant's home. this study was approved by the university of michigan institutional review board (approval number hum00018442). all clinical investigations were conducted according to principles expressed in the declaration of helsinki (http://www.wma.net). at the initial assessment, parents or guardians completed an extensive questionnaire, which included standardized questions about presence and frequency of asthma symptoms, an inventory of a child's asthma medications and current usage, and queries about environmental exposures, and child and family demographic information. baseline asthma severity was assessed using national asthma education and prevention program guidelines [19] incorporating an adjustment for asthma controller therapy use [20] . we performed home measurements of respiratory symptoms and collected nasal secretions (for detection of viral rna by pcr and host biomarkers by pcr and elisa) on 3 days during a week when children were healthy (not reporting upper respiratory tract infection or asthma symptoms), and again during a week when they experienced cold or flu-like symptoms. families were given a calendar and a simple respiratory symptom scale and asked to mark the level of their symptoms. we used a modified version of the respiratory symptom score developed by the child origins of asthma study [21] , which assessed fever, cough, nasal symptoms, wheezing, difficulty breathing, waking up at night with cough, and interference with usual activities. when the patient experienced a symptomatic respiratory illness, as defined by a symptom score of two or higher on a scale of 0-13, the family notified the study staff and scheduled a visit within 48 h of the beginning of symptoms (defined as day 1 of the illness). information regarding impact of respiratory symptoms on daily activities and recent use of asthma medicines was also collected. as noted above, study technicians visited the home every 2-3 days to retrieve additional nasal washing samples, for a total of three visits during the week following reporting of symptoms. the three specific days of the week selected for analysis were based on the convenience of the subjects and laboratory technician. although specimens were most often collected on days 1, 4, and 7 of a given week, specimen collection was sometimes compressed into a 5 or 6-day period. to collect a nasal lavage sample, we utilized a protocol developed by powell and shorr [22] and modified by james gern (university of wisconsin, personal communication). two squirts of isotonic 0.65% sodium chloride were instilled into the child's nostrils (estimated at < 1 ml per nostril) using a commercially available nasal saline spray (b.f. ascher, lenexa, ks, usa). the subject then blew their nose into a zippered plastic bag, and 3 ml of m4rt viral transport medium (remel, lenexa, ks, usa) was added. in general, samples were collected in the presence of study staff and were transported from homes to the laboratory within 3 h of collection in a cooler with ice packs. however, due to logistical issues scheduling home visits, families were also provided with kits for independent collection of nasal washings specimens at home. if a visit could not be scheduled within 48 h, families were instructed to collect the sample, double bag the sample, place in a tightly sealed collection box, and to keep it in the refrigerator until the staff could collect the sample. we required a 1 week interval between sample collections for sequential illnesses. nasal aspirates were homogenized using a handheld homogenizer to allow pipetting of viscous samples and frozen at à70°c to allow for batched analysis. viral rna and dna were extracted using a minelute kit (qiagen, valencia, ca, usa). samples were assessed for the presence of viral rna or dna via pcr using the seegene seeplex rv-12 detection kit (seegene, rockville, md, usa). this kit detects human parainfluenza viruses 1, 2, and 3, human metapneumovirus, human coronavirus 229e/nl63, and oc43, human adenovirus, influenza viruses a and b, human respiratory syncytial virus (rsv) a and b, and human rhinovirus a. we also analysed specimens for respiratory viruses using a novel polymerase chain pcr-ldr multiplex assay [23] . the original system, which was designed to detect influenza viruses, was expanded to include parainfluenza 1, 2, 3, 4a and 4b, coronaviruses 229e and oc43, influenza a and b, rhinoviruses a, b, and c, adenoviruses a-e, metapneumovirus, and rsv a and b. we have detected all the viruses included in this multiplex system in clinical samples (i.e. nasal aspirates), with the exception of the adenoviruses, for which we used laboratory positive controls. the viral sequences for the multiplex assay are listed in table 1 . protein levels of ifn-c, cxcl8/il-8, cxcl10/ip-10, ccl5/rantes, ccl11/eotaxin-1, ccl2/mcp-1, ccl4/ mip-1b, ccl7/mcp-3, ccl19/mip-3b, and ccl20/mip-3a were determined using a magnetic bead-based multiplex immune assay (bio-rad, hercules, ca, usa). our interest on the above cc chemokines was prompted by gene array results from rv1b-infected, ovalbumin-sensitized, and -challenged mice (data not shown). ifn-a and ifn-b levels were measured using standard elisa (r&d systems, minneapolis, mn, usa). aspirates were homogenized and mrna extracted as described above, using the rneasy or the rneasyplus kit (qiagen). mrna was analysed for cxcl8/il-8, cxcl10/ ip10, ccl5/rantes, ccl11/eotaxin, ifn-k1, ifn-k2/3, ifn-a, ifn-b, icam-1, tlr3, mda-5, rig-i, and irf7 using quantitative real time pcr using specific primers and probes. signals were normalized to gapdh. we assessed feno in exhaled breath on 3 days during a week when the child was well, and on at least 3 days during a viral infection. to measure feno, we employed the niox mino (aerocrine, new providence, nj, usa). because feno measurement can be influenced by diet and exercise, participants were asked to refrain from eating or drinking within 1 h of their exhaled breath assessment. triplicate samples were obtained to assess reliability. mean, standard deviation and interquartile range were used to describe measured values of nasal cytokine levels, nasal mrna, and symptom score before and during viral illnesses. box plots were used to represent the change in biomarkers at different points of the cold relative to the baseline. whiskers of the boxplots represent the minimum and maximum values. distributions of these continuous outcome variables were examined and appropriate transformations taken to achieve normality. the effects of viral illness, as defined by the seegene kit results, on biomarker protein levels, and of biomarker level on symptom score were determined using a generalized mixed models (proc mixed), with an auto-regressive correlation structure using sas statistical software (sas, cary, nc, usa). we evaluated and adjusted for relevant covariates such as age, gender, ethnicity/race, and nasal steroid use. other potential explanatory variables, such as family income, baseline asthma severity, tobacco smoke exposure, and oral antihistamine use were evaluated, but not included in final models as they were not significant predictors. for all mrna outcomes except ifn-b, levels were undetectable in a large number of samples. we therefore categorized our results into detectable/non-detectable levels, and analysed as a binary variable using the generalized estimating equation (gee) approach with the tobit link [24] . we analysed ifn-b mrna levels as a continuous variable using the gee approach with identity link. unadjusted models are shown. sixteen children with physician-diagnosed asthma were recruited. participants ranged in age from 6 to 16 years old, were 69% boys, 36% non-white, and reported symptoms or medication use consistent with persistent asthma ( table 2) . participants completed a total of 37 weeks of assessment ( table 3 ). the current report focuses on the 28 weeks where there was concordance between selfreported illness and viral detection using the seegene kit (16 virus-positive 'sick' weeks, and 12 virus-negative 'well' weeks). we re-tested eight positive and seven negative samples (by seeplex) using the pcr-ligation detection multiplex assay. twelve of 15 samples were concordant between the two assays. two samples were positive by seeplex and negative by pcr-ldr. one sample showed rsv by seeplex assay and coronavirus oc43 by pcr-ldr. symptom scores, which qualitatively evaluated the severity of illness, rose during the sick weeks (fig. 1a) . respiratory symptoms were highest at the first assessment during sick weeks, 1-3 days after initial report of illness. children with confirmed viral illnesses experienced significant increases in cough, wheeze, and chest tightness, indicative of asthma exacerbation (table 4) . selected nasal aspirate cytokines were measured using magnetic bead-based multiplex immune assay. there were significant increases in all cytokines examined during weeks of reported symptoms, with the single exception of ccl7 (table 5 , fig. 1b) . this pattern was more striking when samples with documented viral infections were compared to those confirmed to be virus-negative. unadjusted estimates of the association of confirmed viral infection and cytokine level were highly significant (not shown) and did not change appreciably when adjusted for age, gender, race, and nasal steroid use. changes in cytokines over the course of the illness are shown in fig. 2 . in most cases, cytokines increased during the first 2 days of infection and persisted throughout the week. we also examined the relationship between cytokines and symptom score. unadjusted estimates of the association of confirmed viral infection and cytokine level with symptom score were significant for ifn-c, cxcl8, ccl5, ccl20, ccl2, and ccl4 (table 6) . cxcl10, ccl11, ccl19, and ccl7 cytokine levels did not correlate with symptom score. we also attempted to measure ifn-a and ifn-b protein levels in the nasal aspirates by elisa. ifn-a levels over the lower detection limit (12.5 pg/ml) were found in only five of 116 specimens (all virus-positive weeks). for ifn-b, levels over the detection limit (25 pg/ml) were found in only 12 samples (five virus-negative, seven virus-positive). many aspirates were dilute and a number of specimens showed no mrna signal (table 7) . nevertheless, we detected transcripts for icam-1, cxcl-10, ifn-k1, cxcl-8, rig-i, mda-5, tlr3, ifnk2/3, irf7, ifn-a, and ifn-b from patients both before and during viral infections. we could not detect ccl5 and ccl11 mrna in any specimens. finally, infection significantly increased the number of samples that were positive for cxcl8, ifn-k1, ifn-k2/3, tlr3, rig-i, and irf7 mrna. we measured feno before and during virus-positive sick weeks (fig. 3) . there was no significant change in feno measurement with viral infection. viral infections are the most frequent cause of asthma attacks [1] [2] [3] . in theory, chemokine production by virus-infected epithelial cells induces the recruitment of inflammatory cells to the airways, which in turn elaborate cytokines and mediators capable of increasing airway responses. data suggest that immune cells may also be infected by respiratory viruses and produce chemokines [7, [25] [26] [27] [28] [29] [30] . in the present study, we found that, during natural colds, respiratory tract cytokine levels significantly increase in children with asthma. levels of a subset of cytokines correlated with the degree and time course of respiratory symptoms. the chemokines detected are responsible for recruitment of a broad array of inflammatory cells including neutrophils, monocytes, macrophages, and eosinophils. finally, we detected changes in nasal lavage specimens, which were collected at home on a repeated basis, both before and in association with infection. although we did not measure cytokine levels in normal subjects, these data show that children with asthma are apparently capable of a robust cytokine response to viral infection, even during mild exacerbations. in addition, home collection of nasal lavage specimens appears to be a practical tool for studying the natural history of viral infection in children. our results expand upon prior work characterizing cytokine responses detectable in respiratory secretions of asthmatics in association with viral illnesses. pizzichini et al. [15] found that, compared to 21 days after infection, sputum levels of cxcl8, eosinophil cationic protein and fibrinogen from six adult asthmatics were significantly elevated 4 days after the start of a coldinduced exacerbation. furthermore, cxcl8 levels correlated with the number of sputum neutrophils. teran et al. asthma [16] found that, compared to asymptomatic periods, levels of major basic protein, ccl5 and ccl19 were increased in the nasal aspirates of 26 children during acute viral-induced exacerbations. grissell et al. asthma [17] found that compared to a group of stable asthmatics, levels of ccl5 and il-10 were significantly elevated in the induced sputa of older children and adults suffering from acute viral-induced asthma exacerbations, along with neutrophils and eosinophils. cxcl8 and ccl19 were also increased, although not significantly. finally, santiago et al. [18] found that compared to control samples, ccl7 and ccl13 were increased in the nasal aspirates of asthmatic children 12 -24 h after upper respiratory tract infections. chemokine levels correlated with macrophages in the nasal aspirate and upper respiratory symptoms scores. in the present study, in which patients were used as their own controls, we confirmed the above changes in cxcl8, ccl5, ccl19, and ccl7, and provide new data showing significant increases in cxcl10, ccl11, ccl2, and ccl4. importantly, we found that increases in these chemokines were sustained throughout the week following viral infection. we also examined the relationship between cytokines and respiratory symptom score. interestingly, we found that some cytokines correlated with symptom score (ifn-c, cxcl8, ccl5 , ccl20, ccl2, and ccl4) whereas others did not (cxcl10, ccl11, ccl19 or ccl7). although we did not examine lower airway cytokine levels, it is tempting to speculate that the former set of cytokines is responsible for the acute asthmatic response to viral infection, whereas the latter set may modulate future immune responses. based on differences in ifn-b and ifn-k production between cells isolated from controls and asthmatic subjects [31] [32] [33] , it has been proposed that patients with asthma are prone to rhinovirus-induced exacerbations due to deficient ifn production on the other hand, other in vitro studies showed no differences in rhinovirus-induced gene expression in epithelial cells isolated from asthmatic and healthy subjects [34, 35] , and con-trol and asthmatic subjects experimentally infected with rhinovirus show no difference in respiratory tract viral titre or copy number [14] . we found that viral infection during natural colds significantly increased the levels of ifn-c protein and ifn-k mrna in the nasal aspirates. viral infection also significantly increased the expression level of rig-i and irf-7, each of which are inducible by type i ifns [36, 37] . together, these data suggest that asthmatic children are capable of a functional ifn response. on the other hand, we failed to detect ifn-a or ifn-b protein in nasal aspirates, and there was no significant change in mrna levels during natural colds. detection of type i ifns in respiratory secretions is made difficult by the low sensitivity of commercially available assays, physiologically low levels of these cytokines in biological fluids (particularly in fluids without sufficient numbers of plasmacytoid dendritic cells) and presence of natural inhibitors (e.g. soluble receptors). also, we could not compare the results from our experimental subjects to children without asthma. our finding that irf7 mrna is elevated after respiratory viral infection in children with asthma is validated by a recent study analysing patterns of gene expression in nasal lavage samples from children experiencing picornavirus-induced asthma exacerbations [38] . consistent with our previous work examining the requirement of irf7 for rhinovirus-induced gene expression in cultured airway epithelial cells [39] , coexpression analysis demonstrated irf7 to be a major hub connecting ifn-mediated responses in virus-induced asthma exacerbations. in this study, we piloted a new pcr-ldr-based method for respiratory virus detection. twelve of 15 samples were concordant between the two viral detection techniques; in two cases, samples were positive by seeplex and negative by pcr-ldr. the precise cause of the discrepancy between the two tests is not certain, but the seeplex test, which relies on visual detection of bands on agarose electrophoresis gels, may be liable to false positives. we also optimized our pcr-ldr test for maximum specificity, with the goal of avoiding false positives. this may have resulted in a reduction in sensitivity if copy number of viral nucleic acid was low. we measured the effect of natural colds on feno. previous studies have shown feno to be a reliable measure of eosinophilic airway inflammation, steroid responsiveness, and clinical control in children and adults with allergic asthma [40] [41] [42] [43] . feno levels have also been shown to increase during emergency steroid treatment of acute asthma exacerbations [44, 45] . in contrast, we found that despite increases in airway cytokines and respiratory symptoms, there was no increase in feno during natural colds in children relative to their baseline state. these data are consistent with the notion that airway inflammation in the context of viral-induced asthma exacerbations is different in character than that associated with chronic asthma. there are several limitations to our study. first, although nasal sampling has the advantage of increased safety and decreased participant burden, sputum speci-mens more closely reflect the response of the lower airways to viral infection. however, as noted above, levels of ifn-c, cxcl8, ccl5, ccl20, ccl2, and ccl4 significantly correlated with respiratory symptoms, including lower respiratory tract symptoms such as cough, wheeze, chest tightness, and shortness of breath, each of which are indicative of asthma exacerbation. in addition, previous studies have found similar changes in nasal aspirate and sputum cytokine concentrations following viral exacerbations of asthma [16, 17] . finally, observations demonstrate consistent effects of nasal and bronchial provocation [46] . second, we did not measure inflammatory cells in the nasal aspirates. we therefore could not assess the functional effects of chemokine release in our subjects. previous studies have shown recruitment of neutrophils, eosinophils, and macrophages to the respiratory tract following rhinoviral infection of asthmatic subjects [9, 15, 17, 18, [47] [48] [49] [50] . also, we cannot determine the cellular source of the mrnas measured in our study. pilot analysis showed primarily epithelial cells and neutrophils in the nasal aspirates, suggesting that epithelial cells were the primary source of mrna. third, as noted above, we did not compare responses of asthmatic subjects to controls. a recent study showed that asthmatics and non-atopic subjects experience similar colds, including chemokine responses, following experimental rhinovirus infection [17] . fourth, although we were able to detect significant differences in many cytokines following upper respiratory tract infection, a fraction of the samples were too dilute to detect mrna. (there may have been other reasons for the loss of rna, for example sample ribonucleases). dilution may also affect the concentration of measured biomarkers. we did not adjust measurements by total protein content, as vascular leakage due to inflammation may alter protein concentrations in children with upper respiratory infections [51] . in our experience, total protein is difficult to measure in many nasal (and tracheal) aspirate specimens, even when cytokines are readily detectable, and therefore normalization for total protein does not increase the reliability of the concentrations. finally, studying naturally occurring colds in children using home-based methods inherently involves some variability in sample timing and handling that is not present in the controlled environment of the laboratory. yet this approach also offers an opportunity to observe 'real world' scenarios. our ability to detect statistically significant changes in specific mrnas and proteins using the current study design suggests that this is a viable approach for use in future investigations, for example, studies examining whether an early adjustment of asthma medications could abort or temper the impact of respiratory viral infections. we conclude that in children with asthma, naturally occurring viral infections apparently induce a robust innate immune response including expression of specific chemokines, ifns, and ifn-responsive genes. cytokine responses are sustained the first week following viral infection. future analyses of controls and asthmatics which combine the determination of cytokine responses and asthma health outcomes will provide further insight into the cellular pathways responsible for virus-induced asthma exacerbations. respiratory viruses and exacerbations of asthma in adults community study of role of viral infections in exacerbations of asthma in 9-11 year old children persistence of rhinovirus rna after asthma exacerbation in children respiratory syncytial virus 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between exhaled nitric oxide, sputum eosinophils, and methacholine responsiveness in patients with mild asthma exhaled nitric oxide correlates with airway hyperresponsiveness in steroid-naive patients with mild asthma noninvasive assessment of airway inflammation in children: induced sputum, exhaled nitric oxide, and breath condensate expired nitric oxide levels during treatment of acute asthma corticosteroids decrease exhaled nitric oxide in children with acute asthma inhalation of swine dust induces cytokine release in the upper and lower airways role of nasal interleukin-8 in neutrophil recruitment and activation in children with virusinduced asthma experimental rhinovirus 16 infection. effects on cell differentials and soluble markers in sputum in asthmatic subjects the effect of an experimental rhinovirus 16 infection on bronchial lavage neutrophils rhinovirus-induced airway inflammation in asthma. effect of treatment with inhaled corticosteroids before and during experimental infection upper airway sampling the authors declare no conflicts of interests. key: cord-280859-3ff72mlq authors: abe, nozomi; yasudo, hiroki; fukano, reiji; nakamura, tamaki; okada, seigo; wakiguchi, hiroyuki; okazaki, fumiko; shirabe, komei; toda, shoichi; okamoto, reiko; ouchi, kazunobu; ohga, shouichi; hasegawa, shunji title: multi‐season analyses of causative pathogens in children hospitalized with asthma exacerbation date: 2019-08-12 journal: pediatr allergy immunol doi: 10.1111/pai.13102 sha: doc_id: 280859 cord_uid: 3ff72mlq background: respiratory viral and mycoplasma infections are associated with childhood asthma exacerbations. here, we explored epidemiologic profile of causative pathogens and possible factors for exacerbation in a single center over a three‐year period. methods: hospitalized asthmatic children with attack aged 6 months‐17 years were recruited between 2012 and 2015 (n = 216). nasopharyngeal mucosa cell samples were collected from the participants and examined by reverse transcription‐polymerase chain reaction to detect rhinovirus (rv), respiratory syncytial virus (rsv), enterovirus (ev), parainfluenza virus (piv), mycoplasma pneumoniae, and others. clinical features, laboratory data, asthma exacerbation intensity, and asthma severity were compared among participants. epidemiologic profile of causative pathogens and possible factors for exacerbation were explored. results: viruses and/or mycoplasma pneumoniae were detected in 75% of the participants. rhinovirus (48%) was the most commonly detected virus in the participants with single infection, followed by rsv (6%). the median age at admission in the rv group was significantly higher than that in the rsv group. insufficient asthma control and allergen sensitization were significantly related to rv‐associated asthma exacerbation. there was no seasonality of pathogen types associated with asthma exacerbation although a sporadic prevalence of ev‐d68 was observehinovirud. rhinovirus were repeatedly detected in multiple admission cases. conclusion: our three‐year analysis revealed that patients with rv infection were significantly prone to repeated rv infection in the subsequent exacerbation and good asthma control could prevent rv‐associated asthma development and exacerbation. multiple‐year monitoring allowed us to comprehend the profile of virus‐ and/or mycoplasma‐induced asthma exacerbation. respiratory viral infections are associated with the pathophysiology of childhood asthma exacerbation. 1 the major pathogens involved are human rhinovirus (rv), respiratory syncytial virus (rsv), enterovirus (ev), influenza virus, and human metapneumovirus (hmpv). 2 in previous studies, rsv has been associated with wheezing during infancy, whereas rv has been detected more frequently in school-age children with wheezing. 3 however, most studies on the association of viral infection with asthma exacerbation were conducted for only one season. [4] [5] [6] one season analysis is insufficient to comprehend the prevalence of virus-and mycoplasma-induced asthma exacerbation as viral or mycoplasma prevalence might show seasonal variation or some might be found temporary as an epidemic, suggesting that a longer-term analysis is needed. therefore, this study aimed to clarify the association between asthma exacerbation and causative pathogens for three seasons. in addition, epidemiologic profile of causative pathogens and possible factors for exacerbation were explored. asthmatic children hospitalized with asthma attack (n = 226) were enrolled at the department of pediatrics, yamaguchi university hospital, between april 2012 and may 2015. five subjects were excluded due to lack of the consents from the patients and parents, and three subjects were excluded due to sufficient clinical and laboratory data. two subjects were excluded because the nasopharyngeal samples were not properly obtained. as a result, 216 participants were enrolled for the analysis ( figure s1 ). bronchial asthma was diagnosed according to the japanese pediatric guideline for the treatment and management of bronchial asthma 2012 (jpgl 2012), 7 which includes recurrent respiratory symptoms such as whistling, wheezing, difficulty in breathing, and chest tightness appearing during the night or early morning, chest auscultation for wheezing, respiratory function tests, ige tests, and family and patients' past histories of allergic diseases. asthma exacerbation was defined as respiratory symptoms such as wheezing, cough, difficulty in breathing, chest tightness with chest auscultation for wheezing, and/or decrease in airway flow relieved by inhaled short-acting beta-2 adrenergic agonists (saba), and the intensity of asthma exacerbation was classified into four stages: mild, moderate, severe exacerbation, and respiratory failure according to jpgl 2012. 7 the level of asthma control was categorized in accordance with international consensus on (icon) pediatric asthma. 8 the criteria for hospitalization were episodes of difficulty in sleeping at night, or oral ingestion difficulty, and/or oxygen saturation of peripheral artery (spo 2 ) < 95%. patient demographic information was obtained from the hospital chart and questionnaires. informed consent was obtained from the parents and/or the patients recruited in this study. this protocol was approved by the institutional review board of yamaguchi university hospital (h24-11). nasopharyngeal samples were collected from all patients. sampling from the nasopharyngeal and transportation of the specimen to yamaguchi prefectural institute of public health and environment were performed by well-experienced pediatricians. the samples were analyzed by reverse transcription-polymerase chain reaction (rt-pcr) to amplify specific genes from ev, 9 rsv, 10 piv, 11 hmpv, 12 rv (subtypes a, b, and c), 13 influenza viruses (subtypes a and b), adenoviruses (adv), 14 coxsackie virus (cox), 9 human coronavirus (hcov), 15 and mycoplasma pneumoniae 16 pathogen-specific clinical and laboratory features such as bronchial asthma severity, intensity of asthma exacerbation, the level of the asthma control, and hematologic and immunologic tests were analyzed both by univariate analyses (mann-whitney u test or • asthma children (n = 216; 6 months-17 years) hospitalized with exacerbation were enrolled consecutively for 3 years in a single center. • multi-season analyses allowed us to explore epidemiological profile of causative pathogens and possible factors for exacerbation. • rhinovirus (rv) and respiratory syncytial virus were most frequently detected. • although a sporadic epidemic of ev-d68 was detected, no seasonality in pathogen types were observed. • children with rv-associated exacerbation were more likely infected with rv on the subsequent admission. • multivariate analyses suggested that good asthma control and avoidance of allergy sensitization could prevent rv-associated asthma. chi-square test) and by multiple logistic regression analysis. analyses and calculations were performed using bellcurve for excel and statflex for windows ver 7.0 (artech inc). the characteristics of clinical and laboratorial data were summarized ( 48%) was the most commonly detected virus in participants with asthma exacerbation followed by rsv (n = 10; 6%). as rv and rsv were mostly detected in the participants with asthma exacerbation, we compared clinical characteristics among participants with single infection in whom we detected rv or rsv ( table 1 ). the median age and serum house-dust mite ige levels at admission were significantly higher in the rv group than those in the rsv groups (p < .01). there was no significant difference in body temperature, spo 2 , duration of admission, the median number of peripheral white blood cells (wbcs), and serum levels of c-reactive protein (crp) between the two groups. no significant difference was observed in the intensity of asthma exacerbation on admission, bronchial asthma severity, and the level of asthma control between the groups as well. although rv type a and type c were detected in the majority of participants infected with rv (type a, n = 33; type b, n = 1; type c, n = 52; unknown, n = 1), there were no significant differences in ta b l e 1 clinical characteristics, asthma exacerbation intensity, and asthma severity in the total subjects and the asthmatic subjects with single infection of rv and rsv body temperature, spo 2 , duration of admission, laboratory data, intensity of asthma exacerbation, bronchial asthma severity, and the level of asthma control between the two groups (data not shown). to explore epidemiologic features of rv-associated asthma exacerbation, multiple logistic regression analyses were performed by setting the status of rv vs. non-rv-associated exacerbation as objective variable (table s1 ). it revealed that insufficient control status and higher serum house-dust mite ige levels are related to rv-associated asthma exacerbation requiring hospitalization (p < .05 and p < .01, respectively). next, clinical characteristics, intensity of asthma exacerbation, bronchial asthma severity, and the level of asthma control were compared in the asthmatic patients with single infection and superinfection ( table 2 ). the median age and house-dust mite ige levels at admission were significantly higher in the single infection group than those in the superinfection group (p < .001), whereas there were no significant differences in body temperature, spo 2 , duration of hospitalization, serum levels of crp, intensity of asthma exacerbation, and bronchial asthma severity between the two groups. multiple logistic analyses revealed that elder age and higher housedust mite ige levels at admission were related to single infection as well (p < .001 and p < .05, respectively, data not shown). seasonal pathogen distribution associated with asthma exacerbation has not been conducted so far because most studies on the association of pathogens with asthma exacerbation were conducted for only one season. 4 distribution based on the month of admission ( figure 2 ). there were no seasonal peaks in virus and/or m pneumoniae detections, although rv and piv were detected in all seasons. next, we evaluated the detected pathogens in the patients with asthma exacerbation on multiple admissions. among the 31 patients on multiple admissions, rvs were repeatedly detected in 18 patients on subsequent admissions as well as on the initial admission (table 3) , which showed that those with initial rv infection associated asthma exacerbation were likely to be infected with rv on the subsequent admission as well (p < .01). in this study, six asthmatic patients had ev infection, and ev-d68 was detected in all six patients. we evaluated the relationship between ev-d68 infection and hospital admission due to asthma exacerbation ( figure 3) . a low prevalence was observed only in 2013, but not in 2012 or 2014, suggesting that ev-d68 prevalence was not annual, unlike that of rv, rsv, or piv. in this study, rv (48%) was the most detected virus among subjects with asthma exacerbation followed by rsv (6%), and the age on admission was significantly higher in the rv group than in the rsv group. the detection frequency of rv and rsv in our study was consistent with that in previous reports on the relationship between causative viruses and exacerbation in asthmatic patients, suggesting that our study illustrates the actual virus prevalence associated with asthma exacerbation. 2, 3 heymann et al 20 reported prevalence of rhinovirus infection was much less in the wheezing patients aged <3 years compared to those above the age. thus, we compared rv prevalence between the patients with <2 years old (n = 67) and those above the age (n = 149). pathogens were identically detected in 79% in both groups. however, rv was detected in only 38% of the patients <2 years of age, whereas the virus was detected in 57.6% of those ≥2 years. this difference in the rv detection rate was statistically significant (p = .002), which explains an overall lower prevalence of rv in our study (data not shown). there are several studies showing that rv infection is more associated with wheezing in older children. 3, 21 in our three-season analysis, the median age of subjects with rv infection was significantly higher than that of participants with rsv infection, which was consistent with the results of previous reports based on one season analysis. allergic sensitization was reported to be related to rv-associated wheeze. 22 interestingly, we observed a closer association of house-dust mite-specific ige with the rv group than with the rsv group. multiple logistic regression analysis revealed that there is a closer association of insufficient asthma control and house-dust mite-specific ige with the rv group than with the non-rv group. these suggest that rv-associated asthma exacerbation is related to allergen sensitization and that good asthma control could prevent rv-associated asthma exacerbation. rhinovirus type c is reported to cause more severe attacks than other rv types. 23, 24 however, there was no significant difference in the intensity of asthma exacerbation between the rv type a and type c groups in our study. zheng et al 25 reported that rv type a infection with high viral load leads to severe asthma exacerbation; we therefore speculate that the difference in the viral load of subjects between rv type a and type c may reflect similar results in asthma exacerbation intensity and asthma severity in our study. there was no significant difference in intensity of asthma exacerbation and bronchial asthma severity between the single infection group and the superinfection group, suggesting that superinfection does not exert additional effect on asthma exacerbation. interestingly, we observed the association of elder age and higher house-dust mite ige levels with single infection in multiple logistic analyses. allergic sensitization was suggested as leading to increased susceptibility to rv, and rv-associated wheeze. 22 our results confirmed the reported finding of exacerbation of asthma associated with rv. it is interesting that rvs were repeatedly detected in multiple admission cases based on our three-season analysis; that is, patients with initial rv-associated asthma exacerbation were likely to be inwas only detected in 2013 during the three-season study, which is in agreement with the outbreak that occurred in japan during the study period. 27 we previously reported ev-d68 outbreak in the same area in 2010. 28 there has never been an outbreak of ev-d68 since autumn 2010 to spring 2015 (data not shown). this suggests that ev-d68 outbreak is not an annual but a time-limited event. there are some limitations in this study. first, this is a pilot study conducted in a single center. further multi-center studies involving different regions are warranted to confirm the relationship between causative pathogens and asthma exacerbation. second, the patients with asthma exacerbations requiring hospitalization were recruited in our study, which may have resulted in a selection bias; that is, children presenting with mild exacerbation in relatively good control were not included. therefore, there can be some limitation in analyzing the impact of pathogens for the entire range of asthma exacerbation. in conclusion, our three-season analysis on the prevalence of causative pathogens in hospitalized children with asthma exacerbation revealed that rv and rsv were most frequently detected. insufficient asthma control and allergen sensitization were clearly related to rv-associated asthma exacerbation. rhinovirus were repeatedly detected in multiple admission cases in our three-season analysis, suggesting that repetitive rv infections could contribute to subsequent aggravation of asthma. putting these findings together, good asthma control could prevent rv-associated asthma development and exacerbation. additionally, epidemic of ev-d68 infection was observed during a few months, suggesting the requirement for multiple-year monitoring to comprehend the prevalence of asthma exacerbation with viral infections including temporary small epidemic. we are grateful to prof. kiyoshi ichihara of our university, a biostatistician with medical background, for his dedicated support for the statistical analyses and writing to improve the scientific quality of our manuscript. there are no conflicts of interest to declare. na and hy contributed equally to this work. hy, ks, ko, so, and sh were the principal investigators taking primary responsibility for the manuscript. rf and so performed the clinical management with helpful discussion for the completion of the study. na, tn, hw, fo, st, and ro took responsibility for the diagnosis and data collection. the nucleotide sequences determined in this study were deposited in the ddbj 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at the end of the article. how to cite this article multi-season analyses of causative pathogens in children hospitalized with asthma exacerbation key: cord-308169-a0ft6wdy authors: custovic, a.; johnston, s. l.; pavord, i.; gaga, m.; fabbri, l.; bel, e. h.; le souëf, p.; lötvall, j.; demoly, p.; akdis, c. a.; ryan, d.; mäkelä, m. j.; martinez, f.; holloway, j. w.; saglani, s.; o'byrne, p.; papi, a.; sergejeva, s.; magnan, a.; del giacco, s.; kalayci, o.; hamelmann, e.; papadopoulos, n. g. title: eaaci position statement on asthma exacerbations and severe asthma date: 2013-11-06 journal: allergy doi: 10.1111/all.12275 sha: doc_id: 308169 cord_uid: a0ft6wdy asthma exacerbations and severe asthma are linked with high morbidity, significant mortality and high treatment costs. recurrent asthma exacerbations cause a decline in lung function and, in childhood, are linked to development of persistent asthma. this position paper, from the european academy of allergy and clinical immunology, highlights the shortcomings of current treatment guidelines for patients suffering from frequent asthma exacerbations and those with difficult‐to‐treat asthma and severe treatment‐resistant asthma. it reviews current evidence that supports a call for increased awareness of (i) the seriousness of asthma exacerbations and (ii) the need for novel treatment strategies in specific forms of severe treatment‐resistant asthma. there is strong evidence linking asthma exacerbations with viral airway infection and underlying deficiencies in innate immunity and evidence of a synergism between viral infection and allergic mechanisms in increasing risk of exacerbations. nonadherence to prescribed medication has been identified as a common clinical problem amongst adults and children with difficult‐to‐control asthma. appropriate diagnosis, assessment of adherence and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors) have to be a priority in clinical assessment of all patients with difficult‐to‐control asthma. further studies with improved designs and new diagnostic tools are needed to properly characterize (i) the pathophysiology and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma. and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma. at a recent summit organized by the european academy of allergy and clinical immunology (eaaci), a group of experts discussed current issues of concern and unmet needs in regard to the treatment of asthma. most attendees presented evidence that the current guideline-driven treatment strategies fail in two vital aspects of asthma. there was a general consensus that the needs of patients with severe asthma or frequent asthma exacerbations are not being adequately covered by the current treatment guidelines and are of major health and socio-economic concern. such patients suffer from significantly reduced quality of life and incur disproportionately higher costs on health service resources. this report summarizes the current data that indicate the need for a more rational approach to the treatment of asthma and one that takes into account the emerging evidence for pathophysiological heterogeneity of the disease, including its more severe forms. a significant outstanding problem in the clinical management of asthma is the failure to prevent and/or efficiently treat asthma exacerbations, which are associated with significant morbidity, risk of death and high treatment cost (1) (2) (3) . generally, an asthma exacerbation is considered to be an increase in a patient's asthma symptoms with increasingly impaired lung function that require increased medication, an unscheduled visit to a physician or hospitalization. a single asthma exacerbation requiring extra medication and possibly emergency treatment and hospitalization can increase the annual treatment costs by more than threefold (3) . recurrent asthma exacerbations lead to a progressive decline in lung function (4) , and the risk of an exacerbation doubles in children who have had one or more in the previous year (5) . a rare but distinct phenotype of asthma exacerbation is characterized by the development of sudden severe asthma symptoms in an otherwise mild or asymptomatic asthmatic subject, which may be triggered by an allergen, drug (e.g. aspirin), food, air pollutant, occupational agent, virus infection or, in many cases, an unknown (or unidentified) trigger (6) . it has been proposed that within the group of patients with recurrent exacerbations, detailed phenotyping in terms of clinical symptoms, lung function, inflammatory and other biomarkers is warranted (7, 8) . there is a significant unmet need for identifying and characterizing the factors that increase the risk of asthma exacerbations and the therapeutic and preventive options that reduce these risks. patients with severe asthma have high morbidity and mortality, often require hospitalization and are expensive to treat. they have diverse clinical profiles, which probably reflect diverse disease mechanisms, and, for many of them, standard treatment is not sufficiently effective (9) (10) (11) . severe asthma comprises a highly heterogeneous group of patients, which is defined in various ways in the published literature and in the national and international guidelines. a consensus is emerging that patients should be considered to have a 'difficultto-control asthma' if they have persistent symptoms and recurrent exacerbations despite being prescribed therapy at the highest steps of the guidelines' pharmacological management (12) . however, it is worth emphasizing that the guidelines also make clear that 'difficult-to-control asthma' is multifactorial, and issues such as incorrect diagnosis, comorbid conditions, nonadherence to prescribed medication, psychosocial morbidity and a number of other factors discussed later in this manuscript are major causes of 'difficult' asthma (12) . patients should be considered to have severe asthma that is resistant to currently available therapies only following a detailed analysis and appropriate management of all these background problems that are amenable to intervention. a recently published consensus statement on severe asthma broadened the concept of 'difficult asthma' to reflect the situation in less developed countries, where access to medications and appropriate care is a major issue, by defining three different patient groups including un(der)treated symptomatic patients, patients with low treatment adherence or unconventional therapies, and those remaining symptomatic despite high doses of anti-asthmatic therapies (13, 14) . nonadherence to prescribed medication has been identified in a number of studies in the developed countries as the most common clinical problem amongst adults (15) and children (16) with asthma, including those with difficult-to-control asthma (15, 17) . appropriate assessment of adherence (18) and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors, etc.) (19) has to be a priority in clinical assessment of all patients with difficult-to-control asthma, before any decision about increasing the treatment is made (including possible prescription of an expensive biological therapy) (17) . the clinical diversity and the underlying pathophysiology of severe treatment-resistant asthma need to be characterized, so that rational therapeutic targets can be identified and relevant biomarkers validated (20) . in addition, there is a need for controller as well as noninterventional studies in this patient population. although inhaled corticosteroids may protect against asthma exacerbations due to allergen exposure, they are reported to be relatively ineffective in children with virus infectioninduced wheezing (21) . this suggests the existence of different types of childhood asthma with different underlying pathophysiologies (22, 23) . recent joint modelling of longitudinal observations on wheezing from parental reports and medical records identified a novel phenotype of persistent troublesome wheeze with high rates of severe asthma exacerbations and healthcare utilization (24) . despite having phenotypic markers commonly considered to be indicators of good therapeutic response (atopy and eczema), these children had relatively poor response to currently available antiinflammatory treatments (24) . an atopy-related phenotype of children with high risk of asthma exacerbations has recently been identified by bayesian inference in two birth cohort studies in which multiple skin and ige tests were collected throughout childhood (25, 26) . the analysis revealed several different atopic vulnerabilities, only one of which had a much higher risk of asthma exacerbations (25, 26) . however, this group of children with a significant risk of asthma exacerbations was identified only using longitudinal data, and cross-sectional biomarkers allowing their identification in clinical practice are still lacking. several attempts have been made to identify predictors of asthma exacerbations. several comorbidities associated with recurrent asthma exacerbations have been identified in adult patients (27) , including severe nasal sinus disease, gastrooesophageal reflux disease, recurrent respiratory infections, psychological dysfunction and obstructive sleep apnoea. psychological dysfunction (28) and treatment nonadherence are separate psychosocial factors that may significantly contribute to the risk of asthma exacerbations. a significant number of patients with high rates of asthma exacerbations, and increased airway eosinophilia, were found to have a low perception of their lung dysfunction (29) . asthma exacerbations are frequent in asthma patients with poor treatment adherence, and poor adherence remains one of the major challenges in the treatment of severe asthma (15, 18) . the basis of asthma treatment guidelines is the use of clinical symptoms or impaired lung function to guide treatment of airway inflammation. however, there is a strong rationale for using direct measurement of airway inflammation as an additional means to guide treatment in severe asthma. green et al. (30) reported that titrating treatment to sputum eosinophil counts was more successful in reducing asthma exacerbations than treatment in accordance with guidelines. this was confirmed in a larger, multicentre study (31) , which also reported that the frequency and severity of eosinophilic exacerbations were reduced without increasing the dose of inhaled corticosteroids (ics) (the severity but not the frequency of noneosinophilic exacerbations was also reduced). the treatment strategy of these authors was to (i) treat patients with sputum eosinophil counts of >2% with the minimal ics dose required to reduce sputum eosinophil counts to normal and (ii) consider other treatment options in patients with normal sputum eosinophil counts, such as treatment of airway obstruction with long-acting beta-agonists (labas) or a leukotriene receptor antagonist, or treatment of neutrophilic inflammation with antibiotics. of interest, a treatment approach aimed at specifically reducing airway eosinophils using a monoclonal antibody directed against interleukin (il)-5 reduced the risk of asthma exacerbations in patients with severe asthma and persisting airway eosinophilia (32, 33) . however, it is of note that even after using this targeted approach, approximately 50% of severe exacerbations remained unaffected by the treatment. attempts to identify clinical biomarkers for predicting the risk of asthma exacerbation have so far failed. however, some small studies have identified possible candidate biomarkers. for example, gelb et al. (34) evaluated the use of spirometry and exhaled nitric oxide (f e no) in predicting the risk of asthma exacerbations in 44 stable, mild-to-severe patients with asthma over 18 months. those patients with a baseline fev 1 < 76% of predicted plus an f e no >28 ppb had a probability of an asthma exacerbation in 18 months of 85%, while those with fev 1 > 76% of predicted plus a f e no <28 ppb had zero probability of an asthma exacerbation in the same period. the f e no parameter may be a robust measure of the degree of eosinophil airway inflammation (35, 36) . numerous epidemiological studies indicate that asthma exacerbations are associated with upper respiratory viral infections, mostly with rhinoviruses, and to a lesser degree with respiratory syncytial virus or coronavirus, with frequency estimates of 85% and 60% for childhood and adult asthma, respectively (37, 38) . this was confirmed by the ga 2 len-dare systematic review (39) that reviewed data from 98 published epidemiological studies. the data for childhood asthma are more extensive than that for adult asthma and reveal the absence of geographical influence. the same review indicated that high rates of respiratory bacterial infections are also associated with asthma exacerbations, but the data are inconsistent. however, bisgaard et al. (40) provided evidence that bacterial infection and viral infection were independently associated with wheezing episodes in infants (<3 years old), with odds ratios of 2.9 and 2.8, respectively. although confirmatory studies need to be performed, current data strongly suggest that respiratory infections are the major cause of asthma exacerbations. case-control studies have revealed a synergism between viral infection and allergen exposure in increasing the risk of asthma exacerbation requiring hospitalization in children (41) and in adults (42) . atopic asthmatic patients have more severe and prolonged lower respiratory tract symptoms during rhinovirus infections than nonatopic healthy controls (43) . this may be explained by impaired innate and acquired immunity of the airways in asthma, as indicated from the studies of experimental and clinical viral infection (37, 44) . such impairments in airway immunity correlate with the in vivo severity of the infections and with the viral load (45, 46) . consequently, specific and nonspecific antiviral strategies may have great potential as therapeutic and preventative strategies for asthma exacerbations, a hypothesis that is supported by preliminary clinical studies (37) . patients with asthma also have deficient interleu-kin-12 and type iii interferon responses to bacterial stimuli, suggesting that inadequate host defence mechanisms and mechanisms specific to the infectious agents are the underlying factors for increased susceptibility (45, 46) . rhinovirus and enterovirus infections are more likely to cause an asthma exacerbation than most other viruses in patients of any age, with the exception of rsv in infants (39) , while virus load and virus co-infection rates correlate with symptom severity (47) . case-control studies indicate that asthma subjects are at greater risk of invasive pneumococcal infections than patients without asthma, with reported ors ranging from 2.5 to 12.0 (48-50). for example, the population-based case-control study by klemets and colleagues (49) assessed the risk of invasive pneumococcal (streptococcus pneumoniae) infection (ipi) amongst adult patients with asthma. using a national population-based laboratory surveillance, 1,282 cases of ipi were selected in patients aged 18-49 years (thus largely excluding copd patients) along with 10 noninfected controls per ipi case, matched for age, sex and health district. asthma cases were categorized as high (≥1 hospitalization within the previous 12 months) and low risk (with prescription drug entitlement and no hospitalization within the previous 12 months). overall, 7.1% of cases had asthma (6.0 and 2.4% with high-and low-risk asthma, respectively) vs 2.5% of controls (1.0 and 1.1% with high-and low-risk asthma, respectively), indicating that adults of working age with asthma are at substantially increased risk of ipi. impaired immune responses may be associated with exacerbations in asthmatic children with reduced lung function, but not in those with normal lung function (51) . specifically, at the time of an asthma exacerbation, a lower expression of th1 response genes was observed in children with reduced lung function than in children with normal lung function. other studies have shown that genetic factors such as vitamin d (52) or particulate matter (pm 10 ) (53) can modify the effect of environmental exposure on exacerbation frequency. the advent of genomewide association studies in populations with severe asthma (54) and asthma exacerbations (55) may aid in better prediction of exacerbation phenotypes and the subclassification of patients into subphenotypes that may reflect the differing aetiopathogenesis and response to treatment and so allowing better targeting of treatment. attempts to characterize severe asthma in childhood in childhood asthma, guidelines that outline stepwise treatment escalation with increased disease severity or impaired symptom control fail to adequately deal with nonresponders (56) (57) (58) . in particular, the stepwise treatment appears not always to be appropriate for children younger than 4 years, particularly those with mainly virus-driven asthma, who often do not respond to inhaled corticosteroids (57) . severe asthma in children is complex, with the asthma phenotype changing during development and requiring continual reassessment (56, 58, 59) . this makes cross-sectional analyses of childhood asthma less useful, as any apparent phenotypic stability within a population will obscure the significant individual instability of disease expression. one of the characteristics of severe treatment-resistant asthma in childhood is the large size of skin test wheal to inhalant and food allergens (60) . furthermore, in this patient group, the results of skin tests and ige measurements for individual allergens are not always concordant; as a consequence, both tests should be carried out and quantified (61) . similar quantitative relationship between skin tests (and sige levels) has also been reported in relation to severity of airway hyper-reactivity in adults (62) . rhinovirus infection in infants induces wheeze and, in a longitudinal study, was shown to be significantly associated with the development of childhood asthma (63) . in another 11-year prospective study, teenage asthma was strongly associated with infant wheezing requiring hospitalization (64) . this study identified eczema and allergen-specific ige as early asthma-predictive factors and the risk of developing teenage asthma to be increased fivefold after respiratory syncytial virus-induced wheezing in infants and >10-fold after rhinovirusinduced wheezing. rhinoviruses are frequently found in the lower airways in infants with recurrent respiratory symptoms, with the majority of these rhinovirus-infected infants exhibiting increased airway resistance (65) . in infants with wheezing requiring hospitalization, sole rhinovirus infection, but not sole infection with any other common airway viruses, was associated with atopy (66) . a recent study has demonstrated that a cardinal feature of bronchial epithelial cells from children with severe treatment-resistant asthma is impaired interferon-b and ifn-k induction by rhinovirus (67) . although this patient group was highly atopic, no relationship was observed between atopy, allergy or th2-mediated inflammation with impaired interferon (67) . a longitudinal study of an unselected birth cohort, which monitored lung function from the age of 3-26 years (68), reported that persistent wheezing, starting early in life, was associated with a decline in lung function in adult life and increased risk of exacerbations. a decline in lung function has also been associated with severe asthma exacerbations in adult asthma (4) . a german birth cohort of more than 900 children showed that the risk of development of persistent asthma at age 13 years was significantly increased by early allergen sensitization in combination with exposure to high levels of perennial allergens early in life (69) . in a recent study, predictors of subsequent troublesome symptoms amongst 3-year-old children with wheezing were large skin test responses to allergens and history of previous exacerbations and eczema (24) . attempts to identify phenotypes of adult asthma include the use of unsupervised cluster analyses (70, 71) aiming to group patients who share key features of asthma and airway inflammatory disease. haldar and colleagues (70) grouped patients according to clinical symptoms and evidence of airway inflammation (based on sputum eosinophil count) and found that symptom-led treatment of airway inflammation was appropriate in patients with mild and moderate asthma, but failed in more severe forms. they identified two discordant groups of patients who were refractory to standard treatment approaches and represented about 25% of all patients. one discordant group of patients were characterized as an obese, symptom-predominant, noneosinophilic phenotype, while the other group had few asthma symptoms, but a high degree of airway inflammation. using symptom-driven asthma treatment in these two discordant groups would lead to overtreatment of the former and undertreatment of the latter group. one difficulty with attempts to use clustering techniques to define disease mechanisms is defining cause and effect. in other words, 'are the pathophysiological features a consequence or an underlying cause of the disease?' a further confounding factor is the influence of treatment or lack of it (nonadherence). defining groups of patients with chronic diseases according to different personality traits (72) has identified personality traits that govern treatment adherence. there was a significant overlap between the phenotypes identified by haldar et al. (70) and those identified by moore et al. (71) . other similar initiatives included the eu-sponsored unbiased biomarkers for the prediction of respiratory disease outcomes (u-biopred) consortium that has published a consensus-based systematic algorithm approach to differentiate between 'problematic', 'difficult' and 'severe refractory' asthma in the evaluation of patients with chronic severe asthma symptoms for use in clinical research and specialized care (73) . the published practal consensus report on 'endotypes' (74) attempts to assign patients with asthma to groups sharing specific pathophysiological features, with the aim of identifying a basis for rational treatment of heterogeneous groups. patients with severe asthma are found in each of these groups. three recognizable clinical phenotypes of severe asthma emerge from these various analytical studies (see table 1 ): (i) a severe atopic form, (ii) severe 'intrinsic' asthma (the most malignant severe asthma phenotype (75)) and (iii) severe asthma with obesity. however, it has to be emphasized that distinct pathophysiological mechanisms underpinning these different clinical phenotypes of severe asthma have not as yet been identified. one potential problem of the cross-sectional approach to unbiased clustering is that the analysis does not include the important dimension of time, which may be essential to take into account potentially crucial longitudinal changes. furthermore, while unsupervised learning may be a useful tool to generate new hypotheses, using these techniques to find an association with predefined outcomes such as severe asthma can be misleading if asthma severity is derived using the same variables that are used for clustering. there is mounting evidence to demonstrate a close association between sensitisation to fungi and asthma severity (76) , and the term 'severe asthma with fungal sensitization' (safs) has been proposed for patients with persistent severe asthma and fungal sensitization (77) . proof-of-concept pilot studies have suggested an improvement in asthma after antifungal treatment in this patient group (78) . several studies have shown that the standard guideline treatment of persistent asthma with ics provides a variable response, with 25-35% of asthmatic subjects showing little improvement in fev 1 and/or bronchial hyper-responsiveness (9) (10) (11) . in the gaining optimal asthma control ('goal') study (79) , bateman and colleagues used 1 year of increasing doses of combined ics and laba treatment in patients with persistent asthma and reported that about 30% of patients, with varying degrees of disease severity, did not achieve 'well-controlled asthma'. asthma exacerbation risk may be further reduced using the same medication (i.e. an inhaled combination of a rapid-acting beta-2 agonist and corticosteroid (80)) as a controller and as a reliever of the disease. the price trial (81) aimed to identify predictors of short-term (6 weeks) response to ics. although several baseline biomarkers and asthma symptoms correlated with short-term improvements, only greater bronchodilator (short-acting b2agonist) reversibility showed a strong (p < 0.001) correlation. differentiating between responders (>5% fev 1 improvement) and nonresponders (<5% fev 1 improvement) revealed that asthma control in responders was maintained only with continued ics, while, in nonresponders, no improvement was observed with or without ics. interestingly, tiotropium, a long-acting antimuscarinic agent, still approved only for copd, has been recently shown to further improve lung function in patients with severe uncontrolled asthma (82) . of the four clinical phenotypes of severe asthma described in table 1 , the severe atopic form partially responds to standard treatment. table 2 indicates possible treatment approaches in the two groups of patients with severe asthma, which were described by haldar et al. (70) , that are less responsive to standard treatment. these treatment options for patients with severe asthma who remain symptomatic despite adhering to standard medical care include novel anti-inflammatory drugs that have been shown in preliminary studies to be effective in treating airway inflammation in asthma and so warrant further investigation (32, (83) (84) (85) (86) , and other novel approaches such as bronchial thermoplasty (87) . it is important to note that, for a more effective use of these novel treatment options, a better understanding of the pathophysiology and of the inflammatory mechanisms of the severe asthma subtypes are required in order that studies can delineate specific response patterns. as previously noted, antifungal treatments may be of benefit in patients with severe asthma with fungal sensitization (78, 88) , but large studies are needed to support these initial findings. current treatment of asthma exacerbations is inadequate, and new approaches to treatment are needed. these may include interferon-based treatments, treatments that aim to boost deficient antiviral immune responses and/or specific antiviral treatments. there may be patients with severe asthma who could benefit from treatments that target neutrophilic inflammation without further suppressing anti-infective immunity. another question that needs to be addressed is the possible benefit in asthma exacerbations of antibacterial treatments that are widely used (89), despite not being recommended in guidelines. the advances in molecular biology and immunology are being used to develop novel biological drugs for asthma treatment. these include therapeutic antibodies, soluble receptors, cytokines, small molecules and combinations thereof that target different effector molecules that influence the underlying immune and inflammatory processes. some biological drugs are currently in clinical trials in asthma (90) . however, there are major difficulties in developing novel drugs to treat asthma. these include (i) the complexity of the disease (in terms of the different disease phenotypes and the underlying molecular mechanisms), (ii) the limited number of biomarkers that have been identified for disease classification, (iii) the effectiveness of the current standard treatment approaches (combined inhaled steroid and beta-adrenergic agonist is not only effective but cheap) makes any comparative improvement difficult to identify in multicentre clinical trials, (iv) low patient adherence, which is characteristic of treatments of chronic disease, and (v) preclinical animal models may be poorly predictive of clinical efficacy (90) . importantly, future clinical trials will need to identify the patient groups that respond to novel treatment to provide evidence for the stratified, personalized approach to asthma management. in primary care, recognition of the clinical heterogeneity of asthma and the existence of different forms of severe asthma is obscured by a number of general deficiencies, including limited available time and clinical resources and lack of capacity and clinical capability. nonguideline treatment of asthma is high, and provision of treatment to patients with asthma varies greatly, for example, in the use of ics across european countries (91) . the influence of comorbidities and of asthma exacerbations on asthma symptoms, in both children and adults, are not sufficiently recognized (92, 93) . most patients with asthma in primary care have been found to have uncontrolled disease (94) . furthermore, it is becoming increasingly clear that many patients diagnosed as asthmatic, even after full evaluation at tertiary centres, do not have asthma, but various other diagnoses (95, 96) , which indicate a fundamental need to establish improved diagnosis as a basis of appropriate management (97) . the resources needed to review patients frequently until disease control is achieved vary between healthcare systems. the finnish national asthma programme (98) , predicated on a systematic approach to disease management and underpinned by educational and skills training in primary care, demonstrates that investment in the structure of the health system that delivers asthma care reduces morbidity significantly and at a lower overall cost. the above discussion aims to highlight the prominent issues and the attempts to acquire a better understanding of asthma exacerbations and severe asthma. however, there are several additional clinical and pathophysiological issues of importance for improving our understanding of asthma as a complex disease. these have not been highlighted here partly because there is no scientific consensus of their exact relevance. however, two examples are briefly reviewed here. airway remodelling is associated with poor clinical outcomes amongst asthmatic patients, but the pathophysiological relevance of, and the effect of treatment on, airway remodelling is unclear (99) . airway remodelling is a feature of adult asthma and is found to a similar extent, and quite early, in children with difficult-to-treat asthma (100). using epithelial reticular basement membrane thickening as a marker for airway remodelling, no association between airway remodelling and age, symptom duration, lung function and concurrent eosinophilic airway inflammation was found (100) , albeit in a small number of patients. inflammatory and structural changes typical of asthma, such as airway eosinophilia and angiogenesis, have been observed not only in children with asthma but also in atopic children without asthma, raising the possibility that some of these pathological lesions may be associated with atopy even in the absence of asthmatic symptoms. reticular membrane thickening and the eosinophilic inflammation characteristic of asthma in older children and adults are not present in the wheezing infants with reversible airflow obstruction, even in the presence of atopy (101, 102) . it was proposed that this lack of rbm thickening in wheezy infants was due to the apparent paucity of eosinophilic inflammation (102) , which may have a role in driving allergic airway remodelling (103) . based on the data from many population studies, it is generally considered that the environment has an important influence on the development of asthma and other allergic diseases. however, the proposed mechanisms, particularly the role of atopy, that underlie the effects of environment on asthma aetiology need to be revised in the light of recent findings (104) , such as the evident increase in prevalence of severe asthma in developing countries and its parallel decline in several developed countries (105) . the interaction of environment and asthma disease mechanisms is complex, and genetic variants that are protective in one environment may be associated with increased risk in another environment (106) . • although clinical guidelines improve patient treatment by bringing treatments to groups of patients who best benefit from them, they fail many patients who fall outside of the 'mean' clinical characteristics on which clinical guidelines are based. labas is insufficiently effective in many patients with severe asthma. • young children, particularly those with virus-driven asthma, are often poorly managed with currently available medications. • in asthma, there is a need to focus more on the individual patient, particularly those with severe asthma. • there is a need to recognize asthma as a heterogeneous disease and to properly identify the different disease mechanisms involved in patients with severe asthma. only in this way, we will begin to understand what is 'driving' severe asthma and identify novel therapeutic targets. • in childhood asthma, expression of atopy varies over time and in different characteristic ways that suggest differences in underlying pathophysiological mechanisms in relation to exacerbation-prone asthma phenotype. • in adult asthma, several forms of severe asthma have become recognized, and different treatment approaches to these forms of severe asthma are proposed. • there is a need for a consensus definition of asthma exacerbation that could usefully guide treatment. we need to better understand the mechanisms of asthma exacerbation, develop novel treatments for exacerbations and carry out studies of existing and new treatments to better guide their use. • as in copd, asthma diagnosis and treatment decisions should include consideration of future risk of exacerbations. • current data strongly link impaired innate immune responses and consequent increased risk of infection with increased risk of asthma exacerbations. this provides a sound basis for the development of novel treatments. • there is general concern that patients with asthma are not being sufficiently alerted to the risk of asthma exacerbations and that another term be considered other than 'asthma exacerbation' when describing these events to patients (such as 'lung attack' or 'asthma attack' to equate the seriousness of such an event with a heart attack). • development of diagnostic procedures accessible within primary care to ensure correct diagnosis. • an acceptance of the need for iterative review to gain control of the disease; patients, in whom asthma fails to become controlled, need further evaluation to confirm that asthma is the correct diagnosis and what further evaluations are required. • improved tools for 'scoring' the asthma patient in terms of disease severity, and future risk needs to be developed for use in primary care (97, 107) . • future studies should aim to establish whether serum ige, f e no and induced sputum eosinophil counts are valuable biomarkers of the severity of asthmatic airway inflammation. • new biomarkers are needed to predict the severity of asthma, the risk of exacerbation and the response to treatments. • there is a need for a more objective definition of childhood asthma, with broader use of lung function tests, especially in preschoolers, and so obtain more uniform criteria for diagnosis before initiating treatment to control the disease. • in both childhood and adult asthma, expression of atopy varies over time and in different characteristic ways that reveal differences in underlying pathophysiological mechanisms, including a severe asthma-prone phenotype. • observational longitudinal studies should be performed in a standardized way with patient and biological data sampling (using an asthma register) to allow a better characterization of the epidemiology, current healthcare utilization, risk factors (including genetic susceptibility) and comorbidities that are linked to exacerbations and severity. • the future task is to devise studies that differentiate between patient phenotypes, use robust clinically relevant biomarkers, include longitudinal outcomes (such as time to exacerbation and increase in airway remodelling) and identify relevant environmental factors, including the influence of current and prior medication. to facilitate the identification of new asthma endotypes, such studies should contribute to a repository (or biobank) of biological samples from the asthma population. • for characterization of the heterogeneity of severe asthma, more and improved clinical studies are needed to improve the evidence base. • randomized, controlled trials in asthma include highly selected patients, who are, almost exclusively, 'healthy asthmatics' with ß 2 -agonist reversibility. • cohort studies may complement clinical trials. • there are still insufficient longitudinal data in adult asthma, and cohort studies in this age group need to be established. • improving primary care of the asthmatic patient is in need of urgent attention and requires radical changes. • the ideal approach to dealing with the asthmatic patient in primary care is to (i) characterize the patient, (ii) confirm diagnosis, (iii) confirm whether a new or existing patient gains control by the iterative application of a structured review (108) and consider reducing treatment when control is achieved, while undertaking appropriate monitoring, (iv) maintain control by teaching the patient about asthma and developing the patient's self-management skills (109) according to the model developed by glasziou (110) , (v) attempt to understand the patient's perspective; this may be the key to improving patient compliance (111) , (vi) consider the risk of exacerbations (which is separate from controlling everyday symptoms) and factors that may increase the risk of exacerbations (93) and (vii) realize that nonsymptomatic patients are also at risk of exacerbations. • the complexity of the multifactorial nature of asthma and the resource limitations in primary care needs to be better characterized in order to address the wide variability of care delivered in this environment (98) . • support mechanisms that enable readily accessible means for patient self-management and self-education, having already met with varying degrees of success (112) (113) (114) (115) , need to be further developed. • primary clinicians have themselves recognized the research agenda that is needed to direct improvement in asthma care (97). • whether seen in primary care or secondary care, patients with uncontrolled asthma either (i) have treatment-resistant disease, (ii) are not fully compliant with treatment, (iii) are unable to appreciate deterioration in their disease, (iv) have a physician who is underestimating the degree of disease control, is undertreating or not recognizing the effect of comorbidities, or (v) do not have asthma. l. m. fabbri has received consultancy fees from: boehringer ingelheim, chiesi, glaxosmithkline, msd, nycomed, pearl therapeutics, sterna, peer voice europe, om pharma sa, kyorin pharmaceutical, boston scientific and bayer. readings, advisory board or reimbursement of expenses: astrazeneca, novartis, sigma-tau, roche, deutsches zentrum f€ ur luft und raumfahrt, german aerospace center, mundipharma int., genetech inc., elevation pharmaceutical, ferrer group, nycomed, dynamicon and laboratori guidotti. e. bel has received consultancy fees from novartis, gsk and sanofi-regeneron, and fees for speaking from gsk. p. le sou€ ef has received speaker fees from glaxo smith kline and astrazeneca and has received research funding from astrazeneca and pharmanet ag. he has received research grants from the national health and medical research council of australia and the australian research council. j. l€ otvall has over the last five years been a consultant and/or given lectures for gsk, astrazeneca, aerovant, novartis, ucb, oriel and merck, for which he has received honoraria. he has also received research grants and participated in clinical trials for novartis, gsk, astrazeneca and actelion under the full organization of the university of gothenburg. p. demoly is a consultant and a speaker for stallergenes, alk, circassia and chiesi and is a speaker for merck, astrazeneca, menarini and glaxosmithkline. c. akdis serves in the scientific advisory boards of novartis, actellion, circassia, allergopharma and stallergenes. he received research grants from novartis, swiss national science foundation, swiss-polish research grant. d. ryan has been supported to attend conferences, provide consultancy services to or lectured on behalf of az, novartis, chiesi, mundipharma, msd and aerocrine. mika m€ akel€ a has received speaker fees from berlin-chemie menarini, glaxosmithkline, msd and orion pharma. he serves as a consultant for orion pharma. he from bronchoconstriction to airways inflammation and remodeling risk factors and costs associated with an asthma attack an international observational prospective study to determine the cost of asthma exacerbations (coax) severe exacerbations and decline in lung function in asthma the origins of asthma and chronic obstructive pulmonary disease in early life near-fatal asthma phenotype in the enfu-mosa 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remodeling urbanisation, asthma and allergies the international study of asthma and allergies in childhood (isaac): phase three rationale and methods allergic diseases, skin prick test responses, and ige levels in north karelia, finland, and the republic of karelia identifying 'well-controlled' and 'not well-controlled' asthma using the asthma control questionnaire setting the standard for routine asthma consultations: a discussion of the aims, process and outcomes of reviewing people with asthma in primary care selfmanagement education and regular practitioner review for adults with asthma. cochrane monitoring in chronic disease: a rational approach can asthma control be improved by understanding the patient's perspective? improving asthma control through telemedicine: a study of short-message service internet-based self-management plus education compared with usual care in asthma: a randomized trial an internet-based interactive telemonitoring system for improving childhood asthma outcomes in taiwan clinical and cost effectiveness of mobile phone supported self monitoring of asthma: multicentre randomised controlled trial slj is funded by the asthma uk clinical professorship (ch11sj). we acknowledge the editorial support of gerard p mcgregor, of omniscience sa, who was financed by a grant from the eaaci. the authors wish to thank professor christian virchow, universit€ at rostock medizinische fakult€ at, klinik & poliklinik f€ ur innere medizin, abteilung pneumologie, ernst-heydemann-str. 6, rostock, germany, for reviewing the manuscript and extremely useful comments. a. custovic serves as a consultant for circassia. he received speaker fees from glaxo smith kline, thermo fisher scientific, airsonet, novartis, msd and alk. he received research grants from the uk medical research council, moulton charitable foundation national institute of health research.in the past five years s. l. johnston has had research grants from astra zeneca, centocor, glaxosmithkline, med-immune, sanofi-pasteur and synairgen. s. l. johnston holds share options in synairgen. s. l. johnston does some consultancy work for astrazeneca, centocor, glaxosmithkline, medimmune, sanofi-pasteur and synairgen.in the last five years, i. d. pavord has received speaker's honoraria for speaking at sponsored meetings from astra zeneca, boehringer inglehiem, aerocrine and gsk. he has received honoraria for attending advisory panels with almirall, astra zeneca, boehringer ingelheim, gsk, msd, schering-plough, novartis, dey and napp. he has received sponsorship to attend international scientific meetings from boehringer ingelheim, gsk, astra zeneca and napp.m. gaga received research grants from novartis, bi, cephalon, teva and gsk. the other authors of the paper declare no conflicts of interest. key: cord-301022-0q2ertja authors: mims, james w.; veling, maria c. title: inhalant allergies in children date: 2011-04-29 journal: otolaryngol clin north am doi: 10.1016/j.otc.2011.03.013 sha: doc_id: 301022 cord_uid: 0q2ertja children with chronic or recurrent upper respiratory inflammatory disease (rhinitis) should be considered for inhalant allergies. risk factors for inhalant allergies in children include a first-degree relative with allergies, food allergy in infancy, and atopic dermatitis. although inhalant allergies are rare in infancy, inhalant allergies are common in older children and impair quality of life and productivity. differentiating between viral and allergic rhinitis can be challenging in children, but the child's age, history, and risk factors can provide helpful information. allergic rhinitis is a risk factor for asthma, and if one is present, medical consideration of the other is warranted. james w. mims, md a, *, maria c. veling, md b most otolaryngologists see pediatric patients and treat disorders associated with chronic upper respiratory inflammation (rhinitis, otitis, pharyngitis, and laryngitis) as a routine part of their practice. in 2009, otolaryngologists were surveyed by telephone as part of the pediatric allergies in america survey. otolaryngologists estimated that they saw 43 patients aged 4 to 17 years per week and that 41% were diagnosed with ar. 1 pillsbury and colleagues 2 noted that ar was the most common international classification of diseases-9 code used by otolaryngologists in a workforce study conducted in 2000. because allergy is a common contributor of upper airway inflammation, a working knowledge of pediatric allergy is beneficial in the evaluation and treatment of children presenting to otolaryngologists. upper and lower airway inflammation is linked epidemiologically and physiologically. 3 therefore, considering and appropriately identifying coexisting lower respiratory inflammation (eg, asthma) is also logical. identifying asthma in otolaryngology patients is especially compelling because unmanaged asthma impairs quality of life and can be fatal. it is also likely that asthma is underdiagnosed and undertreated. 4 this article informs the otolaryngologist about the development, manifestations, and treatment of allergy in pediatric patients. atopy is the predisposition to develop allergic diseases. the phenotype of allergy seems to have a complicated and variable genetic contribution. gene-environment interactions have been identified, 5 and add another layer of variability to the development of allergic disease. there is no single genetic test to identify if an individual is likely to be atopic. genetic studies looking at single nucleotide polymorphism have focused primarily on allergic inflammatory cells and mediators. although hundreds of associations have been identified, each alone tends to be difficult to reproduce or represents only a small percentage of allergic individuals. 6 large genome-wide association studies use a hypothesis-independent strategy to identify which genes are statistically different between an affected and nonaffected population. in asthma, genome-wide association studies have identified a small number of genes, such as ormdl3, 7, 8 of which the functions remain unclear. currently, the allergy phenotype probably represents multiple and variable combinations of genetic predispositions many of which require a specific environmental interaction to be manifested. so far, the genes identified suggest alterations in both innate and adaptive immunity play a significant role in allergic disease. 9 as suggested by the complicated genetics, family history of allergy is a risk factor, but inheritance does not follow a simple pattern. for ar, family history of atopy is one of several risk factors that include cigarette exposure; higher socioeconomic class; first-born or only child; and elevated total ige (>100 iu/l) before age 6 years. 10 in the danish twin study of asthma by skadhauge and coworkers, 11 the proban-wise concordance of monozygotic males to develop asthma was 0.51 (0.39-0.63), whereas dizygotic opposite sex twins was only 0.07 (0.03-0.11). another study showed that of those with one asthmatic parent, 26% developed asthma. of note, maternal history was more predictive. 12 although not definitive, asking about allergies in first-degree relatives is useful in the evaluation of a child with chronic upper or lower respiratory inflammation. there have been multiple studies investigating if variables in pregnancy affect the later development of allergies including the time of year the child is born, maternal diet, or route of delivery. one study suggested that north american children born in the late fall have a higher risk of developing asthma. 13 this is attributed to the role of winter respiratory viruses, such as respiratory syncytial virus, occurring in the first few months of life increasing the risk of asthma. however, the authors are not aware of any recommendations advising timing of pregnancy based on allergy risk because studies are conflicting and the overall evidence insufficient. restricting maternal diet in pregnancy from proallergic foods has been shown not to affect the development of atopy in the child. 14 some studies have shown some protection from atopy in children delivered vaginally compared with those delivered by cesarean section. 15 the affect is attributed to the "hygiene hypothesis," which is discussed later. ige in cord blood has also been of interest. nonspecific ige is produced in utero starting around 11 weeks gestation, but specific ige is first identified after birth. initial reports of ige levels in cord blood predicting atopy have not been supported in later prospective studies. 16 difficulties in identifying children at high risk for allergy beyond parental allergic history complicates research aimed at attempting to prevent the development of allergic disease. although inhalant allergy is not prevalent during the first 2 years of life, there are clues in infancy as to the risk of later developing inhalant allergic disease. knowledge of these risk factors can be useful when trying to determine if an older child's rhinitis may be allergic. many studies have also examined if there are ways to prevent or reduce the development of allergic disease in children. a basic knowledge of the infant's developing immune system places the risk factors context. in the atopic child, the bias of the immune system toward an allergic response is at least partially influenced by lymphocytes. attention has been focused on t-helper cell lymphocytes because they direct much of the immunologic response to antigens. stimulated t-helper lymphocytes produce different cytokine profiles that are broadly classified as th1 or th2 (a th3 phenotype has also been described). 17, 18 th1 cytokines primarily influence the immune system to act against bacteria and include interleukin (il)-2 and interferon-g. th2 cytokines direct activity more appropriate toward parasites. the th2 influence toward ige and eosinophils also occurs in allergic inflammation. th2 cytokines include il-4, il-5, and il-13. at birth, t-helper lymphocytes are th2 biased (or allergy biased), and as the immune system develops the t-helper cells change to a th1 bias. the "hygiene hypothesis" suggests that challenges to the immune system early in life facilitate the shift to a th1 bias, which protects against allergy. infections early in life, 19 or increased risk of infections represented by exposure to siblings or by early entry into daycare, 20 have been associated with a decreased risk of later developing allergic disease. some studies of t lymphocytes from infants at high risk for atopy have shown not only bias toward th2, but also a decreased production of both th1 and th2 cytokines. it may be that the greater reduction of stimulated th1 cytokines accounts for most of the imbalance compared with controls. 21 paradoxically, as infancy has become more sanitized in developed countries, atopy has become more prevalent. the reason for the increase in allergy is likely to be more complicated than the "hygiene hypothesis" alone and multiple competing theories from changes in exposures, to nutrition, to air pollution exist. manifestations of allergy in infancy include food allergy and atopic dermatitis, which are both risk factors for the later development of inhalant allergy. food allergy is commonly seen in infants and is frequently the first identifier of the atopic child. 22 ten percent of 1 year olds have an elevated ige to a food, most commonly milk or egg. 23 infants with milk or egg food allergy are at increased risk for developing ar and asthma. 23, 24 atopic dermatitis is another marker of atopy in infancy. atopic dermatitis in infancy frequently presents as pruritic eczema of the cheeks and flexural surfaces of the elbows and knees. infants with atopic dermatitis have a 30% risk of developing asthma and a 35% risk of developing ar. 25, 26 early sensitization to inhalant allergies in infancy occurs, but infrequently. herr and colleagues 27 used a standardized questionnaire in 1850 infants at their 18th-month examination to identify children with ar-like symptoms defined as runny nose, blocked nose, and sneezing apart from a cold. of the 1850 infants, 9.1% were found to have ar-like symptoms. all children were then assessed with a specific inhalant ige screen, total ige, and eosinophilia. there was no difference in eosinophilia or total ige in the "ar-like symptoms" group compared with the "no ar-like symptoms" group. inhalant-specific ige was elevated in 5.5% with ar-like symptoms versus 2.7% (p 5 .04) of those without symptoms. however, the allergic rhinitis and its impact on asthma (aria) guidelines include both specific ige sensitization and symptoms in the definition of ar. 28 only 9 of the 1850 children had both ar-like symptoms and elevated inhalant-specific ige. in comparison, there were 43 of 1850 infants with elevated inhalant-specific ige that were identified in the "no ar-like symptoms group." this suggests that ar is rare at 18 months of age and that screening infants for elevated specific ige would lack specificity in identifying infants with clinical symptoms. of interest, five of the nine infants with both ar-like symptoms and inhalantspecific ige elevation were sensitized to dust mite. 28 although ar is uncommon in infancy, viral rhinitis is prevalent. children less than 6 years old average six to eight "colds" annually with symptoms lasting 10-14 days. 29 rhinovirus accounted for 46% of childhood upper respiratory infections in one study. 30 distinguishing between ar and viral rhinitis is clinically significant because a physician might reasonably treat an infant with ar with antihistamines, but antihistamines have been demonstrated as ineffective compared with placebo in viral rhinitis. 31 lower respiratory inflammation in infants has a similar clinical dilemma in differentiating viral bronchiolitis from asthma. viral bronchiolitis (wheezing and tachypnea) accounts for outpatient visits in 15% of infants and 3% are hospitalized. 32 the common causes include respiratory syncytial virus, rhinovirus, metapneumovirus, and coronaviruses. viral-triggered asthma and bronchiolitis are difficult to distinguish from each other, but viral-triggered asthma tends to occur in children who have multiple wheezing episodes, are older than 2 years, and have a family history of atopy. 33 once children are older than 2 years, an association between viral-induced wheezing and asthma risks (elevation in inhalant-specific ige, maternal asthma history) becomes significant. 34 the clinical distinction between bronchiolitis and asthma affects pharmacologic treatment. although bronchodilators and corticosteroids are mainstays of asthma treatment, neither bronchodilators 35,36 nor corticosteroids 37 have been shown to be effective in uncomplicated viral bronchiolitis (discussed later). attenuating the development of allergy through environmental manipulation has not been very successful. a substantial number of studies have investigated restriction of food antigens or environmental controls to prevent inhalant sensitization, but these have yielded conflicting and often paradoxic results. because food allergy is frequently the first allergic manifestation in the atopic child and the prevalence of food allergy is increasing, multiple studies have investigated if restricting allergenic foods (eg, peanut products) from the infant's diet would reduce the development of allergic disease. dietary avoidance of highly allergenic foods was supported by a 1990 study of 1200 infants that correlated the number of solid foods introduced by age 4 months with eczema at age 10 years. 38 however, dietary antigen avoidance has not proved to be effective in most studies and a 2008 review in pediatrics states, "for infants at high risk of developing atopic disease, there is evidence that exclusive breastfeeding for at least 4 months compared with feeding intact cow milk protein formula decreases the cumulative incidence of atopic dermatitis and cow milk allergy in the first 2 years of life." 39 beyond this, whether exposure to antigenic foods early in life promotes sensitization or tolerance is unclear. the effect of breastfeeding in the development of asthma is controversial and studies conflict. 39 in a large cohort, breastfeeding seemed to reduce wheezing episodes in children less than 4 years, but in infants who had a family history of maternal asthma breastfeeding increased the risk of developing asthma after age 6 years. 39, 40 however, a 2009 isaac ii study of 54,000 children found no association between breastfeeding and allergy. 41 this type of disparity between study results is common in research examining the development of atopic diseases, but perhaps not unexpected given allergy's complicated genetics and multiple environmental influences. preventing the development of inhalant allergies with environmental modifications has also yielded inconsistent results. studies have looked at whether cat exposure in infancy might increase the risk of allergic sensitization to cat. in sweden, most children with allergic asthma are sensitized to cat. unexpectedly, a large study reported that having a cat in the home during infancy was associated with a decreased risk of developing asthma. 42 however, the influence of cat exposure seems to be opposite in high-risk groups. in a high-risk population defined by maternal asthma, having a cat in the home during infancy was associated with an increased risk of asthma. 43 attempts to reduce house dust mite exposure to prevent atopic disease in high-risk infants have yielded mixed results. 44, 45 in the manchester asthma and allergy study wheezing was reduced with early intervention against dust mites. 44 the isle of wight study also found dust mite precautions reduced the development of allergy and asthma. [46] [47] [48] however, three other large studies showed no effect: the piama study in the netherlands, 49 the space study in europe, 45 and the caps study in australia. 50 effective interventions to prevent development of allergic disease seem to vary by geographic location, ethnicity, socioeconomic class, and risk factors. genetic tests may one day identify populations where allergic risk and effective prevention strategies are better matched. although preventing allergy through environmental control has shown mixed results, two controlled studies have shown that treating young children who have atopic dermatitis with antihistamines decreases the risk of developing asthma. bustos and colleagues 51 treated children with atopic dermatitis, age 1 to 36 months, with daily antihistamine in a randomized, placebo-controlled trial. they reported 25% fewer diagnoses of asthma in the antihistamine group. the etac study treated 817 atopic dermatitis infants with either placebo or cetirizine. fifty percent developed asthma in the control group, but 25% less in the cetirizine group when they had sensitization to dust or grass. 52 infants with food allergy or atopic dermatitis are at risk for later developing inhalant allergies, but inhalant allergies are uncommon in infancy. successful prevention of inhalant allergy has remained elusive, but treating atopic dermatitis with antihistamines may have a modest but significant benefit. asking about a family history of allergies, food allergy, and atopic dermatitis is likely helpful when considering if allergies contribute to upper or lower respiratory inflammation encountered in the older child. inhalant allergy sensitivities generally develop after the third birthday. 23 there is rarely a need to test for allergies in children less than 4 years of age. total and specific ige increases rapidly in children from 3 to 6 years and peaks in the teenage years. 23 prevalence and spectrum of inhalant ige sensitization increase with age. allergies in children play a well-defined role in nasal and conjunctival inflammation. however, the role of allergy in adenoid hypertrophy and eustachian tube function is less clear. for this section, allergic disease is separated by the different anatomic sites. allergic rhinitis ar is defined by the aria guidelines of 2008 as a chronic disorder of the upper airways that is induced by ige-mediated inflammation after exposure of the nasal membranes in sensitized patients to a specific allergen. 27 the symptoms include nasal congestion, rhinorrhea, sneezing, nasal itching, and postnasal drainage. ar has been traditionally categorized as seasonal or perennial depending on allergen sensitivity. the more recent aria guidelines of the world health organization include a classification that uses duration of symptoms and impact on quality-of-life parameters. 53 the duration of symptoms is either "intermittent" (symptoms for <4 days per week or for a duration of <4 weeks per year) or "persistent" (symptoms that occur >4 days per week and are present for >4 weeks per year). the effect on quality of life is subdivided into either "mild disease" (no impairment of daily activities, no sleep interruption, and no troublesome symptoms) or "moderate to severe disease" (one or more of the previously mentioned symptoms). other guidelines (and the food and drug administration [fda]) divide ar into seasonal and perennial. 54 ar is estimated to affect 60 million people in the united states, and its prevalence is increasing. 55 the prevalence of ar in children is possibly as high as 40%, 56 making it the most common chronic disease in the pediatric population. however, whether ar is self-described, physician diagnosed, or includes allergy testing affects the reported incidence and prevalence. 27 additionally, there is profound geographic variability. 57 most individuals develop symptoms of ar before 20 years of age, with 40% of patients becoming symptomatic by age 6 years. in adults diagnosed with ar, 40% have perennial ar and 20% have seasonal ar; an additional 40% have perennial ar with seasonal flare-ups. 10 the recently published pediatric allergies in america survey suggests that children are more likely to have seasonal allergies compared with perennial ar. 1 the most common triggers of nasal symptoms in the allergic children were pollen, dust, and animal dander. the single most frequently experienced nasal allergy symptom reported by parents was nasal congestion (52%), which was said to occur either every day (25%) or most days (27%) each week during their children's worst month for allergy symptoms. in addition to parental responses, the children 10 to 17 years of age were asked which nasal allergy symptoms they experienced every day or most days during their worst allergy month in the past year. nasal congestion or stuffedup nose (39%), repeated sneezing (36%), runny nose (35%), and watering eyes (20%) were frequently reported as occurring either every day or on most days of the worst month. 1 although ar is not life-threatening, it can be associated with significant morbidity through loss of productivity, 58 cognitive functioning, 59 missed school, 60 and impaired quality of life. 61 many of these health-related quality-of-life issues seem to stem in part from sleep disturbances associated with ar. 62 in addition to impaired quality of life that ar elicits in patients, it can have a substantial economic impact including both direct costs to patients and indirect costs that include patient absenteeism and inefficient performance at school. 60 walker and colleagues 63 compared national examination test performance in winter (practice) and summer (final) in grass-allergic and nonallergic students. compared with controls, grass-allergic students were found to have a significantly increased risk to unexpectedly fail a test section in the summer (grass pollen season) that they had previously passed in the winter. the diagnosis of ar in children is based on clinical evaluation and allergy testing. allergy testing in the absence of clinical likelihood of allergic disease yields unacceptable false-positive rates illustrated by a positive skin prick test in 53.9% of 10,509 americans randomly sampled in third national health and nutrition survey. 64 the differential diagnosis of ar in children differs from adults. children are more likely to have adenoid hypertrophy, nasal foreign body, or choanal atresia contributing to their nasal obstruction than adults. polyps, deviated septum, and neoplasia are more likely causes of nasal obstruction in adults than children. treatment of ar in children is similar to adults. 27 environmental control, pharmacologic therapy, and desensitization are the three main options for treating ar. although counseling about environmental control of ar is recommended, clinical efficacy in controlled studies is often disappointing. terreehorst and colleagues 65 performed a randomized placebo-control trial of dust mite mattress covers in 279 subjects allergic to dust mite. although they did demonstrate decrease in dust mite counts, no clinical improvement in ar was detected between the groups. a recent cochrane review suggested an extensive bedroom-based program including acaracides may "be of some benefit" in ar symptoms. 66 pharmacotherapy for ar consists of antihistamines, decongestants, intranasal corticosteroids, and leukotriene antagonists. the use of first-generation antihistamines should be limited in children because of drowsiness, impaired learning, 67 and paradoxical hyperactivity. pediatric formulations of second-generation antihistamines are found in table 1 , and although appropriate for allergy they have not shown benefit in viral rhinitis or otitis media. topical antihistamines have indications starting at age 5 years for azelastine and age 6 years for olopatadine but compliance in children can be hampered by taste in the authors' experience. decongestants and over-thecounter cough and cold preparations are not currently recommended in children under 2 years of age because of lack of proved efficacy and an association with rare cardiac fatalities in infants. 68, 69 intranasal corticosteroids are indicated down to age 2 years. concerns of reduced growth and adrenal axis suppression have led to differences in the lowest indicated age listed for different steroid molecules ( table 2) . paired papers published in pediatrics in 2000 measured a 0.9-cm reduction in annual height gained with intranasal beclomethasone 70 and no difference in height with intranasal mometasone. 71 the fda has recommended using the lowest effective dose and monitoring growth in children when prescribing intranasal steroids. nasal steroids seem to reduce adenoid size and can be considered for moderate adenoid hypertrophy. however, it is unclear how long the nasal steroids have to be maintained to sustain the reduced adenoid size. 72 other allergy medications for children include pseudoephedrine, chromolyn, ipatropium, and montelukast ( table 3) . montelukast is indicated for perennial ar in children down to age 6 months and may also have a beneficial effect on lower respiratory inflammation. desensitization by subcutaneous immunotherapy in children has been shown to be effective. 73, 74 risk, time, and expense of subcutaneous immunotherapy needs to be carefully matched to severity and ability to control allergic disease. desensitization is unique in its beneficial effect on allergies after the treatment is discontinued, its affect on reducing additional sensitizations, and reduction in the development of allergic asthma. 73 data on sublingual immunotherapy in children have been less convincing than adults. roder and colleagues 74 published a systematic review of sublingual immunotherapy in children that identified seven high methodologic studies of which only one of seven showed efficacy. however, in 2009 and 2010 three large studies showed statistical results for sublingual immunotherapy for grass ( table 4) . [75] [76] [77] each of these three studies showed similar percentages of symptom although ocular disease is not part of the respiratory system, the overlap between ar and allergic conjunctivitis is so great that it is often considered one disease: rhinoconjunctivitis. bielory 78 summarizes several epidemiologic studies to estimate that there is 80% overlap, with 10% having ar alone and 10% having allergic conjunctivitis alone. the large isaac studies looked at rhinoconjunctivitis as single diagnosis and reported symptoms in 8.5% of 6 to 7 year olds and 14.6% in 13 to 14 year olds. 57, 79 as such, children with ar should be assessed for allergic conjunctivitis and topical antihistamine or cromolyn eye drops considered. the relationship between otitis media and allergy has been the focus of several studies with a discrepancy of findings 80 suggesting either large regional differences or bias in associating otitis and allergic disease. the relationship between allergy and otitis media likely varies with the age of the children studied. in the authors' experience, inhalant allergy plays a smaller role in acute recurrent otitis media during infancy compared with chronic otitis media with effusion in 5-or 6-year-old children, especially when there is no infant history of eustachian tube dysfunction. there is very little evidence that acute recurrent otitis media in infancy is associated with inhalant allergies. in 3549 case-controlled pairs, no increased risk of ar at age 6 81 however, the melbourne atopy cohort study of 448 children identified at high risk by having an atopic first-degree relative found an association with asthma. they showed that of the 59% who had at least one episode of acute otitis media when less than 2 years old there was a small to moderate increased risk for physician-diagnosed asthma at age 6 years (relative risk, 1.3; 95% confidence interval, 1.15-1.81). 82 allergic rhinitis may occur more frequently in children with chronic otitis media with effusion, 80 but common pharmacologic therapy for ar (antihistamines, decongestants, and nasal steroids) has not been shown to be effective. 83 one study found 89% of children aged 3-8 years with "glue ear" also had ar diagnosed by symptoms and either nasal eosinophilia or a positive skin prick test 84 ; however, some of these children may have had nonallergic rhinitis with eosinophil syndrome and there may have been a referral bias. in contrast, another study showed a lower but statistically significant association of 16.3% versus 5.5% between chronic otitis media with effusion and ar defined by nasal symptoms independent of a "cold" and positive skin prick test compared with a control group. interestingly, 16.3% would not be characterized as an elevated rate of ar in some epidemiologic studies of children. 56 this underscores how regional differences, age of subjects, and different definitions of ar make comparing outcomes across studies difficult. the american academy of otolaryngology head and neck surgery's 2004 practice guidelines for chronic otitis media with effusion specifically made no recommendation about allergies as a causal agent or effective treatment of chronic otitis media with effusion because of insufficient evidence. 83 the relationship between adenoid hypertrophy and ar is also unclear and there is little evidence linking adenoid hypertrophy with allergy. nuhoglu and coworkers 85 compared adenoid size in ar and non-ar, finding that non-ar was more significantly associated with adenoid hypertrophy in a retrospective study of 108 children (p 5 .0001). marchisio and colleagues 86 found that the poor correlation between adenoid size and clinical nasal obstruction was worse in allergic children, presumably because of turbinate hypertrophy playing a larger role. however, adenoids from atopic children may be different pathologically and have showed increased ige-positive macrophages and plasma cells compared with controls. 87 if turbinate hypertrophy is more frequently the cause of nasal obstruction in allergic children relative to adenoid hypertrophy, nasal steroid sprays or other management of the child's allergies should be carefully considered in the treatment of their nasal obstruction. although there are many causes of inflammation in the lower airway including infections, asthma is the archetypal disease of chronic lower respiratory inflammation in the allergic child. however, not all asthmatic children have allergies. like many other complex chronic diseases, asthma is a single name for a spectrum of disease. hundreds of genes likely influence the pathogenesis of asthma, many of which are influenced by environmental interactions. 88 asthma varies clinically in onset, severity, triggers, and response to therapy. asthma comprises a range of heterogeneous phenotypes that differ and overlap in presentation. although we may be on the cusp of tailoring the diagnosis and treatment of asthma using genetic markers, in 2011 asthma is approached clinically by selecting treatment based primarily on severity and triggers (eg, exercise-induced asthma or allergic asthma). awareness of asthma is important for otolaryngologists because of the epidemiologic link between chronic upper and lower airway inflammation. 27 asthma is underdiagnosed, impairs quality of life, and even mild persistent asthma is potentially life threatening. 4 the ability to identify asthma, initiate treatment, and ensure appropriate continued care should be the goal of every specialist who cares for children that are known to be at increased risk of this common disease. asthma is influenced by both genetic and environmental factors. family and twin studies have indicated that genetics play an important role in the development of allergy and asthma. twin studies suggest that approximately 60% of asthma susceptibility is caused by genetic factors, with indicators of allergic sensitization, such as serum ige levels, also demonstrating heritability. 89 genome-wide linkage studies and case-control studies have identified 18 genomic regions and more than 100 genes associated with allergy and asthma. 9 recently, the gene ormdl3 has been identified as exhibiting a highly significantly association with asthma, a finding that has been replicated in several populations. 90 although genetic predisposition is clearly evident, environmental factors also play a large role in asthma susceptibility and are likely to underlie the increases that have occurred in recent decades. 91 observations of migrating populations and of germany after unification have strongly supported the role of local environmental factors in determining the degree of expression of asthma within genetically similar populations. 92 during early childhood, certain viruses have been associated with the development of the asthmatic phenotype. in a landmark 2008 study, jackson and colleagues 93 showed that wheezing with rhinovirus at age 3 years was more predictive of asthma at age 6 years (or, 25.6) than aeroallergen sensitization (or, 3.4). respiratory syncytial virus, rhinovirus, influenza, and parainfluenza are among viral pathogens associated with wheezing in the first few years of life. 94 in contrast, exposure of an infant to a substantial number of infections, as suggested by the hygiene hypothesis, is seen as protective against the development of the asthma phenotype. 95 although this theory has been supported by some studies of allergy prevalence, 96 it has been partially refuted by recent studies of asthma prevalence suggesting that although large family size (more than four children) is associated with a decreased risk of asthma, birth order is not involved. 97 wheezing and asthma are not synonymous in children. although some 50% of preschool children have wheezing with viral respiratory infections, only 10% to 15% have a diagnosis of asthma by the time they reach school age. 98 wheezing in early infancy and childhood has been divided into three courses: (1) transient wheezing, (2) persistent wheezing, and (3) late-onset wheezing. 99 transient wheezing in early infancy has been well characterized, with decreased airflow rates on pulmonary function testing at birth, onset of wheezing within the first year, and resolution by mid-childhood with no lasting effects on pulmonary function. 98 transient wheezing is the most prevalent form of early wheezing and accounts for 60% of the children who wheeze in infancy. it has no significant relationship to atopy but maternal smoking during pregnancy has been identified as a variable significantly associated with this phenotype. 100 it is suspected that these children have smaller airways, which seems to be associated with maternal smoking, and as they grow the episodic narrowing of the already small airway by viral-induced inflammation becomes asymptomatic. 98 children with persistent wheezing can be subdivided into nonatopic and atopic. nonatopic persistent wheezing comprises 20% of wheezy children under the age of three years and is associated with the first episode of wheezing occurring less than 1 year of age. 98 it is believed that this phenotype may be caused by an alteration in the regulation of airway tone leading to viral-induced wheeze. 101 the atopic persistent wheezing phenotype is found in 20% of children who wheeze during the first 3 years of life and symptoms typically present after age 1 year. risk factors associated with atopic wheeze include male gender, parental asthma, atopic dermatitis, eosinophilia at 9 months, and a history of wheezing with lower respiratory tract infections. 101 this phenotype is also associated with early sensitization to food or inhalant allergens 102 and reduced lung function at age 6 years (compared with children with no history of wheezing with lower respiratory illnesses). 98 late-onset wheezing (wheezing absent before age 3 years, but present at age 6 years) seems to represent another phenotype. these children are more likely to be male, have mothers with asthma, be sensitized to allergens, and have early rhinitis than children who never wheezed. late-onset wheezing represented 15% of children in one cohort. 98 wheezing may also have less common noninflammatory causes, such as an airway foreign body, subglottic cyst, hemangioma, or vascular ring. the most common cause of asthma symptoms in children less than 5 years old is viral infections. there is no single test or risk factor that predicts who will progress to asthma. instead, a predictive index may be used based on the cohort data that separated transient wheezing from persistent and late-onset wheezing. castro-rodriguez and colleagues 103 created a predictive index for ages 2 to 3 years that conferred a 76% chance of asthma by age 6 and a greater than 95% chance of not having asthma by age 6 if negative. guilbert and colleagues 104 modified these criteria for the peak study for clinical use. the index used in the peak study was recommended by the 2007 national institutes of health (nih) asthma guidelines and is as follows: children between ages 2 and 4 years who have had more than three episodes of wheezing (one physician diagnosed) within 1 year and who have met either one major criteria (parental asthma, physician-diagnosed atopic dermatitis, or inhalant allergen sensitization) or two minor criteria (wheezing unrelated to colds, food sensitization, or eosinophilia >4%). children positive for this index had fewer asthma exacerbations and decreased burden of disease if treated with inhaled corticosteroids compared with placebo, but early inhaled corticosteroids failed to prevent asthma development. 105 because atopic children with rhinitis are well represented in otolaryngology clinics and at increased risk for asthma, asking about recurrent wheezing and considering treatment in children who meet the index's criteria would benefit these patients. a check list is provided in table 5 . other important risks for childhood asthma include sensitization to the smaller inhalant allergens by age 6 to 8 years and maternal history of asthma. smaller inhalant allergen travel preferentially to the lungs by virtue of their size and include cat, alternaria, dust mite, and cockroach. the 2007 nih asthma guidelines divides asthma into age groups of 0 to 4 years, 5 to 11 years, and older than age 12 years. asthma is classified into intermittent and persistent disease. persistent asthma is stratified into mild, moderate, and severe. children can be classified based on frequency of wheezing, night time awakenings, frequency of inhaled b2 agonist use, and exacerbations lasting greater than a day. once classified, simple charts recommend the initial treatment for each age group. 4 asthma is a heterogeneous disease and response to treatment needs to be assessed. in most children, optimally managed asthma should result in no missed school, rare use of rescue inhalers, no emergency room visits, and no hospitalizations. treating asthma also reduces asthma mortality. the number of corticosteroid inhalers used annually is inversely proportionally to the chance of death in those with asthma. 106 the 2007 nih asthma guidelines, including charts for classifying severity, stepwise approach to management, and recommendations for altering therapy based on standardized assessment of the control of asthma control, are available free online. the nih asthma guidelines are written to improve the diagnosis and management of asthma by primary care physicians and can be easily incorporated by otolaryngologists. children with rhinosinusitis and rhinoconjunctivitis are at risk for inhalant allergies. allergies often contribute to upper and lower chronic respiratory inflammation. this population of children is likely well represented among otolaryngology patients. inhalant allergies are uncommon in infancy, but food allergy, atopic dermatitis, and allergic disease in a first-degree relative are important risk factors. the differential diagnosis and treatment of ar and allergic asthma are different in children than adults and change with the age of the child. the prevalence of viral rhinitis and viral bronchiolitis should be carefully considered in young children suspected of inhalant allergies. inhalant allergies play a significant role in rhinitis and the associated conditions of allergic conjunctivitis and asthma, but it is less clear how inhalant allergies affect other upper respiratory conditions, such as eustachian tube dysfunction and adenoid hypertrophy. familiarity with the diagnosis and treatment of pediatric inhalant allergy offers an opportunity substantially to improve the quality of life of allergic children. burden of allergic rhinitis: results from the pediatric allergies in america survey the workforce in otolaryngology-head and neck surgery: moving into the next millennium the unified airway: conceptual framework nih guidelines for the diagnosis and 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organization, ga(2)len and allergen) the common cold symptom profile of common colds in school-aged children over-the-counter cold medications. a critical review of clinical trials between 1950 and 1991 bronchiolitis-associated hospitalizations among us children, 1980-1996 bronchiolitis and asthma: are they related? risk factors for acute wheezing in infants and children: viruses, passive smoke, and ige antibodies to inhalant allergens pharmacologic treatment of bronchiolitis in infants and children: a systematic review bronchodilators for bronchiolitis glucocorticoids for acute viral bronchiolitis in infants and young children early solid feeding and recurrent childhood eczema: a 10-year longitudinal study effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas long-term relation between breastfeeding and development of atopy and asthma in children and young adults: a longitudinal study effect of breastfeeding on asthma, lung function and bronchial hyperreactivity in isaac phase ii does early exposure to cat or dog protect against later allergy development? exposure to cat allergen, maternal history of asthma, and wheezing in first 5 years of life effect of environmental manipulation in pregnancy and early life on respiratory symptoms and atopy during first year of life: a randomised trial effect of mite-impermeable mattress encasings and an educational package on the development of allergies in a multinational randomized, controlled birth-cohort study-24 months results of the study of prevention of allergy in children in europe effect of allergen avoidance in infancy on allergic manifestations at age two years allergen avoidance in infancy and allergy at 4 years of age primary prevention of asthma and atopy during childhood by allergen avoidance in infancy: a randomised controlled study placebo-controlled trial of house dust mite-impermeable mattress covers: effect on symptoms in early childhood eighteen-month outcomes of house dust mite avoidance and dietary fatty acid modification in the childhood asthma prevention study (caps) prevention of asthma with ketotifen in preasthmatic children: a three-year follow-up study a double-blinded, randomized, placebo-controlled trial of cetirizine in preventing the onset of asthma in children with atopic dermatitis: 18 months' treatment and 18 months' posttreatment follow-up allergic rhinitis and its impact on asthma diagnosis and management of rhinitis: complete guidelines of the joint task force on practice parameters in allergy rhinitis: a dose of epidemiological reality epidemiology of physiciandiagnosed allergic rhinitis in childhood what have we learnt from isaac phase iii in the asia-pacific rim? presenteeism: at work-but out of it decrements in vigilance and cognitive functioning associated with ragweed-induced 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children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray using nasal steroids to treat nasal obstruction caused by adenoid hypertrophy: does it work? new visions in specific immunotherapy in children: an ipac summary and future trends immunotherapy in children and adolescents with allergic rhinoconjunctivitis: a systematic review five-grass pollen 300ir slit tablets: efficacy and safety in children and adolescents safety and efficacy in children of an sq-standardized grass allergen tablet for sublingual immunotherapy efficacy and safety of 5-grass-pollen sublingual immunotherapy tablets in pediatric allergic rhinoconjunctivitis allergic conjunctivitis and the impact of allergic rhinitis worldwide time trends for symptoms of rhinitis and conjunctivitis: phase iii of the international study of asthma and allergies in childhood the link between allergic rhinitis and chronic otitis media with effusion in atopic patients original article: infections presenting for clinical care in early life and later risk of hay fever in two uk birth cohorts early childhood infections and immunisation and the development of allergic disease in particular asthma in a high-risk cohort: a prospective study of allergy-prone children from birth to six years clinical practice guideline: otitis media with effusion the prevalence of atopic disorders in children with chronic otitis media with effusion a retrospective analysis of adenoidal size in children with allergic rhinitis and nonallergic idiopathic rhinitis clinical assessment of adenoidal obstruction based on the nasal obstruction index is no longer useful in children ige-positive plasma cells are present in adenoids of atopic children using genetics to predict the natural history of asthma? asthma genetics and intermediate phenotypes: a review from twin studies a polymorphism controlling ormdl3 expression is associated with asthma that is poorly controlled by current medications the asthma epidemic prevalence of asthma and atopy in two areas of west and east germany wheezing rhinovirus illnesses in early life predict asthma development in high-risk children viral infections in relation to age, atopy, and season of admission among children hospitalized for wheezing the many faces of the hygiene hypothesis association between sibship size and allergic diseases in the glasgow alumni study asthma prevalence, family size, and birth order asthma and wheezing in the first six years of life. the group health medical associates wheeze phenotypes and lung function in preschool children risk factors for early, persistent, and lateonset wheezing in young children. sidria collaborative group wheezing disorders in the preschool child: pathogenesis and management atopic characteristics of children with recurrent wheezing at high risk for the development of childhood asthma a clinical index to define risk of asthma in young children with recurrent wheezing the prevention of early asthma in kids study: design, rationale and methods for the childhood asthma research and education network long-term inhaled corticosteroids in preschool children at high risk for asthma inhaled corticosteroids: impact on asthma morbidity and mortality table 5 asthma risk checklist for pediatric otolaryngology patients with rhinitis or allergies has your child had greater than four episodes of wheezing in the last year?has a physician diagnosed wheezing in your child in the last year?did your child have wheezing in absence of a "cold" in the last year?has the child's father ever been diagnosed with asthma?has the child's mother ever been diagnosed with asthma?has your child ever been diagnosed with atopic dermatitis?does your child have a food allergy or did they have a food allergy?has your child tested positive for allergies?does your child use an inhaler or nebulizer sometimes?did your child wake up with coughing or difficulty breathing in the last month when they did not have a "cold"? does your child wheeze or become abnormally short of breath with exercise? key: cord-022155-9759i9wr authors: nag, pranab kumar title: sick building syndrome and other building-related illnesses date: 2018-08-18 journal: office buildings doi: 10.1007/978-981-13-2577-9_3 sha: doc_id: 22155 cord_uid: 9759i9wr sick building syndrome (sbs) and building-related illnesses are omnipresent in modern high-rise buildings. the sbs is a complex spectrum of ill health symptoms, such as mucous membrane irritation, asthma, neurotoxic effects, gastrointestinal disturbance, skin dryness, sensitivity to odours that may appear among occupants in office and public buildings, schools and hospitals. studies on large office buildings from usa, uk, sweden, finland, japan, germany, canada, china, india, netherlands, malaysia, taiwan, and thailand, substantiate the occurrence of sbs phenomena. the accumulated effects of a multitude of factors, such as the indoor environmental quality, building characteristics, building dampness, and activities of occupants attribute to sbs. a building occupant manifests at least one symptom of sbs, the onset of two or more symptoms at least twice, and rapid resolution of symptoms following moving away from the workstation or building may be defined as having sbs. based on the peer-reviewed documentation, this chapter elaborates the magnitude of building-related health consequences due to measurable environmental causations, and the size of the population affected. the mechanisms and causative factors of sbs and illnesses include, for example, the oxidative stress resulting from indoor pollutants, vocs, office work-related stressors, humidification, odours associated with moisture and bioaerosol exposure. related regulatory standards and strategies for management of sbs and other illnesses are elaborated. challenging lawsuits to redress grievances. the term sbs has been in use for some time now and widely recognized, in spite of suggestions for alternative names, such as problem buildings, building-related occupant complaint syndrome, abused building syndrome. acknowledging that the incidences of sbs symptoms are straightforward, its characterization and linkages to an indoor exposure require more in-depth analysis. an impediment towards this effort is to make the primary distinction as to whether the problem is chemical, biological, physical, or psychogenic. the questions to examine are the mechanism how workplace or environmental processes trigger physical health symptoms, and whether some individuals are more prone to illnesses. further, it calls for a review on the kind of critical work settings that precipitate illness conditions, and how the work or environmental aspects influence building occupant's psychophysiological threshold, making oneself hypersensitive even to mild irritants. priority is placed on exploring organizational interventions to restrict the spread of the syndrome and efficiently manage causes of building-related illnesses. several researchers indicate the sbs as a phenomenon that occurs among building occupants, perhaps one out of five building occupants reports symptoms associated with their respective place of work and attributed to the iaq. the interactions of a multitude of factors, such as the site, climate, building system, construction materials, building dampness, contaminant sources, activities of occupants, affect the quality of indoor air. typically, maintaining allowable iaq in office buildings depends on effective ventilation systems in operation. ineffective or inadequate ventilation systems result in inefficient removal of pollutants from indoor air and display signs of sbs among the occupants. health impact assessment addresses qualitative or quantitative evaluation of the magnitude of health consequences due to measurable environmental causation or metric, and the size of the population affected (fehr et al. 2012; mesa-frias et al. 2014) . apparent relationships exist between the external stimuli, kinds of human responses and about the type of building environment. therefore, the discomfort and symptoms of occupants in the building require acknowledging that an exposure scenario exists, and the discomfort and disease have a strong association with psychologic or physiological components. a structured questionnaire (table 3 .1) may be used to ascertain the sbs of the respondents in an office building. the office workers who had at least one symptom of sbs and onset of two or more symptoms at least twice weekly, overnight resolution of symptoms after leaving the workstation or building, and the absence of known medical causes, may be defined as having sbs (ooi et al. 1998 ). the prevalence of symptoms among building occupants is linked to personal exposure to the indoor environment. the symptoms may vary during the day, in the course of changes in the concentrations of indoor pollutants. further, the prevalence of syndrome might differ with the specificity of criteria for the definitive diagnosis of a case. accordingly, there may be a shift in the frequency distribution of affected workers when the requirements were changed to one symptom, instead of two or more symptoms (ooi et al. 1998) . for measuring the concentration of indoor air pollutants, one may adopt area sampling by placing an environmental monitoring device in general building locations and placing a personal sampling device close to the nose of the person that better represents the inhaled dose of individuals. chapter 10 is dedicated to indoor environmental quality (ieq) assessment, concerning primary exposures. the exposure assessment based on area sampling and recording of symptoms of occupants from the vicinity of the samplers may indicate some dose-response relationships between exposures and symptoms. however, there are limitations to extrapolate the relation to other buildings, since the problem situations in buildings are unlikely to be similar. epidemiological evidence is abundant of the occurrence of sbs in real-world settings all over the world. within the limited scope, and the author's comprehension on the subject, only a selected number of cross-sectional studies that have been reported in the recent years are briefly summarized in table 3 .2. different research groups emphasized on the association of prevalence of sbs symptoms among the office workers with the organic floor dust concentration, the floor covering of the workplaces, the age of the building, and the kind of ventilation system in operation. the size of the office and the number of occupants in the office were critical, presumably because of likely rise of pollutants during the day. the shelf factor was identified as a risk factor for mucosal irritation, and the fleece factor, such as fleecy surfaces, paper, and cardboard was recognized for general symptoms in the office buildings (skov et al. 1990; mølhave 2011) . despite that carpets give a cozy atmosphere and an aesthetic acoustic environment in a building, carpet fibres and accumulated dust, especially the organic part of the dust, have been found to be associated with sbs, namely mucosal irritation. further details of work and building-related respiratory illnesses are elaborated elsewhere in the chapter. the us epa building assessment survey and evaluation (base) study (apte and erdmann 2003 ) is a landmark study covering 100 large office buildings and extensive measurements of both sbs symptoms and environmental monitoring. the occupant must have reported an occurrence of one sbs symptom, at least 1-3 days per week during the month, and resolution of the symptoms when the occupant moves away from work. analysis indicated dose-dependent associations in many of sbs symptoms with the delta change in indoor and outdoor co 2 concentrations. voc sources had a direct association with mucous membrane and lower respiratory irritation. the whitehall ii sbs study is a longitudinal health survey of uk office-based civil servants, commenced with 10308 males and females, exploring the significance of the physical and psychosocial work environment to the occurrence of sbs. analysing ten sbs symptoms among 4052 participants from 44 buildings, marmot et al. (2006) did not observe the significant relation between most aspects of the physical work environment and sbs symptom prevalence. the features of the psychosocial work environment, such as high job demands and low support, appear to be more determining in explaining differences in the prevalence of sbs symptoms, than those attributed to local aspects of the physical environment of office buildings. examined the occurrence of sbs related symptoms, chronic respiratory symptoms, and respiratory infections, using a questionnaire survey of 342 office workers in finland. a case definition of sbs was taken as symptoms of nasal (dryness or itching of nose, blocked or a runny nose, or sneezing), eye (dryness and irritation, watering, or redness), throat (dry irritative cough, sore throat, or hoarseness), skin (dryness, irritation, redness patches, itching, sore skin, or urticaria), and non-specific symptoms (headache and fatigue), which workers had more sbs symptoms in buildings that were humidified or air-conditioned. complaint: lethargy (57%), nasal congestion (47%), dry throat (46%), headache (46%). symptoms (mean building sickness index) were more in women than in men and were independently more frequent in clerical workers, secretaries than in technical and professional employees and managers skov et al. (1989) were more among females than males might have occurred during the past year, at least 1-3 days per week and mainly during workdays or work shifts. there were significant health effects due to office work exposures, adjusting confounders such as psychosocial factors at work. exposures to paper dust and carbonless paper that contains solvents and colour-forming chemicals increase the risk of a headache and fatigue, chronic breathlessness, and chronic bronchitis (a chronic cough and phlegm production). exposure to carbonless paper through its touching can cause sinus infections, middle ear infections, and increased risk of eye symptoms and diarrhoea. gupta et al. (2007) undertook a questionnaire-based investigation on the prevalence of the sbs at a multi-story centrally air-conditioned airport authority of india building in new delhi. qualitative analysis included the relationships between sbs score, co 2 and other parameters related to building and work environment. quantitative analysis included monitoring of pollutants, namely no x , so 2 , co, and suspended particulate matter. despite that the concentrations of pollutants complied with iaq standards were generally within limits, the prevalence of sbs (a headache-51%, lethargy-50%, and dryness in body mucous-33%) was higher in the third floor as compared to other floors and the control tower. the third floor and the control tower of the airport were affected by infiltration, mainly from entrance doors. hengpraprom et al. (2010) showed the influence of airborne fungi on allergic rhinitis among office occupants (49%) of a high-rise building in bangkok. allergic rhinitis was defined as having the symptoms of nasal congestion, an itchy nose, sneezing, and running nose without a cold in the past 12 months (teeratakulpisarn et al. 2000) . work-related allergic rhinitis was defined as (a) having the above symptoms with a cold at least twice in the past month; (b) expressing the manifestation at work or seeing it worsen at work; and (c) the frequency of manifestation occurred at least 1-3 days per week. indoor humidity was strongly correlated with airborne fungi concentrations. however, the fungal concentration was not associated with work-related allergic rhinitis. asthma and asthma-like symptoms among office workers, respiratory sensitization with exposure to hot or cold weather, the presence of visible mould, and carpeting resulted in a positive association with allergic rhinitis. syazwan et al. (2009) compared the data of sbs and iaq of 176 office workers in old and new buildings in kuala lumpur city. the investigators suggested that improvement in ventilation effectiveness and increase in ventilation rates per person may reflect on the reduction of indoor pollutants and also reduction in the prevalence of sbs in buildings. norhidayah et al. (2013) investigated associations between iaq parameters and sbs in three buildings in malaysia. the prevalence of sbs symptoms, having 1 to 3 symptoms per week, was similar in the buildings. the co concentration and fungal counts were not significantly different between the buildings. however, the observed co 2 concentration and climatic factors suggest that the predictors of sbs might be ventilation and accumulation of contaminants within the indoor environment. many abiotic agents from building materials and interiors like wall coverings, synthetic paints (a&b-pinene), thinners, glue, floor coatings of linoleum and pvc, solvents, such as formaldehyde, hairspray, perfume, photocopiers and printers, disinfectants and detergents (members of linear alkylbenzene sulphonates), and soap as cleaning agent (sodium or potassium salts mixed with fatty acids) add to air pollution to cause sbs symptoms (guo 2011; mcdonnell and burke 2011) . therefore, it may be reiterated from reviewing voluminous literature that no one single cause explains most sbs complaints, but instead assumes that multiple factors interact to manifest occupant complaints. the symptoms typically grow worse during the workday and disappear or diminish after the person leaves the building. women appeared to show a higher prevalence of sbs symptoms as compared to men in the same buildings. individual characteristics, such as education level, working conditions, job characteristics, and other psychosocial factors, can also influence sbs prevalence positively or negatively in men and women. the technical factors associated with the increased prevalence of sbs are the building factors, such as the age of the building, indoor dampness, presence of some photocopiers and humidifiers in the building (sundell 1996) . zweers et al. (1992) examined 7043 occupants (65% female) in 61 office buildings in the netherlands and noted that occurrence of sbs symptoms was related to air conditioning and humidification in buildings. females had more prevalence of sbs (e.g., skin/eye/ nasal symptoms) and complaints of indoor climate, such as temperature, air quality, lighting, and noise. carrying out of study on 4943 office workers (53% female) in sweden, stenberg and wall (1995) observed a higher prevalence of sbs among females (or = 3.4) than males. questionnaire survey and ergonomic data from the german proklima-project (brasche et al. 2001 ) also substantiated a significantly higher prevalence of sbs symptoms among women, as compared to men folks, both under the most favourable and most unfavourable job characteristics. undoubtedly, the physical and psychological disposition, on the one hand, and work-and job-related factors, on the other hand, are risk factors on the perception of the indoor environment and the pathogenesis of complaints. with a sample size of 368 office workers (*77% females) from 6 office buildings in the usa, reynolds et al. (2001) observed that the psychosocial factors were positively correlated with the incidences of sbs in females. however, the environmental factors were correlated with symptoms in males. by examining 877 occupants (50% female) in 12 office buildings in quebec, canada, donnini et al. (1997) observed no significant differences in thermal neutrality between males (23.5°c) and females (23.8°c). females expressed significantly higher thermal dissatisfaction (63% female vs. 37% male). nakano et al. (2002) examined 406 japanese office workers (37% females) and noted a significant difference in thermal neutrality, i.e., females (25.1°c) and males (22.9°c), while females reported a higher frequency of sbs symptoms, as compared to the male group. in a study on 935 office occupants (48% female), in 22 office buildings in australia, cena and de dear (1999) noted the votes of thermal unacceptability, and females complained of significantly higher thermal dissatisfaction than those of males. choi et al. (2010) had a similar observation by studying 402 office workers (*53% females) from 20 office buildings in the usa. runeson et al. (2003) investigated the prevalence and change of sbs symptoms in buildings with suspected indoor air problems about antonovsky's sense of coherence (soc), a psychological measure of life attitude. the study was conducted on a cohort of 194 workers from 19 swedish buildings with indoor environmental problems between 1988 and 1998. information on 16 sbs symptoms was gathered, as well as the soc measure was administered in a postal follow-up. after adjusting for age, gender, history of atopy, and ets, runeson et al. (2003) noted that sbs was more common in women, younger ones, and those with a history of atopy. a low soc was related to a higher prevalence of ocular, nasal, and throat symptoms, tiredness, and headache. also, subjects with a low soc developed more symptoms during the follow-up period. saijo et al. (2009) undertook postal self-administered questionnaire survey to 1,582 dwellings from 40 municipal, and 24 prefectural apartment buildings in the city of asahikawa, japan, and 480 questionnaires were finally analysed. from the questionnaire about moisture condensation and visible mould on window panes, walls, closets, bathrooms, the perception of mouldy odour, and water leakages, a building dampness index was defined as the sum of positive dampness indicators. sbs symptoms recorded for the preceding 3-month period were-fatigue, feeling heavy-headed, headache, nausea/dizziness, difficulty in concentrating, irritation of the eyes, running nose, dry throat, cough, dry or flushed facial skin, itching of the scalp, ears, and hands. the symptoms were significantly higher among females than males. the building dampness index was also significantly related to all sbs symptoms, as also noted by engvall et al. (2001) in the study covering 609 multi-family buildings (14,235 dwellings) in stockholm. saijo et al. (2009) noted allergic diseases as risk factors for sbs development, and therefore, the history of allergic diseases was taken as a confounder for sbs symptom analysis. the us niosh study in 80 office buildings also found a positive association between moisture and debris in the ventilation systems and lower respiratory tract symptoms (mendell et al. 2003) . kim et al. (2013) undertook a comprehensive literature survey, based on north american post-occupancy evaluation (poe) database (n = 38,257). the survey indicated that the satisfaction levels of female occupants were significantly lower than males on all fifteen ieq factors (such as thermal comfort, air quality, lighting, acoustics, office layout, furnishings, cleanliness, and maintenance). the results were consistent, even after controlling the potential confounders, such as age and work characteristics. chronic fatigue syndrome (cfs) manifests as a clinical entity characterized by prolonged severe and disabling fatigue (fukuda et al. 1994) . the syndrome usually occurs sporadically, but occasionally may appear as epidemics. typically, the syndrome follows a cyclical course, alternating between periods of illness and relatively good health. the onset of cfs has been related to a variety of psychological, environmental, and behavioral factors (pizzigallo et al. 1999) , and exposure to pesticides, organophosphates, solvents, and other chemicals (bell et al. 1998) . in tropical areas, many cfs-like cases follow an episode of gastroenteritis due to food toxins from ciguatoxic fish (pearn 1995) . ciguatera consists of a food-chain disease that starts with a reef-dwelling dinoflagellate, gambierdiscus toxicus (gillespie et al. 1986 ), which is heat-stable. individuals can be poisoned from eating fresh or frozen fish, or fish products. symptomatology of some outbreaks of sbs resembles cfs, associating with building characteristics, such as old buildings, inadequate ventilation, non-functioning windows, and inefficient hvac system (chester and levine 1997) . thousands of gulf war veterans, even 5 years after the operation desert storm in 1991, remained ill with vague symptoms that resemble cfs. these veterans were exposed to an array of hazards, such as extremes of climate, dust, and smoke from oil well fires, petroleum fuels and products, depleted uranium (used in artillery shells), chemical warfare agents, pesticides, infectious diseases, and pervasive psychological and physical stress. the veterans were administered with pyridostigmine bromide (as pre-treatment for potential poison gas exposure), anthrax and botulinum toxoid vaccines (landrigan 1997) . haley et al. (1997) identified six different syndromes among the war veterans, namely: syndrome 1 (impaired cognition)-reported by veterans wearing flea collars during the war than those who never wore them; syndrome 2 (confusion-ataxia)-reported by veterans involved in chemical exposure (e.g., pyridostigmine bromide); syndrome 3 (arthro-myo-neuropathy)-exposure to insecticides containing 75% deet (n,n-diethyl-m-toluamide); syndrome 4 (phobia-apraxia); syndrome 5 (fever-adenopathy); and syndrome 6 (weakness-incontinence). the case definition of cfs (fukuda et al. 1994) a. persistent or recurrent fatigue (lasting >6 months) 1. recent and or well-defined onset; 2. not secondary to excessive physical activity; 3. not resolved by rest; and 4. inducing reduction of previous levels of physical and mental activities. b. presence of more than four symptoms (for >6 months), not previous to fatigue onset: 1. impaired memory or concentration; 2. a sore throat; 3. tender cervical or axillary lymph nodes; 4. muscle pain; 5. multi-joint pain; 6. new headaches; 7. unrefreshing sleep; and 8. post-exertion malaise. if the combined number of elements of a and b present exceeds 4, a case of cfs would be considered. the multifactorial aetiology of sbs in office buildings is yet to understand clearly. evidence favours that the accumulated effects of building characteristics and ieq manifest in health outcomes, including sbs symptoms, allergy, asthma, and other respiratory illnesses. the health effects, in turn, cause adverse impacts on job satisfaction, work performance, productivity, and healthcare costs (fisk 2000) . the potential environmental stressors that might be responsible for causing sbs symptoms are briefly mentioned herewith. further details of iaq associated with different pollutants in the indoor environment are described in chap. 10. indoor air pollutants include oxides of nitrogen (no x ), co, co 2 , vocs, and particulates, which are emitted from building materials, office equipment, and as combustion by-products. the intrusion of pollutants from the outdoor air through leakages and ventilation systems is a critical component. the build-up of co 2 may be considered as a surrogate for many occupant-generated pollutants in the indoor built environment. review of studies of sbs symptoms in office buildings indicated increased indoor co 2 levels were associated with an increase in the prevalence of one or more sbs symptoms (seppänen et al. 1999) . findings from more mechanically ventilated and air-conditioned buildings indicated a significant association between an increase in co 2 and sbs symptoms, and total symptom scores. as mentioned earlier, the base dataset (1994-98) yielded significant dose-response relationships between the delta change in indoor and outdoor co 2 concentrations, and the sbs symptoms, such as a sore throat, nose/sinus irritation, mucous membrane symptoms, and tight chest (apte et al. 2000) . headaches represent the single most common symptom in almost all indoor environmental studies ). the current knowledge highlights different forms and mechanisms of a headache, such as a migraine, or a tension-type headache, or any plausible exposure to chemical toxicants, e.g., co or pesticide poisoning. whereas, many of the events do not provide a precise characterization of the office environment (schneider et al. 1999) , such headaches are no less significant given the productivity implications, and the potential for active intervention in the office environment. volatile organic compounds (vocs)-vocs are ubiquitous indoors, due to human activities, building product emissions, including floorings, linoleum, carpets, paints, surface coatings and furniture, and infiltration of the outdoor air. for new or renovated buildings, vocs are primarily emitted from building products. secondary emissions of vocs result from ageing of building products, by chemical decomposition (e.g., moisture build-up or inadequate maintenance) or physical damage due to heat and uv light (wolkoff 1999) . furniture coatings release nearly 150 vocs (aliphatic and aromatic aldehydes, aromatic hydrocarbons, ketones, esters, and glycols) (salthammer 1997) . office equipment and supplies, such as laser printing toners, emit vocs, ozone, formaldehyde, resin, and other particles. use of perfumes indoors may release vocs. indoor fungi are also a source for the production of vocs. many vocs are known toxic compound, with potential for carcinogenicity, mutagenicity, or teratogenicity. documented evidence strongly affirms that occurrence of sbs follows predictable dose-response relationships with increasing concentrations of mixtures of vocs. the vocs, such as o-xylene, styrene, d-limonene and other terpene compounds may readily react with ozone and no x entrained from outdoors and produce highly reactive compounds, including aldehydes and ultrafine particles, leading to sensory irritant symptoms (sarwar et al. 2002; sundell 2004 ). these effects have been observed in case of carpet emissions, latex paint off-gassing, and other office pollutants. it has been viewed that sbs may be related to the lost vocs, i.e., the difference in the concentration of vocs entering the room to that leaving the room. in california healthy buildings study, brinke et al. (1998) adopted an approach in developing voc metrics and identified relationships between sbs symptoms and clusters of vocs by its possible emission sources. the principal component analysis (pca) allowed to cluster vocs into a reduced set of principal component (pc) vectors and further estimated the association between sbs symptoms and the voc exposure metrics, using logistic regression analysis. a similar approach was taken by apte and daisey (1999) in exploring the causal associations between sbs and environmental stressors, using a subset of data from 28 office buildings of the us epa base study. four source-based pc vectors were derived that identify sources as photocopiers, automotive emissions, ets, and latex paints. regression analyses indicated significant associations between mucous membrane-related symptoms and the photocopier vector, after adjustment for age, gender, smoking status, the presence of carpeting, and thermal exposure. sore throat symptoms were associated with the paint vector. analysis of dataset of all 100 base buildings revealed 36 vocs, formaldehyde and acetaldehyde corresponded to 41 buildings, whereas 19 vocs were available in all buildings. the pca yielded ten pcs identified as the voc sources (apte and erdmann 2003) . seven components referred to as furniture coatings (pc1), paint (pc2), construction materials (pc3), printing materials and processes (pc4), carpet and undercarpet (pc5), parking garage (pc6), and cleaning products (pc7) met the criterion of having eigenvectors 1.0. oxidative stress and sbs-several studies suggest that a shallow concentration of vocs in indoor environment may cause sbs symptoms, but how such symptoms generate disability at such low levels remains unexplained. little is known about the likely oxidative stress that can attribute to the occurrence of sbs due to exposure risks of air pollutants or other factors of the environment. reactive oxygen species (ros) are components found in many of the air pollutants and can cause oxidative damage to lipids, proteins, and nucleic acids. urinary 8-hydroxydeoxyguanosine (8-ohdg) is a known biological marker of oxidative stress on dna. accumulation of ets, vocs, formaldehyde in the building due to insufficient ventilation can result in the rise of urinary 8-ohdg levels among occupants (calderon-garciduenas et al. 1999) . lu et al. (2007) gathered data from self-reported questionnaires and analysis of on-site air pollutants and urinary 8-ohdg of 389 employees in 87 government offices of eight high-rise buildings in taipei city. the urinary 8-ohdg was significantly associated with vocs and co 2 levels in offices, and the 8-ohdg level were significantly higher among the employees with sbs symptoms than in those without such complaints. a positive dose-response effect between 8-ohdg levels and the number of symptoms was suggestive that the urinary 8-ohdg as a viable non-invasive marker can be taken as a predictor for sbs. office exposures and work stress-office work-related exposure to paper dust emanated from carbonless copy paper and fumes from photocopiers and printers are health concerns, including respiratory illness among office occupants. observations of substantiated that the exposure to paper dust and carbonless papers carries potential risks of chronic respiratory symptoms, respiratory infections, and other health concerns in an office environment. the stress of work, including extended hours of work, reflects as different work stressors and consequent health impacts among occupants in modern office buildings. there are multiple aspects of work, including physiological, motivation, technical, psychosocial, environmental, perceptual as well as organizational that attribute to work stress. as mentioned earlier, outbreaks of psychogenic illness (sbs) are perhaps a symptom of underlying stress at work and workplace (selvamurthy and ray 1996) . mizoue et al. (2001) carried out a cross-sectional survey of 1281 municipal employees from different buildings in a japanese city. findings indicated that both ets exposure and overtime work contributed to the development of sbs. working overtime for 30 or more hours per month was also associated with sbs symptoms, but the occurrence of sbs reduced by 1/5th after adjustment for variables associated with overtime work and about an-half after further adjustment for perceived work overload. runeson et al. (2006) undertook a postal questionnaire survey as regard to sbs on a sample of 1000 subjects (20-65 years of age), including the three-dimensional model of demand-control-support, regarding social support in actual work situations. results indicated that males and females perceived psychosocial work conditions differently and reacted differently to job stressors. that is, the psychosocial work environment was as important as gender and atopy as a predictor of sbs symptoms. nag and nag (2004) examined the work stresses of women vdt-cum-telephone operators in selected office buildings (telephone exchanges) and observed that the behavioural response to the work stressors, and health and well-being dimensions did vary with the work schedules. the pca analysis of the ergonomics checkpoints yielded five aspects of work, as organizational (pc1-describing job design needs, workplace interventions, and constraints of vdt workstations), environmental (pc2-covering illumination-, climate-, and noise-related hazards), mechanistic (pc3-referring to job specialization, pace of work, information handling), perceptual and motor (pc4-describing visual and auditory displays and controls), and motivational (pc5-referring to personal job characteristics and core dimensions). the loading of the work stressors explained in pc1 to pc3 appeared autonomous, irrespective of the shift schedules at which the women were engaged. the operators in the rotating shift had higher sensitivity to the stressors related to pc4. the day workers responded greater to the stressors related to the core job dimensions that reflect growth needs (pc5). the sleep disturbance, flexibility to sleeping habits, and personality dimension (neuroticism) were negatively correlated with pc1. the digestive problems, social and domestic disruption, and languidity dimensions were positively correlated to pc4 and pc5. the operators in rotating shift had increased demand in the perceptual and motor, and the motivational aspects of work, and thus causing greater negative influence on physical health symptoms, and social and domestic disruption. the job design interventions tailoring to delay the morning shift and adjust the shift length based on the work and climatic load (that is, reduce work hours in the evening shift to avoid peak workload, and extend hours of day work during the hot summer months) might alleviate work stress and enhance health and well-being. manifestations of work-related stress call for organizational analysis and job design interventions in structuring the workplace. thermal discomfort-exceedance beyond the thermal comfort range is associated with increased symptoms, such as a headache, fatigue, and mucosal irritation. besides the relative effectiveness of ventilation systems, uses of increasing numbers of electronic devices in the offices add to the heat loads in buildings. in real-life work environment, a significant proportion of the population remains in uncomfortable situations and shows thermal discomfort. clothing habits in different seasons may also contribute to the causes of thermal discomfort in a hotter environment. humidification-a sensation of air dryness and irritative symptoms from eyes, skin, and upper airways are common factors in the sbs (stenberg et al. 1993) . by examining 104 employees from four geriatric hospital units in southern sweden, nordstrom et al. (1994) evaluated the effect of steam air humidification on sbs and perceived air quality during the heating season. air humidification was raised to 40-45% rh in two units during a four-month period, whereas the other two units were maintained at 25-35% rh. after four months of air humidification during the heating season, 24% of the employees reported a weekly sensation of dryness in humidified units, compared with 73% in controls, indicating that air humidification during the heating season in colder climates can decrease symptoms of sbs and perception of dry air. in a tropical environment, rh remains at a much higher level even in an indoor office environment; therefore, incidences of sbs in such situations may be attributed to factors other than air dryness or humidification. odours-odours associated with moisture and bioaerosol exposure are familiar in buildings and best considered in the context of disease with physiological indicators. the odour characteristics are the basis to investigate the possible adverse effects of moulds on human health, in what is often referred to as sbs. from mouldy buildings, the fungal vocs (such as 1-octen-3-ol and 3-octanone) can produce a range of musty odour (morey et al. 1997) , as listed (table 3 .3). odour recognition thresholds are usually several orders of magnitude below the irritant thresholds (cometto-muniz and cain 1996) . fanger (1988) proposed an unit of pollution, olf (for olfactory) for arbitrarily defining the emission rate of air pollutants from a standard person (white male, 18-30 years of age, showering 0.7 time/day, wear no perfumes, and energy expenditure equivalent of one met for person sitting at rest). the number of olfs is indicated on the initial perception of the odour, referring to discomfort from irritation and annoyance from odour, and overall acceptability. this method was deployed in a project assessing air quality in 20 offices/assembly halls in copenhagen, and 54 external judges adjudged the air quality in unoccupied and occupied, and with or without ventilating systems in buildings. about 42% of the perceived defects in air quality was due to ventilation systems, 38% was due to combined occupant activities and occupants themselves, and 20% due to building materials. the stated method has limitations of efficacy since the raters assess the pollution level in a site within minutes of entering the site. the majority of the occupants may not be able to rate odours consistently, and also the odour annoyance is generally perceived most severe early on first exposure and recedes over time. the building professionals may be amazed at recognizing how the proliferation of fungi in buildings damages the building materials and affects the health of occupants, and more importantly to the causation of sbs and building-associated illness. inadequacy in the ventilation system, moisture controls, and dirt management thrive microbial proliferation in the hvac systems and office carpeting. water incursion into the building envelope is a common cause of moisture build-up and fungal growth. there could be visible mould growth on surfaces, the wall behind wallpaper or under the floor covering, suspended ceiling panels, localized damp areas between a wall and a large item of furniture, and in cavity wall spaces (lugauskas and krikstaponis 2004) . through the routes of inhalation or ingestion, propagules of fungi and bacteria may elicit symptoms of illness, like bronchial irritation and allergy (britton 2003; beezhold et al. 2008 ). broadly, bioaerosol contains fungal and bacterial cells and cellular fragments, and by-products of microbial metabolism build-up in the buildings. particles that range in size from 1 to 5 µm remain suspended in the air, whereas larger particles are deposited on the surfaces (martinez et al. 2004; horner et al. 2004 ). it is not within the present scope to elaborate on the classification of fungi, which are grouped by phylum (division), class, order, family, genus, and species, in the order. khan and karuppayil (2012) indicated that *600 species of fungi are in contact with humans and *50 of them are frequently described in epidemiologic studies on indoor environments. in the present context, several fungal species have been referred to by the researchers about an infestation in building materials and contamination of the indoor environment. some of the species are listed in table 3 .4. wood, wooden building materials, and kiln dried wood surfaces are vulnerable to fungal attack, with infestation by cladosporium and penicillium (penicillium brevicompactum and penicillium expansum) (sailer et al. 2010) . acylated wooden furniture, plywood, and polyurethanes used in wood composites for insulation are found to be susceptible to infestation by aspergillus, trichoderma harzianum, paecilomyces variotii, and penicillium species (yazicioglu et al. 2004; doherty et al. 2011) . prefabricated gypsum board that is used as inner wall materials in buildings favours the growth of stachybotrys chartarum. sterflinger et al. (2013) examined five different indoor insulation materials, i.e., bloated perlite plaster, bloated perlite board, loam and reed, soft wooden board, and sprayed cellulose, for their biosusceptibility. a. versicolor, alternaria, cladosporium, and penicillium species grow in fibreglass insulation and ceiling tiles (erkara et al. 2008) . galvanized steel accumulated with dust or lubricant oil residues allows the growth of fungi (rene et al. 2010; yau and ng 2011) . dampness can cause chemical degradation of polyvinyl chloride (pvc) floor coverings, including formation and emission of 2-ethyl-1-hexanol, 1-butanol (tuomainen et al. 2004) . acrylic painted surfaces are attacked by alternaria, cladosporium, and aspergillus (shirakawa et al. 2011) , and also aureobasidium pullulans can deteriorate the paints (lugauskas et al. 2003) . moisture damage of building frames was characterized by meklin et al. (2003) , studying 17 wooden and 15 concrete or brick school buildings. aspergillus versicolor, stachybotrys, and acremonium were detected in samples from moisture-damaged buildings. observations indicate that moisture damage of the building did not alter the fungal concentrations in wooden school buildings, whereas, in concrete schools, the effect of moisture damage was seen with higher fungal concentrations. the presence of oidiodendron and elevated concentrations of cladosporium and actinobacteria were associated with moisture damage in concrete schools. most fungi are mesophilic, and the optimum temperature for fungal sporulation (number of conidiophores and conidia formed in each conidiophore) is within the range of 20-25°c (burge 2006) . incidently this temperature range corresponds to the human comfort indoors, at which fungi flourish in working environments (burge 2006) . the relative humidity and air currents influence the release of conidia. fungal growth is favoured at a water activity (a w ) of 0.95-0.99, which is a ratio of the partial vapour pressure of water in a substance to the standard state partial vapour pressure of water. ph range of 5-6.5 in building materials allows better growth of most of the fungi (vacher et al. 2010; hoang et al. 2010) . the thermophilic and xerophilic (dry tolerant) fungi are found more in hot-dry climates, than in cooler wetter environments. in tropical and subtropical places, thermophilic and xerophilic fungi tend to be abundant in outdoors with optimal heat and moisture. however, an array of factors are necessary for optimal growth of different kinds of fungi. cladosporium, penicillium, and aspergillus produce high numbers of small and light spores (<10 µm in size). penicillium and aspergillus can grow in substrates with water activity lower than 0.80. the smaller particles can penetrate into the alveolar region when inhaled, evade phagocytosis by macrophages, and transport through systemic circulation (reponen et al. 2007; seo et al. 2009 ), whereas the larger spores and other fragments get deposited in the nasopharynx. kildeso et al. (2003) studied the release of particles from indoor fungi growing in wetted wallpapered gypsum boards, for 46 weeks. when penicillium chrysogenum were subjected to air currents, only spores were released from the colonies, but with aspergillus versicolor, both spores, and fragments were released. with trichoderma harzianum, particles released are-groups of spores (5-6 µm), individual spores (2-3 µm) and fragments (0.7-1 µm). seo et al. (2009) reported the release of fragments and spores from aspergillus versicolor and stachybotrys chartarum growing on the surface of ceiling tiles, wallpapered gypsum board, and culture medium. the studies are suggestive that long-term mould damage in buildings may increase the contribution of fungal fragments to the overall mould exposure. in non-culture-based methods, fungal spores in samples and its morphological identification are determined by light microscopy. components or metabolites of fungi can also be used to quantitate fungi population. specific assays can detect extracellular polysaccharides for partial identification of fungal genera in indoor environments (jovanovic et al. 2004) . polyclonal antibody-based assays detect a broad range of fungal antigens but cannot detect the spores (mitchell et al. 2007 ). molecular methods for quantitation of fungi include the use of genus-/ species-specific probes, polymerase chain reaction (pcr)-based methods, restriction endonuclease analysis, and karyotyping. mitochondrial dna can be used for restriction enzyme analysis and dna fingerprinting for fungal identification. the typical approach for fungal detection in a building utilizes culture and microscopy. different surface and air sampling methods are used for detection and counting of fungi, fungal spores and fragments in ambient air and settled dust, pieces of wallboard, duct linings, carpets (asadi et al. 2011; reponen 2011) . surface sampling allows determining the degree and the types of microbial growth on environmental surfaces (cabral 2010) . adhesive tape sampling method examines the fungi and the hyphal fragments in the specimens using a compound microscope (aydogdu et al. 2010) . in air sampling of fungi, the principles of impaction, impingement, and air filtration have been used. in the impactor method, the airstream is passed through progressively narrower slits into a culture medium and microscopic glass slides covered with an adhesive substance or tape strip is used to collect the sample, and counted by optical microscopy (zhen et al. 2009 ). andersen six-stage impactor is used for collection of particles on culture medium. in andersen sampler, in a petri dish could grow 400 colonies. fast-growing colonies may grow above the slow growing and hinder in counting colonies (stetzenbach et al. 2004 ). the dichloran-glycerol-18 agar (dg-18) culture medium with fungistatic properties prevents the growth of the fast-growing fungi (horner et al. 2004) . liquid impingers collect the samples into the fluid, and the micro-organisms are retained in the liquid until they are cultivated, or evaluated by techniques like biochemical or immunoassays (jo 2011) . shipe sampler, agt-30 glass impinger, midget, multi-stage, and micro impingers are common impinger devices (gralton et al. 2011) . air filtration is used to collect the samples of indoor air in volume. in this method after sampling, the filters are agitated or sonicated in a solution (bazaka et al. 2011) . readers may refer to standard manuals for analytical details. however, the choice of air or surface sampling techniques depends on the purpose of measurement (jung et al. 2011) . air sampling by impingement has some advantages over impaction on solid surfaces; for example, if the concentration of microbes in the atmosphere is too high, the liquid could be diluted before adding to the culture medium. collection of the cells in a liquid avoids desiccation resulting from impaction on solid surfaces (stetzenbach et al. 2004 ). impaction directly onto agar plates may maximize survival of culturable organisms. in addition to impaction and impingement, other methods like filtration by aspiration and sedimentation sampling have been used. in filtration, three types of filter media are used, such as porous fibrous filters with overlapping fibres, porous gel membrane filters, and capillary pore filters. filter materials include glass fibre, mixed cellulose esters, polytetrafluoroethylene, polyvinyl chloride, gelatin, and polycarbonate (martinez et al. 2004) . membrane filters can be placed directly on the surface of culture medium or washed with a liquid, and this added to culture medium. specific filters (namely gelatin) are dissolvable in warm liquids, and the resulting suspension can be plated on agarized medium. that is, filtration devices are adaptable for air sampling of wall cavities or roof spaces to pinpoint foci of contamination. sedimentary sampling (e.g., the gravity slide and the settle plate techniques) is the simplest of all methods. in the gravity slide method, microscopic glass slides, smeared with an adhesive substance, are exposed during a specified period. in the settle plate method, open petri dishes with appropriate culture medium are left open for a given time, depending on the air contamination load. after a certain period of incubation, colonies are counted. an index of microbial air (ima) contamination was proposed; that is, a standard petri dish (dia: 9 cm) containing plate count medium is left open to the air, for 1 h, 1 m from the floor and at least 1 m away from walls. after 48 h incubation at 36°c, the colonies are counted, and the number of colonies is the ima. five ima classes were defined, as 0-5 very good; 6-25 good; 26-50 fair; 51-75 poor; and >76 very poor. the conventional sampling apparatus gives values for fungal particles present in the atmosphere, at the time of sampling; however, other spores and fragments can be attached to the colonies and be released later. the fungal spore source strength determines the maximum amount of fungal particles that can be released from contaminated materials by the action of air currents. from the counting of released particles, the maximum fungal load for a given indoor environment can be calculated (gorny 2004; sivasubramani et al. 2004a, b) . damp concrete floor and visible mould in buildings are constant sources of risk of respiratory tract symptoms, infections, and exacerbation of asthma (lanier et al. 2010; araki et al. 2010) . mucociliary clearance represents the first strategy for removal of fungi/mould from the human respiratory tract. hypersensitivity syndromes, such as hypersensitivity pneumonitis (both acute and chronic) or extrinsic allergic alveolitis, can occur in individuals exposed to conidia, hyphae, or fungal fragments, mycotoxin (trichothecene) (eduard 2009; franks and galvin 2010) . hypersensitivity pneumonitis is generally associated with high igg antibodies concentrations in response to alveolar or bronchiolar inflammation caused by fungi or other allergens. the patients may present neutrophilic inflammation with increased production of tnfa and il-6, and symptoms such as fever, chilliness, dry cough, dyspnoea, changes in nodular bilateral x-ray, fatigue, and headache (eduard 2009 ). aspergillus spp. develops allergic bronchopulmonary aspergillosis and pulmonary aspergilloma (kawel et al. 2011) . undoubtedly, exposure to fungi in indoor environments elicits an ige-mediated hypersensitivity response that precipitates into rhinitis and other forms of the allergic syndromes, such as upper airway irritation, eye irritation, and sinusitis (yike 2011) . during this process, antigen-specific ige is produced that attaches to receptors on mast cells which are concentrated on the gastric and respiratory mucosa. the principal fungal allergens, such as (1-3)-b-d glucan or water-soluble glycoproteins, may become airborne and when its concentration exceeds 4 ng/m 3 , susceptible individuals may show non-specific inflammatory airway reactions and that affect the immune system (kalyoncu 2010; tercelj et al. 2011) . (1-3)-b-d glucan, a cell wall component of filamentous fungi, is readily detected in moisturedamaged building materials, dust samples, and textile floor coverings (reponen et al. 2010; rylander 2010) . ergosterol is found in the cell membranes of fungi, but its content varies with the fungal species (heinrich 2011) . besides, people who inhabit mouldy buildings (presence of s. chartarum and aspergillus spp. in air samples) were reported with cognitive defects and difficulties in concentration (drappatz et al. 2007 ). in mouldy buildings, occupants complain of dermatological symptoms, gastrointestinal problems, reproductive effects, rheumatologic, and other immune diseases. breda et al. (2010) recorded that the rheumatic diseases (inflammation and stiffness in muscles, joints, or fibrous tissues) are exacerbated by indoor environmental conditions, including dampness and fungi infestation. rheumatoid arthritis, ankylosing spondylitis, sjogren's syndrome, and psoriatic arthritis have been observed among occupants in water-damaged buildings with mould growth (muise et al. 2010 ). various fungi produce mycotoxins that are low molecular weight and non-volatile compounds, and potentially carcinogenic, teratogenic, and mutagenic. mycotoxins can also be isolated from fungi-contaminated building materials and house dust (engelhart et al. 2002) . the production of mycotoxins by indoor fungi growing in building materials is usually lower than that cultivated in vitro in building materials (e.g., gypsum board, chipboard) (nielsen 2003; nieminen et al. 2002) . aflatoxins, trichothecenes, and ochratoxins are common mycotoxins in indoor environments (zain 2011; halios and helmis 2010) . other toxins (e.g., t-2, ht-2, deoxynivalenol (don), nivalenol, diacetoxyscirpenol, satratoxins, trichoverrols, verrucarol, verrucarins, trichoverrins) have been described in this group. trichothecenes are a family of mycotoxins produced by species such as cladosporium, aspergillus, penicillium, fusarium, trichoderma, myrothecium, trichothecium, stachybotrys, cephalosporium, giberella, memnoniella (tuomi et al. 2000) . a possible causal relationship exists between mycotoxin exposure and building related illnesses (sen and asan 2009; di giulio et al. 2010) . the effects of trichothecenes exposure in humans include internal burning, vomiting, and diarrhoea with blood, cutaneous necrosis, and internal haemorrhages. evidence gathered that exposure to higher concentrations of penicillium and aspergillus in the indoor environment could induce health problems and sbs symptoms. severe asthma and acute exacerbations of asthma have been associated with alternaria sensitivity and increased airborne concentrations of alternaria spores (salo et al. 2005) . vance and weissfeld (2007) warned that the presence of s. chartarum indoors is a concern since its growth requires water saturation of cellulose-based materials such as paper, cardboard, wood, and gypsum board (menetrez and foarde 2004; gottschalk et al. 2006) . it is likely that plumbing and roof leaks provide the needed moisture for the fungus to grow. the small size, ellipsoid shape stachybotrys spores can reach the lower respiratory tract (murtoniemi et al. 2003) . the causal relationship between s. chartarum and sbs has been debated, with the view that health effects may be due to the presence of other pollutants, like vocs (mvocs), endotoxins, respirable dust, and other compounds in the indoor environment (bloom et al. 2007 ). don, a trichothecene mycotoxin mainly produced by fusarium molds, like other mycotoxins, is an immunomodulator that can enhance or suppress the immune system depending upon the dose and duration of exposure (lee et al. 1999; zhou et al. 1999 ). the t2-toxin, which is produced by species of fusarium and diacetoxyscirpenol, has been shown to modulate apoptosis in human promyelocytic leukaemia cells (yoshino et al. 1996; yang et al. 2000) . several types of research explore the potential association of sbs with particular microbes, biotoxins, or other complex exposure mixture components observed in the water-damaged buildings . trichothecene mycotoxins produced by stachybotrys, satratoxin, and roridin have been identified in serum using an elisa assay. generally viewed that the mixture components, including fungi, bacteria, mycotoxins, endotoxins, and lipopolysaccharides, interact synergistically, through the feedback control of pro-inflammatory cytokine production and induce sbs (huttunen et al. 2004 ). the onset of sbs is typically observed following chronic exposure in water-damaged buildings, extending for many months. needless to mention that health risk assessment for sbs has many uncertainties, such as the extent of toxin accumulation in tissues, interspecies differences in susceptibility, and threshold shifts of the repair mechanisms during chronic exposure (shoemaker and house 2005; . there is an evident need to make the focus on innovative and effective therapeutic interventions (e.g., cholestyramine (csm) therapy) to remove biotoxins from the body, caused by toxic mould exposure. there are nearly 250 vocs of fungal origin that often referred to as microbial vocs (mvocs). these mvocs produce mixtures of simple hydrocarbons, heterocycles, aldehydes, ketones, alcohols, phenols, thioalcohols, thioesters, and their derivatives, including benzene derivatives, and cyclohexanes (korpi et al. 2009; ortiz-castro et al. 2009 ). currently, gas chromatography-mass spectrometry (gc-ms) is the primary method for the detection of mvocs (matysik et al. 2009 ). the electronic nose (e-nose) is an alternative non-invasive technique to detect essential fungi and mvocs. the instrument combines an array of electronic chemical sensors, a pattern recognition processing unit, and a reference library for recognizing odours baietto 2009, 2011) . molhave (2008) emphasized the exposure to mvocs as the aetiological agents associated with sbs, including lethargy, headache, as well as irritation of the mucous membranes. however, the types and concentrations of mvocs in mould-infested buildings vary with the ventilation rate indoors, moisture level, the composition of mould population, and other parameters (schleibinger et al. 2008) . for example, penicillium, aspergillus, and stachybotrys are vocs as well as mycotoxin producers (matysik et al. 2008) . mvocs are produced by the cells and released to the indoor environment, whereas mycotoxins are present inside the cells and fragments (reponen et al. 2007 ). in healthy individuals, the fungal spores and fragments are destroyed by cells of the immune system, but a small number of mycotoxins can still enter in the systemic circulation with possible chronic or sub-chronic toxic effects (straus 2009 ). the fungal release of vocs is sometimes referred to like products of secondary metabolism, and these compounds remain reasonably stable in a range of growth media and conditions (moularat et al. 2011) . moularat et al. (2008a, b) described the assay of vocs produced by aspergillus niger, a. versicolor, and penicillium brevicompactum and identified nineteen compounds resulting from fungal metabolism. mvocs also cause indirect metabolic effects. fungal colonization in urea formaldehyde insulation materials results in the cleavage of urea from the polymer releasing formaldehyde (shinoj et al. 2011; asan et al. 2010) . like other sources of vocs, the exposure of mvocs even at deficient concentrations has been linked to symptoms such as a headache, nasal irritation, dizziness, fatigue, and nausea, independent of exposure to other allergenic fragments and toxins (weinhold 2007; burton et al. 2008 ). researchers have attempted to distinguish between the sbs and building-associated illness tsai et al. 2012) . as discussed, the sbs represents multiple non-specific symptoms among the building occupants, but its occurrence is correlated with some factors, such as the type of ventilation and the condensation or the leakage of water in building indoors. on the other hand, building-associated illness consists of different diseases with known aetiologies (craig and mindell 2011) ; for example, allergic alveolitis, with specific aetiologies, is usually linked to ventilation-based, wet microbial breeding places, such as humidifiers, air washers, heater/cooler units. in multifactorial causal situations, however, several components attribute to creating complex environmental conditions. ventilation inadequacy in indoor spaces may aggravate ieq, resulting in health symptoms, sbs or br and other communicable respiratory illnesses, such as allergy and asthma symptoms, respiratory infections and cardiovascular diseases. the literature emphasizes association of building characteristics, iaq, and inhaling of bioaerosol with the prevalence of respiratory illnesses among building occupants. for easy understanding by the professionals from other building sciences, some common forms of respiratory illnesses are briefly described herewith. details of the respiratory illnesses are found in several online sources, e.g., http://www.mayoclinic.org/ diseases-conditions/copd/symptoms-causes/dxc-20204886. increased prevalence of asthma has long been known as the impacts of outdoor and indoor exposures to air pollutants, and lifestyle habits, as well (eder et al. 2006 ). asthma can be adult onset or occupational in origin. from a clinical point of view, bronchial asthma is a well-known lung condition, defined as a chronic inflammatory disease, due to the contraction of the bronchial muscles, increased mucous production or decreased clearance, and muscle tightening, causing variable airflow obstruction (fig. 3.1) . coughing, wheezing, chest tightness, shortness and shallow breathing, anxiety, and tachycardia are the common signs and symptoms of asthma. the inflammation causes airway hyper-responsiveness and is the reason for the appearance of variable and reversible airflow obstruction. occupational asthma is caused by breathing substances present at workplaces, such as chemical fumes, gases or dust which are irritating or sensitizing. exposure to these substances develops an immune response either to respiratory irritants (gas, fume, or vapour), usually of low molecular mass at high concentration, referred to as irritant-induced occupational asthma, or to sensitizing agents (e.g., high molecular mass-glycoproteins of biological origin), referred to as sensitizer-induced occupational asthma. these exposures are characteristically associated with symptoms at work with relief on weekends and holidays. with early diagnosis and treatment, occupational asthma may be reversible. table 3 .5 includes the most common asthmagen agents. irritant-induced acute occupational asthma (also termed as reactive airway dysfunction syndrome-rads) may occur following a short-duration single high-level irritant exposure to substances, such as chlorine or oxides of nitrogen, or multiple exposures to gas, smoke, fume, or vapour characterized by irritant capacity. respiratory symptoms (a cough, wheezing, chest tightness, and dyspnea) may persist for 3 months. low-molecular mass agents probably become antigenic after conjugation with a body protein (e.g., serum albumin), and its response clinically manifest as direct epithelial cell injury. the procedure to diagnose rads includes analysis of occupational history, inventory of exposures in the workplace, pulmonary function tests (pft), serial peak expiratory flow measurement on work days and days off, histamine or methacholine challenge, and immunological tests, such as specific ige and skin prick, epicutaneous tests (fishwick et al. 2008; tarlo et al. 2008 ). the pft may show evidence of airway obstruction (fev 1 /fvc ratio less than 0.7), although the absence of airway obstruction does not exclude a diagnosis of the disease. for irritant-induced asthma due to indoor environmental exposures, specific bronchial challenges may not diagnose; also the peak expiratory flow (pef) is not diagnostically specific. however, conventional approach of observing an elevated diurnal variation in pef might suggest the presence of asthma. bronchodilator response may be seen in individuals with acute irritant-induced asthma. a chest radiograph is usually normal, although it may show no specific signs associated with coexisting respiratory infection. a bronchial biopsy may indicate possible inflammation with lymphocytes and plasma cells, as a manifestation of epithelial cell injury. sensitizer-induced occupational asthma is characterized by a latency period, which may last from several weeks to months or years, between first occupational exposure to a respiratory sensitizer and the development of immunologically isocyanates (e.g., toluene diisocyanate), acid anhydrides (e.g., phthalic anhydride), amines (e.g., ethylenediamine), fluxes (e.g., colophony), metals (e.g., platinum salts), drugs (e.g., penicillin), plastics (e.g., acrylates), wood dust (e.g., western red cedar) auto-spray painting, varnishing, metal grinding, platinum refineries, pharmaceutical manufacturing, sawmill work, woodworking, other chemicals biocides (e.g., glutaraldehyde), polyvinyl chloride fumes, organophosphate insecticides janitorial work, meat packaging mediated symptoms. once the subject is sensitized, asthma attacks are provoked even with exposure to a shallow concentration of the sensitizing agent. diagnosis is typically achieved from the evidence of reversible variable airway limitations, along with asthmatic trends between periods of work and rest. pft may become normal rapidly after the cessation of the exposure. a serial pef (about four recordings a day) over three weeks has high specificity and sensitivity in making the diagnosis of occupational asthma. serum-specific ige may assist in making a diagnosis, due to its likely presence in persons exposed to allergens with high molecular weight and some chemical agents. skin prick tests may also be positive for the workplace allergen. increased bronchial reactivity to challenge with the agents, such as histamine, methacholine, is evidence of sensitizer-induced occupational asthma, and this may be carried out sequentially over time. allergens that cause occupational asthma can also cause allergic rhinitis (nasal symptoms) that may precede the onset of occupational asthma symptoms or may commence at the same time as asthma symptoms. simoni et al. (2010) showed that upper respiratory tract symptoms were more prevalent in poorly ventilated classrooms. that is, with co 2 levels exceeding 1000 ppm had a higher risk of a dry cough and rhinitis. increased ventilation rate (>0.7 l h −1 ) was associated with a decreased prevalence of allergic symptoms among college students living in dorms in china (sun et al. 2011a ). the occurrence of wheeze decreased with the increase in ventilation rates when co 2 concentration reduced from 1359 to 915 ppm. the prevention of occupational asthma requires environmental intervention and medical management. the primary prevention of exposure, such as improved ventilation and dust control for elimination of the formation of dust, and localized aspiration, is the direct approach towards reducing the incidences of the disease. avoiding cold temperature and air dryness, wearing ppe, and in some cases, adopting prophylactic pharmacological treatments can mitigate asthma symptoms. population screening for early detection is the secondary prevention. the term asthma-like (suspected asthma) is indicative that all asthma-like symptoms are not associated with asthma. these include chronic obstructive pulmonary disease, chronic bronchitis, chronic cough, hyperventilation, mechanical obstruction of the airways, congestive heart failure, pulmonary embolism, gastro-oesophageal reflux, multiple chemical sensitivity/idiopathic environmental illness, sbs, sjogren's syndrome, vocal cord dysfunction. the chronic obstructive pulmonary disease is characterized by a slowly progressive reduction of pulmonary ventilation due to a combination of emphysema and bronchiolitis with obstruction of the small airways. ets is a critical aetiological factor. chronic cough has different aetiologies-a cough at night or associated with physical exercise may be indications of asthma. the asthma tests such as reversibility to a bronchodilator and increased levels of exhaled nitric oxide should be positive (chatkin et al. 1999) . hyperventilation syndrome is indicated by symptoms induced by physiologically inappropriate hyperventilation or voluntary hyperventilation. shortness of breath, accelerated/deepened breathing, and feeling of inability to breathe deeply are asthma-like. symptoms reproduced by a hyperventilation test and a slow recovery of co 2 in blood or expired air are the two criteria for establishing the diagnosis (ringsberg and akerlind 1999) . rads is an illness with asthma-like symptoms that may occur as the direct consequence of excessive toxic inhalation exposure. the bronchial histological changes show an increase in inflammatory cells. however, eosinophils and mast cells do not dominate. multiple chemical sensitivity (also named as idiopathic environmental intolerance) is a disease caused due to some low dose of exposure to chemical toxicants, manifesting diverse symptoms (e.g., headache, weakness, memory problems, inability to concentrate, throat soreness, abdominal pain, and discomfort). one may suffer from nasal congestion and asthma-like symptoms such as cough and chest tightness. as elaborated earlier, sbs is a complex disease caused primarily due to building characteristics of the indoor environment, including inadequacies in air-handling systems. sjogren's syndrome is a systemic rheumatic disease. vocal cord dysfunction is characterized by episodic or acute attacks of breathing troubles similar to attacks of asthma. in asthma-like disorder, treatment compliance with conventional therapy is low (schmier and leidy 1998; chan et al. 1998) . medication with steroids are the most potent drugs in the treatment of asthma. sensory hyper-reactivity (earlier referred to as functional breathing disorder) manifests common symptoms, such as heavy breathing, cough, and increased secretion, difficulty in getting air, and chest pressure (lowhagen et al. 1997) . the symptoms are often induced by trigger factors, such as allergens, chemical irritants, ets and strong scents, cold air, viral infections, physical exercise (millqvist and lowhagen 1998) . symptoms, such as difficulty in breathing and breathlessness, which indicate asthma, may also be indicators of sensory hyper-reactivity. the diagnosis of sensory hyper-reactivity is a clinical challenge; pft is sometimes difficult to obtain due to inability to perform an adequate forced expiration, giving a false indication of bronchoconstriction (ringsberg et al. 1997) . asthma-like symptoms can be provoked by a sensory nerve-mediated disturbance of the respiratory pattern; for example, a capsaicin inhalation test provokes these kinds of symptoms . extrinsic allergic alveolitis (eaa, also termed as hypersensitivity pneumonitis) is type iii and iv hypersensitivity reaction of the alveolar and bronchiolar tissue and interstitium of the lungs, in response to inhaled antigens. a range of environmental allergens, including fungi, bacteria, plant proteins, and other reactive chemicals, may be related to the occurrence of eaa (simon-nobbe et al. 2008; robertson et al. 2007 ). farmer's lung caused by mouldy forage is a well-studied form of eaa. microbiological contamination of air conditioners or humidifiers has been reported to cause of eaa in an office environment. the eaa may manifest as an acute, sub-acute, and chronic form. the former form is more natural to recognize, with symptoms, like a cough, chest tightness, febrile chills, and flu-like illness appear 3-8 h after exposure, fades away gradually over a few hours, and may reappear on subsequent exposure. the sub-acute form presents as progressive shortness of breath, dry cough, and weight loss. the chronic form may show the slow development of interstitial fibrosis. diagnosing eaa requires identifying the source of exposure to contaminants, recording exposure history, including worksite visit and environmental measurements. in physical examination, crackles in the lower fields of the lungs may be noticed. a chest x-ray may show fine interstitial infiltrates in acute and sub-acute forms of the disease, whereas in the chronic form, irregular scarring may indicate diffuse pulmonary fibrosis. in pft, typically patients may show restrictive impairment, i.e., the fev 1 /fvc ratio reduced in comparison with its normal range. the eaa is a diffuse parenchymal disease, and thus, the diffusion capacity of the lungs is affected (both dl co and k co ). bronchoscopy with bronchoalveolar lavage (bal) and transbronchial biopsy may be carried out when investigating a patient with suspected eaa. bal typically shows increased total cell count, with an increased proportion of lymphocytes (>40%). t-helper to t-suppressor ratio is usually reduced to less than 1. after acute exposure, neutrophils are transiently increased. the histopathologic findings include diffuse interstitial infiltrate, scattered non-caseating granulomas, and cellular inflammation of the bronchioles. an inhalation provocation test with the specific antigen can be performed to confirm the diagnosis; a worksite challenge test is a conventional approach, with pft before and after workplace exposure. management of eaa primarily demands to remove the affected persons from the source of exposure. drug intervention with corticosteroids is given at the acute episodes. any dampness or mould problems in buildings should be repaired promptly. humidifier fever, like in eaa, is also termed as a disease related to bioaerosol exposure from contaminated humidifier water, often referred to as monday morning fever. the affected person experiences fever, nausea, sweating, and myalgia, sometimes with breathlessness, about 3-8 h after exposure, which is very similar to those described in outbreaks of eaa. the symptoms diminish towards the end of the working week, and over the weekend, for example, the episode may be worse again. humidifier fever differs from eaa in that the affected person may have specific igg antibodies to the micro-organisms growing in water reservoirs as a sign of exposure. regular maintenance of humidifiers and air conditioners is the best approach to prevent humidifier fever (pal et al. 2000) . legionnaires' disease presents as pneumonia, due to infection with legionella pneumophila, a bacterial micro-organism that may be found in wet surroundings and capable of forming colonies in cooling towers and hot water systems in hospitals and office buildings. an outbreak of legionella pneumophila in philadelphia in 1976 (fraser et al. 1977) with the source identified at the ventilation and humidification system of a hotel, affected 221 persons, with about 20% mortality. the incubation period of the disease is about a week. the early symptoms include illness, headache, myalgia, fever and mild cough, blood in the sputum, and watery diarrhoea (cunha 2008) . there may be a neurological symptom of severe encephalopathy. a chest x-ray may show unilateral lobe infiltrate, with rapidly progressive infiltrations of legionella. complete recovery of the infiltrates may take several weeks to months. urinary antigen detection is a rapid test. however, it is less sensitive than culturing respiratory secretion. superheating of hot water to >50°c and flushing the water distribution systems are crucial to prevent legionella infections. office environment exposures through handling of self-copying paper that contains ink, solvent and dust, acrylate glues used in flooring, pvc, phthalate compounds, and wall-to-wall carpet might induce airway inflammation in humans jaakkola and knight 2008) . professional cleaners in buildings are regularly exposed to cleaning chemicals containing ammonium, bleach, chlorine, and some disinfecting substances, and these people may develop irritant-induced asthma (zock 2005) . table 3 .6 includes different environmental, physical, and social factors, which may cause one or more signs and symptoms related to sbs. second-hand tobacco smoke exposure (shs), containing irritant substances, can potentially induce mucus hypersecretion and inflammation in the airways (jaakkola et al. 2003; gilmour et al. 2006) . in adults with asthma, shs exposure is related to increased occurrence of respiratory symptoms, reduced lung functions, increased use of bronchodilator and steroid medications, and increased bronchial hyper-responsiveness (jaakkola and jaakkola 2002) . fisk et al. (2007) from a meta-analysis of 33 epidemiological studies on dampness and mould problems revealed 30-50% increased risk of asthma about indoor dampness and mould problems in buildings. the ige-mediated hypersensitivity reactions to fungal allergens and mycotoxins produced by fungi and inflammatory reactions caused by fungal cell wall components (1,3-b-d-glucan, ergosterol) are the suggested mechanisms that could lead to asthma. there is a whole range of airborne pathogens, such as aspergillus and bacillus spp., that may be found in the built environment and also during construction or renovation activities (balm et al. 2012; fournel et al. 2010) . particular focus is on hospitals and healthcare buildings, to create healthy conditions. natural ventilation and availability of sunlight in buildings serve as effective strategies in infection control of diseases, such as measles, tuberculosis, smallpox, chickenpox, influenza, sars and h1n1 . the transmission of pathogen takes place through contact, dust, respiratory droplets, and droplet nuclei, e.g., inhalation of large droplets from contagious individuals or contaminated surfaces. the transmission depends upon the number and size of particles produced, the velocity at which they are produced, micro-organisms contained within the droplets, and proximity of a susceptible target (gralton et al. 2011) . the longevity of the pathogens depends on temperature and humidity, ultraviolet (uv) radiation, and atmospheric pollutants (tang 2009 ). depending on the size and density, residues of suspended droplet nuclei can remain suspended and penetrate deep into the lung tissues. droplet nuclei that are exhaled during normal breathing are only a small fraction than those aerosols produced when coughing or sneezing (gralton et al. 2011) . factors, such as local ventilation, the activity of occupants indoors, and thermal gradients produced due to office equipment influence the movement of the suspended droplets (nielsen 2009; eames et al. 2009; clark and de calcina-goff 2009) . towards controlling infection in healthcare and other building facilities through sunlight and natural ventilation, transmission and control of some pathogens are briefly described herewith. influenza is assumed to be transmitted by large droplets. however, the aerosol transmission, such as h5n1 avian influenza that demonstrates high virulence and lethality involves the lower respiratory tract (tellier 2009; tang and li 2007) . direct contact with diseased poultry and other birds may cause h5n1 transmission through the air, without recombination in an intermediate host (herfst et al. 2012) . severe acute respiratory syndrome (sars) epidemic in 2003 was assumed direct contact as the primary transmission route. the hong kong, amoy gardens outbreak, is an affirmative indication of the airborne transmission of the sars virus (mckinney et al. 2006) , such as transmission of virus-laden aerosol through inadequate ventilation, the ventilating shaft of adjacent buildings, floor drainage. before the sars epidemic, hantavirus transmission causing the pulmonary syndrome in humans has been demonstrated, due to the inhalation of aerosolized excreta and saliva from wild rodents (kimmel et al. 2010; clement et al. 2008) . the primary prevention is to clean the ventilation system of buildings that show signs of rodent infestation. norovirus that causes gastrointestinal illness is transmitted via contact with food materials, contaminated surfaces, and the spread of aerosolized particles from vomiting or liquid diarrhoea (marshall and bruggink 2011; greig and lee 2012) . tuberculosis is mainly contracted through airborne droplets; that is, transmission of m. tuberculosis to a non-infected person is possible if there are overcrowding and confined environment, and poor indoor ventilation (beggs et al. 2003) . earlier it was presumed that smallpox virus spreads by face-to-face contact. however, airborne transmission of the virus is evident now. occupants in hospital, health care, and allied facilities are at potential risk from staphylococcus aureus (kerr 2010 ) that get deposited throughout a room. nasal cavities of susceptible adults become colonized with s. aureus by inhaling particles from the air. there are many other pathogens found in an aerial spread in building facilities, such as escherichia coli, klebsiella, acinetobacter, pseudomonas, clostridium difficile (wu et al. 2011) . persons infected with c. difficile may shed spores in faeces, and therefore, when a toilet is flushed without a closed lid, aerosol production may contaminate the surrounding environment (best et al. 2012 ). office goers and building occupants are usually not exposed to high levels of physical, chemical, or biological compounds potentially hazardous to health. office environments have traditionally been considered as safe. however, an ample body of the literature is available on sbs and building-associated illnesses (bri) from different kinds of studies, including epidemiological cohort and cross-sectional studies, population questionnaire surveys, and experimental studies. the risk of sbs may occur at different levels, for example, (a) building level-indoor environmental quality, different sources pollutants, and exposure to bioaerosols, (b) personal level -interpersonal differences (women, younger and the elderly people, persons predisposed with chronic disease show more sbs related complaints), and (c) workplace stressors-aspects of work and psychosocial environment of the building occupants, and ones' ability to cope with the conditions of workplace and workspace. since all these levels are simultaneously present, one major problem emerges in sbs and bri is its lack of generalizability. on a simplistic way, the overall impression of the building environment may be rated by the occupants on an ordinal 100 point scale, against the stated levels of ieq, personal characteristics, aspects of work and the psychosocial environment. the summated scores are scaled into an overall dissatisfaction score for the building occupants. mitigation of iaq problems may require the involvement of building management and related people of responsibility in facility operation and maintenance, housekeeping, policy-making, and staff training. three methods have been suggested to improve the iaq, namely source control, increase ventilation, and air cleaning. the source control is the most cost-effective approach to mitigating iaq problems in which point sources of contaminants can be identified. conventional pollution source control method, such as adsorption by microporous activated carbon and chemical scrubbers, has reasonable efficacy to mitigate pollutants. thermal catalytic oxidation (everaert and baeyens 2004; roark et al. 2004 ) and photocatalytic oxidation (carp et al. 2004 ) are promising technologies for air purification. however, the former is not economically feasible at low pollutant concentrations. photodegradation may be more cost-effective for air purification since the process takes place at room temperature and pressure. tio 2 , a popular photocatalyst, is employed for removal of vocs from indoor air (wang et al. 2006 (wang et al. , 2007 . by incorporating tio 2 catalyst with adsorbent may yield better results for adsorption of pollutants and oxidation efficiency. this type of catalyst, however, exhibits high catalytic activity at uv light. the literature suggests a robust affirmative link between ventilation and the respiratory health of building occupants (seppänen and fisk 2004) . due to the random character of natural ventilation during different seasons of the year, emphasis among the building designers goes in installing mechanical ventilation and hvac systems. the natural ventilation no longer provides optimal distribution of fresh air in the buildings. however, several views have been put forward with regard to mechanical ventilation systems and acute health symptoms (sbs/br), asthma and allergy symptoms among occupants in buildings. mendel et al. (2003 mendel et al. ( , 2006 , examining us niosh data of 80 office building, emphasized that improperly maintained ventilation systems increase the adverse health effects among the occupants, particularly the asthmatics, due to exposure to accumulated pollutants and microbiological growth. comparing with naturally ventilated systems, the presence of air-conditioning increased respiratory symptoms in office buildings located in a hot and humid climate (graudenz et al. 2005) . takahashi et al. (2008) reported that the presence of a ventilation system was associated with increased allergic symptoms, probably due to the entry of large quantities of pollen into the dwellings through the air ducts and other factors, not directly related to the ventilation system. dwellings installed with air conditioners, and those had poor maintenance of ventilation systems, resulted in increased prevalence of sbs (wong et al. 2004; coelho et al. 2005) , as compared to those in naturally ventilated dwellings. some multidisciplinary reviews on relationships between ventilation rate and health outcomes are summarized in table 3 .7. table 3 .7 case studies on the influence of indoor ventilation rate on health outcomes godish and spengler (1996) increasing the ventilation rate up to 10 l/s per person may be useful in reducing the prevalence of sbs symptoms and occupant dissatisfaction with air quality. the use of ventilation as a mitigation measure for iaq problems should be dealt with factors that may limit its effectiveness seppanen et al. (1999) ventilation rates below 10 l/s per person in different building types were associated with significant worsening in one or more health or perceived air quality outcomes. some studies determined that increasing ventilation rates above 10 l/s to *20 l/s per person significantly decreases the prevalence of acute health symptoms or improvement in the perceived air quality. the sbs symptoms continued to decrease significantly with decreasing co 2 concentrations below 800 ppm wargocki et al. (2002 wargocki et al. ( , 2004 ventilation rates below 25 l/s per person increase the risk of acute health (sbs) symptoms, increase short-term sick leave, and decrease productivity mendell and heath (2005) no substantial evidence on the causal relationships between indoor pollutants or thermal conditions in schools and the performance of students. suggestive evidence links low ventilation rates in buildings to decreased performance in children and adults seppanen et al. a 1-3% improvement in average performance was associated with an increase in ventilation rate by 10 l/s per person. the performance increase per unit increase in ventilation was more substantial with ventilation rates in the range 15-17 l/s per person, and almost negligible with ventilation rates over 45 l/s per person li et al. (2007) strong evidence of the association between ventilation, air movements in buildings, and the transmission/spread of infectious diseases. data insufficiency to define the ventilation rates that can reduce the spread of infectious diseases via the airborne route in hospitals, schools, offices, homes, and isolation rooms. overcrowding is a risk factor related to the ventilation of buildings and also infection transmission via direct contact fisk et al. (2009) reduction in ventilation rate from 10 to 5 l/s per person led to increased prevalence of sbs symptoms by *23% (12-32%). increase in ventilation rate from 10 to 25 l/s per person led to the decreased prevalence of acute symptoms by 29% (15-42%) sundell et al. (2011) ventilation rates, up toper person, were associated with reduced prevalence of sbs symptoms in offices. ventilation rates in homes above 0.5 ach are associated with a reduced risk of allergic manifestations among children in a nordic climate the above stated studies provide a fair understanding that ventilation (air change in a built environment) plays a central role to exhaust pollutants of both non-biological and biological agents of the occupied space or generate pollutants within systems. chapter 12 elucidates the design, installation, operation, and maintenance of ventilation systems in buildings. ventilation inadequacy may be due to poor building design, inadequate ventilation system, and its improper maintenance and operational strategies. lack of control of hvac systems aggravates the growth of microorganisms. besides, the quality of outdoor air, building materials, and accumulated dust are also sources of microbial contaminants in indoor environments. the presence of mould, spores, musty smell, and water intrusion are warning signs, reflecting the inefficiency of a building's ventilation system (radon et al. 2008) . it is emphasized that the strength of elimination of pollutants from building space is the determinant of exposure-associated adverse health effects of occupants. in spite of differing views, ventilation rates below 10 l/s per person would increase the risk of symptoms of sbs (jaakkola and miettinen 1995) . the assertion from the base study of the association of sbs with the increasing difference in concentration of co 2 between indoor and outdoor brings forward the suggestion that a relative increase in the ventilation rates per person in an office building may reduce the prevalence of sbs symptoms. a concentration of co 2 (800 ppm) has been suggested as a control limit value. erdmann and apte (2004) observed a remarkable reduction in mucosal symptoms ranging from 65 to 85% when co 2 levels in offices dropped in the range from 610 to 40 ppm above outdoor levels. frequent contributors to biological pollutants are water damage in buildings, leaks in plumbing, roofs or air conditioners, and humidifiers (mckernan et al. 2008; li et al. 2010) . given that some airborne moulds may always be present in the indoor environment, various guidance limits and remediation measures have been proposed (baubiologie maes 2008) . ec guidelines state that mould count greater than 500 cfu/m 3 may be considered an intermediate level of exposure for a building occupant, whereas >1000 cfu/m 3 is a high level of exposure in indoor non-industrial workplaces. levels more than these guidelines do not necessarily imply unsafe or hazardous conditions. in the usa, there are no exposure levels for airborne concentrations of mould (us osha 2003) . every country must establish the requisite legislation and environmental standards and guidance concerning building maintenance specifications. also, building-associated illnesses manifest in multiple forms of symptoms, and often in combinations of asthma, hypersensitivity pneumonitis, and interstitial pneumonitis (bornehag et al. 2001) . evidence of markers for individual susceptibility might separate normal from more sensitive groups. symptoms of allergy and asthma may be triggered by allergens in the indoor air including those from house dust mites, pets, fungi, insects, and pollens. as elaborated earlier, asthma symptoms can be evoked by irritating chemicals or sensitizing agents. there are approaches to reducing allergy and asthma symptoms via changes in buildings and indoor environments. reductions in allergy and asthma symptoms would be expected by a substantial reduction in the associated allergens and irritants, from indoors. overall, intervention and management of sbs and bri may encompass measures, as described herewith. for new buildings, the prevention measures in reducing mould contamination include, for example, (a) minimizing moisture accumulation in construction materials, (b) maintaining the integrity of building impermeable envelope, and (c) ensuring the effectiveness of hvac system to control thermal comfort and relative humidity. in the existing buildings, corrective measures include (a) repair and maintenance of water leakage in ceilings, walls, and draining systems, (b) deep cleaning of building interiors and hvac systems, (c) control of the reservoirs of visible mould in ceiling and carpets, and (d) periodic assessment of iaq. once a mould problem is established, a well-documented action plan may be followed to notify people for (a) rectifying the underlying moisture problem, (b) minimizing spread of contamination, by cleaning of ventilation pathways and enhancing ventilation to exhaust the relevant pollutants from indoors, and (c) removing mouldy materials. it is important to consider that fungal spores are continually entering into the indoor environment and a remedial measure to fungal contamination is the maintenance of dry conditions in a building. as part of remediation, an entire or part of a building may be heated to a temperature that should kill most of the fungal spores. caution is needed that heat may not damage specific equipment and plastic materials. apart from dilution of airborne pathogens, high ventilation of outdoor air results in an adverse effect on viability and virulence of micro-organisms, including influenza and the category iv pathogen, francisella tularensis (hood 2009 ). infection of rhinoviruses causes adults to suffer the frequent common cold. myatt et al. (2004) provided evidence of aerosol transmission of rhinovirus in mechanically ventilated office buildings that resulted in an increased risk of inhaling infectious droplets. in student rooms having a ventilation rate of about 1 l/s per person, the frequency of common colds was six times more among 35% of the students. the number of common colds was higher in winter. reported common colds were higher when some students shared a room. by increasing the ventilation rate to 5 l/s per person, the self-reported common colds dropped to a mere 5% (sun et al. 2011b ), suggesting that ventilation from outdoor-to-indoor bears greater significance in diluting and dispersing virus-laden droplets (mendell et al. 2002) . milton et al. (2000) observed a reduction in short-term sick leave among office workers when the outdoor air supply rates increased from 12 to 24 l/s per person in an office building. mendell et al. (2013) reported the relative decrease of illness absence of about 1.6% for each additional ventilation rate of 1 l/s per person. natural ventilation brings many advantages, whereas entry of unfiltered air containing free contaminants such as fungal spores (bartley et al. 2010; phares et al. 2007 ) is a possible disadvantage of natural ventilation. natural ventilation can be more effective than mechanical systems for preventing transmission (kembel et al. 2012) . despite that an outbreak of infectious disease is an outcome of several factors, as stated above, the evidence is supportive that ventilation is a modifying factor in the transmission of infection. following the 2001 incidents of anthrax attacks, preventive intervention is to relocate air intakes to publicly inaccessible locations, e.g., secure roofs. coughing and sneezing activities can carry infectious aerosols a long distance within a built environment (zhu et al. 2006) . intervention in building ventilation airflow patterns (chen and zhao 2010) can thwart particle transport from a source to a receiver. the exposed concentration of aerosol from sneezing, at the breathing zone of a receiver occupant is slightly higher under displacement ventilation, dv than mixing ventilation, mv system (seepana and lai 2012) , due to its low local air velocities. high discharge velocity air curtains provide a strong momentum to redirect coughing and sneezing jets and minimize cross infection (aubert and solliec 2011; nino et al. 2011) , and also influence heat gain/loss in a facility (foster et al. 2006) . with a protected occupied zone ventilation, pov system, the intake fraction of coughed particles in the breathing zone of the receiver occupant decreased to a significant extent, as compared to an mv system (liu et al. 2014) . a narrowly concentrated plane jet was more effective at reducing the direct exposure to expiratory particles than with multiple low-velocity jets. the majority of micro-organisms that cause airborne infections cannot tolerate sunlight. direct sunlight passing through an ordinary window can kill m. tuberculosis and meningococci within a few hours. streptococcus pyogenes cannot survive more than 5 min under sunlight, compared with more than an hour in diffuse daylight. lethality of sunlight against staphylococci is due to radiation at 300-380 nm; in addition to bactericidal effect, solar radiation is mutagenic. ordinary window glass absorbs solar radiation at <300 nm, which permits entry of solar uv-a and small amounts of uv-b. research indicates that uv wavelengths inactivate microbes by causing cross-links between constituent nucleic acids; the formation of intra-strand cyclobutyl-pyrimidine dimers within dna leads to mutations and cell death (maclean et al. 2010 ). exposure to high-intensity visible violet light at 405 nm is likely to be associated with photoexcitation of porphyrin molecules, resulting in the production of reactive oxidative species that are strongly 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cluster of sars among medical students exposed to single patient quantification and analysis of airborne bacterial characteristics in a nursing care institution apoptosis induction by the satratoxins and other trichothecene mycotoxins: relationship to erk, p38 mapk, and sapk/ jnk activation a comparison study on energy savings and fungus growth control using heat recovery devices in a modern tropical operating theatre indoor airborne fungal spores and home characteristics in asthmatic children from edirne region of turkey fungal proteases and their pathophysiological effects transient elevation of intracellular calcium ion levels as an early event in t-2 toxin-induced apoptosis in human promyelotic cell line hl-60 impact of mycotoxins on humans and animals impact of perceived indoor environment quality on overall satisfaction in swedish dwellings a comparison of the efficiencies of a portable biostage impactor and a reuter centrifugal sampler (rcs) high flow for measuring airborne bacteria and fungi concentrations amplified proinflammatory cytokine expression and toxicity in mice coexposed to lipopolysaccharide and the trichothecene vomitoxin (deoxynivalenol) study on transport characteristics of saliva droplets produced by coughing in a calm indoor environment world at work: cleaners health and indoor climate complaints of 7043 office workers in 61 buildings in the netherlands key: cord-022467-j2trahab authors: loo, may title: select populations: children date: 2009-05-15 journal: complementary and alternative medicine doi: 10.1016/b978-0-323-02028-2.50015-2 sha: doc_id: 22467 cord_uid: j2trahab nan the majority, usually seeking cam therapy as an adjunctive management for pain and other discomforts related to the oncologic illness or to medications. 207 in the general pediatric population, chiropractic is the most common form of cam treatment used by children. reports indicate that children made up 1% of chiropractic patients in 1977 and 8% in 1985. 303 a survey of the boston metropolitan area revealed that an estimated 420,000 chiropractic visits were made by children in 1998. 237 childhood disorders being treated include pain, respiratory and gastrointestinal tract problems, ear infection, enuresis, and hyperactivity. 303 homeopathy was the second most popular form of cam therapy used by children in spiegelblatt's 1994 report. 386 in 2001, however, the university of pittsburgh found that homeopathy was the most common cam therapy used by children who visited an emergency department (ed). 329 also, in a 2000 survey of homeopathic practitioners in massachusetts, children constituted one third of patient visits. 236 homeopathic remedies are highly diluted substances that induce self-healing. these remedies are readily available from a variety of sources, including some grocery stores. although homeopathy may be safe and effective in many childhood conditions, many practitioners believe that homeopathic remedies are best used as adjunctive therapy to conventional medicine in chronic conditions and in acute disorders that respond poorly to conventional therapy. 197, 198 acupuncture is the third most common therapeutic method used in children 386 but has the largest body of scientific data compared with other cam therapies. 248 a harvard survey of 47 patients with a median age of 16 years who received acupuncture treatment, which included needle insertion, moxa/heat, cupping, and magnets, reported that 67% of patients rated the therapy as pleasant and 70% thought treatment helped their symptoms. 209 electrical stimulation, laser, heat, magnet methods, and acupressure or acumassage 324 are effective alternatives to needles for treating children with needle phobia. acupuncture and traditional chinese medicine (tcm) have been used in asia and europe to treat a wide spectrum of childhood illnesses. their use in the united states has been recent but is growing rapidly in popularity. naturopathy ranks with acupuncture as the third most common complementary therapy used by children, 385 although scientific data are sparse. currently, evidence-based information is limited about safety and efficacy of herbal remedies, especially in terms of dosage and application in infants and children, who may be more susceptible to some of the adverse effects and toxicities because of differences in physiology and immature metabolic enzyme systems. 293, 412 other cam treatments used in children include touch therapy (therapeutic touch), osteopathy, oligotherapy, and hypnosis. religious practices such as prayer have also become prevalent in the pediatric population. 22 children have reported the ability to readily feel energy field from touch therapy. 118 the increasing support for therapeutic touch (tt) 223, 226 has been anecdotal with little scientific data. approximately 9% of children receiving treatment with cam therapies seek osteopaths, 386 who claim success in treating many common childhood conditions, including colic and otitis. 19 approximately 4% of pediatric cam visits are to oligotherapists, 386 who administer poorly absorbed trace elements such as copper, manganese, and zinc to improve health. relaxation training and imagery are forms of hypnosis that have also been effective in children. 309 in fact, children seem to be able to learn relaxation training better and faster than adults. 122 table 11 -1 summarizes the cam therapies most often used to treat various pediatric conditions. box 11-1 lists additional and recent surveys and reviews of cam therapies used to treat pediatric conditions. vaccination is an essential component of pediatric well-child care and has both public health and educational ramifications because up-to-date vaccination is required for vaccine safety is monitored closely. adverse events are reported to the vaccine adverse event reporting system (vaers), administered by the centers for disease control and prevention (cdc) and the u.s. food and drug administration (fda). approximately 10,000 adverse cases are reported each year. data are shared internationally by independent scientific experts on the joint committee on vaccination and immunization and committees of the medicines control agency. surveillance results in product withdrawal when there is clear evidence of a safety issue. 300 currently, several serious pediatric conditions are controversially attributed to vaccination: immune compromise, 377 neurologic sequelae, autism, and crohn's disease. the medical community has expressed concern about the effects of vaccination on an immature immune system, especially in neonates. 419 controversial debates are ongoing regarding the possible connection between vaccination and autoimmune illnesses, such as the association between measles and anti-hepatitis b virus (hbv) vaccines with multiple sclerosis. tetanus toxoid, influenza vaccines, polio vaccine, and others have been related to autoimmune phenomena ranging from autoantibody production to full-blown illness, such as rheumatoid arthritis and guillain-barré syndrome. recent evidence suggests that autism may be related to the immune system. 273 the mechanism of autoimmune reactions after immunization has not yet been elucidated. one possibility is molecular similarity between some viral antigen (or other component of the vaccine) and a self-antigen. this similarity may be the trigger to the autoimmune reaction. 16, 374 before 1991, whole-cell pertussis vaccine was used, composed of a suspension of formalin-inactivated bordetella pertussis b cells. convulsions occurred in 1 case to 1750 doses administered, and acute encephalopathy occurred rarely, at 10.5 cases per million doses administered. sudden infant death syndrome (sids) and infantile spasms have also been suggested to be associated with diphtheria-pertussis-tetanus (dpt) vaccination. 103 in the 1970s, reports linking pertussis vaccine with infant brain damage attracted media attention, 227 which in turn caused great parental and professional anxiety; the immunization rate fell from 80% to 30%. between 1976 and 1988, three major pertussis epidemics occurred in the united states, resulting in more than 300,000 hospitalizations and at least 70 deaths. 300 in countries such as sweden, japan, united kingdom, ireland, italy, and australia, antivaccine movements targeted pertussis whole-cell vaccines. 129 opponents to the pertussis vaccine have argued that the risks of vaccination outweigh the benefits. 103 the largest study to date conducted by the national institute of child health and human development at the national institutes of health (nih) revealed that sids was actually less likely to occur in recently vaccinated infants. 165 another large study showed that the permanent neurologic sequelae due to pertussis vaccine are so rare as to be unquantifiable. 280 nevertheless, concerns about brain damage led to the development of acellular pertussis vaccine (dtap) that contains purified, inactivated components of b. pertussis cells. this form is associated with a lower frequency of adverse events and is more effective in preventing pertussis disease. dtap was first licensed for the fourth and fifth doses of the pertussis series in 1991 and for the primary series in 1996. several studies conducted in europe and africa revealed that u.s.-licensed dtap vaccines have efficacy ranging from 71% to 84%. currently, only acellular pertussis vaccine is used. 103 no encephalopathy has been reported. hypotonic hyporesponsive episode (hhe) is the sudden onset of hypotonia, hyporesponsiveness, and pallor or cyanosis that occurs within 48 hours of vaccination, usually after pertussis vaccine administered to children under 2 years of age. hhe occurred in approximately 1 of every 1750 dta vaccinations. the largest published report of 40,000 cases concluded that although hhe does occur after the administration of dtap and other non-pertussis-containing vaccines, it is generally benign, self-limited, and nonrecurrent. 92 the connection of encephalopathy with pertussis vaccine was biologically more plausible than the proposed link between pertussis, measles vaccines, and autism. 300 the incidence of autism has increased from 1 in 10,000 in 1978 to 1 in 300 in 1999 in some u.s. communities. a study of 60 autistic children suggests that autism may be caused by a pertussis toxin found in the dpt vaccine. the toxin separates the g-alpha protein from retinoid receptors, which are critical for vision, sensory perception, language processing, and attention-characteristic problems of autism. those children most at risk have at least one parent with a preexisting g-alpha protein defect, presenting clinically with night blindness, pseudohypoparathyroidism, or adenoma of the thyroid or pituitary gland. natural vitamin a may reconnect the retinoid receptors. 273 in recent years, discussion has increasingly centered on the controversy concerning the possible association of the measles-mumps-rubella (mmr) vaccine with autism and crohn's disease.* the chinese were among the first populations to vaccinate, beginning with smallpox vaccine, which was injected intranasally. tcm considers most childhood illnesses to occur at superficial levels, and vaccination actually introduces pathogens, still considered energetically active, into deeper blood levels of the body. in addition, tcm also posits that the body can usually effectively handle only one process at a given time. when two separate processes occur at the same time, the human system could become overwhelmed, especially the tender system of an infant or a young child. therefore, although multiple vaccines given at the same time are less traumatic for children and save nursing time, they can easily overwhelm an immature immune system and make the child weak and deficient. 352 although the fear of epidemics motivates the chinese to vaccinate all their children, tcm practitioners in the west often advise against immunization. 320 there is discrepancy among the homeopaths regarding recommendation of conventional vaccines. a german questionnaire survey reported that homeopathic physicians generally do not refuse vaccinations but show a preference for the dpt vaccines. 239 a british survey conducted between 1987 and 1993 reported that preference for homeopathic remedies for illnesses and religion were the most common reasons parents refused immunization; 21% believed the risk of diseases to be less than the risk of vaccination and would seek homeopathic treatment if any illness developed in their children, and 17% believed that children "are protected by god and not by vaccines." 379 a u.s. cross-sectional descriptive survey of 42 homeopathic practitioners and 23 naturopathic practitioners in massachusetts revealed that the majority of the practitioners did not actively recommend immunizations. 236 many homeopaths recommend homeopathic vaccines, which are not yet supported by scientific data. 399 a random sample survey by mail of 1% of american chiropractors revealed that one third believe there is no scientific proof that immunization prevents disease, that vaccinations cause more disease than they prevent, and that contracting an infectious disease is safer than immunization. 66 a reported 81% believed that immunization should be voluntary and that spinal adjustment is a viable alternative. a crosssectional, descriptive survey of 90 chiropractics in the boston metropolitan area reported that only 30% actively recommended childhood immunization. 237 the decision of whether or not to immunize a child is difficult for both parents and practitioners. the advantages of vaccination are difficult to refute, but the temporal relationship between immunization and side effects and the controversies surrounding potential risks are disconcerting. although data are insufficient on cam approaches to vaccination today, practitioners should be aware of the slow yet steady trend toward alternatives and should properly address parental concerns and questions regarding immunization. 348 each practitioner needs to inform parents of the most up-to-date pros and cons of vaccination, be as objective as possible, put aside personal belief systems, and be supportive and understanding of whichever decision the parents make. parents need to become as informed as possible, consider all the pros and cons, weigh the risks and benefits, and realize that ultimately they must live with the outcome of their decision. the common cold is the most frequent infection in children in the united states and throughout the industrialized world. 394 a preschool-aged child has an average of 4 to 10 colds per year. the clinical symptoms vary greatly without any correlation with specific viruses. 94, 121 the majority of the symptoms are mild, consisting of rhinorrhea, sneezing, nasal congestion and obstruction, postnasal drip, and cough. there may often be additional symptoms of low-grade fever, sore throat, clear eye discharge, digestive discomfort, and general malaise. 180, 213, 276 some common viruses that cause upper repiratory tract infections (uris) include rhinovirus, coronavirus, adenovirus, respiratory syncytial virus (rsv), influenza virus, and parainfluenza virus. 101, 121, 139 transmission varies with different viruses. for example, rsv spreads primarily through contact with symptomatic children and contaminated objects, whereas influenza spreads mainly through airborne droplets. the precise route of transmission for rhinovirus remains controversial. 139 the virulence of rhinovirus is maximum in infants before 1 year of age (median age 6.5 months) 327 and in immunocompromised children. 330 wheezing is associated with rsv in children younger than 2 years of age and with rhinovirus in those over age 2. 338 simultaneous infection by more than one virus, such as rsv and adenovirus together, can also occur frequently in the pediatric population. many children may also have associated bacterial infection, such as haemophilus influenzae conjunctivitis. 327 the viruses gain entry into host cells through specific viral surface proteins, which cause tissue injury and result in clinical disease. 432 recent studies suggest that the host's response to the virus, not the virus itself, determines the pathogenesis and severity of the common cold. proinflammatory mediators, especially the cytokines, appear to be the central component of the response by infected epithelial cells. 158, 417 specific viral diagnosis is not necessary because of the benign, self-limiting nature of the disease 294 and the prevalence of different viruses overlapping from fall to spring, which makes it difficult to determine precisely which virus or viruses are causing the symptoms. 121 current medical management of uri remains symptomatic, controversial, and in most cases, ineffective. fluid, rest, humidifier, and saline nose drops constitute the mainstay of nonpharmacologic treatment. topical adrenergic agents do not have systemic side effects, but overuse can result in rebound congestion. 84, 114 antihistamine and combinations of antihistamine with decongestants are the ingredients in at least 800 over-the-counter (otc) cold remedies. the majority of studies have concluded that antihistamines are of marginal or no benefit in treating cold symptoms. 47, 110, 153, 254, 383 dextromethorphan is an antitussive that is abundant in otc formulations. although this medication is reportedly safe when taken in the recommended dosages, there have been cases of "recreational" use by teenagers, and deaths by overdose have been reported. 291 codeine is ineffective in controlling uri cough. 95 medications are often overprescribed, leading to higher health care costs 102 and dangerous side effects, such as greater antibiotic resistance. 257 more steroids are prescribed, which leads to a myriad of complications. 274 although interferon has been shown to produce good protection against infection, the high doses necessary to produce a prophylactic effect are often associated with serious undesirable side effects, including nasal stuffiness, bloody mucus, and mucosal erosions, 213 and the trauma of daily intramuscular injection makes it an unlikely remedy for children. 169 research for new medical therapies for the common cold is directed toward increasing resistance to or immunity against the viruses. histamine antagonists are not indicated in the common cold. 369 antiinflammatory mediators 417 and specific antiviral agents 361 may be promising. development of an effective vaccine against the common cold is unlikely because of the large number of viral serotypes. 213 rhinovirus, for example, has at least 100 different immunotypes. 158 although viral uri is a benign illness of short duration, it can lead to bacterial complications such as otitis media, sinusitis, lower respiratory tract infections, mastoiditis, and even meningitis. 330 scientific data on cam treatment for the common cold are surprisingly sparse. in 1971, linus pauling carried out a meta-analysis of four placebo-controlled trials and concluded that vitamin c alleviates cold symptoms, but subsequent reviews indicated that the role of vitamin c in uri is still controversial. [146] [147] [148] 199 although breast-feeding has been believed to protect against infection in infants, studies have been inconsistent in demonstrating its efficacy. in a 4-year prospective study that actively tracked breast-feeding and respiratory illnesses in 1202 healthy infants, breast-feeding was found to reduce significantly the duration of respiratory illnesses during the first 6 months of life. 75 a retrospective review from saudi arabia of randomly selected charts revealed that a direct correlation exists between duration of breast-feeding and frequency of uri in the first 2 years of life. 1 a hospital-based descriptive recall study from sri lanka examined the relationship between breastfeeding and morbidity from respiratory illnesses in infants. of the 343 infants, 285 were admitted and 58 were controls. an inverse relationship was found between the length of breast-feeding and incidence of respiratory illnesses. 319 a nutritional study of 170 healthy newborns followed for 6 months demonstrated that breast-feeding lowers frequency and duration of acute respiratory tract infection compared with formula feeding. 251 a more recent japanese study examined the incidence of pathogenic bacteria isolated from the throat of 113 healthy infants fed with different methods. 166 no pathogens were detected in breast-fed and mixed-fed infants, while h. influenzae and moraxella catarrhalis were isolated from the oropharynx of formula-fed infants. the investigators suggest that breast milk may inhibit the colonization by respiratory bacterial pathogens of the throat of infants. the mechanism was thought to be enhancement of mucosal immunity against respiratory tract infection. in addition to the presence of secretory immunoglobulin a (iga), another mechanism may be the presence of complex carbohydrates in human milk. these glycoconjugates may exert various antipathogenic effects, such as inhibiting the binding of pathogens to the receptors and reducing the production of bacterial toxins. 299 however, a u.s. study that examined nasopharyngeal swabs from 211 infants at 1 month of age and swabs from 173 of these infants at 2 months of age (keeping environmental parameters similar, e.g., number of children in household, number of siblings in day care, proportion with recent uri) revealed that the exclusively breast-fed (n = 84) and exclusively formula-fed (n = 76) infants did not differ significantly in the number of pathogens. 196 a multicenter randomized trial was conducted in 31 hospitals in the republic of belarus. 228 evaluation within the first year revealed that breastfeeding had no significant reduction in respiratory tract infection compared with the control group. a survey from singapore of breast-feeding mothers at 6 months postpartum revealed no significant differences in the rates of uri between breast-fed and non-breast-fed infants. 64 data are sparse on acupuncture, herbal, and homeopathic remedies for treatment of uri, especially in children. most data are uncontrolled, clinical reports. current information on adults supports efficacy of acupuncture for treating the common cold. 172, 311, 454, 462 acupuncture has been shown to increase the velocity of the nasal mucociliary transport in chronic rhinitis patients. 454 one possible use of acupuncture in uri is its potential effect on the immune system. 322 when chinese herbs were pasted onto acupoints for treating rhinitis and bronchitis in infant, serum immunoglobulin m (igm), igg, complement c3, and especially iga levels increased. 461 acupuncture has also been shown to increase t lymphocytes. 404 even massaging local acupoints was effective in relieving symptoms and in enhancing immune functions, with increases in immune indices that persisted for at least 6 months. 466 one report of acu massage of only one point for just 30 seconds resulted in clinical relief from nasal congestion, even though there was no change in nasal airway resistance or airflow. 403 these reports are encouraging for parents because acupressure can be easily learned by nonprofessionals, is well tolerated by children of all ages (including infants), has no side effects, and costs nothing. a clinical trial administering a nontoxic chinese herbal mixture to 305 infants demonstrated more than 95.1% effectiveness in treatment of uri. 465 in a single-blind trial using a chinese herb for acute bronchiolitis with serologic evidence of rsv, 96 hospitalized children were randomized into three treatment groups: herbs, herbs with antibiotics, and antibiotics alone. herbal treatment was found to decrease symptoms and duration of illness without adverse effects. 218 in a randomized, controlled trial using an herbal mixture, 89 children in the treatment group demonstrated 92% efficacy versus 67% of 61 children in the control group. 255 there was no description in the abstract (original article in chinese) of what constituted control (e.g., placebo herb, no treatment, conventional drugs) or what constituted efficacy (e.g., improvement in symptoms, duration, of illness). further rigorous studies are needed to demonstrate safety and efficacy of herbal treatment. a recent clinical trial that included children over age 12 years and used a fixedcombination homeopathic remedy for a mean 4.1 days of treatment reported that 81.5% reported subjective feelings of being symptom free or significantly improved without complaint of any adverse side effects. 4 a randomized, double-blind, placebocontrolled study from great britain of 170 children with a starting median age of 4.2 years in the experimental group and 3.6 years in the placebo group concluded that individually prescribed homeopathic remedies seem to be ineffective in reducing symptoms or decreasing the use of antibiotics in pediatric patients with uri. 78 otitis media (om) represents a continuum of conditions that include acute om, chronic om with persistent effusion, chronic suppurative om, recurrent om, unresponsive om, and om with complications. 28 acute otitis media (aom) is most prevalent in young children 8 to 24 months of age. approximately two thirds of all children will have had at least one episode of aom before age 3 years, and half of them will have recurrences or chronic serous om with effusion into early elementary school years. 132 by the time the child reaches adolescence, aom occurs infrequently. 443 almost one third of pediatric office visits are for treatment of aom. 109 the most common etiologic factors are allergic rhinitis 72,336 and ascending bacterial or viral agents from the nasopharynx attributable to eustachian tube dysfunction. the most common viral culprits are rsv, 10 influenza virus, 153 and adenovirus. 108 two thirds of middle ear infections are caused by bacteria. 109 the predominant organisms are pneumococci, h. influenzae, m. catarrhalis, 53, 305, 358, 388 and group b streptococcus. 325 bacterial pathogens adhere to mucous membranes, and colonization ensues. the severity of infection or the response to the invading bacteria depends on the health of the child's immune system. 53 the humoral system is especially significant in protecting the middle ear cavity from disease, and the nasopharyngeal lymphoid tissues are the first line of defense against bacterial colonization. 335, 359 the sterility of the eustachian tube and tympanic cavity depends on the mucociliary system and on secretion of antimicrobial molecules, such as lysozyme, lactoferrin, and betadefensins. 313 evidence indicates that a number of children with recurrent episodes of aom have minor immunologic defects. 359 pneumococcus is by far the most virulent of aom bacteria. it causes approximately 6 million cases of om annually in the united states. 468 uncontrolled pneumococcal otitis can lead to meningitis. 416 the incidence of aom is higher in winter and early spring. clinically, the child with aom presents with earache and fever, usually accompanied by upper respiratory symptoms such as rhinorrhea. on otoscopic examination the tympanic membrane varies from hyperemia with preservation of landmarks to a bright-red, tense, bulging, distorted appearance. in advanced stages of suppuration the tympanic membrane ruptures with a gush of purulent or blood-tinged fluid from the ear. 108 because viral or bacterial om usually cannot be distinguished by otoscopic examination, aom is usually treated empirically, using antibiotics such as amoxicillin that have a high concentration in the middle ear fluid. 214, 224 however, the widespread use of antibiotics has resulted in increasing resistance to the more common medications. 53, 358 currently, 10% of children with aom are recalcitrant to antibiotic therapy. 277 the prevalence of resistant organisms tends to increase in the winter months. 43 economically, treatment failure due to drug resistance has been responsible for further escalating the billions of dollars spent treating aom. 287 in addition, antimicrobials suppress normal flora, which is beneficial to the host because the antibiotic can interfere with and therefore prevent pathogenic infections and may enhance recovery from uris. 43 on the other hand, since the advent of antibiotics, complications such as mastoiditis and intracranial infections have significantly decreased. 297 the current focus is on prevention of aom. breast-feeding confers lifesaving protection against infectious illness, including otitis. 134, 156 pneumococcal conjugate vaccine (pcv), approved in 2000 for use in the united states, covers the seven serotypes that account for about 80% of invasive infections in children younger than age 6 years. pcv was demonstrated to have more than 90% efficacy 468 and has resulted in a modest reduction of total episodes of aom. 317 the goal of pcv is to prevent symptomatic infections in the middle ear and prevent colonization of the pneumococci that can cause subsequent middle ear infections. 41 pcv may eliminate nasopharyngeal carriage of pneumococci. 235 however, because pcv only prevents disease caused by the most common serotypes, there is concern that the nonvaccine serotypes will become more common, especially in children less than 2 years of age. 317 an effective rsv vaccine for the infant and young child could greatly decrease om disease. 10 intranasal spray of attenuated viruses is currently under investigation, in the hope that early antiviral therapy would reduce the risk of om after uri. 137, 153 chronic otitis media with effusion (ome) is one of the most common diseases in childhood. 91 ome is associated with infection, eustachian tube obstruction, allergic or immunologic disorders, and enlarged adenoids. 108 the serous fluid still contains bacteria, such as h. influenzae and pneumococci. 48 ome has been implicated to be an immune-mediated disease 91 because immune complexes have been demonstrated in the middle ear effusion, 268 and highly organized lymphatic tissue has been found in the middle ear mucosa. 422 the rationale for treating ome is prevention of recurrence of aom. currently, a once-daily antibiotic regimen is the recommended prophylaxis. the benefit is also weighed against the increasing risk of emergence of resistant bacteria. 134 when antibiotics fail to control recurrent om, a short trial of prednisone may be prescribed. surgery is recommended when medical treatment fails, 277 especially when the child has hearing loss. 305 tympanostomy tubes appear to be beneficial in ome but are of less value in chronic suppurative otitis. 134 increase in hearing loss has been reported with insertion of ventilation tubes. 144 adenoidectomy is sometimes recommended, 193 especially after tympanostomy tube failure. 134 any safe and effective cam therapy for om would be an important contribution to the pediatric population. large-scale, randomized, controlled studies for cam treatment would need medical collaboration, especially for otoscopic examination and tympanometry. 366 in addition, since aom has a high rate of spontaneous resolution, any clinical study must also prove that treatment effect is faster than natural improvement. although breast-feeding has been found to reduce uri, data concerning its association with frequency or duration of om have been conflicting. epidemiologic reports consistently provide evidence of protection of young children from chronic otitis with prolonged breast-feeding. 138 a u.s. study that followed 306 infants at well-baby visits in two suburban pediatric practices reported that the cumulative incidence of first om episodes increased from 25% to 51% between 6 and 12 months of age in infants exclusively breast-fed versus 54% to 76% in infants formula-fed from birth. 89 there was a two-fold risk of first episodes of aom or ome in formulafed babies in the first 6 months. a danish study that evaluated 500 infants using monthly questionnaires reported no statistical difference in the breast-fed versus formula-fed infants in incidence of om. 355 an earlier jewish study comparing 480 infants visiting a pediatric ed with 502 healthy infants found that breast-feeding significantly reduced infectious diseases, including om in infants under 5 months of age. 76 a study from switzerland evaluated 230 children with aom by administering individualized homeopathic medicine in the pediatric office. 119 if there was insufficient pain reduction after 6 hours, a second (different) homeopathic medicine was given. antibiotics were given if there was lack of response to the second dose. pain control was achieved in 39% of the patients after 6 hours, with another 33% after 12 hours. the resolution rate was 2.4 times faster than in placebo controls. no complications were observed in the study group. 119 in a u.s. double-blind, placebo-controlled pilot study, 75 children ages 18 months to 6 years with ome and ear pain and/or fever for more than 36 hours were randomized into individualized homeopathic medicine or placebo group. 181 no statistically significant results were noted. a british nonblinded, randomized pilot study was done with 33 children ages 18 months to 8 years who had ome and hearing loss greater than 20 db and an abnormal tympanogram. 150 the results revealed that the homeopathy group had more children with a normal tympanogram, fewer referrals to specialists, lower antibiotic consumption, and a higher proportion with a hearing loss less than 20 db at follow-up. however, the differences were not statistically significant. further research with larger groups is needed for a definitive trial. in a prospective, observational study carried out by one homeopath and four conventional ear-nose-throat (ent) physicians, a single (nonindividualized) homeopathic remedy was compared with nasal drops, antibiotics, and antipyretics. 125 children between 6 months and 11 years of age were included in the study. homeopathic treatment was given to 103 children and conventional treatment to 28 children. homeopathic remedies were found to be significantly more effective in reducing duration of pain and in preventing relapses. because om tends to affect predominantly young children, it would be more appropriate for studies to compare results in children of similar age rather than a wide range of ages, from infancy to preadolescence. a retrospective, nonrandomized study of 46 children under 5 years of age receiving 3 weeks of treatment from a single chiropractor reported a decrease in om symptoms. the limitations to this study included retrospection and a lack of comparison with the natural course of ear infections. 124 an israeli controlled clinical trial examined the efficacy and tolerance of ear drops made with naturopathic extracts in the management of aom pain. 362 ranging in age from 6 to 18 years, 103 children were randomized into the treatment group and control group using a conventional anesthetic ear drop. there was statistically significant improvement in both groups, indicating that the naturopathic ear drops were as effective as the anesthetic ear drops. the university of arizona has initiated a study of the use of echinacea, a dietary supplement, in the prevention of recurrent om. 261 acupuncture data are lacking on treatment of om in children. 411 the theoretical potential benefit of acupuncture would appear to be its effect on the immune system, as discussed in the section on uri. allergic rhinitis affects 5% to 9% of children. 113 perennial rhinitis is related to allergens that children are exposed to continuously, such as animal dander, house dust mites, mold, and feathers. seasonal rhinitis is related to seasonal pollenosis and rarely affects children under age 4 or 5 years. 100 allergic diseases are major causes of morbidity in children of all ages, 437, 447, 448 and allergic rhinitis is a significant cause of middle ear effusions. 72, 267, 336, 452 conventional therapy usually consists of avoidance of allergens, use of air-clearing devices, desensitization shots, and medication with antihistamines and at times steroids, both of which are frequently abused. 179, 200 antihistamines may be beneficial when sneezing and itching are present. 114 cam therapy is common among children with allergic diseases in sweden 155 and is becoming more popular in the united states, although scientific data specifically on children are still lacking. physicians have become more aware of the importance of nutrition 384, 424 and environmental factors in the development of allergic symptomatology in childhood. 289, 396, 446 a prospective, longitudinal study of healthy infants followed from birth to 6 years of age concluded that recurrent wheezing is less common in nonatopic children who were breast-fed as infants. 450 hypnosis has been reported anecdotally to be effective in hay fever. 439 homeopathic efficacy has received increasing attention in recent years, 342 but data consist of adult studies. an international multicenter study involving 30 investigators in four countries and 500 patients with three diagnoses, including upper and lower respiratory tract allergies, concluded that homeopathy appeared to be at least as effective as conventional medicine. 345 another multicenter study using a randomized, double-blind, placebo-controlled parallel group design also demonstrated that homeopathic preparations differ from placebo for allergic rhinitis. 408 homeopathic remedies for allergic children are unsupported by scientific studies at this time. an adult study using changes in conductance of specific acupuncture points for diagnosis and treatment demonstrated statistically significant changes that correlated with clinical improvement. 195 in a randomized study of 143 patients that included older teenagers, desensitization was compared with specific acupuncture treatment for allergic asthma, allergic rhinitis, or chronic urticaria. the study was ridden with multiple, tedious variables. the conclusion that acupuncture was significantly more effective than desensitization in improving symptoms and in reducing recurrence in all three conditions did not give a breakdown in age groups. 228 in a clinical report of 75 chronic allergic rhinitis cases that included three cases in children 6 to 10 years of age and 17 cases in 11-to 20-year-olds, two different acupuncture treatments were administered according to tcm diagnoses. there was a cumulative 40% cure rate without age differentiation. 454 asthma is the most common cause of chronic illness in childhood, with approximately 10% of children in the united states carrying the diagnosis. 259, 297, 442 a significant number of school days are lost because of asthma. a wide variation of incidence is found in different countries, with the highest rates in the united kingdom, australia, and new zealand and the lowest rates in eastern europe, china, and india. 296, 442 in recent years, prevalence of asthma is increasing worldwide, especially in children under 12 years of age. 17, 382 although asthma can have onset at any age, 80% to 90% of asthmatic children have their first symptoms before 4 to 5 years of age. 297 children up to age 4 years have distinct symptoms and require special consideration. 36 they have increased health service utilization, including a higher annual rate of hospitalization, 298 which has almost doubled in the united states from 1980 to 1992 for children 1 to 4 years of age. 17 the same trend is observed by other nations worldwide. 9,18 among american children ages 5 to 14 years, asthma death rates almost doubled from 1980 to 1995. 17 new zealand and canada have observed a similar increase in severity and mortality. 73, 387 asthma is a diffuse, reversible, obstructive lung disease with three major features: bronchial smooth-muscle spasm, edema and inflammation of the mucous membrane lining the airways, and intraluminal mucus plugs. 442 during the last two decades, chronic airway inflammation, rather than smooth muscle contraction alone, has been recognized as playing the key role in the pathogenesis of asthma in adults. 63, 131 although this association is less well established in children, recent guidelines for managing asthma in the pediatric population still have emphasized that treatment be directed toward the inflammatory aspects of the disease. 206, 402, 440 chronic inflammation is caused by the local production of inflammatory mediators and an increase in recruitment of inflammatory cells, predominantly eosinophils and mast cells. studies in young adults suggest that the chronic inflammation may be responsible for longterm pulmonary changes, including bronchial hyperresponsiveness, airway remodeling, and irreversible airflow obstruction. because of difficulties in conducting studies in infants and young children, pediatric information is incomplete. 230 limited studies have detected increases in inflammatory cells and thickening of the lung basement membrane in infants and young children and have found that asthmatic children have significantly lower lung function at 6 years of age compared with nonwheezers when both groups of children began with the same baseline at age 6 months. these data support the possible presence of an asthmalike inflammation at a very early age that is associated with nonreversible impairment of lung function. 263 the excessive inflammatory changes indicate that asthma is caused by a poorly regulated "immunologic runaway response" that, instead of protecting the host, destroys normal structure. increased concentrations of proinflammatory mediators, such as histamine and leukotrienes, are found in the airways as well as the blood and urine of asthmatic patients 131 during an acute attack and after allergen and exercise challenge. 34 strong evidence correlates asthma with rsv infection; children who enter day nursery before age 12 months and who are exposed to viruses early in life have built up immunity, with decreased development of allergies. 88 in most children, whose asthma is triggered mainly by respiratory infections at a younger age, asthma symptoms appear to remit by the adolescent years. 263 in older children and teenagers, emotions play a significant role both as the cause of symptoms and as the result of interplay of a chronic illness affecting the child's self-image and family dynamics. 297 the latest asthma management guidelines classify pediatric asthma into four groups of severity: mild intermittent, mild persistent, moderate persistent, and severe. 206 mild intermittent asthma can be typified by exercise-induced asthma, a common pediatric condition. status asthmaticus, defined as progressive respiratory failure that does not respond to conventional management, is becoming more prevalent in american children. 442 conventional treatments for pediatric asthma vary from allergen avoidance to state-of-the-art biochemical therapy. avoiding allergens has been a successful management of asthma since the sixteenth century. asthma is a much more complex problem today because of the increasing number of pollutants and chemicals in the environment that are potential allergens for children. 157 parental education, especially in regard to smoking, can reduce hospital admissions. 449 because infections that trigger asthma attacks are mostly viral, 31 antibiotics are not routinely indicated. medication consists primarily of bronchodilators and inhaled steroids, which are now justified as first-line therapy, 191 both as long-term management 402 and for acute attacks. 231 because growth suppression due to inhaled corticosteroids has been well documented, 61 it is important to distinguish infants with early-onset asthma from those with transient wheezing. 469 recently, the fda has also approved leukotriene receptor antagonists for use in asthmatic children under 4 years of age. 380 these agents counteract the hyperimmune response, resulting in diminished airway inflammation and decreased eosinophilia in the airway mucosa and peripheral blood. 34 parents turn to cam for their asthmatic children because of drug side effects or fear of taking long-term medication, especially steroids. 11,62 a recent survey from texas of 48 multicultural parents of children with asthma reported the usage of a variety of cam therapies, including homeopathy, herbal therapy, vitamins, and massages. hispanic parents were more likely to use herbal and massage therapies, whereas african-american parents often turned to prayers. 269 the relatively abundant studies on cam therapy in asthma are on adults and often have flaws in methodology. significant improvement 15,308,310 and even complete cure 83 have been demonstrated with hypnosis, although most studies had weak designs. hypnosis was recommended for children because they were found to be more hypnotizable, 68 but it is unclear whether the efficacy of hypnosis in asthmatic children is a reflection of children's greater suggestibility or a result of a more reversible disease process. 439 in a recent preschool program, 25 children ages 2 to 5 years received treatment with seven hypnotherapy sessions. the number of physician visits was reduced, and parental confidence in self-management skills increased. 217 tcm has been used to treat asthma for centuries. asthma epitomizes the chinese medicine concept of "winter disease, summer cure," which means the best treatment for asthma should be given during the summer, when the child is symptom free. in china, many asthmatic children who were treated with herbal patches applied to acupoints during the summer had minimal or no symptoms during asthmatic seasons. 37, 58, 320 although several recent adult studies used herbs for asthma, 107 only two involved children. a controlled study comparing herbal treatment of 30 children with penicillin and aminophylline treatment of another 30 children revealed no significant difference in the response from the two groups. 242 a multicenter doubleblind, placebo-controlled clinical herbal study from taiwan evaluated 303 asthmatic children using tcm diagnoses. 170 the children were randomized into three different herbal and placebo groups. although both groups showed improvement, the herbal groups showed greater improvement in symptomatology and in biochemical changes, such as increase in total t cells and decrease in histamine. an animal experiment using a 13-herb concoction revealed 99.1% efficacy in easing bronchial spasm. 170 another animal study with an herbal preparation demonstrated strong smooth muscle relaxation through inhibition of histamine and acetylcholine. 242 from the pediatric standpoint, it would be worthwhile to follow the development of external tcm approaches and noninvasive acupuncture. one clinical obser-vation of pasting chinese herbs to acupuncture points in 72 infants with acute bronchitis showed high cure and improvement rate, especially in infants. 461 humoral immune substances, especially iga, were found to be increased after treatment. another clinical observation reported 78% efficacy in 46 children treated with external application of plasters made of herbal mixtures with antitussive and antiasthmatic properties and 88% efficacy in 17 children treated with antiasthmatic herbal patches. success was also reported with a different herbal patch for acute attacks. the patches were well received by the children. 401 improvement from acupuncture treatment has been reported in asthmatic adults. 392, 406, 428, 463 despite methodologic weaknesses, it still seems that acupuncture may help asthma, especially drug-induced or allergic asthma. 439 in some european countries, almost a fourth of general practitioners believe in the efficacy of acupuncture in the treatment of asthma. 216 its role in the united states is still controversial; some physicians accept acupuncture's effectiveness, 426 whereas others criticize data based on poorly conducted studies. 5 the few current studies and clinical reports on acupuncture treatment of children with asthma are generally favorable. 168, 457 a german practitioner reported good results treating asthmatic children using a simple acupuncture regimen in uncontrolled clinical experience. 145 one study demonstrated that although acupuncture did not affect the basal bronchomotor tone, when administered 20 minutes before exercise, acupuncture was shown to be effective in attenuating exercise-induced asthma, 128 which is common in children. one possible mechanism of acupuncture is in reducing the reflex component of bronchoconstriction, but not in influencing direct smooth muscle constriction caused by histamine. 460 for children who are fearful of or who cannot tolerate needles, safe and painless treatments such as cupping and auricular press pellets, 457 laser acupuncture, 288, 292 and massage of acupuncture points 168 have also been found to be effective. the most interesting future role for acupuncture in asthma lies in its potential both in stimulating an immune response and, more importantly, in regulating or modulating a hyperimmune response. at this time, ample biochemical data in the literature support the theory that acupuncture activates both the humoral and the cellular immune systems to protect the host.* studies have also demonstrated that acupuncture can modulate the synthesis and release of proinflammatory mediators. 192, 256, 458 current hypotheses suggest that this is most likely mediated through a common pathway connecting the immune system and the opioids, 30,321,363 which has been well known to be associated with analgesic effects of acupuncture. homeopathic remedies have been reported to be remarkably effective in asthma in adults, 120, 345, 427 and homeopathic doses of allergens have been shown to alleviate allergic symptoms and desensitize patients to allergens. 433 however, there is paucity of scientific data on homeopathy in both children and adults, as well as a lack of consensus among homeopaths as to the appropriate treatment, administration regimen, or potency for asthma. 439 homeopathic practitioners believe that in chronic conditions such as asthma, homeopathic remedies can stimulate the child's innate healing ability, thereby leading to improvement. 197, 198 two recent large reviews on the role of homeopathy in clinical medicine concluded that, except for the occasionally demonstrated benefit, little scientific evidence exists to support the use of homeopathy in most clinical settings. 159, 439 the availability of homeopathic, nutritional, and herbal remedies without a prescription is appealing to the asthmatic adolescent's desire for independence. 12 in a number of european countries, chiropractic is often used for treatment of asthma. 186 one of the many difficulties in evaluating chiropractic efficacy lies in the varying abilities of the manual therapy practitioners. natural human differences exist in manual applications and techniques. the practitioners have various training backgrounds, including physiotherapy, respiratory therapy, chiropractic, and osteopathy. a danish questionnaire survey of 115 families with children up to age 7 years reported that 92% of parents who sought chiropractic help considered the treatment beneficial for their children. 77, 423 an australian survey reported that the most common cam visits were to chiropractors. 87 a u.s. prospective, observer-blinded, clinical pilot evaluated 36 children from 6 to 17 years of age with mild to moderate persistent asthma for chiropractic treatment in addition to optimal medical management. 42 children were randomized into treatment and sham spinal manipulative therapy (smt) for 3 months. the children with combined smt and medical treatment rated their quality of life substantially higher and their asthma severity substantially lower, and their improvements were maintained at 1-year follow-up. however, there were no significant changes in lung function or hyperresponsiveness. further research is needed to determine which components of the chiropractic encounter are responsible for the improvements. a controlled, patient-blinded trial of chiropractic manipulation for 91 children with mild or moderate asthma randomized the children into an active or a simulated chiropractic manipulation for 4 months. 20 each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. no significant benefit was observed in the treatment group. a few studies in adults generated statistically insignificant data. 176 one study found subjective but not objective improvements in individuals with asthma who received treatment in a chiropractic clinic. 186 a 2001 systematic review revealed that the majority of the studies on smt had poor methodology; the two good studies did not demonstrate significant differences between chiropractic smt and sham maneuver. 167 the reviewers concluded that the evidence is still insufficient at this time to support the use of manual therapies for patients with asthma. a german pilot study of 15 children ages 5 to 11 years with bronchial asthma combined relaxation using various techniques, including progressive muscle relaxation, autogenic training, fantasy travels, mantras, and periodic music, and demonstrated significant improvement in a number of pulmonary function parameters. 142 however, it is difficult to interpret the results because of the variety of techniques used. 143 a u.s. review of anecdotal reports indicated that massage therapy can improve asthmatic symptoms. [110] [111] [112] diarrhea acute diarrhea is a common occurrence in the pediatric population and a significant cause of pediatric morbidity and mortality in both developed and underdeveloped countries. 79, 302, 354 each year an estimated 54,000 to 55,000 u.s. children are hospitalized for diarrhea, 136 and more than 4 million infants and young children worldwide die of acute infectious diarrhea. 354 infants under 3 months of age have the highest risk for hospitalization and mortality. 304 children under age 3 years have an average of approximately 2.5 episodes of gastroenteritis per year in the united states. 143, 302 internationally, the average is approximately 3.3 episodes annually. 354 both diagnosis and treatment continue to be problematic in the pediatric population. 260 the infectious pathogens that cause acute diarrheal episodes in children include viruses, bacteria, and parasites. 229 transmission is most likely through the fecal-oral route, from ingesting contaminated food or water, 434 or in infants and toddlers, by mouthing contaminated toys. the nature of food-borne diseases is changing as more mass-produced, minimally processed, and widely distributed foods result in nationwide and international outbreaks of diarrheal disease instead of just a few individuals who shared a meal. 143 a majority of the cases are caused by viral infections. rotavirus is the most prevalent, 264 and human astrovirus (hastv) is a significant cause of diarrheal outbreaks. 434 frequently, children are co-infected by several viruses. viral diarrhea tends to involve the small bowel, producing large, watery, but relatively infrequent stools. 82 these illnesses usually have short, self-limiting courses, 6 typically lasting 3 to 7 days. 264 however, the diarrheal bouts can be devastating to children with compromised immune systems or structural abnormalities of the gastrointestinal tract. 143 the most common bacterial agents are enteropathogenic escherichia coli, shigella/salmonella, and campylobacter. 82, 264 these are much more virulent pathogens that usually cause mucocal injury in the small and large intestines, producing frequent, often bloody stools containing leukocytes. 82 e. coli has become an important public health problem in recent years, causing more than 20,000 cases of infection and up to 250 deaths per year in the united states. 220, 381 transmission of infection is most often linked to consumption of contaminated meat, water, unpasteurized milk, leafy lettuce, alfalfa sprouts, and goat's milk, 220, 413 and exposure to contaminated water in recreational swimming sites. 413 the most common parasitic infection is giardia lamblia, which often causes secretory diarrhea without blood 264 and frequently leads to chronic diarrhea. 161 diagnosis and treatment are still inconsistent. because most acute diarrheal conditions are self-limited, physicians often do not obtain stool cultures or examination for ova and parasites because the results are not available sometimes for several days. stool culture can identify different types of bacteria, but detection of specific enteropathogenic strains of e. coli requires specific serotyping that is not performed in routine stool cultures. 220 it is expensive, time-consuming, and often not sufficiently specific or sensitive and therefore is not recommended for routine diagnosis. 151 the primary treatment focus is on correction of dehydration, 275 which is the most important cause of morbidity and mortality in acute diarrhea. 243 oral rehydration treatment (ort) with solutions containing appropriate concentrations of electrolytes and carbohydrates is recommended by the world health organization (who) and has significantly reduced mortality. 82, 140, 367 after rehydration, early refeeding with a lactose-free 82 or normal, age-appropriate diet 229 is important for reducing diarrheal duration, severity, and nutritional impact. supplementation with specific dietary ingredients that are lost in diarrhea, such as vitamin a, zinc, and folate, is also recommended. 140 because most of the acute infectious diarrheal conditions are viral, patients do not require antimicrobial therapy. 326, 333 the rotavirus vaccine was put on the market in the united states in october 1998. this vaccine, as the natural infection, decreases the risk of acute rotavirus diarrhea by 50% and the risk of severe diarrhea with dehydration by more than 70%. 367 improving hygiene such as handwashing is also important, especially in day care. breast-feeding is one of the most important preventive measures. 351 continuation of breast-feeding has been found to control acute diarrheal episodes 140 and lower the frequency and duration of acute diarrhea, especially in infants under 6 months of age. 251 a large-scale randomized trial was conducted in 31 hospitals in the republic of belarus. evaluation within the first year revealed that breast-feeding significantly reduced the risk of gastrointestinal tract infection compared with the control group. 228 however, a survey from singapore of breast-feeding mothers at 6 months postpartum revealed no significant differences in the rates of diarrheal diseases between breast-fed and non-breast-fed infants. 64 treatment with antimicrobial therapy must be instituted carefully and only with specific identification of pathogen and drug sensitivity. with the increasing frequency of antibiotic resistance, common antibiotics may be ineffective in patients with acute diarrhea. 143, 351, 367 treatment of salmonellosis with antibiotics can prolong the carrier state and lead to a higher clinical relapse rate. 143 injudicious antimicrobial therapy may also lead to susceptibility to other infections, enhance colonization of resistant organisms, 29, 143 and disrupt the normal intestinal flora, the body's natural defense against infection. 270 homeopathy has the most convincing evidence of efficacy in treating diarrhea in children. a randomized, double-blind clinical trial comparing homeopathic medicine with placebo in the treatment of acute childhood diarrhea was conducted in nicaragua in 1991. eighty-one children 6 months to 5 years of age were given treatment with individualized homeopathic medicine. standard ort was also given. there was a statistically significant decrease in the duration of diarrhea in the treatment group. 182 although criticisms of the study include homeopathic theory being inconsistent with scientific belief 378 and possible toxicity of the dilute homeopathic remedies, 210 the report was also praised for being an impressive, 54 well-designed 44 study that paves the way for future research into the efficacy of homeopathy and other cam therapies. 115 using the predefined measures based on the 1991 study, the same group of researchers more recently carried out a similar study and replicated the same findings of decrease in the duration of diar-rhea and number of stools in 126 children in nepal, ranging in age from 6 months to 5 years. 183 a few studies have demonstrated effectiveness of acupuncture in pediatric diarrhea. the treatment protocols in point selections generally depend on tcm diagnoses, with the majority of points chosen on the two major digestive channels. 109, 190, 245, 398, 455 acupuncture has also been shown to induce favorable anatomic and biochemical changes in improving intestinal peristaltic function and in enhancing both humoral and cellular immunity. 244 a randomized study comparing shallow acupuncture treatment (needles inserted superficially and withdrawn swiftly) with drugs in 761 children ages 1 to 35 months reported significantly higher therapeutic effect in the acupuncture group. 244 the diagnosis and subsequent choice of points were based on tcm principles, not on stool culture results. unlike the homeopathy study, this investigation grouped together patients with acute and chronic diarrhea. in a clinical trial using one chinese herbal formula for treatment of acute diarrhea, there was significant reduction of symptoms and duration of diarrhea. 38 a clinical report of 20 years' application of a seven-herb concoction in 419 children demonstrated 96.4% improvement and 90% cure rate. 241 this nonrandomized, nonblinded report used tcm diagnoses that encompassed a variety of diarrheal conditions, including acute, chronic, infectious, and noninfectious diarrhea. the mechanisms were hypothesized as eliminating pathogenicity, improving immunity, accelerating intestinal digestion, and inhibiting intestinal peristalsis. in a clinical report comparing chinese herbs to western medicine in 158 children with diarrhea due to rotavirus, the herbs were reported to be superior and had a viral inhibitory rate of 71.43%, but no mention was made of the efficacy of conventional medicine. 435 chronic nonspecific diarrhea of childhood differs from acute diarrhea in that it is not associated with significant morbidity. once potentially serious causes are excluded, appropriate diet can be instituted to minimize complications, and reasonable time is then allowed for spontaneous resolution. 414 in a nonrandomized clinical trial involving 30 children ages 3 months to 8 years with chronic diarrhea of 2 to 4 months' duration that was unresponsive to western medicine and tcm, individualized acupuncture treatment eliminated symptoms and normalized stools. 109 infantile colic is estimated to affect 20% to 30% of all infants under 4 months of age and remains a medical enigma of nature versus nurture. colic may represent a heterogeneous expression of developmental variance, unmet biologic needs, psychologic or emotional distress from poor parent-infant interaction, intrinsic temperamental predisposition, colonic hypermotility, 278 or milk allergy.* although colic is selflimiting by 3 to 4 months of age, treatment is mandated because the psychologic consequences may result in a disturbed mother-infant relationship. 174, 355 evidence suggests that uncontrollable crying is the precipitating factor in many cases of infant abuse. 178, 441 because the precise etiology is not understood, the therapeutic goal of western medicine is not aimed at "curing" colic but at containment of the crying. 328 removing cow's milk protein from the mother's diet, changing formula, and prescribing antispasmodic medications are the mainstays of conventional treatment and may be helpful. 69 treatment is often directed toward behavioral changes in mothers. parents may be referred for therapy to learn parenting and coping skills. cam treatments yield inconsistent results. herbs have not yet been proven to be efficacious, 265 although a survey of 51 hispanic mothers in an urban neighborhood in texas revealed that herbal teas were commonly used for colic. 346 evidence is controversial for chiropractic treatment of colic. a multicenter prospective, uncontrolled study of 316 colicky infants involving 73 chiropractors in 50 clinics in the united kingdom for 3 months demonstrated efficacy with chiropractic smt in controlling colic, as reported by mothers in 94% of cases. 215 a retrospective questionnaire study in 1985 revealed satisfactory results of chiropractic treatment in 90% of infants. 301 a randomized, blinded, placebo-controlled clinical trial of 100 infants with typical colic reported that chiropractic manipulation was no more effective than placebo. 307 however, a randomized, controlled, 2-week trial comparing smt with the drug dimethicone demonstrated significantly better results in the chiropractic treatment group. 444 craniosacral therapists empirically claim success in treatment of colic. 19 massage therapists have also found empirically that touch therapy can decrease severity of colic. 111 in a finnish clinical trial, 58 infants less than 7 weeks of age perceived as colicky by their parents were randomized into an infant massage group (n = 28) and a crib vibrator group (n = 30). 173 over 4 weeks there was no difference in the reduction of colicky crying between infants receiving massage and those with a crib vibrator, leading the investigators to conclude that the decrease of crying reflects more the natural course of early infant crying and colic than a specific effect of intervention. therefore infant massage is not recommended as treatment for colic. enuresis is defined as inappropriate or involuntary voiding during the night at an age when urinary control should be achieved. 7 enuresis is a complex disorder with poorly understood pathogenicity and pathophysiology. it affects children worldwide, 297 with about 5 to 7 million children affected in the united states 281 and as many as 30% of school-age children in italy. 48 the condition is classified as primary nocturnal enuresis (pne) when the child has never been dry at night or secondary nocturnal enuresis (sne) when wetting follows a dry period, usually after an identifiable stress. 203, 297 by age 8 years, 87% to 90% of children should have nighttime dryness. 65 in 85% of pne patients, bedwetting is monosymptomatic, with a spontaneous remission rate of 15% per year of age. both the etiology and the pathophysiology of enuresis are still not well understood. multiple factors may interplay: genetic and psychologic predispositions, delayed maturation of the central nervous system, sleep disorders, urinary reservoir abnormalities, detrusor-sphincter incoordination, and urine production disorders. 48 although enuresis is benign, treatment is warranted because of adverse personal, family, and psychosocial effects. 281, 282 nocturnal enuresis delays early autonomy and socialization because of a decrease in self-esteem and self-confidence and a fear of detection by peers. the child may be at increased risk for emotional or even physical abuse from family members. 368, 438 the conventional treatment modalities are still controversial. because the vast majority of pne cases resolve spontaneously with time, treatment should carry minimal or no risk. the moisture alarm is both safe and inexpensive and should be the treatment of choice in most cases 65, 286, 357 but is often the one least prescribed. 15, 258 the medications imipramine and ddavp were frequently chosen as first-line treatment choices. adjunctive therapy may include bladder-stretching exercises, which have a success rate of 30%, and behavioral conditioning. 357 numerous cam therapies are available for childhood enuresis; the most common are hypnosis, acupuncture, and biofeedback. less common cam therapies are chiropractic and nutrition management. hypnotherapy has been recognized by conventional practitioners as a potentially effective therapy. 262, 286 uncontrolled studies have reported high rates of success. 24, 67, 74, 308, 310 in one comparative study of imipramine and direct hypnotic suggestion with imagery for functional nocturnal enuresis in 5-to 16-year-old patients, 76% of the imipramine group and 72% of the hypnosis group had positive response. 21 after termination of treatment, the hypnosis group continued practicing self-hypnosis. at 9-month follow-up, 64% of the hypnosis group maintained dryness compared with only 24% of the imipramine group. hypnosis and self-hypnosis were found to be less effective in younger children (ages 5 to 7 years) compared with imipramine treatment. hypnotherapy has the added advantage that nonphysician health care professionals, such as nurse practitioners, can easily learn the technique to help children. 163 a recent review of controlled studies reported promising findings for hypnosis in children with enuresis, but none of the interventions can currently qualify as efficacious. a major limitation is the lack of treatment specification via a manual of its equivalent. 283 the requirement that the child practice the self-hypnosis technique several times a day limits compliance with the program. 286 acupuncture has been used as an effective treatment for enuresis since at least the 1950s. 459 current worldwide literature in general demonstrates its viability as either a primary or an adjunctive therapy for the enuretic child.* a turkish clinical study on 162 subjects treated with electroacupuncture therapy reported a success rate of 98.2%. 418 acupuncture has been found to be successful both in decreasing the occurrence of enuresis during treatment and in exerting a long-term effect after treatment. 35, 48, 370 parents also report a decrease in sleep arousal threshold. 35 although the precise mechanism of acupuncture is still unknown, a multidisciplinary approach that included acupuncture demonstrated on electroencephalography (eeg) that treatment normalized activities of the cerebral cortex. 415 data from china usually consist of clinical reports of large sample populations. results in one study of 500 patients treated with acupuncture on only two body points demonstrated cure in 476 patients (98%), improvement in 14, and no response in 10 patients. 459 number of treatments ranged from one to three in 453 patients and four to six in 23. another study of 302 enuretic children ages 3 to 15 years (10 over 15 years; oldest 23 years) used tcm diagnosis of organ imbalance and different combinations of acupuncture points, with 10 treatments constituting one course. 453 the results showed that 221 patients were cured, 71 showed marked improvement, and 10 were "effectively" treated. treatment using scalp acupuncture has also been reported to be successful. in one clinical study, 59 children ages 4 to 17 years were treated for 10 to 15 sessions, and some needed a second course. 61 cure was obtained in 9 children, marked improvement in 27, improvement in 19, and no response in 4 children. in all these clinical reports, subjects of a wide range of ages were included in the same study; the discussions were short and generalized, giving very few or no details about the children (e.g., types of enuresis, duration of enuresis, number of wet nights, types of improvement); the methods of treatment were laden with numerous variables (e.g., number of points, treatment courses). a clinical study from italy of 20 children with bladder instability due to uninhibited contractions of the detrusor muscle reported that acupuncture treatment was successful in gradual elimination of enuresis in 11 and improvement of symptoms in 7 children. the mechanism was not clarified. 284 a russian clinical trial of using acupuncture specifically for enuresis due to neurogenic bladder dysfunction demonstrated that acupuncture was beneficial in 17 of 25 children. 194 in a clinical report of 54 enuretic children, short-term success in reducing wet nights was 55% with acupuncture versus 79% with ddavp, whereas long-term success rates were 40% and 50%, respectively. 48 a zagreb report of a clinical trial of acupuncture treatment on 37 children with mean age of 8 years who failed psychotherapy demonstrated a statistically significant decrease in enuresis even at 6 months after treatment. 350 a self-controlled regulating device operating on the principles of acupuncture was found to be effective in the treatment of nocturnal enuresis attributable to neurogenic bladder dysfunction. 233 a controlled clinical study of 40 children between 5 and 14 years of age randomly selected into four groups of 10: treatment with ddavp alone, acupuncture alone, combined ddavp with acupuncture, and placebo. efficacy of treatment, expressed as a percentage of dry nights, was high in both ddavp and acupuncture groups, but the combined-treatment group had the best results. 52 a scandinavian clinical trial used traditional chinese acupuncture for treatment of primary persistent pne in 50 children ranging in age from 9 to 18 years. the response rate was monitored at 2-week, 4-week, and 3-month intervals. 370 within 6 months, 43 (86%) of children were completely dry and 2 (10%) were dry on at least 80% of nights, leading the clinicians to conclude that acupuncture is effective, with stable results. another scandinavian study investigated the efficacy of electroacupuncture in treating 25 children ranging in age from 7 to 16 years. 35 twenty treatments were administered over 8 weeks. the number of dry nights consistently increased when the children were reevaluated at 3 weeks, 3 months, and 6 months after treatment. five children had more than 90% reduction of wet nights at 6 months, and 65% had more dry nights at the 6-month follow-up. a recent teaching round at the china academy of traditional chinese medicine in beijing discussed successful acupuncture treatment of a complicated case of enuresis in a 16-year-old student who had previously failed both western and chinese medicines for his physical and emotional sequelae. 171 using tcm diagnosis of organ imbalances, the treatment combined body acupuncture, scalp acupuncture, and auricular acupressure seed. the patient began improving after three treatments in the first week. he received 3 more weeks of treatment, with no recurrence of enuresis at 6month follow-up. children are often unwilling to undergo needle acupuncture because of fear of pain, 61 prompting researchers to use noninvasive forms of acupuncture. simple acumassage has been previously reported to be beneficial to the enuretic child. 21 an austrian prospective, randomized trial evaluated efficacy of laser acupuncture versus desmopressin in 40 children over age 5 years with pne. 337 at 6-month follow-up, the desmopressin-treated group had 75% success rate with complete resolution of symptoms, an additional 10% had a more than 50% reduction in wet nights, and 20% did not respond. the laser acupuncture group had 65%, 10%, and 15% rates, respectively. the results were not statistically significant. therefore laser acupuncture should be considered as an alternative, noninvasive, painless, cost-effective, and short-term therapy in children with normal bladder function and high nighttime urine production. worldwide reports have demonstrated efficacy in treating enuresis with biofeedback, 164, 250, 318, 332 which aims at learning or relearning of influence of involuntary functions. 266 a clinical study from italy treated 16 boys and 27 girls ages 4 to 14 years with detrusor-sphincter dyssynergy. biofeedback was successful in all the children, with sne resolving significantly sooner than pne and girls responding better than boys. two-year follow-up still revealed an 87.18% success rate, with 80% at 4 years. 332 in a french study, 120 children with three predominant urinary disorders that included nocturnal enuresis were treated with biofeedback. detrusor-sphincter discoordination was diagnosed in 33 children. pelvic floor biofeedback produced excellent results in these children. 323 belgian investigators reported a clinical biofeedback study of 24 children with median age of 10.4 years who did not respond to anticholinergics. 164 seventeen subjects had complete resolution of enuresis, six had a decrease in symptoms, and one child did not respond. at 6-month follow-up, two children in the cured group had recurrence of enuresis. another study from belgium also reported success in using biofeedback in 26 children with pseudo-detrusor-sphincter dyssynergy; 17 were completely cured, and 5 improved considerably. 266 a spanish study used biofeedback to treat unstable detrusor in 65 enuretic children; complete disappearance of symptoms was seen in 70.5%, with improvement in 78.2%. 318 in a u.s. report of 8 boys and 33 girls ages 5 to 11 years who underwent an average of 6 hours of biofeedback for nocturnal and diurnal enuresis, improvement was noted in 90% of nocturnal enuresis and 89% of diurnal enuresis. 272 another u.s. clinical study used biofeedback for 21 children with dysfunctional voiding; 17 (81%) had an excellent response, 3 (14%) had a fair response, and 1 (5%) was too inconsistent to rate. 70 the average number of sessions to achieve a consistent urodynamic response was 3.7 (range 2 to 14). average follow-up was 34 months (range 14 to 51 months). the investigators recommended biofeedback as an effective method that requires only a short period for treating dysfunctional voiding. 70 all these worldwide studies were clinical reports, not randomized, controlled, blinded studies. the efficacy of chiropractic manipulation in enuresis has been inconsistent. one clinical report identified an 8-year-old boy with functional enuresis who had successful treatment with manipulation. 37 in an uncontrolled study of 175 children ages 4 to 15 years, with responses monitored by parents, chiropractic manipulation resulted in only 15.5% success. 234 however, a randomized, controlled clinical trial of 57 children demonstrated that 25% of the treatment group had 50% or more reduction in enuretic symptoms, although the pretreatment to posttreatment change in wet night frequency was not statistically significant, and there was no long-term follow-up. 341 a comprehensive review of the literature revealed that smt was no more effective than the natural regression of enuresis with age. 225 food allergy as a cause of enuresis has been in the literature for several decades. 106 a recent study of children with severe migraine or attention deficit disorder (add) included 21 children with enuresis. oligoantigenic diets were successful in curing 12 children and improving enuresis in 4 other children. relapse of wetting occurred when foods were reintroduced; the substances implicated most often were chocolate, citrus, fruits, and milk from cows. 281 although no studies are available on naturopathic approaches, which focus on natural remedies (e.g., corn silk and tea, tea and honey), physicians should not dismiss parental opinion that these remedies may be safe and effective. the future of treatment for enuresis should combine various methods to increase the probability of treatment success and minimize risk to the child. 281 atopic dermatitis affects almost 10% of all children 56 and 20% of children ages 3 to 11 years. 201, 202 it accounts for more than 30% of outpatient pediatric visits. 95 most children with atopic dermatitis typically come to medical attention with cradle cap and facial and extremity rashes by age 2 to 3 months. 95 despite considerable research, the etiology of allergic disease remains poorly understood. 16 allergic dermatitis can be thought of as an inherited skin "sensitivity" that reacts to various external allergens and changes in psychologic states. 357 food causes atopic dermatitis in 50% of infants, 20% to 30% of young children, and 10% to 15% of children after puberty. 395 topical steroids remain the main therapeutic method. dermatologists tend to prescribe antibiotics and use potent topical steroids, 343 which are more readily absorbed in children and can result in hypothalamic-pituitary-adrenal axis suppression. 179 new immune modulators have shown promise in severe atopic dermatitis. 149, 212 cam therapies are increasingly used for dermatitis, 127 although most of the information is in clinical reports, and research data are limited. a database review of 272 randomized clinical trials of atopic eczema covering at least 47 different interventions revealed that evidence is still insufficient to make recommendations on maternal allergen avoidance for disease prevention, herbs, dietary restrictions, homeopathy, massage therapy, hypnotherapy, or various topical cam therapies. 162 a multicenter randomized clinical trial conducted in 31 hospitals in the republic of belarus reported that breast-feeding significantly reduced the risk of atopic eczema compared with the control group in the first year of life. 228 psoriasis was found to worsen with cam treatments such as herbs, dietary manipulation, and vitamins. 116 dietary management with evening primrose oil, rich in gamma-linolenic acid, has been found to be inconsistently effective in small studies. fish oil supplements (enriched in n-3 polyunsaturated fatty acids) have also been used. 357 various herbs offer relief for eczema. 127 a placebo-controlled, double-blind trial used a chinese herbal prescription specifically formulated for widespread nonexudative atopic eczema. thirty-seven children were randomly assigned to 8-week active treatment and placebo, with an intervening 4-week "washout" period. the response to active treatment was significantly superior to placebo, without evidence of hematologic, renal, or hepatic toxicity. 373 the same investigators monitored the children over the following 12 months. eighteen children had at least a 90% reduction in eczema, and five showed lesser degrees of improvement. 374 two randomized, double-blind placebo-controlled trials from singapore revealed that a concoction of 10 chinese herbs was efficacious in the treatment of atopic dermatitis in both children and adults, and that the mechanism may be through the beneficial immunosuppressive effects. toxicity is a concern, however, because exact dosing of the active derivatives is difficult to achieve. 339 acupuncture treatment of acne has been reported to be successful 247 in as many as 91.3% of adolescents given treatment. 456 other tcm techniques have also been reported to be helpful. 57 a clinical trial treated 20 children with severe, resistant atopic dermatitis with hypnosis. 393 nineteen showed immediate improvement, 10 maintained improvement in itching, and 9 maintained improvement in sleep disturbance 18 months after treatment. homeopathy is frequently used to treat dermatitis. in one homeopathic clinic in israel, more than 80% of the patients expressed satisfaction with treatment. however, the authors of the survey believed that homeopathic medicine complements conventional medicine and is not an alternative. 316 chiropractic treatment has also been sought by children for allergic problems. 303 a small british study tested the hypothesis that massage with essential oils (aromatherapy) used as a complementary therapy in conjunction with normal medical treatment would help to alleviate the symptoms of childhood atopic eczema. 9 eight children were randomized into the treatment group, who were massaged with oil, and the control group, massaged without essential oil. no significant difference was found between the two groups. there was a later deterioration of eczema in the oil massage group, suggesting allergic contact dermatitis provoked by the essential oils themselves. attention deficit-hyperactivity disorder (adhd) is the most common neurodevelopmental disorder of childhood, with a prevalence rate between 2% and 11%, 373 averaging about 5%. 14, 371, 405 the road constellation of hyperactive, inattentive, and impulsive symptoms combined with the multiple comorbid conditions makes the definition and adhd controversial and the diagnosis flawed. 405 adhd is a chronic, heterogeneous condition with academic, social, and emotional ramifications for the school-age child. 371 the disabling symptoms persist into adolescence in approximately 85% of children and into adulthood in approximately 50%. 14, 32 there is a developmental pattern in the primary symptoms of the disorder; hyperactivity diminishes while attentional deficits persist or increase with age. 371 the precise etiology of adhd is still unknown, and assessment and management remain diverse. medication continues to be the mainstay of treatment, with methylphenidate (ritalin) the treatment of choice. 141 the tricyclic antidepressants were added as an alternative medication in the 1970s, 32 with clonidine, buspirone (buspar), and other antidepressants and neuroleptics added to the list in the 1980s. 55, 60 although it is generally agreed that drugs are beneficial on a short-term basis, there is a paucity of data on the long-term efficacy and safety of medications, especially in children younger than 3 years of age. these drugs have not been shown to produce long-term gains academically or socially. 90 besides pharmacotherapy, a multimodal approach using a combination of drugs and other methods, such as cognitive-behavioral therapy (cbt), psychotherapy, social skills training, and school interventions, is frequently prescribed for adhd. cbt represents the most widely used alternative to pharmacotherapy, although previous studies have shown disappointing results. 2, 3, 45, 177 in 1992 the national institutes of mental health (nimh) began a 14-month, multisite clinical trial, the multimodal treatment study of adhd (mta). 160, 189 the results indicated that high-quality medication management (with careful titration and follow-up) and a combination of medication and intensive behavioral therapy were substantially superior to behavioral therapy and community medication management. there is slight advantage of combination of medication and behavioral therapy over medication alone. psychotherapy can be an effective adjunct to medication 364,365 but usually requires a long-term commitment to several years of treatment. concerns about side effects of medication, 232,391 treatment acceptability, 27,334 and compliance are additional factors that complicate management of the adhd child. clearly, there is room to explore safe, acceptable, and relatively easy alternatives. interest is increasing in more natural, holistic integrative approaches to adhd. studies using cam therapy for treating adhd encompass more than the usual research difficulties because of the complexity and heterogeneity of the disorder, as well as subjective evaluation by parents and teachers of a wide range of 18 characteristics that may qualify for several different diagnoses. a majority of the cam therapies to date continue to have mostly anecdotal and empiric evidence. the few welldesigned studies include biofeedback, herbal medicines, dietary modifications or supplements, and acupuncture. 46 studies have demonstrated that there is a significant difference in baseline eeg measurements in children with attention deficit disorder (add) compared with normal-achieving preadolescent males. these differences occur mainly in the parietal region for on-task conditions 187 and in the cortex and corticothalamic excitatory and inhibitory interactions. 252, 255 biofeedback or neurofeedback is a technique for modifying neurophysiology for learning. 252 in 1991 a critical review of 36 studies in which biofeedback was used as a treatment for hyperactivity indicated that biofeedback alone had not been effectively evaluated, and methodologic problems limit generalizations that it may be applicable to the entire hyperactive population. 238 a 2001 review continues to indicate that although anecdotal and case reports cite promising evidence, methodologic problems coupled with a paucity of research preclude any definitive conclusions as to the efficacy of enhanced alpha and hemisphere-specific eeg biofeedback training. 340 some recent studies using more sophisticated technology claim that neurofeedback can improve attention, behavior, and intellectual function in the child with add, 49, 246, 253 with measurable eeg improvement in the frontal/central cortex. 295 its stabilizing effect has also been found to last as long as 10 years after treatment. 407 hypnotherapy and biofeedback do not appear to alter the core symptoms of adhd but may be helpful in controlling secondary symptoms. these methods allow children to become active agents of their own coping strategies. 26 a mailed questionnaire survey of 381 children with adhd with a 76% response rate reported that 69% were using stimulant medication and that 64% of the respondents used or were using a nonprescription therapy. diet therapies constitute the most common cam therapy (60%). 397 one review of cam therapy lends support to individualized dietary management and specific trace element supplementation in some children with adhd. 26 nutritional management of add includes elimination diet, megavitamins, 26,372 supplements, and trace element replacement. simple sugar restriction seems ineffective. 14 the well-known feingold diet eliminates natural salicylates, food colors, and artificial flavors. studies have demonstrated mixed results. 211 megavitamins were demonstrated to be ineffective in the management of add in a two-stage study with clinical trial and double-blind crossover. potential hepatotoxicity is a major concern with use of megavitamins. 152 in a recent longitudinal, nonrandomized clinical trial, 17 adhd children were given a glyconutritional product containing saccharides known to be important in healthy functioning and a phytonutritional product containing flash-dried fruits and vegetables. 93 five children were not receiving methylphenidate (ritalin), six children were taking prescribed doses of methylphenidate, and the remaining six children had their medications reduced by half after 2 weeks. the glyconutritional supplement was administered for the entire 6 weeks, and the phytonutritional supplement was added after 3 weeks. the teachers and parents rated behavioral items for adhd, oppositional defiant disorder, and conduct disorder. the conclusion was that the glyconutritional supplement decreased the number and severity of adhd, associated odd and cd symptoms, and side effects of medications during the first 2 weeks of the study; there was little further reduction with the addition of the phytonutritional supplement. the three groups did not differ statistically in degree or reduction of symptoms. 93 this 6-week study had too many variables and too few subjects without control for a definitive conclusion, although the concept of simple nutritional supplement is important to explore. there is increasing interest in abnormality of fatty acid metabolism as the etiology of at least some features of adhd. 344 these abnormalities can range from genetic abnormalities in the enzymes involved in phospholipid metabolism to symptoms that were reportedly improved after dietary supplementation with long-chain fatty acids. 436 in a randomized, double-blind, placebo-controlled trial of docosahexaenoic acid (dha) supplementation, 63 children ages 6 to 12 years receiving stimulant medication were randomly assigned to receive dha supplementation or placebo for 4 months. there was no significant improvement in the treatment group. 429 oligotherapy focuses on deficiency of trace elements in children with add. 221, 389 in a polish controlled clinical trial, magnesium deficiency was found in blood and in hair of hyperactive children. 390 fifty 7-to 12-year-old add children were given a magnesium supplement of 200 mg/day for 6 months while the control group of 25 children continued on their medical regimen. increase in magnesium contents in hair correlated with a significant decrease of hyperactivity in the treatment group, whereas hyperactivity actually intensified in the control group. the same investigators also found deficiencies of copper, zinc, calcium, and iron, with magnesium being the most common deficiency, in 116 children with adhd. 389 a thorough literature review of alternative treatments for adhd identified 24 cam therapies and reported that chinese herbal treatment has promising pilot data. 14 a clinical trial using chinese herbs in the treatment of 66 children with a diagnosis of hyperkinesia based on the american psychiatric association's diagnostic and statistical manual of mental disorders, ed 3 revised (dsm-iiir) criteria demonstrated 84.8% effectiveness in ameliorating hyperactivity and improved attention and school performance. 401 the herbal remedy was prepared according to the tcm diagnosis of common energetic (qi) imbalance found in these children. clinical observations were substantiated by laboratory findings of significant increase in urinary content of norepinephrine, dopamine, dihydroxyphenylacetic acid, cyclic adenosine monophosphate, and creatinine. 401 in a randomized study, chinese herbal treatment was found to be comparable to methylphenidate but had fewer side effects. 464 research is currently being conducted to investigate the efficacy of herbal and homeopathic remedies because current evidence is inconsistent or lacking. 26 in a prospective, randomized, double-blind pilot study funded by nih that integrated dsm-iv diagnostic criteria, conventional theories of frontal lobe dysfunction, and neurotransmitter abnormalities with traditional chinese theories of energetic imbalances, laser acupuncture was used in the treatment of adhd in 7-to 9-year-old children. 249 preliminary data on the six children in the treatment group showed promise in reducing signs and symptoms of adhd. using conners scale as a weekly follow-up measure, improvement in classroom behavior was reflected by substantial drops in the teachers' scores before and after treatment in five of six children. the parents' scores dropped in three children but did not change in the other three children (figures 11-1 and 11 -2). one child was promoted to the gifted program, and another demonstrated marked improvement in learning disabilities. there are no data at this time on homeopathic or chiropractic treatment of adhd, although many practitioners claim anecdotal success with the use of homeopathic desipramine (norpramin) and manipulation. pediatric use of cam therapies continues to increase. 385 it is therefore advisable for physicians who treat children to take a thorough history of cam use, especially in those with chronic disorders, to become knowledgeable about the various alternative therapies that can complement conventional care. this allows practitioners to consider possible adverse effects or interactions of cam with conventional therapy, to open lines of communication with cam providers, and even to consider integrating effective cam therapy into their medical regimen. although cam therapy is in general considered safe, there have been a few reports of significant side effects. 219, 271 continuous research is needed to investigate the safety and efficacy of cam therapies for children; to address explicitly the tremendous heterogeneity between and among the practices, beliefs, and providers of professional and lay services; and to study how cam may enhance the quality of mainstream health services. 208 although children are entitled to new therapies, pediatric research in cam is further complicated by children's vulnerability to violation of their personal rights and to risk exposure. 420 in children of the same age, varying cognitive capacity can be required for informed consent. 315, 353 differences in physiologic maturation can change the kinetics, end-organ responses, and toxicity of therapy, so data from adult studies cannot be extrapolated for children. 240 even in conventional medicine, children are often rendered "therapeutic orphans" 376 because of history of abuses in pediatric research, a heightened sensitivity to risks in children-especially since the thalidomide 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cases of bronchial asthma preliminary study of traditional chinese medicine treatment of minimal brain dysfunction: analysis of 100 cases clinical and experimental study on yifei jianshen mixture in preventing and treating infantile repetitive respiratory infection clinical investigation on massage for prevention and treatment of recurrent respiratory tract infection in children pneumococcal conjugate vaccine for young children prevention of asthma morbidity: recent advances key: cord-257244-gryp0khc authors: edwards, m. r.; walton, r. p.; jackson, d. j.; feleszko, w.; skevaki, c.; jartti, t.; makrinoti, h.; nikonova, a.; shilovskiy, i. p.; schwarze, j.; johnston, s. l.; khaitov, m. r. title: the potential of anti‐infectives and immunomodulators as therapies for asthma and asthma exacerbations date: 2017-08-10 journal: allergy doi: 10.1111/all.13257 sha: doc_id: 257244 cord_uid: gryp0khc asthma is responsible for approximately 25,000 deaths annually in europe despite available medicines that maintain asthma control and reduce asthma exacerbations. better treatments are urgently needed for the control of chronic asthma and reduction in asthma exacerbations, the major cause of asthma mortality. much research spanning >20 years shows a strong association between microorganisms including pathogens in asthma onset, severity and exacerbation, yet with the exception of antibiotics, few treatments are available that specifically target the offending pathogens. recent insights into the microbiome suggest that modulating commensal organisms within the gut or lung may also be a possible way to treat/prevent asthma. the european academy of allergy & clinical immunology task force on anti‐infectives in asthma was initiated to investigate the potential of anti‐infectives and immunomodulators in asthma. this review provides a concise summary of the current literature and aimed to identify and address key questions that concern the use of anti‐infectives and both microbe‐ and host‐based immunomodulators and their feasibility for use in asthma. research in asthma over the last 20 years or more repeatedly shows an overwhelming link between the actions of microorganisms and asthma. 1, 2 from acting as direct pathogens, to educating the immune system and preventing opportunistic pathogen colonization through occupying specific niches, it is now well accepted that viruses, bacteria and fungi are positively associated with asthma onset, 3,4 asthma severity, 5,6 asthma exacerbation (ae) 7, 8 and asthma management 9 and even secondary prevention strategies of asthma (summarized in table 1 ). despite these important associations, the use of antiinfectives (antibiotics, antivirals, antifungals, vaccines) that specifically target known pathogens, or drugs that are based on or exploit microbe-host receptor interactions (toll-like receptor agonists, bacterial lysates) or are immunomodulators (vitamin d), and/or may work in part by altering our associated microbiology (probiotics) are, with the exception of severe asthma, seldom considered in asthma treatment, prevention and guidelines. these treatment options are summarized in figure 1 . task force on anti-infectives in asthma was initiated in 2014 to ask open questions about the potential use of anti-infectives and immunomodulators as treatments for asthma and ae. we thus provide a thorough review of the field ( table 2 for search methods and terms), and specifically, have considered several important points in relation to the use and implementation of anti-infectives in asthma, thus identifying important challenges for the field. in our investigation, we chose to include any such studies of treatment that is based on microorganisms or host molecules, or exploits microbe-host interactions and thus alters the host response or microbiome. in this review, we offer our findings on the above points and consider the role of anti-infectives, immunomodulators and alteration of host microbiology in both asthma development and ae. we include findings from recent clinical trials and discuss the relative merits of these approaches in the light of the many challenges facing asthma research and the state of the art of the field. this review thus provides important insights aimed at young researchers and clinicians and also experienced researchers in the field to inform and stimulate scientific discussion of this important topic. overall, antibiotic use is associated with asthma risk rather than protection at most stages of human development, including pregnancy, 10, 11 early life 12 and childhood, 13 although why this is so is a subject widely debated. in denmark, antibiotic use in pregnancy use was shown to increase risk of ae in five-year-old children by twofold if used in the third trimester. 10 antibiotic exposure in foetal life was associated with an increased risk of asthma in cohort analyses, and this association more than tripled if antibiotics were used to treat respiratory tract infections rather than antibiotics used for either urinary tract or skin infections. these associations decreased, however, when sibling analysis was included (when nonaffected siblings are used as controls). 11 early antibiotic use is also believed to increase asthma risk by two-to threefold in seven-to eight-year-olds. 13 t a b l e 1 common respiratory tract pathogens linked with asthma and ae. this aspect of the field has been thoroughly reviewed elsewhere 2 can produce aerosolized allergen common in asthma epidemics associated with thunder storms, involved in severe asthma with fungal sensitization (safs) the potential negative impact of antibiotics was explored in a birth-cohort study at age 11 from manchester, united kingdom. 12 there was a significantly higher risk of physician-confirmed wheezing after antibiotic prescription and a twofold increase in severe wheeze or ae after antibiotic prescription. in children who wheezed, the risk of ae and admissions to hospital were also significantly increased in the 2 years after the first antibiotic prescription. children who received antibiotics in infancy had significantly lower induction of cytokines from pbmcs (taken at age 11) stimulated ex vivo with viruses, but surprisingly, not bacteria. the authors concluded that an increased susceptibility to viral infections is associ the microbiome describes the bacteria, fungi and other microorganisms that are present in the environment and co-exist within our bodies. the respiratory microbiome can now be studied by 16s rrna sequencing, and certain microbial phyla or genera are thought to be harmful or protective. 5, 16 antibiotics may negatively affect bacterial ecology in early life and this in turn affects asthma development. 10 in retrospective studies, the association between antibiotic use and increased risk of asthma or wheezing in children is further confused due to the potential of reverse causation. 12, 17 in experimental animals, the negative impact of antibiotics has already been shown, and long-term oral antibiotic treatment affects the gut microbiome, which in turn affects lung immunity to influenza virus. 18 indeed, how diet and the gut microbiome affect mucosal immunity including respiratory immunology is now a subject of wide interest; 19, 20 hence antibiotics through regulating the gut microbiota thus directly affect f i g u r e 1 summary of anti-infectives, immunomodulators and microbiome modulators and their methods of action. anti-infectives (such as antibiotics, antifungals and antivirals) directly act on the pathogen or its receptor limiting infection or replication. vaccines work by boosting both innate and importantly, adaptive immune responses (provided by dendritic cells, t and b lymphocytes) to the pathogen providing longlasting protection. immunomodulators including tlr agonists, bl, vitamin d act on the immune system, boosting innate immune responses providing short-term protection. vitamin d may act on underlying immune responses, such as inflammatory responses or allergic inflammation, reducing pathogen-driven inflammation or pathogen-driven enhanced allergic inflammation. microbiome modulators such as probiotics may alter the microbiome of the gut. this may have important downstream effects on the immune system, such as those that affect respiratory immunology and asthma the development of the immune system. the potential of antibiotic-induced changes in the developing microbiome to be directly responsible for asthma or ae risk is yet to be formally proven, however. macrolide antibiotics are a class of antibiotic commonly prescribed for respiratory tract infections or inflammatory respiratory disorders. macrolides may have additional properties to their bacteriostatic function, such as anti-inflammatory 21 and even antiviral activity. 22, 23 despite their ability to inhibit both bacteria and virus infections, only a few studies have tested macrolides as therapies for asthma or ae. guidelines state very little on macrolide use in asthma, and studies have shown positive effects on severe and neutrophilic asthma, yet the evidence supporting this is conflicting. these studies in both stable asthma and ae have been recently reviewed, 24 and the data suggest macrolide-responsive subgroups (eg neutrophilic asthma) may exist. 25, 26 additionally, recent studies also report a reduction in severe lrti rates 27 and asthma-like symptoms 28 antibiotics are associated with asthma risk and their use should be discouraged for asthma or wheeze-like illnesses. a possible explanation for this association is that antibiotics affect the microbiome in a negative way and thus increase susceptibility to disease. with the realization that the microbiome is key in controlling host immunity early in life, and the design of supportive animal studies that have modelled this association and identified protective genera, 31 this idea has merit but the overall hypothesis remains to be thoroughly tested in human clinical models. antibiotics may also be associated with asthma via other, as yet to be identified mechanisms, and likely involve reverse causation. the narrower antibacterial spectrum of some macrolide antibiotics, combined with their other advantageous properties, suggests that these may have use in ae but their use remains controversial. the prophylaxis with intramuscular/intravenous antibody palivizumab has been shown to effectively decrease respiratory syncytial virus (rsv)-induced bronchiolitis-related hospitalization, need for mechanical ventilation and recurrent wheezing. 32 interestingly, it has also decreased recurrent wheezing induced by other viruses postbronchiolitis. the second-generation monoclonal antibody motavizumab has also markedly reduced hospitalization with rsv. 33 but the development programme has been discontinued. 38 only a few patients benefit from the m2 ion channel inhibitors, amantadine and rimantadine, drug resistance is high, and they have significant adverse events. 39 neutralizing antibodies against rsv, coronaviruses and influenza viruses are being developed. inhibiting virus replication through interfering with viral enzymes active within cells poses additional problems in drug discovery; however, several useful inhibitors for respiratory tract viruses have found their way into phase i/ii clinical trials. few, however, have been specifically tested in asthma. favipiravir is a novel antiviral compound that selectively and potently inhibits the rna-dependent rna polymerase of many rna viruses including influenza virus, enteroviruses and paramyxoviruses. 40 a phase iii clinical trial of favipiravir for influenza therapy has been just completed in japan and the united states. rupintrivir is a potent, irreversible inhibitor of rv 3c protease. it has a broad antipicornaviral spectrum, but the development programme has been discontinued. 41 the nucleoside inhibitor ribavirin is a synthetic purine nucleoside analogue exhibiting antiviral activity against a broad range of both dna and rna viruses in vitro. 42 it is the only antiviral agent currently available against rsv infection, but its use has many concerns. als-008176 is an oral rsv replication inhibitor (a cytidine nucleoside analogue). in randomized, double-blind, clinical trial in healthy adults inoculated with rsv, more rapid rsv clearance and a greater reduction in viral load were observed in the groups of patients treated with als-008176 than in the placebo group. 43 small interfering rna (sirna) 44 infected with wild-type rsv. 46 it was well tolerated, effective as well as decreased the incidence and progression of bronchiolitis obliterans syndrome in lung transplant recipients with naturally occurring rsv infection. 47 the development of cidofovir and its derivative, brincidofovir, broad-spectrum antivirals active against five families of dsdna viruses (including adenoviruses), are currently in phase iii clinical trials. 48 the neuraminidase inhibitors prevent influenza virus release from infected cells and infection of adjacent cells. oral oseltamivir and inhaled zanamivir are recommended for the treatment and chemoprophylaxis of influenza in children and adults. 49 inhaled laninamivir has shown good safety and efficacy profiles in the treatment for influenza in patients with chronic respiratory tract diseases and has been approved in japan. 50 single dose of intravenous peramivir has been shown to be noninferior to oseltamivir and to have good safety profile also in patients with chronic respiratory tract diseases. 51 biologically, interferons (ifns) are induced within hours of infection 52 and consequently induce the expression of hundreds of antiviral effecter molecules blocking virus replication. 53 the effectiveness of itraconazole in the treatment for abpa has been confirmed in two randomized, placebo-controlled trials 60, 61 leading to the recommendation for azole use in asthma-abpa by the cochrane collaboration. 62 pooled data from these studies suggest itraconazole is effective in around 60% of asthma-abpa patients. 63 newer triazoles including voriconazole and posaconazole have also been studied in abpa with promising results. however, the greater incidence of drug toxicity with voriconazole, and substantial financial costs of both voriconazole and posaconazole limit their current widespread use. more recently, the use of azoles has also been studied in safs. in the first such study by denning et al, 64 subjects with over half having to discontinue treatment due to bronchospasm. 66 consequently, the prospect of amphotericin b use in asthma remains unlikely. the majority of reports to date have investigated the use of antifungal agents in adult asthmatics; however, the potential for their use in children has also been highlighted in a recent paediatric study describing sensitization to fungal allergens in 59% of severe asthmatic children. 67 unfortunately, reports of azole use in asthmatic children are limited to a few subjects only leading to the current joint ers/ats guideline recommending the consideration of treatment only after detailed evaluation in a specialist severe asthma centre. 68 in summary, to date, there have only been a handful of placebo-conheterogeneity of asthma continues to develop, it is possible that subgroups within abpa/safs will emerge in whom treatment with antifungal therapy will be predictably beneficial. however, we still remain some distance away from this goal at present. influenza infections can precipitate acute aes and may be more severe among asthma patients 69 more studies are needed to validate these findings. a comparison of laiv with tiv also failed to show significant differences in ae numbers in adults or children (>6 years). 70 thus, the potential role of influenza vaccines in ae prevention requires further in-depth study, in virologically confirmed influenza and with improved definition and characterization of asthmatic subgroups. aes. three large cross-over trials show no evidence of increases in aes in the two weeks following tiv in adults or children. 71 concerns that laiv could increase aes, wheezing episodes and hospitalizations in children 70 were allayed the absence of an association of laiv with ae in high-risk children. 72 f i g u r e 3 challenges and unknowns facing new treatments for asthma exacerbations that target respiratory pathogens. challenges facing the design and implementation of therapies that directly target pathogens or their biology (in blue) include site of infection and site of drug delivery, route of delivery, specific mechanism of action, the drug's pharmacodynamics (pd) and pharmacokinetics (pk) and also the patient demographic (pt), subset or specific endophenotype of asthma concerned. these challenges can at least in part be addressed by preclinical studies and are often taken into account during drug design. unknowns are also identified (in red) and can be model or pathogen specific. these include, but are not limited to, the window of therapeutic opportunity (dt) for therapeutic treatments, which defines the time between infection and onset of clinical disease (lrti symptoms for asthma), and importantly, this variable thus describes the window in which suppressing replication in theory will suppress symptoms and/or clinical disease. how pathogen load affects clinical disease is also controlled by a second variable (dl), which defines the quantity of pathogen that has to be affected to observe a quantitative change in clinical disease or symptoms. the unknown c defines a comparison, between a new drug (eg antiviral) versus the standard treatment (eg gc). this unknown is important as regulatory authorities will not approve a new drug if does not show improvements or a better safety profile compared with the standard treatment already available. the unknown d represents duration of treatment; this takes into account other variables that are often difficult to predict and include the possible effects of secondary infections (eg bacterial co-infection), drug resistance (eg as seen with macrolides), plasticity of endophenotype treated and other complexities that can impact on clinical disease after pathogen load is decreased as defined by dl. theoretical relationships between pathogen and load and clinical disease are based on human challenge studies with rv, in asthmatic individuals 57,58 the presence of streptococcus pneumoniae (pneumococcus) has been linked to ae, and in children, early-life pneumococcal colonization is associated with an increased risk of wheezing and asthma later in childhood. 4 furthermore, asthma is a risk factor for invasive pneumococcal disease (ipd), 75 warranting pneumococcal vaccination, which is recommended for all people with asthma over 6 years of age if they did not receive routine childhood pneumococcal immunization. 76 the there has been concern over potential pro-allergic and pro-asthmatic effects of childhood immunizations, in particular regarding measles, mumps and rubella vaccine (mmr). however, the suspected association between mmr and asthma (since been discredited) was based on a small study comparing anthroposophic to nonanthroposophic children and was not confirmed in a subsequent multinational study in these populations. 82 a wealth of studies has also failed to show evidence of pro-asthmatic effects of vaccination against poliovirus, pertussis, tetanus, hepatitis b or haemophilus influenzae. in contrast, significant evidence suggests antiasthmatic effects of childhood vaccinations. inverse associations between childhood asthma prevalence and high cumulative vaccine doses, 83 pertussis vaccination 84 and mmr 85 have been found and reduced asthma hospitalization rates and medication use in mmr-vaccinated children. 86 the immunogenic potential of different vaccine formulations in asthma has been questioned, but normal antibody responses to pertussis, varicella, hepatitis b, measles and rubella vaccination have been reported. mumps antibody titres after mmr were lower and measles antibodies waned more quickly from 9 years of age in asthmatics. treatment with inhaled glucocorticoids (gcs) did not affect the antibody response to hepatitis b or varicella immunization, but these were impaired by oral gc therapy. the vaccinations discussed are safe and effective in asthma, may help prevent asthma development, and pneumococcal and annual influenza vaccination in particular should be offered to asthmatics. future vaccines against rv and rsv, which are the main triggers for aes and have been linked to asthma inception, should help reduce asthma morbidity and mortality. host responses bacterial lysates (bl) have been extensively used in europe to effectively reduce the number of seasonal acute respiratory illnesses (ari). bl are microbial products that when given orally, may exhibit certain immunostimulatory and immunomodulatory effects. 87 their effectiveness was confirmed in numerous interventional trials (reviewed in ref. 88) . bl have been successfully tested in preventing wheezing attacks provoked by aris in preschool children demonstrating a 38% reduction in symptomatic wheezing and a decrease in the number of urti. 89 there is only one interventional clinical study to date, demonstrating a promising antiallergic potential of an orally applied bl. 90 therefore, one may speculate that bacteria-derived preparations may become an interesting class of immune modulators for the future. recognition of invading microbes is controlled by a range of innate pattern recognition receptors including tlrs which are directed at highly conserved molecular motifs expressed on the invading pathogen. this ancient surveillance network provides a form of first line of defence in the airway. 91 signalling through tlrs produces a broad range of pro-inflammatory cytokines, chemokines and importantly, antimicrobial proteins. therefore, precise targeting of individual tlr pathways could provide a mechanism of promoting specific immunity, allowing for tailored immunomodulation, an approach that is highly attractive in chronic diseases such as asthma where numerous immunological disparities are evident. withdrawal of inhaled gcs whilst asthma conditions remain stable or even improved. 101 the proposed mechanism is the restoration of the th1/th2 balance. however, supporting evidence is yet to be provided. a follow-up, double-blind, placebo-controlled study carried out in poorly controlled, moderate-to-severe asthmatics where cyt003a was administered as an add-on to current gcs and b 2agonist therapy showed no significant advantage over placebo in relation to the primary outcome of change from baseline in asthma control questionnaire (acq) or in secondary outcomes of change from baseline in prebronchodilator forced expiratory volume (fev 1 ). 102 these data suggest that whilst cyt003a may have a use in initial control of disease in gc-sensitive patients, it has no efficacy as an add-on therapy for more severe patients. in addition, more prolonged administration of the tlr9 agonist, assessing its ability to readdress the supposed th2 skewing, was not conducted. additional concerns stem from recent reports of potential impairment of tlr9 function in pbmcs in severe asthmatic patients. 103 evidence is accumulating on the potential of vitamin d in immunoregulation, particularly in lymphocyte function and cytokine production, suggesting its potential in modifying asthma incidence and severity. 104 the association between low levels of vitamin d and asthma has been supported by many observational and epidemiologic studies. 105 a recent meta-analysis of epidemiological studies demonstrated a positive association of vitamin d deficiency and asthma (rr 1.68 95% ci 1.3-2.2). 106 parallel-conducted, prospective, observational studies on vitamin d supplementation in infancy, however, showed rather conflicting data and do not support these implications. 107 other studies in pregnant woman, including two large clinical trials, did not find protective effects on offspring wheeze. 108, 109 interpretations of existing evidence argue an advantage of vitamin d supplementation. 107 115 however, interventional trials in infants receiving both pre-and probiotics in allergy and/or asthma prevention provided equivocal results. 116 whilst moderate positive effects in infant eczema were found, a lack of evidence that probiotics prevent any other allergy including asthma in three other similar meta-analyses remains a matter of concern. [117] [118] [119] in view of two well-conducted meta-analyses, an opportunity of asthma/wheezing prevention with probiotics seemed to not be plausible. 118, 119 one may speculate, however, that the studies to date may not have used the right probiotic, the right dose, the right timing or duration and/or population. therefore, more studies are still needed. evidence to date suggested that modulation of the gut microbiome may represent an interesting therapeutic or preventative opportunity for the prevention of allergic asthma and ae, whilst clinical trials do not confirm initial enthusiastic expectations. in view of the recent systematic reviews, probiotics cannot be recommended as adjunctive therapy for asthma or asthma prevention. though, recent technological developments that permit identification of the most promising microbial strains and their products that may exhibit more profound positive effects will keep this area active and interesting to follow. with the exception of antibiotics and antifungals, current guidelines do not take into account the potential of specific or broader-spectrum anti-infectives or immunomodulatory agents in asthma or ae. despite wide interest and active research in this area, the basis for this is likely due to a lack of clinical studies that allow robust or clear conclusions to be made regarding efficacy. for the clinical studies that have been performed with available anti-infectives or immunomodulatory agents, conclusions are often contradictory or show a lack of robust evidence supporting an effect. reasons for these outcomes include a small number of studies, differences in study design making direct comparisons difficult or studies that are underpowered for primary or secondary endpoints, or subgroup analysis. as shown in table 3 there is also a substantial body of literature investigating preclinical development of anti-infectives and immunomodulatory drugs and preparations in animal models, with many studies endeavouring to better understand the scientific principles behind their mechanism (s) of action. this is an absolute necessity in the anti-infective drug discovery pipeline; however, there is some confusion regarding how best to progress these anti-infectives in these studies in clinical trials, or alternatively, how interpretations of preclinical work can best inform on future clinical trials is a subject of wide debate. much consideration still needs to be given to how future drug targets related to anti-infectives are progressed, and how drug discovery programmes are best implemented to exploit these. this manuscript is the result of a task microbes and mucosal immune responses in asthma the microbiology of asthma short-and long-term efficacy of prednisolone for first acute rhinovirus-induced wheezing episode childhood asthma after bacterial colonization of the airway in neonates disordered microbial communities in asthmatic airways airway microbiota and bronchial 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events among older patients hospitalized with pneumonia the health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease asthma in the elderly: a study of the role of vitamin d eaaci anti-infectives in asthma and asthma exacerbations task force. the potential of anti-infectives and immunomodulators as therapies for asthma and asthma exacerbations interests in respect to this publication. all authors participated in the discussion and approved the final version of this position paper. key: cord-295575-zgta5ah8 authors: howard, evin; orhurhu, vwaire; huang, lisa; guthrie, barbara; phipatanakul, wanda title: the impact of ambient environmental exposures to microbial products on asthma outcomes from birth to childhood date: 2019-11-28 journal: curr allergy asthma rep doi: 10.1007/s11882-019-0890-2 sha: doc_id: 295575 cord_uid: zgta5ah8 purpose of review: asthma is a chronic respiratory condition with increasing domestic and worldwide prevalence that burdens individuals and the healthcare system with high costs associated with long-term treatments and acute emergency room (er) visits. it can be triggered by ambient microbes, including bacteria, viruses, and fungi. in this review, we examine the outcomes of asthma patients in relation to environmental exposures to ambient microbe products, focusing on whether exposure leads to asthma development from birth to childhood and if particular microbes are associated with worsened asthma exacerbations. recent findings: bacterial endotoxin is more prominent in homes with pets and may cause cytokine cascades that lead to asthma exacerbation. however, some studies have demonstrated a protective effect with early exposure. patients with positive aspergillus skin testing are more prone to moderate-severe or severe-uncontrolled asthma. fungal sensitization is also associated with earlier onset of asthma and demonstrates a dose-dependent relationship of symptom severity and duration. among viruses, rhinovirus has the greatest association with decreased lung function, severe asthma, and asthma-related hospital admissions. distribution of microbial products and associated asthma symptoms depends on the geographical climate. genetic variations among individuals also mitigate the effects of microbial products on asthma development and symptom severity. summary: microbial products of bacteria, fungi, and viruses are associated with the development of asthma, more severe asthma symptoms, and worse outcomes. however, some early exposure studies have also demonstrated a protective effect. bacterial and fungal products are related to decreased lung function and earlier onset of asthma. viral products are related to asthma-associated hospital admissions; and the climate and patient genetics can also temper or intensify the relationships between microbial products, asthma development, and asthma symptom severity. further research should focus on the effects of early microbe exposure and its interaction with human immune systems and asthma-related outcomes. every day, 10 people in the usa die from asthma [1] . in 2017 alone, there were 3,564 asthma-related deaths [1, 2] . within the usa, the prevalence of asthma is 1 in 13 people, producing annual economic costs of over $81.9 billion, related to missed school and work, medical costs, and asthma-related mortality [1] [2] [3] . ambient microbes have been shown to trigger asthma attacks [4] [5] [6] . the most common microbes are bacteria, viruses, and fungi [7] . though the literature has clearly demonstrated that microbes and allergens can trigger asthma exacerbations, controversy still remains whether or not microbes promote the development of asthma with early-life exposure or if they have a preventative effect against asthma symptoms in an individual with established disease [4] [5] [6] . many longitudinal studies have demonstrated that early this article is part of the topical collection on allergies and the environment exposure to ambient microbial products increases the risk of the development of asthma [8•, 9, 10, 11•] . whereas, other studies, particularly related to human contact with animal microbes, have shown protective effects against the development of asthma [8•, 12, 13] . with over 1.8 million asthma-related er visits each year, which may be potentiated by exposure to various ambient microbial products in the environment, earlylife exposure to microbial products and its effect on the respiratory system later in childhood warrants further investigation [2, 6, 14, 15] . the purpose of this literature review was to specifically examine asthma outcomes related to environmental exposures to microbial products, pertaining to endotoxin from bacteria-(1,3)-β-d-glucan and ergosterol from fungus, and common viruses associated with worsening asthma morbidity (rhinovirus, respiratory syncytial virus (rsv), enterovirus, and the influenza virus) during infancy, and to assess the risk of asthma development later in childhood [15] [16] [17] [18] (see table 1 ). while other reviews have focused on common routes of exposure and the concentration of microbial products (endotoxin, fungal spores, virus, etc.) in urban vs. suburban regions [19, 20] , this review investigates if the exposure to microbial products during infancy leads to the development of asthma during childhood, and whether particular microbes have a higher severity for triggering asthma exacerbations over others. primary questions for this review consisted of the following: what microbes are associated with asthma severity and outcomes? what microbial products are known for triggering asthma symptoms and/or exacerbations? does the exposure of microbial products in the environment lead to the development of asthma? for this review, we selected original manuscripts in english, published in peer-review journals on the basis of bacterial, fungal, and viral products within the environmental matrix with children exposed to these microbial products. thus, we selected articles examining health outcomes for the development of asthma related to microbial product exposure during the time of infancy until childhood. however, we also highlighted factors in the literature that contribute to microbial exposure and their effect on asthma for people with an established diagnosis of asthma. only journal articles within the last 5 years were chosen; however, there were no restrictions pertaining to specific populations or geographical locations. exclusion criteria consisted of animal studies, investigative procedures using only in vitro methods, studies not translated into english, articles focusing on the measurement of microbial products without their effect on asthma outcomes, and articles not assessing microbial exposure from the time of infancy. with this thought process in mind, the following word criteria was applied using pubmed as the primary search engine: ( the search returned a total of 2999 articles. after the removal of 2924 studies, consisting of reviews, duplicates, mouse studies, and irrelevant articles to asthma health outcomes, this then left 76 studies. 65 studies were pertaining to adults, which left a total of n = 11 studies (see fig. 1 ). the majority of the studies had a prospective cohort design (9/11), while the other two studies were retrospective cohort designs. environmental sampling consisted of different locations in participants' homes (living room, kitchen, bedroom, mattress), outside air, and settled dust in classrooms. all of the studies included examined asthma health outcomes related to ambient exposure to bacterial, fungal, and viral microbial products. considering bacterial products and asthma outcomes, the literature has discussed endotoxin, β-glucan, and lipopolysaccharide (lps). of these microbial products, when bacteria are destroyed or lysed, lps is dispersed into the environment or blood as endotoxin, which can lead to a cascade of inflammatory cytokines (il-6, il-12, il1β, and tnf-α) and exacerbation of asthma symptoms [22, 23] . the main route of contact to endotoxin is via inhalation, which has been demonstrated in multiple studies [5, 14, 21, 22] . of the 11 studies selected for review, there were two that specifically discussed endotoxin exposure from infancy [8•, 24 ••] (see table 2 ). tischer et al. conducted a prospective longitudinal study examining whether early exposure to microbial products in dust was associated with allergy and asthma later in childhood for children in suburban areas using the following three birth cohort studies for children born between 1996 and 1999: [24••] , dust samples were collected from children's mattresses, bedroom floors, and living room floors; and showed no association between endotoxin nor the fungal membrane lipid ergosterol in the development of asthma with exposure from birth to 7 years of age. previous research has shown that endotoxin levels tend to be higher in homes with a pet such as a cat or dog in addition to homes of families that are low-income and/or may be in community projects that contain cockroaches [5, 31] . similar results were seen in children by a study conducted by mendy et al. [32] who found that overall for people who had a cat or dog, endotoxin levels were higher in the household with a pet and was associated with wheeze (or = 1.30; 95% ci (1.04-1.62)) but not with asthma [32] . co-exposure with dog and cat allergens modified the association with asthma, increasing the risk when exposed to endotoxin (or = 2.00; 95% ci (1.04-3.83)) [32] [5] demonstrated that endotoxin exposure is associated with wheeze with exercise, office or er visits, and use of prescription medication for wheezing [5] . studies have indicated that lung function and capacity can be decreased due to continuous exposure to endotoxin in patients with atopic asthma [22, 33] . lipopolysaccharide has also been shown to promote eosinophil airway inflammation in patients with asthma despite maintenance treatment with inhaled corticosteroids (ics) [34] . besides having a pet, there are other factors that could have contributed to the varying results between the cohorts within the tischer et al.'s study. the climate also plays a role in the concentration of endotoxin in the surrounding environment [14, 31] . researchers have found a positive correlation between log 10 -endotoxin and current asthma (or = 1.56, 95% ci (1.11-2.18), p = 0.046) for hot-humid regions and a higher incidence of exercise-induced wheeze (or = 1.48, 95% ci (1.22-1.80), p = 0.009) for subarctic/very cold/cold regions [31] . high levels of endotoxin, regardless of being inside or outside the home environment, are associated with severe asthma [14, 35] . a study conducted in japan by khan and colleagues showed that asthma-related visits to the er for patients 15-years-old or older was highest during the seasons of autumn and spring, when the environmental endotoxin was highest in the air [14] . oluwole et al. [35] showed that for 7 to 17-year-olds, high concentrations of endotoxin within households, including mattresses, are associated with an elevated risk of moderate or severe asthma (adjusted or = 11.40, 95% ci (1.45-89.43)). tischer et al. [8•] also supported these • sleeping with animal fur was inversely associated with early wheezes at age 4 and current asthma at age 6 • sleeping on animal fur during the first 3 months of life was associated with persistently stimulated interferon-γ response until age 3 • animal fur exposure might act as an immune system stimulant and offer protective mechanisms against asthma and allergy, as observed in farm/rural environments not able to determine the microbial profile of the animal fur nor the intensity of the exposure. lifestyle factors also play a role in developing asthma bonnelykke et al. • after adjusting for total respiratory episodes and number of episodes per pathogen, only the total number of episodes were significantly associated with asthma development • risk factor for development is asthma is the number of respiratory episodes, not the specific viral trigger assumed that children who did not present to clinic did not have clinically significant respiratory episodes • maternal history of asthma and depression were associated within higher risk of asthma by age 7. • bacterial species kocuria, bifidobacterium, alloiococcus, and acinetobacter were found in homes of children without asthma, but not in homes of children with asthma. • endotoxin and ergosterol were not found to be associated with the development of asthma gastrointestinal and airway microbiome were not measured during early childhood results for children from infancy to 6 years of age. in addition, these findings are also in accordance with previous investigations in the early 2000s [36] [37] [38] [39] . non-environmental patient characteristics can also impact the development or severity of asthma. mendy et al.'s [40] study determined that the combination of high levels of endotoxin exposure and low vitamin d levels are associated with an asthma diagnosis or recurrent wheeze (or = 1.88, 95% ci (1.33-2.66), p = 0.02), current asthma (or = 1.97, 95% ci (1.09-2.23), p = 0.03), wheeze over the last 12 months (or = 1.72, 95% ci (1.10-3.7), p = 0.002), and recurrent wheeze (or = 1.97, 95% ci (1.0-4.0), p < 0.001) [40] . nevertheless, this study was conducted in adults and the effect from infancy to childhood, regarding vitamin d levels in combination with endotoxin exposure, would need to be assessed. no studies on fungal spore exposure were found for the time period from birth to childhood to assess the development of asthma. [8•] . sensitization to fungal antigens is a key component to understanding asthma severity. chopra and colleagues showed that asthma patients with skin reactivity to the aspergillus skin test (ast) had more cases of moderate and severe asthma versus nonreactive ast patients (98.6% vs. 3.2%, p < 0.001) in a cohort of 282 adult asthma patients over a 1-year period. sensitization to aspergillus has been found to have a more significant impact on asthma outcomes compared to other species of fungus [41, 42] . for instance, vincent et al. [41] demonstrated that adult asthma patients who were sensitized to penicillium chrysogenum, [41] . masaki and colleagues' study in japan implicates a different species; their study investigated sensitization to candida and found that out of 124 adults with asthma, more people had sensitization to candida than aspergillus (16 vs. 11%) [6] . the researchers also found that fungal sensitization leads to a higher rate of early-onset asthma (< 16 years of age) compared to those without sensitization (45% vs. 25%) and sensitization increases with age [6, 43] . however, further investigation is needed to examine early exposure of various fungal species during infancy and its effect on the development of asthma during childhood. the fungal genus alternaria has also provided more insight into fungal sensitization and asthma outcomes. recently, baxi and colleagues conducted a study in 37 inner-city schools in new england with school-aged children with asthma and observed that children sensitized to alternaria had an association with asthma symptom days (or = 3.61, 95% ci (1.34-9.76), p = 0.01); however, this did not apply to children not sensitized to alternaria (or = 1.04, 95% ci (0.72-1.49), p = 0.85) [44] . researchers found that asthmatic children who were sensitized to alternaria and exposed to high levels had 3.2 more symptom days per 2week period when compared to asthmatic and sensitized children exposed to lower levels of alternaria. this suggests a dose-dependent relationship between mold exposure and asthma severity [44] . this finding is supported by oluwole et al. [45] , who demonstrated that high mold levels in children's play areas are associated with current asthma (adjusted or = 3.0, 95% ci (1.11-8.0)). furthermore, additional studies have demonstrated that sensitization to alternaria increases with higher mold concentration exposure and may lead to a risk of hospitalization, especially in the urban setting [46] [47] [48] [49] . fungal exposure also impacts lung function [41] . asthma patients with sensitization to aspergillus fumigatus have been found to have higher total serum ige levels and an increased degree of broncho-obstruction (as measured by fev 1 /fvc), compared to asthmatic patients without sensitization [41, 50] . the impact of fungal exposure on lung function has been evaluated in adults; however, this has not been thoroughly evaluated in infants and young children. the fungal product (1,3)-β-d-glucan has been shown to have a low association with severe asthma (or = 0.55, 95% ci (0.24-1.26), p = 0.003) in children [51, 52] . ergosterol has also demonstrated a low affinity for the development of asthma [52] . however, exposure to fungal spores has been shown by multiple studies in adults to be associated with asthma exacerbations; yet, there are very few studies involving children [53] [54] [55] . in a study analyzing the fungal microbiome in exhaled breath condensate (ebc) of patients with asthma in italy, carpagnano et al. [53] found that in 47 adults with asthma, 94% of the people were colonized in the ebc by cladodosporium species, 21% by alternaria, and 24% by penicillium species [53] . fungal colonization tended to be higher in asthmatics with severe and uncontrolled asthma with sensitization to fungal species such as alternaria [53] [54] [55] . the differing levels of fungal species, with cladosporium being the most abundant, and alternaria and penicillium in lower quantities, was also found in manitoba, canada, by polyzoi and polyzois, examining mold within the bedrooms and basements of 3424 school-aged children [56] . cladosporium was the most common mold found in homes (98.2% of bedrooms and 97.8% of basements), followed by alternaria (82.4% of bedrooms and 77% of basements), and penicillium (35.4% of bedrooms and 48.8% of basements). in addition, visible mold in bedrooms and basements in participants' homes were associated with persistent asthma and colds (16.8%, p < 0.0001). other fungal studies conducted in europe, canada, and australia have also found similar results [45, 57, 58] . viral exposure also plays a critical role in the development of asthma and asthma morbidity [9, 11•] . two studies were found that were conducted on early-life exposure to rhinovirus and asthma outcomes: one by rubner et al. [9] and another by lukkarinen et al. [11•] . rubner et al. [9] conducted a prospective cohort study with 217 children, examining early-life rhinovirus exposure from birth to 13 years of age. the researchers observed that wheezing with rhinovirus was associated with asthma at age 13 (or = 3.3, 95% ci (1.5-7.1), p = 0.02) and sensitization to allergens increased with age [9] . fev 1 % predicted has also been shown to be lower in asthmatic patients admitted to the hospital with an asthma exacerbation with concurrent rhinovirus infection, compared to children with asthma admitted for an exacerbation but negative for rhinovirus [29, 59] . lukkarinen et al. [11• ] performed a 7-year long prospective cohort study following 127 finnish children from birth to 7 years of age and found that the risk factors for atopic asthma at study entry were sensitization to common allergens (dust, mold, etc.), and wheezing with rhinovirus infection (aor 4.8, p < 0.014) [11•] . zheng et al. [15] conducted one of the numerous studies that demonstrated that human rhinovirus (hrv) was the most common viral microbe to induce an asthma exacerbation in children [60] [61] [62] . zheng and colleagues collected data from 143 inpatient children with asthma exacerbations, 131 outpatients, including 88 patients with asthma exacerbations, and 43 controls with stable asthma [15] . researchers tested for common viruses including hrv, respiratory syncytial virus (rsv), parainfluenza virus type 3 (piv3), influenza virus (ifv), human bocavirus (hb0v 1 ), atadenovirus (adv), human coronavirus (hcov), and hepatitis e virus. of all the viruses, hrv was the most prominent among inpatients with severe asthma exacerbations at 50.3% and hcov was the least at 0% [15] . the researchers found three variants of the hrv: hrv-a, hrv-b, and hrv-c, with hrv-c being the most virulent for severe asthma exacerbations [15] . other studies conducted in japan, france, and australia have also identified rhinovirus as the most common viral culprit for asthma exacerbations [28, [60] [61] [62] . white blood cells and neutrophil counts were significantly higher in patients with all hrv variants versus those who were negative for hrv ( [15] . thymic stromal lymphopoietin (tslp), a cytokine that impacts t cell maturation, also plays a role in asthma severity in patients with viral illnesses. it has been demonstrated to have a positive outcome on patients during viral infections in patients with asthma [60] . bjerregaard et al. [60] performed a study in australia with 44 virus-positive adolescent and adult patients (including rhinovirus, human coronavirus, parainfluenza virus, and human metapneumovirus) and 44 controls. the researchers found that patients with tslp expression had lower levels of sputum eosinophils, lower fractional exhaled nitric oxide, higher blood neutrophils, lower asthma control questionnaire scores, and higher fev 1 in comparison to patients with low tslp expression levels [60] . again, these types of studies are rare for examining variances in lung function and asthma development from birth to childhood. in total, four studies were found on respiratory syncytial virus (rsv) that followed children from birth to childhood for the development of asthma [10, [28] [29] [30] . two of the rsv studies showed that males from infancy to childhood have a high tendency of developing asthma after an infection, compared to females [28, 29] (see table 2 ). two out of the four studies were retrospective cohort studies and the other two were prospective cohort studies [10, [28] [29] [30] . one of the retrospective studies showed that peak time for rsv-related hospitalizations was during autumn [29] . the rsv studies showed a high risk for asthma with rsv infection and that the cytokines il-6, il-1β, and il-8 are elevated during infection, which leads to respiratory inflammation [10, 28] . kitsantas et al. [30] conducted a 6-year long study from birth to 6 years of age, examining the risk of the development of asthma by 6 years with early exposure of rsv infection during infancy. results showed that exposure to rsv did increase the risk of asthma by age 6 (or = 1.99, 95% ci (1.06-3.74)). however, children who had a parent with a history of asthma posed a higher risk for childhood asthma by age 6 (or = 3.86, 95% ci (2.61-5.71)) [30] . a maternal history of asthma has also been demonstrated by o'connor et al. [24••] to increase the likelihood of asthma in childhood by age 7 (or = 1.79, 95% ci (1.18-2.74)). similar to what was discussed about fungi, asthma patients can also be colonized by viruses. nguyen-thi-dieu et al. [63] conducted a cohort study in hanoi, vietnam, on 115 hospitalized children under the age of 15 with a diagnosis of asthma exacerbation and a control group of healthy children under the age of 15. patients underwent a clinical examination, blood analysis for a cytokine profile, pediatric asthma score (pas) for severity of asthma exacerbation, and nasopharyngeal aspirates to determine viral infection using real-time polymerase chain reaction (pcr). of the 115 children diagnosed with an asthma exacerbation, there were 18.2% with a mild pas, 37.4% with a moderate pas, and 44% with a severe pas [63] . nguyen-thi-dieu and colleagues found that 54.8% of the asthmatic children were positive for hrv [63] . the high number of asthma patients with a severe pas score (44%) was associated with a high number of children diagnosed with hrv [63] . the researchers also found that the percentage of leukocytes in asthmatic children with hrv was significantly higher, compared to children without hrv (76.2% vs. 59.6%, p < 0.05) [63] . no enterovirus longitudinal studies from birth to childhood were available, assessing asthma development; however, studies have been done in children with a diagnosis of asthma [64] . smith-norowitz et al. [64] studied patients in ireland, examining the levels of ige and igm antibodies (ab) for enterovirus 71 with a mix of 77 children and adolescents, and found that asthmatic children have higher ige ab levels, compared to non-asthmatic children, who have higher igm levels of ab (p < 0.001). the levels of enterovirus ige ab were shown to increase with age especially among the asthmatic group [64] . another study analyzed data on a 16-year longitudinal study with 36,935 children from infancy to 18 years of age in taiwan and found that children were diagnosed with asthma within 2.77 years after an enterovirus infection [16] . there was also a higher incidence of asthma associated with enterovirus infection (hr = 1.65, 95% ci (1.60-1.71), p < 0.0001) [16] . overall, the literature suggests that the rate of hospitalization due to enterovirus infection is low and does not increase asthma severity or length of hospital stay for asthma-related admissions [65, 66] . the influenza virus is a major cause of acute exacerbation of bronchial asthma (aeba); however, rhinovirus has still been shown to be the number one viral cause of asthma exacerbations [67] . yoshi et al. and other researchers have shown that obtaining the flu vaccine reduces aeba morbidity significantly when compared to individuals who are unvaccinated for the influenza virus (20.5% vs. 0%), p = 0.047 [67, 68] . influenza can worsen asthma morbidity; however, it has yet to be determined if there is a relationship pertaining to the development of asthma in association with an influenza infection [69] . recent studies have found that certain bacteria play a role in preventative effects against the development of asthma. den hollander et al. [27] performed a population-based prospective cohort study of pregnant women and their children in rotterdam, netherlands, and followed the children from pregnancy to 6 years of age for evaluation of asthma. colonization of a european child with a cytotoxin-associated protein a (caga)-negative-helicobacter pylori (h. pylori) strain at age 6 was associated with an increased prevalence of asthma overall (or = 2.11, 95% ci (1.23-3.60)) but was different for european children (or = 3.64, 95% ci (1.97-6.73)) and significantly less for non-european children (or = 0.52, 95% ci (0.14-1.89)) [11•] . there are also common bacteria within the environmental matrix that have been shown to have an effect on the development of asthma in children. teo et al. [26] found that early childhood nasopharynx (np) colonization typically involved staphylococcus or corynebacterium, which was later replaced by moraxella or alloiococcus. staphylococcus was the dominant colonizing bacteria in the early healthy np microbiomes, but its presence declined rapidly with age. these researchers found that early asymptomatic colonization with streptococcus increased the risk of developing asthma [26] . most infants were initially colonized with staphylococcus or corynebacterium before stable colonization with alloiococcus or moraxella [26] . transient incursions of streptococcus, moraxella, or haemophilus marked virus-associated acute respiratory infections (aris) [26] . o'connor et al. [24••] found supporting results in a study examining early-life exposure to environmental factors, including dust, fungal products, bacterial taxa; cockroach, mouse, and cat allergen; from infancy to 7 years of age. staphylococcus, haemophilus (pasturellaceae), several sphingomonas species members, and corynebacterium were among the taxa found in children's homes who had asthma [24••] . however, for children who did not have asthma, there was a prevalence of alloiococcus (aerobacteriaceae), kocuria (micrococcaceae), acinetobacter (moraxellaceae) species, and bifidobacterium [24••] . more research is needed to investigate the mechanism of transition of bacteria from one species to another in the infant microbiome and how this may possibly contribute to the development of asthma. in addition to the microbiome, children's genes affect how their bodies will react to their environment. like most illnesses, symptoms and severity can vary at the individual level based on unique genetic differences. carnes et al. [22] found that there is a gene-by environment interaction for cd14 variant rs2569190 (p interaction = 0.16) but not for the tlr4 variants rs4986790 and rs4986791. this research is also supported by an older study conducted by kljaic-bukvic et al. [70] , who found that there are two genetic variants related to cd14 and endotoxin signaling that are highly related with asthma exacerbation hospital admissions. for cd14 single nucleotide polymorphism (snp) rs5744455, carriers of the t-allele in children 5 to 18 years old had a decreased risk of repeated hospital asthma-related admissions, compared to homozygotes for the c-allele (or = 0.42, 95% ci (0.25-0.88), p = 0.01) [70] . c-allele carriers were at lower risk of asthmarelated hospitalizations in comparison with t-allele homozygotes (or = 0.59, 95% ci (0.38-0.90), p = 0.01) [70] . a human interleukin 4 receptor alpha chain gene (il4r) variant that results in a glutamine to arginine substitution at amino acid residue 576 (il4rα-q576r polymorphism) has previously been associated with asthma diagnosis and severity [71] . lai et al. [72] have demonstrated that there is a gene-byenvironment interaction between the il4rα-q576r polymorphism and environmental endotoxin exposure in school-aged children with asthma. higher classroom endotoxin levels were associated with fewer asthma symptoms for children with the q/q genotype (or = 0. 76 [72] . in addition to genetics, exposure to animals, especially within the farm setting, has shown to play a role in asthma. the environment of a farm is a great example of exposure to all of the microbes and microbial products discussed in this review. carnes et al. [22] found that high concentrations of endotoxin exposure at homes of people not born on a farm have a risk for the development of asthma (or = 1.67, 95% ci (1.26-2.20), p = 0.05), compared to individuals who were born on a farm (or = 1.18, 95% ci (1.02-1.37), p = 0.05). in addition, lampi et al. [12] found that people born on a farm had a higher fev 1 , compared to those not raised on a farm. the limitation here is that these participants in the lampi study could be more physically fit having to do the chores of farm work, compared to people not living on a farm. prior studies have attributed farm-specific protection from the development of asthma from endotoxin exposed in utero and during early childhood [13, 73, 74] . an older study conducted on amish and hutterite communities whom participate in farming activities has revealed two very different results [75, 76] . the amish farm children of indiana were found to have a lower prevalence of asthma and allergen sensitization (5.2% vs. 21.3% and 7.2% vs. 33.3%, respectively), compared to the hutterite farm children of south dakota [75, 76] . the difference between these two farming communities was that the amish have constant direct contact with animals to do all of their farming traditionally, and the hutterite community relies on machinery and maintains the animals in one localized area away from the community homes [75, 76] . this finding brings up a few questions. why is early farm exposure to endotoxin related to protective effects against the development of asthma and asthma symptoms; whereas, non-farm house endotoxin exposure is generally associated with asthma and asthma exacerbations? are there different microbes related to farm animals versus household pets, which are associated with increasing asthma symptoms [5, 31] ? in a different study, tischer et al. [25] examined the german lisaplus birth cohort and found that children who slept on animal fur during the first 3 months of life had higher exposure to endotoxin in their mattress, compared to children who did not sleep on fur. more importantly, the researchers found a decrease in the risk of asthma development by age 6 for children who slept on animal fur during the first 3 months of life (aor = 0.56, 95%, ci (0.31-1.01). in addition, for tnf-α, il-2, and il-4 producing t cells, there were no significant changes found in blood levels associated with sleeping on animal fur the first 3 months of life [25] . this review has shed light on several different findings within the literature. based on the information provided, sensitization within the non-farming community for bacterial, fungal, and viral products increases with ige ab expression and over time with age [43, 64, 77] . in terms of the fungal species, aspergillus fumigatus has shown to induce one of the highest sensitizations for moderate/severe asthma [54, 78] . in addition, human colonization of the genera cladosporium, alternaria, and penicillium have been associated with severe asthma and their ambient environmental concentration is similarly proportional in various parts of the world [41, 45, 53, [56] [57] [58] . for viruses, rhinovirus has been shown to be one of the most common triggers of a viral source for an asthma exacerbation [9, 11•, 15, 63, 79, 80] . early exposure to endotoxin at a young age within the farm setting with direct animal contact may reduce the chances of developing asthma later in life [12, 22, 75, 76] . for children not living on a farm, growing up with a cat or dog may have a protective effect against asthma symptoms [8•, 24••] . the mechanism of this effect is yet to be understood and it appears that genetics plays a role in asthma severity especially among ethnic minorities [72] . further research is needed to investigate the difference in microbes between farm animals and household pets and how early exposure effects the human microbiome and the immune system's response to inflammatory triggers. in addition, since studies have shown that people with severe asthma may be colonized with various genus of fungi, it would be worthwhile to further investigate the treatment of moderate/severe asthmatics colonized with fungi with other methods not associated with toxic side effects related to current medications for anti-fungals. in addition, more studies are needed examining the mechanism(s) for the transition of bacteria in the microbiome during childhood and how this may effect asthma outcomes. biomarkers such as dimethylamine, a metabolite produced by bacteria within the gastrointestinal tract, may pose a clue as it has been demonstrated to decrease in concentration from higher to lower levels with the development of asthma in children [81] . further advances are also being made with dupilumab, a monoclonal antibody that blocks a common receptor for interleukin-4 (il-4) and interleukin-13 (il-13), involved in type 2 inflammation [82] . in adult patients with atopic asthma, it has been shown to reduce severe asthma exacerbations [82] . this medication has recently been approved for children 12 years old and up for the treatment of severe asthma [83] . continued exploration of the human microbiome and its interaction with the environment hopefully may lead to more discoveries. all reported studies/experiments with human subjects performed by the authors have been previously published and compiled with all applicable ethical standards (including the helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines). the authors declare no conflicts of interest relevant to this manuscript. human and animal rights and informed consent this article does not contain any studies with human or animal subjects performed by any of the authors. most recent national asthma data the economic burden of asthma in the united states airway microbiota in severe asthma and relationship to asthma severity and phenotypes endotoxin exposure: predictors and prevalence of associated asthma outcomes in the united states characteristics of severe asthma with fungal sensitization harrison's principles of internal medicine ,3)-β-d-glucan, and lps on each cohort from different geographical regions for the development of asthma in children from birth to age 6 [8]. it has been demonstrated that the climate and geographical region can affect asthma outcomes [14, 25]; and this was observed as high endotoxin levels were associated with asthma at age 6 for the piama cohort (dutch); an inverse relationship with the inma cohort (spanish), and no association with the lisaplus cohort (german). also, other studies have shown that early constant animal exposure reduces the risk of asthma early life rhinovirus wheezing, allergic sensitization, and asthma risk at adolescence association between respiratory infections in early life and later asthma is independent of virus type previous studies have demonstrated that early infant exposure to human rhinovirus (hrv) is associated with triggering asthma attacks this study demonstrated that early childhood exposure to rhinovirus significantly increased the risk for the development asthma, and found clinical markers that could be used to predict the development of atopic and non-atopic asthma in children [11]. this study was different from previous studies farm environment during infancy and lung function at the age of 31: a prospective birth cohort study in finland exposure to farming in early life and development of asthma and allergy: a cross-sectional survey association of airborne particles, protein, and endotoxin with emergency department visits for asthma in kyoto epidemiological analysis and follow-up of human rhinovirus infection in children with asthma exacerbation association between enterovirus infection and asthma in children: a 16-year nationwide population-based cohort study ev-d68 infection in children with asthma exacerbation and pneumonia in mexico city during 2014 autumn. influenza other respir viruses high fractional exhaled nitric oxide and sputum eosinophils are associated with an increased risk of future virus-induced exacerbations: a prospective cohort study the indoor environment and inner-city childhood asthma environmental exposure to endotoxin and its health outcomes: a systematic review house dust endotoxin levels are associated with adult asthma in a u.s. farming population endotoxin tolerance: new mechanisms, molecules and clinical significance this study not only demonstrated this concept, following patients from birth to 7 years of age, but also found that the bacterial species kocuria, bifidobacterium, alloiococcus, and acinobacter are found in the home of children without asthma furthermore, a previous study has demonstrated that the microbiome of infants' nasopharynx is initially colonized with alloiococcus when healthy and declines with acute respiratory infections and the development of asthma thus, this study shows key bacteria may have the potential to suppress or trigger the development of asthma from early childhood exposure sleeping on animal fur is related to asthma outcomes in later childhood the infant nasopharyngeal microbiome impacts severity of lower respiratory infection and risk of asthma development helicobacter pylori in children with asthmatic conditions at school age, and their mothers predictors of asthma following severe respiratory syncytial virus (rsv) bronchiolitis in early childhood association between respiratory syncytial viral disease and the subsequent risk of the first episode of severe asthma in different subgroups of high-risk australian children: a whole-ofpopulation-based cohort study effects of respiratory syncytial virus infection in infancy on asthma and respiratory allergy in 6-year-old children endotoxin predictors and associated respiratory outcomes differ with climate regions in the u exposure and sensitization to pets modify endotoxin association with asthma and wheeze relations of exhaled nitric oxide and fev1 to personal endotoxin exposure in schoolchildren with asthma lipopolysaccharide amplifies eosinophilic inflammation after segmental challenge with house dust mite in asthmatics the association between endotoxin and beta-(1->3)-d-glucan in house dust with asthma severity among schoolchildren indoor determinants of endotoxin and dust mite exposures in hong kong homes with asthmatic children endotoxin exposure and eczema in the first year of life a longitudinal analysis of wheezing in young children: the independent effects of early life exposure to house dust endotoxin, allergens, and pets endotoxin exposure in asthmatic children and matched healthy controls: results of ipeadam study endotoxin exposure, serum vitamin d, asthma and wheeze outcomes relationship between mold exposure, specific ige sensitization, and clinical asthma: a case-control study evaluation of the association between sensitization to common inhalant fungi and poor asthma control clinical relevance of ige-mediated sensitization against the mould alternaria alternata in children with asthma association between fungal spore exposure in innercity schools and asthma morbidity indoor mold levels and current asthma among school-aged children in saskatchewan impact of occupational exposures on exacerbation of asthma: a population-based asthma cohort study fungal sensitization is associated with increased risk of life-threatening asthma indoor fungal diversity in primary schools may differently influence allergic sensitization and asthma in children the role of outdoor fungi on asthma hospital admissions in children and adolescents: a 5-year time stratified case-crossover analysis the relationship between biomarkers of fungal allergy and lung damage in asthma indoor microbial communities: influence on asthma severity in atopic and nonatopic children -3, 1-6)-beta-d-glucan, and ergosterol concentrations in dust are not associated with asthma, rhinitis, or eczema diagnoses in children analysis of the fungal microbiome in exhaled breath condensate of patients with asthma fungal sensitisation in severe asthma is associated with the identification of aspergillus fumigatus in sputum mould and grass pollen allergy as risk factors for childhood asthma in zaragoza presence of household mold, children's respiratory health, and school absenteeism: cause for concern identification of fungal candidates for asthma protection in a large population-based study associations between outdoor fungal spores and childhood and adolescent asthma hospitalizations influence of viral infection on the relationships between airway cytokines and lung function in asthmatic children characteristics associated with clinical severity and inflammatory phenotype of naturally occurring virus-induced exacerbations of asthma in adults the molecular epidemiology of respiratory viruses associated with asthma attacks: a single-center observational study in japan serum igg concentrations in adult patients experiencing virus-induced severe asthma exacerbations study of clinical characteristics and cytokine profiles of asthmatic children with rhinovirus infection during acute asthma exacerbation at national hospital of pediatrics increased seroprevalence of enterovirus 71 ige antibodies in asthmatic compared with non-asthmatic children clinical characteristics of children infected with enterovirus d68 in an outpatient clinic and the association with bronchial asthma enterovirus d68 respiratory infection in a children's hospital in japan in 2015 detection of pathogens by real-time pcr in adult patients with acute exacerbation of bronchial asthma effects of inactivated influenza vaccine on respiratory illnesses and asthma-related events in children with mild persistent asthma in asia hospitalizations associated with respiratory syncytial virus (rsv) and influenza in children, including children diagnosed with asthma genetic variants in endotoxin signalling pathway, domestic endotoxin exposure and asthma exacerbations the r576 il-4 receptor alpha allele correlates with asthma severity gene-environment interaction between an il4r variant and school endotoxin exposure contributes to asthma symptoms in inner-city children farm exposure in utero may protect against asthma, hay fever and eczema environmental exposure to endotoxin and its relation to asthma in school-age children amish children living in northern indiana have a very low prevalence of allergic sensitization rising prevalence of asthma is sex-specific in a us farming population staphylococcal enterotoxin ige sensitization in late-onset severe eosinophilic asthma in the elderly correlation of aspergillus skin hypersensitivity with the duration and severity of asthma. monaldi arch chest dis rhinoviruses significantly affect day-to-day respiratory symptoms of children with asthma absence of back to school peaks in human rhinovirus detections and respiratory symptoms in a cohort of children with asthma longitudinal urinary metabolomic profiling reveals metabolites for asthma development in early childhood dupilumab efficacy in patients with uncontrolled, moderate-to-severe allergic asthma targeted therapy for severe asthma in children and adolescents: current and future perspectives publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-307202-iz1bo218 authors: shaw, dominick; portelli, michael; sayers, ian title: asthma date: 2014-05-02 journal: handbook of pharmacogenomics and stratified medicine doi: 10.1016/b978-0-12-386882-4.00028-1 sha: doc_id: 307202 cord_uid: iz1bo218 asthma is a common respiratory disease with a complex etiology involving a combination of genetic and environmental components. current asthma management involves a step-up and step-down approach based on asthma control with a large degree of heterogeneity in responses to the main drug classes currently in use: β(2)-adrenergic receptor agonists, corticosteroids, and leukotriene modifiers. importantly, asthma is heterogeneous with respect to clinical presentation and the inflammatory mechanisms that underlie it. this heterogeneity likely contributes to variable results in clinical trials, particularly when targeting specific inflammatory mediators. these factors have motivated a drive toward stratified medicine in asthma based on clinical/cellular outcomes or genetics (i.e., pharmacogenetics). significant progress has been made in identifying genetic polymorphisms that influence the efficacy and potential for adverse effects of all main classes of asthma drugs. importantly an emerging role for genetics in phase ii development of newer therapies has been demonstrated (e.g., anti-il4). similarly, the stratification of patients based on clinical characteristics (e.g., blood and sputum eosinophil levels) has been critical in evaluating newer therapies (e.g., anti-il5). as a proof of concept, anti-ige is the latest therapy to be introduced into clinical practice, although only for severe, allergic patients (i.e., in a stratified manner). as new asthma genes are identified using genome-wide association, among other technologies, new targets (e.g., il33/il33 receptor (il1rl1)) will emerge and pharmacogenetics in these development programs will be essential. in this chapter we review the current understanding of asthma pathobiology and its clinical presentation, as well as the use of stratified medicine, which holds great promise for maximizing clinical outcomes and minimizing adverse effects in existing and new therapies. umbrella definition will require integrating bench and bedside approaches using data from ongoing genomic and proteomic profiling studies of large, well-characterized asthma populations-such as the current eu-wide ubiopred study (formally, "unbiased biomarkers in prediction of respiratory disease outcomes")-with feedback to improved in vitro and in vivo animal models and human studies. the international consensus report on the diagnosis and treatment of asthma defines asthma as "a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells and eosinophils. in susceptible individuals this inflammation causes symptoms which are usually associated with widespread, but variable, airflow obstruction that is often reversible either spontaneously or with treatment, and causes an associated increase in airway responsiveness to a variety of stimuli." the interaction of these features determines the clinical manifestations and severity of the disease and the response to treatment [3] . how these features relate to each other, how they are best measured, and how they contribute to clinical manifestations of the disease remains unclear. age of disease onset also complicates understanding, although there are many shared features in the diagnosis of asthma in children and in adults, there are also important differences. the differential diagnosis, the natural history of wheezing illnesses, and the ability to perform certain investigations are all influenced by age [4] . according to the world health organization (who), between 100 and 150 million people around the globe (roughly equivalent to the population of the russian federation) suffer from asthma. worldwide, deaths from asthma have reached more than 180,000 annually. overall, asthma affects 5-10% of the population in many developed countries. one study found that the annual estimated incidence of physician-diagnosed asthma ranged from 0.6-29.5 per 1000 persons. risk factors for incident asthma among children include male gender, atopic sensitization, parental history of asthma, early-life stressors and infections, obesity, and exposure to indoor allergens, tobacco smoke, and outdoor pollutants. risk factors for adult-onset asthma include female sex, airway hyper-responsiveness, lifestyle factors, and work-related exposures. while the exact cost of asthma care is difficult to determine, a 2009 systematic review [5] found eight national studies reporting a national total cost. the total costs in 2008 in u.s. dollars were high and varied widely: singapore, $49.36m; canada, $654m; switzerland, $1413m; germany, $2740m; united states, $8256m. although the costs of asthma care vary by country, it is estimated that worldwide the number of disability-adjusted life years (dalys) lost from asthma is about 15 million per year. worldwide asthma accounts for around 1% of all dalys lost, which reflects the high prevalence and severity of asthma. the number of asthmacaused lost dalys is similar to that for diabetes, cirrhosis of the liver, and schizophrenia. costs are related to other factors, including asthma control, demographics, medical history, and doses of inhaled corticosteroid (ics) prescribed [6] . improving asthma control is associated with decreased cost. asthma classically causes wheeze, cough, chest tightness, and breathlessness (dyspnoea). the pattern of symptoms can be a clue to the diagnosis. episodic symptoms worse at night and in the early morning, or in response to exercise, allergen and cold air exposure, or after taking aspirin or beta blockers are very suggestive of asthma. moreover, symptoms that are relieved by bronchodilators point toward asthma as the underlying cause. symptoms that lower the probability of asthma include those of prominent dizziness, light-headedness, and peripheral tingling (all point toward dysfunctional breathing); a chronic productive cough in the absence of wheeze or breathlessness (more likely bronchiectasis); a repeatedly normal physical examination of chest when symptomatic; and voice disturbance, symptoms with colds only, or a significant smoking history. taking a detailed patient history and recording spirometry when the patient is symptomatic is crucial to the accurate classification of the disease. there are several differential diagnoses that must be considered when making a diagnosis of asthma. these are outside the scope of this chapter. a good guide to the clinical diagnosis and management of asthma are the british thoracic society asthma guidelines, which are updated regularly and are available at www.brit-thoracic.org.uk/clinical-information/ asthma/. triggers for asthma symptoms include allergens (proteins) derived from, among others, house dust mite (hdm), cat and dog dander, cockroach, and fungi, especially aspergillus fumigatus. there are numerous other nonallergic symptom triggers, including weather and atmospheric change, air pollution, exercise, menstruation, emotion and laughter, viral infection, gastroesophageal reflux, and rhinitis. various occupations can both cause and worsen asthma (e.g., welding, baking, paint spraying). asthma symptoms often overlap with other allergies, including oral allergy syndrome and food allergies. delineating between causes of symptoms can be difficult. if a specific aeroallergen is identified that triggers asthma (classically tree or grass pollen), a course of either sublingual or subcutaneous desensitization can be undertaken to reduce symptoms on exposure to that specific allergen. there are multiple other symptom triggers that can include both allergic and non-allergic mechanisms; examples include exposure to chemicals, such as perfumes, paint and bleach, plants (e.g., ligustrum vulgare-privet hedges), salicylates, and sulphites. multiple factors have been shown to either directly cause or worsen symptoms of asthma [4] . these are listed in box 28.1. other factors not directly related to the disease can worsen symptoms and are associated with more frequent exacerbations. these include dysfunctional breathing, vocal cord dysfunction, psychosocial problems, and poor adherence to treatment regimes [4] . other forms of asthma are recognized, among them occupational, exercise-induced, and pregnancy-related asthma. these subdivisions are somewhat arbitrary, but may have different causes, prognoses, and complexities. for example, occupational asthma includes that triggered by ige-mediated mechanisms, that due to specific agents with unclear pathophysiology, and that secondary to irritants (also known as rads-reactive airways dysfunction syndrome). underlying asthma can also be made worse by occupational exposure (work-aggravated). most experts regard exercise-induced asthma as a different disease, albeit one resulting in similar symptoms. exercise-induced asthma is often diagnosed with different investigations, including eucapnic voluntary hyperventilation or exercise testing. it is associated with certain sports (swimming and cross country skiing in particular) and has a unique pathophysiology directly related to damage of the airway epithelium. asthma control can deteriorate in pregnancy, due to both hormonal effects and the physical effects of a gravid uterus on diaphragm and respiratory muscle function. pregnancy can also impact treatment decisions. leukotriene modifiers are generally contraindicated, and the health of the fetus as well as that of the mother needs to be considered. poor adherence is probably the biggest single issue affecting asthma control. studies have shown that people with asthma over-report use of ics; one study found that although 95% of responders said they used their inhalers, only 58% actually did. adherence to ics therapy is associated with a lower rate of death, whereas increasing use of reliever (salbutamol/bricanyl) medication, which improves symptoms but does not treat underlying airway inflammation, is associated with increased mortality [7, 8] . a 2010 report entitled evaluation of the scale, causes and costs of waste medicines: report of dh funded national project (trueman et al. york health economics consortium and university of london school of pharmacy, 2010) put figures to the possible cost benefits from improving asthma treatment adherence in the united kingdom. it estimated the resulting net benefit associated with compliance to be £2250 per patient, with a reduction in expected annual treatment costs of approximately £75 per patient per year. based on an asthma point prevalence of 5.8%, the findings suggest that there are almost 1.8 million asthmatics in the united kingdom who are noncompliant. if interventions were available to change the behavior of all partially compliant medicine users to raise the percentage to 80% or more, the report estimated that over £130 million in treatment cost savings could be realized in the united kingdom alone. a more modest target of doubling current compliance rates would result in savings of approximately £90 million per year. the aim of asthma treatment is to improve symptoms, maintain lung function, and prevent exacerbations. from a patient's perspective, these are simple aims, but for the purposes of study design and treatment trials they do not address the complexity of the disease process. accordingly, guidelines now specifically address asthma control (symptoms and lung function) and severity (need for treatment) separately. the current global initiative for asthma (gina) guidelines assess levels of control based on daytime symptoms, limitation of activities, nocturnal symptoms/awakening, need for reliever/rescue treatment, lung function (pef or fev 1 ), and exacerbations [9] ( treatment steps are defined by the treatment level required to maintain asthma control (table 28 .1), with patients at steps 1-2 having well-controlled asthma requiring little treatment, and patients at step 4 having poorly controlled asthma despite four or five different drugs. the step approach is similar to that used by the british thoracic society (bts) guidelines [4] . asthma is a variable disease both temporally and clinically. there is also overlap between symptoms and exacerbations. this overlap was the subject of a recent consensus document that defined asthma exacerbations as "events characterized by a change from the patient's previous status." severe exacerbations are "events that require urgent action on the part of the patient and physician to prevent a serious outcome, such as hospitalization or death from asthma," and moderate asthma exacerbations are "events that are troublesome to the patient, and that prompt a need for a change in treatment, but that are not severe…clinically identified by being outside the patient's usual range of day-to-day asthma variation" [10] . the most practical definition of an asthma exacerbation is probably an episode of worsening symptoms not responding to increasing bronchodilator therapy. this definition was employed in an elegant study on the time course of peak flow changes [11] . for the purposes of clinical studies, most authors define exacerbation as the need for rescue courses of systemic corticosteroids (prednisolone/prednisone). although the majority of patients with asthma are treated and investigated in primary care settings, the main burden of asthma is due to its severe form (i.e., step 4) and exacerbations. using the united kingdom as an example (population 60 million), asthma is responsible for more than 1200 deaths per year and for over 50,000 hospital admissions, with an annual expenditure of £800 million on pharmaceutical costs alone. it was recently estimated that a patient controlled at the mildest end of the spectrum (british thoracic society (bts) guidelines: step 1 with no exacerbations) would cost 50 times less to provide his or her package of care than would a patient at the worst end of the spectrum (bts guidelines: step 5 with exacerbations) [12] . it is also calculated that 5% of asthma patients are responsible for at least 50% of the total healthcare burden [4] ; the most expensive individual cost is an icu admission (bts level 3) due to a life-threatening exacerbation. in the u.s. more than half (53%) of asthma sufferers in 2008 had an asthma attack, and of these half of the children and one-third of the adults missed school or work because of it; on average, children missed four days of school and adults missed five days of work. exacerbation pathogenesis is not fully understood. although research has focused on infective agents, especially viral, there may be other explanations. asthma exacerbations are associated with both inflammatory and immunological cell infiltration. the inflammatory cell infiltrate is composed of varying numbers of eosinophils, neutrophils, and lymphocytes. this airway inflammation, combined with smooth-muscle hypertrophy step 1 (intermittent) fewer than once/week; asymptomatic, normal pef between attacks two or fewer/month 80% or more less than 20% step 2 (mild persistent) more than once/week, fewer than once/day; attacks may affect activity >2 times a month >/=80% 20-30% step 3 (moderate persistent) daily; attacks affect activity more than once/week 60%-80% more than 30% step 4 (severe) continuous; limited physical activity frequent 60% or less more than 30% and thickening of the lamina reticularis, is accentuated by mucus plugs, serum protein deposition, inflammatory cell and cellular debris, leading to blockage of the airway (airflow obstruction) and wheeze. approximately 80% of exacerbations are associated with respiratory tract viral infections, with rhinovirus responsible for about two-thirds of cases [13] . asthmatic subjects also have much more severe lower respiratory tract illness with rhinovirus infection than do healthy control subjects. the mechanism for this is not fully understood. infection induces inflammation, increasing levels of neutrophils, eosinophils, cd41+ cells, cd81+ cells, and mast cells through increased mrna expression and translation of il-6, il-8, il-16, eotaxin, ifn-γ-induced protein 10 (ip-10), chemokine (c-c motif) ligand 5 (ccl5/rantes), and other proinflammatory cytokines. other viruses implicated in exacerbations include enterovirus, coronavirus, influenza, parainfluenza, respiratory syncytial virus, metapneumovirus, adenovirus and bocavirus [14] . although influenza vaccination is recommended for all individuals with asthma, there is currently no hard evidence that this improves outcomes. bacterial infection has also been implicated in asthma exacerbation. individuals with asthma have an increased risk of invasive pneumococcal disease [15] , and an increased frequency of detection of chlamydophila pneumoniae [16] . one study found mycoplasma pneumoniae infection in 20% of patients hospitalized for severe asthma [17] . several trials have evaluated the role of macrolide antibiotics in treating and preventing asthma exacerbations. one study randomized adults with exacerbations to the ketolide antibiotic telithromycin or placebo; the telithromycin group had a small but significant improvement in symptoms and lung function from exacerbation to the end of treatment [18] . further studies of macrolide antibiotics (which have immunomodulatory as well as antibiotic properties) are under way, but as yet macrolide antibiotics are not recommended by international asthma guidelines. new techniques for assessing the airway bacterial microbiota have established that the airways are not normally sterile, and may permit the role of bacterial infection in airways disease to be further delineated. a recent study found that pathogenic proteobacteria, particularly haemophilus species, were much more frequent in the bronchi of patients with asthma or copd than in controls [19] . prolonged exposure to aeroallergens can result in chronic airway inflammation via th2-driven ige mechanisms. this immunological reaction may intensify airway inflammation, increase inflammatory cell activation, and stimulate mucus glands to hypersecrete, leading to airway obstruction. studies of bronchoalveolar fluid before and after allergen challenge show eosinophilic inflammation as the major airway response, associated with late-phase responses of airflow obstruction. in addition, il5 and il13 are significantly raised. exposure to seasonal allergens has been implicated in sudden asthma-related deaths; hdm, cat, and cockroach allergen sensitization are risk factors for emergency treatment [20] . grass pollen sensitization, or ''thunderstorm asthma,'' has also been associated with epidemics of exacerbations [21] . fungal allergens are found both outdoors and indoors, and sensitivity to them is a risk factor for the development, persistence, severity, and mortality associated with asthma. individuals with asthma are often sensitized to fungi such as cladosporium species, alternaria species, penicillium species, and candida species [22] . alternaria species sensitization and exposure are associated with symptoms and a 200-fold increased risk of respiratory arrest in subjects with asthma [23] . fungal exposures may worsen disease by different mechanisms; fungalassociated proteases may lead to the development of allergic airway inflammation along with ige-mediated responses; fungal allergen-induced asthmatic reactions evoke an il5 response with increased eosinophil recruitment and degranulation [24] . the relationship between fungal exposure and asthma is complicated by the degree of sensitivity to fungal allergens and the resultant allergy. a specific disease entity called allergic bronchopulmonary aspergillosis (abpa) exists in which colonization of the respiratory tract with the ubiquitous aspergillus fumigatus is associated with an increased allergic response (both type 1 and type 3) and severe asthma exacerbations. trials in both abpa and a related disease, severe asthma with fungal sensitization (safs), have shown some benefit with the oral antifungal itraconazole [25] , but good-quality trial data are lacking. unlike other chronic conditions, there is no gold standard for the diagnosis of asthma. although tests of airway function can be used to diagnose and study different aspects of airway disease (airway inflammation/airway hyper-responsiveness), diagnosis still depends on the presence of specific symptoms, which include wheeze, cough, chest tightness, and difficulty breathing. these symptoms are often variable, worse at night, or worse in response to triggers. they often respond to asthma therapy and may be associated with atopy/allergy and a family history of similar problems. the lack of a gold standard affects clinical provision and studies alike; most estimates suggest that asthma is wrongly diagnosed in approximately 30% of patients [26] . the development of a cheap and reliable noninvasive test that can diagnose asthma is seen as the holy grail for diagnosisbased research. measurements of airflow limitation provide an assessment of the severity, reversibility, and variability of airflow obstruction, and can help confirm the diagnosis of asthma. spirometry (forced expiratory volume in 1 second (fev 1 ), forced vital capacity (fvc), and fev 1 /fvc) is the preferred method of measuring airflow limitation, as it is more repeatable and less effort dependent than peak flow. a fev 1 /fvc ratio of less than 0.7 is consistent with a diagnosis of airflow obstruction, and an increase in fev 1 of >12% (or >200 ml) after administration of a short-acting bronchodilator indicates reversible airflow limitation consistent with asthma [27] . importantly, most asthma patients will not exhibit reversibility at each assessment, and repeated testing is advised to confirm a diagnosis. consequently, an absent response to bronchodilators does not exclude asthma. peak expiratory flow (pef) measurements can be used to monitor asthma. they are ideally compared to the patient's own previous best measurements using his or her own peak flow meter. an improvement of 60 l/min (or >20% of the prebronchodilator pef) after inhalation of a bronchodilator, or diurnal variation in pef of more than 20% (with twice-daily readings, more than 10%), suggests poorly controlled asthma. other approaches have been utilized to diagnose asthma, both to confirm a formal diagnosis and to identify corticosteroid response. these approaches include noninvasive measurements of airway inflammation or assessment of airway hyper-responsiveness. measuring airway inflammation is relatively easy, either using techniques to induce sputum and then counting the differential eosinophil and neutrophil cell numbers present, or by measuring the fraction of nitric oxide (no) present in the exhaled breath (f e no) using portable chemical analyzers. airway hyper-responsiveness can be assessed by several different methods. all are designed to provoke bronchoconstriction, which is measured using spirometry. the concentration (or dose) at which bronchoconstriction occurs is then used to categorize the degree of airway responsiveness and the presence or absence of asthma. although these tests are widely employed in research settings, their use in a clinical setting is hampered by their varying sensitivity and specificities for asthma diagnosis [4] , as both airway inflammation and airway hyper-responsiveness can be present in healthy individuals without symptoms. the symptoms of asthma in children are recurrent wheezing, cough, difficulty breathing, and chest tightness. evaluation of these symptoms is critical to the diagnosis, treatment, and outcome measures used in clinical studies; however, asthma triggers and inflammatory cell type are increasingly used to define childhood asthma phenotypes. pediatric asthma is complicated by wide variations in symptom prevalence. the majority of children with asthma have mild or moderate disease; 5% of all asthmatic children have chronic symptoms and/or recurrent exacerbations, despite maximum treatment with conventional medications [28] . asthma in childhood is heterogeneous in several ways, including etiology, clinical presentation, and response to treatment. several attempts have been made to stratify treatment on the basis of different asthma phenotypes in children, with varying degrees of success. stratifying treatments in pediatric asthma is more complicated because of patient age and the inability (dependent on age) to perform more complicated or invasive tests. in children, the onset and progression of asthma result from a complex interplay between genetic background and environmental exposures. the complexity is confounded by wheezing illnesses consisting of several distinct disease entities, with no general agreement on their number or underlying mechanisms [29] . among the environmental factors that influence the risk of asthma are viral and bacterial respiratory infections. exposure to environmental tobacco smoke is also associated with increased rates of early viral illnesses. other factors associated with the risk of wheeze include physical factors associated with increased breathing (exercise, laughing, crying, and excitement) or allergens (aeroallergens and food allergens). there are considerable age-related changes in the relative importance of trigger factors for wheeze in children. human rhinovirus (hrv) has been implicated in both the etiology of asthma and exacerbations; infants who have hrv infections with wheezing are at a significantly increased risk for subsequent asthma, and over 50% of childhood asthma exacerbations are triggered by hrv. it is important to note that exposure to hrv does not lead to wheezing illness in all children, nor does wheezing illness result in asthma in all cases, suggesting that the host genotype also plays a role. a recent study of two cohorts of children with asthma found that variants at the 17q21 locus were associated with asthma in children who had hrv wheezing illnesses, implicating an interaction between hrv wheezing illness in early childhood and the 17q21 genotype (see section 28.3.2). the presentation of asthma symptoms and exacerbations in childhood also varies. some children have frequent exacerbations with few daily symptoms, while others have recurrent symptoms without airway inflammation and exacerbations. other diseases coexist with childhood asthma, including gastroesophageal reflux disease, severe asthma with fungal sensitization, obesity, and vocal cord dysfunction. targeting these coexisting disorders has met with varying clinical success [30] . an important component of the development of asthma is the inflammatory cascade. this involves the infiltration of a number of inflammatory cells, such as eosinophils, neutrophils, b-and t-lymphocytes, macrophages, mast cells, dendritic cells, and basophils, into the airway, and the release of inflammatory mediators (e.g., leukotrienes, histamine, cytokines, and chemokines) by airway, structural cells (including epithelial, smooth-muscle, endothelial, and fibroblast cells). however, since the degree of inflammation in asthma is not directly related to asthma severity, this suggests that other factors, such as structural changes in the airways, also play a role in disease modulation and progression. these structural changes have been termed airway remodeling and may exist in the presence or absence of inflammatory mechanisms in the airway [31] . the inflammatory response in asthma is a result of excessive activation of mast cells in the airway, where in the early response to allergen challenge, degranulation of mast cells results in the release of a number of proinflammatory factors such as il4, leukotrienes, and histamine. this causes an immediate hypersensitivity response that in turn leads to airway narrowing. the concomitant release of other inflammatory factors such as cytokines and chemokines from the same mast cells provides an optimal environment for recruitment to the airways of other inflammatory cells such as eosinophils, basophils, neutrophils, and t-lymphocytes. once in the airways, these cells act in tandem with allergen-activated macrophages, resulting in what is termed the late asthmatic response (occurring at 4-8 hours postchallenge). here, through the action of a number of released potent immunomodulators (e.g., tnfα, il3, il4, il5, and il13), airway narrowing occurs. this may occur in periods that last more than 24 hours. of the inflammatory cells involved in the asthmatic response, it is the infiltration of eosinophils that is considered characteristic of the asthmatic phenotype, particularly that of mild/moderate allergic asthma ( figure 28.1) . for a more extensive description of inflammatory mechanisms underlying allergic asthma see hodge & sayers [32] . although inflammation in asthma has been extensively studied, the relationship between inflammation and clinical symptoms of asthma is still unclear. this may be partially explained by a possible link between airway inflammation and airway hyper-responsiveness [33] . here, airways become more susceptible to sensitizing agents, which would otherwise be unable to trigger an airway response, because of (a) increased release of mediators such as histamine and leukotrienes, (b) abnormal smooth-muscle behavior, and (c) airway thickening. airway remodeling plays an important role in asthma pathogenesis. airway structural changes characteristic of airway remodeling occur because of prolonged airway inflammation. here, prolonged release of inflammatory factors results in: l thickening of the smooth-muscle bronchial walls, leading to airway narrowing l denudation of the bronchial epithelium l hyperplasia and hypertrophy of the airway smoothmuscle l hyperplasia and hypertrophy of the epithelial goblet cells, resulting in the formation of large mucus plugs liable to occlude the airway and increase airway hyper-responsiveness airway remodeling also involves changes occurring in the extracellular matrix and its constituent proteins (collagens i/iii/iv, fibronectin, and laminin) and structural changes such as angiogenesis, vasodilation, increased airway blood flow, and changes in autonomic neurological function [34] . the development of asthma results in a degree of airway remodeling. the structural changes that define airway remodeling are an important feature in asthmatic airways, where even in newly diagnosed asthma patients, a degree of structural change can be identified in the bronchial wall [35] . airway remodeling can be defined as a process of sustained disruption and modification of structural cells and tissues leading to the development of a new airway wall morphology [36] . airway remodeling ( figure 28 .2) is initiated either through various inflammatory pathways, highlighting the importance of the inflammatory pathway [37] , or through bronchial hyper-responsiveness, where airway remodeling occurs independently of inflammation [38] . our understanding of the extent and nature of genetic variation in the human genome has dramatically improved since the publication of the first draft genome sequence in 2001, figure 28.1 asthma pathophysiology. exposure to allergens-for example, dermatophagoides pteronyssinus 1 (der p1) and dactylis glomerata (dacg1)-originating from various sources, including pollen, house dust mite, and mold, are taken up by dendritic cells, b-lymphocytes, epithelial cells, and macrophages, which present the antigens to t-lympocytes. this activates the t-lymphocytes to produce cytokines that regulate immunoglobulin e (ige) production by the b-lymphocytes. bound ige activates mast cells in the airways. activated mast cells initially release a number of factors, including il4, leukotrienes, and histamine, that cause airway hyper-responsiveness and result in an early response to allergen stimulus via bronchoconstriction. the concurrent release of cytokines and chemokines from the mast cell recruits eosinophils, basophils, and t-lymphocytes to the airway. these cells, in association with t cell-activated neutrophils and with antigen stimulated macrophages, release chemokines and leukotrienes over an extended period of time, resulting in a late response to allergen stimulus via bronchoconstriction. prolonged stimulation of the late-response factors ultimately leads to the airway structural changes such as mucus hypersecretion, myofibroblast, and airway smooth-muscle proliferation, which are common to the asthmatic lung. and it continues to improve exponentially with initiatives such as the 100,000 genomes project, which aims to genome-sequence this number of uk subjects, and the encyclopedia of dna elements consortium (encode), an initiative to identify the genome's regulatory regions. recent figures suggest that more than 6.9 million singlenucleotide polymorphisms (snps) or single-base-pair changes exist in a genome consisting of 3 billion base pairs. similarly there is a growing realization that deletions, insertions, and expansions of tandem repeats also represent significant variation. these genetic polymorphisms are found throughout the genome and have the potential to influence gene function in several ways leading to human disease: (1) a coding-region nonsynonymous polymorphism can alter the amino acid sequence and structure/function of the protein; (2) a polymorphism can introduce a stop codon leading to the production of a nonfunctional protein; and (3) a polymorphism in a regulatory region can regulate the expression levels of a gene. it has long been known that atopic diseases such as asthma run in families. in 1916, using 621 atopic probands and 76 nonatopic controls and their respective families, it was shown that 48.4% of atopic probands had a family history of atopy, compared with 14.5% in the control population [39] . similarly, a study of 176 families showed a very high concordance of asthma, hayfever, and eczema in parents and children [40] . twin studies have been useful in identifying a significant concordance of asthma that is higher in monozygotic twins (identical genotype) versus dizygotic twins (on average sharing half of their genes). in the largest study to date, using 11,688 danish twin pairs, it was suggested that 73% of susceptibility to asthma was genetic, with a substantial environmental component [41] . more recent studies suggest hereditability estimates of 35-95% for asthma [42] . therefore, asthma is considered a complex genetic disorder and, in contrast to single-gene disorders (e.g., cystic fibrosis), involves multiple genes, with expression influenced by both genetic and environmental factors. multiple environmental factors are important in asthma development, including tobacco smoke exposure, respiratory viral infections, antibiotic use, diet, and allergen exposure. gender and ethnic background also make a significant contribution. this complex mode of inheritance combined with the heterogeneity in the presentation of the disease has made gene discovery a challenge. early studies investigated inheritance through families containing multiple affected children, using linkage analyses and candidate gene approaches based on biology or location in the genome. however, the figure 28.2 asthmatic airway pathology. this schematic comparison of a normal airway with that observed in severe chronic asthma indicates histological changes that accompany recurring inflammation seen over time. unlike that from the unaffected individual, the bronchial mucosa from the severe asthmatic displays thickening of the basement membrane, airway smooth-muscle hypertrophy, leukocyte infiltration, epithelial cell desquamation, goblet cell hyperplasia in the epithelial lining accompanied by mucus hypersecretion, and plugging of the bronchial lumen, as well as edema and collagen deposition in the submucosal area. (not drawn to scale.) source: reproduced with permission from hodge and sayers [32] . reproducibility of these findings was disappointing primarily because of inadequate power, subject heterogeneity (different phenotype definition), population stratification, and multiple testing without correction. more recently, hypothesis-free genome-wide association studies (gwas), which examine association with typically 500,000+ common (>5% frequency) polymorphisms spanning the genome in cases and controls, using very stringent statistical thresholds ( figure 28 .3), have been very successful. via these multiple approaches, over 190 asthma genes have been described in more than 1000 publications. the major reproducible findings for asthma follow below (for more comprehensive reviews see [42, 43] ). although this chapter focuses on the genetics of asthma diagnosis, subphenotypes in asthma (e.g., atopy, serum total ige levels, and lung function (e.g., fev 1 )) have also been investigated for genetic influences. positional cloning involves linkage analyses (region or whole genome) followed by fine mapping using association. linkage analysis uses family data to follow the transmission of genetic information spanning the entire genome (commonly short tandem repeat markers) across generations. these data are used to determine if a genetic marker is close to, or linked with, a gene involved in a particular disease using families with multiple affected children. once a specific chromosomal region has been identified in this hypothesis-free approach, snps spanning the region are tested to see if they are more common in people with asthma compared to people without. the first gene to be identified with confidence using positional cloning was disintegrin and metalloprotease 33 (adam33) [44] . using a cohort of 460 families, linkage was demonstrated to a locus on chromosome 20p13 for asthma, bronchial hyper-responsiveness (bhr), and total ige levels. subsequently, polymorphisms spanning adam33 were associated with asthma in the second stage. adam33 is thought to contribute to airway remodeling via its enzymatic functions. using positional cloning, multiple genes have been identified with functions varying from transcription factors to epithelial differentiation and tissue remodeling. these genes have provided a novel insight into potential mechanisms that are altered in asthma (table 28. 2). polymorphisms spanning the urokinase plasminogen activator receptor (plaur or upar) were also associated with asthma susceptibility and were associated with rate of decline of lung function in asthma through linkage/association analyses on chromosome 19q13 [45] . upar is a serine protease receptor involved in multiple mechanisms, including cell proliferation, migration, and extracellular matrix degradations via plasmin generation. these data suggest that genetic factors may be important in determining airway structural changes or "remodeling" in asthma [46] . genotype for typically 500,000+ snps in large numbers of cases and controls using arrays compare differences to identify disease-specific snps using stringent correction for multiple testing candidate gene studies are hypothesis-driven and based on the suggested biology of a gene product or the location of the gene in a chromosomal region previously linked to asthma. such studies commonly employ asthma cases versus controls, although family-based association has also been used. for excellent reviews of candidate gene studies in asthma, see ober and hoffjan [47] and undarmaa et al. [48] . the primary highly reproducible genes identified using candidate gene approaches are multiple components of the interleukin 4/13 axis (see table 28 .2), including the cytokine genes themselves (il4/il13); related receptor (il4ra) and downstream signaling effector signal transducers and activators of transcription (stat ) 6. the role of the il4/il13 axis in the pathogenesis of asthma has been extensively documented [49] . human studies have identified elevated numbers of cells expressing il13 mrna in the bronchial tissue of atopic and nonatopic asthmatic subjects [50] ; administration of recombinant il13 in mouse lungs resulted in an increase in airway mucus secretion, development of subepithelial fibrosis, airway hyper-responsiveness (ahr), and eosinophilic airway inflammation-that is, several key features of the human disease [51] . il13 is produced by a variety of cells, including th2 cd4+, th1 cd4+, cd8+ t cells, mast cells, basophils, and eosinophils. il13 mediates its effects by interacting with a complex receptor system comprising an il-4rα/il13rα1 heterodimer and the il13rα2 receptor [49] . the finding that genetic polymorphisms within il13 that determine levels and/or structure and are associated with the development of asthma make biological sense. the use of gwas approaches to identify asthma susceptibility genes has revolutionized our understanding of asthma genetics. while positional cloning showed great success with simple mendelian disorders, it did not perform well for complex diseases. similarly, candidate gene studies are useful but very inefficient. the capacity to interrogate the entire genome for 500,000+ common snps in cases and controls has provided an excellent platform for gene discovery. the first gwas for asthma used a discovery cohort of 994 patients with childhood onset asthma and 1243 nonasthma controls, and identified significant association to a locus on chromosome 17q21 [52] . this locus includes genes for zona pellucida binding protein 2 (zpbp2), gasdermin b (gsdmb) and orm1-like protein 3 (ormdl3). the 17q21 locus has been reproduced as a locus associated with childhood onset asthma in many studies; however, the identification of the specific gene(s) underlying these effects remains to be resolved. zpbp2, gsdmb, and ormdl3 have been implicated in gene transcription, cell apoptosis, and sphingolipid synthesis, respectively. this initial gwas has now been superseded by several larger-scale studies. in particular, the gabriel consortium study, involving 10,365 asthma cases and 16,110 controls, identified association between polymorphisms spanning il33, il1rl1/il18r1, hla-dq, smad3, and il2rb [53] . note: for candidate gene approaches, genes focused to replication in more than 10 studies [47, 48] . for gwas, genes focused to those meeting conventional genome-wide significance (p < 5 × 10−8) and/or independent replication in the caucasian population. to date, two of the most reproducible association signals are to the il33 gene on chromosome 9p24 and the il33 receptor (il1rl1 or st2) gene on chromosome 2, both of which highlight the significance of this ligand/receptor system in asthma. interestingly, these loci are associated with severe asthma as well [54] . there is good evidence from biology that the il33/st2 axis may be of relevance in asthma; mice induced to develop allergic airway disease were treated with an antibody that blocks il33 binding to its receptor. this treatment was shown to block many of the features of the disease, including reduced serum ige and airway eosinophil and lymphocyte counts. significantly, both induction and resolution of the disease were attenuated [55] . in human studies, il33 has been shown to be elevated in the airways of asthma patients, particularly in the airway structural cells, including the bronchial epithelium, and is induced in these cells by relevant stimulations (e.g., hdm [56] ). in addition, a soluble form of the st2 receptor has been shown to be elevated during asthma exacerbation [57] . overall, it is thought that the il33/st2 axis may be particularly important in attracting and activating inflammatory cells in the airways; however, the precise role(s) of this pathway remains to be resolved. as outlined in table 28 .2, other genes have been identified using gwas, including those involved in diverse roles such as inflammatory cell function and airway smoothmuscle contraction, again providing a unique insight into potentially altered mechanisms in asthma. however, most gwas determined single variants only confer a very modest odds ratio of 1.1-1.5 of developing asthma. for a more comprehensive review of gwas findings in asthma, see akhabir and sandford [43] . over the last 40 years, there has been great progress in identifying asthma susceptibility genes. current and future approaches include meta-analyses using cohorts of tens of thousands of asthma patients, the incorporation of gene expression/snp analyses (the expression quantitative trait loci (eqtl)), the investigation of asthma subphenotypes using gwas, and whole-genome sequencing. the real challenge is the translation of these genetic findings into a deeper understanding of the biology of asthma and the potential identification of therapeutic targets. already several of these newly identified genes (e.g., il33 and il33 receptor (il1rl1/st2)) represent excellent pharmacological targets, and it is anticipated that genetics in these loci will be essential to identifying patients most likely to gain clinical benefit from targeting this pathway. the lack of concordance between approaches (e.g., linkage versus gwas) can be explained by the fact that the methodologies are designed to detect different types of variants, e.g., linkage analysis has good power to detect high-risk disease-causing alleles but is not effective at identifying common alleles of modest effect, as gwas does. it is reassuring that many of the genes identified in candidate gene approaches have been reproduced in gwas (e.g., the il13/il4 locus on chromosome 5q31, a region that has also been linked to asthma). while there has been much success in recent years in identifying genes for asthma using gwas, the overall genetic variation accounted for by these genetic polymorphisms is very small, leading to the concept of "missing hereditability." possible explanations for missing hereditability include: (1) rare variants (<5% frequency) with larger effect size not measured on existing platforms; (2) structural variation (e.g., copy number variation); (3) gene-environment contributions; (4) gene-gene interactions; (5) epigenetic mechanisms; and (6) overestimation of initial hereditability. the aim of treatment is to achieve control of asthma and prevent exacerbations. most guidelines adopt a stepwise approach to the management of asthma and advise stepping up treatment as necessary and stepping down when control is achieved for at least three months. although there are several pharmacological options for asthma treatment (see figure 28 .4), the two main classes remain bronchodilators (short-or long-acting) and corticosteroids. short-acting bronchodilators (e.g., salbutamol/terbutaline) are sympathomimetics (β 2 -adrenergic receptor agonists) that relax airway smooth-muscle, enhance mucociliary clearance, decrease vascular permeability, and possibly modulate mediator release from mast cells. they are used for symptom control, acute exacerbations, and exerciseinduced asthma. frequent or regularly scheduled use of rapid-acting inhaled β 2 agonists for long-term management of asthma does not adequately control symptoms, pef variability, or airway inflammation. long-acting bronchodilators (e.g., salmeterol/formoterol) activity is identical to that of short-acting β 2 -adrenergic receptor agonists, but should be used in combination with inhaled corticosteroids because of concerns regarding increased mortality when used as a monotherapy. long-acting bronchodilators are normally introduced at treatment step 3. inhaled corticosteroids (ics) form the backbone of treatment for all but the very mildest asthma. ics improve lung function, symptoms, and quality of life, reduce exacerbations, and improve mortality. they have broad anti-inflammatory and immunosuppressive effects. corticosteroids enter the cell cytoplasm and bind with the inactive glucocorticoid receptor complex. the activated glucocorticoid receptor binds to dna at the glucocorticoid response element sequence and promotes synthesis of anti-inflammatory proteins (transactivation), and inhibits transcription and synthesis of many proinflammatory cytokines (transrepression). they also reduce the number of t-lymphocytes, dendritic cells, eosinophils, and mast cells in the airway, and reduce inducible nitric oxide production. ics (beclomethasone dipropionate/fluticasone propionate/budesonide/ flunisolide/ciclesonide/mometasone) all have side effects related to their transactivation properties, including local effects on the oropharynx (hoarseness, candidiasis, cough, and dysphonia) and systemic effects (cushing syndrome, osteoporosis, cataracts, dermal thinning and bruising, adrenal insufficiency, and growth suppression) in children [58] . consequently, the lowest dose required to control symptoms and prevent exacerbations should be prescribed. other medications are normally reserved for second-or third-line treatment. these include methylxanthines (theophylline), leukotriene modifiers (montelukast), inhaled anticholinergics (ipratropium bromide/tiotropium), and sodium chromoglycate. a wide range of interventions have been assessed for both the primary prevention of asthma and the secondary prophylaxis of the disease once present. these treatments have varying effects, but may be recommended in individual cases. primary prevention measures include aeroallergen and food allergen avoidance, fish oil supplementation, avoidance of tobacco smoke and air pollutants, immunotherapy, and immunization. measures that have been assessed for secondary prophylaxis include hdm and allergen avoidance, smoking reduction, subcutaneous and sublingual immunotherapy, dietary manipulation, weight loss, breathing techniques, and exercise training. some investigators argue that severe asthma is an inflammatory condition separate from mild/moderate asthma, rather than simply the severe end of the disease spectrum. this is difficult to prove, as underlying asthma may be complicated by other aspects (obesity/reflux/smoking/poor adherence), making it more difficult to treat and control. there are different definitions of severe asthma, but all require high-dose inhaled corticosteroids or oral corticosteroids and include recurrent exacerbations and poor control. as high-dose ics and oral corticosteroids are associated with side effects attempts have been made to design treatments to either reduce the amount of corticosteroid prescribed (steroid-sparing agents) or treat the underlying asthma in a different manner. steroid-sparing agents trialled include methotrexate, gold, cyclosporin, and azathioprine. currently, none have been recommended in any asthma guidelines. box 28.2 lists other treatments used on an individual basis. the need for a stratified-medicine approach to asthma has become apparent over the last decade. this has followed the realization that the term asthma covers a whole range of disease phenotypes. as techniques for investigating and researching asthma have evolved, it has become clear that different disease processes are present that require different treatments and approaches. whether this represents disease phenotyping or just a better understanding of disease pathogenesis is unclear. over the years, research focus has moved from the airway smooth-muscle via airway inflammation to airway immunology, and on to the epithelial-mesenchymal trophic unit. future insight into disease pathogenesis and new treatment developments will follow with the use of the latest technologies, which include "omics" platforms and assessment of airway microbiota. improving our understanding of stratified medicine for asthma-targeting the right therapy to the right patientaims to reduce hospital admissions due to poorly controlled asthma and fatalities. although most asthma can be controlled by ics and bronchodilators, there remains a cohort of patients with persistent symptoms, recurrent exacerbations, and worse quality of life. the current stepwise management approach (see figure 28 .4) is inefficient, particularly in light of heterogeneity in clinical presentation and response to existing therapies, making a stratified approach essential. early work conceptualized asthma as extrinsic (allergic) and intrinsic (nonallergic) [59] . however, the recent use of unbiased approaches to classify disease using three large datasets and cluster analysis [60] [61] [62] has highlighted the different types of disease under the umbrella term asthma ( figure 28 .5). although these early studies were performed in different parts of the world and had statistical variations, their results were similar. age at disease onset was found to be a key differentiating factor; early-onset disease was associated with more atopic and allergic conditions, whereas later-onset disease was associated with eosinophilic inflammation and obesity. these studies were all limited by a cross-sectional design and by the fact that treatment may have determined clusters. longitudinal studies initiated in childhood are ongoing. for example, pacman (formally, "pharmacogenetics of asthma medication in children: medication and anti-inflammatory effects") aims to differentiate children with uncontrolled asthma, despite ics treatment, using a range of clinical and cellular markers [63] . the role of allergy (an inappropriate and harmful immune response to a normally nonharmful substance which requires sensitization) and that of atopy (the tendency to develop ige antibodies to commonly encountered environmental allergens by natural exposure in which the route of entry is across intact mucosal surfaces) have been well studied in asthma. people with extrinsic asthma were thought to develop the disease earlier in life, be atopic, and have identifiable allergic triggers as well as other allergic diseases such as rhinitis or eczema. intrinsic asthma was thought to develop later in life (after 40 years of age), and be associated with aspirin-exacerbated respiratory disease but not with allergic sensitization. when small studies in humans suggested that levels of th2 cytokines were similar in extrinsic anti-ige bronchial thermoplasty macrolide antibiotics antifungals (itraconazole/voriconazole) anti-il5 anti-il13 box 28.2 new and emerging therapies reserved for severe asthma and intrinsic asthma, and that treatment with ics was effective in the majority of mild to moderate asthma cases, the distinctions between extrinsic and intrinsic asthma fell out of favor [64] . heterogeneity in response to existing medication is exemplified by malmstrom's study, which investigated individual response to leukotriene receptor antagonist (ltra) (montelukast 10 mg once daily), and the inhaled steroid beclomethasone (200 μg twice daily) over a 12-week period in 895 chronic asthma patients [65] . overall, there was a clear improvement in lung function (primary outcome fev 1 ) for both treatments; however, when stratified based on individual patient data, there was a very large degree of heterogeneity for both treatment groups, with some patients showing up to 50% improvement in fev 1 and others showing a decline in lung function with a 30% decrease in fev 1 (figure 28.6 ). this interindividual variability, a component of clinical trials that is seldom appreciated, is thought to have a strong genetic component. the therapeutic regimen for the treatment of asthma has been well defined and was described earlier in this chapter. despite such well-defined treatment regimens, which are constantly updated and streamlined, as well as the availability of high-quality medications, in many cases asthma is still not sufficiently controlled. while current asthma therapeutics are able to successfully treat 90-95% of the asthmatic population, around 50% still have daily symptoms and almost all patients report limitations of daily activities [66] . this also leaves around 5-10% of patients who do not respond to conventional treatments. this demonstrates that the current one-size-fits-all approach is not perfect, and emphasizes the need for a stratified medicine approach to asthma. variability in current therapy involves variation in drug efficacy and presentation of side effects, each of which presents challenges to successful maintenance of asthma. variability in drug efficacy, especially when occurring for β 2 -adrenergic receptor agonists and glucocorticosteroids, and in the presentation of side effects, can result in patient therapy having to deviate from the standard therapeutic regimen for the treatment of asthma. this high degree of interpatient variability in treatment response and in side effects can be attributed to a number of factors: (1) the interaction of genetic factors; (2) individual patient characteristics, such as weight, gender, and pregnancy; and (3) exposure to environmental insults, such as air pollution, allergens, and cigarette smoke. these factors interact, making the control of asthmatic episodes and the reduction of exacerbations more difficult. for example, asthma attacks can affect different age groups differently according to the season-children are more affected in summer while the older population suffers more in winter. when considering variation in treatment efficacy, one must also be mindful of individual patient factors such as inhaler technique and noncompliance (discussed earlier). currently asthma therapy is planned without consideration of genetic variance. however, genetic variance is arguably the most important of the factors listed previously-a claim supported by evidence gained from investigating the repeatability of response to therapy. this approach demonstrated that repeatability was between 60-80%, with a substantial proportion of the variance due to genetic factors [67] . one important form of variance in therapeutic efficacy is non-response. non-response is an important limitation in the maintenance and control of asthma, in that therapeutics expected to manage the disease at a certain level of severity fail outright, leading to the use of a trial approach in which different therapies are utilized with variable results until a suitable regimen is determined. a good example is severe asthma, where the patient is on permanent oral glucocorticosteroid therapy because of nonresponse to other therapies such as ics, leukotriene receptor antagonists, and β 2 -adrenergic receptor agonists. non-responders present with longer duration of asthma exacerbations and worse morning lung function, as well as a more frequent family history of asthma, when compared to those individuals responsive to glucocorticosteroid therapy [67] . the recognition that allergen specific ige activation of mast cells is central in driving allergic asthma lead to the discovery that the primary mast cell-signaling cascade could be inhibited by a monoclonal antibody toward the ige binding site to the high affinity receptor (fcer1). anti-ige (omalizumab) became the first specific biologic to be used in the treatment of severe allergic asthma. clinical trials revealed efficacy as well as almost total inhibition of early and late asthmatic responses to inhaled allergen [68] . following a rigorous examination of trial data by the national institute for clinical excellence (nice), omalizumab is now recommended as an option for treating severe individual data persistent, confirmed allergic ige-mediated asthma as an add-on to optimized standard therapy in people aged six and older who need continuous or frequent treatment with oral corticosteroids (defined as four or more courses in the previous year) in the united kingdom. although the drug is prescribed for cases of therapy-resistant asthma associated with allergy, it is also licensed for patients with evidence of allergy but a normal ige. omalizumab represents the first stratified treatment for asthma, but there is evidence that its use can be further stratified by using biomarkers of th2 inflammation to predict response. in a recent paper studying the effect of omalizumab on uncontrolled severe persistent allergic asthma, treatment effect was analyzed in relation to f e no, blood eosinophils, and serum periostin (an epithelial protein that is induced by il13). after 48 weeks of omalizumab, reductions in protocol-defined exacerbations were greater in high versus low subgroups for all three biomarkers, suggesting a potential prognostic ability [69] . this biomarker approach has helped divide asthma into and th2 high and th2 low disease. asthma has traditionally been considered a th2 process linked to atopy and allergy, type i hyper-sensitivity reactions, eosinophilic inflammation, and response to corticosteroids. "th2 high disease," as evidenced by high f e no and a sputum eosinophilia of >2%, has been associated with a better response to corticosteroids when compared to "th2 low disease" [70] [71] [72] . studies on lebrikizumab, a novel monoclonal antibody to il13 [73] , have suggested that serum periostin may be a biomarker for a more general th2 asthmatic phenotype. in one study a subgroup of individuals who had asthma and persistent elevation in serum periostin showed greater improvements in airway function and fewer exacerbations after lebrikizumab treatment than those with lower serum periostin. interestingly, levels of f e no, produced by inducible nitric oxide synthase, an enzyme induced in human airway epithelial cells by il13, were as informative as periostin in identifying th2-high individuals responsive to lebrikizumab. both the role of stratification based on phenotyping and the need for correct study end points in treatment trials have been informed by the salutary lesson of the anti-il5 antibody mepolizumab. although mepoluzimab effectively blocks eosinophilic inflammation, initial studies were disappointing in that no effect was demonstrated on spirometry or peak flow, despite a significant reduction in blood eosinophil numbers [74] . when the effect of the drug was studied on an outcome measure related to eosinophilia, namely severe exacerbations, there were significantly fewer exacerbations with a concomitant improvement in asthma-related quality of life [75] . tellingly, there were no significant differences with respect to symptoms, postbronchodilator fev 1 , or airway hyper-responsiveness, suggesting that different physiological processes determine these asthma outcomes. the study also helps researchers reflect upon the need to measure the correct end point in a disease that has different pathological mechanisms that all respond differently to treatment. phenotyping asthma has led to the identification of new disease targets, but aside from the use of anti-ige, it has not yet led to a step change in management. other approaches assessing the separate aspects of asthma pathophysiologynamely, airway inflammation, airway hyper-responsiveness, and airflow obstruction have been trialled with differing results. the key determinant in the design of these stratified approaches was the recognition that although asthma is a disease defined by symptoms, with treatment response also assessed by symptom improvement, there is no clear correlation between pathophysiology and symptomatology/ exacerbation risk. in the facet study (designed to evaluate the benefits of adding a long-acting β 2 -adrenergic receptor agonist to different doses of ics), higher-dose ics had a marked beneficial effect on exacerbation frequency, but relatively less effect on symptoms and peak expiratory flow. the opposite was true with the addition of long-acting β 2 -agonists [76] . this indicates that exacerbation frequency does not closely relate to symptoms and measures of disordered airway function, suggesting that the mechanisms responsible for these features are different [77] . numerous studies have demonstrated that in asthma the features of airway inflammation, airway hyper-responsiveness, variable airflow obstruction and associated symptoms can overlap, occur independently or change over time, in response to treatment or other external factors such as allergen exposure, or viral infection. one obvious example of this is eosinophilic bronchitis, a condition characterized by corticosteroid-responsive cough and the presence of a sputum eosinophilia occurring in the absence of variable airflow obstruction or airway hyper-responsiveness [78] . although asthma guidelines recommend the assessment of airflow obstruction (fev 1 /pef) and related symptoms for their primary treatment response outcomes, the realization is that this approach looks only at one aspect of asthma pathophysiology which is not closely related to exacerbation risk. this has led to new approaches aimed at reducing asthma exacerbations and symptoms while maintaining corticosteroid burden at the lowest possible level. airway hyper-responsiveness is defined as increased sensitivity to an inhaled constrictor agonist and a steeper slope of the dose-response curve. two main forms of bronchoconstrictor stimuli exist: direct and indirect. direct bronchoconstrictors, such as histamine or methacholine, stimulate receptors on the airway smooth-muscle, while indirect ones cause bronchoconstriction by secondary release of bronchoconstrictor mediators from mast cells or activation of neural pathways. airway responsiveness is usually measured as the provocative dose of methacholine causing a 20% fall in fev 1 by linear interpolation of the log dose-response curve (pc 20 ). in the general population, the distribution of airway hyper-responsiveness follows a continuous unimodal log-normal distribution, with asthma sufferers representing the hyper-responsive part of the distribution curve. a pc 20 is not usually measurable in non-diseased individuals, which suggests a large difference in airway responsiveness between non-diseased individuals and asthma patients. the cut-off used to identify asthma is normally a methacholine concentration of <8 mg/ml. this value had a sensitivity of 100%, a specificity of 93%, and a negative predictive value of 100% in a study on a population of 500 college students with a diagnosis of current symptomatic asthma. the use of methacholine pc 20 to diagnose asthma has been evaluated; one study demonstrated that when asthma is defined as consistent symptoms with objective evidence of abnormal variable airflow obstruction, a positive methacholine challenge is more sensitive than pef amplitude % mean and the acute bronchodilator response in diagnosis [79] . the use of methacholine pc 20 to guide treatment has also been assessed. although it was found that pc 20 -guided treatment resulted in a reduction in asthma exacerbations, this was at the expense of increased inhaled corticosteroid use [80] ; consequently, although pc 20 is often used for asthma diagnosis, or as a study end point, it is not routinely used to guide treatment decisions. asthma has been traditionally viewed as a condition where airway inflammation causes airway hyper-responsiveness, which in turn leads to variable airflow obstruction and symptoms; however, cross-sectional and longitudinal studies of airway inflammation using sputum induction in large populations with a diverse range of presentations suggest that this hypothesis requires modification. a recent bronchoscopy study demonstrated that bronchoconstriction is independent of airway inflammation and can lead to airway remodeling [38] . the development of noninvasive techniques to assess airway inflammation, including induced sputum and f e no, has made it possible to relate airway inflammation to objective measures of disordered airway function in larger and more heterogeneous populations than was possible with bronchoscopy studies. in general, these newer studies contradict findings in earlier studies and do not find a correlation between sputum eosinophil count and various markers of airway dysfunction. it has been observed that a subset of patients with symptomatic asthma do not have sputum evidence of eosinophilic airway inflammation [81] . many have sputum neutrophilia. this sputum profile is evident in corticosteroid-naïve as well as corticosteroid-treated subjects, suggesting that it is not always an artifact related to treatment. importantly, patients with noneosinophilic asthma respond less well to inhaled budesonide than do a group with more typical sputum features [82] . similar sputum findings have been reported in more severe asthmatics; a subgroup of patients with refractory asthma have been identified who have bronchoscopic evidence of neutrophilic airway inflammation, normal eosinophil counts, and a normal basement membrane thickness. these findings suggest the presence of a distinct asthma phenotype characterized by a predominantly neutrophilic airway inflammatory response and relative corticosteroid resistance. furthermore, there is evidence that neutrophilic asthma may result from activation of the innate immune system with the production of proinflammatory cytokines. the use of noninvasive measures to guide treatment decisions by stratification based on the presence or absence of airway inflammation has been assessed. the strongest evidence for effect relates to the use of induced sputum to guide corticosteroid dose in moderate to severe asthma. two studies have shown that using induced sputum differential counts to guide treatment results in fewer exacerbations for the same overall corticosteroid burden [81, 83] . although the evidence is clear that this approach works, induced sputum is not widely employed, possibly because it is seen as time consuming, requiring expertise both to induce the sputum and to perform the differential counts. the discovery that levels of f e no, measured via a device similar to a breathalyzer, correlate well with sputum eosinophilia and relate to corticosteroid responsiveness, has driven the application of inflammometry (noninvasive measurement of inflammation in the airways). inflammometry using f e no measurements has also been used to guide and stratify treatment decisions. though one study was positive in patients with asthma in pregnancy, with a reduction in exacerbations, most have failed to show an improvement when compared to guideline-driven (fev 1 /pef and symptoms) management. the hunt is still on for a reliable, inexpensive, and valid biomarker of airway inflammation. fev 1 and pef measurements reflect changes in the caliber of the large airways. our knowledge of anatomical and physiological changes in the small airways of patients with asthma is based on small case series of resected lung tissue from patients with asthma undergoing surgery for cancer, or on cases of fatal asthma. these case series have demonstrated that there is significant inflammation present in the small airways (<2 mm diameter) in asthma. fatal asthma is associated with peripheral airway inflammation and differences in the number of activated eosinophils in the distal lung. other studies have revealed alterations in the epithelium and smooth-muscle, as well as mucous hypersecretion and distal airway plugging of the small airways. the presence of inflammation in the small airways in asthma may explain why small airways account for up to 50-90% of total airflow resistance in asthma, but only 10% of airflow resistance in normal airways. recently, the development of "small-particle" ics, designed to target the peripheral lung, and the advent of new technologies-nitrogen washout, impulse oscillometry, and hyperpolarized noble gas magnetic resonance imaging, which allows assessment of peripheral lung function-have led to a resurgence of interest in the distal lung. studies of small-particle ics have been inconsistent; those comparing small-particle and standard-particle icss have failed to demonstrate improved asthma outcomes when administered in clinically comparable doses. future asthma treatment may yet be stratified by the presence or absence of small airway inflammation. there have been several attempts to base treatment decisions on measures of airway inflammation, including induced sputum and f e no in children. generally, they have been unsuccessful, although some experts do stratify treatment decisions on the response to oral or intramuscular steroids. while methods of stratifying asthma patients to specific treatments based on nongenetic factors such as clinical outcomes, cellular measures, or protein biomarkers have shown some success, a large body of work has investigated the potential of genetic markers as predictors of patient responses to existing therapies, i.e., pharmacogenetics. pharmacogenetics, the investigation of the effect of genetic polymorphisms on response to treatment or risk of adverse side effects, is one of the first steps in developing personalized prescribing. the use of genetic information to stratify patient prescribing is potentially more desirable compared to nongenetic stratification, as technology now allows a small amount of blood or saliva sample to be taken and a dna test can be completed within hours. to date, asthma pharmacogenetic studies have suffered from relatively small retrospective designs and a focus on only a few candidate genes; however, more recent, larger prospective studies have been completed that provide greater confidence in original findings and hypothesis-free approaches such as gwas. these studies are primarily focused on pharmacodynamic aspects (e.g., improvement in lung function post-treatment), and only limited information is available about the impact of pharmacogenetics on adverse effects. pharmacogenetics in asthma is relatively advanced compared to that for other diseases. genetic factors influencing the main treatment classes (i.e., β 2 -adrenergic receptor agonists, corticosteroids, and leukotriene modifiers) have been identified with some confidence (table 28. 3). an overview of these findings follows; however, for more in-depth analyses, see portelli and sayers [84] . β 2 -adrenergic receptor agonists carry out their function through the β 2 -adrenergic receptor-a 413-amino-acid g-protein-coupled receptor encoded by an intronless gene (adrb2) located on chromosome 5q31.32. binding of agonists to the receptor activates adenyl cyclase through stimulatory gs proteins, which in turn activate protein kinase a. the latter phosphorylates several target proteins, resulting in a decrease in intracellular calcium that, importantly, causes smooth-muscle relaxation in the airways. it is not surprising that the majority of evidence of genetically driven effects on β 2 -adrenergic receptor-agonist therapy stem from the adrb2 gene, which has therefore been extensively studied for pharmacogenetic effects on β 2 -adrenergic receptoragonist responses. adrb2 is a highly polymorphic gene containing 51 known and validated polymorphisms, of which 49 are snps and 2 are insertion/deletion variants. most studies have focused on the role of four nonsynonymous coding-region polymorphisms: arg16gly (arginine-to-glycine substitution at position 16 in the protein), gln27glu, val34met, and thr164ile [85] . in a caucasian population, the frequency of the polymorphisms at positions 16 and 27 were identified as 59% (arg16glu) and 29%, (gln27glu) [85] . the remaining val34met and thr164ile polymorphisms are rare, having approximate frequencies of <0.001% and 0.05%, respectively. the arg16 variant has been shown to have pharmacogenetic potential through association with; an enhanced acute response to β 2 -adrenergic receptor agonists l a decline of asthma control following prolonged use of β 2 -adrenergic receptor agonists l a subsensitivity of response for bronchoprotection by β 2 -adrenergic receptor agonists however, several studies have failed to reproduce these effects, meaning that a common consensus on the contribution of arg16 has yet to be reached. this lack of consensus can be explained when we consider that there are at least 12 different haplotypes (a specific combination of snps across the gene) in adrb2. investigations into the effect of a genotype in isolation, without consideration of its haplotype, is likely to introduce confounding into the association. functional effects of coding-region polymorphisms in adrb2 have been identified through in vitro work carried out in cell lines. these have included the following: [86] . in one of the larger studies, basu et al. identified an arg16 copy numberdependent increase in disease exacerbations in 1182 patients with asthma aged 3 to 22 years on daily exposure to β 2 -adrenergic receptor agonist (regularly inhaled corticosteroid plus salbutamol on demand group, and regularly inhaled corticosteroid plus salmeterol and salbutamol on demand group) [87] . it is important to note that this effect was driven by asthma patients who used salbutamol and/or salmeterol daily, supporting the suggestion that the arg16 polymorphism has an integral role in the effectiveness of β 2 -adrenergic receptor-agonist therapy [87] . however, as with other studies, study limitations did not allow a clear association to be made between the adrb2 gene (via its polymorphisms) and β 2 -adrenergic receptor-agonist efficacy. namely, all participants were using β 2 -adrenergic receptor-agonists as a reliever; a study arm of non-β 2 -adrenergic receptoragonist reliever use would have provided a clearer interpretation of the detrimental effects of salbutamol/salmeterol in the arg16 subjects. large studies have failed to observe a clinically relevant effect of these polymorphisms. these include longitudinal studies of β 2 -adrenergic receptor-agonist efficacy and the study of concomitant administration of corticosteroids. a good example is a study of 2250 asthma patients randomly assigned to: (1) budesonide plus formoterol maintenance and reliever therapy; (2) fixed-dose budesonide plus formoterol; or (3) fixed dose fluticasone plus salmeterol for six months. no overall effect of the gly16arg genotype on clinical outcomes was found [88] . another contributing factor to the pronounced differences in the conclusions from different studies investigating these adrb2 polymorphisms is trial design variation. the majority of studies have focused on the adrb2 arg16gly polymorphism; however, other potential pharmacogenetically relevant polymorphisms also affect β 2 -adrenergic receptor-agonist efficacy. multiple polymorphisms in the gene's regulatory regions that have potential clinical relevance are present in adrb2. by studying eight common haplotypes based on 26 snps, a recent in vitro approach using "whole gene" transfection identified differential effects on receptor expression and downregulation that are haplotype-driven [89] . this study identified four common haplotypes with elevated receptor expression and two haplotypes with enhanced receptor downregulation. another area recently investigated is polymorphisms occurring in the gene's untranslated regions, which may have an effect on gene expression and resultant drug efficacy. multiple genes are likely to be involved in the regulation of β 2 -adrenergic receptor-agonist response and expression of side effects, due to the agonists' known complex and multifactorial mechanism of action. one gene that has been associated with patient response to these agonists is arginase 1 (arg1), which was identified using a novel algorithm implemented in a family-based association test (fbat) [90] . in this study of 209 children and their parents, the arg1 snp, rs2781659, was associated with bronchodilator response (bdr) when snps from 111 candidate genes (42 involved in β 2 -adrenergic receptor-signaling/regulation, 28 involved in glucocorticoid regulation, and 41 from prior asthma association studies) were investigated for their association with acute response to inhaled β 2 -adrenergic receptor-agonist in 209 children and their parents. in agreement with this study polymorphisms spanning arg1 and influencing patient response to salbutamol have also been identified in a candidate gene study involving 221 asthma subjects [91] . the arg1 polymorphisms identified in both studies were in linkage disequilibrium (ld) (inherited together), suggesting a common causative mechanism involving potential transcriptional regulation due to the polymorphisms' location (predominantly 5′ to the gene). this alteration in transcription has now been confirmed in promoter-reporter studies, which found that the key arg1 haplotype associated with improved bdr drives the highest level of arg1 promoter activity [92] . in the study by vonk et al., arg2 snps were also associated with patient responses to salbutamol [91] , suggesting an integral role for the arginase family in β 2 -adrenergic receptor-agonist therapy. recently a s-nitrosoglutathione reductase (gsnor) snp (rs1154400, promoter region) was associated with a decreased response to salbutamol in 107 african-american children [93] . in the same study, a post hoc multilocus analysis discovered that a combination of rs1154400 with adrb2 arg16gly, gly27glu, and the carbamoyl phosphate synthetase-1 (cps1) snp rs2230739 gave a 70% predictive value for lack of response to therapy [93] , implying that pharmacogenetic regulation of β 2 -adrenergic receptoragonist therapy may depend on several loci acting together via gene-gene interactions. in confirmation, 4/5 snps tested in gsnor were associated with asthma patient responses to salbutamol in 168 puerto rican asthma patients [94] . these snps were also associated with asthma susceptibility, and the key risk haplotype was associated with increased transcriptional activity based on promoter-reporter studies [94] . gsnor is an alcohol dehydrogenase that breaks down gsno, an endogenous bronchodilator [95] . in addition, gsno regulates nitrosylation of proteins, leading to alterations in function, including g-protein coupled receptor kinase 2 (grk2), which phosphorylates and desensitizes the β 2 -adrenergic receptor [96] . other novel genes have recently been associated with β 2 -adrenergic receptor-agonist therapy including the spermatogenesis-associated, serine-rich 2-like (spats2l) and collagen (col22a1) genes [97] . the col22a1 gene, through association with the intronic snp rs6988229, was associated with acute bronchodilator response to inhaled salbutamol in a genome-wide association study in which ∼500,000 snps were tested in 403 caucasian trios. this association was replicated in a pooled population of three asthma trial populations, as well as in three additional asthma populations [97] . spats2l was also identified as a modulator of β 2 -adrenergic receptor-agonist function through a gwas. here, the snp rs295137, located near the spats2l gene, was significantly associated with percentage change in baseline fev 1 in 1644 caucasian asthma patients; this was replicated in two alternate caucasian populations (n ∼ 500 each). molecular biology techniques confirmed these results and identified that spats2l may be an important regulator of β 2 -adrenergic receptor downregulation. the identification of patients at risk from potential adverse effects of β 2 -adrenergic receptor-agonists remains a critical clinical question, as does the targeting of this class of drug to patients most likely to benefit from it. while there has been clear progress with respect to study design (e.g., examining haplotypes instead of genotypes in isolation) and adequately powered studies using thousands of individuals, there is still a need for large prospective studies of asthma patients with matched phenotypes and carefully controlled covariates that include environmental influences. similarly, these studies would benefit from gwa approaches and the identification of gene-gene interactions. while investigations of the effect of genetic polymorphisms on β 2 -adrenergic receptor-agonist responses have predominantly focused on clinical end points (e.g., lung function parameters) in the different genotype groups, there has been recent interest in the real-life application of genetic knowledge. as outlined, the first-line treatment for asthma is a shortacting β 2 -adrenergic receptor-agonist (e.g., salbutamol) as needed (step 1); if symptoms persist, the addition of inhaled corticosteroid (e.g., beclomethasone) is considered (step 2); for further control, a long-acting β 2 -adrenergic receptor agonist (e.g., salmeterol) or a leukotriene receptor antagonist (ltra) (e.g., montelukast) is added (step 3) (figure 28.4) . in a recent study, lipworth et al. set out to use genetic information on the adrb2 arg16 polymorphism to inform the choice of prescribing salmeterol or montelukast as addon therapy [98] . children with persistent asthma and homozygous for the arg16 genotype (n = 62) were randomized to receive salmeterol (50 μg, bd) or montelukast (5 or 10 mg, once daily) as an add-on to inhaled fluticasone propionate for one year. the study tested whether carriers of the arg16 genotype were more prone to adverse effects (e.g., prolonged β 2 -adrenergic receptor-agonist use associated exacerbations), and hence whether montelukast provided superior control for this preselected population. outcomes were school absences (primary outcome), exacerbation score, reliever use (salbutamol), morning dyspnoea, and asthma control questionnaire (acq) qualityof-life scores. montelukast provided superior benefit for all measures, with clinically relevant differences within three months. no significant difference in fev 1 (% pred) was observed, providing further evidence of limited correlation between lung function and symptom-based scores [98] . these results suggest that larger and longer prospective studies are warranted to provide more definitive data on the clinical utility of arg16 stratification including a gly16 study arm and the use of additional markers to define the population would provide clearer interpretation. as outlined, leukotriene synthesis inhibitors (ltsis) and leukotriene receptor antagonists (ltras) are commonly used as an add-on therapy in asthma to provide greater control or steroid-sparing effects. the cysteinyl leukotrienes (ltc 4 , ltd 4 , lte 4 ) and dihydroxy leukotriene (ltb 4 ) contribute to the inflammatory process in asthma and are synthesized from arachidonic acid via the 5-lipoxygenase pathway (figure 28.7) . cysteinyl leukotrienes have been implicated in bronchoconstriction, mucus secretion, vascular permeability, inflammatory cell infiltration and cytokine production. arachidonic acid is converted to 5-hydroperoxyeicosatetraenoic acid and leukotriene a 4 (lta 4 ) by 5-lipoxygenase (5-lo/alox5) and 5-lipoxygenaseactivating protein (flap/alox5ap), which acts as an adaptor protein for this reaction. lta 4 is then converted to leukotriene b 4 (ltb 4 ) by lta 4 hydrolase (lta4h) or, alternatively, is conjugated with reduced glutathione to form ltc 4 via the actions of leukotriene c4 (ltc 4 ) synthase (ltc4s). ltc 4 is next transported to the extracellular space via the multidrug resistance protein 1 (mrp1) ( figure 28 .7). leukotriene modifiers include ltsis, which act by targeting 5-lo (e.g., zileuton), resulting in a decrease in all leukotriene biosynthesis (ltc 4 , ltd 4 , lte 4 , and ltb 4 ) or ltras, which act by specifically blocking cysteinyl leukotrienes from binding to their primary receptor, cysltr1, which is found on many cell types including inflammatory cells and airway smooth-muscle cells, (e.g., montelukast and zafirlukast). data demonstrating the large degree of heterogeneity of asthma patient responses to this class of drug are summarized in figure 28 .6. these data have led to extensive genetic studies investigating the roles of snps in a large number of candidate genes associated with leukotriene production and/or activity and acute responses to ltras and ltsis. associations have been described for polymorphisms in alox5, alox5ap, ltc4s, cysltr1, cysltr2, and mrp1; however, many of these studies have been small and so have led to a lack of reproducibility in findings [99] . more recent studies have looked at different aspects of leukotriene modifier functions, including the association of montelukast absorption (i.e., pharmacokinetics) with polymorphisms in oatp2pb1 [100] . however, others have failed to observe these associations [101] . 5-lo (along with 5-lo-activating protein) is the major regulatory switch for leukotriene production, and extensive studies have demonstrated that the level of 5-lo can have dramatic effects on both cysteinyl and dihydroxy leukotriene production. 5-lo catalyzes the conversion of arachidonic acid to lta 4 , one of the early stages in leukotriene production ( figure 28.7) . alox5 is found on chromosome 10q11.2 and is a large gene composed of 14 exons and 13 introns; it spans approximately 82 kb. multiple studies suggest that alox5 polymorphisms can influence clinical responses to ltras and ltsis-in particular, a functional repeat polymorphism in the promoter region (resulting in alterations in sp1 transcription factor binding) have been associated with altered gene transcription and with response to the ltsi, abt-761 [99, 102] . these early studies have now been extended to investigate multiple polymorphisms, spanning the entire gene, and association with ltra and/or ltsi responses in asthma patients. for example, tantisira et al. observed an association between alox5 intronic snps-rs892690, rs2029253, and rs2115819-and change in fev 1 post-ltsi(zileuton)-in a cohort of 577 asthma patients [103] . the rs2115819 snp was also a predictor of response to the ltra, montelukast, in a previous study of 252 asthma subjects using percentage change in fev 1 as the primary outcome [104] . in both cases, the gg versus ga or aa genotype had the greatest improvement in lung function (fev 1 ) post-drug [104] . the lack of association for the rs892690, and rs2029253 snps in the montelukast study may be due to the reduced power of this study compared to the zileuton study. the functional significance of these snps remains to be resolved, and it is important to note that they may not be the causative genetic change, and that polymorphisms inherited at the same time (i.e., in ld) may be of relevance. two alox5 snps (rs4987105 (synonymous thr120thr) and rs4986832 (5′ region)) were also associated with improvement in pef on treatment with montelukast in a 12-week study in 174 asthma patients. this further confirmed the relevance of alox5 snps and this key enzyme in leukotriene production [105] . additional support for the relevance of alox5 in asthma control is provided by a recent study of 270 children which found that the alox5 sp1 promoter polymorphism determined urinary lte 4 levels and was associated with reduced lung function and, potentially, an acq score in non-5 copy carriers [106] . in this study, there was an inverse relationship between urinary lte 4 levels and fev 1 . another important enzyme in the leukotriene pathway is leukotriene c 4 synthase (ltc4s), which specifically results in the generation of the first cysteinyl leukotriene, ltc 4 , by conjugating glutathione to lta 4 . there has been intense research into the role of ltc4s in asthma susceptibility because this enzyme, like 5-lo, is thought to be a key regulatory switch for cysteinyl leukotrienes, which are thought to play a more prominent role in asthma (e.g., via bronchoconstriction) than the dihydroxy ltb 4 . ltc4s is relatively small, spanning 2.51 kb on chromosome 5q35. in particular, a promoter polymorphism (a-444c, rs730012) has been intensely investigated for pharmacogenetic effects as it is thought to alter ltc4s levels via transcription (higher levels in c allele carriers) and therefore alter ltc 4 production [107] . of the ten published studies investigating the role of ltc4s-444 a>c, five showed an improvement in outcome measures, including fev 1 post-ltra therapy for carriers of the c allele, as hypothesized, although results were not always statistically significant. in a more recent study of zileuton responses (fev 1 change over time) in 577 asthma subjects, the ltc4s-444 polymorphism showed no effect; however, an alternative ltc4s polymorphism (rs272431, intron 1) was associated with improved response (mean fev 1 ) [103] . as these results were obtained in different populations and using different end points, the relative contribution of the ltc4s polymorphism to ltra or ltsi therapeutic responses in asthma are still unclear. larger prospective studies using multiple ethnic groups are required. montelukast and other ltras target the cysteinyl leukotriene receptor 1, which is expressed in a variety of cells, including airway smooth-muscle and various inflammatory cells (e.g., eosinophils), therefore inhibiting the activation of this receptor by cysteinyl leukotrienes (figure 28.7) . cysteinyl leukotriene receptor 1 is thought to be the main receptor mediating cysteinyl leukotriene receptor smooth-muscle contraction and inflammatory cell cytokine production in asthma. again, genetic variation in the target receptor for these compounds may influence how effective they are in carriers of these alleles by regulating receptor function/expression. the cysteinyl leukotriene receptor 1 gene, cysltr1, is intronless and found on chromosome xq13-21; it generates a 337 amino acid g-protein-coupled receptor (gpcr). a second receptor for cysteinyl leukotrienes has also been described and, while not the target of ltras, may modulate the effects of cysteinyl leukotrienes in vivo. the gene for cysteinyl leukotriene receptor 2 is found on chromosome 13q14 and encodes for a 346 amino acid gpcr. interestingly, in combination with several alox5 snps, polymorphisms spanning cysltr1 have been identified as determinants of responses to montelukast, suggesting snp-snp interactions may be important [108] . however, direct evaluation of cysltr1 polymorphisms and responses to montelukast [104] or zileuton [102] have not identified a significant effect for them to date. studies of cysltr2 are limited; however, snps rs91227 and rs912278 (3′utr) have been associated with an improvement in morning pef following administration of montelukast for 12 weeks [105] . while the majority of studies have focused on candidate polymorphism analyses in genes directly involved in leukotriene production or activity, several studies have identified additional genes of relevance to ltsi and ltra response. in addition to its effects on vasodilation and bronchoconstriction, the prostaglandin d2 receptor (gene: ptgdr) is thought to regulate, at least in part, levels of leukotriene c 4 . in a study of 100 asthmatic children prescribed montelukast (5 mg/day), a modest effect of the ptgdr-4441t/c was observed. similarly, in a more extensive study of 169 snps in 26 candidate genes in asthma patients prescribed fluticasone, fluticasone propionate plus salmeterol or montelukast, a significant association between four snps in the cholinergic muscarinic receptor 2 gene (chrm2) and montelukast response (change in fev 1 ) over 16 weeks was observed [106] . chrm2 and chrm3 are thought to mediate airway tone via regulation of contractile/relaxation responses and targeting of chrm3 using antagonists; for example, tiotropium has shown clinical efficacy in multiple respiratory diseases. these data potentially suggest that the nature of the airway obstruction/tone determined by altered chrm2 expression and/or activity may influence responses to montelukast. while the majority of studies have investigated the association between gene polymorphisms and acute responses to asthma therapy, a recent study by mougey et al. identified that solute carrier organic anion transporter family, member 2b1 (slco2b1, alternative name: organic anion transported sb1; oatp2b1), was able to mediate montelukast permeability using a model cell system engineered to express the oatp2b1 protein [100] . subsequently, the same group also showed that an alteration in the protein structure of oatp2b1 that occurs naturallythat is, arg312gln (rs12422149)-was associated with reduced morning plasma concentrations of montelukast following an evening dose during one month or six months of treatment in 80 asthma patients [100] . more specifically, ga (arg/gln) genotype carriers had ∼20% lower montelukast concentration than the gg (arg) group at one month, and ∼30% lower concentration at six months, and of clinical relevance a allele carriers did not demonstrate benefit from montelukast using a symptom-based score [100] . the same researchers have now replicated these findings on montelukast absorption [109] ; however, another study did not replicate this finding and failed to identify any effect of the arg312gln polymorphism on montelukast plasma concentrations, albeit in a different study design involving fewer subjects [101] . these studies highlight the potential importance of genetic factors influencing drug transporters that may be anticipated to affect pharmacokinetics and the pharmacodynamics. similarly, several snps in another transporter protein, multidrug resistance protein 1 (mrp1) (alternative name: atp binding cassette, subfamily c, member 1 (abcc1))-for example, rs119774have been associated with montelukast response (change in fev 1 % predicted) [110] and zileuton response [103] . this association potentially confirms the pharmacogenetic significance of this mrp1 snp marker. this snp is intronic, and the underlying functional mechanism, including which genetic variant explains these effects, remains to be resolved. overall, there has been good progress in the pharmacogenetics of leukotriene modifier therapy in asthma, with snps in multiple leukotriene-synthesising enzymes (e.g., alox5) showing robust association with lta and ltsi responses. multiple genes in the leukotriene synthesis pathway and/or receptors have polymorphisms that have been associated with asthma susceptibility, which implies that there may be a more leukotriene-driven asthma that is therefore more amenable to treatment with ltsis and ltras. of interest in this drug class, preliminary data suggest a significant contribution of snps in drug transporter genes, ultimately determining both the pharmacokinetics and the pharmacodynamics. these data set the scene for larger prospective studies to provide accurate effect sizes and determine clinical implications with greater confidence. corticosteroids are an important pharmacogenetic target in asthma. initial investigations into a pharmacogenetic approach for the corticosteroid element of asthma therapy focused on the glucocorticoid receptor gene (gr, alternative name: nuclear receptor subfamily 3, group c, member 1, nr3c1), which maps to chromosomal region 5q31-a region associated with multiple asthma phenotypes. as with other genes discussed in this chapter, several polymorphisms have been described in the gr gene that have functional consequences, such as a val641asp polymorphism that has been shown to influence the binding affinity for dexamethasone. however, similar to most polymorphisms shown to have potential pharmacogenetic effects, several of these polymorphisms are rare and their functional significance is questionable [84] . despite this, the gr remains a tantalizing target for asthma pharmacogenetics, and it is surprising that there have not been further recent investigations into the role of gr polymorphisms in corticosteroid responses. gr is not the only gene to be associated with geneticbased variance in corticosteroid efficacy in asthma treatment. a number of other genes have been implicated, including crhr1, tbx1, nk2r, stip1, dusp1, and fcer2, and these are discussed below. snps in the corticotrophin-releasing hormone receptor 1 (crhr1) gene are associated with response to inhaled corticosteroid treatment, based on end point change in fev 1 following 8 weeks of treatment in three asthmatic cohorts using a candidate gene approach (131 snps in 14 genes, n = 1117 asthma subjects). for example, the intronic crhr1 snp rs242941 exhibited genotype-specific changes in the percentage predicted change in fev 1 in response to corticosteroid therapy in 470 adult asthma subjects [111] . this study was the first to show a pharmacogenetic effect for steroid efficacy in an asthmatic cohort, and it highlights the crhr1 gene to be at least one of a number of factors determining corticosteroid efficacy. crhr1 is thought to influence responses to exogenously administered corticosteroid through the regulation of endogenous levels of corticosteroid. the t box 21 (tbx21) gene has been shown to be a predictor of improvement in bronchial hyper-responsiveness (bhr) (4 year change) post-corticosteroid treatment in children, based on a genotype-dependant variation of the nonsynonymous snp rs2240017 (his33gln), where the presence of the g allele gave greatest improvements [112] . however, the association of this gene remains under question because of its low allele frequency in caucasians (maf ∼0.04), which resulted in only a few subjects (n = 5) being available to contribute to this observation [112] . additional data have given more confidence to the involvement of tbx21 because the his33gln polymorphism was significantly associated with improved asthma control in the presence of corticosteroids, although the alternative allele to that described was associated with greater control in 53 korean asthma patients during 5-12 weeks treatment [112] . interestingly in the same study, ye et al. identified a novel gene, the neurokinin 2 receptor (nk2r), which was associated with improved asthma control in the presence of corticosteroids; the g allele (gly) of the nk2r snp rs77038916g/a, (gly231glu) was associated with the greatest improvement. neurokinin a induces bronchoconstriction and inflammation, therefore modulation of the neurokinin receptor may influence the magnitude of these responses. multiple snps in the stress-induced phosphoprotein 1 gene (stip1) were associated with variable fev 1 responses to treatment with the inhaled corticosteroid flunisolide in 382 asthma subjects [103] . this study investigated snps spanning eight candidate genes and identified stip1 snps rs4980524, rs6591838, and rs2236647 as snps affecting percent change in fev 1 in response to flunisolide at 4 weeks and 8 weeks [103] . stip1 codes for an adaptor protein that coordinates functions with hsp70 and may be involved in formation of the glucocorticosteroid receptor heterocomplex. the dual-specificity phosphatase 1 (dusp1) gene encodes a protein that has dual specificity for tyrosine and threonine and inactivates p38 mitogen-activated protein kinase (mapk). recently, several snps including a 5′ region snp, rs881152, were associated with (1) bronchodilator responses and (2) asthma control in the presence of corticosteroid in a cohort of asthma patients (n = 430) [113] . the mechanism underlying these effects is unclear; however, it was suggested that corticosteroid induces dusp1 expression, which may be altered in carriers of the rs881152 5′-region snp. this influences the ability of dusp1 to target the p38 mapk signaling pathway. in a cohort of 311 asthmatic children, the low-affinity ige receptor gene (fcer2) has been highlighted as putatively involved in corticosteroid (budesonide) regulation of exacerbation by virtue of an association between the snp t2206c (rs28364072, intronic) and the relative risk of severe exacerbations while taking budesonide [114] . interestingly, the c allele was also associated with elevated ige levels in the 311 asthma patients [114] . importantly, this pharmacogenetic association has now been replicated in two other asthma cohorts (n = 386 and 939, respectively), with the 2206c allele being associated with increased hospital visits and uncontrolled asthma in patients receiving ics [115] . it is not surprising that this polymorphic variation in an ige receptor influences receptor expression, which alters ige levels and is associated with more severe forms of asthma. in turn, these subjects cannot be adequately controlled by corticosteroid treatment. the first gwas in asthma, published in 2012, identified snps in the glucocorticoid-induced transcript 1 gene (glcc1) as determinants of glucocorticoid response in 935 asthma subjects [116] . this study examined 534,290 snps using the human hap 550v3 beadchip to identify 100 snps of interest in an initial cohort of 403 parent-child trios. the primary outcome was change in fev 1 . of interest was a snp in the glcc1 gene promoter region (rs37972c/t) that was associated with attenuation in fev 1 improvement post-corticosteroid in three of four cohorts tested [116] . a subsequent gwas identified the t-gene as a novel player in lung function response (fev 1 ) to inhaled corticosteroids. analyses were carried out in 418 caucasian asthmatics and replicated in a secondary asthmatic population (n = 407), where 3 out of 47 successfully replicated snps were associated under the same genetic model in the same direction, including 2 of the top 4 snps ranked by p value. these snps (rs3127412c/ t and rs6456042a/c) were in strong ld with a variant located in the t-gene, suggesting that this gene is a novel player in the pharmacogenetic regulation of corticosteroid efficacy. this was confirmed by a follow-up association, where the t-gene variant was associated with lung function response to inhaled corticosteroids in the initial gwas analysis (an average 2-3-fold increase in fev 1 response for homozygous wild-type subjects; rs3127412 tt; and rs6456042 cc) [117] . not all recent developments have been due to gwas. for example, a recent hypothesis-driven study implicated the cytochrome p450 3a enzymes in glucocorticosteroid efficacy through modulations in corticosteroid metabolism. in this study, roberts et al. showed, through mrnadriven studies confirmed via microsomes and recombinant enzymes, that cyp3a4 and cyp3a5 metabolize corticosteroids (budesonide) into inactive metabolites [118] . they suggested that differences in the expression or function of these enzymes in the lung and/or liver could influence corticosteroid efficacy in the treatment of asthma. to date, the majority of pharmacogenetic studies have focused on one class of asthma therapy. however, several recent studies have investigated combination therapy, which more accurately reflects the clinical situation. we have summarized the main findings regarding the influence of adrb2 polymorphisms, including arg16gly, on combination therapies, particularly fluticasone/salmeterol and budesonide/formoterol in section 28.5.5.1. however, it is clear that reports on associations between adrb2 arg16 and increased exacerbation in asthma patients using regular salbutamol in addition to their maintenance combination are mixed, with some studies failing to report the association, potentially because of differences in study design. more recently, additional genes have been investigated for snp associations with patient responses to combination therapy. in a study of 81 asthma patients regularly using an ics/laba combination, it was shown that polymorphisms in the nitrous oxide synthase 3 (nos3) gene involving an amino acid change (g894t, glu298asp), were associated with post-drug improvement in lung function (change in fev 1 (% pred)) [119] . nos3 codes for a key enzyme in the production of no in the airways, and f e no has been shown to be elevated in asthma and is considered a marker of ongoing inflammation. importantly, earlier data identified that the glu298asp polymorphism is functional in nos3 and influences levels of f e no with the tt genotype associated with lower f e no levels. these data suggest that lower nos3 activity and potentially lower f e no levels identify patients more likely to respond to combination therapy; however, larger prospective trials are required to validate these findings because they are potentially counterintuitive if no is a marker of inflammation and ics target inflammation. a recent 16-week study on the effect of genetic determinants (169 snps in 26 candidate genes) on asthma patient response to combined fluticasone propionate/salmeterol therapy identified three snps in the cholinergic muscarinic receptor 2 gene (chrm2) that are associated with asthma acq scores, and found a single snp, rs1461496 in heat shock 70kd protein 8 (hspa8), to be associated with change in fev 1 [106] . of interest, chrm2 snps were also associated with responses (lung function) to montelukast (see earlier), suggesting that the "tone" of the airways as determined by muscarinic receptors is important for therapies that target airway contraction. hspa8 is involved in protein folding in the cell, but it is important to note that hspa8 snps previously were not associated with response to ics [120] . drug development in asthma has been slow to generate new classes, and the major advances in patient care have come from new compounds and/or indications for existing drug classes (e.g., improved duration of action for labas). one potential explanation for this limited progress is the design of and recruitment to phase i and phase ii trials for the evaluation of new compounds. we have already outlined how initial trials of anti-il5 demonstrated disappointing effects on lung function and asthma symptoms. only after careful selection of patients, based on clinical and cellular parameters, were clinically relevant improvements observed. researchers now understand that asthma is heterogeneous and, particularly for strategies targeting specific mediators, careful selection of patients is necessary to fully understand the therapeutic potential of new drugs. recent approaches to the treatment of asthma [121] include the following: the specific targeting of single mediators is unlikely to provide a therapeutic option for asthma in its broadest definition. however, targeting specific subpopulations has shown clinical efficacy. very recently, a study investigating a human il13-neutralizing monoclonal antibody (tralokinumab) used a carefully balanced population of atopic and nonatopic asthmatics, with exclusions for additional respiratory pathology, cigarette smoking ≥10 pack-years, recent infection, or treatment with immunosuppressive medication, in a randomized double-blind study [122] . here, tralokinumab was associated with improved lung function based on an increase in fev 1 and a decrease in daily β 2 -adrenergic receptor-agonist use [122] . these studies overall demonstrate that careful selection of asthma subjects, in this case based on phenotype, is critical in asthma drug development. as novel asthma genes are identified, it is paramount that their evaluation as potential drug targets, particularly in the context of phase ii trials, takes into account pharmacogenetic factors. preliminary data support genetic testing in phase ii trials of newer compounds, as shown in a recent report on a il4/il13 dual antagonist (pitrikinra). polymorphic variation in the target receptor for this antagonist (i.e., il4rα) significantly influenced outcomes in allergic asthma subjects [123] . pitrikinra is a recombinant form of il4 differing at two amino acid residues (i.e., a mutein, r121d/y124d). this has been shown to reduce late-phase antigen responses (lar) to inhaled antigen as defined by changes in lung function (fev 1 ) over 4-10 hours postantigen exposure. in one study, subjects had been following a four-week period of twice daily active treatment of nebulized pitrikinra or placebo, with an increased lar ratio correlating with a reduced fev 1 [124] . stratification of subjects (pitrikinra n = 15, placebo n = 14) into genotype groups for the nonsynonomous il4ra snp rs1801275 (gln576arg) identified arg/arg carriers as having an attenuated lar (p < 0.0001) following pitrikinra treatment compared to gln/gln or gln/arg genotypes. similarly, stratification based on rs1805011 (glu400ala) showed an attenuated lar in the glu/ala group but not the glu/glu group [123] . interestingly, the arg576 variant (when in combination with val75) was shown to be a risk factor for allergic asthma and to lead to enhanced il4rα signaling post il4 stimulation [125] . these preliminary data suggest that selecting a subgroup of patients with a particular genotype when it is anticipated that the receptor/pathway may have a more dominant role in that individual's asthma is critical to interpreting phase ii clinical trials. approaches to further define asthma subphenotypes (e.g., using cluster analyses) have been useful and further confirm this heterogeneity in clinical presentation. while current medications have been extremely successful in asthma management (e.g., ics), it is clear that individual responses to these medications and to therapies in development are heterogeneous, with large variation in clinical benefits and/ or detrimental effects. the stratification of asthma treatment using clinical and/or genetic approaches therefore shows great potential for maximizing clinical outcomes and minimizing adverse effects, leading to improvement in the management of asthma. there has been excellent progress in this area of research over the last five to ten years with the introduction of anti-ige (omalizumab) therapy into mainstay asthma treatment, but only for those patients with clinical indications (i.e., severe allergic asthma) with an elevated serum ige level. this stratification in prescribing for anti-ige shows proofof-concept by targeting this expensive biologic to those patients most likely to show clinical benefit. similarly, there is accumulating evidence that stratification of patients in phase ii trials of newer therapies-for example, anti-il5 (mepoluzimab) and anti-il13 (lebrikizumab), again based on clinical and cellular patient profiles, is essential to adequately evaluate these therapies and will be important if these therapies are introduced into clinical practice. clear progress in asthma pharmacogenetics has come with completion of newer studies that interrogate multiple snps in large prospective cohorts. to date, predominantly candidate gene/pathway approaches have been used, but several genetic variants have now been identified with confidence (e.g., alox5 and leukotriene modifier response; fcer2 and glucocorticoid response). importantly, these studies show independent replication (the gold standard in genetic studies, including specific snps and direction of effect). also importantly, several gwass have now been completed that provide integration of common variation spanning the entire genome (typically testing 500,000 snps) identifying novel gene variants in a hypothesis-free approach (e.g., the collagen (col22a1) locus and spats2l and response to albuterol/salbutamol). these more recent findings still need further replication and validation; however, they potentially pave the way for a "responder" and "nonresponder" profile based on multiple snps in multiple genes, all measured on the same platform. a key question is the relative contribution of common variation (measured on these platforms) and rare variation (not currently measured to these outcomes). another remaining question relates to the magnitude of changes in clinical measures between genotype groups in asthma patients (e.g., fev 1 ). data so far suggests that these differences can be considered clinically relevant; however, further work with larger populations is required to accurately estimate effect sizes. similarly, the genetic variation identified to date accounts only for a modest proportion of the overall variation of the trait (e.g., a recent estimate suggests the hereditability of bronchodilator response at ∼28.5%). it is likely that studies so far have been confounded by factors including snp/haplotype analyses, gene-gene interactions, and the relative contribution of snps in different ethnic backgrounds. therefore, while our knowledge has dramatically increased, there is a need for prospective trials of these current compounds that involve large numbers of subjects and hypothesis-free approaches including gwas. as with gwas approaches to identifying disease susceptibility genes, "missing hereditability" will be an important issue in pharmacogenetics studies. this small proportion of hereditability currently assigned to identified loci (e.g., crhr1 < 3%) of corticosteroid response needs to be addressed because asthma medications cannot be successfully personalized unless we resolve a larger degree of genetic variability and/or environmental factors. as with clinical/cellular approaches to stratifying phase ii trials of newer asthma therapies, it is clear that genetic stratification has a role to play. for example, the recent phase ii trials of the il4/il13 dual antagonist (pitrikinra) suggests patient selection is critical to evaluating the clinical efficacy of this compound, with specific il4rα genotypes identifying responder groups. more pharmacogenetic integration is required for phase ii trials, which represents a clear challenge for drug development pipelines. as our understanding of the genetic basis of asthma increases other therapeutic targets for asthma will become apparent (e.g., il33 receptor antagonists). it is clear that the genetic variation associated with asthma susceptibility in these genes will influence pathways targeting methods, as they essentially identify individuals in which the pathway may be particularly important. it is also likely that existing therapies may be influenced by the genetic factors that underlie asthma susceptibility, particularly therapies that have multiple targets (e.g., ics). the impact of our genetic knowledge on asthma management and prescribing practice is limited at this time, as there is a need to further define the complex genetic basis of responders and adverse effects in large prospective studies. however, preliminary "real-life" studies with related outcome measures (e.g., days from school) have provided proof of concept that genetic information can have important implications for disease management (e.g., informing second-line therapy in asthma using adrb2 arg16) [98] . there remain many unanswered questions regarding the potential of stratified approaches in the management of asthma. while progress has been made in identifying patient subgroups based on clinical measures, cell counts, or marker expression, more work is required using very large studies to extensively characterize asthma patients not only cross-sectionally, but also longitudinally over many years to identify the natural progression of the disease. the field of genetics is rapidly progressing, with great technological developments moving at a dramatic pace, e.g., gwas comprising a million common snps or several million rare snps, gene expression studies, and wholeexome or targeted resequencing. these approaches will allow the interrogation of genetic variation effect in patient subgroups. it is likely that a drug-specific genetic profile involving several genes (e.g., receptors, signaling mediators, transcription factors) will be a step toward personalized medicine in asthma, with associated benefits including avoidance of adverse side effects and adequate control of the disease. we anticipate that through these approaches many novel common variants/genes will be identified as underlying responses to current asthma medication. as the cost of genetic analyses continues to fall, the potential of a relatively simple test that will have an impact on asthma management costs becomes a real possibility. if genetic or clinical information is going to influence clinical practice, there must be a simple, reproducible diagnostic test based on snp combinations or simple clinical measures, with adequately high specificity and sensitivity that distinguishes responders and nonresponders. however, the introduction of routine genetic and/or clinical testing into practice will require a clear demonstration of health benefits and cost-effectiveness that outperforms the current stepwise approach to asthma management. a plea to abandon asthma as a disease concept a brief history of asthma and its mechanisms to modern concepts of disease pathogenesis guidelines for the diagnosis and management of asthma. national asthma education and prevention program: expert panel report iii. nih publication no. 08-4051 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asthma pathological features and inhaled corticosteroid response of eosinophilic and non-eosinophilic asthma t-helper type 2-driven inflammation defines major subphenotypes of asthma characterization of within-subject responses to fluticasone and montelukast in childhood asthma lebrikizumab treatment in adults with asthma effects of an interleukin-5 blocking monoclonal antibody on eosinophils, airway hyper-responsiveness, and the late asthmatic response mepolizumab and exacerbations of refractory eosinophilic asthma exacerbations of asthma: a descriptive study of 425 severe exacerbations. the facet international study group sputum analysis, bronchial hyperresponsiveness, and airway function in asthma: results of a factor analysis eosinophilic bronchitis: clinical features, management and pathogenesis a comparison of the validity of different diagnostic tests in adults with asthma clinical control and histopathologic outcome of asthma when using airway hyperresponsiveness as an additional guide to long-term treatment. the ampul study group asthma exacerbations and sputum eosinophil counts: a randomised controlled trial analysis of induced sputum in adults with asthma: identification of subgroup with isolated sputum neutrophilia and poor response to inhaled corticosteroids determining asthma treatment by monitoring sputum cell counts: effect on exacerbations genetic basis for personalized medicine in asthma mutations in the gene encoding for the beta 2-adrenergic receptor in normal and asthmatic subjects polymorphisms of the beta2-adrenergic receptor correlated to nocturnal asthma and the response of terbutaline nebulizer adrenergic beta(2)-receptor genotype predisposes to exacerbations in steroid-treated asthmatic patients taking frequent albuterol or salmeterol effect of adrb2 polymorphisms on response to longacting beta2-agonist therapy: a pharmacogenetic analysis of two randomised studies common adrb2 haplotypes derived from 26 polymorphic sites direct beta2-adrenergic receptor expression and regulation phenotypes arg1 is a novel bronchodilator response gene: screening and replication in four asthma cohorts arginase 1 and arginase 2 variations associate with asthma, asthma severity and beta2 agonist and steroid response regulatory haplotypes in arg1 are associated with altered bronchodilator response genetic variants of gsnor and adrb2 influence response to albuterol in african-american children with severe asthma gsno reductase and beta2-adrenergic receptor gene-gene interaction: bronchodilator responsiveness to albuterol endogenous nitrogen oxides and bronchodilator s-nitrosothiols in human airways regulation of beta-adrenergic receptor signaling by s-nitrosylation of g-protein-coupled receptor kinase 2 a genome-wide association study of bronchodilator response in asthmatics tailored second-line therapy in asthmatic children with the arg(16) genotype leukotriene pathway genetics and pharmacogenetics in allergy absorption of montelukast is transporter mediated: a common variant of oatp2b1 is associated with reduced plasma concentrations and poor response slco2b1 c.935g>a single nucleotide polymorphism has no effect on the pharmacokinetics of montelukast and aliskiren. pharmacogenet pharmacogenetic association between alox5 promoter genotype and the response to anti-asthma treatment the glucocorticoid receptor heterocomplex gene stip1 is associated with improved lung function in asthmatic subjects treated with inhaled corticosteroids influence of leukotriene pathway polymorphisms on response to montelukast in asthma pharmacogenetics of the 5-lipoxygenase biosynthetic pathway and variable clinical response to montelukast pharmacogenetics of asthma controller treatment variant ltc(4) synthase allele modifies cysteinyl leukotriene synthesis in eosinophils and predicts clinical response to zafirlukast asthma pharmacogenetic study using finite mixture models to handle drugresponse heterogeneity effect of citrus juice and slco2b1 genotype on the pharmacokinetics of montelukast treatment heterogeneity in asthma: genetics of response to leukotriene modifiers corticosteroid pharmacogenetics: association of sequence variants in crhr1 with improved lung function in asthmatics treated with inhaled corticosteroids pharmacogenetic study of the effects of nk2r g231e g>a and tbx21 h33q c>g polymorphisms on asthma control with inhaled corticosteroid treatment dualspecificity phosphatase 1 as a pharmacogenetic modifier of inhaled steroid response among asthmatic patients fcer2: a pharmacogenetic basis for severe exacerbations in children with asthma fcer2 t2206c variant associated with chronic symptoms and exacerbations in steroidtreated asthmatic children genomewide association between glcci1 and response to glucocorticoid therapy in asthma genome-wide association identifies the t gene as a novel asthma pharmacogenetic locus metabolism of beclomethasone dipropionate by cytochrome p450 3a enzymes g894t polymorphism of enos gene is a predictor of response to combination of inhaled corticosteroids with long-lasting beta2-agonists in asthmatic children pharmacogenetics of asthma ancestry, ancestry-informative markers, asthma, and the quest for personalized medicine a phase ii placebo-controlled study of tralokinumab in moderate-to-severe asthma il-4 receptor alpha polymorphisms are predictors of a pharmacogenetic response to a novel il-4/il-13 antagonist effect of an interleukin-4 variant on late phase asthmatic response to allergen challenge in asthmatic patients: results of two phase 2a studies v75r576 il-4 receptor alpha is associated with allergic asthma and enhanced il-4 receptor function research in the authors' laboratory is funded by asthma uk, the medical research council, and the british medical association. we thank dr emily hodge for originally generating figure 28 .2. key: cord-332737-iclruwmx authors: webley, wilmore c.; hahn, david l. title: infection-mediated asthma: etiology, mechanisms and treatment options, with focus on chlamydia pneumoniae and macrolides date: 2017-05-19 journal: respir res doi: 10.1186/s12931-017-0584-z sha: doc_id: 332737 cord_uid: iclruwmx asthma is a chronic respiratory disease characterized by reversible airway obstruction and airway hyperresponsiveness to non-specific bronchoconstriction agonists as the primary underlying pathophysiology. the worldwide incidence of asthma has increased dramatically in the last 40 years. according to world health organization (who) estimates, over 300 million children and adults worldwide currently suffer from this incurable disease and 255,000 die from the disease each year. it is now well accepted that asthma is a heterogeneous syndrome and many clinical subtypes have been described. viral infections such as respiratory syncytial virus (rsv) and human rhinovirus (hrv) have been implicated in asthma exacerbation in children because of their ability to cause severe airway inflammation and wheezing. infections with atypical bacteria also appear to play a role in the induction and exacerbation of asthma in both children and adults. recent studies confirm the existence of an infectious asthma etiology mediated by chlamydia pneumoniae (cp) and possibly by other viral, bacterial and fungal microbes. it is also likely that early-life infections with microbes such as cp could lead to alterations in the lung microbiome that significantly affect asthma risk and treatment outcomes. these infectious microbes may exacerbate the symptoms of established chronic asthma and may even contribute to the initial development of the clinical onset of the disease. it is now becoming more widely accepted that patterns of airway inflammation differ based on the trigger responsible for asthma initiation and exacerbation. therefore, a better understanding of asthma subtypes is now being explored more aggressively, not only to decipher pathophysiologic mechanisms but also to select treatment and guide prognoses. this review will explore infection-mediated asthma with special emphasis on the protean manifestations of cp lung infection, clinical characteristics of infection-mediated asthma, mechanisms involved and antibiotic treatment outcomes. incidence and etiology of childhood and adult onset asthma asthma incidence is highest in childhood and thereafter decreases and remains stable at~1-3 new cases per 1000 per year throughout late adolescence and adulthood [1] . in adult populations, the prevalence of active cases of childhood-onset asthma (coa) and adult-onset asthma (aoa) are approximately equal, or favor aoa [2] . reasons for this counterintuitive prevalence ratio include (1) the propensity for coa to remit more frequently than aoa and (2) the greater number of years of adulthood in which to accrue new cases [2] . of relevance to clinical management and population disease burden is the wide range of asthma severities, from mild intermittent to severe persistent; the most severe 20% of cases account for 80% of health care utilization and morbidity [3] . robust population-based data indicate that around half of adults with asthma remain suboptimally controlled, even when treated with currently available anti-inflammatory medications, and~15% of adults with active asthma are severely uncontrolled [4] [5] [6] . these data indicate the need for novel therapies that are effective in the most severe and treatment-resistant cases of asthma that account for the majority of morbidity, mortality and health care utilization. the emerging evidence that a wide variety of microbes are present in the lower airway and may play a role in asthma pathogenesis suggests that manipulating the airway microbiome may be a novel approach towards this goal. studies confirm the existence of an infectious etiology mediated by chlamydia pneumoniae (cp) [7] and possibly other viral [8] , bacterial [9] and fungal [10] microbes. among the various infections associated with asthma, the obligate intracellular respiratory pathogen cp is of particular interest, as it is associated with both asthma severity and treatment resistance [11] [12] [13] . although this review focuses on cp we will discuss mycoplasma pneumoniae (mp) briefly under treatment (section v). it is possible that microbes such as cp and mp that have been implicated in recurrent wheeze and asthma etiology may serve as cofactors for viral infections, but certainly appear to act independently in asthmatic disease. the etiology of asthma remains unknown and is almost certainly multifactorial. many "triggers" for asthma attacks are well known (e.g., allergens, viral respiratory infections, fumes, cold air, exercise) but underlying mechanisms for why some exposed individuals develop asthma while most do not remain elusive [14] . genetic studies have failed to locate a unique "asthma gene" and instead point towards complex multifactorial genetic and environmental factors [15] . a currently popular paradigm, the "hygiene hypothesis," posits that the increased incidence of allergies (hayfever and eczema) and asthma noted in recent decades, is associated with less exposure to childhood infections and bacterial products (e.g., endotoxin). emerging evidence supports the hygiene hypothesis for hayfever and eczema but not for asthma which appears instead to be related to infections throughout the life cycle [16] [17] [18] . the host lung and gut microbiome as they relate to asthma are active areas of research [19] . yet it must be pointed out that studies of bacterial rrna may fail to detect cp due to low copy numbers or sampling problems due to deep tissue intracellular locations for this species [20, 21] . an increasing number of studies have now confirmed that the host microbiome has a significant impact on the risk of asthma development. a study published in 2010 by hilty and colleagues using 16s rna clone-library sequencing showed that when compared with healthy controls, patients with asthma had significantly more pathogenic proteobacteria and fewer bacteroidetes [22] . careful assessment of both healthy controls and asthmatic patients has confirmed the presence of bacterial communities. however, the bacterial burden was significantly greater in patients with asthma than in the healthy controls [23] . the microbial burden was even greater in asthmatics with greater bronchial reactivity upon methacholine challenge. these patients showed marked improvement in bronchial reactivity to methacholine after 6 weeks on clarithromycin. importantly, greater bronchial reactivity also correlated with greater relative abundance of members of certain bacterial communities known to exhibit characteristics that contribute to asthma pathophysiology, including species capable of inducing nitric oxide reductase, produce sphingolipids or have the ability to metabolize steroid compounds [24, 25] . a recent study showed that 1-month old infants who had positive oropharynx cultures of streptococcus pneumoniae, moraxella catarrhalis, or haemophilus influenzae showed increased susceptibility for development of childhood asthma [19, 26] . another recent study concluded that the nasopharyngeal microbiome within the first year of life was a determinant for infection spread to the lower airways and predicted the severity of accompanying inflammatory symptoms, as well as risk for future asthma development. the authors showed that early asymptomatic colonization of the nasopharynx with streptococcus was a strong asthma predictor [27] . these authors also demonstrated that antibiotic usage disrupted this asymptomatic colonization and prevented asthmatic onset [27] . these findings support the hypothesis that colonization of the developing airway by certain microbes (both viral and bacterial) can significantly alter the airway architecture and overall immune function, influencing how the airway responds to a variety of insults [28] . these findings also suggest that antimicrobial agents may represent an effective therapeutic tool with the potential to curtail both the duration and severity of asthma exacerbations initiated by a variety of microbes and exposes the limitation of the hygiene hypothesis in this regard [26] . the microbiome studies cited here have not specifically targeted cp and mp in upper airways. studies that have specifically tested for these atypical organisms have reported positive detection [29, 30] . intracellular detection of cp in adenoid tissue of symptomatic children was extremely common [30] and raises questions regarding a potential for cp-microbiome interactions. infections in early life can act either as inducers of wheezing or as protectors against the development of allergic disease and asthma. many young children have wheezing episodes associated with early-life respiratory infections. the infections most likely to be associated with these wheezing episodes include respiratory syncytial virus (rsv), human rhinovirus (hrv), human metapneumovirus, parainfluenza viruses and coronavirus [31] . the hygiene hypothesis has proposed that, for some infants, frequent early life infections may protect against asthma [17] and this certainly appears to be the case for most infants, as wheezing episodes with respiratory infections diminish as the child ages. however, for others, early-life wheezing episodes may mark the beginning of asthma. regarding established asthma, many types of viral respiratory infections have been shown to have a significant influence. in fact, viral respiratory infections are diagnosed in 80% of episodes of asthma in both children and adults [32, 33] . the question then remains; what factors determine if a viral respiratory infection provokes the onset of chronic asthma? factors appear to include the type of virus and the viral infectious dose as well as host susceptibility factors leading to inflammation, airway cellular infiltration with neutrophils and eosinophils or the presence of allergens in the airway and their interactions with the host immune system. if this combination of host and pathogen factors results in airway inflammation and hyperresponsiveness, the outcome could be asthma. could cp play a key role in this complex scenario? a clue to the answer to this question was found in a secondary analysis [34] of data from a community-based pediatric viral respiratory infection study that identified viral infections in 80-85% of exacerbations [33] . one hundred and eight children with asthma symptoms completed a 13-month longitudinal study in which exacerbations were recorded, and cp pcr and cp-specific secretory iga (cp-siga) antibodies were measured both during exacerbations and during asymptomatic periods. cp pcr detections were similar between the symptomatic and asymptomatic episodes (23% v 28%, respectively). children reporting multiple exacerbations remained cp pcr positive (p < 0.02) suggesting chronic infection. cp-siga antibodies were more than seven times greater in subjects reporting four or more exacerbations compared to those who reported just one (p < 0.02). the authors suggested that immune responses to chronic cp infection may interact with allergic inflammation to increase asthma symptoms [34] . notably, mp was not found to be important in this study. emerging evidence links cp infection with both de novo asthma (asthma onset during/after an acute lower respiratory tract infection in a previously non-asthmatic individualalso referred to as the "infectious asthma" syndrome) and with asthma severity [11, 12, 35, 36] . this section will review what is known about cp in asthma initiation and severity, and the multiple experimentally established mechanisms that might mediate these associations. therapeutic implications are reviewed in section v. de novo wheezing during an acute lower respiratory tract infection is remarkably common [37] . most of these wheezing episodes appear to resolve without chronic sequelae but sometimes chronic asthma develops. surprisingly, clinical studies report that asthma onset after an acute respiratory illness is exceedingly common (up to 45% of adult-onset asthma cases [38] . this strong temporal association of respiratory infections and asthma onset has been confirmed in a population-based study [39] . the most reliable way to establish whether a specific respiratory pathogen can initiate asthma would be to perform large, long-term prospective microbiological and clinical cohort studies of the general (non-asthmatic) population. such a study would be very expensive and has not yet been undertaken. a second approach would be to perform prospective studies in selected non-asthmatic patients exhibiting "risk factors" for asthma in clinical settings [40] . if the selected "risk factors" do indeed identify people at higher likelihood of developing the "infectious asthma" syndrome, this type of study might be feasible. characteristics associated with cp/mp biomarkerpositive "infectious asthma" include patients with severe, treatment-resistant asthma, exhibiting a neutrophilic airway inflammation or test pcr positive for cp or mp. it should however, be noted that there is currently no test or set of tests that will definitively diagnose who will benefit maximally from azithromycin treatment. factors that predict risk in non-asthmatics for developing the "infectious asthma" syndrome include a previous history of self-limited lower respiratory tract illnesses such as acute bronchitis (often with wheezing) and/or pneumonia [35, 38, 39] . other risk factors may be operative but are poorly understood at this time. over a 10-year time period, hahn et al. [35] collected prospective cp microbiologic testing and clinical data on 10 patients with de novo wheezing. nine of these subjects exhibited an acute bronchitic illness and one had community-acquired pneumonia. all 10 met serological criteria for an acute primary (n = 8) or secondary (n = 2) cp infection. of the nine patients with acute bronchitis and wheezing, four improved without treatment and five progressed to chronic asthma. the patient with pneumonia was treated with a traditional short course of a macrolide with resolution of pneumonic infiltrate, yet developed chronic bronchitis and cp was isolated by culture from his sputum 6 months later. this type of study has not been replicated but raises several questions. cp is well known to cause protean manifestations of acute respiratory illness; these observations suggest that cp may also be capable of causing protean manifestations of chronic respiratory conditions (e.g., asthma, chronic bronchitis and copd, reviewed in [41] ). whereas some of the cp infected patients with de novo wheezing resolved their acute illness without treatment, others developed chronic sequelae; identification of underlying protective and promoting factors might help address the current asthma pandemic. once established, cp-associated asthma has been linked with increased severity in several studies. cook et al. [42] first identified cp biomarkers in what they referred to as "brittle asthma" (asthma that was hard to control and more severe than average). an accumulating body of evidence supports the association of cp infection with asthma severity [11, 12, 43] and with steroid resistant asthma [44] . multiple mechanisms support the biologic plausibility of these associations (reviewed in [45] ). exposure to cigarette smoke is an established factor tied to steroid resistance in asthma [46] . similar to cigarette smoke, cp induces pulmonary bronchial epithelial ciliostasis [47] . additionally cp infects alveolar macrophages and lung monocytes leading to enhanced production of tnf-α, il-1β, il-6 and il-8; infects human bronchial smooth muscle cells to produce il-6 and basic fibroblast growth factor (with potential effects on bronchial hyper reactivity and lung remodeling that have yet to be thoroughly investigated); and chronic infection exposes tissues to chlamydial heat shock protein 60 (chsp60) and bacterial lipopolysaccharide (lps) that have been associated with increased inflammation and asthma (reviewed in [48] ). lastly, cp-specific ige has been demonstrated to be strongly associated with severe persistent asthma (80% of cases) [43] and other chronic respiratory illnesses in children severe enough to justify undergoing bronchoscopy [49] . whereas exposure to recognized allergens can be mitigated, exposure to unrecognized bacterial "allergens" may result in chronic unrelenting exposures that could contribute to severity [43, 50] . it may prove difficult or even impossible to unravel exactly which mechanism(s) contribute to producing an "infectious asthma" phenotype. in regard to the involvement of cp in asthma pathogenesis, the controversy of whether the association is causal or coincidental can be settled in two ways: (1) patients diagnosed with asthma can be treated with the aim of evaluating the effects of antibiotics in ameliorating asthma symptoms compared to untreated of placebo controls and (2) animal models can be performed to evaluate the role of cp in asthma initiation and/or exacerbation. experimental animal inoculation studies may help to elucidate mechanisms underlying cp asthma pathogenesis. over the past three decades, animal models of asthma have been extensively utilized to elucidate mechanisms of the disease, determine the activities of genes of interest, investigate cellular pathways and predict the safety and efficacy of various drugs being considered for asthma treatment. initial murine models of chlamydial lung infections were carried out in adult mice and seemed to closely represent acute human asthma. these studies utilized the mouse pneumonitis biovar of c. trachomatis (mopn) since it is well known as a natural mouse pathogen [51] and would therefore represent the best choice for investigating host-pathogen interactions in this context. these early studies recorded extensive lung consolidation after 7 days of airway infection and found significant airway inflammation characterized by neutrophil infiltration in airway exudates [52] . these early studies also confirmed that multiple reinfections were required to induce symptoms of chronic asthma and that a th1 immune response contributing ifn-γ and subsequently activated macrophages was necessary to clear the infection [53, 54] . more recently, many studies have utilized neonatal mouse models for infectious asthma since early studies demonstrate that neonatal t cell immune responses in both mice and human are skewed toward a th2 cellular phenotype as a result of placental immune pressure. these th2 cells are much less effective in the immune response compared to their adult counterparts [55, 56] . horvat, et al. later demonstrated that neonatal chlamydial lung infection induced mixed t-cell responses that drive allergic airway disease (aad) using a balb/c mouse model with ovalbumin to induce aad [57] . further work from this group confirmed that chlamydial infection in neonatal and infant, but not adult mice, exacerbated the development of hallmark features of asthma in ovalbumin-induced allergic airways disease models. some of these notable features include increased mucus-secreting cell numbers, il-13 expression, and airway hyperresponsiveness [58] . studies from our own lab confirm that early-life chlamydial airway infection induces a th2 immune response, both airway eosinophilia and neutrophilia, and permanent alteration of lung structure and function with concomitant enhancement of the severity of allergic airways disease in later life [59] . we confirmed that neonatally infected mice never cleared the infection, showed dissemination to the liver and spleen through the peripheral circulation, and the development of chlamydia-specific ige antibodies in the infected neonates but not adult controls [59] . recently, hansbro et al. completed work using a bone marrow chimera reconstitution that clearly demonstrated that infant lung infection results in lasting alterations in hematopoietic cells, leading to increased severity of aad later in adult life [60] . a significant study by kaiko et al. [61] , demonstrated that infection of bone marrow-derived dentritic cells (bmdc) promoted th2 immunity and airways hyperreactivity in a mouse model. intratracheal passive transfer of infected bmdc but not uninfected control bmdc into naïve balb/c mice resulted in increased il-10 and il-13 in the bal fluid [61] . these animals also showed significant increases in airways resistance and a reduction in airways compliance compared to their uninfected counterparts. these are hallmarks of asthma and further confirm the role of chlamydial infection in asthma initiation and pathology, at least in mice. a further set of experiments by schröder et al. [62] demonstrated that adoptive transfer of lung dendritic cells from cp infected mice, but not from uninfected mice, produced eosinophilic airway inflammation after challenge with an exogenous allergen (human serum albumin) that was dose-, timing-, and myd88-dependent. taken together, these findings suggest it is plausible that cp infection solely of lung dendritic cells may be sufficient to induce an asthma "phenotype" that may demonstrate characteristics that are both "infectious" and "allergic". these animal model studies have added significantly to our understanding of the mechanisms involved in the inflammatory process of chlamydial infection leading to asthma initiation and exacerbation. it also appears that the damage caused by chlamydial airway infections over time leads to an exaggerated airway repair or airway wall remodeling. the major features of this type of response include epithelial cell shedding, goblet cell hyperplasia, hypertrophy and hyperplasia of the airway smooth muscle bundles, basement membrane thickening and increased vascular density through angiogenesis [63] . the functional and mechanical consequences of this type of aberrant repair leads to bronchial wall thickening which can uncouple the bronchial wall from the surrounding parenchyma, significantly enhancing airway narrowing and severe obstruction [63] . this type of airway damage might prove irreversible even with long-term inhaled steroid treatment. moreover, it is well documented that corticosteroid use drives cp out of a persistent state into active replication, since corticosteroids negatively impact several aspects of cell-mediated immunity while favoring the shift from a th1 towards a th2 immune response [64] . this shift in response significantly impedes the ability of the host to eradicate intracellular pathogens like cp and may lead to the release of chsp60 which exacerbates the inflammatory process [11] . there is also evidence that cp infection may promote airway remodeling by decreasing the ratio of mmp9 to timp1 secreted by inflammatory cells, and by altering cellular responsiveness to corticosteroids [65] . see fig. 1 the concept that asthma is a syndrome with different underlying etiologies is well accepted. the use of the word "phenotype" to describe asthma subtypes based primarily on the inflammatory composition of respiratory secretions and/or peripheral blood is more problematic. the original definition of "phenotype" referred to relatively stable somatic manifestations of underlying genetics (such as eye color) whereas current asthma inflammatory "phenotyping" is based on cross sectional sampling of a dynamic physiologic process (host inflammatory response) and does not account for the fact that inflammatory composition is not necessary a fixed characteristic [66] . in the context of a review that focuses on chlamydial infection we are reluctant to place too much emphasis on asthma phenotypes based on inflammatory cell compositions because well described host responses to acute, sub-acute and chronic chlamydial infections involve a wide array of inflammatory cells (including eosinophils, neutrophils and monocytes) the composition of which varies significantly at different temporal stages of the infection [67] . we have commented on some fairly well defined asthma categories but even these can change over time (e.g., mild asthma can become severe, stable asthma can become uncontrolled). the dynamic and often unpredictable nature of asthma symptomatology is one of the factors that make asthma research so challenging. historically asthma was categorized as either allergic or non-allergic but this distinction was put into question as early as the 1980s [68] . an early report of the association between cp and asthma did find independent associations of cp biomarkers, clinical allergy and asthma [40] yet in the clinical setting there is overlap between atopy and cp infection [69] . the animal models described earlier indicate that cp can promote both asthma and atopy, thus an absolute distinction between these two categories as indicators of differing underlying etiologies may not be warranted. macrolide treatment trials that examine subgroup responses are one approach to examining the predictive value of this and other subgroups. asthma has also been characterized as either "eosinophilic" or "neutrophilic" based on the cellular composition of respiratory secretions or bronchoalveolar lavage fluid (balf) [70] . simpson et al. [71] performed an rct of a macrolide (clarithromycin) in severe refractory asthma in adults and reported no overall benefit in the group as a whole. however, there was a positive effect in the pre-specified subgroup of patients with "neutrophilic" asthma as defined by sputum il-8 and neutrophil numbers. the predictive power of these findings is limited since it is unclear whether sputum composition is stable over time in severe refractory asthma (or any asthma, for that matter). the majority of people with asthma can be well controlled with conventional guideline-based anti-inflammatory treatments (mainly inhaled steroids, sometimes in combination with an inhaled long-acting bronchodilator) [72] . nevertheless, a significant minority of people with asthma is not well controlled by guideline treatments [73, 74] . the proportion of all people with "refractory" asthma (asthma that is not responsive to guideline therapies) has been estimated at between 5 and 15% but the contribution of refractory asthma to asthma morbidity and mortality is considerably greater, as the most severe 20% of asthma cases account for 80% of asthma morbidity and health care costs [3] . if patients with the "overlap syndrome" (asthma and copd) are included, the numbers of people with refractory disease increases significantly [75] . of the various novel therapies under consideration for refractory asthma [76] , macrolides appear to be one of the most promising. a 2013 metaanalysis of 12 randomized, controlled trials (rcts) of macrolides for the long term management of asthma in both adults and children found positive effects on peak expiratory flow rate (pefra measure of pulmonary function), asthma symptoms, asthma quality of life (aql), and airway hyper responsiveness (ahr), but not on forced expiratory flow rate in 1 s (fev1) [77] . the updated 2015 cochrane review of 18 rcts [78] reported positive benefits on asthma symptoms and fev1 but not on aql (ahr and pefr were not analyzed). a joint european respiratory society/american thoracic society (ers/ats) guideline on severe asthma recommends against the use of macrolides ("conditional recommendation, very low quality evidence") [79] . the ers/ats guideline states "this recommendation places a relatively higher value on prevention of development of resistance to macrolide antibiotics, and relatively lower value on uncertain clinical benefits." the inconsistent findings of the meta-analyses, along with the uncertainties surrounding the clinical benefits of macrolides, underscore the need for higher quality evidence. this section adds some evidence not included in the meta-analyses, reviews what is known about macrolide side effects (including the clinical consequences of resistance) and suggests research approaches to obtain better evidence. we conclude with some provisional recommendations for clinicians who may be approached by patients with new-onset, uncontrolled and/or refractory asthma who are asking for macrolide treatment. current evidence for all asthma treatments is limited due to selection bias initiated by researchers, clinicians, and even asthma patients themselves. researcher bias. the academic literature is replete with asthma efficacy studies lacking in generalizability [80] . the efficacy trials on which current asthma treatment guidelines are based systematically exclude >90% of people with asthma encountered in the general clinical population [81, 82] . only pragmatic effectiveness trials, with minimal exclusions, are able to provide evidence applicable to the general population [44] . clinician bias. a recent trial of azithromycin for acute exacerbations of asthma (aza-lea) is notable because over 95% of patients with an exacerbation were not eligible for enrollment primarily because they had received an antibiotic from a treating clinician [83] . an accompanying editorial speculated that one possible reason for the negative results of azalea was that clinicians were somehow able to identify and treat likely candidates, making them ineligible for the research [84] . be that as it may, azalea is an example of asthma research made less informative due to nonresearcher clinician behavior. patient bias. hahn et al. [44] performed a pragmatic trial of azithromycin for asthma (azmatics) in which the likely candidates excluded themselves from randomization. this unanticipated event occurred because azmatics was an internet-based trial; people with severe, refractory asthma identified themselves as likely candidates and contacted the pi for enrollment; but upon learning that they had a 50% chance of receiving placebo, they opted out of randomization in favor of receiving a comparable azithromycin prescription from their personal clinician [85] . rather than lose data on this "open-label" (ol) group, the study protocol was altered to include a third (ol) arm. randomized results were similar to azalea (negativesee fig. 2 ); however, ol subjects exhibited large and unprecedented improvements in symptoms and quality-of-life (qol) that persisted long after treatment was completed (figs. 2 & 3) . because the ol group was not randomized, these results do not appear in any meta-analysis of rcts; nevertheless they strongly suggest that future macrolide rcts should focus on the severe end of the asthma spectrum, as also recommended by others [42, 71, 86] , and preferably engage patient populations that are unlikely to want to opt out of randomization. macrolide mechanisms of action in asthma are thought to be directly anti-inflammatory, indirectly anti-inflammatory (i.e., antimicrobial), or both. it is difficult to invoke direct anti-inflammatory macrolide effects as responsible for large clinical benefits persisting to 9 months after treatment completion. antimicrobial effects, against specific respiratory pathogens or against the general lung microbiome, remain likely possibilities. circumstantial evidence suggests that macrolide treatment effects may, at least in part, be attributable to antimicrobial actions against chronic atypical infections [9, 87] . this issue is by no means settled and requires further research that may be challenging given the selection biases noted above coupled with likely low sensitivity of lung sampling leading to false negative diagnosis of, for example, chronic cp lung infection [20] . fig. 2 azithromycin improves asthma symptoms and patient quality of life. subjects with severe refractory asthma treated with azithromycin (open label) had fewer persisting asthma symptoms a and greater asthma quality of life b than groups with lesser asthma severity randomized to azithromycin or to placebo [44] azithromycin is generally well tolerated and is widely used for a variety of acute respiratory illnesses. concerns about adverse effects of azithromycin include development of antibiotic resistance, sudden cardiac death, hearing loss and effects on the host mcrobiome. development of resistance is a possibility whenever antibiotics are used; azithromycin is no exception. however, there are no reports of patient harm from resistant organisms in any cardiorespiratory trial performed to date [89] . rather, the only detectable clinical effects of azithromycin in these trials were decreased incidences of sinusitis, acute bronchitis and pneumonia, and less use of other antibiotics [88, 89] . sudden cardiac death attributable to azithromycin (1 in 4000 prescriptions in high cardiac risk patients) was plausibly documented in an epidemiologic study of a medicaid population in tennessee [91] . the same risk was also present for a quinolone (levofloxacin). subsequent population-based studies in average risk populations showed no increased risk of sudden death [92, 93] . mild hearing loss was reported in an excess of <1% of heart disease subjects randomized to 600 mg azithromycin once weekly for 12 months [88, 90] . hearing test changes leading to discontinuation of azithromycin occurred in 2.8% of 1142 severe copd subjects randomized to 250 mg azithromycin daily for 1 year [90] . the clinical significance of these hearing test changes is unclear. notably, it is likely that daily azithromycin dosing is unnecessary [94] and may lead to increased adverse events [91] . the prolonged half-life of azithromycin within cells, including within immune system cells, allows weekly dosing and may be preferable to daily dosing when targeting either immune cells or intracellular pathogens such as cp. although largely speculative at this time, it appears that macrolide effects against the lung microbiome may be potentially harmful or helpful in asthma. segal et. al. reported that an 8 week treatment with azithromycin did not alter bacterial burden but reduced α-diversity [95] . they also observed significant reduction in certain pro-inflammatory cytokines, which might explain the non-specific anti-inflammatory effects proven beneficial in copd and asthma [95] . published findings from slater et al. that specifically evaluated azithromycin effects on the lung microbiome revealed a significant reduction in bacterial richness in the airway microbiota [96] . importantly, reductions were most significant in three pathogenic genera: pseudomonas, haemophilus and staphylococcus [96] . overall, available data suggest that azithromycin treatment of severe asthma, while controversial, may benefit those with confirmed atypical bacterial infection [97] . resistance, adverse events including sudden death, hearing loss and changes in host microbiome should be monitored in future pragmatic trials. protean manifestations of chronic cp infection, that may include asthma, chronic bronchitis, copd, and the "overlap syndrome" (asthma and copd) argue in favor of pragmatic trials with broad inclusion criteria that include patients with lung multi-morbidity. at least nine domains distinguish pragmatic (or effectiveness) trials from explanatory (efficacy) trials (table 1 ) [98] . in the context of future rcts of macrolides for asthma, we fig. 3 asthma quality of life (aql) improvement scores at 12 months (9 months after completing azithromycin). the minimum clinically important score is ≥0.5; a score of 1.5 is considered a large important change [44] propose that the most important pragmatic domains are (1) broad eligibility to account for the protean clinical manifestations of both chronic reactive/obstructive lung disease and cp infections as discussed previously and (2) a comprehensive patient-centered primary outcome. asthma exacerbations are a current popular choice as a primary outcome because they are clinically relevant [99] . however, exacerbations are only one of many outcomes that are important to asthma patients [100] . compared to exacerbations, asthma quality-of-life (qol) more comprehensively measures patient-important outcomes. qol includes, but is not limited to, the adverse effects of exacerbations on patient well-being [100] and qol has proven robust in the sole pragmatic macrolide-asthma trial performed to date [44] (figs. 2 and 3 ). many patients in this pragmatic trial [44] had significantly decreased asthma qol at study entry and large important improvements in qol after azithromycin, but did not experience exacerbations. this significant subgroup would have been either possibly ineligible for inclusion or not counted as successes in a trial using exacerbations as the primary outcome. pragmatic trials primarily ask does this treatment work? explanatory trials primarily ask what is the mechanism? addressing target groups/mechanisms in pragmatic trials of macrolides is desirable and possible as secondary aims by specifying a priori hypotheses coupled with subgroup analyses. we recommend studying a wide array of biomarkers using this approach. it is notable that rcts of macrolides have been performed and/or macrolides are being recommended in the treatment of many chronic lung conditions (diffuse pan-bronchiolitis, cystic fibrosis, bronchiectasis, copd, post-transplant bronchiolitis obliterans) [101, 102] . a planned trial will test the effectiveness of azithromycin in patients with the "overlap syndrome" (asthma-copd) [103] . it is time to add asthma to the growing list of chronic respiratory conditions that are being evaluated by robust macrolide rcts that are pragmatic in nature. in the meantime, patients with severely uncontrolled and/or refractory asthma, or new-onset asthma are increasingly searching the internet for new information and are sometimes better informed than their doctor about current evidence regarding macrolides for asthma (hahn: personal observations). pending more robust data from asthma rcts that have yet to be performed, how should practicing clinicians respond when such patients request macrolide treatment? as stated above, the ers/ats guidelines on severe asthma recommend against the use of macrolides, albeit with caveats that the evidence for this recommendation is weak and provisional [79] . informal guidelines from a pulmonology research group state that they recommend macrolide treatment only for confirmed diagnoses of atypical lung infection [104] . from a practical standpoint, their recommendation limits treatment only to those who have undergone bronchoscopy; even then the diagnostic sensitivity is likely to be less than perfect due to sampling issues discussed earlier. both these recommendations have met resistance from patients who have read and understood the evidence (hahn: personal communication). we offer a third alternative recommendation, repeated word for word from the conclusion of the sole practice-based pragmatic trial of azithromycin for asthma conducted to date [44] : "pending further randomized trials, given the relative safety of azithromycin and the significant disease table 1 proposed design for a randomized trial of azithromycin for the long-term management of asthma. seven of nine precis-2 [98] domains are recommended as pragmatic and two as explanatory domain pragmatic or explanatory? a comments eligibility. who is selected to participate in the trial? pragmatic exclusions only for safety; comorbidities included. recruitment. how are participants recruited into the trial? pragmatic recruited from practice sites (emergency rooms, clinics). setting. where is the trial being done? pragmatic performed at the practice site. organization. what expertise and resources are needed to deliver the intervention? no extraordinary expertize required. flexibility: delivery. how should the intervention be delivered? total weekly oral dose can be administered on any schedule desired. flexibility: adherence. what measures are in place to make sure participants adhere to the intervention? adherence encouraged by frequent contacts by the research team and monitored by patient report and pill count. follow-up. how closely are the participants followed-up? explanatory 3-monthly study visits to collect non-routine information (e.g., spirometry, biomarkers, qol) primary outcome. how relevant is it to participants? pragmatic outcome is patient-centered (see text for discussion). to what extent are all data included? pragmatic intention-to-treat. a precis-2 grades on a scale from 1 (extremely explanatory) to 5 (extremely pragmatic). column 2 presents recommendations for which end of the spectrum is emphasized burden from severe refractory asthma, prescribing prolonged azithromycin therapy to patients with uncontrolled asthma may be considered by managing clinicians, particularly for patients who have failed to respond to conventional treatment and as an alternative to instituting immunomodulatory agents". interested clinicians and others wishing more information on patient experiences, scientific evidence and treatment alternatives are referred to a book on the subject [69] . evidence supports a complex interaction between host genetics/immune response and environmental factors (e.g., viral infections, microbiome) in the development, exacerbation and severity of asthma. emerging evidence from animal models and human studies points to chlamydia pneumoniae (cp) as a key player in this complex scenario. future research is required to unravel the quantitative 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anti-inflammatory microbial metabolites in the emphysematous lung the impact of azithromycin therapy on the airway microbiota in asthma chronic infection and severe asthma the precis-2 tool: designing trials that are fit for purpose the role of macrolides in asthma: current evidence and future directions measuring quality of life in asthma role of long term antibiotics in chronic respiratory diseases long-term macrolide treatment for chronic respiratory disease rofumilast or azithromycin to prevent copd exacerbations (reliance) the role of atypical infections and macrolide therapy in patients with asthma not applicable. not applicable. data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. authors' contributions ww initiated the writing of the manuscript and contributed to the sections highlighting basic research and animal models. dh contributed to sections dealing mainly with clinical analyses, treatment and clinical trials. however, both authors contributed to its multiple revisions and formatting. both authors read and approved the final manuscript. ww is an associate professor of microbiology at the university of massachusetts amherst and director of the premed/prehealth advising center. he was the first to show a direct link between cultivable c. pneumoniae in the lower airway and pediatric asthma severity. ww has carried out animal model studies confirming a link between early life airway infection with c. pneumoniae and reactive airway disease. the authors declare that they have no competing interests. figures 2 and 3 were reproduced by permission of the american board of family medicine. ethics approval and consent to participate not applicable.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord-010078-8lkkez3n authors: nan title: invited speakers date: 2010-11-24 journal: respirology doi: 10.1111/j.1440-1843.2010.01863.x sha: doc_id: 10078 cord_uid: 8lkkez3n nan the physiology of respiration reaches its extreme limits when man is exposed to the effects of high altitude, which is basically a decrease in ambient pressure and temperature. the process of acclimatization of humans to high altitude occurs within minutes of ascent, starting with increases in cardiac output, and ventilation. these result in acute changes in pao 2 and paco 2 . slower changes of acclimatization include increase in hemoglobin concentration (polycythemia), and muscle capillarity, but decrease in mitochondrial volume density and cellular aerobic capacity. through acclimatization, animals and human inhabitants of high altitude areas have developed adaptations that allow them to function as near normal as those living at sea level. humans who undergo acute ascent to high altitude could acclimatize, but some fail to do so. if there is failure to acclimatize, oxygen diffusion impairment results, due to decreased partial pressure, and lower affi nity of hb for oxygen. in addition, there is signifi cant increase in ventilation/perfusion heterogeneity. the resulting hypoxia leads to hypoxic pulmonary vasoconstiction (hpv) which results from multiple components: changes in epithelial cell wall that lead to intracellular calcium increase and/or calcium sensitization. subsequently, pulmonary hypertension develops, with actual breaks in the capillary endothelium leading to an infl ammatory process (seen more during exercise), and decrease in alveolar fl uid clearance. these mechanisms contribute to the development of alveolar edema, high altitude pulnary edema (hape), which is one of the two major diseases due to acute mountain sickness (ams). both hape and the other ams, high altitude cerebral edema (hace) could be potentially fatal, and must be recognized and treated early. knowledge of the pathophysiology of the ams would allow more rational approaches to their prevention and treatment. high altitude illnesses can develop among healthy individuals who sojourn for recreation and work: cerebral form called acute mountain sickness (ams) and potentially fatal pulmonary form called high altitude pulmonary edema (hape). ams is generally self-limited. high-altitude cerebral edema (hace) is likely a continuum of ams and the end-stage of ams. ams is not a precondition for the development of hape. hape develops in non-acclimatized mountaineers after rapid ascent to altitudes above 2500 m. hape may develop even in the absence of ams. severe ams may be a risk factor for hape. the altitude, the rate of ascent to new altitude, (>300 m/day to an altitude above 4000 m), and individual susceptibility are major determinants of ams and hape. on ascent to high altitudes all people have swelling of the brain. patient with ams often experience "hangover headache." other symptoms occur within the fi rst 6 to 36 h. these include malaise, anorexia, nausea and vomiting, and insomnia. ams patient must be evaluated for signs of global encephalopathy rather than focal fi ndings, although retinal hemorrhage is commonly seen. when these are present, the subject has hace until proven otherwise. patient may die if not treated promptly. brain herniation is the usual cause of death. the hallmark of hape is an excessively elevated pap which precedes the development of pulmonary edema. symptoms are incapacitating fatigue, chest tightness, dyspnea with effort, orthopnea, cough, and pink frothy sputum in advanced stage of disease. prevention of all altitude complications requires ascending at an increment rate to allow acclimatization. at >3000 m, one should not spend subsequent nights 300 m higher than the previous night. trekker must take a rest day every 2 to 3 days. anyone with ams should not ascend until symptoms are resolved. acetazolamide and dexamethazone are effective in prevention and treatment of ams from proceeding to hape or hace. at the fi rst sign of hace, patients should descend to a lower altitude while supplementary oxygen is given. increasing oxygenation is the highest priority in the treatment of and prevention of hape. if supplemental oxygen is unavailable, then descent, use portable hyperbaric chamber, or both become lifesaving. nifedipine is necessary only when supplemental oxygen is unavailable or descent is impossible. because of its pulmonary vasodilatory effects, phosphodiesterase inhibitors can be used for prevention and treatment of hape. rudolf virchow in 1856 described that the 3 determinant risk factors for venous blood clot formation are stasis, endothelial injury and hypercoagulable state. dr simpson et al 1940, a british surgeon observed that during the london blitz, the world war ii, britons who were forced to remain on sitting in cramped position and deck chairs for hours during the air raids developed fatal pulmonary embolism. it was suggested in 1954 by homans that "prolonged dependency stasis" or immobilization is one factor that predisposes patients to develop thrombosis in the deep veins of the legs. several risk factors have been identifi ed for developing venous thromboembolism (vte). travel is one of the transient risk factors. it is not confi ned to one mode of travel such as air travel. it is also incriminated to other modes of land travel such as car, bus and train. the term "economy class syndrome" was proposed by symington and stock (1966) and by the group of cruickshank (1988) for venous thromboembolism occurring in patients during air fl ight travel. it is usually seen in patients sitting in limited or cramped circumstances in the economy coach or tourist class seats, however it is also found out that patients who were also seated in the business class also develop this syndrome. factors implicated were the long duration of travel, immobilization or inactivity in sitting position, and the low cabin pressure, low humidity and dehydration during air fl ights. in several studies performed on large airports in europe, the presence of genetic factors such as factor v leiden and environmental factors such as the use of oral contraceptives predispose patients several fold to develop venous thromboembolism. signs and symptoms pertaining to vte develop not only during and after the fl ight but also several weeks after the travel. nowadays, airlines as well as bus companies have advisories and measures impose to prevent development of vte and deaths due to vte during the travel period. with the steadily increasing use of air travel, more and more patients with pulmonary disease are fl ying long distances, at high altitude in partially pressurised aircraft. this is associated with long periods of reduced mobility and exposure to reduced inspired pressures of oxygen and reduced barometric pressure. some individuals therefore may be at risk of barotrauma, hypoxia or venous thrombo-embolism (vte). therefore it is important to identify these individuals and adequately assess the real risk entailed by fl ying. the effect of reduced atmospheric pressure is a potential risk for patients with recent or pre-existing pneumothorax but otherwise is unlikely to be associated with risk other than that due to the associated reduced inspired oxygen fraction (fio 2 ), typically 0.15 (15%) in a commercial aircraft at cruising altitude. the reduced (fio 2 ) may be problematic for patients with hypoxic lung disease or in patients with other co-morbidities that may exacerbated by hypoxia. medical history, lung function and resting oxygen saturation will help identify patients at risk although it is diffi cult to predict the clinical effects of altitude from tests (even hypoxic challenge tests) conducted at sea level. there is currently a lack of good data defi ning the clinical outcomes due to hypoxia during fl ight in patients with lung or other diseases. the risk of vte increases with duration of fl ight above four hours, presumably related to the duration of immobility, although the role of prolonged hypoxia remains to be determined. preventive measures are now currently invoked on most airlines and guidelines for the use of antithrombotic agents are available, stratifi ed by risk. it is anticipated that guidelines will continue to be updated as new data are made available. cardio-pulmonary exercise testing is now well accepted as an appropriate test for the investigation of shortness of breath on exertion. in addition the test has been found to be useful for the assessment of pulmonary vascular dysfunction and the assessment of fi tness for major thoracic surgery. even though there are well described and internationally accepted protocols to perform the test, the interpretation of a cardio-pulmonary exercise test often leaves the interpreting physician confused. importantly with the multiple facets of the test (respiratory, cardiac, peripheral vascular) that need to be interpreted it is easy for the interpreting physician to look at a certain aspect of the test relating to their specialty and to give the other facets relatively little attention. in this presentation we review the process of interpreting cardio-pulmonary exercise tests. in addition we will interpret a number of tests based on our previous discussion on how to interpret these tests. finally we will review the literature regarding new interpretive strategies for exercise induced pulmonary vascular disease. bronchoscopy as an image-guided intervention has benefi tted from advances in optical and non-optical imaging technologies. some current bronchoscopy advances incorporate higher resolution ccd (charged-couple device) digital-"chip" technology and magnifi cation lenses to enhance the image resolution. the hope is that improved visualization combined with analysis of concomitant tissue biopsies may realize so-called "in-vivo endoscopic diagnosis" without the need for tissue biopsies, however studies of highmagnifi cation endo-cytoscopy, co-focal micro-endoscopy and optical coherence tomography (oct) remain investigational. further limiting these near-histologic resolution imaging modalities is the need for an initial screening of "highly suspicious" mucosa to focus attention upon. to facilitate identifi cation of abnormal airway mucosa, there are advances in the bronchoscopic detection of dysplastic and malignant mucosa. newer generations of autofl uorescent (af) bronchoscopes combine video ccd technology with af signaling to enhance the visual resolution of the images. non-af technologies being evaluated for the same purpose include fi ltered-light narrow band imaging (nbi) and post image-capture processing by a number of other spectral estimation technologies (set). bronchoscopic image guided interventions (bigi) also benefi tted from advances in non-traditional bronchoscopy technologies. foremost has been endobronchial ultrasound (ebus), initially designed as radial probes modeled after intravascular us and modifi ed for the airways. while useful in advancing our understanding of endobronchial mucosal structure, predicting tumor invasion depth and responsiveness to endobronchial interventions, radial ebus did not permit real-time guidance. dedicated linear-array ebus bronchoscope has changed this dramatically as the 7.5 mhz needle-puncture ebus bronchoscope has increased diagnostic accuracy of peri-bronchial lymph nodes/masses from a previous average of <50% to >90% for even small targets (<1 cm) in experienced hands. simultaneously miniaturization of radial ebus probes (thin 1.4 mm) and incorporation of guide-sheaths have increased the utility of ebus in evaluating parenchymal lung pathology. concomitant work in image processing of radiology imaging data (dicom data of chest ct images) has made available a number of "virtual bronchoscopic navigation" programs to assist the bronchoscopists in navigating towards smaller peripheral focal targets, and to improve the historic diagnostic yield of smaller (<2 cm) peripheral nodules from 20-30% up to 65-80%. these systems include passive endobronchial "road-maps" view (similar to "mapquest"/"google earth") and more technology enhanced electromagnetic navigation bronchoscopy (enb) (similar to gps guidance). all these ancillary technologies have spurred improvements in the basic bronchoscope, as thinner bronchoscopes capable of reaching peripheral segments (2.8 mm and 3.5 mm with 1.2 mm working channel; 4.0 mm with 2.0 mm working channel) are coupled with new biopsy instruments. the eventual development of steerable single fi ber scanning endoscopes with multi-wavelength imaging may change our current concepts of the bronchoscopes and how we can use them. journal compilation © 2010 asian pacifi c society of respirology pg 03-02 diagnostic tests pleural effusions are common and often present diagnostic challenges. the new british thoracic society guidelines 2010 on investigation of pleural effusions detailed some of the new approaches to undiagnosed pleural effusions. traditional teaching recommends measurement of blood and pleural fl uid protein and ldh levels as the fi rst step of investigation to categorize the effusion into a 'transudate' and 'exudate' using light's criteria. the need to apply this to all effusions is questionable in 2010. current efforts focus on the development of disease-specifi c diagnostic tools incorporating clinical, radiologic and biochemical parameters. • elevated ntpro-bnp levels in pleural fl uids are useful in confi rming cardiac failure as the etiology of a pleural effusion, especially in patients whose fl uid may be falsely elevated into the 'exudative' range by concurrent diuretic therapy. • pleural ntpro-bnp levels are elevated in cardiac failure effusions, but not in other transudative effusions (eg hepatic hydrothorax). • pleural fl uid ntpro-bnp appears a better marker than pleural fl uid bnp. variations in accuracy may also in part depend on the commercial kits used. adenosine deaminase: • ada measurements in pleural fl uids are useful in the diagnosis of tb pleural effusions with a sensitivity and specifi city of 92 and 90% respectively. limiting the test to lymphocytic pleural effusions will further improve the diagnostic accuracy. • ada is cheap and fast to perform and is now widely used in endemic countries. false positives can occur with bacterial infections, rheumatologic effusions, and occasionally malignant effusions. false negatives are uncommon, and therefore present a valuable 'rule-out' test in regions of low tb rates. • ada is at least as diagnostically useful as pleural fl uid total interferon-gamma levels. • igras have been tested in pleural fl uid and blood of patients with tb pleural effusions in several studies. the diagnostic sensitivity and specifi city are poor and igras are not recommended for the investigation of tb pleuritis. • serum mesothelin is a fda-approved test for the diagnosis and monitoring of mesothelioma. • pleural fl uid mesothelin adds information to pleural fl uid cytology in the diagnosis of mesothelioma, providing a diagnostic sensitivity of 71% (specifi city 90%). elevated pleural fl uid mesothelin levels suggest epithelioid or biphasic mesothelioma or occasionally metastatic carcinomas. procalcitonin: • early evidence suggest that serum level of procalcitonin may aid differentiation of pleural infection from pleural effusions of non-infective etiologies. the value of pleural fl uid procalcitonin level is limited. management strategies imaging guidance for pleural procedures: • pleural procedural complications are often under-estimated and underreported. studies have now shown that mandatory imaging guidance (especially bedside pleural ultrasound), and restricting procedural privilege to certifi ed trained clinicians can signifi cantly reduce complication rates from pleural procedures. this practice is now incorporated into many national and professional society guidelines. intrapleural therapy for pleural infection/empyema: • recent clinical trials on intrapleural delivery of fi brinolytics alone have failed to improve important clinical outcomes of pleural infection. however, the combination of tissue plasminogen activator and dnase has shown promising results. • recent studies have revealed increasing concerns of complications of talc pleurodesis, and randomized studies have shown a much lower success rate than previous non-randomized literature, even in selected patients. the concept of drainage without needing to create pleurodesis has growing appeal and the use of indwelling pleural catheters is now regarded as fi rst-line therapy in increasing number of centers. chronic respiratory disease (crd) is non-communicable respiratory disease including asthma, chronic obstructive pulmonary disease (copd), allergic rhinitis, idiopathic pulmonary hypertension, hypersensitivity pneumonitis, occupational respiratory disease. among these crd asthma and copd are important for regional health. facts of asthma 300 million people suffer from asthma. 255,000 people died of asthma in 2005. prevalence of asthma has increased or is increasing. asthma is the most common disease among children over 80% of asthma death occurs in low and lower-middle income countries. asthma is underdiagnosed and under-treated (who, 2010). facts of copd copd is a life-threatening lung disease that interferes with normal breathing. it is more than a "smoker's cough". an estimated 210 million people have copd worldwide. more than 3 million people died of copd in 2005, which is equal to 5% of all deaths globally that year. almost 90% of copd deaths occur in low-and middle-income countries. the primary cause of copd is tobacco smoke (through tobacco use or second-hand smoke). the disease now affects men and women almost equally, due in part to increased tobacco use among women in high-income countries. copd is not curable, but treatment can slow the progress of the disease. total deaths from copd are projected to increase by more than 30% in the next 10 years without interventions to cut risks, particularly tobacco smoking (who, 2010). prevention and control of crd in asia pacifi c were held by dokkyo medical university group, later designated as who collaborating centre for prevention and control of crd (du-wcc). seven countries and a district in asia pacifi c joined the meeting. prevalence of asthma in adults was reported from 0.99 to 7.2% with a median of 4.0% based on 13 reports. prevalence of childhood asthma (13-14 y/o) was from 0.8 to 13.2% with median of 7.7% based on 13 reports. prevalence of copd was 3.5 to13.1% with a median of 7.1% based on 9 nation-wide surveys. in spirometry-based survey reported, prevalence of copd was 8.5% in adults 40 years and over in japan, 8% in adults 45 years and over, and 8.2% in adults 40 years and over in china. management in most of the countries gina and gold were adopted for their national guidelines. major risk factors for crd, especially for copd were smoking and indoor air pollution for cooking/heating. pharmacological early interventions have been reported to improve the prognosis of asthma and copd. occupational respiratory diseases are disorders which are induced by occupational and industrial conditions. providing information of the risks of industrial activities would reduce this disorder. strategic direction for the prevention and control of crd most of crd are treatable and at least partially preventable. development of user-friendly guides for prevention and control of crd for offi cials in health care, fi rst-line health-care givers and patients and their family and its implementation would decrease the burden of these crd. the scientifi c foundation of asthma diagnosis and management has grown in leaps and bounds. evidence-based strategies to control asthma and treat its exacerbation are published yearly in the gina guidelines. the 10-year finland study showed that these strategies work. while cases treated did increase (through better detection), the hospital days and cost per case markedly decreased. the study also showed that widespread adaption and effective implementation of these strategies is best done through a national program. cmes for medical practitioners are important but are of limited reach. all stakeholders must be enlisted to buy-in. for asthma, the target stakeholders are the health care personnel, nurses and village health volunteers included; the patients and their families; the government and its public health offi cials; the asthma advocacy groups; the community-at-large; and the pharmaceutical industry. the idea is to present the problem to them, include their inputs in the formulation of the plan, collegially decide on target indicators of success and engage them to work for the implementation of the program in the context of what each one can do best. duplicating the finnish experience is a big challenge in the asia pacifi c region. while most countries have their own adaptation of the gina guidelines, few have working national asthma programs. in developing economies, the health infrastructure is not that well developed yet to absorb all guideline recommendations. spirometry may not be widely available nor affordable. government spending for health is commonly below the 5% of gdp level that who recommends. in the philippines, signifi cant out-of-pocket health expense is borne by the patient. furthermore, programs like tb control, dengue treatment and malaria eradication, which are no longer concerns in developed countries, compete for the meager public health funds. for low income countries, the international recommendations may have to be rewritten to emphasize on simple algorithm for separating non-infectious from infectious respiratory illnesses; practical objective measurements for diagnosis and management such as peak fl ow; available, affordable, and low-risk medications recommended for asthma control; and a simple regimen for recognizing severe asthma (gina). to be viable, the national asthma program will have to piggy back to the existing national health delivery infrastructure which must ensure, among others, access to free or cheap medication. lung cancer and copd commonly coexist in smokers, and the presence of copd increases the risk of developing lung cancer. in addition to smoking cessation and preventing smoking initiation, understanding shared mechanisms in these smoking-related lung diseases is critical, to develop new methods of prevention, diagnosis and treatment of lung cancer and copd. common mechanisms may involve infl ammation, abnormal repair, oxidative stress, epithelial-mesenchymal transition, altered nicotine receptor biology and epigenetic alterations. strategies to study genomics and epigenomics, in addition to gene-environment interaction, will yield greater insight into the shared pathogenesis of lung cancer and copd. copd clinical guidelines are important to guide diagnosis and management of people with copd. the australian 'copdx' guidelines are evidence-based guidelines that are prepared by the australian lung foundation and thoracic society of australia and new zealand. relevant literature is searched regularly and evaluated by a clinical committee. updates are then produced regularly during the year. challenges regarding critical appraisal, resources and dissemination to clinicians will be discussed. national copd guidelines in this region are different from country to country, but basically are adapted from gold. copd prevalence in 12 asia pacifi c countries and region estimated by regional copd working group was 6.3%. vietnam has the highest prevalence: 6.7%. the copd management and guideline implementation problems in the asia pacifi c region are: smoking, biomass using are common; continuous medical education (cme) for health workers are not compulsory; lack of device and personnel for performing proper spirometric tests; over burden for health workers; low access to medical care and low affordability for copd medications. all of these problems result in that copd diagnosis are mostly in late stage, high rate of emergency room visit, icu admission and hospitalization. the consensus is expected to cover following resolutions: reducing the smoking and biomass smoke exposure, screening for copd in large scale using questionnaires and confi rming by spirometry, advocacy for compulsory cme on copd, establishing asthma and copd outpatient care unit (acocu) in different levels of health care settles and introducing copd medications into insurance medication list. infections caused by environmental mycobacteria are more common than tuberculosis in many parts of the world. the more than 120 species of mycobacteria have similarities, but generally the diseases and hosts fi t in specifi c patterns. disease due to environmental mycobacteria can be diffi cult to diagnose and treat and can confuse workup for tuberculosis. mycobacteria have low virulence and even lower invasiveness. they form biofi lms that protect them and allow long term persistence. the treatment is often frustrating for the patients and physicians. learning their metabolic mechanisms and attacking them should be the strategy for combating the disease caused by these organisms. lung cancer and copd commonly coexist in smokers, and the presence of copd increases the risk of developing lung cancer. in addition to smoking cessation and preventing smoking initiation, understanding shared mechanisms in these smoking-related lung diseases is critical, to develop new methods of prevention, diagnosis and treatment of lung cancer and copd. common mechanisms may involve infl ammation, abnormal repair, oxidative stress, epithelial-mesenchymal transition, altered nicotine receptor biology and epigenetic alterations. strategies to study genomics and epigenomics, in addition to gene-environment interaction, will yield greater insight into the shared pathogenesis of lung cancer and copd. airway epithelial cells, which are the fi rst line of cells to contact with inhaled substances such as microorganisms, play an important role in the host defense by two major mechanisms. first, they actively contribute to the innate immune system by recognition of the pathogen and production of antimicrobial substances and cytokines. second, they provide a passive barrier function that prevents invading microorganisms, air pollutants and airborne allergens into the internal milieu. on the other hands, airway epithelial cells are involved in the production of airway infl ammation in asthma and copd by excessively and un-regulatory expressing pro-infl ammatory and pro-allergic cytokines, executing apoptosis and losing barrier function. there is very close relationship between epithelial barrier function and innate immune response of epithelial cells. for instance, losing barrier function results in not only allowing foreign substance and pathogens to invade into the internal milieu but also enhancing innate immune responses. asthma and copd are different diseases, but they may have the same mechanism in the pathogenesis of exacerbation of these diseases in term of losing epithelial barrier functions. in this symposium, we will present the latest information on and the regulatory mechanism of airway barrier function and discuss in the context with asthma and copd pathogenesis and exacerbations. key words; airway epithelial cells, barrier function, asthma, copd patients with severe and diffi cult-to-treat asthma ("refractory asthma", approximately 5% of total asthma) have impaired health status refl ected by persistent symptoms, severe airfl ow limitation and frequent asthma exacerbations despite taking maximally recommended doses of inhaled corticosteroids and long-acting β 2 -agonists. a better understanding is thus needed regarding factors associated with such troublesome condition and, in our cross-sectional observational study, clinical and demographic characteristics of patients fulfi lling the american thoracic society workshop criteria for refractory asthma (ajrccm, 2000, group a) were compared with those of patients with severe persistent asthma defi ned on the basis of the gina guideline (group b). there were no signifi cant differences between the two groups with respect to age, gender, smoking status, disease duration, pulmonary function (fev 1 , pef, dlco), or markers of airway infl ammation in the induced sputum (eosinophils, neutrophils, ecp, tryptase). however, in contrast to group b, all patients in group a were adult-onset, and 93% of the patients already had severe symptoms at the time of disease onset. prevalence of atopy, postbronchodilator fev 1 /fvc ratio and fev 1 reversibility were signifi cantly less in group a than in group b. patients in group a complained of copious amounts of phlegm associated with chronic sinusitis and/or chronic bronchitis, and showed high concentrations of mucin (muc5ac + muc5b) in the sputum. in addition, nasal clearance time assessed by saccharine test was signifi cantly longer in the group a than in the group b patients, indicating impairment of airway mucociliary clearance. these fi ndings and other pathophysiological and clinical data suggest that "refractory asthma" may be a different form of asthma (phenotype) rather than a progression of asthma severity during follow-up of natural history of the disease. furthermore, it is likely that irreversible airway narrowing possibly due to airway remodeling and airway mucus hypersecretion are important factors contributing to the pathogenesis of severe and diffi cult-to-treat (refractory) asthma. the results prompt for further longitudinal studies and interventions to defi ne the mechanisms of this unique phenotype of asthma. journal compilation © 2010 asian pacifi c society of respirology drug development is a long and expensive process. on average it takes at least 10 years and more than a billion dollars to develop a compound from basic science discovery through clinical trials and fi nal approval by regulatory authorities of a new therapeutic. one of the main obstacles to development of new compounds is the diffi culty in obtaining good pre-clinical proof of effi cacy for a new drug. most of this is currently obtained from experiments using animal models of disease or cell lines, neither of which refl ect well human disease nor predict whether responsiveness in these models predicts responsiveness in human disease. recent studies have focused on developing methods that employ human cells or tissues taken from the relevant organ and from relevant patient populations. of these models, the explant model, which uses whole tissue samples, is the closest to the in vivo situation because it maintains the complex cell-to-cell interactions. in asthma, studies have shown that this model can sometime be even better than in vivo study. thus, for example, the explant model vivo offers several advantages over in vivo allergen challenge of asthmatic volunteers. first, repeat bronchoscopy to sample the airways after initial allergen challenge is not required. second, tissue responses of more severe asthmatics, who for safety reasons cannot be challenged with allergen in vivo, can be studied. third, problems of dilution of secreted mediators during bal are avoided and released mediators are not consumed by in-coming infl ammatory cells, thus increasing the sensitivity of the model. finally, and most importantly when seeking pre-clinical proof of concept of drug effi cacy, the model allows testing of novel compounds at an early stage before its full safety profi le is established, a process that is both expensive and time-consuming. we have previously shown that the asthmatic airways generate increased t cell chemotactic activity compared to healthy controls. using a highly selective ccr4 antagonist we have recently shown that the ccr4-chemokine axis plays a key role at least in the traffi cking of t cells into the asthmatic airways. having established this, we then showed that predominantly the ccr4+ t cells are recruited in response to allergen stimulation. we have further shown that the selective removal of these ccr4+ t cell from blood signifi cantly reduced allergic infl ammation as shown by a marked reduction in the production of the th2 cytokines il-4, il-5 and il-13 but with no consequences for th1 responses. taken together, our studies have strongly suggested that inhibiting the migration of t cell to the asthmatic airway by targeting ccr4 is likely to abrogate the allergic infl ammation in the airways without affecting immune responses that serve to protect against infection. these studies have also shown the value of using such ex vivo models of asthma to provide proof of concept for new drugs, giving the pharmaceutical industry the necessary pre-clinical proof to proceed with confi dence into further clinical development. sleep-disordered breathing (sdb) or obstructive sleep apnea (osa) is a prevalent but largely undiagnosed sleep disorder. apnea-hypopnea index (ahi: the number of apneas and hypopneas per hour of sleep) is used to classify sdb severity. in icsd-2 (international classifi cation of sleep disorders ver. 2), "osa syndrome" was defi ned as ahi ≥ 5 with hypersomnolence/ daytime symptoms or as ahi ≥ 15 regardless of the symptoms. epidemiological studies clarifi ed that sdb is associated with increased likelihood of hypertension, cardiovascular disease, stroke, motor vehicle accidents, depression, diminished quality of life, and even mortality. clinical guidelines for hypertension put weights on sdb as a cause of hypertension. international diabetes federation (idf) made a consensus statement on sleep apnea and type 2 diabetes. "overlap syndrome" (coexist of copd and sdb) was reported to have much higher mortality than sdb alone. sleepiness was thought to be a major symptom for osa syndrome. it is true that there is a signifi cant trend that the severe the sdb is the more the subjects had sleepiness. however, the majority of sdb subjects (even the majority of subjects with ahi ≥ 15) do not have sleepiness (ess: epworth sleepiness scale >10). the berlin sleep questionnaire was used to screen high or low risk subjects for sdb. four-item screening tool was also developed (gender, bmi, blood pressure, snoring frequency). these tools may be useful, when certifi ed with sleep monitoring in each population. prevalence of ahi ≥ 15, estimated from two-stage sampling, was 9-14% in male and 2-7% in female. two-stage sampling is oversampling the subjects with sleepiness or snoring to perform sleep monitoring, and weighting of results to the survey sample. when all the participants underwent sleep monitoring, the prevalence of ahi ≥ 15 was 22-25% in male and 10-12% in female. there is a strong need for better recognition, screening and treatment of sdb. more studies are needed, especially for long-term outcomes of asymptomatic sdb. genome-wide association studies may be useful to elucidate causes or underlying mechanisms of sdb. continuous positive airway pressure (cpap) is a standard treatment for patients with obstructive sleep apnea (osa), especially for moderate to severe osa. the mechanism of action is to provide a pneumatic splint to preserve upper airway. the pressure level required to maintain airway patency is determined by manual pressure titration by a sleep technologist during attended laboratory polysomnography (psg) to eliminate obstructive respiratory-related events (e.g., apneas, hypopneas, respiratory effort-related arousals [rera], and snoring). despite wide acceptance as a standard therapy for treatment of osa patients, very few pap titration protocols have been published so far, and there are inconsistency and variations in cpap titration protocol among clinical sleep laboratories. for this reason, the pap titration task force developed evidence-and consensus-based standardized pap titration protocol and published its guideline entitled "clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea" in journal of clinical sleep medicine 2008. in this lecture, i will explain about manual cpap titration guidelines as below based on publications which are recommended by positive airway pressure titration task force of the american academy of sleep medicine (aasm): (1) important considerations prior to cpap titrations. (2) criteria for cpap pressure to be increased. (2) minimum and maximum starting cpap pressure. (3) an interval and minimum pressure to eliminate obstructive respiratory events. (4) different algorithms for cpap pressure to be increased to eliminate obstructive respiratory events observed for patients ≥12 years and <12 years. interventional bronchoscopy has typically been associated with obstructive tumor removal to regain central airways patency; such interventions, whether with rigid or fl exible instruments were also limited to the navigable fourth or fi fth generation airways. tissue destructive techniques included ablative heat techniques (laser, electrocautery and argon plasma coagulation), cold techniques (cryotherapy) and mechanical coring with the rigid bronchoscope. a current new crop of tissue debridement devices include modifi cations of established technologies: fl exible co2 laser fi ber usable beyond the trachea, cryotherapy using non-contact surface cryospray, rotational microdebrider devices adopted from otolaryngology, pulsating balloon resectors. the latter three devices do not involve heat that may cause post-treatment infl ammation and cartilage destruction and subsequent airway fi brosis or malacia. previous direct intra-lesional injection, with mitomycin or steroid was directed towards non-malignant fi brotic lesions, conversely on-going studies with cytotoxic agents (5fu) and compounds thought to have immune adjuvant effects (pts) are demonstrating potential utility in endobronchial tumors. photo-dynamic therapy (pdt) compounds with shorter half-lives require fewer bronchoscopies and have shortened photo-toxicity side effects. therapeutic bronchoscopic image guided interventions (bigi) have benefi tted from advances in "virtual bronchoscopic navigation" software available to improve reaching small peripheral lesions. for radiation therapy for focal lung lesions not resectable because of patient co-morbidities or preference, the accurate placement of fi ducial markers (gold) are used to direct high-dose rate external-beam intentiy modulated radiation therapy (imrt) including cyberknife machine. trials also demonstrate feasibility and effi cacy of treating peripheral lesions by high-dose rate (hdr) brachytherapy through catheters placed with image guidance. one area of new focus is bronchoscopy in the management of chronic obstructive lung diseases (old) including emphysema and severe asthma. based on lung volume reduction surgery for severe emphysema with heterogeneous distribution and air-trapping, non-surgical bronchoscopic lung volume reduction (blvr) has taken on a number of innovative approaches including exclusion by spigots (watanabe), valves (emphysys, spiration), metallic coil retraction (pneumrx), airway bypass to relieve trapped gas (broncus), atelectasis by bio-glue (aeris) or by heat steaming (uptake). although none of the clinical devices in trials have shown unqualifi ed success, some devices are now being marketed (europe), or are available on a compassionate basis for management of broncho-pleural fistulas (bpf). airway radio-frequency ablation (rfa) of airway smooth muscle is usa-fda approved for management of severe asthma. future innovations in interventional bronchoscopy will likely incorporate advances in diagnostic bronchoscopy such as video-autofl uorescence and "in-vivo biopsy" techniques to guide local endobronchial therapies for in-situ cancers; image processing software to design custom stents for compromised airways; and drug-eluting stents to maintain airway integrity in a variety of malignant and benign airway diseases. pleuroscopy describes a minimally invasive procedure that provides the physician a window into the pleural space. it refers to a procedure that is performed in an endoscopy suite or operating room with the patient under conscious sedation and local anesthesia. increasingly these procedures are being performed by nonsurgeon pulmonologists to diagnose pleural pathology such as pleural effusions or pleural carcinomatosis; talc pleurodesis and chest tube placement under direct visual guidance. pleuroscopy was fi rst conceived in a report dated 1866, which documented the fi rst endoscopic examination of the pleural space by richard cruise in a 11 year old girl with empyema. it did not gain widespread application until 1910 when hans christian jacobaeus published his technique also known as the jacobaeus operation. in this procedure he created a pneumothorax by severing adhesions using galvanocautery that collapsed the underlying lung, and allowed safe entry as well as unobstructed examination of the pleural space. since then, pleuroscopy has been applied both as a diagnostic and therapeutic tool. for a hundred years, rigid endoscopic instruments such as stainless steel trocars and telescopes have been pivotal in the technique. smaller telescopes and instruments have been applied with excellent views of the pleural space and comparable diagnostic yield. a signifi cant advance is the creation of fl exrigid pleuroscope that is fashioned like the fl exible bronchoscope. the fl ex-rigid pleuroscope consists of a handle, and a shaft that measures 7 mm in outer diameter, 22-cm proximal rigid portion and 5-cm fl exible distal end. the fl exible tip is movable by a lever on the handle, which allows 2-way angulation 160 degrees up and 130 degrees down. it has a 2.8 mm-working channel that accommodates biopsy forceps, needles and other accessories, and is compatible with various electrosurgical and laser procedures. the fl ex-rigid pleuroscope allows autoclaving. a notable advantage is its easy interface with existing processors and light sources made by the manufacturer for fl exible bronchoscopy or gi endoscopy at no additional costs. although certain endoscopic characteristics such as nodules, polypoid masses and "candle wax drops" are suggestive of malignancy, early stage mesothelioma can resemble pleural infl ammation. autofl uorescence and narrow band imaging have been incorporated to white light pleuroscopy to enhance diagnostic accuracy. both modes of imaging discriminate early malignant lesions from non-specifi c infl ammation, aid in selecting appropriate sites for biopsy and better delineate tumor margins for more precise staging, but are of little value at present in clinical practice since most patients with malignant pleural effusions have extensive pleural involvement that is easy to diagnose with white light pleuroscopy for pleuroscopic guided pleural biopsies, specimens obtained with the rigid forceps are larger than those with the fl ex-rigid pleuroscope since they are limited by size of the fl exible forceps, which in turn depends on the diameter of the working channel. the fl exible forceps also lacks mechanical strength in obtaining pleural specimens of suffi cient depth, which can be overcome by the use of insulated tip (it) diathermic knife. full thickness parietal pleural biopsies are obtained with it knife, and the electrocautery knife is particularly useful when smooth thickened lesions are encountered, of which nearly half are due to mesothelioma. to improve analgesia before talc poudrage, lidocaine can be administered to the parietal pleura via spray catheter inserted through the working channel of the pleuroscope. similarly talc poudrage can be administered under visualization using the spray catheter. with the introduction of the fl ex-rigid pleuroscope, similar in design and handling to the fl exible bronchoscope, and compatible with standard light source and video processor available in most bronchoscopy suites, pleuroscopy will enjoy an expanded interest as more practitioners acquire the skill. the fl exrigid pleuroscope is a signifi cant invention in the history of minimally invasive pleural procedures and will revolutionize the practice of pulmonary medicine by replacing conventional biopsy methods in future. the common known causes of interstitial lung disease (ild) are drug toxicities, environmental exposures and collagen vascular disease (cvd). among these causes, drug or environmental exposures can be excluded by medical history. however, cvd-related ild may often be confused with idiopathic interstitial pneumonia (iip) because the radiological and histological characteristics of cvd-related ild are often indistinguishable from those of their idiopathic counterparts and occasionally, systemic manifestations of the underlying cvd develop several months or years after the diagnosis of ild. early diagnosis of occult cvd is very important in patients presenting with ild, because there are signifi cant differences in prognosis between the iip and cvd-ild groups. patients with cvd-ild survive longer than those with iip. additionally, different treatment regimens and evaluation for additional systemic involvement or malignancy may be needed in patients with cvd-ild. although, cvd-ild and iip is often considered indistinguishable, there are some clues that can help clinicians detect occult cvd in patients presenting with ild. first, a thorough medical history and physical examination can detect occult cvd. its importance cannot be overemphasized. the cvds frequently associated with ild are scleroderma, rheumatoid arthritis (ra), polymyositis/dermatomyositis (pm/dm), sjögren's syndrome, mixed connective tissue disease (mctd), undifferentiated connective tissue disease (uctd) and systemic lupus erythematosus (sle). therefore, symptoms and signs that occur frequently in these cvds should be searched for. these symptoms and signs include raynaud's phenomenon, gastro-esophageal refl ux disease, telangiectasis, dry eyes, dry mouth, arthritis, the characteristic skin lesions of dm (heliotrope rash, gottron's papule, mechanic's hand) and various serositis etc. second, certain fi ndings on hrct can help in the diagnosis of cvd. although the parenchymal abnormalities are similar to their idiopathic counterparts, the presence of airway-related abnormalities -mosaic attenuation, bronchial wall thickening, and nodules -are more common in cvd-ild. the presence of extrapulmonary abnormalities may also provide important clues to the underlying diagnosis. patients with cvd more frequently have pleural and pericardial effusions, pericardial thickening, enlarged pulmonary artery and esophageal dilatation. hrct can also show joint abnormalities or soft tissue calcifi cations. third, there are some serologic tests that can help in the diagnosis of cvd even in patients with obscure symptoms. high titers of antinuclear antibody and rheumatoid factor are often found in patients with cvd. other more disease specifi c tests currently available are anti-ssa/ssb antibody for primary sjögren's syndrome, anti-scl-70 antibody for systemic sclerosis, anti-jo-1 antibody for pm/dm, anti-u1 ribonucleoprotein (rnp) antibody for mctd, antibody to cyclic citrullinated peptides (ccp) for rheumatoid arthritis and so on. fourth, the frequent pathologic patterns of ild associated with cvd are nsip, uip, op, lip and dad. among them, nsip is the most frequent pathologic pattern in cvd-ild. therefore, pathologic pattern consistent with nsip should raise suspicions about the possibility of cvd. other pathologic fi ndings that may be suggestive of an underlying cvd include follicular bronchiolitis and lymphoid follicles. however, it is still impossible to diagnosis all occult cvds at the outset of ild because the initial clinical presentations can be essentially indistinguishable from those of iip. therefore, close follow up for a developing cvd is very important especially in patients with nsip. the role of pathological diagnosis for non-neoplastic lung disease is important and critical. however, agreement of pathological diagnosis in iips may not be that high. despite the expectations after publication of 2002 ats/ers classifi cation of idiopathic interstitial pneumonias (iips), interobserver variability in the pathological diagnosis of iips is still problematic. there are several major reasons for the poor agreement in pathological diagnosis of iips in which the biggest reason is a lack of specifi c and diagnostic fi nding to any type of iips. in the session, i would fi rst share the virtual steps of making diagnosis on surgical lung biopsy with audience, indicate recent data of inter-observer agreement in iips cases, and then, introduce factors behind the poor agreements followed by several possible solutions to this important issue. children's interstitial lung disease (child) differs from adult interstitial lung disease in that certain classic idiopathic pneumonias described in adults are not seen in children and unique forms of interstitial lung disease are found in infants and young children but not in adults. the most common form of idiopathic interstitial pneumonia in adults is idiopathic pulmonary fi brosis (ipf), also known as cryptogenic fi brosing alveolitis (cfa), a progressive and fatal disorder, defi ned pathologically as usual interstitial pneumonia (uip). uip is characterized by a heterogeneous mixture of normal lung, mild infl ammation, and fi brosis and the presence of fi broblastic foci, felt to be the leading edge of fi brosis. previously, although many infants and children were given the diagnosis of ipf, cfa, or uip, they did not have the characteristic fi broblastic foci. thus although the uip pattern is occasionally seen in the context of another primary disorder, such as abca3 mutations, true ipf/uip does not exist in children. the tendency to use the term ipf in children merely serves to obscure the real diagnosis and creates anxiety in families whose affected children may not actually have a fatal disorder. unique conditions have been described mainly in infants and young children that do not occur in adults. these include growth abnormalities, inborn errors of surfactant metabolism, neuroendocrine cell hyperplasia of infancy (nehi), and pulmonary interstitial glycogenosis (pig). growth abnormalities occur as a consequence of an early insult to the lung that results in retarded or arrested lung development and alveolar simplifi cation. risk factors associated with growth abnormalities include prematurity, congenital heart disease, and chromosomal defects, most commonly down syndrome. the major advance in child has been the discovery of genetic mutations that lead to surfactant dysfunction. these include mutations in the sp-b, sp-c, abca3, ttf-1, and gm-csfra genes. clinical presentation can vary from severe respiratory failure at birth leading to death (sp-b, abca3 mutations) to more insidious onset with chronic lung disease (sp-c, abca3, ttf-1, gm-csfra mutations). nehi is a chronic benign form of child presenting in the fi rst year of life with tachypnea, crackles, hypoxemia, characteristic features of symmetric ground glass densities in the right middle lobe and lingula and central lung regions on hrct, and a mixed restrictive/obstructive pattern on infant lung function testing. lung biopsy shows increased numbers of neuroendocrine cells and neuroepithelial bodies in the distal airways with otherwise normal lung architecture. pig is another benign form of child seen in infants and characterized by interstitial widening with glycogen-rich interstitial cells. pig is seen as a primary disorder ("pure" pig) and as a patchy disorder seen in the background of some other primary disorder, such as a growth abnormality ("patchy" pig). in conclusion, it is important to recognize the differences between pediatric and adult interstitial lung disease so that the proper diagnosis and prognosis can be given and the appropriate treatment applied. journal compilation © 2010 asian pacifi c society of respirology not to treat acute bronchitis with initial antibiotics, with the following exceptions. those at high risk of serious complications because of preexisting co-morbidity, patients over 65 years of age with acute cough and two or more of the following, or patients over 80 years of age with one or more of the following; (1) admission to hospital in the previous year (2) type 1 or type 2 diabetes (3) history of congestive heart failure (4) current use of oral glucocorticoids. clinicians need to address patients' concerns, perspectives, and expectations about the treatment and explain to patients that antibiotics are not necessary for a self-limiting respiratory tract infection. physicians should tell patients that antibiotic use increases the risk of an antibiotic resistant infection. and physicians also need to spend time answering questions and offer a contingency plan if symptoms worsen, and advise patients to return for a consultation if symptoms are not starting to settle in accordance with the expected course of the illness or if symptoms worsen signifi cantly. some physicians are certain that patients will benefi t from antibiotics and prescribe for expectation of fast relief. they are mostly comfortable with their prescribing decisions by their clinical experiences. taiwan's study demonstrates substantial variations among physician groups in the practice of prescribing antibiotics for viral respiratory infections. older physicians and those practicing in clinics rather than medical centers were signifi cantly more likely to prescribe antibiotics, and dispensing doctors in contrast to those without dispensing privileges or on-site pharmacists were signifi cantly highly prescribing antibiotics. statistical data from nhic in korea showed that general physicians in clinics prescribe antibiotics in 68% of acute bronchitis patients, while doctors at tertiary hospitals showed less but still fairly high rate of 51%. efforts and interventions to reduce the potentially inappropriate prescription of antibiotics should target modifi able factors. quality improvement (qi) strategies like using active clinician education, delayed prescriptions and targeting management, may yield reductions in antibiotic use. anti-tussives are occasionally useful and can be offered for short-term symptomatic relief of coughing. a meta-analysis and systematic review found that beta-2-agonists were not effective for the treatment of acute bronchitis or cough of <4 weeks duration in children or in adults unless airfl ow obstruction was present. summary acute bronchitis is one of most commonly diagnosed and treated diseases in daily clinical practice. however, since it is mostly a self limiting disease, the standardization of diagnosis and treatment has long been neglected leaving various controversies in the management, particularly the use of antibiotics. the inappropriate prescription of antibiotics for acute bronchitis will surely lead to the emergence of resistant organisms in the community let alone the increase of socio-economic burden. further attention and research is needed for the reasonable approach to the treatment of acute bronchitis in order to prevent overuse of antibiotics and improve health-economy. prevalence acute bronchitis is one of the most common conditions encountered in clinical practice, accounted for approximately 10 million visits to korean physicians in 2008, and consistently ranks among the top 10 reasons for ambulatory visits in the united states. defi nition acute bronchitis refers to a clinical syndrome distinguished by a relatively brief, self-limited infl ammatory process of large and midsized airways that is manifested predominantly by cough with or without phlegm production which lasts for up to 3 weeks and absence of fi ndings suggestive of pneumonia. acute bronchitis should be distinguished from acute exacerbations of chronic bronchitis and acute infl ammation of the small airways -asthma or bronchiolitis. those with underlying lung disease, congestive heart failure, or a compromised immune system are considered to be at high risk for complications of acute bronchitis. etiology acute bronchitis is one of the most common causes of antibiotic abuse. in healthy communities, there is little evidence of bacterial infection in people with bronchitis, but there are few practical studies to distinguish between bacterial and viral bronchitis. within this context, the use of antibiotics to treat acute bronchitis is controversial but common in real practice. viruses are usually considered the most common cause of acute bronchitis but have been isolated in a minority of patients. those isolated in acute bronchitis include, in order of frequency of occurrence, are infl uenza, parainfl uenza, respiratory syncitial virus (rsv), coronavirus, adenovirus, and rhinovirus. the yield of specifi c pathogens varies according to several factors, including the presence or absence of an epidemic, the season of the year, and the infl uenza vaccination status of the population. bacterial pathogens are thought to play a very minimal role in acute bronchitis. the bacteria that have been causally linked to acute bronchitis in otherwise healthy individuals include only mycoplasma pneumoniae, chlamydophila pneumoniae and bordetella pertussis. antibiotic treatment of patients with pertussis is indicated to limit transmission, but there are no compelling data to support the prospect that cough will be less severe or less prolonged with antibiotic therapy. clinical manifestations acute bronchitis cannot be distinguished from upper respiratory infections in the fi rst few days. acute bronchitis is suggested by the persistence of cough for more than fi ve days, and most often lasts from 10 to 20 days. approximately 50% of patients with acute bronchitis report the production of purulent sputum. it usually represents sloughing of cells from the tracheobronchial epithelium, along with infl ammatory cells, and does not signify bacterial infection. pulmonary function test fi ndings consistent with bronchial hyperresponsiveness are common. fev1 less than 80% at the initial visit was present in 40% of adults from the mid western united states with no history of underlying lung disease. pft abnormalities are usually transient, typically resolving after 2 to 3 weeks, although they may last as long as 2 months. fever is a relatively unusual sign in acute bronchitis and, when accompanying cough, suggests either infl uenza or pneumonia. diagnosis acute bronchitis is established in a patient who has the sudden onset of cough, with or without sputum expectoration, and without evidence of pneumonia, the common cold, acute asthma, or an acute exacerbation of chronic bronchitis. the absence of the following fi ndings reduces the likelihood of pneumonia suffi ciently to eliminate the need for a chest radiograph: (1) heart rate >100 beats/min; (2) respiratory rate >24 breaths/min; (3) oral body temperature of >38°c; and (4) chest examination fi ndings of focal consolidation, egophony, or fremitus. chest radiography should be reserved for use in patients with any of these fi ndings or cough lasting >3 weeks. an exception, however, is a cough in elderly patients; pneumonia in elderly patients is often characterized by an absence of distinctive signs and symptoms. rapid diagnostic tests exist for several pathogens currently linked to acute bronchitis. patients with severe paroxysmal cough, with or without post-tussive vomiting should be evaluated for pertussis regardless of the immunization history. rapid tests should be used primarily when the suspected organism is treatable, the infection is known to be circulating in the community, and the patient has suggestive symptoms or signs. treatment statistical data from korea national health insurance corporation (nhic) shows that approximately 50-60% of patients with acute bronchitis receive antibiotics despite the evidence that, with few exceptions, they are ineffective. meta-analyses of randomized, controlled trials all concluded that routine antibiotic treatment is not justifi ed. the decision not to use an antibiotic should be addressed individually and explanations should be offered because many patients expect to receive an antibiotic based on previous experiences and public expectations. main challenges for appropriate antibiotic use in acute bronchitis are the diagnosis is based on clinical fi ndings, without standardized diagnostic methods and sensitive or specifi c confi rmatory laboratory tests. how to identify accurately the few patients who are seriously ill or whose symptoms could be meaningfully ameliorated by prompt antibiotic treatment is not standardized. recent studies have suggested that the annual decline in fev1 is greater in gold stage ii than in later stages of the disease. (1) if the decline in pulmonary function predominantly occurs early in the course of the disease, then it is logical that diagnosis and intervention aimed at reducing the progression of the disease should mainly occur in the early stages of the disease. severity of copd at diagnosis differs enormously on where it is done: population based studies, screening or hospital patients. epidemiologic studies: prevalence, underdiagnosis and severity there are increasingly more data on the prevalence and distribution of copd from around the world. the prevalence of chronic obstructive pulmonary disease (copd) varies from country to country, mainly due to the effects of cumulative exposure to smoking and the increased life span of the population. (2) (3) (4) (5) systematic review of epidemiological studies concluded that the prevalence of copd, in adults aged 40 years and more, worldwide ranges around 9-10%. (6) these differences may be related, at least in part, to differences in genetic background, smoking habits and exposure to other environmental risk factors, and are accompanied by differences in diagnostic rates and in management of the disease around the world. there is a large underdiagnosis of copd with about only one out of three or four of all subjects fulfi lling diagnostic criteria of copd identifi ed by the health care system. (2) (7) (8) copd in general population is diagnosed at earlier stages. data from latinamerica (platino), similar from those from spain, showed severity was distributed as follows: stage i, 59 % and stage ii, 33.8%. screening for copd screening, combined with smoking cessation advice, help motivated smokers to attempt quitting smoking. (10) in general practice, when individuals were preselected on the basis of smoking age and respiratory symptoms chronic cough was a better predictor of airfl ow obstruction than other symptoms, such as wheeze and dyspnoea. age was also a good predictor of obstruction; smokers over 60 with cough had a 48% chance of having an obstruction. (11) diagnosis at the hospital the decrease in lung function is gradual. the disease is usually diagnosed late because patients may adapt to the condition or doctors may not notice the symptoms. by then, the patient is diagnosed at the hospital, when lung function is often poor, sometimes less than 50% of normal. the relationship between lung disease and increased body weight can take two forms: the effects of increased body weight on the normal respiratory system and the association of increased body weight with diseases of the respiratory system. obesity (body mass index, bmi, greater than 30 kg/m 2 ) can reduce normal static lung volumes (principally functional residual capacity, but also total lung capacity and residual volume at very high bmi), ventilation (particularly during sleep and exercise) and gas exchange (increased gas transfer). the epidemic of overweight and obesity has been associated with the increased prevalence of asthma through proposed mechanisms such as dietary effects, reduced lung volumes and lung recoil affecting airway responses to breathing, a general infl ammatory effect and through associated sedentary lifestyle. however more recent epidemiological data suggests the association between asthma and obesity is not as close as once thought. overweight and obesity clearly are associated with the high prevalence of obstructive sleep apnoea with increased body weight increasing the likelihood of upper airway collapse on a background of reduced upper airway dimensions and snoring and reducing minute ventilation in patients with obstructive sleep apnoea, predisposing to hypoventilation and chronic hypercapnoeic respiratory failure. the increased load to breathing also affects breathing, especially during sleep, in patients with respiratory muscle weakness or abnormal chest wall mechanics due to kyphoscoliosis or previous chest wall surgery such as thoracoplasty. increased body weight will also exacerbate the effects on symptoms of existing chronic respiratory diseases including asthma, chronic obstructive pulmonary disease and interstitial lung diseases. avoidance of weight gain and continued efforts at weight loss remain an important goal in patients with respiratory disease. this presentation will be a review of recent fi ndings and implications from imaging studies in asthma. the use of 3-dimensional imaging in asthma has provided useful insights into the understanding of pathophysiology of disease, which may have implications on how asthma is treated. small airways disease plays a major role in asthma and has traditionally been diffi cult to probe. however, the combined use of new imaging methods combined with complex lung function has provided useful insights into pathophysiology. findings and implications from hrct, pet, spect and mri will be discussed. the assessment of pulmonary function has changed very little over the past 30 to 40 years. all techniques performed in the laboratory still view the lung as a very simple single compartment unit. measures of volume and fl ow only assess disease in the medium to large airways whilst the small airways receive relatively little attention. however there are a number of emerging techniques on the horizon that have the potential to give great insight in to the periphery of the lung where most respiratory disease emanates. the measurement of mechanics using the forced oscillation technique and gas mixing using the multiple breath nitrogen washout test are now emerging as very powerful tools for assessment of peripheral lung function. in this presentation we will be discussing the state of the art in terms of assessing pulmonary function and what may we expect to see in the future. copd is a major public health problem in asia. copd prevalence was 8.2% (12.4% in males and 5.1% in females) in china (>40 yrs), 9.5% in japan (>40 yrs). in most of the developing countries in asia, copd is always underdiagnosed by physicians owning to lack of routine spirometry test and only based on symptomatic diagnosis. smoking is the most important risk factor contributing to development of copd. however, copd prevalence was 4.2% in chinese non-smokers (>40 yrs) and 8.8% in korea (>45 yrs), similar to those in mexico city (6.2%) and caracas (6.6%). in china, non-smokers accounted for 38.6% of copd patients compared with 24.9% in usa and 22.9% in the uk. exposure to environmental tobacco smoke (passive smoking) and indoor air pollution (particularly the coal and biomass combination) may contribute to the higher prevalence of copd in developing countries. to reduce the risk factors (smoking, coal or biomass fuel for cooking, indoor and outdoor air pollution) are the priority for reducing the prevalence in the asian developing countries. government in some countries had made some effect in tobacco control and reducing air pollution. unlike hypertension or diabetes, the management of copd is only based on symptomatic treatment, owing to lack of specifi c biomarkers. annual lung function test with spirometer is the only parameter in detecting early stage of copd. data showed that more reversibility of fev1 was demonstrated in stages i-ii copd patients with ics/laba or tiotropine administration, as compared with those in stages iii-iv. an intervention study at the community level has shown that early intervention (improvement of indoor ventilation, bronchodilators) was able to reverse rapid annual fev, decline in copd patients. more affordable medication should be developed in the low income countries. data showed that oral administration of carbocysteine (thio compounds) reduced exacerbation rate by 24.5%, which was consistent with inhaled administration of fluticasone/formoterol (seretide) or tiotropine. in addition, orally administered low dose teophylline (100 mg, bid) improved pre-bronchodilator fev, and reduced exacerbation rate. there was a synergistic effi cacy in fev1, with the combination of teophylline and inhaled corticosteroids. chronic obstructive pulmonary disease (copd) is characterized by the presence of airfl ow limitation due to loss of lung elasticity and/or airway narrowing. the pathological hallmark of loss of lung elasticity is emphysema and airway wall remodeling contributes to the airway narrowing. using computed tomography (ct) these lesions can be assessed by measuring low attenuation areas (laa) and airway wall thickness/luminal area, respectively. recently, copd has been widely recognized as a systemic infl ammatory disease, and body weight loss is one of its clinical features. traditionally, the patients who had copd with predominant emphysema and a low body mass index (bmi) were called "pink-puffers". however, the relationship between body weight loss and emphysema had not been assessed. based on these back ground, we have evaluated the body composition, emphysema and airway dimensions in 201 copd patients using ct images. bmi was signifi cantly lower in the emphysema dominant phenotype compared to the airway dominant phenotype. furthermore, bmi correlated with laa% (ρ = −0.557, p < 0.0001) but not with wa%. chest subcutaneous fat mass was also correlated with laa% (ρ = −0.307, p < 0.0001). these data indicated that the "pink-puffer hypothesis" is correct in some aspects. next, we postulated that reduced leptin and leptin receptor signaling could contribute the development of emphysema. serum leptin was correlated with bmi which was correlated with dl co /v a . the expression of leptin and leptin receptor was evaluated pcr in 52 human lung tissues. both genes were detected in the lung tissues, but the expression of leptin gene was low. the leptin receptor gene expression was signifi cantly lower in copd patients and it was signifi cantly correlated with dl co /v a . the leptin receptor gene expression in the lung did not correlated with body weight. these data suggested that the patients' physique can be associated with the relative contribution of emphysematous lesions in copd and leptin and leptin receptor system might affect the mechanism of developing emphysema. nutritional support has been one of possible clinical approaches as a copd therapy these days. however, its effect is still controversial. to clarify the relationship between low bmi and emphysema and to classify the phenotypes of copd based on the patients' physique may help to fi ne the defi nite targets for nutritional support even in the early stage of copd. journal compilation © 2010 asian pacifi c society of respirology sy 07-03 at present copd is often only treated in gold stage iii or iv 1 . it is without question possible to diagnose copd earlier. if spirometry would be more readily performed in general practice, copd could be diagnosed in gold stage i and ii, as is evident from the practice of "spirometry days" organized by the belgian thoracic society in which the majority of the patients were diagnosed in gold stage ii 1 . whether gold stage i and ii truly represent the "early" stages of the disease may be debated 2 , but this defi nition of early copd could certainly be used as an operational defi nition. it is clear now that spirometry is required for early diagnosis of copd 3 . although at present there is no irrefutable evidence that early treatment of copd is warranted, there is accumulating suggestive evidence that early treatment of copd may result in better outcomes. this evidence is primarily related to secondary analyses of the torch 4 and uplift 5,6 studies. first, it was demonstrated in a secondary analysis of the torch study, that inhaled corticosteroids, long-acting betaagonists and their fi xed combination reduced the rate of decline of fev 1 by 13, 13 and 16 ml, respectively 7 . if treatment indeed reduces the progression of the disease, then an easy case for early treatment is made. in addition, a subgroup analysis demonstrated that except for the effect on the sgrq (st. george's respiratory questionnaire) all other treatment effects were numerically larger in gold stage ii than in gold stage iii and iv 8 . a subgroup analysis of the uplift study demonstrated numerically greater treatment effects in gold stage ii as well. in addition, tiotropium reduced the rate of decline of fev 1 in these patients (albeit only by 6 ml/year), which was not the case in the later gold stages 9 . finally, in patients not taking any medication at the onset of the study (maintenance naïve patients) tiotropium substantially reduced the rate of decline of fev 1 and the rate of deterioration of the sgrqscore 10 . taken together these data demonstrated that: 1) large treatment effects were obtained in early disease; 2) indications of disease modifi cation were present in early disease. hence, they support early treatment of copd. pulmonary rehabilitation is now the standard of care for patients with chronic obstructive pulmonary disease (copd) who remain symptomatic despite bronchodilator therapies. combining the best of interprofessional, personalized and evidence-informed care, pulmonary rehabilitation allows clinicians and their patients to realize signifi cant benefi ts in a variety of important patientcentered copd outcomes. the fundamental elements required for an effective pulmonary rehabilitation program will be discussed, and the scientifi c evidence supporting their effectiveness will be summarized. issues relating to optimal site of delivery, components of effective rehabilitation programming, duration of rehabilitation, timing of rehabilitation and target populations will be reviewed. recent developments in this rapidly expanding area will also be highlighted. lastly, methods to establish or enhance an existing pulmonary rehabilitation program will be discussed, with the goal of fully realizing the many substantive benefi ts of pulmonary rehabilitation in copd. however, only very low gene transfer seen after a second dose with either 14 day and 7 day spacing. we attribute this to rapid upregulation of neutralizing antibodies against adenovirus. anti-tumor humoral immune responses were seen almost all patients with reactions seen against known meso tumor antigens (sv40 large t antigen and mesothelin) and against unknown proteins in cell lysates. given the caveats of phase 1 trials (small numbers, different doses, heavily pretreated patients), we still saw clinical responses (defi ned as prolonged stable disease, prolonged survival, partial or complete responses by modifi ed resist criteria, decreased metabolic tumor activity by pet scanning, or "mixed" responses) in about 1/3 of the patients. we are currently administering two doses spaced only three days apart. this appears to be well tolerated. based on strong preclinical data supporting the combination of gene therapy and chemotherapy, we have started a trial using ad.inf instillation into the fi rst treatment cycle of fi rst line (cisplatin/pemetrexed) or second line chemotherapy (gemcitabine). our groups is also generating "designer chimeric t cells" in which a single chain antibody fragment is linked to the transmembrane and cytoplasmic regions of the t-cell receptor. this artifi cial t-cell receptor is then transduced into t-cells that are then reinfused. the t-cells are then activated by cells expressing mesothelin. preclinical data show striking activity against mesothelin-expressing tumors in mice. mesotheliomas make large amounts of the immunoinhibitory cytokine, transforming growth factor-beta (tgf-β). preclinical studies using tgf-β blockers have shown activity in mouse models of mesothelioma and a clinical trial using an anti-tgf-β antibody is now underway at the university of pennsylvania. in summary, gene-based and immunotherapies are being actively studied in mesothelioma and have shown some promising results. future trials are focusing on combining these approaches with chemotherapy and surgery. given the relatively mild and non-overlapping toxicities, we believe these, or other gene therapy and/or immunologic approaches will soon become part of the standard therapeutic armamentarium. the burden of asbestos-related diseases (ards), in particular mesothelioma, has been shouldered mostly by the developed countries of the west. this is a consequence of the heavy dependence on asbestos use up to around the 1970s by those countries. in contrast, the majority of asian countries started to depend on asbestos since then and has not yet reached the suffi cient latency time for the related diseases to manifest. japan is an exception, because it heavily used asbestos during the period to catch-up with the west. japan has now become one of the global epicenters of ards. it is a tragic consequence of experiencing the burden of ards that many developed countries decided to move towards banning asbestos or a de facto non-dependence. in the asia-pacifi c, this group comprises australia, new zealand, japan, korea and singapore (the "forerunner" group in terms of ards). in contrast, the many other countries in asia still use asbestos at substantial levels, turning asia into the world's center of asbestos consumption today. however, as these countries start to use up the latency time, and manage to improve medical recognition, reporting and recording, ards will soon emerge as a major public health issue in the region. early indications of this forecast do exist. not only should lessons be learnt from the experiences incurred by the "forerunner" group of countries, but more importantly, they should crystallize in international collaboration involving national administrators, academia, ngos and international organizations, for the effective recognition and countermeasures of ards. i will also refer to the progress made and hurdles encountered by the asian asbestos initiative and the who global plan of action on the elimination of asbestos-related diseases. at the international level, ards present a domino-effect that needs to be coped with. sy 08-03 interstitial pneumonia (ip) can be classifi ed into two groups in terms of known causes. pneumoconiosis, drug-induced pneumonitis, radiation-induced pneumonitis, and hypersensitivity pneunonitis (hp) are categorized as ip with known causes. on the other hand, idiopathic interstitial pneumonias (iips), which include idiopathic pulmonary fi brosis (ipf), nonspecifi c interstitial pneumonia (nsip), cryptogenic organizing pneumonia (cop), and desquamative interstitial pneumonia (dip), have no known causes. most physicians tend to diagnose of ip patients as iips without intensive examinations. however, some environmental and occupational lung diseases, especially asbestosis and chronic hp, should carefully be differentiated from iips. asbestosis is one type of pneumoconiosis, which is induced by asbestos exposure with a latent period of usually more than 10 years. bilateral fi ne crackles can be frequently auscultated and pulmonary function test shows restrictive and diffusing impairments. chest hrct shows subpleural dot, subpleural curvilinear shadow, ground glass opacity, interlobular septal thickening, traction bronchiectasis, and honeycombing. in our case series of asbestosis (n = 51) in yokosuka, a town of shipyard for more than 100 years, honeycombing was seen in 6 cases (12%). chronic hp is an allergic disease induced by long-term exposure to antigens. major causative antigens are avian dropping and feather, mold, and bacteria. chest hrct tends to show traction bronchiectasis and honeycombing in advanced stages, which are similar to ipf. in surgical lung biopsy, most cases are classifi ed as nsip-like and uip-like patterns. to clarify the importance of unrecognized exposure to avian antigen, we precisely reviewed 56 patients with bird-related chronic hp. in the 56 patients, 24 patients were bird-breeders with direct exposure to avian antigen by contacting their own birds, whereas 32 patients seemed to be exposed to wild birds, neighbor's birds, feather duvets, stuffed bird, and fertilizer with chicken droppings without recognition of avian contact. number of patients is very limited both in asbestosis and chronic hp, which suggests that there is a small group of subjects who are susceptible to develop pulmonary fi brosis after exposure to asbestos or antigens. however, genetic background of susceptibility to pulmonary fi brosis has not elucidated. in our case series of chronic hp (n = 184), 22 cases (12%) had the fi rst-degree family members with ip, who might have common environmental and/or genetic factors. further studies are needed to determine host susceptibility to pulmonary fi brosis, which might contribute to clarify the pathogenesis of ip. long acting beta-2 agonists has been in the doctors' armory of asthma medications for about 20 years (available in 1990 in uk and 1994 in usa). there is little doubt that laba when combined with inhaled corticosteroids can improve asthma symptoms for a subsection of people with asthma, and is generally superior to add-on leukotriene receptor antagonist. 1 indeed addition of laba to inhaled corticosteroids is in all major asthma guidelines as a step-up therapy. however, after the salmeterol multicentre asthma research trial was prematurely halted, a focus on effi cacy and safety of the wide use of laba severe pulmonary arterial hypertension (pah) is a fatal condition associated with complex pathobiology. vasoconstriction, thrombosis, and remodeling of the pulmonary vessel wall contribute to increased pulmonary vascular resistance in pah. the pathology of pulmonary hypertension can be classifi ed into endothelial, smooth muscle, and/or adventitial lesions, although not all compartments of the pulmonary artery wall are involved in each case of severe pah. the classic lesion of severe pah is the plexiform lesion, an abnormal proliferation of predominantly endothelial cells. smooth muscle thickening can be seen in all forms of the disease but is not a constant feature in the idiopathic pulmonary arterial hypertension. the adventitia is often markedly remodeled in patients with certain forms of collagen vascular diseases associated with severe pah, most notably scleroderma. the obligatory lining of pulmonary arteries with a monolayer of endothelial cells is disrupted in severe pah. the three-dimensional vascular pattern is rather suggestive of an intravascular tumor-like proliferation (tumorlet), instead of a retracted scar if this lesion would represent an abnormal healing to an injury to the vascular wall. the evidence of a tumorlike endothelial cell proliferation was provided by the demonstration that plexiform lesions in patients with idiopathic pah were preferentially monoclonal, whereas similar lesions in lung of patients with secondary pah due to congenital heart malformations were polyclonal. monoclonality was also observed in plexiform lesions of patients from anorexigen-induded pah. vasoconstriction has been related to abnormal potassium channels and to endothelial dysfunction. endothelial dysfunction leads to impaired production of vasodilators such as nitric oxide and prostacyclin along with overexpression of vasoconstrictors such as endothelin (et)-1. many of these abnormalities not only elevate vascular tone and promote vascular remodeling but also represent logical pharmacological targets. recent genetic and pathophysiologic studies have emphasized the relevance of several mediators in this condition, including nitric oxide, prostacyclin, et-1, serotonin, angiopoietin-1, and members of the transforming-growth-factor-beta superfamily. disordered proteolysis of the extracellular matrix is also evident in pah. the unraveling of the pathobiology of severe pah may lead us to novel therapies and approaches to better treat the disease. unfractionated heparin (ufh) and low-molecular-weight-heparin (lmwh), acted by enhancing the ability of antithrombin (at) to inhibit coagulation proteases, have been used as initial anticoagulant therapy for vte. they are delivered intravenously or by subcutaneous injection. subcutaneous fondaparinux, a synthetic pentasaccharide with specifi c anti-factor xa activity, is also recommended as the initial treatment for vte according to recent guideline. oral vitamin k antagonists, acting by reducing the activity of several coagulation proteases, are used for long-term anticoagulation. the major disadvantage of vitamin k antagonists is the need for frequent coagulation monitoring to maintain a therapeutic level. new anticoagulants, including oral direct thrombin inhibitors, such as dabigatran, and oral anti-factor xa inhibitors, such as rivaroxaban and apixaban, are emerging in recent clinical trials.11 these new drugs may replace heparins and vitamin k antagonists, which are expected to have a huge impact on the treatment of vte in the near future. thrombolytic therapy should immediately be used in patients with massive (high risk) pte. the effect of thrombolysis in patients with submissive (intermediate risk) pte remains controversial. further stratifi cation of these patients is necessary. patients with multiple poor prognostic indicators such as right heart dysfunction, thrombolytic therapy should be considered. several countries have started to support activities raising public awareness of vte, with the goal to decrease mortality and morbidity. in us, national institutes of health (nih) and centres for disease control (cdc) have fostered thrombosis activities to improve the prevention of vte and its long-term complications. in the united kingdom, a thrombosis group has been formed to promote awareness among parliamentarians about the risk and management of vte; to increase knowledge of its causes, effects, and treatments; and to monitor the implementation of government initiatives and other researches being and this program has corrected the wrong perception that pte is a rare disease in china pulmonary hypertension (ph) is a common complication of chronic respiratory diseases, such as chronic obstructive pulmonary disease (copd) or interstitial lung diseases (ild). ph associated with respiratory diseases is classifi ed as diagnostic group iii according to the current clinical classifi cation of dana point 2008. it is suggested that the pulmonary vascular abnormalities originate at an early stage of the diseases. the functional (hypoxic vasoconstriction) and morphological factors (vascular remodeling, destruction of the pulmonary parenchyma) explain the elevation of pulmonary vascular resistance that leads to ph. the ph is mild to moderate in copd with mean pulmonary artery pressure (mpap) usually ranging between 20 and 25 mmhg, however, worsening during exercise and exacerbations. a small proportion of copd patients may exhibit severe ph defi ned by a resting mpap >35 to 40 mmhg, whose prognosis is particularly poor. ph is relatively frequent in advanced ild, particularly in idiopathic pulmonary fi brosis, which predicts a poor prognosis. the diagnosis of ph is suggested by doppler echocardiography, but the confi rmation still requires right heart catheterization. the potential treatments of ph associated with respiratory diseases are as follows: 1) treat underlying lung disease; 2) provide supplemental oxygen therapy when appropriate; 3) rehabilitation; 4) treat right heart failure; 5) consider vasomodulator therapy; and 6) consider lung transplantation when indicated. journal compilation © 2010 asian pacifi c society of respirology sy 11-01 tobacco use is the most common preventable cause of death. about half of the people who don't quit smoking will die of smoking-related problems. the epidemic varies among countries and is increasingly affecting developing countries, where most of the world's smokers (82%) live. close to half of all men in low income countries smoke daily and this has been increasing. legislation the framework convention on tobacco control (fctc) was adopted by who member countries in may 2003 to commit all countries to protect nonsmokers from tobacco smoke in public places, to eliminate all tobacco advertising, promotion and sponsorship, to require warning labels of cigarette packs and to prohibit misleading tobacco product descriptors such as "light" and "mild". even though many countries have passed legislation mandating smoke-free environments and the total global population covered by comprehensive smoke-free laws increased from 3.1% to 5.4% in one year, the overwhelming majority of countries still have no smoke-free laws, very limited laws, or ineffective enforcement. compliance with smoke-free laws is low. treatment to aid smoking cessation support for smoking cessation or "treatment of tobacco dependence" refers to a range of techniques including motivation, advice and guidance, counselling and appropriate pharmaceutical aids, all of which aim to encourage and help tobacco users to stop using tobacco and to avoid subsequent relapse. the success of these interventions depends on their synergistic use in the context of a comprehensive country tobacco-control strategy. in many countries, provision for treatment, training of health-care providers, education and information on the wide use of cessation is scarce. therapies, as well as fi nancial resources are limited and rarely incorporated into standard health care. also, smoking cessation is not seen as a public health priority and is not necessarily approached as a key tobacco-control strategy. smoking cessation services are most effective when they are part of a coordinated tobacco control programme. brief cessation counselling is relatively inexpensive when integrated into existing primary health-care services, is usually well received by patients, and is most effective when it includes clear, strong and personalized advice to quit. communication technologies -such as telephone quitlines, text messaging, interactive telephony, and online counselling -as well as psychological and behavioural modifi cation therapies, offer important support. cessation prescription medicines, available in many countries like nicotine replacement therapies, bupropion and varenicline can double the likelihood that someone will successfully quit. bronchiectasis is an old disease that we all treat, but surprisingly little about this disease has been well studied. the defi nition, diagnosis, natural history, pathogenesis and treatment are all uncertain. this talk examines these points in the light of new information about biofi lms and "normal" bacteria. it asks more questions than it answers, but the questions raise thoughts on whether our usual approaches are the best. the mediastinum is generally split into three compartments strictly for the purpose of classifi cation of the most likely abnormality in the individual compartment. there are no anatomical boundaries or fascial planes that divide one compartment from the other. classically, the compartments have been classifi ed as anterior, middle, and posterior. a recent change in classifi cation has used the categories of anterior, middle-posterior, and paravertebral compartments. approximately 50% of mediastinal tumors are located in the anterior compartment, 25% in the middle compartment, and 25% in the posterior compartment. asymptomatic masses are more likely to be benign than malignant, and symptomatic masses are more likely to be malignant than benign; however, there is a large variation the most common tumors in the anterior mediastinum consist of thymoma, lymphoma, germ cell tumors, and thyroid tumors. thymoma is by far the most common anterior mediastinal tumor and approximately 2/3 are encapsulated and non-invasive while 1/3 are invasive. the most common paraneoplastic syndromes associated with thymoma include myasthenia gravis, hypogammaglobulinemia, and pure red blood cell aplasia. benign teratomas occur in both male and females, while malignant germ cell tumors of the mediastinum are almost exclusively in males. lymphoma can occur most commonly in the anterior or middle mediastinum and may be associated with systemic symptoms and occasionally superior vena cava syndrome. the most common abnormalities in the middle mediastinum include lymphoma, granulomatous disease, and developmental cysts. bronchogenic cysts are almost always benign, although they can cause symptoms such as obstructive pneumonia and are generally treated with surgical resection. recent mediastinal compartment classifi cation has switched from posterior mediastinum to naming this the paravertebral compartment. it is located posterior to an imaginary line drawn to connect the anterior aspects of the vertebral bodies on the lateral chest radiograph. the most common tumors in this location are neurogenic tumors, meningoceles, or thoracic spine lesions. the most common neurogenic tumors in adults are neurilemomas, and they are almost always benign. neurofi bromas also occur in this compartment. they are frequently benign, but may be malignant, especially in patients with neurofi bromatosis. in these individuals, malignant tumors of the nerve sheath origin are more common. ganglioneuroma, ganglioneuroblastoma, and neuroblastoma are more common neurogenic tumors in children or adolescents.. cough is an important lung defense. in a refl ex manner, noxious agents are expelled from the airways as these are sensed by the receptors in the airway epithelium. in addition to appreciating its cleansing function, understanding cough refl ex is important in the diagnosis and treatment of common clinical conditions. most diseases associated with cough are transient. a problem arises when cough persists and becomes chronic. an in-depth search for the underlying pathology is warranted since treatment directed to the cause of the cough is curative in over 90% of cases. an anatomic-diagnostic protocol ensures a systematic search for cough etiology but unfortunately, this approach can be lengthy and in many settings, impractical. thus an empiric syndromic approach is now recommended. this paradigm shift is borne by the following premises: (1) the current awareness of the relative frequency of the disorders (alone or in combination) that can cause cough; (2) the sensitivity and specifi city of many (but not all) diagnostic tests in predicting the cause of cough has been established; (3) a sequential evaluation and treatment for the common causes of cough using a combination of selected diagnostic tests and empiric therapy has been proven effective; and (4) a sequential and additive therapy is often crucial because more than one cause of cough is frequently present. a recent study by dr. aileen wang on "the management of chronic cough in a tertiary center: an asian perspective" showed that even in a filipino immunocompetent population, the most common causes of chronic cough is asthma, post-nasal drip syndrome (pnds) and gastroesophageal refl ux disease (gerd). the study concluded that: (1) the accp recommendations are generally applicable to an asian setting. research of viruses, their structure, pathogenicity and host-interactions has burgeoned. we now understand how viruses infect cells, how they replicate, how they interfere with host defences and how they interact with other tissue events and pathologies. rhinovirus infection causing the common cold is the most frequent and 'common' infection in humans. it is also implicated in most exacerbations of asthma and copd. the patho-biology of rhinovirus will be used to illustrate virus pathogenicity, virus-host-interactions and to highlight potential future therapeutic options. sy 12-02 much hope has been placed in the discovery of biomarkers to help understand the mechanisms of diseases such as copd, help stratify the disease better and guide treatment. it is also hoped that some of these could speed up drug discovery by serving as surrogate markers that respond to novel drugs within a shorter timescale than is the case with current drug trials in which the main outcome is the spirometric measurement of forced expiratory volume in one second (fev1). although studies in patients with copd have identifi ed several biomarkers, most of these need to be validated and their prognostic value is unclear. many of the markers have been identifi ed in blood and although it is recognised that there are non-pulmonary consequences of copd, some of which can be viewed as systemic biomarkers measured and/or generated in the lungs are likely to be most informative. there are several methods to identify and quantify biomarkers of copd and different biological samples (blood, bal, sputum and lung tissue) can be used to provide material for such analyses. whilst most studies to date used commercial immunoassays (elisa), there has been a keen interest in applying unbiased approaches such as proteomics. we have recently completed a large programme of work which applied 2-dimenshional electrophoresis and mass spectrometric analysis to identify biomarkers of copd. induced sputum was obtained from copd patients with a spectrum of disease severity and control subjects. two-dimensional gel electrophoresis and mass spectrometric identifi cation of differentially expressed proteins was fi rst applied to induced sputum from gold stage 2 copd patients and healthy smoker control subjects. initial results thus obtained were validated by a combination of immunoassays (western blotting and elisa) applied to a large subject cohort. the biomarkers were localised to bronchial mucosa by immunohistochemistry. of 1325 individual protein spots identifi ed, 37 were quantitatively and 3 qualitatively different between the two groups. 40 protein spots were subjected to tandem mass spectrometry, which identifi ed 15 separate protein species. seven of these were further quantifi ed in induced sputum from 98 individuals. using this sequential approach, two of these potential biomarkers (apolipoprotein a1 and lipocalin-1) were found to be signifi cantly reduced in copd patients when compared to healthy smokers. their levels correlated with fev1/fvc, indicating their relationship to disease severity. in summary, a potential role for apolipoprotein a1 and lipocalin-1 in innate defence has been postulated previously; our discovery of their reduction in copd indicates a defi cient innate defence system in airways disease that could explain increased susceptibility to infectious exacerbations. persistent chronic infl ammation, repetitive tissue injury, and dysregulated epithelial repair leading to tissue remodeling and fi brosis are the hallmarks of chronic lung diseases, such as chronic obstructive pulmonary disease (copd), chronic asthma, pneumoconiosis, pulmonary fi brosis and sarcoidosis. the innate immunity system with its pattern recognition receptors are recently identifi ed to involve in the pathogenesis of these chronic lung diseases. the neutrophilic infi ltration of the airway mediated through t h 17 and il-17 family may play an important role in steroid-resistant asthma and status asthmaticus. in addition, the epigenetic modifi cation of gene expressions and cellular senescence may modulate the progression of chronic asthma and copd. histone deacetylase 2 (hdac2), which can be inactivated by oxidative stress or pi3k-akt pathway, may regulate corticosteroid-related anti-infl ammatory response. manipulation of hdac2 activity is a new treatment direction in steroid-resistant asthma and copd. sirt1, a nad + -dependent deacetylase, is an important signaling pathway related to cell survival, dna repair, and apoptosis. the sirt1 is decreased in alveolar macrophages of smokers and copd patients, and associated with pro-infl ammatory response through the activation of nf-κb. understanding the complexity of infl ammatory and epigenetic regulations in chronic lung diseases may potentiate the development of novel therapies. fibrosis is a common fi nding in chronic lung diseases, with tgf-β-related pathways play important roles. myofi broblasts are the principal effective cells in the fi brogenic process. they can be evolved from the activation of resident pulmonary fi broblasts, marrow-derived fi brocytes, or the trans-differentiation of pulmonary epithelial cells through epithelial mesenchymal transition (emt). further understandings on the emt process in lung tissue repair may help to elucidate the mechanism of lung remodeling and fi brosis. in addition, lung stem/progenitor cell study appears to be a new and potential fi eld in lung injury and repair. it is anticipated that more clear mechanisms behind lung remodeling and fi brosis can be identifi ed and new treatment modalities be developed accordingly. sy 12-04 cancers are genetic diseases with constitutional genomic variations that are present in normal cells contributing to an individual's risk of developing cancer such as lung cancer. furthermore, cancer cells acquire genetic mutations and genome wide changes in their dna as well as their epigenome compared to their normal cellular counterparts. some of these mutations have turned out to be important driver mutations and are associated with exquisite sensitivity to targetted cancer therapies. some of these genetic changes include egfr and eml4-alk fusion gene mutations. epigenetic changes include methylation abnormalities as well as histone modifi cations, and possess the characteristic of potential reversibility which is attractive for the development of new therapies. the human genome project and rapid technological advances including deep dna sequencing have contributed signifi cantly to the ability to detect cancer specifi c genetic, genomic and epigenomic aberrations. these genetic and genomic abnormalities have promise across the translational spectrum from identifying individual susceptibility to cancers, early diagnosis markers, molecular pathology and tailoring of treatment (predictive biomarkers) as well as informing on outcome (prognostic biomarkers). much work remains to be done to validate clinical utility and translate these potential useful biomarkers into useful clinical tools. this session will review some of the developments in the genomics and epigenomics of lung cancer and mesothelioma. asthma is a disease that is diagnosed largely on a history of variable symptoms and the demonstration of variable airway narrowing. it is associated with airway infl ammation (cd4 t-lymphocytes, b-cell lymphoid aggregates, macrophages, eosinophils and, in adults, neutrophils) and airway wall remodelling (airway wall thickening, principally increased airway smooth muscle and deposition of collagen below the basement membrane, with minor encroachment on the airway lumen). it is not associated with a prominent effect on the lung parenchyma. the cause(s) of asthma remains unknown and the severity of disease remains largely constant. copd is diagnosed with a spirometer and is defi ned as a fi xed reduction in fev1, relative to fvc. when caused by cigarette smoke it is associated with airway infl ammation (cd8 t-lymphocytes, b-cell lymphoid aggregates, macrophages and neutrophils) and airway remodelling (mild increase in airway wall thickness including airway smooth muscle with encroachment on the airway lumen) and tissue destruction (emphysema and loss of small conducting airways). the severity of copd increases with age and continued exposure to irritants. copd has many causes including smoking cigarettes, burning of biomass fuels, asthma and early life respiratory illness and exposures (viral infections, bronchopulmonary dysplasia). as a group, patients with asthma have reduced lung function, in relation to disease severity, and may have a slightly increased rate of decline in lung function. patients with asthma who smoke have reduced lung function and an accelerated decline in lung function. apart from stopping smoking there is no current treatment that can improve the rate of decline in lung function in patients with asthma or copd. therefore prevention, early intervention and uncovering the unknown environmental and genetic contributions to airway diseases remain critical. sy 13-02 situation the isaac and ariap studies have showed the different prevalence but heavy burden caused by asthma in asia pacifi c countries is common. goals with inhaled corticosteroids and other medications, the goals in managing asthma in developing countries should attain those stated in gina: control of symptoms, maintaining normal activity levels, normal pulmonary functions, preventing asthma exacerbations, avoiding adverse affects and preventing asthma mortality. in developing countries, avoiding the abuse of short-acting beta 2 agonists, systemic corticosteroids and antibiotics is also a major problem. accessing medical care and medications is crucial. steps a core group, preferably at an university medical center, is the basic step. the asthma and copd outpatient care unit (acocu) run by this core group will help in getting experience and capacity building. the following steps are gina dissemination and implementation, patient club formation, increasing awareness, training doctors and nurses, advocacy, researches, efforts for the availability of affordable asthma drugs, and multiplying acocu in the whole country. the sustainability of acocu is assured by successful implementation of gina. a network of acocu will encourage and improve the activities of acocus. successful provincial acocu will encourage the building of district and even commune acocus. diffi culties the continuous medical education for all doctors on gina, the medication affordability, spirometers and mechanism to maintain an acocu. despite the advances in asthma diagnosis and treatment, slta cases continue to present in the er, sometimes leading to unnecessary mortalities. these are highly preventable situations with inhaled steroid based chronic therapy. with expert care, most patients get through er/icu urgent phase with good outcomes. these strategies are published and updated regularly in the international asthma guidelines. the finnish experience confi rms that a national program that pushes for implementation of guideline recommendations is able to reduce asthma hospitalizations and cost of care. not all countries have such a program but in most developed economies, the cost of asthma care including medications is covered provided the guidelines are followed. unfortunately, even in these affl uent countries, a subset on patients still lands in the er with sltas. while there may have been a failure of health care delivery, the cross-country existence of this problem raises the prospect that some patients are prone to life-threatening exacerbation. sltas may have its own specifi c risk factors that are distinct from the risk factors for simple hospital admission for acute severe asthma. by defi ning risk factors for slta within the population of those admitted to hospital with acute asthma, we may be able to develop specifi c interventional strategies to reduce its occurrence. reported slta risk factors include advancing age, chronic severe asthma, increased infl ammation markers, asthma exacerbated by pneumonia and low nutritional status. other risk factors include recent hospital admission, prior intubation, steroid dependence, non-adherence to inhaled corticosteroids, psychological or psychosocial problems, lack of access to medical care, lower fev1, and current cigarette-smoking. a specifi c phenotype of severe brittle asthma has been reported. the backbone of er management for slta includes quick assessment of severity, oxygen therapy, early use of systemic steroids and repetitive saba bronchodilator administrations. enhancements include the use of saba with high intrinsic effi cacy, the addition of ipratropium in refractory cases and the concurrent administration of inhaled corticosteroid for its non-genomic, airway edema-reducing effect. mgso4 can also be considered for refractory cases. when ventilator support is needed, niv may be attempted in some patient. for intubated cases, the ventilatory strategy includes low tv and rr, high i : e ratio, and monitoring for the development of dynamic hyperinfl ation. the burden of the slta problem can be mitigated by identifying its phenotype a priori, providing preventive therapy before actual exacerbation occurs and putting in the er/icu the appropriate treatment protocols. journal compilation © 2010 asian pacifi c society of respirology available treatment of asthma using inhaled corticosteroids and long-acting inhaled β2-agonists (labas) is highly effective and safe. importantly, it is also relatively inexpensive. however, many patients remain poorly controlled despite the use of optimal treatment. most advances in asthma therapy have been achieved by improving these drugs and more recently several promising once-a-day labas have been developed. new corticosteroids are also being developed with differential effect on trans-activation and trans-repression of pro-infl ammatory transcription factors, thus giving them a better therapeutic index. the big challenge in asthma is posed by corticosteroid unresponsiveness which is relative and therefore requires high doses to achieve symptom control which inevitably leads to side-effects. one option being pursued is to develop activators of the nuclear enzyme histone-deactylase (hdac)2 which is recruited to the gene initiation site of pro-infl ammatory mediators. there is an increasing appreciation that asthma is not a single disease and is increasingly seen as a syndrome consisting of several phenotypes. so far, two relatively clear subsets have been identifi ed: eosinophilic and neutrophilic forms of asthma. with this notion in mind, attempts are being made to develop more-specifi c inhibitors for a range of mediators with the hope that sub-phenotypes of asthma will be identifi ed that respond well to either single mediator inhibitors or a combination of these. a number of cytokine modulators have been tested in clinical trials, the most notable example being anti-tnf inhibitors which is felt to be more relevant to neutrophilic asthma. unfortunately, large clinical trials with tnf inhibitors have not found them to be very effective. treatment with blocking antibody for the eosinophils growth factor, il-5, has been slightly more effective, with early clinical trials showing that the treatment reduces the frequency of exacerbations in patients who have eosinophilia. whilst the exact mechanisms leading to the development of these two subphenotypes is not fully understood, it is thought that eosinophilia represents a risk factor for exacerbations which has led to eosinophils counts in sputum being used as a guide to treatment; this has been benefi cial in reducing exacerbations. neutrophilic forms of asthma represent a special challenge because patients with neutrophilia tend not to respond well to corticosteroids, making them reliant on bronchodilators. such patients' asthma may be driven by mechanisms that involve il-17 which induces the production of neutrophil chemoattractants by the epithelium, which makes il-17 and its chemo-attractant axis a target for novel therapies. the major unmet need in asthma is the treatment of infections. there are early indicators of antibiotic treatment (macrolides) being effective in the treatment of severe asthma. but the real hope comes from novel strategies aimed at the effects of viruses which are the cause of most acute exacerbations, both in milder and more severe forms of disease. recent studies have identifi ed a defi ciency in type i interferons (ifn), the production of which by the bronchial epithelium -the prime target of virus infection -has been shown to be reduced when epithelial cells from asthmatic are grown in culture and infected ex vivo. in the acute care setting, niv must usually start without delay to avoid further deterioration and an increased likelihood of failure. thus, the decision to start must be made quickly based on a bedside assessment. i recommend a simple two step process, the fi rst of which is to assess the patient's need for ventilatory assistance. if the patient has increased dyspnea (moderate to severe) and evidence of increased work of breathing including tachypnea (>24/min in obstructive diseases and >30/min in hypoxemic respiratory failure), increased accessory muscle use or abdominal paradox, the patient needs ventilatory assistance. arterial blood gases are helpful in making this assessment, but i discourage awaiting blood gas results before starting if the need is obvious, because the window of opportunity may close if initiation is too delayed. i do recommend obtaining baseline blood gases, however, and using them for comparison with later measurements to make certain that the patient is responding. the second simple step is to make sure patients have no contraindications to niv. these include patients with a need for immediate intubation by virtue of a respiratory arrest, hypotensive shock, or uncontrolled arrhythmias or upper gastrointestinal bleeding. the inability to fi t a mask because of a facial deformity, recent facial surgery or burns is also a contraindication. relative contraindications include agitation that prevents the patient from tolerating the mask, increased secretions or diminished ability to protect the airway. patients with these contraindications are at increased risk of failure if placed on niv and should be promptly intubated. patients with multiple risk factors for niv failure should be started only by experienced personnel under very close monitoring. in patients with hypercapneic respiratory failure, these include higher acute physiology scores, marked tachypnea, greater acidemia at baseline and a worse neurological score. in hypoxemic respiratory failure, risk factors for niv failure include the diagnosis of ards or pneumonia, greater age, hypotension and the failure to improve oxygenation substantially within the fi rst hour. although patients at high risk of niv failure can still be given a trial if the clinicians judge it to be indicated, but they must be watched very closely in an icu, with plans to intubate if there is no improvement within the fi rst hour or two. just as the decision to endotracheally intubate a patient in respiratory failure is a clinical judgment that requires the consideration of multiple factors, so is the decision to implement noninvasive ventilation. in the largest rct to date, cpap and nppv performed similarly, both improving dyspnea scores and ph more rapidly than with oxygen alone, but neither lowered intubation nor mortality rate (the major outcome variable) compared to oxygen-treated controls. however, this study enrolled patients whose intubation rate was slightly below 3% in all of groups, including controls, suggesting that they were too mildly ill to manifest a signifi cant mortality benefi t. meta-analyses of the rcts on cpap or nppv compared with o 2 therapy alone have confi rmed the benefi ts described above, even showing a signifi cant mortality benefi t with cpap. meta-analyses comparing the 2 modalities show equivalency of nppv and cpap with regard to reduction of intubation, lengths of stay and mortality, and with similar myocardial infarction rates. therefore, by virtue of its greater simplicity and potentially lower cost, cpap alone is generally regarded as the initial noninvasive modality of choice for cardiogenic edema patients. but because some studies have found that nppv reduces dyspnea and improves gas exchange more rapidly than cpap alone, nppv is preferred by some initially and can be substituted for cpap if patients treated initially with cpap remain dyspneic or hypercapnic. the success of noninvasive positive pressure to treat cardiogenic pulmonary edema has encouraged its extension into the pre-hospital setting. an emerging trend is to provide cpap devices on ambulances for initial therapy of cardiogenic pulmonary edema, a practice that has been associated with decreased need for intubations in the fi eld. patients with advanced chronic obstructive pulmonary disease (copd) experience poor quality of life and very high levels of symptom burden, including intractable shortness of breath, activity limitation, fatigue, social isolation, anxiety and depression. many of the these burdens are shared with caregivers, and resources in the community to support individuals and their families with chronic illness in the community are often lacking. with the recognition that patients with advanced copd and their caregivers have so many unmet needs, there is a growing acceptance for the need to improve the care and quality of life for patients with advanced copd. while signifi cant gaps in our knowledge and understanding of this area remain, factors contributing to these adverse experiences will be discussed. the importance of prevention, relief, reduction, and soothing of symptoms, without affecting a cure, will be emphasized as an integral component of the care provided for these patients. techniques and tools to optimize the care of patients with advanced copd, including optimizing pharmacologic therapies, inter-professional team care, anticipating and appropriately initiating end-of-life planning, patient and caregiver advocacy, as well as timely and effective communication will be reviewed. withdrawal or withholding life support in medically futile cases has been recognized as an ethical and a legal procedure. it is based on the inherent right of a person to autonomy in making health care decisions. the western model however may not apply to the asian setting being widely varied in terms of cultures, religions and economic progress. more than an individual decision, it may actually be a communal decision with a heavy reliance on input of relations, especially the elders. life support withdrawal often entails complete discontinuation of all measures. efforts to avoid feelings of guilt or abandonment may make families opt for partial withdrawals even when they are not shown to be any more benefi cial. studies have shown that distrust with the medical system does play a major role. active discussions may be diffi cult with reticent cultures or when there are gender differences between patients or their families and the physicians. in this era of globalization and migrations, an understanding of these differences may minimize potential confl icts that arise out of these discussions. awareness that the western approach may not fi t the asian medical model allows the health care providers to be sensitive to the needs and wants of their patients and their families. it is hoped that the data reviewed spurs the development of asia pacifi c guidelines that try to fi nd some uniformity in the diversity of the region. screening for lung cancer is not currently recommended by any major medical organization. multiple phase ii non-randomized trials of computed tomography (ct) screening have yielded enticing results. they have demonstrated that ct screening detects smaller size lung cancer of 12-15 mm in diameter. it has been documented that the chest radiographs miss 70-80% of the cancers detected by screening ct. in prevalence studies, 60-80% of detected cancers are stage i. when ct screening results were compared to a validated control group, ct has been shown to detect 3 times more lung cancer than would be expected and results in ten times more thoracic operation than would be expected. additionally, no decrease in advanced stage cancers or decrease in lung cancer deaths were observed. to date, multiple small randomized controlled screening trials (rct) have been reported, but they have been too small to assess if ct screening reduces mortality. a meta-analysis of baseline fi ndings from six small randomized controlled trials observed more stage i and more total lung cancers in the ct screened group. for every 1000 individuals screened with low dose ct, 9 stage i nsclc and 235 false positive nodules were detected and 4 thoracic operations were performed for benign nodules. the two large rct of ct screening that may defi natively answer the question of ct screening and its ability to decrease lung cancer mortality are the national cancer screening trial (nlst) and the nederlands-leuvens longkanker screenings onderzoek (nelson) trial. mortality results from those two trials are anticipated in 2011 and 2015 respectively. a recent report from the nelson trial validated the use of ct volumetric assessment of nodules to assess malignancy and determine which nodules should be treated surgically. currently, there is considerable effort to identify susceptibility genes for lung cancer with particular interest in 15q 24-25 which is strongly associated. this region contains several genes of interest, including three genes that encode nicotinic acetylcholine receptor subunits. however, these genes may just be associated with nicotine dependence. a recent report utilizing gwas (genome wide association scan) methodology identifi ed 2 snps at 13q31.3 associated with lung cancer susceptibility in never smokers. an enormous research effort is underway related to biomarkers in airway epithelial cells, blood, sputum, breath, and urine for early diagnosis or prediction of high risk. intense efforts are devoted to develop models of risk for determining which individuals should be offered screening. journal compilation © 2010 asian pacifi c society of respirology sy 16-02 lung cancer is the leading death-related cancer worldwide. molecular targeted therapy appears to be an alternative approach for patients with non-small cell lung cancer (nsclc). the epidermal growth factor receptor (egfr) is one of these targets, responsible for the cell growth, proliferation, apoptosis and metastasis of the tumors. egfr-tyrocine kinase inhibitor (tki) has been applied to target egfr and suppress the development of tumors. some egfr-tkis, including gefi tinib and erlotinib, have been approved, while the others are still under development or in clinical trials. several studies demonstrated that egfr somatic mutations might predict the high response rate and greater survival benefi t of egfr-tki. in addition, egfr amplication, k-ras mutation, met amplication or the egfr t790m mutation might predict the clinical effect of these drugs. both erlotinib and gefi tinib have been undergoing several clinical trials for nsclc treatment as a single drug or in combination with chemotherapy. br.21 trial showed that erlotinib improved survival with 731 previously treated nsclc patients in a randomized multicenter during phase iii study. thus, erlotinib was approved to be the second or third-line treatment of advanced nsclc patients. however, isel failed to demonstrate a statistically important benefi t of gefi tinib in overall survival as compared with placebo. different study population, dosing and drugs of br.21 and isel might explain the different results. in ipass trial, 1217 clinical selected nsclc patients with asian origin and characterised by adenocarcinoma histotype were treated with gefi tinib or paclitaxel/carboplatin doublets as the fi rst line therapy. the results showed that gefi tinib had the superiority in terms of progression free survival (pfs) in patients with egfr mutation. in eortc 08021 and perol trials, gefi tinib and erlotinib maintenance therapy showed the trend of improved pfs, but not overall survival in advanced nsclc patients. the toxicity of gefi tinib and erlotinib includes diarrhea, rash, etc., which can be well-tolerated. novel egfr-tkis include vandetanib, sorafenib, sunitinib, and cediranib, of which some are under evaluation in phase iii trials as monotherapy or in combination with standard chemotherapy. vandetanib targets both egfr and vegfr and was tested in the second phase trial, suggesting the addition of vandetanib to the single chemotherapy might improve response rates and survival. sorafenib has been applied to different carcinoma histology and in combination with different chemotherapy. when combined with paclitaxel and carboplatin to treat patients with squamous cell cancer, no survival benefi t was seen. however, another clinical trial was launched to investigate the effect of sorafenib, in which squamous cell cancer were not eligible. novel egfr-tkis are under development with hope of overcoming resistance to egfr-tki gefi tinib and erlotinib. there is a great need of further clinical trials. egfr-tki is one of the important alternatives in treatment of nsclc and has shown promising potential in the future. more promising results may come out if the combination and sequence of egfr-tki with traditional therapies, like chemotherapy, radiotherapy and surgery, can be optimized. there is also a need of disease-specifi c biomarkers to predict the effect of the drugs and identify the patients most likely to benefi t from the drugs. lung cancer is the number one cause of cancer death. most cases are found after distant metastasis, and outcome of drug therapy for these patients used to be disappointing. however, we have faced a new paradigm shift, i.e., the molecular targeted therapy and the individualized therapy. many promising data has reported from not only western countries but also asian countries such as the effi cacy of egfr tki to tumors with mutated egfr, that of alk inhibitor to tumor with eml4-alk fusion protein, and that of pemetrexed to non-small non-squamous cell lung cancers. new questions have emerged from these new evidences derived from some important clinical trials. among them, questions regarding with ethnic difference would be one of the most important issues. is survival data same between asian and caucasian? (data from japan lung cancer registry study as well as some global trials have shown survival of asian patients with lung cancer appears to be obviously better than that of caucasian.) why egfr mutation is frequent in asian patients? is only egfr gene status related with prognosis of lung cancer? what would be the cause of alk abnormality? is the criteria of pathological diagnosis for lung cancer same between asian countries and western countries? here, newest evidences for treatment of lung cancer will be presented, and importance of ethnic difference and asian trials will be discussed. the burden of chronic obstructive pulmonary disease (copd) is growing. despite these growing numbers, many patients with patients with copd remain undiagnosed, the greatest number being those with milder disease. delays in the diagnosis of copd are common. evidence suggests that patients with mild copd experience increased symptoms, reduced activity levels and exercise capacity, and impaired health-related quality of life. this growing body of evidence has made it clear that mild copd is not 'normal'. with recognition of this reality and efforts to appropriately recognize copd at an earlier stage, clinicians must be aware of the various therapeutic options for their patients. the defi nition of mild copd will be discussed, as well as effective strategies for the targeted early diagnosis of copd. the numerous and varied disease manifestations and consequences for patients with milder copd will be reviewed. in addition, practical and effective management options available to clinicians caring for patients with mild copd will also be examined. clinicians have been long aware that neither the traditional distinctions of "emphysema" versus "chronic bronchitis" nor the traditional clinical phenotypes of "blue bloater" and "pink puffer" are suffi cient to categorize patents that suffer from chronic obstructive pulmonary disease (copd). recently, the global initiative for chronic obstructive lung disease (gold) workshop has used quantitative measures (fev1 and fev1/fvc ratio) to defi ne copd, but this defi nition fails to take into account the full heterogeneity of copd. with an increased understanding of pathophysiologic variation, copd now clearly represents a spectrum of overlapping diseases with important extrapulmonary consequences. a "phenotype" describes the outward physical manifestations of a particular disease, and comprises anything that is part of the observable structure, function or behavior of an individual. such phenotypic distinctions in copd include: frequent exacerbator, pulmonary cachectic, rapid decliner, airways hyperresponsiveness, impaired exercise tolerance, and emphysema versus airways disease. these variable manifestations, each with unique prognostic, clinical and physiologic implications, represent distinct phenotypes within copd. while all of these phenotypes have smoking as a common risk factor, the other risk factors that determine these phenotypes remain poorly understood. an individual smoker has variable expression of each phenotype and there is mounting evidence that copd phenotypes have different clinical outcomes. these phenotypes can be broadly classifi ed into one of three groups: clinical, physiologic and radiographic. thus, the paradigm that copd is one disease may be incorrect, and suggests that copd should be considered as a spectrum of smoking-related diseases. failure to consider copd phenotypes is likely to limit the power of therapeutic trials since not all copd patients are likely to benefi t from each therapy. the challenge to future copd researchers is to better characterize these phenotypes and identify their risk factors. measurement of fractional exhaled nitric oxide (feno) is an attractive biomarker of diseases where airway eosinophilia dominates. indeed even before any randomized controlled trials were published some were advocating treatment tailored in accordance to feno data. commercially available bench-top and portable feno analyzers are now readily available and in some countries, feno measurements attract a payment. however, despite the ease of measuring feno, it has its drawbacks in biological and measurement issues. biologically feno is signifi cantly infl uenced by atopy, intake of caffeine, exercise, ethnicity, etc on the measurement front, variabilites include: feno measured by different analyzers may provide different values and on-line vs off-line measurements. the cut-off for determining 'abnormally high results' is yet unknown. not surprisingly, there is discordance on the effi cacy of tailoring asthma medications in accordance to sputum eosinophils [1] and feno [2] in people with asthma, although both are eosinophilia infl ammatory markers. tailoring of medications in accordance to sputum eosinophilia (compared to standard practice) significantly reduced exacerbations in adults with asthma (odds ratio 0.47, 95%ci 0.28, 0.87). in contrast, the benefi t of tailoring of medications in accordance to feno was, at best, modest. the utility and limitations of using feno levels in the clinical setting will be discussed in this talk. shortness of breath and activity limitation are cardinal symptoms experienced by patients suffering from respiratory illness or disease. cardiopulmonary exercise testing (cpet) allows for the objective evaluation of these symptoms, recognizing that exercise involves the effective integration of respiratory, cardiovascular, neuromuscular and metabolic functions. the organs involved in these varied and important roles have a sizeable reserve, with the consequence that clinical manifestations of a disease state or abnormality may not become readily apparent until the functional capacity of the organ(s) is markedly impaired. objective assessment of various parameters during exercise, which places an increased physiologic demand on the functional reserve capacity of these organs, can provide a sensitive method for the early detection of abnormal function and responses(s). the results from exercise testing also parallel functional capacity and quality of life more closely than measurements obtained only at rest, and have been shown to accurately predict important outcomes, such as mortality, in a variety of patients and clinical circumstances. a brief overview of normal exercise physiology and characteristic responses demonstrated by patients with various disorders frequently assessed by the pulmonologist will be offered. in addition, a summary of the indications, conduct, and practical interpretation of cpet will be presented in this session. effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (uplift): a prespecifi ed subgroup analysis of a randomised controlled trial obstructive lung disease and low lung function in adults in the united states: data from the national health and nutrition examination survey international variation in the prevalence of copd (the bold study): a population-based prevalence study chronic obstructive pulmonary disease in fi ve latin american cities (the platino study): a prevalence study prevalence of copd in spain: impact of undiagnosed copd on quality of life and daily life activities global burden of copd: systematic review and metaanalysis prevalence of chronic obstructive pulmonary disease in china. a large, population-based survey diagnostic labeling of chronic obstructive pulmonary disease in fi ve latin american cities copd prevalence in a random population survey: a matter of defi nition treatment of copd: the sooner the better clinical copd phenotypes: a novel approach using principal component and cluster analyses offi ce spirometry signifi cantly improves early detection of copd in general practice: the didasco study salmeterol and fl uticasone propionate and survival in chronic obstructive pulmonary disease clinical trial design considerations in assessing long-term functional impacts of tiotropium in copd: the uplift trial a 4-year trial of tiotropium in chronic obstructive pulmonary disease mortality in the 4-year trial of tiotropium (uplift) in patients with chronic obstructive pulmonary disease effi cacy of salmeterol/fl uticasone propionate by gold stage of chronic obstructive pulmonary disease: analysis from the randomised, placebo-controlled torch study effects of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (uplift): a prespecifi ed subgroup analysis of a randomised controlled trial tiotropium as a first maintenance drug in copd: secondary analysis of the uplift trial treating tobacco use and dependence: 2008 update. clinical practice guideline tobacco atlas the mpower package. geneva, world health organization implementing smoke-free environments. geneva, world health organization curbing the epidemic: governments and the economics of tobacco control clinical and public health signifi cance of treatments to aid smoking cessation we report that pulmonary emphysematous lesions appear to be a dynamic phenomenon that involves not only the gradual loss of alveolar structure, but apoptosis, cellular proliferation, and cellular senescence as well. cellular proliferation compensates for increased alveolar cell apoptosis in chronic obstructive pulmonary disease (copd) patients. however, smoking, age, and the increased cell cycle turnover that compensates for apoptosis accelerate alveolar cell senescence, thereby halting cellular proliferation and tipping the balance toward apoptosis, which, in turn, promotes the formation of emphysematous lesions. as a result, alveolar cells disappear and the emphysematous lesions progress. at the same time, cellular senescence is thought to induce infl ammation. more specifi cally, senescent alveolar cells induce infl ammation by producing various infl ammatory cytokines in tissue. lymphocytes and clara cells may also age more rapidly in the lungs of copd patients. lymphocyte senescence may induce an autoimmune reaction and increase susceptibility to infection, and clara cell senescence may impair airway regeneration as well as sustain airway infl ammation. thus, cellular senescence may be involved in arrested tissue repair, chronic infl ammation, and increased susceptibility to infection, which are the typical features of copd. there is increasing recognition that copd is an increasing global burden. new drug treatments continue to emerge suggesting that copd is more responsive to treatments than previously thought. however, there is still much that is unknown about copd that will contribute to further advances in treatment and management. pulmonary imaging can contribute by providing information on how structure and function relate to relevant clinical parameters, such as disease progression, treatment responses and exacerbations. in other words, imaging can help characterise copd in terms of clinical outcomes or phenotypes. there have been many advances in imaging methodology, including ct, mri, spect and pet. recent fi ndings from research studies using innovative methods of studying structure and particularly function, in copd will be reviewed. their clinical implications will be discussed. the spectrum of children's interstitial lung disease (child) encompasses a large, heterogeneous group of pediatric diffuse lung disorders that are diffi cult to diagnose and treat. as the differential diagnosis is large, a systematic approach is needed for accurate diagnosis. the classic fi rst step of obtaining a detailed history and performing a careful physical examination remains essential for providing diagnostic clues as well as assessing severity of illness. as examples, a history of hemoptysis and fatigue would suggest an alveolar hemorrhage syndrome; exposure to avian antigens, hypersensitivity pneumonitis; and a history of adenovirus pneumonia, bronchiolitis obliterans. the presence of growth failure, crackles, loud p2, and clubbing on physical examination would point to a severe and progressive lung process with cor pulmonale. recent advances in diagnostic modalities have greatly improved the ability of clinicians to identify these disorders. in infants and children with diffuse lung disease, genetic testing can be diagnostic for surfactant dysfunction mutations (sp-b, sp-c, abca3, ttf-1, gm-csfra receptor). infant lung function testing has proven useful for assisting in the diagnosis of certain disorders, such as neuroendocrine cell hyperplasia of infancy (nehi) and distinguishing nehi from surfactant mutations. hrct may detect extent and severity of disease, but can also be useful in diagnosing specifi c disorders, such as nehi (symmetric ground glass densities in the right middle lobe and lingula and the central lung regions), bronchiolitis obliterans (mosaic perfusion, vascular attenuation, and central bronchiectasis), hypersensitivity pneumonitis (ill-defi ned centrolobular micronodules), and pulmonary alveolar proteinosis (crazy-paving). bronchoalveolar lavage can aid in the diagnosis of specifi c conditions, such as alveolar hemorrhage syndromes (hemosiderin-laden macrophages), aspiration (lipid-laden macrophages), hypersensitivity pneumonitis and sarcoidosis (lymphocytosis), eosinophilic pneumonias (eosinophilia), and histiocytosis (cd 1a + cells). lung biopsy performed by video-assisted thoracoscopic surgery (vats) has largely supplanted conventional open lung biopsy as the procedure of choice as it is equally accurate, but associated with less morbidity. although lung biopsy remains the gold standard for diagnosis of child, it must be interpreted in the context of the clinical and radiologic fi ndings. it should be emphasized that although lung biopsy can be diagnostic in some disorders, such as bronchiolitis obliterans, it may not be necessary because less invasive studies such as hrct may be suffi cient for diagnosis. finally, some pulmonary vascular disorders, such as pulmonary vein stenosis or atresia, may mimic child. for these disorders, echocardiography, mra, or cardiac catheterization may be required for diagnosis. with a systematic approach and improved diagnostic capabilities, it is reasonable to expect that a specifi c diagnosis can now be made in the vast majority of child cases. key: cord-016009-qa7bcsbu authors: starkel, julie l.; stapke, christina; stanley-o’malley, abigail; noland, diana title: respiratory date: 2019-10-07 journal: integrative and functional medical nutrition therapy doi: 10.1007/978-3-030-30730-1_51 sha: doc_id: 16009 cord_uid: qa7bcsbu lung disease rivals the position for the top cause of death worldwide. causes and pathology of the myriad lung diseases are varied, yet nutrition can either affect the outcome or support treatment in the majority of cases. this chapter explores the modifiable risk factors, from lifestyle changes to dietary intake to specific nutrients, anti-nutrients, and toxins helpful for the nutritionist or dietitian working with lung disease patients. general lung health is discussed, and three major disease states are explored in detail, including alpha-1 antitrypsin deficiency, asthma, and idiopathic pulmonary fibrosis. although all lung diseases have diverse causes, many integrative and functional medical nutrition therapies are available and are not being utilized in practice today. this chapter begins the path toward better nutrition education for the integrative and functional medicine professional. anti nutrients and inhibitors of lung physiology -942 51 lung disease is far more prevalent worldwide than commonly thought. in fact, death from chronic lung disease is increasing, and as of 2017, chronic obstructive pulmonary disease (copd) has become the third leading cause of death in the united states in the past decade, disproportionately affecting the elderly [1] . another lung disease, asthma, affects 1 in 13, or about 25 million americans, according to the centers for disease control and prevention and the national center for health statistics [2] . this is 7.6% of adults, more women than men, and 8.4% of children. asthma is the leading chronic disease in children [3] . this disease has been increasing since the early 1980s in all age, sex, and racial groups. in europe, lung disease represents 15% of all deaths -the fourth leading cause. according to the world health organization (who), in 2008, 9.5 million people died from acute or chronic lung disease, representing one sixth of the global total deaths [4] . worldwide, four respiratory disease categories appear in the top ten leading causes of death in 2010 [5] . specifically, copd was the third leading cause of death, followed by lower respiratory infections as the fourth, lung cancer as the fifth, and tuberculosis as the tenth [4] . the major risk factor is smoking, leading to 50% of all lung disease-related deaths in europe, where smoking is more prevalent (28% prevalence) than in the united states (15% prevalence) by nearly twofold [6, 7] . lung cancer, particularly non-small-cell lung cancer (nsclc) subtype, is the leading cause of cancer-related death worldwide [8] . added together, lung disease rivals the position for the top cause of death. throughout the life cycle, diet and lifestyle are important modifiable risk factors in the development, progression, and management of obstructive lung diseases, such as asthma and copd [9] , as well as restrictive lung diseases such as pulmonary fibrosis and sarcoidosis. inflammation, in particular, seems to be the leading contributor toward the progression of lung diseases. as with many diseases, maintaining a healthy lifestyle, including sufficient sleep, low stress, regular exercise, a whole foods diet rich in phytonutrients from plants (fruits and vegetables), and potential anti-inflammatory supplements, is beneficial in supporting the body during these difficult diseases. inflammation, in particular, seems to be the leading contributor toward the progression of lung diseases. high inflammatory foods should be avoided, such as fried foods and foods disproportionately high in carbohydrates, sugar, alcohol, and excessive protein. a healthier suggestion would be a diet with more than half of all food consumed as vegetables, about one third as protein, and the remainder (one sixth) as other foods, such as fruits, dairy, grains, or starches. some dietary supplements may also be recommended for their anti-inflammatory benefits, which will be discussed later in the chapter. as human life expectancy increases, we can expect to see more chronic disease. the world health organization estimates that by 2030, chronic lung disease will account for 20% (one fifth) of all deaths [10] , up from one sixth in 2008. despite these growing numbers, relatively little human nutrition research exists for respiratory health, compared to other, less prevalent, diseases. investigators in the areas of aging and lung biology suggest some hope, using genetics and animal models, as well as epidemiological research, to further the general medical approach to lung disease. the pulmonary system is composed of the upper and lower respiratory tracts. air flows in through the nose or mouth, past the frontal and maxillary sinuses, down the pharynx (throat), past the larynx (voice box), and then down the trachea. this makes up the upper respiratory tract. once past the trachea, the air divides into the left and right bronchi, which supply the left and right lungs, each divided into five sections called lobes. the bronchi then divide into smaller bronchioles, at the end of which are air sacs called the alveoli. this makes up the lower respiratory tract [11] (. fig. 51 .1). the diaphragm is the central muscle that is used for breathing. the intercostal muscles, located between the ribs, and the abdominal muscles are helpful for breathing out when the breath becomes labored, such as during exercise. the neck muscles and the muscles in the collarbone area help with breathing when the other muscles are compromised or impaired. in some neurological diseases, such as amyotrophic lateral sclerosis (als) [see 7 chap. 51, newton], nerve damage from the brain to breathing muscles can result in impaired movement of these muscles and thus impaired breathing. in certain cases, such as in lung cancer when a lobectomy, removal of part of the lung, is required, there is an expected decrease in short-and long-term pulmonary function and oxygenation. however, respiratory muscle strength may be preserved [13] . in a pneumonectomy, removal of the entire lung, dramatic changes in thoracic anatomy take place, such as elevation of the hemidiaphragm, hyperinflation of the remaining lung, and influx of fluid into the postpneumonectomy space [14, 15] . there are phagocytic macrophages on the cellular surface of the alveoli, type i epithelial cells and type ii epithelial cells. phagocytic macrophages destroy inhaled bacteria and serve an important role in suppressing or activating the immune response to antigens and pathogens, similar to dendritic cells discussed below. macrophage function has been shown to be inhibited by cigarette smoke [16] . alveolar macrophages also secrete enzymes, arachidonic acid metabolites, growth factors, immune response components, cytokines, and lymphocytes [17] . type i cells are responsible for maintaining the structure of the alveolar wall, whereas type ii cells and clara cells are responsible for the production of pulmonary surfactant (composed of 85-90% lipid and 10-15% protein as lecithin and myelin), which is essential for lung function. the surfactant reduces surface tension, facilitating easier stretching and collapsing of alveoli during respiration [18] . diseases associated with inadequate surfactant production are acute/adult respiratory distress syndrome (ards) and infant respiratory distress syndrome (irds) [19] . irds is seen in premature babies born prior to 32 weeks of gestation due to immature development of pulmonary surfactant, which only begins to develop around the 20th week of gestation [18] . dipalmitoylphosphatidylcholine, phosphatidylglycerol, and cholesterol compose the lipid portion of the surfactant, where apoproteins and proteins found in blood plasma compose the protein portion [18, 20] . the importance of cholesterol is minimized in today's medical community. those with higher levels of cholesterol tend to have more in their fatty cell membranes which resist pathogenesis at a cellular level. low cholesterol predicts a greater risk of dying from gastrointestinal, neoplastic, or respiratory diseases. it occupies 30-40% of our cell membranes, enhances the mechanical strength of the membrane, and reduces permeability [21] . it suppresses main-phase transition of the lipid bilayer [22] . collagen, a fibrous protein, along with elastin and proteoglycans, is a fundamental component of the connective tissue that composes the lungs, and collagen is present in the blood vessels, bronchi, and alveolar interstitium [23] . connective tissue in the lung is key for the passive diffusion of oxygen and carbon dioxide that characterizes alveolar-capillary gas [18] . collagen homeostasis is vital to maintaining respiratory function, where collagen production and degradation are balanced. dysregulated collagen homeostasis that favors collagen production over degradation can lead to pulmonary fibrosis and compromised lung function [24] . some key nutrients to consider for collagen synthesis and crosslinking to maintain connective tissue integrity are vitamin c, vitamin b6, iron, copper, zinc [25] , riboflavin, thiamin, and pantothenic acid [11] . the airways of the respiratory system (with the exception of parts of the nose and mouth) have cilia, special hairs coated with mucus that trap pathogens and other particles that enter with the air that is inhaled. cilia are responsible for triggering this mucus upward toward the pharynx where these particles or bacteria can be coughed out or swallowed. mucus present in the lungs can also trap inhaled particles such as viruses, bacteria, and smoke particulates [11, 12] . along the lining of the respiratory tract, there are several types of cells that are involved in immune response, such as secretory cells (i.e., goblet cells and clara cells) and mast cells. ciliated epithelium and mucus secreted by glands present on airways, goblet cells, and the secretory products of clara cells serve an important mechanism for lung protection. however, excessive goblet cells or hypertrophy of mucous glands may result in increased viscosity of mucus seen in pathologies like bronchitis [16] . ciliary function is also impaired by cigarette smoke [16] . dendritic cells are also found in the airway lining from the trachea to the alveoli. immature dendritic cells phagocytize bacteria or other antigens, where they then mature and travel to lymphoid tissues to communicate with the immune system. this delivery of antigens can promote tolerance of the antigen by releasing anti-inflammatory cytokines. conversely, this delivery can also trigger the opposite response if the antigen is recognized as a pathogen, where t lymphocytes are activated and inflammatory cytokines are released [16] . one potential cause of infections in the upper respiratory tract or bronchial tubes, such as bronchitis, or deep in the lungs, such as pneumonia, is when cilia become damaged and do not trap inhaled germs and particles as effectively. in diseases such as cystic fibrosis, thick mucus secretions can accumulate in the airways and lungs, making it hard to clear and thus increasing risk for infection. in asthma, specific inhaled particles can trigger a reaction causing the airways to narrow, restricting breathing [12] . surface enzymes and factors can also be found in the lining of the airways that compose the majority of the innate immune system of the respiratory tract. these include: 5 lysozymes: found in leukocytes with bactericidal properties 5 lactoferrin: a bacteriostatic agent (inhibits bacterial reproduction) synthesized by lymphocytes and glandular mucosal cells 5 alpha-1 antitrypsin: an antiprotease to protect lung tissue from excessive enzymatic activity 5 interferon: an antiviral substance that may be produced by lymphocytes and macrophages 5 complement: participates as a cofactor in antigenantibody reactions [16] gas exchange takes place in the alveoli so oxygen can enter the body to support metabolic function and the carbon dioxide product from these functions can be removed. this is accomplished through millions of capillaries in the alveoli. these capillaries in the alveoli then connect to arteries and veins that move blood throughout the body. the pulmonary artery supplies carbon dioxide-rich blood to these capillaries within the alveoli to remove carbon dioxide, and the oxygen-rich blood then gets delivered to the heart through the pulmonary vein. the lungs also serve the vital function of maintaining acid-base balance through changes in minute ventilation. these changes affect the ph of the blood by either retaining or excreting carbon dioxide [11] . poor physiologic management of co 2 and bicarbonate can lead to the conditions of respiratory acidosis and respiratory alkalosis. respiratory acidosis is characterized by higher blood concentrations of co 2 and h + , caused by hypoventilation or decreased rate of breathing. hypoventilation can have acute or chronic etiologies, resulting from copd, interstitial lung diseases, respiratory muscle fatigue (i.e., extended asthma attack), or mechanical abnormalities (i.e., deformities). respiratory alkalosis is characterized by lower blood concentrations of co 2 and h + due to hyperventilation, or increased rate of breathing. possible causes of hyperventilation can also be chronic or acute, such as pneumonia and fever, increased stress and anxiety, liver disease, stroke or meningitis, pregnancy, overuse of aspirin and/or caffeine, excessive mechanical ventilation, or increases in altitude [18] . a pulse oximeter tool can be used to measure the percentage of oxygenated hemoglobin in an individual's blood to determine their overall respiratory status. typically, oxygen saturations of 92% or less are indicative of central hypoxia [26] . pulse oximetry is especially useful for assessing individuals with asthma and copd [26] . oral health must also be considered as a contributing factor to respiratory health [27] . for example, in patients affected with periodontal disease, 1 mm of dental plaque could contain around 10 9 of bacteria. one potential mechanism of this connection is aspiration of bacteria from the oropharynx into the upper or lower respiratory tracts, leading to their adherence to the alveolar and bronchial lining, potentially colonizing respiratory ducts and causing respiratory infections. in addition, cytokines and enzymes associated with inflammation of periodontal tissues can be transferred into the lungs, potentially triggering or exacerbating lung infections [27] (. fig. 51 . a systematic review done in 2013 examined oral health in the elderly and its association with risk of aspiration pneumonia. this review suggested that maintaining oral health, such as brushing after each meal, cleaning dentures once per day, and professional oral healthcare, potentially reduced the amount of potential respiratory pathogens that resulted in lower incidence of aspiration pneumonia [28] . several other systematic reviews have found that adequate oral hygiene plays an important role in preventing pneumonia, particularly in clinical settings where there is increased risk for hospital-acquired pneumonia (hap) and ventilatorassociated pneumonia (vap), as well as in older populations [29] . in addition, associations have been made between copd and the risk of periodontitis, although systematic reviews have established that these associations are preliminary and further studies are needed [29] . another important consideration in respiratory health is orofacial development and structure. anatomical obstructions at the level of the nose and pharynx, such as those caused by allergic rhinitis and hypertrophy of the tonsils, pose an increased risk for obstructive sleep apnea syndrome and respiratory infections due to lack of airflow through the upper respiratory system [30] . it has been established that the lung has a microbiome of its own that may have a large impact on health and disease [31] . the fungal microbiome, or mycobiome, may also have a significant impact on respiratory health, although more research is needed to determine definitive associations [31] . dysbiosis may occur in the lungs with a bacterial infection. a few specific bacterial strains have been studied, and one, in particular, pseudomonas aeruginosa, seems to grow in inflammatory conditions. it then seems to encode inflammatory components causing further inflammation. anti-inflammatory nutrients could help stop the cycle, and vitamin d use has some research supporting this. recurrent bacterial respiratory infections may damage lungs and lead to worse outcomes in future lung disease [32] . an increased interest in research of the relationship of the airway and gut microbiome is indicating potentially positive results regarding the use of probiotics in pediatric populations that may aid in asthma prevention and intervention [33, 34] . the gut-lung axis has also been established, where the microbiomes of the lung and gut have been immunologically linked and are thought to have an impact on respiratory disease [35, 36] . the autophagy mechanism within our microenvironment provides a constant "cleanup" system to recycle cell debris from microscopic biowaste generated by dynamic cellular biochemistry [37] . enzymes such as neutrophil elastase function like garbage disposals recycling waste molecules. alpha-1 antitrypsin is a thermostat-like control factor that signals the proteolytic enzymes to stop and protect healthy tissue from being affected. antiproteases in the lung, such as alpha-1 antitrypsin, are required to prevent the overactivity of neutrophil elastase to prevent the degradation of healthy lung tissue. those with the genetic mutations of a1at deficiency are at disadvantage, and subsequent lung tissue damage can occur promoting lung diseases like copd, asthma, bronchitis, and emphysema. key components of lung structure are elastin and collagen, which provide support for the bronchioles and clusters of alveoli (acini). the key enzyme present in these cells is neutrophil elastase, which is responsible for the destruction of respiratory bacteria. protease and antiprotease imbalance in the lung resulting in emphysema can be caused by alpha-1 antitrypsin deficiency and nicotine in cigarette smoke or polluted inhalant exposure [18] . ifmnt approaches to the a1at-deficient patient assess for nutrient insufficiencies for some of the important connective tissue, collagen, and elastin system key nutrients: vitamin c, vitamin d, biotin, balanced fatty acids, and gut microbiome. when insufficiencies or deficiencies are identified, appropriate food and dietary supplementation interventions can be recommended. it should be noted that if an individual is identified with a1at deficiency genotype, the status of liver health should also be assessed, as a1at pathophysiology can express in liver cirrhosis. more recent studies of respiratory disease [38] have revealed the relationship with bacterial or viral infections exacerbating the individual's genotype eliciting expression of the associated diseases. one of the most recognized inherited conditions of altered autophagy mechanisms is alpha-1 antitrypsin deficiency, with 80-100 genetic variants affecting severity of lung expression. low levels of circulating a1at allow potentially harmful enzymes like neutrophil elastase to remain in the lungs unchecked. low levels of a1at, and the consequent proliferation of neutrophil elastase, leave lung tissue vulnerable to destruction, resulting in a decline in lung function. there are several categories of lung disease and many diseases within those categories (. table 51 .1). some micronutrients and phytonutrients have important antioxidant and methyl-donating properties important for the lungs and therefore have great role in a nutritional approach to lung health. iron's interaction with the lungs is essential. it carries oxygen from the lungs to the peripheral parts of the body, as well as carbon dioxide back to the lungs to be exhaled. however, too little or too much iron can pose a problem for the lungs. before iron administration, it is important to rule out hemochromatosis, or iron overload, for an individual. iron-deficiency anemia often presents in many chronic diseases including those of the lung, such as copd, lung cancer, and ipf [57] . increased mortality, decreased quality of life, increased hospital admissions, and cost of treatment have been reported for those with chronic disease and low iron [58] . anemia of chronic disease (acd) is usually at the root of this. acd is often the result of inflammation. inflammatory proteins, including il-6, stimulate the production of hepcidin in the liver, which inhibits absorption and increases storage of iron resulting in a functional iron deficiency. typical iron markers, such as transferrin saturation, total iron binding capacity (tibc), and ferritin, are also affected by inflammation and are less useful markers in chronic disease. soluble transferrin receptor (stfr) seems to be a lesser known marker that is less affected by inflammation [59] . because of the difficulty with iron absorption, intravenous iron is often used to replete deficiencies. as iron is a pro-oxidant, researchers studied any negative repercussions. there does not seem to be any increased oxidative stress with intravenous iron, but glutathione, the body's endogenous super antioxidant, does seem to decrease, likely in response to the pro-oxidative activity of iron. in a recent study, administration with vitamin e was seen to eliminate these negative effects [57] . excessive iron can also be problematic for lung health for those with the genetic mutation for hemochromatosis (hfe). disorders of iron overload are increasingly being recognized as risk factors for most of the chronic diseases like cardiovascular, alzheimer's, and cancer [60] . high iron can catalyze the formation of highly reactive hydroxyl radicals, oxidative stress, and programmed cell death. in the instance of lung cancer and other cancers affecting the lungs, tumors sequester iron for their own growth, usually leaving the patient with iron-deficiency anemia. in fact, 90% of cancer patients undergoing chemotherapy are iron deficient. inflammation also plays a role in iron homeostasis. the pro-inflammatory cytokines cascade down to affect the proteins that regulate . chronic obstructive pulmonary disease (copd) disease that restricts airflow through either inflammation of the lining of the bronchial tubes or destruction of alveoli increased risk of emphysema if genetic variant of alpha-1 antitrypsin deficiency and smoking or exposed to high levels of air pollution [11] bronchiectasis a disorder of the airways that leads to airway dilation and destruction, chronic sputum production, and a tendency toward recurrent infection [39] bronchiolitis airway injury that can be caused by infections, irritants, toxic fumes, drug exposures, pneumonitis (typically viral), organ transplants, connective tissue disorders, vasculitis, or other insults [40] dyspnea shortness of breath or difficulty breathing [11] emphysema thinning and destruction of the alveoli, resulting in decreased oxygen transfer into the bloodstream and shortness of breath. increased risk of emphysema if genetic variant of alpha-1 antitrypsin deficiency and smoking or exposed to high levels of air pollution [11] alpha-1 antitrypsin deficiency a deficiency of a1at, a protein produced in the liver that protects the lungs from excessive neutrophil elastase, an autophagic enzyme. a1at may also accumulate in liver and cause liver disease [55] obstructive asbestosis fibrotic lung disease resulting from extensive inhalation of asbestos fibers [42] desquamative interstitial pneumonitis (dip) form of idiopathic interstitial pneumonia that is more common in cigarette smokers but may be seen in nonsmokers, in patients with underlying connective tissue diseases or those exposed to inorganic dust/particles [43] sarcoidosis immune-mediated systemic disorder that is characterized by granuloma formation of the lung parenchyma and the skin [44] restrictive pathophysiologyneuromuscular weakness amyotrophic lateral sclerosis (als) progressive neurological disease that affects the motor neurons of the nervous system [11] guillain-barre syndrome progressive immune system attack on the peripheral nerves, usually following an infectious illness such as a respiratory infection. may eventually cause respiratory distress syndrome [11] restrictive pathophysiologychest wall/pleural disease kyphoscoliosis kyphoscoliosis: a deformity of the thoracic cage that results in restriction of the lungs and impairs pulmonary function [45] ankylosing spondylitis autoimmune inflammatory disorder characterized by inflammation of the axial skeleton and peripheral joints [46] chronic pleural effusions chronic accumulation of fluid between the two outer membranes surrounding the lungs [11] pulmonary vascular disease pulmonary embolism blood clot that typically originates from thrombi in the deep venous system of the legs and travels to the lungs pulmonary arterial hypertension (pah) progressive disorder of primary pulmonary arterial vasculopathy characterized by a mean pulmonary arterial pressure >25 mm hg at rest (>30 mmhg during exercise) [48] iron homeostasis [61] . iron can also impair cytokine secretion, which can leave those with an iron overload much more susceptible to infection, increasing the morbidity and mortality of infectious diseases, including those of the lung [59] . oxidative stress may contribute to injury of lung tissue, causing further fibrosing in those lung diseases with that characteristic. allele variants in the genes associated with iron homeostasis (c282y, s65c, and h63d hfe) are significantly more common in those with idiopathic pulmonary fibrosis (ipf) than those without ipf (40.4% ipf patients vs 22.4% non-ipf) and are associated with higher irondependent oxygen radical generation [62] . iron is implicated in lung pathology. monitoring iron status and using supplements or diet to aid the body in increasing or decreasing the iron load are imperative for the nutritionist working with lung disease patients. choosing a good non-constipating form of iron is important, such as iron glycinate. the b vitamins are also important to monitor for lung health. vitamin b6 and its bioactive form, p-5-p, are typically known to protect dna from mutation or damage [63] . however, there is mixed evidence on its role for lung cancer. some research has shown that it is helpful for lung cancer patients as it is important for apoptosis when using chemotherapy, because it sensitizes cancer cells to apoptosis [63] . however, research in 2017 showed that adult male smokers taking greater than 20 mg vitamin b6/day for long periods tended to have a greater risk for lung cancer. many variables, including genetic variants, form of b6, and the status of other co-nutrients may be at play [64] . other studies showed that men in the top quintile of vitamin b6 serum concentration had about one half the risk of lung cancer, and specifically, vitamin b6 and folate were inversely associated with risk of lung cancer [65] . . squamous cell (epidermoid) carcinoma about 25-30% of all lung cancers. these start in early versions of squamous cells, which are flat cells that line the inside of the airways in the lungs. often linked to a history of smoking and tend to be found in the central part of the lungs, near the bronchus [50] large cell (undifferentiated) carcinoma about 10-15% of lung cancers. it can appear in any part of the lung and tends to grow and spread quickly. a subtype of large cell carcinoma, known as large cell neuroendocrine carcinoma, is a fast-growing cancer that is very similar to small-cell lung cancer [51] small-cell lung cancer (sclc) about 10-15% of lung cancers are sclc. typically start in the cells lining the bronchi and parts of the lung such as the bronchioles or alveoli [52] infectious diseases pneumonia inflammation of the lungs, usually caused by bacteria, viruses, or fungi [11] bronchitis inflammation and eventual scarring of the lining of the bronchial tubes accompanied by restricted airflow, excessive mucus production, and persistent cough [11] tracheitis bacterial infection that can develop in the trachea [53] infant respiratory distress syndrome also known as hyaline membrane disease (hmd) or respiratory distress syndrome, this condition affects the alveolar ducts and terminal bronchioles in which the hyaline membrane is a fibrinous material composed of blood and cellular debris, caused by the absence of proper surfactant production due to an immature or poorly developed lung [54] upper respiratory infection (uri) acute infections involving the nose, sinuses, pharynx, larynx, trachea, and bronchi, referred to as the common cold [11] bronchopulmonary dysplasia (bpd) chronic lung disorder which may affect infants who have been exposed to high levels of oxygen therapy and ventilator support [11] other cystic fibrosis disease characterized by abnormally thick mucus secretions from the epithelial surfaces of many organ systems, including the respiratory tract, the gastrointestinal tract, the liver, the genitourinary system, and the sweat glands [11] acute lung injury clinical and radiographic changes in lung function associated with critical illness (acute respiratory distress syndrome is most severe form) [11] respiratory because of disagreement in research, particularly with smokers or former smokers, using food first for b vitamins may be a prudent way forward. good sources of vitamin b6 are fish, chickpeas, chicken, potatoes, turkey, bananas, ground beef, and winter squash. pyridoxal kinase (pdxk) is the enzyme that converts pyridoxine and other vitamin b6 precursors to its bioactive form of p-5-p. dysfunction of this enzyme is a good prognostic for lung cancer and other lung diseases. mthfr 1298aa genotype is associated with a higher risk of lung cancer in women but not in men. the mthfr 677tt genotype was associated with a significantly decreased risk of lung cancer in women but not in men. in contrast, the mthfr c677t and a1298c polymorphisms interacted with smoking status in men but not in women [66] . methylation gene testing is imperative to understand the patient's status. some studies suggest that a higher intake of riboflavin (vitamin b2) may protect against lung cancer in smokers [67] . folate deficiency was also associated with asthma and attacks of shortness of breath [8] . correcting acidosis may preserve muscle mass in diseases where wasting is an issue, such as copd or ipf. for those receiving chemotherapy, a higher ph (more alkaline status) is helpful for muscle mass protection. high alkaline diets contain more fruits and vegetables, and those supply more magnesium, which is needed to activate vitamin d. as discussed below, vitamin d is extremely helpful for lung health. sleep quality involves maintaining adequate 7-8 hours with good sleep hygiene (see 7 chap. 34). good rem cycling, feeling refreshed upon awakening, and other characteristics of good sleep play significant roles in maintaining healthy acid-base balance. dietary intake of the minerals magnesium, potassium, sodium, chloride, and calcium promotes the balance of acidbase microenvironment. after exposure and tissue retention of toxic minerals and metals, these substances can contribute to perturbations in the acid-base metabolic milieu. some conditions reduce oxygen intake and should be addressed. one of the most common oxygen-impairing conditions is sleep apnea, altered sleep with random halting of breathing during sleep that is often accompanied by snoring. other limiting conditions are respiratory diseases like copd, a1at deficiency, asthma, cystic fibrosis, etc. vitamin a is an important antioxidant and a general umbrella term for several fat-soluble retinoids, including retinol, retinal, and retinyl esters. there are also other substances that are provitamin a carotenoids or precursors to vitamin a. two forms are found in foods, the preformed forms of retinol or retinyl esters, which are found in dairy, fish, caviar, and meats (especially liver), and the provitamin a carotenoids, including the most important and common provitamin a carotenoid, beta-carotene, as well as others including alpha-carotenes and cryptoxanthin, which are found in plant-based foods. our bodies must convert these two forms within our cells to retinal and retinoic acid, the active forms of vitamin a in the body. new studies of the gene, β-carotene 15,15′-monooxygenase (bcmo1), which is responsible for the enzymatic conversion of β-carotene to vitamin a, are revealing that individuals with heterozygous or homozygous bcmo1 snps have 30-60% less efficient conversion than those with normal gene function (see 7 chap. 17) [68] . other carotenoids found in food, such as lycopene, lutein, and zeaxanthin, are not converted to vitamin a but have other antioxidant benefits in the body. most vitamin a is stored in the liver as retinyl esters, and deficiency is not visible until these stores are nearly depleted. vitamin a's role as an antioxidant helps the lungs in several ways, including maintaining alveolar epithelium cells and preventing development of respiratory tract infections. most of the developed world's population does not have a risk of deficiency due to sufficient vitamin a intake. however, most people with cystic fibrosis have pancreatic insufficiency, which reduces the ability to absorb fat and therefore the fat-soluble vitamins a, d, e, and k. according to a study in 2002, between 15% and 40% of people with cystic fibrosis had a vitamin d deficiency, also a fat-soluble vitamin. with the addition of pancreatic replacement treatments, better nutrition, and vitamin a supplementation, deficiency has become rare. however, improved vitamin a status has not been thoroughly studied as of 2018, and therefore it is largely unknown if an improved vitamin a status has any effect on cystic fibrosis [69] . vitamin a deficiency has been shown to be associated with emphysema in rats. smoke exposure significantly decreases vitamin a concentration in lung tissue, significantly more in those with copd [70] . retinoic acid seems to play a beneficial role in the treatment of ipf. a review showed that in all studies, retinoic acid decreased fibrosing, the formation of collagen, and reduced the expression of alpha-smooth muscle actin (alpha-sma), all hallmarks of ipf [71] . it is important to not take large doses of vitamin a if one is in a malnourished state as it can cause toxicity and should be monitored with blood testing of vitamin a retinol. nourish the body with all foods and all nutrients slowly. the non-provitamin a carotenoids have also shown some benefit. lycopene, found in high amounts in guavas, watermelon, tomatoes, papaya, grapefruit, sweet red peppers, asparagus, purple cabbage, mangos, and carrots, slowed forced expiratory volume (fev) decline in former smokers [70] . vitamin d's importance with lung health cannot be understated. vitamin d deficiency, or even insufficiency, is linked to accelerated decline in lung function, increased inflammation, and reduced immunity in chronic lung diseases. vitamin d has a role in the regulation of inflammation, immunity, cellular proliferation, senescence, differentiation, and apoptosis. sufficient vitamin d levels are correlated with better asthma control, better immune response related to respiratory infections, and reduced severity of exacerbations with copd and asthma when exposed to inflammation-causing pathogenic activity [72] . vitamin d is obtained through sunlight on the skin (without sunscreen) and very few dietary sources. therefore, supplementation is generally recommended. higher vitamin d levels are shown to be protective in many lung disease states. sufficient levels improve treatment response with medications and reduce asthma severity [68] . with infectious diseases of the lung, higher vitamin d concentrations are shown to have a protective action [6] . vitamin d has a protective effect on lungs of smokers, and higher levels of vitamin d inhibit the pro-fibrotic phenotype of lung fibroblasts and epithelial cells. current data suggest an inverse association between serum vitamin d and lung cancer risk, and vitamin d deficiency at 16-20 weeks' gestation is associated with impaired lung function and asthma at 6 years of age [73] . lower levels of vitamin d are associated with an increased risk for respiratory infections, cystic fibrosis, chronic obstructive pulmonary disease, and interstitial lung disease [74] . vitamin c is an important antioxidant that helps decrease oxidative damage in the body, including in lung tissue. it is also essential for lipid metabolism. it is present in the airway surface liquid and creates an interface between the epithelial cells and the external environment. vitamin c is a cofactor in collagen synthesis, which can aid in repair of bronchial and alveolar tissue when damaged. it also provides beneficial control of lipid peroxidation of cellular membranes, including those surrounding as well as those within intracellular organelles. vitamin c has some of the best lung protective capabilities, according to current research. vitamin c may also diminish oxidative attack on nonlipid nuclear material and is an antioxidant component of plasma and extracellular fluids surrounding the lungs. it is an antioxidant that not only fights oxidative stress but also reduces oxidized vitamin e and glutathione, allowing them to become active as antioxidants again. vitamin c is antiinflammatory and is helpful in all inflammatory states of the lung, even allergies. there are many ways in which vitamin c, along with its antioxidant partners, glutathione, vitamin e, vitamin a, and plant-based phytonutrients, affects lung health. it is well established that increased levels of vitamin c in the diet improve health outcomes for smokers and their offspring, as smoking depletes vitamin c [75, 76] . vitamin c is also helpful in fighting infectious diseases such as respiratory infections and pneumonia, copd regardless of smoking status, asthma, and lung cancer [77] . specifically, in certain lung cancers, vitamin c, along with other nutrients such as lysine, proline, epigallocatechin gallate, and zinc, can inhibit the proliferation of certain carcinoma lines and induce apoptosis, as well as inhibit lung cancer metastasis [78] . even in lung transplants, vitamin c is helpful against oxidative stress by reducing glutathione and lowering lipid peroxidation, along with vitamins a and e [79, 80] . the literature suggests these benefits can be achieved at 500-3000 mg/day. check iron status before administering vitamin c supplementation as vitamin c doubles iron absorption from foods. vitamin e's primary role is as an antioxidant, breaking free radical chain damage and preventing peroxidation of lipid molecules. this vitamin also is promising with regard to beneficial effects on lung function preservation. oxidative stress and inflammation are key features in many lung diseases; therefore nutrients with antioxidant capacity can be useful. a few studies suggest that alpha-tocopherol found in sunflower and olive oils has a beneficial effect on fev (forced expiratory volume), whereas gamma-tocopherol found in canola, soybean, and corn oils has a negative effect on fev [81] . however, from these authors' perspective, this is likely due to the source and type of the oils, which can be inflammatory, rather than the form of vitamin e. for example, a recent study showed that gamma-tocopherol was protective in allergic asthma [82] . in addition, sufficient levels of vitamin e, in the alpha-tocopherol form, were found to reduce susceptibility of the elderly to acquiring pneumonia. some of the positive effects of vitamin e are synergistic with vitamin c [83] . phytonutrients have been found to have two effects with respect to lung disease: one is a symptom-improving pattern, and the other is a rate-reducing pattern [84] . idiopathic pulmonary fibrosis (ipf) is largely characterized by reduced antioxidant and increased inflammatory action. recent literature is showing the ability of certain flavonoids, in particular quercetin, to reduce inflammation and act as a strong antioxidant countering the pro-oxidant environment of ipf. quercetin is recognized as the most potent ros scavenger. taken together with glutathione, the impact is even greater, and it seems to help improve the antioxidant and inflammatory status more for those with ipf than non-diseased controls [85] . curcumin has been shown to slow or limit fibrosing in murine studies related to lung, liver, or kidney fibrosing [86] [87] [88] [89] . it has also been shown to attenuate metastatic melanoma in the lungs when delivered in a nanoparticle [90] . the potential for curcumin is interesting and hopeful. fisetin and fenugreek have also been studied as useful phytonutrients that help combat inflammation in lungs [91, 92] . fisetin is found in apples, strawberries, persimmons, cucumbers, and onions, among many other fruits and vegetables. fenugreek is a plant used frequently in south and central asian cooking, where both the seeds and leaves are used. there are now supplements available for both of these phytonutrients. this is a reminder to eat a primarily plantbased diet when combating inflammation and to broaden our palates to include healthy foods and ingredients from other cultures than our own. lastly, the powerful antioxidant cannabidiol (cbd), from the cannabis and closely related hemp plants, is a powerful shield against oxidative stress, prevalent in lung disease [93] . the research is not robust regarding lung function and minerals, and most has been done with regard to cystic fibrosis where bone density is associated with general nutritional status, including minerals. there have also been many studies trying to determine a correlation between mineral status and copd, where, again, the research shows that mineral status is not predictive but overall nutrient status may fall if not monitored. in contrast, one study in japan showed an inverse association between dietary calcium and the risk for copd [94] . in an nih-aarp diet and health study, magnesium, iron, selenium, zinc, and copper intakes, both dietary and supplemental, were studied with respect to lung cancer. mineral supplementation did not affect lung cancer risk, yet dietary intake of calcium, along with vitamin d, and iron reduced the risk, and dietary intake of magnesium increased risk [95] . boron has been shown to be protective against lung cancer, along with other nutrients, at levels of 3 mg/day [96] . there is some research showing that selenium is helpful, particularly for smokers, for improved fev. higher magnesium status is correlated to better fev but is not yet seen as an association. this may be due to magnesium's role as the vitamin d activator. there have been a few studies showing increased copper levels are related to decreased fev. some recent research has also shown that dietary zinc and iron are associated with reduced lung cancer, but the same was not seen with calcium, copper, magnesium, or selenium [97] . low mineral bone density is prevalent at a higher rate among cystic fibrosis patients, and therefore supplementation with vitamin d, vitamin k2, magnesium, calcium, and the trace minerals can be helpful [98] . alpha-lipoic acid (ala) is a powerful antioxidant endogenously produced in the human body from foods such as yeast, organ meats, spinach, broccoli, and potatoes and is both water-and fat-soluble. ala, along with n-acetyl cysteine (nac), glycine, and vitamin c, is an important precursor to glutathione, which is a powerful endogenous antioxidant and the primary antioxidant in the lungs. ala has been shown to be anti-inflammatory in lung tissue in those with acute lung injury, and the proposed action is via inhibition of the nf-kappab signaling pathway [99] . ala has also been shown to downregulate some cancerpromoting actions prevalent in lung cancer, likely by this same pathway [100] . it also may alleviate nicotine-induced lung oxidative stress [101] . n-acetyl cysteine (nac), another precursor to glutathione, is a powerful antioxidant on its own as well. in relation to the lungs, nac helps the clearance of mucus in the lungs by pulmonary cilia. this has been shown to be effective at 400-600 mg/day in divided doses [102] . there is significant research on nac and lung health, showing improvement with nearly all lung issues, including nearly 40 studies showing improvement for bronchitis [103] , infectious diseases by reducing the bacterial count [104] , smokers, and people with asthma and copd, through both its antioxidant effects and by reducing the viscosity of sputum and mucus. at an oral dose of 1800 mg/day, the mean glutathione concentration in lung tissue increased by 49% on one study [105] . there are additional studies showing improvement for those with copd, asthma, cystic fibrosis, pulmonary fibrosis, and symptoms related to allergies or other infections. the dose that has been studied and has been shown to be most useful is 600 mg twice daily and more effective if nebulized [106, 107] . both ala and nac supplementation should be accompanied by vitamin b6 and the complex of b vitamins to prevent an elevation in liver enzymes (. fig. 51 .3). there are several specialty labs that conduct micronutrient analysis and functional testing, such as genova diagnostics and spectracell. these tests can be useful for evaluating levels of individual nutrients as they function in the body, rather than just in serum, which is not an accurate indicator of tissue or functional status. patients suffering from copd, interstitial lung disease, and other diseases tend to have muscle and weight loss related to respiratory acidosis, and increasing weight and muscle mass helps with quality of life. respiratory acidosis occurs with co 2 buildup where the lungs are no longer able to effectively exchange o 2 and co 2 . nutritional supplementation should attempt to reduce metabolic co 2 production. fat metabolism produces less co 2 than carbohydrate metabolism, so emphasizing a higher fat, lower carbohydrate diet can be helpful [110] . in general, a high intake of omega-6 fatty acids is associated with poorer forced expiratory volume (fev) in patients with lung disease because of their pro-inflammatory nature. however, a complete fatty acid panel or a red blood cell membrane fatty acid test would reveal more details about the status of an individual's omega-6 pathway. certain omega-6s and the work of their corresponding metabolizing enzymes such as elongase and delta-5 or delta-6-desaturase may allow healthful omega-6s (linoleic (la), gamma-linolenic (gla), lipoxins [111] , prostaglandin 1 series metabolites) to flow down an anti-inflammatory pathway instead. important cofactors for this pathway are vitamin b2, vitamin b3, vitamin b5, vitamin b6, biotin, vitamin c, zinc, and magnesium. lipid metabolism dysregulation is understood to be part of the pathogenesis of idiopathic pulmonary fibrosis. in ipf, free fatty acids play a role in the proliferation of fibroblasts. certain fats, in particular palmitic acid, oleic acid, and linoleic acid, are elevated in the lungs of those with ipf, whereas stearic acid is low. stearic acid is found in meat, poultry, fish, grain products, and milk and milk products. the palmitic, oleic, and linoleic acids enhance the tgf-ß1-induced expression of α-smooth muscle actin (sma) and collagen type 1 in mrc-5 cells, which can lead to fibrosis. stearic acid inhibits the levels of these fibrosing cells. stearic acid also improves the thrombogenic and atherogenic risk factor profiles [112] . in one study on patients with copd, omega-3 fatty acids were found to reduce inflammation in bacterial infections of the lungs without suppressing the ability to clear the bacteria. those taking epa, dha, ala, and gla had improved exercise capacity and had lower risk of developing copd [113] . although results have been mixed over the years possibly due to doses used in studies, a recent 2018 prospective study showed that pufas (omega-3s) from fish help prevent lung cancer and can be part of treatment during lung cancer. in general, the strongest evidence for improved lung function and slowing decline is with the epa and dha forms of omega-3 fatty acids [114] . because of toxicity issues in fish, increasing quality supplements vs fish intake may be more prudent. protein is essential for all lung conditions, and lack of it can result in poorer pulmonary function, decreased exercise capacity, and increased risk exacerbations. since many lung diseases have oxidative stress as a characteristic, it can cause protein carbonylation which may negatively affect dna expression and lipid membranes. nutritional supplementation with added protein and healthy carbohydrates can increase body weight and muscle strength and improve quality of life. those with copd, interstitial lung diseases, and others that affect oxygen absorption and co 2 exhalation have greater levels of hypoxia and sometimes respiratory acidosis, which exacerbates the loss of muscle through oxidative stress and inflammation. supplementation of free essential amino acids versus complete proteins has been shown to help prevent muscle wasting among copd patients. muscle-building exercise is often prescribed for those with copd and interstitial lung diseases [115] . supplemental l-carnitine at 2-6 g/day for 1-2 weeks increased the capacity of copd patients to rehabilitate and build muscle and helped inspiratory muscle strength. carbohydrates should be monitored for sufficient but not excessive levels. more co 2 is produced with the utilization of carbs versus fats for energy. therefore, with gas exchange being an issue with most lung disorders, a slightly higher fat and lower carbohydrate diet may be indicated. it is worth mentioning fiber for a moment, as it is mostly delivered in carbohydrate-rich foods. there is evidence that consuming whole fruits and vegetables higher in dietary fiber is associated with reduced severity of asthma and copd [116] . a diet that derives its carbohydrates from vegetables and fruits rather than from processed carbohydrates such as grains, breads, pasta, or added sugars will deliver fewer carbohydrate grams. glutathione (gsh), a tripeptide composed of cysteine, glutamine, and glycine and produced from methionine, is in every cell in the body. it is the most powerful and abundant endogenous antioxidant in the airway epithelial lining and is responsible for detoxification of electrophilic compounds, the scavenging of free radicals, and modulation of cellular processes such as dna synthesis and repair, differentiation, apoptosis, and immune function [117] . it is also a heavy metal chelator. it is more effective than some other antioxidants because it is intracellular and extracellular. in isolated type ii alveolar epithelial cells, extracellular glutathione inhibits hyperoxia-induced injury, inhibits pro-inflammatory cytokine release, and promotes cell growth. it is obviously very important to maintaining lung function as this is the inflammatory process that begins lung cell or tissue damage, as mentioned above. the highest levels of glutathione concentrations in the body are in the lungs, liver, and brain. gsh depletion leads to activation of nf-kb (pro-inflammatory signaling) and increased pro-inflammatory gene transcription and cytokine release from histone deacetylase suppression in epithelial cells. total and reduced gsh concentrations are much lower in people with ards, pulmonary fibrosis, and hypersensitivity pneumonitis than observed in healthy adults. alterations in alveolar and lung gsh metabolism are widely recognized as a central feature of many inflammatory lung diseases such as idiopathic pulmonary fibrosis, acute respiratory distress syndrome, cystic fibrosis, and asthma [118] . we make glutathione in the body with cysteine and methionine, and it is difficult to take exogenously because digestion can destroy it. the precursors of cysteine (essential), glutamine, and glycine and cofactors (vitamin c, vitamin e, vitamins b1, b2, b6, and b12, folate (b9), minerals selenium, magnesium, and zinc, and alpha-lipoic acid, see below) are therefore recommended so that the body can produce it on its own. the two enzymes necessary to produce it, gamma-glutamylcysteine synthetase and glutathione synthetase, must also be functioning well. we also recycle glutathione if the precursors and cofactors are available. cysteine is usually the most rate-limiting precursor, and many people supplement with n-acetylcysteine to provide the body with this nutrient. although glutathione is produced in every cell of the body, the greatest production is in the liver, so focusing on liver health is important to maintain good glutathione production. production declines with age and with lung disease, as well as other conditions. there are very few foods containing glutathione; they are raw or very rare meat, especially liver, unpasteurized milk and other unpasteurized dairy products, and freshly picked fruits and vegetables, such as avocado and asparagus. however, as mentioned earlier, it may be destroyed during digestion. glutathione contains sulfur molecules, which may be why foods high in sulfur help to boost its natural production in the body. these foods include: 5 cruciferous vegetables, such as broccoli, cauliflower, brussels sprouts, and bok choy 5 allium vegetables, such as garlic and onions 5 eggs 5 nuts 5 legumes 5 lean protein, such as fish and chicken other foods and herbs that help to naturally boost glutathione levels include: 5 milk thistle (a liver-regenerating herb) 5 flaxseed 5 guso seaweed 5 whey glutathione is also negatively affected by insomnia. getting enough rest on a regular basis can help increase levels. addressing a drop in glutathione for lung health involves maintaining good levels of the precursors and cofactors mentioned above. a good way to bring in the less abundant amino acid cysteine is to take n-acetylcysteine (nac). doses of 400-600 mg were more effective than placebo in reducing symptoms [117] . supplemental selenium can also help with glutathione production. glutathione supplementation has also become more effective. there are several forms, from capsules to topical liposomal, which have shown good absorption. inhaled gsh has good research for use in cystic fibrosis (cf), chronic otitis media with effusion (ome), hiv seropositive individuals, idiopathic pulmonary fibrosis (ipf), and chronic rhinitis. it is not recommended for asthma due to significant side effects, and additional evidence is needed to determine if use with emphysema is recommended although theoretically it should be useful. it is also not recommended to use inhaled gsh during cancer chemotherapy treatment as it may interfere with the medication's actions. the mechanism of action of inhaled glutathione is limited to the upper airways and lungs and does not seem to affect serum levels. before considering inhaled gsh treatment, the patient should undergo urine sulfite sensitivity testing using a readily available special test strip called "em-quant 10013 sulfite test. " if positive, inhaled gsh should not be used as bronchoconstriction may occur. the recommended dose is 600-5000 mg per day, depending on response, and whether inhaled gsh is considered safe. efficacy should be tested using a baseline pulmonary function test and a follow-up test after a prescribed time later [119] (. fig. 51 .4, 7 box 51.1). there are also serum tests for glutathione levels. these cofactors are vitamin c; vitamin e; vitamins b1, b2, b6, and b12; folate (b9); minerals selenium, magnesium, and zinc; and alpha-lipoic acid. what do the glutathione cofactors do that makes them so important? 5 direct cysteine toward glutathione production and increase cellular uptake of cysteine 5 help form the glutathione molecule out of the three precursor amino acids 5 help recycle glutathione from its oxidized gssg form back to its reduced (active) gsh form 5 help maintain glutathione levels and keep the gssg-gsh ratio balanced 5 recycle each other, improving overall antioxidant activity 5 stimulate the activity of the whole glutathione enzymatic system co10 is a fat-soluble compound produced endogenously and also available through food and supplementation. it is required in the production of atp, is a powerful antioxidant, and therefore is helpful against oxidative stress, an important issue in lung disease. coq10 achieves its strong effects through a set of different mechanisms. it influences genes through its epigenetic effect to reduce inflammation, helps with the immune system, and even reduces aging by reducing systemic oxidative stress and mitochondrial aging [120] . lungs are the most susceptible organ to oxidant damage because they interact directly with oxygen. therefore, it makes sense that antioxidants, and those that especially affect the lungs, are helpful in tissue and lung cell preservation [121] . coq10 levels are significantly lower in those with copd and asthma with insignificant amounts of research on the levels of coq10 with other lung issues. it has been shown that supplementing patients with coq10 resulted in measurable benefits. in one study, patients with copd using steroids to reduce inflammation were able to reduce their steroid dosage when using coq10 [122] . in another study, benefits were shown for copd patients during exercise, measuring performance, tissue oxygenation, and heart rate at a low dosage of 90 mg/day [123] . the levels of coq10 in the blood have been shown to indicate the degree of systemic oxidative stress, which implies it could be used as a marker to assess copd [121] . several studies confirm the beneficial role of coq10 in decreasing oxidative stress, cardiovascular risk, and modulating inflammation during aging. dosage levels of 1200 mg/ day of coq10 have been shown to be therapeutic. however, in the reduced, more absorbable form, ubiquinol, 400 mg/ day, was shown to be as effective. there is a wide range of toxins and anti-nutrients that can significantly impact the respiratory system. this can occur through acute or chronic exposure to these agents. the earth's air is the source of oxygen, and the lungs provide access to that oxygen to support life. the human need for oxygen is precarious because humans can only survive for about 6 minutes without the precious gas. from about 1760 to sometime between 1820 and 1840 in europe and the united states, the ramp-up of new industrial revolution manufacturing processes opened a new era of increasing chemical and heavy metal atmospheric contamination. these pollutants can enter the body through breathing the polluted air. the more concentrated atmospheric pollutant densities cluster around areas of dense population. the dirty air provides a serious direct threat to those with respiratory diseases. an integrative and functional approach to assessing an individual with respiratory disease needs to include consideration of potential environmental contributors to the etiology of a condition. . table 51 .2 lists environmental pollutants that are known to promote lung pathology. a 2016 study published in the canadian respiratory journal examined exhaled fractional nitric oxide (feno)an indicator of inflammation in the lungs -in school children at three different schools located three different distances from a large steel mill [127] . steel processing is known to be a source of ambient iron, nickel, lead, copper, vanadium, and zinc. the study found statistically significant differences in feno between the two closer schools compared to the farthest school from the mill, indicating potential increased lung inflammation caused by heavy metals and/or air pollutants [127] . although acute metal toxicity is possible, chronic, low-grade exposure is more common and may contribute to respiratory complications and disease. an individual's ability to vitamin c -as an antioxidant, it assists glutathione in this function and has been shown scientifically to raise glutathione levels short term; it is recycled by glutathione from its oxidized state back to its active state, thus strengthening antioxidant defenses; vitamin c also recycles vitamin e and alpha-lipoic acid vitamin e -as an antioxidant it also assists glutathione in eliminating free radicals much like vitamin c; it is also required for the proper functioning of glutathione enzymes; it recycles vitamin c and alpha-lipoic acid b vitamins -vitamins b1 and b2 maintain glutathione and its enzymes in their active forms; vitamin b2 participates in the formation of a glutathione molecule; vitamin b6 influences glutathione synthesis indirectly as it is important for the proper functioning of amino acids including gsh precursors; vitamin b6 increases the amount of magnesium (a vital cofactor) that can enter cells; folate (b9) pushes cysteine toward glutathione production rather than homocysteine production; folate and vitamin b12 work together in amino acid metabolism and protein synthesis. you can read more vitamin b12 deficiency and its effect on immune health at 7 http://www. immunehealthscience. com/vitamin-b12-deficiency. html selenium -part of the enzyme glutathione peroxidase (gpx). glutathione peroxidases, also known as selenoproteins, are a family of antioxidant enzymes that speed up the reaction between glutathione and free radicals magnesium -required for the proper functioning of the enzyme gamma-glutamyl transpeptidase (ggt) involved in the synthesis of glutathione zinc -zinc deficiency reduces glutathione levels, especially in red blood cells. however, zinc levels above normal have pro-oxidant properties and reduce glutathione too alpha-lipoic acid -an antioxidant produced by the body; it has been scientifically proven to enhance and maintain glutathione levels by stimulating enzymes involved in the synthesis of glutathione; it also helps increase the cellular uptake of cysteine, the crucial building block of glutathione; in addition, alpha-lipoic acid recycles vitamins c and e based on data from ref. [124] eliminate these metals via detoxification in conjunction with gastrointestinal health and other factors can serve as important factors in whether or not these metals accumulate in the body. chronic arsenic exposure may be linked to respiratory complications [128] . chronic arsenic ingestion via contaminated drinking water may be connected to respiratory symptoms such as chronic cough, shortness of breath, blood in sputum, and abnormal breath sounds [129] . arsenic can also be ingested through foods such as rice and rice products, shellfish, and seaweeds, which have been shown to have high levels of inorganic arsenic (more toxic than organic arsenic found in fish) [120] . however, ingested inorganic arsenic is typically biotransformed and excreted in the urine [130] . that said, altered biotransformation has been observed depending on an individual's age, gender, nutritional status, and genetic polymorphisms responsible for the biotransformation of inorganic arsenic [130] . chronic inhalation versus ingestion may result in irritation of the throat and respiratory tract [131] . individuals most affected by arsenic exposure are children, nursing children, and infants of exposed pregnant mothers [132] . acute inhalation of cadmium may lead to dyspnea and coughing [133] . long-term exposure to cadmium has been reported to contribute to emphysema, dyspnea, and inflammation of the nose, pharynx, and larynx [123] . individuals most affected by cadmium toxicity are those with occupations with cadmium exposure, such as those who work in certain types of factories, women, due to higher intestinal absorption because of low iron stores, and residents of asia due to high intake of rice grown in contaminated soil [134] . the 2013 us national health and nutrition examination survey (nhanes) demonstrated an association between obstructive lung disease and serum lead and cadmium concentrations in the blood, where cadmium was shown to partially mediate the association between smoking and obstructive lung disease [135] . in the 2015 korean nhanes, obstructive lung function was found to be associated with higher serum blood levels of cadmium and lead as well [136] . the specific mechanism of heavy metal burden and its effects on respiratory health must be further investigated. although testing and treatment of heavy metal burden have its limitations, it is worth considering as heavy metal accumulation can wreak havoc on the body. an example of heavy metal testing that can be used in practice is urine provocation testing with a chelating agent, such as fda-approved dmsa. eliminating heavy metals from the body can be potentially harmful and requires careful monitoring and guidance by an experienced healthcare professional. air pollutants that are used as indicators of air quality are carbon monoxide, lead, nitrogen dioxide, ozone, particles, and sulfur dioxide [137] . air pollution has been shown to have adverse effects on human health [138] . a 2017 systematic review and meta-analysis done in china showed an association between respiratory disease and ambient nitrogen dioxide, which is increased through fuel combustion, industrial production, and fuel exhaust [129] . diesel exhaust particles in particular have been associated with an increase in cytokines such as il-2, il-6, and ige in nasal mucosa [139] . nitrogen dioxide in particular can potentially contribute to respiratory disease as it is a free radical that is highly reactive and poorly water-soluble and can be deposited in the lungs when inhaled [138] . in another study performed in england, air concentration of nitrogen dioxide was significantly associated with respiratory hospital admissions [140] . other pollutants, such as fine particulate matter and ozone, have been shown to significantly affect respiratory function in copd patients [141] . increased ozone exposure has also been associated with increased airway inflammation and respiratory symptoms along with decreased respiratory function in children [142] . optimization of nutrition and antioxidant status is essential to combating the potential health effects of air pollutants. . [143] . it would be reasonable to assume having adequate stores and ability to utilize these nutrients may protect against other insults to the respiratory system as discussed in this section through their anti-inflammatory properties. acute and chronic exposure to certain chemicals can also pose a risk to respiratory health. obtaining a full occupational and social history when assessing individuals is important in order to identify any potential exposure to chemicals. one of the most well-known and common toxic chemical exposures that affects respiratory health is cigarette smoke. smoking cigarettes has been identified as a main cause of copd [144] . increased oxidative stress from inhaling cigarette smoke appears to activate the nf-kb inflammatory pathway, increasing the production of pro-inflammatory cytokines such as interleukin (il)-1, il-6, and il-8 and tumor necrosis factor-ɑ (tnf-ɑ) [144] . it also appears to reduce anti-inflammatory cytokines such as il-10 [145] . electronic cigarettes, or e-cigs, have been increasing in popularity in recent years and are marketed as a better alternative to tobacco cigarettes. however, recent evidence suggests that the vapor and associated chemicals produced by e-cigs may be harmful to the respiratory system, although further research is needed to determine the mechanism [146, 147] . exposure to metalworking fluid aerosols has been associated with asthma, hypersensitivity pneumonitis, impaired lung function, allergic alveolitis, and sinusitis [148] . a 2015 review also identified an association between occupational exposure to pesticides and increased risk of asthma and chronic bronchitis [149] . there are many chemicals that are toxic when inhaled. for example, inhalation of chlorine is toxic to the lungs, where low doses can cause airway injury and high doses can cause both airway and alveolar injury [150] . these injuries can manifest as dyspnea, hypoxemia, pulmonary edema, and pneumonitis [150] . high doses of carbon dioxide, such as that released from dry ice, can also induce respiratory failure. stress may also play a role in respiratory health and the body's ability to combat insults imposed on the respiratory system. from a physiological standpoint, it is worth noting that acute stress via activation of the sympathetic nervous system increases ventilation through the production of glucocorticoids [139] . repeated acute stress may also affect growth and repair mechanisms [139] . chronic biological stress in the form of infections can also be inflammatory and negatively affect the immune system and may affect an individual's susceptibility to respiratory complications. see the chronic infections and respiratory health section on page # below for further information on this association. however, appropriate amounts of physical stress, such as in the form of exercise, can be beneficial to respiratory health. some research has indicated a benefit of aerobic exercise to respiratory muscle strength in cystic fibrosis patients [151] . chronic stress can be defined as recurrent acute stress or inability to moderate acute stress responses [139] . this can be in the form of physical or emotional stress. chronic stress and negative emotions such as depression, anxiety, and anger may be linked to endocrine and immune processes [152] . immunoglobulin e (ige) and cytokine production, as well as respiratory inflammation, are markers that characterize the asthma response and have been shown to respond to stress in some capacity [139] . it has been hypothesized that increased stress may increase susceptibility to air pollution given its effects on the inflammatory response [139] . another connection between emotions and respiratory health is acknowledged in east asian medicine, noting the association between the lungs and feelings of sadness, grief, and anxiety [153] (. table 51 .3). asthma is a chronic inflammatory lung disease, triggered by either an ige allergic reaction or nonallergic factors, and results in reversible airway obstruction and inflammation of the airway [11] . it is characterized by recurrent episodes of wheezing, breathlessness, coughing, and chest tightness [11] . severe asthma or asthma that is chronic or poorly controlled may lead to airway and lung remodeling that involves deposition of fibrotic tissue which leads to constriction of the bronchi [18] . although the exact mechanisms have not yet been identified, compromised nutritional status, such as deficiencies in selenium, zinc, and vitamins a, c, d, and e, has been connected to asthma [155] . the pathophysiology of asthma, nutrition considerations, genotypic characteristics, and lifestyle influences will be discussed in this section. there are numerous potential triggers to the development and/or exacerbation of asthma which can be summarized in 7 box 51.2. the various causes of asthma have led to the classification of several different subtypes and endotypes of asthma in hopes of choosing more targeted treatments. the pathophysiology of asthma is complex and not fully understood, due in part to its heterogeneous nature, which necessitates its organization into individual phenotypes and endotypes. this organization is important to be able to utilize targeted treatments by identifying the root causes of the symptoms. however, more research is needed to more clearly identify the specific pathological mechanisms of each phenotype and particular treatment responses [156] . two of the most common asthma phenotypes are allergic and nonallergic asthma [147] ; allergic is characterized by increased th2 immunity (th2 high) and nonallergic defined by varying mechanisms depending on the trigger (th2 low) [157] (see also 7 chap. 19) . allergic asthma involves the ingestion of typically harmless environmental triggers (listed in . table 51 .3) by antigenpresenting cells in the bronchi, which interact with immature helper t cells that, in turn, trigger an unwarranted allergic response [18] . this reaction occurs from repeated exposure to a trigger and is referred to as the type 1 hypersensitivity response [18] . this increased th2 immunity upregulates eosinophilic inflammation, tissue damage, airway hyperresponsiveness, and bronchoconstriction [113] . mast cell activation disorders, which is characterized by diseases and conditions related to mast cell mediators and the activation of mast cells, must also be considered when addressing allergic asthma [158] . in contrast, nonallergic asthma can be caused by other factors such as anxiety, exercise, stress, dry air, cold air, viruses, hyperventilation, smoke, or other irritants [11] . . inhaled cadmium (cd) is deposited in the alveoli where it is then absorbed into the bloodstream cd is transported to erythrocytes or bound to albumin, where it is then taken up by the liver to form a complex with metallothionein (mt) cd interferes with the absorption of zinc and competes for the same enzyme binding sites enzymatic activity of zinc-dependent enzymes reduces preferential binding of cd to mt can cause zinc deficiency altered biotransformation and excretion of ingested arsenic via contaminated water are linked to respiratory complications chronic inhalation of arsenic may result in irritation of respiratory tract diesel exhaust particles in particular have been associated with increase in cytokines such as il-2, il-6, and ige in nasal mucosa [139] nitrogen dioxide is a free radical that is highly reactive and poorly water-soluble and can be deposited in the lungs when inhaled [102] rising pollen and mold counts [154] increasing ozone [154] chemicals increased oxidative stress from inhaling cigarette smoke may activate the nf-kb inflammatory pathway, increasing the production of pro-inflammatory cytokines such as interleukin (il)-1, il-6, il-8, tumor necrosis factor-ɑ(tnf-ɑ) cigarette smoke may reduce anti-inflammatory cytokines such as il-10 [145] stress repeated acute stress may also affect growth and repair mechanisms [139] ige and cytokine production, as well as respiratory inflammation, are markers that characterize the asthma response and have been shown to respond to stress in some capacity [139] increased stress may increase susceptibility to air pollution given its effects on the inflammatory response [139] ( individuals suffering from nonallergic asthma will tend to be less responsive to th2-targeted treatments due to a differing immune response at play [157] . some of the additional proposed phenotypes are eosinophilic, exacerbation-prone, exercise-induced, fixed obstruction/airflow limitation, poorly steroid-responsive, and adult-onset obesity-related [159] . several of the proposed endotypes are summarized in . the american partnership for eosinophilic disorders defines eosinophilic asthma as a type of asthma characterized by especially high levels of eosinophils, more commonly developed later in adulthood, although may occur in some children [160] . many with eosinophilic asthma do not have underlying allergies or history of allergic conditions such as eczema, food allergy, and hay fever, which are thought to be seen more in people with allergic asthma [160] . in contrast to allergic asthma, the cause of eosinophilic asthma is still unknown. histamine intolerance must also be considered in assessing the root cause of asthma. ingesting histamine-rich foods and beverages such as bananas, grapes, strawberries, citrus fruits, tomatoes, nuts, chocolate, pineapples, fish, spinach, fermented foods, and beverages [161] has been shown to provoke a histamine response that may result in asthma exacerbations, among many other potential signs and symptoms [162] . disruptions in redox, or oxidation/reduction, reactions in addition to hindered antioxidant defense have been . usually not responsive to glucocorticoids [159] based on data from ref. [157] found to be a risk factor for asthma severity and development [163] . the levels of glutathione, one of the lung's most predominant antioxidants in both reduced and unreduced forms, are thought to be important for lung homeostasis and tied to asthma [163] . more research is needed to determine the exact differences in the pathophysiologies of the various subtypes of asthma in order to develop more targeted treatments. minerals such as zinc, selenium, copper, and manganese may serve as cofactors to major enzymes with antioxidant activity in the lung, such as superoxide dismutase, catalase, and glutathione peroxidase [164] . asthma has been associated with decreased activity of these enzymes [165] . low selenium intake has been associated with multiple chronic diseases including asthma [163] . selenium serves as a cofactor to glutathione peroxidase, an enzyme with antioxidant activity in the lung that is responsible for maintaining gsh/gssg redox balance [163] . imbalance between oxidants and antioxidants seems to serve an important role in asthma. levels of nonenzymatic antioxidants glutathione, ascorbic acid, alpha-tocopherol, lycopene, and beta-carotene, in addition to antioxidant enzymes superoxide dismutase (sod) and glutathione peroxidase, were significantly lower in asthmatic children compared to healthy controls [165] . the amino acids glycine and glutamine, which are important in glutathione synthesis, were also found to be significantly lower in children with asthma [165] . dha has also been found to be abundant in airway mucosa, where it is decreased in individuals with asthma and cystic fibrosis [166] . magnesium is known to elicit the relaxation of bronchial smooth muscle, decrease responsiveness to histamine, have an anti-inflammatory effect, and decrease the susceptibility of animals to developing anaphylactic reactions [25] . it is estimated that two-thirds of the population in the western world is not consuming the recommended daily allowance of magnesium [167] . magnesium can be used intravenously as an effective treatment of acute asthma attacks. one double-blind controlled trial that used 1.2 g of magnesium sulfate when patients did not respond to treatment with beta-agonists found decreased likelihood of hospitalization and improved lung function [168] . magnesium sulfate as an adjunct therapy with bronchodilators and steroids has also been shown to have a benefit in children with moderate to severe asthma [168] . although the exact mechanism is not yet known, magnesium is thought to increase glutathione concentrations in the lung [169] . more research is needed to determine additional associations between specific nutrients and asthma. however, optimization of the nutrients discussed in this section has the potential to reduce the severity and/or progression of asthma (. fig. 51.5) . asthma has a strong genetic component, with more than 100 genes associated with it in varying degrees across many populations [18] . more recent potential genetic associations include filaggrin, which encodes for the epithelial barrier; ormdl3, which encodes transmembrane protein; beta-2 adrenergic receptor gene, expressed throughout smooth muscle and epithelial cells of the lung; and interleukin-4 receptor gene, which has a variant associated with elevated ige [171] . a 2011 systematic review and meta-analysis showed that deficiencies in selenium, zinc, vitamins a, c, d, and e, and low fruit and vegetable intake could be associated with the development of asthma [155] . although this data is tenuous due to lack of randomized controlled trials, it does give some indication of the relationship between nutrition status and dietary patterns with respect to asthma development. more research needs to be done to isolate the impact of these nutrients and dietary patterns on asthma prevention and development. a 2015 review conducted by berthon and wood noted the protective effects of the mediterranean diet for allergic respiratory diseases as evidenced by epidemiological studies. this diet emphasizes minimally processed plant foods in the form of fruit, vegetables, cereals, beans, breads, nuts, seeds, and olive oil and low to moderate intake of dairy, poultry, fish, and wine, as well as low intake of red meat [172] . this association was the strongest in children, where the mediterranean diet had a protective effect on atopy, wheezing, and asthma symptoms [172] . however, there is less data available to support this pattern in adults. the same review noted an association between the "western" diet, which emphasizes refined grains, red and cured meats, french fries, sweets and desserts, and highfat dairy products and increased risk of asthma in children [172] . a meta-analysis and systematic review done in 2014 showed a reduction of risk in childhood wheezing with high fruit and vegetable intake and also showed negative association between fruit and vegetable intake and asthma risk in adults and children [173] . in contrast, food allergy has been especially linked with allergic asthma in children [161] . a study examining food allergy in asthmatic children identified higher serum levels of ige in asthmatic children compared to healthy controls, where all asthmatic children in the study were also identified as having a positive skin prick test (spt) to various food allergens [174] . a study done on 322 children under the age of 1 diagnosed with asthma, with or without allergic rhinitis, was placed on a meat-based formula of carrots, beef, broccoli, and apricots for 6 weeks. it was found that 61% had nearly complete resolution of symptoms [25] . this same study also found that the most common food triggers were milk, egg, chocolate, soy, legumes, and grains [25] . while food allergy as a cause of asthma is more common in children, hidden food allergy has been reported to be the root cause of asthma in around 40% of adults [25] . improvement in respiratory symptoms was also seen in a small study of adults given an antigen-free elemental diet in a hospital setting [25] . removal of food triggers has also been linked to improvement in exercise-induced asthma [25] . identifying food allergies can be a complicated process because many of the testing methodologies such as skin prick tests (spts) and blood tests can yield false-positive results for up to 50-60% of cases, according to the food allergy research & education organization [175] . a food elimination diet and/or oral food challenge can be a powerful tool in determining food allergy specific to asthma symptoms, where a dietitian or nutritionist in conjunction with physician and/or allergist can serve an important role through this process to support the individual. oxidative stress may play a key role in the development of asthma, which can also be true for the development of chronic diseases such as cardiovascular disease, diabetes, and cancer [117] . it has been shown that obesity may be a risk factor for people with and without allergy and may worsen pre-existing asthma [159] . individuals with asthma are twice as likely to have gastroesophageal reflux disease (gerd) than people who do not have asthma, especially those resistant to treatment [159] . celiac disease and asthma have also been linked. an italian cohort study was done that showed a significant association between treated asthma and celiac disease, where antibiotic exposure in the first year of life was controlled for and not found to contribute to this association [176] . it has also been found that individuals with celiac disease following a glutenfree diet experienced improvement in asthma symptoms [25] . it is well-known that toxic exposure to particulate matter, airborne pollutants, or cigarette smoke can trigger asthma symptoms [165] . more specifically, a dose-dependent relationship between cigarette smoke exposure and rates of asthma has been shown [165] . traffic density and asthma exacerbations have also been clearly demonstrated [165] . certain medications may also serve as triggers to asthma. aspirin-exacerbated respiratory disease (aerd) is considered another asthma subtype caused by nonsteroidal anti-inflammatory drugs (nsaids) and is characterized by asthma, chronic rhinosinusitis, and acute respiratory reactions [159] . in addition, overuse of antibiotics in childhood has been linked to asthma [18] , indicating a connection between the microbiome and asthma development. allergic bronchopulmonary mycosis (abpm) noted in . table 51 .4 is caused by a hypersensitivity reaction to fungal colonization of the airways [159] . this is typically caused by the fungus aspergillus fumigatus. without treatment, this may lead to fixed airflow obstruction and bronchiectasis [159] . the progression of asthma is complex and multifaceted, from preconception through childhood and adulthood. research suggests that early life events are largely predictive for regulatory mechanisms within the pulmonary immune system [177] . for example, prenatal exposure to a farming environment, one rich in microbial compounds, is thought to influence innate immune patterning in the mother which may affect the development of the neonatal immune system [177] . this influence in immune patterning can be seen through higher expression of toll-like receptors 2 and 4 and cd14 on peripheral blood cells, which implies possible desensitization to allergens in children [178] . t regulatory cells, which serve an important role in immune regulation and are thought to play an important role in asthma by suppressing the th2 inflammatory response to harmless air particles, have been shown to be impaired in the cord blood of neonates at hereditary risk for allergy [179] . in the 2017 study performed by singh et al. looking at serum ige and cutaneous sensitivity to food allergens in asthmatic children here was a negative correlation of total ige and duration of breastfeeding, indicating a connection between breastfeeding and the immune response [174] . additionally, reduced maternal intake of vitamins d and e and zinc during pregnancy has been associated with increased asthma symptoms in children [180, 181] . vitamin d has been associated with the maintenance and/or development of the t regulatory cells stated earlier in mice; however more research is needed to determine a definitive association in humans [177] . a clinical trial performed on non-smoking asthmatic patients showed higher vitamin d levels were associated with greater lung function; furthermore, supplementation with vitamin d showed improved treatment response to glucocorticoids [182] . vitamin d may also directly increase the antiinflammatory cytokine, interleukin (il)-10 and also enhance steroid-induced il-10 production (see . fig. 51.6) [177] . more research is needed to determine the exact mechanism of vitamin d in asthma and respiratory disease. beta-agonists, combined with corticosteroids, serve as the primary conventional therapy [183] . typically, a short-acting beta-agonist will first be prescribed to manage symptoms as needed, where low-dose inhaled corticosteroids may also be prescribed [156] . if symptoms persist, it is recommended to evaluate problems such as adherence to use, inhaler technique, or persistent allergen exposure and comorbidities [156] . once these are ruled out, the step-up treatment is a combination of an inhaled corticosteroid with a long-acting beta-agonist [156] . a summary of other conventional treatments and their mechanisms can be found in . table 51 .5 below. unfortunately, conventional methods for the treatment of asthma may have harmful side effects. for example, the use of . fig. 51.6 effect of asthma treatments on regulatory pathways. (reprinted from lloyd and hawrylowicz [177] . with permission from elsevier) systemic glucocorticoids may lead to immunosuppression, cataracts, and osteoporosis, where long-acting beta-agonists have the potential of increasing asthma exacerbation risk and death [25] . beta-agonist desensitization is thought to be one of the reasons for increasing asthma exacerbation risk and death [184] . related to several subtypes of asthma and their differing pathophysiologies, it is important to first determine the subtype before deciding on treatment. for example, in an individual with allergic asthma, this could be a potentially simple fix once the allergen that exacerbates symptoms is identified. a more conventional approach may involve starting the individual on an inhaled corticosteroid or an ige antagonist (i.e., omalizumab) [159] , rather than identifying the root cause of the patient's symptoms. while medications may be warranted until the trigger is identified, finding the underlying causes may not be common practice in many conventional settings. in contrast, the ifmnt assessment takes a much deeper dive into identifying triggers and any nutrient insufficiencies, inflammation or immune dysregulation, biochemical individuality, lifestyle, energy dysfunction, toxic load, sleep, and stress issues are taken into account. with this information, the practitioner can make more targeted dietary, lifestyle, and supplement recommendations to obtain sustained resolution of symptoms by treating the root cause (. table 51 a 26-year-old female presented with a complaint of reactive airway disease, which was diagnosed as asthma and had been prescribed inhalers. she reported that she felt like she had difficulty breathing most of her life, especially when exercising. however, her condition was not severe enough to seek help until she was 25 years of age. she reported a lot of stress during this time related to applying for a postgraduate training position. she also reported 1 year prior to diagnosis developing new allergic symptoms. her past medical history was significant for conditions related to airways, including chronic sinus infections, strep throat, bronchitis, and recurrent pneumonia. she could not remember the last time she felt well but assumed it was sometime as a young child. her nutrition and health goals were to breathe better and to not have to rely on inhalers. the following data was collected on her initial visit. . methyl xanthine found in tea used less commonly due to side effects relaxes airways due to inhibition of phosphodiesterases; acts as a functional antagonist in airway smooth muscle [171] based on data from ref. [18] . table 51 .6 summary of an integrative and functional medical nutrition therapy assessment adequacy of nutrient-dense foods to begin to assess nutritional status organic or nonorganic to assess toxic load and nutrient intake food preparation and processing to assess nutrient content and identify potential contaminants (e.g., plastic endocrine disruptors) assess food sensitivities or intolerances to identify potential triggers microbiome status: assess comprehensive digestive stool analysis for microbiology and fermented food intake; history of antibiotics or microbiota agonists (medications, toxins, stress, etc.) toxin intake via plastics or inhalation and skin absorption which may affect immune response assess flavonoids intake as they are antioxidant and anti-inflammatory compounds with mast cell inhibitory action; adequacy may reduce airway reactivity consider celiac disease and gluten intake as potential inflammatory antigens mineral assess and restore zinc, selenium, magnesium, manganese, iron, and iodine status to normal reference. caution to not supplement or intake of food sources higher than reference antioxidants assess and restore antioxidant balance; vitamins a, c, d, and e and glutathione assess quercetin intake (leafy vegetables, broccoli, red onions, peppers, apples, grapes, black and green tea, red wine) as it may act as mast-cell stabilizing agent inhibiting release of histamine, tnf-alpha release, formation of prostaglandin d2, reducing interleukin production consider supplementation of quercetin if quercetin intake is low [185] protein status assess and restore to support connective tissue and immune status ensure adequate glutamine and glycine intake oils/lipid/fatty acids assess fatty acid balance as dha important in lung tissue integrity assess adequate serum cholesterol and fat intake to support lipid bilayer important for cellular function in lung (epithelial cells, surfactant production, etc.) methylation assess methylation status and detoxification capacity of toxins related to asthma exacerbation; important assessment biomarkers suggested: mcv/mch, homocysteine, methylmalonic acid, rbc folate, genomic methylation snps inflammation/immune dysregulation assess asthma biomarkers to help identify root cause (see . fig. 51 extreme exhaustion, depression, add, anxiety (accompanied by panic attacks), constipation, pain in legs, neuropathy in feet (numbness and tingling), rapid heartbeat, and a very severe rash on feet known as chilblains. 5 utis -recurrent as a child. 5 poor immune function (frequent infections). 5 antibiotic use (very frequent from childhood into adulthood). 5 sinus infections, strep throat, and bronchitis -she had recurrent sinus infections and strep throat about once a year every year and often this would lead to bronchitis, she could not remember if she had these issues before middle school. 5 depression, anxiety, add. 5 acne. 5 peptic ulcers. 5 yeast infections -multiple throughout college. 5 eczema. 5 two recent episodes of pneumonia the last episode resulted in her asthma diagnosis. 5 asthma. evaluate exposure to fungus to identify allergic bronchopulmonary mycosis assess individual's medication history, considering short-and long-term use of conventional treatments evaluate exposure to particulate matter, airborne pollutants, cigarette smoke, or toxic metals such as cadmium and arsenic sleep and stress assess sleep adequacy (7-9 hours with 5-hour rem sleep) and quality (good sleep hygiene with little light/ sound/emf disturbance) to support detoxification of toxins that may worsen respiratory status and aid in repair of damaged lung tissue . periostin plays a role in the pathogenesis of allergic diseases, including asthma, as it is associated as a downstream molecule of the cytokine, il-13. periostin is used as a biomarker for type 2 immunity and can be used to determine the potential effectiveness of medications used to treat asthma, such as anti-ige antibodies and anti-il-13 antibodies. asthmatic patients with high serum periostin tend to be aspirin intolerant, eosinophilic, late asthma onset, and have a high nitric oxide fraction. high periostin can also indicate a reduced response to inhaled corticosteroids [186, 224] . periostin in the right panel is stained brown and is localized in the thickened basement membrane in asthmatic patients. (reprinted from izuhara et al. [186] . with permission from the korean academy of asthma, allergy and clinical immunology) for several weeks, led to being immobile for almost 2 weeks 5 8th-12th grade: was often sick (strep, sinus infections, bronchitis); described it as being constantly sick from fall through winter every year; also developed eating disorder during this time; had severe menstrual cramps (induced vomiting) accompanied by acne, which led to being put on birth control at age 17 as a precursor to accutane (never prescribed); chronic constipation starting during this time university 5 freshman -sophomore year: eating disorder was most severe during this time. 5 first semester of freshman year: developed digestion issues, after eating certain foods (especially mexican or salsas), stomach would become distended, experienced pain, and often would result in vomiting. pain so severe during finals week she was admitted to er with no diagnosis. ct scan revealed possible peptic ulcers. 5 junior-senior year: depression, anxiety, and inability to focus were most severe during this time which resulted in missing a lot of class and struggling as a student; suffered multiple panic attacks; gained a lot of weight (from 120 to 180 lb); end of senior year became engaged to be married -moved to dallas, tx. 5 lived in dallas for 6 months, continued to experience depression and anxiety and weight gain, and moved back to home state 5 initially started running (~2 miles a day) and experiencing inability to breathe, diagnosed with pneumonia, prescribed inhaler to help with running; other symptoms: eczema around the eyes and neck (after running outside), pain in calves, numbness and poor circulation in feet (pulse not detected by several health professionals), and development of chilblain rash (very painful, itching, lasts about 3-4 weeks from development to resolution); increased running -ran a half-marathon. visited pcp and several specialists for help with chilblain rash with no resolution or diagnosis; lost a lot of weight (from 170 to 140 lb). 5 ongoing increased depression, anxiety, and inability to focus; pcp rx cymbalta (depression and anxiety); cymbalta discontinued after ~2 months (did not tolerate side effects), continued psychological therapy for several months; chilblain rash continued. stopped running long distances. gained weight back (from 140 to 170 lb); subsequently saw blog for integrative rd and followed suggestion to eliminate gluten and focusing on whole foods diet. 5 chilblains and eczema began to resolve while following integrative rd recommendations of gluten-free diet with some improvements. however, difficulty breathing got worse, and diagnosis of asthma was made with fast-acting inhaler used for exercise; as time progressed, breathing continued to worsen, led to daily inhaler use. weight at this time is still at around 170 lb. high dairy diet (consumed dairy products at most meals and snacks), consumed three smaller meals with three snacks in between 5 meals and snacks balanced with protein, fat, and carbs, with carbs coming from fruits and vegetables and fat mainly from full fat cheese, greek yogurt, and butter 5 mostly nonorganic produce and commercially raised meats digestion, assimilation, and elimination 5 hx of peptic ulcers and chronic constipation (bm ~1-2 times a month) 5 bms currently at about 2 × per week on encounter utilization, cellular, and molecular (mapdom) 5 hx of likely gluten sensitivity. 5 presented symptoms of possible dairy sensitivity (bloating, acne, asthma). 5 evidence for compromised intestinal barrier. 5 minerals: infrequent bms could indicate low fiber or low mineral status (mg); when bms do occur, they are hard and dry (low mg); severe menstrual cramps (low mg); labs showed low k and na, on yaz birth control (low zinc and low b vitamins). 5 antioxidants: consumed adequate fruits and vegetables each day. 5 protein: has some evidence of poor/slowed wound healing as evidenced by sore on leg that has not completely healed after a year; cuts that take months to heal. 5 d and fat-soluble a, e, and k vitamins -hx of poor immune function (low d), vdr +/+ (low d and possibly a). 5 oils/fatty acids: high omega-6/omega-3 ratio, higher intake of damaged fats, very low intake of omega-3. 5 methylation: symptoms of depression, anxiety, add combined with mthfr c677t snp and on yaz (low b6 and folate). 5 eicosanoid fatty acids status -suspect issues with pge1 series pathway to control inflammation due to following signs and symptoms: allergies, autoimmune condition (asthma), peptic ulcers, eczema, and severe menstrual cramps 5 immune function -suspect gut dysbiosis due to following s&s: poor immune function, yeast infections, hx frequent antibiotic use, cyst, and constipation body composition 5 genetic makeup that indicated prone to gluten and dairy sensitivity, low vitamin d status, and impairment in methylation 5 broad spectrum probiotic + fermented foods 5 bioactive b complex (includes 50 mg p5p b6 and 800 mcg 5 thf) 5 260 mg gla evening primrose oil and zinc 3. aim to eat three larger meals a day, allowing space in between of ~ 5 hours; increase omega-3 intake by adding in small fatty fish, such as sardines or anchovies, once per week and taking fish oil; decrease omega-6 intake, switch from conventionally raised meats to organic, pasture-raised; and replace fat in diet from dairy with coconut sources, more nuts, and avocados. 5 patient presented ~6 months after the initial visit (september 2015). her breathing had improved immensely. she was able to stop taking her albuterol inhaler before exercise, recently stopped daily inhaler. 5 after dairy-free diet for 3 months, reintroduced dairy (cheese, butter, yogurt). asthmatic symptoms returned about 2-3 days after the addition of each. noticed the more dairy consumed, the worse her symptoms became. 5 at time of appointment, diet whole foods, gluten-free, and dairy-free. weight loss 10 lb within the first month of going dairy-free, continued to lose some weight. when reintroduced dairy symptoms of bloating and increase in weight, which resolved returning to dairyfree diet. 5 bms are regular now at ~ 2 × daily. this patient case followed some common patterns in the development of chronic disease and the comorbidities that are common, especially autoimmune conditions like asthma. the first is the genetic susceptibility of the individual; several snps are prone to dairy sensitivity. second, significant evidence for gut dysbiosis, promoted compromised gut barrier, can contribute to the development of dairy sensitivity. third is the exposure to dairy protein antigen. diet history evidenced trigger for asthmatic condition. additionally, inflammation, immune dysfunction, and methylation issues present. signs and symptoms significant for decrease in pge1 series anti-inflammatory pathways. low dietary omega-3s potential contributor to asthma. immune dysfunction evidenced by extensive history of infection-antibiotic use. genomic snp mthfr c667t gene, which indicated a greater need for folate. the use of yaz birth control and symptoms of depression, anxiety, and add known further to deplete b6 and folate. the diet and supplements recommended targeted control of inflammation, restore gut ecology, promote proper methylation, and replete nutrient insufficiencies. results from 6-month follow-up showed successful outcome in helping improve breathing and wean her off of inhalers. this case is an example of the ifmnt approach able to address the complexity of the whole patient story and bring the metabolic priorities into a manageable intervention program for the individual. one study found that the composition of the nasopharyngeal microbiota in children was linked to the frequency of upper respiratory tract infections and acute sinusitis [189] . a study that intranasally inoculated mice with lactobacillus fermentum reduced the amount of s. pneumoniae in the respiratory tract and increased the number of macrophages in the lung and lymphocytes in the trachea [189] . these findings may indicate a benefit of manipulating the upper respiratory tract microbiota with orally or nasally administered probiotics in the prevention and/or treatment of upper respiratory tract infections. allergic bronchopulmonary mycosis (abpm) is caused by a hypersensitivity reaction to fungal colonization of the airways. this is typically caused by the fungus aspergillus fumigatus. without treatment this may lead to fixed airflow obstruction and bronchiectasis [159] . guillain-barre syndrome (gbs) is a rare neurological disorder in which the body's immune system attacks the peripheral nervous system, known as the network of nerves located outside of the brain and spinal cord [190] . it is often preceded by a bacterial or viral infection. there are several potential mechanisms in which these infections trigger gbs. if an individual contracts a campylobacter jejuni bacterial infection, antibodies made to fight this infection can attack axons in motor nerves, which can potentially cause paralysis and respiratory failure [190] . campylobacter can be ingested via contaminated food or other exposures [190] . pérez-guzmán 2005 states that hypocholesterolemia is common among tuberculosis patients and suggests that cholesterol should be used as a complementary measure in antitubercular treatment [8] . alpha-1 antitrypsin (a1at) deficiency is an underrecognized disease in the united states, with around documented 100,000 people suffering from it, according to the alpha-1 foundation. this deficiency is inherited through autosomal codominant transmission, meaning affected individuals have inherited an abnormal aat gene from each parent [191] . individuals with this deficient allele present with aat levels at less than 35% to low-end normal levels [191] . however, it is also possible for individuals with a variant of this allele to be asymptomatic given different environmental conditions or lifestyle factors, such as refraining from smoking to reduce lung disease development risk [191] (7 box 51.4). a1at deficiency most often manifests in the lungs as chronic obstructive pulmonary disease (copd) (i.e., emphysema or bronchiectasis or "genetic copd"). a1at deficiency is often undiagnosed because people with genetic copd experience the same symptoms as people with copd, such as [191] : 5 shortness of breath 5 wheezing the only way you will know for sure if you have genetic copd due to alpha-1 is to get tested. ________ a1at deficiency can manifest in the liver as cirrhosis. symptoms related to the liver 5 unexplained liver disease or elevated liver enzymes 5 eyes and skin turning yellow (jaundice) 5 swelling of the abdomen (ascites) or legs 5 vomiting blood (from enlarged veins in the esophagus or stomach) a1at expresses sometimes in the skin as panniculitis [191] . panniculitis typically appears as raised red spots on the skin, which may break down and give off an oily discharge. while panniculitis spots (called nodules) may appear anywhere on the body, the most common places are the thighs, buttocks, and areas subject to injury or pressure. normal genotype m m 5 most common abnormal genes are called s and z 5 abnormal variant combinations: 5 zz (highest risk) 5 sz (lower risk increasing if smoker, inhalant pollutants) 5 mz (lower risk of carrying an a1at gene variant; considered "carriers") 5 alpha-1 is the most commonly known genetic risk factor for emphysema 5 up to 3% of all people diagnosed with copd may have undetected alpha-1 5 alpha-1 can also lead to liver disease. the most serious liver diseases are cirrhosis and liver cancer 5 the world health organization (who), american thoracic society (ats), and the european respiratory society (ers) recommend that everyone with copd be tested for alpha-1 alpha-1 is a progressive disease that benefits from early detection. it can cause serious lung diseases, such as copd and emphysema when undiagnosed. in some cases, alpha-1 can also cause liver disease [225] symptoms related to the lung [225] : 5 shortness of breath 5 wheezing 5 chronic bronchitis, which is cough and sputum (phlegm) production that lasts for a long time 5 recurring chest colds 5 less exercise tolerance 5 year-round allergies 5 bronchiectasis the alpha-1 antitrypsin (a1at) protein protects the body, especially fragile lung tissues, from the damaging effects of a powerful enzyme called neutrophil elastase that is released from white blood cells. in a1at deficiency, a genetic mutation reduces levels of the protective protein in the bloodstream. a1at deficiency can lead to chronic obstructive pulmonary disease (copd), specifically emphysema, and liver disease. smoking, which can inhibit what little a1at protein an affected person does have, increases the risk of lung disease. alpha-1 antitrypsin deficiency is completely determined by mutations in a single gene. the severity of symptoms is mostly a function of which mutations a person has and how many copies. however, smoking can greatly increase the risk of lung disease due to aat mutations. 23andme reports data only for the pi * m, pi * s, and pi * z versions of the gene that encodes aat. keep in mind that it is possible to have another mutation that causes this condition that is not included in this report [192] . a1at deficiency is a genetic disorder that reduces circulating levels of a protein that protects the lungs by trapping a1at in the liver, where the protein is produced, and prevents a1at from entering circulation. a1at deficiency can lead to chronic obstructive pulmonary disease (copd), specifically emphysema, and liver disease. when a disease-causing mutation is fairly common, as the pi * s and pi * z mutations are in europeans, it suggests that the mutation actually conferred an evolutionary advantage at one time. some researchers have suggested that several thousand years ago when the pi * z and pi * s mutations first arose, these versions of the gene for a1at gave people a survival advantage by creating an environment in their lungs that helped fight off infections. the scientists theorize that the antimicrobial benefits of the aat mutations outweighed the cost of an increased risk of copd and liver disease in the era before antibiotics were available [193] . in contrast to lung disease, manifestation of liver disease related to a1at can be referred to as a "toxic gain of function, " due to accumulation of mutant a1at protein rather than protease deficiency within the liver [144] . when taken together, fibrotic lung diseases are the leading cause of mortality worldwide. under the umbrella of interstitial lung disease (ild), pulmonary fibrosis (pf) is the most common. any ild that involves scarring of the lungs falls in the pulmonary fibrosis category. pulmonary fibrosis is the scarring of lungs, which destroys tissue over time, making it impossible to transfer oxygen from inhaled air into the bloodstream. there are more than 200 different diseases under the pulmonary fibrosis umbrella. because pf is often misdiagnosed or goes undiagnosed, there is not an accurate count of those with these diseases. however, it is estimated that as many as 1 in 200 adults over 60, or 200,000 people in the united states, are affected [184] . there are more than 50,000 deaths from ipf every year in the united states. more people die each year from idiopathic pulmonary fibrosis than from breast cancer [194] . there are other forms of interstitial lung disease including the newly identified pleuroparenchymal fibroelastosis, cryptogenic organizing pneumonia (cop), desquamative interstitial pneumonitis, nonspecific interstitial pneumonitis, hypersensitivity pneumonitis, acute interstitial pneumonitis, interstitial pneumonia, sarcoidosis, and asbestosis [195] . symptoms include cough and dyspnea, restrictive pulmonary function tests with impaired gas exchange, and progressive lung scarring. the disease progresses with an initiation of inflammation. fibrosing starts with the action of transforming growth factor-β (tgf-β)-dependent differentiation of fibroblasts to myofibroblasts, which then express α-sma (smooth muscle actin) [196] . after the tgf-β-dependent differentiation of fibroblasts to myofibroblasts, which express α-sma, there is sustained, excessive deposition of collagen by the myofibroblasts in the lung interstitium leading to the progressive lung damage in patients with pf [185] . research published in 2011 supported the idea that dysfunctional type ii aecs (alveolar epithelial cells) facilitate lung fibrosis through increased susceptibility to injury, leading to excessive and dysregulated remodeling [197] . the disease seems to progress in steps, and inflammation is not typically present continuously, except during certain periodic episodes of deterioration (. fig. 51.8 ). there are five main categories of pf causes: drug-induced, radiation-induced, environmental, autoimmune, and occupational. of these five, four have identifiable causes. some of the autoimmune diseases that can lead to pf are rheumatoid arthritis, scleroderma, sjogren's syndrome, polymyositis, dermatomyositis, and antisynthetase syndrome. idiopathic pulmonary fibrosis (ilp) is defined as pf with an unknown cause, including a genetic cause for some families [see . fig. 51.9 ]. the symptoms of ilp are a dry, hacking cough, shortness of breath, fatigue, chest discomfort, loss of appetite, and unexplained weight loss, all caused by the fibrosing of the lungs. diagnosis can be difficult, and pf is often misdiagnosed as copd or other more common lung diseases. in addition, in the recent past, path to a true diagnosis was invasive. since damage to the lungs, even through a diagnostic biopsy, can trigger further lung damage or a period of fibrosis, many physicians or patients are cautious with a biopsy approach to diagnosis. since the current treatments are limited, one must evaluate whether defining the exact form of pf is necessary for treatment and follow-up. difficulty breathing, crackling sounds while breathing, and low oxygen levels are the first indicators. clubbed fingernails may also be a symptom. high-resolution ct scans are performed, which can show scarring. the pulmonologist will ask many questions and order more blood tests to try to distinguish between the 200 forms of pf. the future is pointing to molecular endotyping as a more accurate way to diagnose. molecular endotyping includes genetic, metabolic, transcriptional, and environmental factors to help determine the pathophysiology [199] . genetic research has been progressing for a couple decades with illuminating results. there are more than a dozen genetic variants that have been associated with this family of diseases. researchers now believe at least 20% of idiopathic pulmonary fibrosis (ipf) patients with multiple family members suffering from ipf have some common familial genetic variants, which may allow researchers to eventually drop the term idiopathic and further define various forms or categories, with differing progression or outcome. the name given to this version of interstitial pneumonias is familial interstitial pneumonia (fip) [200] [see . currently two categories of genetic focus have been defined: those genes related to telomere biology (shorter telomeres) and those related to surfactant protein processing. the genes related to shorter telomeres are tert, terc, htr, dkc1, and rtel1. more mutations have been found in the tert gene, which encodes the protein component of telomerase, than any other gene. further research may allow targeted therapies to affect the genetic expression associated with the development of ipf [201, 202] . a common variant within the promoter of the muc5b gene is the most replicated single-nucleotide polymorphism related to familial and sporadic forms of ipf as well as early radiographic findings of ipf [203] (. figs. 51.9 and 51.10). wound contraction and re-epithelialization . fig. 51.8 the cellular and molecular mechanisms of fibrosis in multiple organs. the cellular and molecular mechanisms of fibrosis in multiple organs. once an injury occurs in an organ, epithelial and/or endothelial cells are impaired, which results in the release of chemokines and growth factors, including il-13 and tgf-b1. macrophages and monocytes are recruited and activated, both of which further release cytokines and chemokines and further induce fibroblast activation. activated fibroblasts transform into a-sma-expressing myofibroblasts and migrate into the wound along the fibrin lattice. ecm is excessively accumulated, and some parenchymal cells (hepatic stellate cells in the liver, tubular epithelial cells in the kidney, alveolar epithelial cells in the lung, or cardiomyocytes in the heart) are further differentiated into myofibroblasts or fibroblasts by the stimulation of cytokines and chemokines, especially for tgf-b1. after the inflammatory phase, two events occur. one is the regeneration of injured tissues followed by wound contraction and reepithelialization. in contrast, once chronic injury, inflammation, and necrosis occur, myofibroblasts are perpetually activated, and excessive ecm is deposited, finally resulting in fibrosis formation. ctgf, connective tissue growth factor; ecm, extracellular matrix; egf, epidermal growth factor; emt, epithelial-mesenchymal transition; hsc, hepatic stellate cell; il, interleukin; mmp, matrix metalloproteinase; tgf, transforming growth factor; timp, tissue inhibitors of metalloproteinase. (reprinted from chen et al. [198] . with permission from elsevier) conventional treatment is typically palliative. the american thoracic society recognizes that supplemental oxygen and transplantation are the only suggested treatments for ipf. supplemental oxygen is prescribed, and the need for oxygen increases over the progression of the disease. keeping the oxygen saturation level over 90% (normal is in the upper 90s) is ideal and is how healthcare providers determine the level of supplemental oxygen to be used. cardiovascular exercise, in this case called pulmonary rehabilitation, is recommended to maintain as much use of the lungs as possible. infrequently, nutrition and counseling are recommended and are placed into the category of symptom management. nutrition can have a significant role in the management of this disease, but little implementation exists in some of the proposed protocols. there are currently two medications available in the united states with minor impact on the disease progression: nintedanib (commonly called ofev) and pirfenidone (esbriet). histopathological quantification showed similar amounts of dense collagen fibrosis, fibroblast foci, and alveolar macrophages in untreated or pirfenidone-or nintedanibtreated ipf patients [204] . both have significant side effects, including fatigue and gi issues, and patients may have to evaluate their quality of life versus length of life. other antiinflammatories or immune-suppressing medications used are corticosteroids, mycophenolate mofetil/mycophenolic acid (cellcept®), or azathioprine (imuran®). immunesuppressing drugs may be harmful for those with short telomeres, and researchers are exploring this potentially contradictory recommendation [205] . lung transplantation is a final effort. about is half of all transplants. with the prevalence of this disease closer to 200,000, this is a small fraction of those with the disease. some of those with the transplant go on to live productive lives, while others develop pf again, in the transplanted lungs. overall, there is a shorter life expectancy in those with pf, because of telomere shortening. bone marrow or immune response abnormalities have been found in some ipf cases before and after lung transplantation, which increases the associated morbidity. as stated above, inflammation occurs at the beginning and throughout the progression of all fibrosing diseases, including those of the lungs. therefore, reducing inflammation is one wise strategy to slow fibrosing. there are several nutrients that can help slow or reverse the inflammation involved in the fibrosing process. the following two-part diagram shows where in the fibrosing pathogenesis each phytonutrient acts [198] (. fig. 51 .11). a few of those compounds are discussed in more detail here. curcumin, the active constituent in the common spice turmeric, has been shown to reduce fibrotic activity in several studies. in mice, curcumin inhibited collagen secretion of ipf fibroblasts. it affects the signaling of tgf-β, in a dosespecific manner, resulting in reduced expression of α-sma, which is responsible for inappropriate fibrosing. this was shown in vitro and in vivo in mice, with intraperitoneal, but not oral, administration. at the time of the study, oral ingestion of curcumin was not adequately absorbed into plasma, and there was greater than ten times plasma concentration of curcumin following an intraperitoneal injection [88] . however, some new oral products on the market are showing greater absorption. the results of this study suggest more research into curcumin, including improved delivery into patients. for example, some delivery options may include nebulized curcumin directly into the lungs, binding it to highly absorbable agents for oral use or liposome-encapsulated curcumin suitable for intravenous use (already shown to be effective in an animal model). according to manufacturers of curcumin products, some are more readily absorbed than others. one study on fibrosing suggested that a dose of around 2200 mg curcumin split into three doses taken with meals including pepper (bioperine) achieved doses that were sufficient to exert the desired therapeutic effect. research into using quercetin also has some promising results in slowing the progression of ipf. quercetin reversed lung fibrosing in mice and reversed the disease progression normally caused by typical pulmonary senescence markers [206] . it is worth mentioning that n-acetylcysteine (nac), a long-used therapeutic agent for breaking down mucus in the lungs, has not been found to be effective in those with ipf. in fact, due to its acidic nature, it has even been shown to be harmful when used in the inhaled form [207] . several of the drugs being developed have a natural product as a model or foundation. until a drug or gene therapy is developed that stops or reverses this disease, it may make sense for the patient to focus on anti-inflammation and reducing myofibroblast activation, the extracellular matrix (ecm) accumulation, and the epithelial-mesenchymal transition (emt) process. the phytochemicals listed in . fig. 51 .11 would be good ones to investigate. with the recent identification of genes associated with ild, a call for gene-related therapies both related to telomere lengthening and connective tissue disease has been initiated, and this type of therapy, as with any disease, could be personalized [208] . one recent study looked at various biomarker values as a more precise way of diagnosing. the biomarker molecules were classified according to their involvement into alveolar epithelial cell injury, fibroproliferation, and matrix remodeling as well as immune regulation. furthermore, genetic variants of tollip, muc-5b, and other genes associated with a differential response to treatment and with the development and/or the prognosis of ipf were identified. research into personalized medicine for treatment is starting [209] . although controversial, because of the lack of research on interpretation of the results, telomere length testing is available directly to consumers and through healthcare . fig. 51.11 antifibrosis therapy. the molecular mechanisms and therapeutic targets of natural products against fibrosis. a tgf-b exerts a profibrotic effect through smad-dependent [target (1)] and smadindependent pathways [target (2) ]. in the smad-dependent pathway, tgf-b1 directly phosphorylates and activates the downstream mediator smad2 and smad3 through tgf-b receptor i, and then smad2 and smad3 bind smad4, which forms a complex that moves into the nucleus and initiates gene transcription. smad7, transcribed by smad3, is a negative regulator of tgf-b/smad signaling, and the imbalance between smad3 and smad7 contributes to fibrosis. pi3k, erk, and p38 mapk are downstream mediators of the smad-independent tgf-b pathway. pparg [target (3)] could inhibit tgf-b to reduce fibrosis, while ctgf [target (4)], a matricellular protein, contributes to wound healing and virtually all fibrotic pathology. additionally, gas6 contributes to fibrosis through the tam receptor, which further activates the pi3k/akt pathway. similarly, lpa triggers fibrosis through the lpa1 receptor [target (5) ] that stimulates b-catenin to induce fibrogenesis. the activation of the hedgehog pathway [target (6) ] induces the transcriptional activity of gli to express target genes, which have an important role in interstitial fibrosis, undergoing myofibroblast transformation and proliferation. il pathway [target (7) ] stimulates nf-kb [target (8) ] to activate tgf-b to induce fibrogenesis, while nrf2 [target (9) ] antagonizes nf-kb activity to protect against fibrosis. b the chemical structures of isolated compounds and their therapeutic targets are presented. ctgf, connective tissue growth factor; il, interleukin; lrp, low-density lipoprotein receptor-related protein; ri, transforming growth factor-b receptor i; rii, transforming growth factor-b receptor ii; sara, smad anchor for receptor activation; stat, signal transducer and activator of transcription; tcf, t-cell factor; tgf, transforming growth factor. (reprinted from chen et al. [198] practitioners. there are a few different methods: quantitative polymerase chain reaction, or qpcr, which has a 20% variability rate, and flow cytometry and fluorescent in situ hybridization, or flow-fish, which has a 5% variability rate. most research labs use flow-fish for research. telomere length is a hot topic in research, the antiaging industry, and with popular health blogs. shorter-thanaverage telomeres have also been linked to heart disease and heart failure [163, 210, 211] , cancer [212] , diabetes [213] , and osteoporosis [214] . research has shown ways to slow telomere shortening. some include reducing stress, meditation, practicing loving kindness (a technique encouraging compassion) [215] , reducing exposure to air pollution and toxins [216] , cardiovascular exercise [217] , and a healthy fat and high vegetable diet [218, 219] . one study showed that 45 minutes of cardiovascular exercise three times per week resulted in longer telomeres representing 10 years of biological age, similar to those of marathon runners, compared to those who didn't exercise much or at all [220] . intermittent fasting, which reduces oxidative stress and keeps weight in check, has exploded in the scientific literature as a way to increase longevity and slow telomere shortening [221, 222] . nicotinamide adenine dinucleotide (nad+) supplements may also help maintain telomere length by activating sirtuins, the antiaging enzymes; parps, which are involved in dna repair; and cd38, which plays a role in insulin production. another supplement, cycloastragenol, derived from the herb astragalus, has also been shown to activate telomerase in mice. an ingredient called ta-65 has been derived and is used in supplements [223] . overall, a healthy lifestyle and diet seem to delay the shortening of telomeres. with relation to pf, the gene mutations involved in telomere shortening may or may not be influenced by the above interventions. more research is needed for this. pulmonary fibrosis is a devastating disease with no management or a known cure. the integrative and functional medicine nutritionist can help her/his patient by managing weight, encouraging a healthy diet full of anti-inflammatory foods and encouraging a healthy lifestyle with exercise and stress reduction. there is some promising research into natural supplement use to target the different areas of progression within the disease process and some ongoing drug and gene therapy development to follow. the prevalence of lung disease in the united states and worldwide is growing and will continue to grow rapidly with the deterioration of earth's atmosphere, which is caused by pollutants such as industrial and construction toxins and volcanic and wildfire particulates. poor maternal, childhood, and adult nutrition from micronutrient-poor diets resulting in nutrient insufficiencies, not necessarily nutrient deficiencies, is also contributing to increased lung disease diagnoses or poorer results during treatment [226, 227] . lifestyle choices and habits also play a role in the development of many of the lung diseases in today's world, such as smoking or vaping, which uses chemicals that are poorly studied to date. other lung diseases have their roots in genetics. some key processes drive many lung diseases, with the inflammatory process being the most important, according to current literature. nutrition can be of great help with inflammation, using a diet rich in whole foods providing micronutrients and phytonutrients. understanding genetics is also key to unraveling the causes and potential future treatments for many lung diseases. those patients with both genetic and environmental determinants, such as in those who smoke and have genes associated with copd, are at the greatest risk [228] . despite the prevalence of lung disease, there is a general lack of nutrition knowledge among practitioners, including familiarity with the research about the use of nutrition for prevention, slowing disease progression, or as a treatment of lung disease. historically, nutrition has been used in a supportive role, primarily monitoring macronutrients to prevent weight loss, muscle atrophy, and acid/alkaline balance. although this is extremely important, more attention needs to be directed toward emphasizing micronutrients and phytonutrients. research is strong regarding the benefits of vitamins, minerals, and pre-and probiotics, and indeed, some integrative and functional practitioners are using vitamin and mineral nutritional therapy in oral, intramuscular, and intravenous applications, when allowed, in practice. a newer area of research is around nutraceuticals, including targeted vitamins, minerals, and plantderived constituents concentrated to therapeutic doses. some exciting research around the use of curcumin and quercetin, for example, has been shown to dampen inflammation to the point of disrupting the disease process (see above). the expanding knowledge of the 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supplementation in stimulating whole body net protein anabolism is comparable between copd patients and healthy older adults whole fruits and fruit fiber emerging health effects glutathione redox control of asthma: from molecular mechanisms to therapeutic opportunities is there any relationship between plasma antioxidant capacity and lung function in smokers and in patients with chronic obstructive pulmonary disease? the treatment of pulmonary diseases and respiratoryrelated conditions with inhaled (nebulized or aerosolized) glutathione. evid based modifications of plasma proteome in long-lived rats fed on a coenzyme q10-supplemented diet increased oxidative stress in patients with chronic obstructive pulmonary disease (copd) as measured by redox status of plasma coenzyme q10. pathophysiology coenzyme q10 supplementation reduces corticosteroids dosage in patients with bronchial asthma effects of coenzymeq 10 administration on pulmonary function and exercise performance in patients with chronic lung diseases glutathione cofactors. available at geology and health: closing the gap pulmonary fluorosis: a review comparison of the fractional exhaled nitric oxide levels in adolescents at three schools located three different distances from a large steel mill inorganic arsenic and respiratory health, from early life exposure to sex-specific effects: a systematic review the broad scope of health effects from chronic arsenic exposure: update on a worldwide public health problem chronic arsenic toxicity & human health human exposure to dietary inorganic arsenic and other arsenic species: state of knowledge, gaps and uncertainties toxic substances portal -arsenic dynamed plus record no. t114977, chronic arsenic poisoning toxicological aspects of cadmium and occupational health activities to prevent workplace exposure in japan: a narrative review current status of cadmium as an environmental health problem serum heavy metals and obstructive lung disease: results from the national health and nutrition examination survey relationship between blood levels of heavy metals and lung function based on the korean national health and nutrition examination survey iv-v department of the environment and energy systematic review and meta-analysis of the association between ambient nitrogen dioxide and respiratory disease in china a framework for examining social stress and susceptibility to air pollution in respiratory health quantifying the impact of current and future concentrations of air pollutants on respiratory disease risk in england short-and long-term effects of ambient ozone and fine particulate matter on the respiratory health of chronic obstructive pulmonary disease subjects weekly personal ozone exposure and respiratory health in a panel of greek school children. environ health perspect nutritional solutions to reduce risks of negative health impacts of air pollution cigarette smoking and inflammation revisited effects of tobacco smoke on immunity, inflammation and autoimmunity electronic cigarette, effective or harmful for quitting smoking and respiratory health: a quantitative review papers review: the toxicity of e-cigarettes and children's respiratory health respiratory health and allergies from chemical exposures among machining industry workers in selangor, malaysia occupational pesticide exposures and respiratory health persistent effects of chlorine inhalation on respiratory health respiratory muscle function in patients with cystic fibrosis. pediatr pulmonol emotions, morbidity, and mortality: new perspectives from psychoneuroimmunology understanding mindbody interaction from the perspective of east asian medicine. evid based complement alternat med climate change and respiratory disease: european respiratory society position statement nutrients and foods for the primary prevention of asthma and allergy: systematic review and meta-analysis global strategy for asthma management and prevention. glob initiat asthma tests for assessing asthma pediatric expression of mast cell activation disorders asthma phenotypes and endotypes: an evolving paradigm for classification a histamine-free diet is helpful for treatment of adult patients with chronic spontaneous urticaria serum diamine oxidase activity in patients with histamine intolerance leukocyte telomere length and cardiovascular disease in the cardiovascular health study regulation of antioxidant enzymes in lung after oxidant injury oxidative stress in asthma resolution of acute inflammation in the lung the alkaline diet: is there evidence that an alkaline ph diet benefits health? magnesium in prevention and therapy effects of magnesium supplementation on the glutathione redox system in atopic asthmatic children diet and asthma: vitamins and methyl donors drugs for asthma dietary inflammatory index is related to asthma risk, lung function and systemic inflammation in asthma fruit and vegetable intake and risk of wheezing and asthma: a systematic review and meta-analysis correlation of cutaneous sensitivity and cytokine response in children with asthma coeliac disease and asthma association in children: the role of antibiotic consumption regulatory t cells in asthma prenatal farm exposure is related to the expression of receptors of the innate immunity and to atopic sensitization in school-age children characterization of regulatory t cells in urban newborns is vitamin d deficiency to blame for the asthma epidemic? maternal food consumption during pregnancy and the longitudinal development of childhood asthma vitamin d levels, lung function, and steroid response in adult asthma camp regulation of airway smooth muscle function quercetin acutely relaxes airway smooth muscle and potentiates β-agonist-induced relaxation via dual phosphodiesterase inhibition of plcβ and pde4 using periostin as a biomarker in the treatment of asthma biomarkers in asthma | aaaai developmental bisphenol a exposure modulates immune-related diseases nasopharyngeal 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histopathological and molecular analysis of idiopathic pulmonary fibrosis lungs from patients treated with pirfenidone or nintedanib telomere shortening is behind the harm of immunosuppressive therapy in idiopathic pulmonary fibrosis quercetin enhances ligand-induced apoptosis in senescent idiopathic pulmonary fibrosis fibroblasts and reduces lung fibrosis in vivo application of n-acetylcysteine in pulmonary disorders. in: the therapeutic use of n-acetylcysteine (nac) in medicine integrating genomics into management of fibrotic interstitial lung disease existing and emerging biomarkers for disease progression in idiopathic pulmonary fibrosis association of shorter mean telomere length with risk of incident myocardial infarction: a prospective, nested case-control approach telomere length of circulating leukocytes is decreased in patients with chronic heart failure de vivo i. telomere length, cigarette smoking, and bladder cancer risk in men and women monocyte telomere shortening and oxidative dna damage in type 2 diabetes telomere length in leukocytes correlates with bone mineral density and is shorter in women with osteoporosis loving-kindness meditation practice associated with longer telomeres in women association between leukocyte telomere shortening and exposure to traffic pollution: a cross-sectional study on traffic officers and indoor office workers physical exercise prevents cellular senescence in circulating leukocytes and in the vessel wall association of marine omega-3 fatty acid levels with telomeric aging in patients with coronary heart disease telomere length, oxidative damage, antioxidants and breast cancer risk physical activity and telomere length: impact of aging and potential mechanisms of action protein restriction, epigenetic diet, intermittent fasting as new approaches for preventing age-associated diseases fasting mimicking diet is very relevant for health and longevity cycloastragenol is a potent telomerase activator in neuronal cells: implications for depression management periostin: an emerging biomarker for allergic diseases zemaira® | alpha-1 antitrypsin deficiency diagnosis assessment of quality of life in children suffered from asthma identifying maternal conditions affecting altered embryologic development. neonatal advanced practice nursing: a case-based learning approach susceptibility for cigarette smoke-induced damp release and damp-induced inflammation in copd key: cord-252769-fe50u028 authors: mendes, j. pinto title: infecção na modulaçâo da asma 1 1 trabalho apresentado no xxiii congresso de pneumologia da spp – guarda, novembro 2007 / paper presented at the xxiii congresso de pneumologia da spp / psp pulmonology congress, guarda, november 2007 date: 2008-10-31 journal: revista portuguesa de pneumologia doi: 10.1016/s0873-2159(15)30275-0 sha: doc_id: 252769 cord_uid: fe50u028 abstract this paper reviews the impact of infections on the onset and clinical course of bronchial asthma. a just emphasis is given to the role viral infections, particularly rhinovirus infections, play in exacerbations, and that played by respiratory syncytial virus, suspected of triggering the asthmatic syndrome. the mechanisms of the immune response to virus attacks are explained, highlighting the asthmatic and allergic patient’s weakened response, particularly in the perinatal period. further stressed is a potentiating effect of viral aggression on the allergic response. the hygiene hypothesis and its lack of scientific consistency is detailed, at least as far as the role it seeks to confer on an unproven antagonism of the th1 and th2 lymphocyte responses. the current importance of research not into bacteria, but into bacterial products, including endotoxins, on the modulation of asthma and allergy is noted. studies which, along these lines, show an environmental impact on genetic secretion in the phenotype are underlined. also discussed in passing are several mechanisms which go towards explaining neutrophilic asthma – for many a contradiction, given eosinophilia’s stranglehold on asthmatic inflammation. rev port pneumol 2008; xiv (5): 647-675 hostil e ambígua a relação do homem com os agentes microbianos! apesar de ser hoje mais limitado o risco de se repetirem as epidemias que, de um só golpe, arrasaram populações inteiras, ainda hoje a memória deste passado povoa o seu imaginário e cria um subconsciente fóbico em relação às infecções. receoso, continua a usar antibióticos mal desconfie que um qualquer gérmen possa esconder -se por detrás do mais tímido sintoma, e julga estar, assim, a levar de vencida o velho inimigo! pura ilusão, porque os microrganismos aprenderam há muito a produzir antibióticos para combater as estirpes que os ameaçam e a criar mutações que os tornam resistentes a idênticas armas dos concorrentes. que as bactérias estavam bem preparadas para os antibióticos, que julgamos ter descoberto, não restam dúvidas! pareceria mais inteligente que, sem deixar de usar as suas armas à medida do risco que a infecção pro-infecção na modulaçâo da asma j pinto mendes man has always had an antagonistic and ambiguous relationship to germs. while we are at much less risk today of epidemics which wiped out entire populations in one fell swoop, we are still aware of those more dangerous times and our subconscious is riddled with phobias when it comes to infection. wary, we continue to take antibiotics as we fear a germ may lie at the root of any seemingly mild symptom and feel in this way we are defeating an age-old enemy. this is pure illusion as microorganisms learnt long ago to produce antibiotics to combat any strains threatening them and to create mutations to make them resistant to their opponent's identical weaponry. there is no doubt that bacteria were more than ready for antibiotics. an intelligent choice would be that in addition to using weapons befitting the risk the infection brings, mankind finds a way to live in har-mete, perante algumas bactérias com as quais já conta um longo convívio, o homem encontrasse formas de coabitação pacífica, como já sucede com a flora comensal das suas mucosas, que protege em troca de um importante papel regulador da resposta imune e da estabilidade funcional local que o abuso de antibióticos pode prejudicar. mas, mais, a sua intempestiva reacção de pânico perante certas agressões microbianas faz com que, por vezes, sejam tão grandes ou maiores os estragos do gesto de defesa do que os da agressão. poderá ser o caso das destruições pulmonares na presença do bacilo de koch. e isto para não falar das doenças autoimunes que, ciclicamente, são julgadas uma consequência de inadequada resposta à presença de bactérias e vírus. é dentro desta problemática do desajuste da resposta de defesa que se equaciona o papel das infecções na reacção imune/inflamatória alterada que se manifesta pelos fenótipos asma brônquica e atopia. tema que ganha cada dia novos contornos, por vezes contraditórios, e daí que temamos que, após este nosso passeio pela literatura, fiquem mais dúvidas do que certezas. de entre os agentes animados, são claramente os vírus os que reúnem provas mais concludentes de uma interferência moduladora na asma, claramente na sua evolução clínica e, presumivelmente, no seu desencadear 1,2 . sem dúvida, são eles os mais potentes e habituais desencadeantes das exacerbações da asma 3, 4 e disso é prova a detecção de vírus durante estes episódios em mais de 80% dos casos em crianças em idade escolar 3 e em mais de 60% em adultos 5 . aliás, os asmáticos que revelam a pre-infecção na modulaçâo da asma j pinto mendes mony with some long-standing bacteria. this is the case with the normal human flora of mucous. this is protected in exchange for a vital regulatory role in the immune response and local functional stability which overuse of antibiotics can harm. further, a panic response to certain bacterial action means that the damage which defensive causes can be greater than that caused by the attack. this is the case with lung damage and koch's bacillus. this is in addition to autoimmune diseases which are cyclically judged a consequence of inadequate response to bacteria and viruses. the role of infection in the changed immune/inflammatory response shown by bronchial and allergic asthma phenotypes is part of the defense overresponse situation. the situation changes on an almost daily basis, sometimes contradicting itself and, as this literature review shows, throws up more questions than answers. viruses are the agents playing a weightier role in the modulation of asthma. they impact on its clinical course and its trigger 1, 2 . they are undoubtedly the most powerful and typical triggers of asthma exacerbations 3, 4 , as shown by the fact that a virus is detected during attacks in over 80% of cases involving school-aged children 3 and in over 60% of cases involving adults 5 . asthmatics suffering exacerbation and who have a virus are more likely to be admitted to hospital 6 , and a virus attack here is clearly linked to bronchial hyperresponsiveness 7 sença de vírus no decurso das exacerbações apresentam um maior índice de hospitalização 6 e a agressão virusal tem neles clara influência no aumento da hiperreactividade brônquica 7 e na diminuição da permeabilidade das vias aéreas, com as consequentes alterações dos volumes pulmonares 8 e das trocas gasosas 9 . discute -se, ainda, a responsabilidade de infecções virusais precoces na persistência de sintomas de asma na infância tardia e na puberdade 3 ou, mesmo, na idade adulta 10 . questão não totalmente respondida é, finalmente, a de o vírus poder ser responsável pelo próprio aparecimento de asma. será ele causa suficiente ou a gota que faz extravasar a água numa situação de particular fragilidade, eventualmente com causa genética? ou será um mero marcador? o vírus sincicial respiratório (vsr) e o rinovírus (rv) são claramente os actores principais neste palco. o segundo o grande responsável pelas exacerbações, e o primeiro o mais prevalente nos três primeiros anos de vida, não se livrando da fama de poder ser capaz de instalar a asma. mas não esqueçamos a influência de vírus há muito conhecidos como os influenza, parainfluenza, enterovírus e adenovírus 2 , enquanto se procura esclarecer o papel de vírus de mais recente descoberta como o hmpv (human metapneumovirus) 11 , os coronavírus nlg 3 12 e hkv 1 13 , o bocavírus humano 14 e o vírus troqueteno 15 . mas o vsr e o rv merecem uma abordagem individualizada, e o enorme volume de publicações que a eles se referem é em grande parte consequência do importante avanço obtido com a utilização de métodos de análise molecular, como o da amplificação enzimática dos ácidos nucleicos virusais, através de pcr (polymerase chain reaction) 16 . pena é que não seja uma técnica acessível infecção na modulaçâo da asma j pinto mendes and decreased airway permeability, with its subsequent lung volume 8 and gas exchange 9 alterations. the role of early viral infections in the persistence of asthma symptoms in late childhood and adolescence 3 or even in adults 10 is also a topic of debate. the jury is still out on whether viruses are responsible for the onset of asthma. is virus on its own the culprit or is it the last straw to break the back of a particularly fragile situation, possibly genetically caused? or is it a mere marker? it is clear that respiratory syncytial virus (rsv) and rhinovirus (rv) are the main players on this stage. rv is the main cause of exacerbations and rsv more prevalent in the first three years of life and thought to promote the onset of asthma. the role played by other and more well know viruses, such as influenza, parainfluenza, enterovirus and adenovirus 2 must not be forgotten, and research is underway into the importance of more recently discovered viruses, including hmpv (human metapneumovirus) 11 , coronavirus nlg 3 12 and hkv 1 13 , human parovirus 14 and torquetenovirus 15 . rsv and rv deserve a separate approach, however. there is a huge body of published work on them, mainly stemming from the important gains brought about by molecular analysis methods, including enzymatic amplification of viral nucleic acids using pcr (polymerase chain reaction) 16 . countries with limited financial means do not have access to this technique, which is a pity. rsv is always present during early life. it infects 70% of children aged one and prac-para estudos epidemiológicos em países de escassos recursos financeiros. o inevitável vsr é presença obrigatória nos primeiros anos de vida -infecta 70% das crianças no primeiro ano e praticamente 100% ao segundo 17 , e é responsável por 70% das hospitalizações por bronquiolite 18 . a sua presença nos primeiros anos de vida acompanha -se com muita frequência de sibilâncias, que se podem arrastar, permanecendo a dúvida de se poderá ser causa de asma ou se apenas a irá precipitar em indivíduos predispostos por influências genéticas ou por imaturidade da resposta imunológica ou do desenvolvimento pulmonar 2 . o certo é que nas populações não consideradas de risco é normal reagir -se ao vsr como se de uma gripe comum se tratasse, se bem que uma minoria possa fazer bronquiolites. desta, 25 a 50% (consoante os estudos) vem a apresentar sintomas de asma intermitente (sibilâncias) aquando de infecções virusais de qualquer natureza, mas só um número muito reduzido virá a apresentar sintomas na idade adulta 19 . não faltam publicações a salientar a influência da infecção por vsr nos primeiros anos de vida na persistência de sibilâncias 15,20 -23 . mas uma grande parte não se revela convincente em atribuir -lhe um papel diferente do de outros vírus respiratórios 2,23,24 . mas uma análise atenta dos diferentes estudos 25 conclui que as bronquiolites graves, que requerem hospitalização, ou seja, as estudadas em meio hospitalar 20, 26 , mais facilmente desenvolverão sibilâncias ou asma atópica na infância tardia, enquanto os estudos populacionais 27 que, em princípio, envolvem casos menos graves, não encontra-infecção na modulaçâo da asma j pinto mendes tically 100% of two year olds 17 . it is the cause of 70% of bronchiolitis-related hospital admissions 18 . rsv in the one to three year old age range often goes hand-in-hand with wheeze, sometimes long-lived, bringing in its wake the question if this is the cause of asthma or just the trigger in patients predisposed due to genetic influences on immature immunological response or on lung development 2 . what is clear is that non-risk populations react to rsv as they do to a normal 'flu virus, although the minority can develop bronchiolitis. of these, 25-50% (it varies from study to study) develops intermittent asthma symptoms (wheeze) in response to any viral infection but only a very small number will develop symptoms at adult age 19 . while many studies underline the role played by rsv infection in early life and the persistence of wheeze 15, [20] [21] [22] [23] , the majority are not convinced it plays a different role to that of other respiratory viruses 2, 23,24 . a close scrutiny of the raft of studies 25 concluded that cases of severe bronchiolitis which needed hospital admission -that it, those studied in a hospital setting 20,26 -, showed a greater tendency to develop wheeze or allergic asthma in later childhood. this is in contrast to population studies 27 which usually involved milder cases and found fewer examples of far-reaching consequences. they sometimes found wheeze, however, which cleared up at 3-5 years and was only rarely prolonged, leading or not to asthma. animal research is difficult to extrapolate to man but suggests rsv can induce allergic sensitisation 28 , increase bronchial and interleukin (il)-13 hyperresponsiveness, and rão, na maioria dos casos, consequências remotas, embora algumas vezes descrevam sibilâncias que irão desaparecer aos 3 -5 anos e só raramente se prolongam, instalando -se ou não uma asma. a investigação animal, difícil de transpor para o homem, sugere a capacidade de o vsr induzir sensibilização atópica 28 , aumento da hiperreactividade brônquica e da interleucina (il) -13, hipereosinofilia e hiperprodução de muco 29 , com maiores probabilidades de tal suceder se a infecção for grave 26 . respostas mais concretas poderão surgir quando for possível uma vacinação anti--vsr, ou se se confirmarem as esperanças que alimentam os esforços de síntese de medicações antivirusais 30, 31 . mas os resultados díspares sobre as potencialidades de o vsr poder ser factor determinante na indução de asma e de atopia não poderão deixar ninguém indiferente à medida que se vão desvendando os mecanismos de defesa antivirusal e as suas potenciais fragilidades na infância precoce, sobretudo no período perinatal e, de um modo particular, em crianças em risco de atopia e asma. não admira que a insuficiência da resposta ao vírus possa passar despercebida em infecções ligeiras e ter consequências indesejáveis nas mais graves. a este assunto voltaremos adiante. poder -se -á dizer, com muitas probabilidades de acertar, que sempre que surge uma exacerbação de asma numa criança até à idade escolar espreita um rv. é que ele é detectado em 80% dos aspirados nasais colhidos quatro dias após os episódios de sibilâncias 3,32 , enquanto no adulto colocará o seu carimbo em 60% das exacerbações agudas de asma 33 . infecção na modulaçâo da asma j pinto mendes stimulate hypereosinophilia and hyperproduction of mucous 29 . there is high probability of this happening in cases of severe infection 26 . more concrete answers will come once an rsv vaccine is available, or if hopes of synthesising anti-virus medications are realised 30, 31 . the different results on rsv's role in inducing asthma and allergy cannot leave anyone indifferent to the way anti-viral defence mechanisms are marshalled and their limited power in early childhood, particularly the perinatal period, especially in children at risk of allergy and asthma. it is no surprise that an inadequate response to the virus can remain undetected in cases of mild infection and bring about unwished for consequences in cases of more severe infection. this subject is dwelt on hereonin. an rv is almost always at the root of an asthma exacerbation in a pre-schooler. it is seen in 80% of nasal aspirate collected four days after episodes of wheeze 3,32 , while it is seen in 60% of acute asthma exacerbations in adults 33 . a review of pcr statistics leads us to the same conclusion; rv is seen in 80% of children taken to emergency rooms with the virus isolated in 20-41% of this population 34 . there are less published studies into rsv, also the cause of childhood asthma attacks 33 . as the name of the virus indicates, rv has a propensity for installing itself in the nasal structures. it is also found in the bronchial structures, extending an influence over the epithelium 34, 35 where it does not cause much lançando mão do pcr, chegamos à mesma conclusão nas crianças que tiveram mesmo de ir a uma urgência, pois revela -se positivo em 80% dos casos, tendo o próprio vírus sido isolado em 20 a 41% desta população 34 . menos publicações a respeito do vsr que também tem sido responsabilizado por ataques de asma na infância 33 . se, como o nome indica, o rv tem uma apetência particular por se instalar nas estruturas nasais, ele também é encontrado nas brônquicas, exercendo a sua importante interacção com o epitélio 34, 35 , onde não causa grandes destruições, e vai ocupar pequenas áreas, em comparação com a vasta destruição do vsr 26 . mesmo assim, os seus efeitos pró -inflamatórios são demonstrados experimentalmente quando a sua inoculação em asmáticos ligeiros produz um aumento da hiperreactividade brônquica, que persiste pelo menos uma semana 36 , e uma diminuição da permeabilidade das vias aéreas dois dias após a sua introdução 37 . o rv pode persistir nos tecidos brônquicos durante duas semanas 24 , induzindo infecções arrastadas que vão comandando uma inflamação progressiva que pode acabar numa exacerbação asmática aguda. mantém -se actual a discussão sobre a cumplicidade da agressão virusal na constituição da atopia, nomeadamente da asma atópica, como deixámos entrever em relação ao vrs. assunto não encerrado porque, se uns defendem poderem ser os vírus determinantes da sensibilização 26 , outros negam -na 27 , e há, até, quem defenda um papel protector da agressão virusal 38 . o vrs é o mais citado, e aponta -se a sua capacidade de aumentar a expressão dos recep-infecção na modulaçâo da asma j pinto mendes damage and occupies only small spaces, unlike the swathe of destruction wreaked by rsv 26 . even so, its pro-inflammatory effects were shown in an experimental model when its inoculation in mildly asthmatic patients induced bronchial hyperresponsiveness lasting at least a week 36 and decreased airway permeability two days after it was introduced 37 . an rv can linger in the bronchial tissues for two weeks 24 , inducing long-lasting infections which give rise to progressive inflammation that can end in an acute asthma exacerbation. the role of virus attacks in building allergy, particularly allergic asthma, is still under discussion, as we can see in relation to rvs. the matter is still the topic of debate; some argue that viruses causes sensitisation 26 ; others refute this 27 , and some believe virus attacks play a protector role 38 . rvs is the most cited and its ability to increase immunoglobulin (ig) e receptor expression, a factor which could make sensitisation to allergens easier, is noted. its role is increasingly suspected by the high rate of rvs infection in early life, when transitory immune system difficulties 4 could theoretically favour a response to the virus, in line with an allergy model. it is an open question as current knowledge of anti-viral responses can provide theoretical support. longitudinal analysis in children aged below two admitted to hospital with viral infection 39 and studies into large populations 27 find no correlation between early life viral infection and onset of allergic asthma up to the age of thirteen years or later, however. tores das imunoglobulinas (ig) e, o que poderia tornar mais fácil a sensibilização perante os alergénios. e torna -se mais suspeito devido à elevada frequência da infecção por este vírus nos primeiros tempos de vida onde dificuldades transitórias do sistema imune 4 podem, em teoria, favorecer uma resposta ao vírus segundo um modelo próprio da atopia. é uma questão em aberto a que os conhecimentos actuais sobre a resposta antivirusal poderão dar suporte teórico. contudo, análises longitudinais em crianças com idades inferiores a dois anos, hospitalizadas por infecção virusal 39 , e estudos em grandes populações 27 , não conseguem encontrar correlação entre infecção virusal precoce e desenvolvimento da asma atópica até à idade de treze anos, ou mais tarde. mas do que parece não restar dúvida é do papel amplificador das infecções respiratórias virusais sobre as consequências da sensibilização, um efeito sinérgico vírus/atopia 23 . e provam -no os estudos experimentais com a concomitância, ou a sequência, de inoculação de rv e provocação alergénica -maior aumento de hiperreactividade brônquica e da infiltração eosinofílica em comparação com qualquer das agressões isolada 40 . esta verificação tem a sua correspondente experimental no animal 41 e na clínica quando se juntam a infecção virusal e a exposição alergénica 42 , mas em qualquer modelo exige--se a proximidade das duas agressões porque se o intervalo for maior do que uma semana este fenómeno já não terá lugar 43 . esta associação imprimiria uma resposta simultânea t helper (th) 1 e th 2 que se potenciariam mutuamente 44 . o vírus também poderia influenciar o processo de tolerância imunitária a agentes estranhos e aumentar a memória específica, a longo prazo, para os alergénios contactados durante a infância 10 . there seems little doubt of the amplification role respiratory viral infections play in sensitisation, a virus/allergic synergy 23 . experimental studies prove that there is a greater increase in bronchial hyperresponsiveness and eosinophilic infiltration with rv inoculation and concomitant or segmental antigen bronchoprovocation and allergenic provocation than with any isolated attack 40 . this is also seen in experimental animal models 41 and in clinical practice when virus infection is in tandem with exposure to allergens 42 . both models demand the two forms of attack in conjunction as the phenomena will not occur if the two are at an interval greater than a week 43 . this association suggests a simultaneous t helper (th) 1 and th 2 response which is mutually potentiating 44 . the virus can also influence the immune response to foreign agents and heighten specific long-term memory to allergens the patient had contact with in childhood 10 . the role of virus is the modulation of asthma and allergy cannot be downplayed. it can intervene on a grand scale in the inflammatory mechanisms which regulate asthma and allergy. it is in fact a thousand piece puzzle which is far from being assembled. we are privy only to a clutch of clues, in themselves seemingly convincing. virus is in the front line of innate immunity which is somewhat dormant, in that infection cannot be fought off quickly and lasts for some time. virus also uses the asthmatic patient's weaknesses, which developed in early life whether he/she is allergic or not 10,25 , vírus nos caminhos da asma e da atopia na modulação da asma e da atopia é difícil menosprezar o papel dos vírus, tal a sua apetência para interferir nos mecanismos inflamatórios que comandam aquelas patologias. é um puzzle de muitas peças que está muito longe de ser resolvido. ficar -nos -emos por algumas pistas que julgamos serem, por si só, convincentes. interferem, logo, na actuação da primeira tropa de choque, a da imunidade inata que é, de certo modo, adormecida para que a agressão infecciosa não possa ser combatida com rapidez e se prolongue no tempo. aproveita também as fragilidades do asmático, atópico ou não, acrescidas nos primeiros tempos de vida 10,25 e que incluem um défice da própria imunidade inata 45 . na agressão virusal às vias aéreas inferiores, o epitélio é a peça fundamental 34, 45 , e conhece--se o seu papel na libertação de moléculas pró -inflamatórias que activam e atraem células t, cd 4 + e cd 8 + , neutrófilos, eosinófilos, macrófagos e mastócitos 10 . se na asma aguda a infecção virusal, nomeadamente pelo rv, a mais bem estudada, está associada à inflamação neutrofílica, lise celular e produção de interferãos (ifn) 46 , se o meio local for rico em il -4 a regra passa a ser a produção de il -5, rantes (regulated upon activated t cell expressed and selected) e eotaxina, a infiltração eosinofílica e a produção de ige 47 . esta mutabilidade dos caminhos da inflamação faz com que não estranhemos que, sendo habitualmente de perfil th 1 a resposta aos vírus, ela possa fazer -se através de citocinas th 2 quando se reúnem as devidas circunstâncias, que o vsr parece com frequência promover. para tal, poderá contribuir uma alteração genética no cromosso-infecção na modulaçâo da asma j pinto mendes one of which is an innate immunity deficiency 45 . in virus attacks the airway below the epithelium is the vital part 34, 45 and its role in the release of pro-inflammatory molecules which activate and attract t, cd 4 + and cd 8 + , cells, neutrophils, eosinophils, macrophages and mastocytes is known 10 . if viral infection in acute asthma, particularly rv -the most studied -is associated with neutrophilic inflammation, cellular lysis and production of interferons (ifns) 46 and if the environment is rich in il-4, the production of il-5, rantes (regulated upon activated t cell expressed and selected), eotaxin, eosinophilic infiltration and ige production 47 generally occur. this change in the inflammation pathways comes as no surprise as, as is usually the case of the th 1 profile in response to virus, it can be made through th 2 cytokines under the correct circumstances, of which the rsv seems to be a frequent promoter. as such it can contribute to a genetic alteration in chromosome 5 (gene 589t il-4 genotype), associated to an hyperexpression of il-4 48 in association to rsv production of the g protein which promotes a delayed th 1 expression (with ifn deficiencies) 49 . this double inflammatory response route, which in the asthmatic can be traced singly or simultaneously, provides good clues to explain the thoroughly discussed eosinophilic and neutrophilic forms of severe asthma. the latter can respond to other stimulation which will not be listed here. one which must be cited is endotoxin inhalation (50) , which is dealt with shortly. epithelial stimulation both promotes neutrophil (through il-8) and eosinophil (il-16), recruitment and increases produc-ma 5 (polimorfismo do gene 589t il -4) que se associa a uma hiperexpressão de il--4 48 em associação com a produção pelo vsr de proteína g, que promove um atraso da expressão th 1 (com um défice de ifn) 49 . esta dupla via da resposta inflamatória, que no asmático pode ser percorrida consoante as circunstâncias ou em simultâneo, fornece boas pistas para a explicação das tão discutidas formas eosinofílica e neutrofílica da asma grave. esta última pode obedecer a outras condicionantes, que não vem a propósito enumerar, mas não poderemos deixar de citar a da inalação de endotoxinas 50 , de que nos ocuparemos adiante. a estimulação epitelial, além de promover o recrutamento de neutrófilos (através da il -8) e eosinófilos (il -16), também aumenta a produção de tumor growth factor (tgf) -β e do vascular endothelial growth factor (vegf), abrindo caminho à remodelação das vias aéreas 1, 24 . e é também a partir daqui que se dá o primeiro passo para a resposta ao vírus, a da imunidade inata, inespecífica, através dos toll -like receptors (tlr) 5,51 , em particular do tlr 3, que reconhece os ácidos nucleicos com dupla cadeia 52 . também fundamental a estimulação dos tlr de membrana dos macrófagos para a activação destes fagócitos das células infectadas. antes, porém, este "varrer da cena" dos vírus intracelulares é preparado pela actuação do tumor necrosis factor (tnf) -α que expõe os vírus intracelulares às células imunes 25 , enquanto os ifn -β dão o seu contributo inibindo a replicação virusal 35 . a prova da importância dos ifn e do tnf--α na luta antivirusal está na demonstração de que a forma de evasão que o vírus põe em infecção na modulaçâo da asma j pinto mendes tion of tumor growth factor (tgf)-β and vascular endothelial growth factor (vegf), laying the groundwork for airway remodeling 1, 24 . it is this which gives the first step towards response to virus, and innate non-specific immunity, through the toll-like receptors (tlrs) 5, 51 , in particular the tlr 3 which recognises double-stranded nucleic acids 52 . tlr stimulation of the macrophage membrane is also vital for activation of these infected cell phagocytes. in fact, this clean sweep of the intracellular viruses is prepared by actuation of the tumor necrosis factor (tnf)-α which exposes the intracellular viruses to the immune cells 25 while the ifn-β contributes by inhibiting viral replication 35 . the importance of ifns and tnf-α in the fight against viruses is shown by the form of evasion which the virus demonstrates and the production of anti-ifns and anti-tnf-α 25 . the entire anti-virus defence process is liable to be different in the asthmatic patient. an ifns deficit, a natural early life occurrence, means the patient cannot fight off a slight attack. this lack can be more deeply felt in the asthmatic patient, a fact not universally accepted, however 10, 53 . it can lead to a reduced clearance due to deficient apoptosis 54 with increased replication of the viruses which linger longer in the airway. innate immunity leads to adaptive and specific immunity, where the dendritic cells play the critical role of introducing the viral antigens to the t, cd 4 + and cd 8 + cells 55 . here too asthmatics could have significant constraints, beginning with an inefficient introduction of the viral antigens, cutting the efficacy of the specific response 1 . marcha é a da produção de anti -ifn e anti--tnf -α 25 todo este processo de defesa antivirusal pode estar alterado no asmático, que não consegue dominar uma agressão maciça pelo seu défice de ifn, natural nos primeiros tempos de vida, e que poderia ser mais acentuado no asmático, factos não aceites por todos 10, 53 . daqui resultaria uma diminuição da clearance por deficiente apoptose 54 com aumento da replicação dos vírus que permaneceriam mais tempo nas vias aéreas. da imunidade inata chega -se à adaptativa, específica, onde cabe às células dendríticas o importante papel de apresentação dos antigénios virusais às células t, cd 4 + e cd 8 +55 . aqui também poderá haver importantes constrangimentos nos asmáticos, a começar por uma ineficaz apresentação dos antigénios virusais, reduzindo a eficácia da resposta específica 1 . uma das populações das células dendríticas, as chamadas plasmacitóides, conseguem fazer a expansão das células t, mas em menor grau do que as suas parentes, designadas por mielóides. contudo, enquanto as primeiras podem induzir tolerância para alergénios, nomeadamente os inalados, as segundas são fortemente imunogénicas e favorecem o perfil th 2 da resposta imune e a atopia, atenuam o papel das plasmacitóides na secreção de tnf -α e facilitam a proliferação das células cd 8 + memória 3, 56 . a estimulação virusal pode originar uma interconversão das células plasmacitóides em mielóides, passando -se, em relação aos alergénios inalados, de um comportamento tolerogénico para o aumento da resposta, com perfil atópico 57 .um importante handicap, sobretudo para as populações em risco de atopia e de asma. one of the dendritic cell populations, the plasmacytoids, is able to make t cells expand but to a lesser degree than their parents, the myeloids. while the first can induce tolerance to allergens, particularly inhaled allergens, the second are strongly immunogenic and favour the th 2 profile in the immune response and allergy, attenuating the role of plasmacytoids in tnf-α secretion and facilitate the proliferation of memory cd 8 + cells 3, 56 . viral stimulation can cause an interconversion of the plasmacytoids cells into myeloids, passing in terms of inhaled allergens from tolerogenic behaviour to an increased response with allergy profile 57 . this is a significant handicap, particularly for the popu lations at risk of allergy and asthma. viral influence in neurogenic inflammation deserves mentioning, even if is seemingly less important or less studied. if the rupture of the epithelium can lead to the discovery of nervous fibre terminals, the virus stimulates the m 2 receptors and determines the hyperexpression of nk 1 , contributing to an increased bronchoconstrictor reflex and inflammation 29, 58 . this fragility demonstrated by the asthmatic in the face of viral attack makes it easy to understand that defences can be easily breached in severe infections, for example rsv, and the virus's persistence is a decisive influence on the phenotype and the syndrome's clinical course. we must not forget that an ineffectual antiviral response can be a determinant in the onset of allergy and asthma, especially in susceptible patients. this is theoretical and widely accepted today, but awaiting scientific confirmation and validation in clinical reality. apesar de aparentemente menos importante, ou menos bem estudada, não deixa de merecer uma palavra a influência virusal na inflamação neurogénica. se a rotura do epitélio pode colocar a descoberto os terminais das fibras nervosas, o vírus estimula os receptores m 2 e determina a hiperexpressão de nk 1 , contribuindo para aumentar o reflexo broncoconstritor e a inflamação 29, 58 . esta fragilidade do asmático perante a agressão virusal, de que apresentamos ao de leve algumas matrizes, faz compreender que em infecções graves, pelo vsr, por exemplo, as defesas possam ser facilmente ultrapassáveis e a persistência do vírus influa decisivamente no fenótipo e na evolução clínica da síndroma. e não é de excluir que, sobretudo em indivíduos predispostos, a insuficiência da resposta antivirusal possa ser determinante no aparecimento da atopia e da asma. isto em teoria, assumida hoje por muitos, que aguarda a confirmação científica da sua validade na realidade clínica. há umas décadas, as preocupações acerca da influência das infecções na modulação da asma centravam -se nas bactérias. falava--se de "asma infecciosa", a não atópica, que muitas vezes se manifestava como grave. e reinou também o conceito de "alergia bacteriana" que aconselhava a administração a longo prazo de vacinas por via subcutânea, muitas vezes preparadas a partir das próprias secreções do doente. hoje, pouca gente acredita na influência bacteriana na génese da asma brônquica, do modo como ela era descrita. mas parece evidente que a inflamação produzida pela infecção, e pela resposta imune subsequente, poderão complicar a instabilidade celular já infecção na modulaçâo da asma and what about bacterial infections? ten years ago, concern over the role played by infection in asthma revolved around bacteria. talk was of 'infectious asthma' and not allergic asthma and it often onset in a severe form. the concept of 'bacterial allergy' was also bandied about, and it advised the long-term administration of sc route vaccines, very often prepared from the patient's own secretions. very few people today believe in a bacterial influence in the genesis of bronchial asthma in the form it was then described. it seems evident, however, that the inflammation caused by infection and the subsequent immune response can complicate the already existing cellular instability. while this is not the place to ask the question, it remains to be discovered if bacteria in themselves are able like viruses to trigger exacerbations or determine the long-term course of asthma. it is not likely that the more common infections such as streptococus pneumoniae, streptococus pyogenes or haemophilus influenzae 19 could also play this role. similar questions are being asked of mycoplasma pneumoniae and clamydia pneumoniae. although there is a lack of evidence, both are believed to be responsible for chronic forms of asthma in children and adults and clamydia alone for acute forms of asthma 1, 18, 59 . faced with a lack of better options, macrolid antibiotics are deemed efficacious in clearing up symptoms, in recovering airway permeability and lowering il-5 expression only in those patients seropositive for those bacteria 1 . the design of those studies left a lot of gaps still to be filled and did not take the anti-inflammatory properties of that antibiotic group into account. instalada. contudo, não é esta a questão que aqui interessa colocar, mas a de saber se, como os vírus, poderão ser as bactérias capazes, por si só, de desencadear exacerbações ou de determinar a evolução a longo prazo da asma. parece fora de causa que tal papel possa ser atribuído às infecções mais comuns, como as do streptococus pneumoniae, do streptococus pyogenes ou do haemophilus influenzae 19 . mas já o mycoplasma pneumoniae e a clamydia pneumoniae têm estado no banco dos réus, embora com culpa mal formada. sugere -se, sem provas suficientes, a sua responsabilidade por formas arrastadas de asma na criança e no adulto e a clamídia, mas não o micoplasma, em formas agudas 1,18,59 . na falta de melhores argumentos, avança -se com a eficácia dos antibióticos macrólidos na melhoria dos sintomas, na recuperação da permeabilidade das vias aéreas e na diminuição da expressão de il -5 apenas nos seropositivos para aquelas bactérias 1 . e se o desenho destes trabalhos deixa muitas dúvidas, também se não têm em conta as potencialidades anti--inflamatórias daquele grupo de antibióticos. mas justificações não faltam, como a da interferência do processo infeccioso nos circuitos inflamatórios, com produção de mediadores ou indução de défices de ifn ou, ainda, a actuação de proteínas de choque térmico indutoras de alterações inflamatórias tendo como alvo o epitélio brônquico, macrófagos e outras células 2,25 . mais do que de afirmação, estamos em fase de pistas para investigação e, como tal, é de aguardar futuros desenvolvimentos. as nossas "amigas" bactérias comensais, com as quais ao longo do processo evolutivo, filo infecção na modulaçâo da asma j pinto mendes justifications abound, including the impact of infection on the inflammatory circuits, with production of mediators or induction of deficits in ifns, or even the performance of heat shock proteins which induce inflammatory abnormalities and whose target is the bronchial epithelium, macrophages and other cells 2,25 . this is more than a theory: it is the subject of research and so we must await future developments. our normal human bacteria with which we have been in more of a trade-off than a coexistence situation throughout the evolutionary process and the phylo-and ontogenetic development process, are now indispensable for our defence system. they give off the strongest signal for the postnatal maturation of innate immunity, with the aid of the tlrs 51 , a fundamental process for the prevention of th 1 and th 2 diseases and for stimulating memory in adaptive immunity. their non-invasive presence in mucous is vital, as a deficiency in this microbial exposure could result in a broad spectrum of immune diseases. it is calculated that in early life there are ten times more bacteria in the mucous, particularly the intestinal mucus and with a genome three times larger than that of the host than there are in the organism as a whole 60 . what has become known as the hygiene hypothesis has been cited as an explanation of the increase in the rates of asthma and allergy in industrialised countries over the last few decades. this hypothesis blames a lack of early childhood exposure to infec-e ontogenético, negociamos, mais do que uma convivência, uma verdadeira parceria, tornaram -se indispensáveis para o desenvolvimento da nossa quadrícula defensiva. delas provém o mais forte sinal para a maturação pós -natal da imunidade inata, com a colaboração dos tlr 51 , um processo fundamental para a prevenção das chamadas doenças th 1 e th 2 e para a estimulação da memória na imunidade adaptativa. a sua presença, não invasiva, nas mucosas tornou -se de tal modo vital que um défice desta exposição microbiana poderá conduzir a um largo espectro de doenças imunes. calcula -se que, nos primeiros anos de vida, existam nas mucosas, com particular relevo para a intestinal, bactérias num número dez vezes superior ao das células de todo o organismo, com um genoma três vezes superior ao do seu hospedeiro 60 . procurando uma explicação para o aumento, nas últimas décadas, da atopia e da asma nos países industrializados, a chamada hipótese higiénica pretende responsabilizar um défice de exposição microbiana nos primeiros tempos de vida pelo acréscimo no desenvolvimento da hipersensibilidade atópica e da asma. esta suspeita foi levantada pela primeira vez por strachan, em 1989 61 :" a diminuição do tamanho das famílias, a melhoria dos cuidados domésticos e os mais elevados padrões de limpeza pessoal reduziram a possibilidade de infecções nos membros mais novos das famílias. daqui pode ter resultado uma expressão mais comum das doenças atópicas". partiu, para esta hipótese, da verificação de uma correlação inversa, em famílias numerosas, entre doenças atópicas e a ordem do nascimento -os mais novos vão -se expondo às infecções dos irmãos mais velhos. infecção na modulaçâo da asma j pinto mendes tious agents for the increase in allergy and asthma. this suspicion was first raised in 1989 by strachan, 61 : '… declining family size, improvements in household amenities, and higher standards of personal cleanliness have reduced the opportunity for cross infection in young families. this may have resulted in more widespread clinical expression of atopic disease'. springboarding from this hypothesis is the verification of inverse correlation between allergic diseases and position in large families: the younger children are exposed to infection from the older. in 1998, peat 62 supported this supposition, attributing the increased rate of asthma particularly in children and teenagers in industrialised countries to our 'sterile' lifestyle. martinez 63 , liu 64 and von mutius 65 found an inverse correlation between exposure to germs and asthma onset, while calvani 38 attributed an identical role to viral infections. there are several other studies of this nature, underlining the role played by several aggressors, such as salmonellas, helicobacter pylori, hepatitis a, toxoplasma gondii and mycobacteria 1, 52, 66 ; all worth evaluating. the explanation given for these statements is that the lack of th 1 stimulation favours the th 2 arm of the immune response, with il-4 and il-13 secretion and ige synthesis, meaning that on balance, there is an unstable opposing th 2 /th 1 equilibrium; as one weakens, the other strengthens. the hygiene hypothesis is far from convincing, however, at least as it stands, but it is at least open to new horizons, which we touch on here. the greater part of these assumptions are difficult to sustain (64) and no one can affirm that in comparing family size and hy-em 1998, peat 62 vem em apoio desta suposição quando atribui ao nosso estilo de "vida esterilizada" o aumento da prevalência da asma, sobretudo em crianças e adolescentes, nos países industrializados. martinez 63 , liu 64 e, também, von mutius 65 encontram relação inversa entre a exposição microbiana e o desenvolvimento da asma, enquanto calvani 38 atribui idêntico papel às infecções virusais. sucedem -se as referências deste tipo, especificando a responsabilidade de vários agentes agressores, como salmonelas, helicobacter piloryi, hepatite a, toxoplasma gondii e micobactérias 1,52,66 , a maior parte não resistindo a um primeiro olhar de avaliação crítica. a explicação levantada para estas verificações é a de que a falta de estimulação th 1 favorece o braço th 2 da resposta imune, com secreção de il -4 e il -13 e síntese de ige. quer dizer que, como se colocadas numa balança de dois pratos, há um equilíbrio instável das vertentes th 2 e th 1 que se opõem de modo a que o enfraquecimento de uma robustece a outra. mas esta hipótese higiénica, pelo menos na explicação que lhe foi dada, está longe de ser convincente, se bem que tenha tido a virtude de ter aberto novas perspectivas que não deixaremos de desenvolver no decurso deste trabalho. na verdade, a maioria destas verificações é dificilmente sustentável 64 e ninguém pode dizer que comparando tamanho familiar e níveis de higiene estamos a medir directamente a exposição a infecções. nesta lógica, como se explica o aumento de prevalência da asma nos bairros pobres dos estados unidos 67 ? ou, em áfrica e na américa latina, em zonas endémicas de xistosomiase, promotora da secreção th 2 e da síntese de ige, que a prevalência daquela parasitose esteja na relação inversa da asma e da atopia 68 infecção na modulaçâo da asma j pinto mendes giene levels we are directly measuring exposure to infection. if we were, how would one explain the rise in the asthma rate seen in the poorer usa neighbourhoods 67 ? or how in africa and latin america, in areas rife with bilharzia, which promotes th 2 secretion and ige synthesis, is the prevalence of that parasite in an inverse correlation with asthma and allergy 68 ? and the high risk of asthma in children who attend nursery schools, with the greatest amount of infections in the lower respiratory tract 69 ? any remaining illusions should be put to rest by the failure of treatment which converts th 1 responses in asthmatics into th 2 with no clinical effect whatsoever 70 . we need new arguments as the th 1 /th 2 dichotomy is no longer accepted. how would the parallel increase in auto-immune inflammatory diseases, th 1, expression and asthma and allergy 71 or the fact that autoimmune diseases are higher in asthmatics 64 be explained on that basis? human and murine studies confirm that there may even be a synergism in both cytokine profiles that goes hand in hand-inmany types of immune response, especially allergic response 72 . this is particularly evident in allergic and viral attacks which combine th 1 and th 2 expressions 73, 74 . rsv attack, inducing th 1 response, occurs in a previously th 2 environment and does not upset the lymphocyte balance. rather it contributes to exacerbating the inflammatory type already installed 42, 43, 72 . in murine models this dual exposure results in a strong response of both cytokine profiles, suggesting that an efficient th 1 response is important for adequate th 2 73 . in 2003, holtzman 75 unveiled a theory that could be true in some cases: the asthmatic risco de asma em crianças que frequentam infantários, com maior número de infecções do tracto respiratório inferior 69 ? se restassem ilusões, bastaria assinalar o fracasso de intervenções terapêuticas que converteram respostas th 2 em th 1 em asmáticos sem qualquer eficácia clínica 70 . temos de arranjar outros argumentos, já que se não aceita hoje a relação dicotómica th 1 /th 2 . como se explicaria, naquela base, o aumento paralelo da prevalência das doenças inflamatórias autoimunes, de expressão th 1, e de asma e atopia 71 , ou o facto de as doen ças autoimunes terem elevada prevalência nos asmáticos 64 ? aliás, os estudos em modelos humanos e murinos confirmam que pode, até, haver um efeito sinérgico de ambos os perfis citocínicos que concorrem de mão dada em muitos tipos de resposta imune, nomeadamente na atópica 72 . isto é bem evidente quando se sucedem as agressões alérgica e virusal que combinam as expressões th 1 e th 2 73,74 . a agressão pelo vsr, indutora de resposta th 1 , acontecendo num ambiente previamente th 2 , não desvia o balanço linfocitário, antes contribui para a exacerbação do tipo inflamatório já instalado 42, 43, 72 . em modelos murinos, desta dupla exposição resulta uma resposta forte de ambos os perfis citocínicos, sugerindo -se, mesmo, que uma resposta eficaz th 1 pode ser importante para uma th 2 adequada 73 . em 2003, holtzman 75 expõe uma teoria que, pelo menos em algumas situações, poderá corresponder à realidade -o fenótipo asmático desenvolve -se pela activação concomitante de mecanismos atópico e antivirusal. seria uma resposta de ampliação mútua th 1 /th 2 que levaria à inflamação crónica, à hiperreactividade brônquica e à remodelação. infecção na modulaçâo da asma j pinto mendes phenotype develops via concomitant activation of allergic and anti-viral mechanisms. a mutual th 1 /th 2 amplification leads to chronic inflammation, bronchial hyperresponsiveness and remodulation. those two types of response seem to fight for the same ground. the immunology battle field is an open and interactive one, allowing multiple combinations of tactics to be selected, and weapons of choice befitting every situation. regulatory t cells stand up to choose the most fitting solutions 45, 76, 77 and as such, those seeking to understand the intricacies of the immune response should study them. romagnani 78 feels any explanation of the hygiene hypothesis has to pass through the altered immunity situation caused by alteration of the regulatory t cells. the role of these cells, whose promotion may well start in the intestinal microbial flora 79 , is becoming increasingly complex as the choices at its disposal are ever-widened by the discovery of new aids to immunology. an example is the recent discovery of the th 17 profile 80 which acts through the il-17 and will fill some gaps in knowledge of the immune/inflammatory phenomena. unlike the th 1 and th 2 profile, the th 17 profile mediates tissue inflammation, promoting neutrophil recruitment and survival and is likely to be a participant in auto-immune diseases as its netralisation prevents tissue inflammation in these types of diseases. it is another clue in severe neutrophilic asthma where suspicion is cast from time to time on auto-immune intervention. the set of variables acting in the immune response is large and complex. it is conditioned by genetic susceptibility (genotypes) definitivamente, vamos deixar de colocar aqueles dois tipos de resposta num quarto fechado, a disputar o mesmo espaço. o campo de batalha imunológico é aberto e interactivo, permitindo múltiplas combinações de escolhas tácticas, seleccionando as armas para cada situação. para gerir a escolha das melhores soluções candidatam -se as células t reguladoras 45, 76, 77 , para as quais se devem dirigir as atenções de quem pretender compreender a intrincada rede da resposta imune. romagnani 78 entende que qualquer explicação para os factos apresentados pela hipótese higiénica tem de passar por fenómenos de desvio imune por alteração das células t reguladoras. e o papel destas células, cuja promoção pode partir da flora microbiana intestinal 79 , afigura -se cada vez mais complexo, na diversidade das escolhas ao seu dispor, com a descoberta de novos braços armados da imunidade. exemplo é a recente descoberta do perfil th 17 80 que actua através da il -17 que vem preencher alguns hiatos na explicação dos fenómenos imunes/inflamatórios. ao contrário de th 1 e de th 2 , o perfil th 17 medeia a inflamação nos tecidos, promovendo o recrutamento e a sobrevivência dos neutrófilos, sendo um provável participante nas doenças autoimunes, já que a sua neutralização previne as lesões tecidulares deste tipo de doen ças. mais uma pista para as asmas graves neutrofílicas, onde se tem ciclicamente vindo a lançar a suspeita de intervenção autoimune. é grande a complexidade de todas as variáveis que intervêm no desenvolvimento da resposta imune, sujeita a factores de susceptibilidade genética (o mundo dos polimorfismos) e, no período perinatal, a muitas variáveis. a começar pelas decorrentes da gravidez, incluindo as infecções da mãe 81 , e continuando com a relação do momento da agressão infecção na modulaçâo da asma j pinto mendes and by many variables in the perinatal period. these begin with occurrences in pregnancy, such as maternal infection 81 , continue with the relationship to the moment of attack and the stage of maturity of the immunologic system and the lung structures. here there are moments when the patient comes under external attack which takes advantage of transitory vulnerabilities with results which are difficult to explain a posteriori. despite criticisms, the epidemiological effort which went into the hygiene hypothesis was extremely worthwhile in that it opened up a new perspective of asthma modulation which promises to bring forth much which is new and vital. we move from microbial infection to nonviable bacterial products such as endotoxins, able to influence the immune response so the rate of asthma and allergy is altered [82] [83] [84] [85] [86] . their performance brings about several sets of consequences, depending on when exposure occurs (important in early life), the amount and frequency of stimulation and any cross-exposure. this is all conditioned by genetic variability. the majority of epidemiological studies conclude that children which are rural born and bred, in contact with farmyards and hay in haylofts, have a lesser rate of asthma and allergy than neighbouring urban populations. this is seen more the earlier the exposure 85 . some conditioning factors are certain life styles, such as those of some hindustan peninsula communities which have a great deal of domestic contact with large animals com o estado de maturidade do sistema imunológico e das estruturas pulmonares. dentro deste contexto, surgem janelas de acessibilidade para agressões externas que exploram vulnerabilidades transitórias com resultados difíceis de explicar a posteriori. pesem, embora, todas as objecções que lhe queiramos colocar, foi de grande mérito o esforço epidemiológico que levou à teoria higiénica porque estendeu a passadeira a uma nova perspectiva da modulação da asma que promete trazer muito de novo e importante. já não se trata aqui da infecção microbiana mas de produtos bacterianos não viáveis, como as endotoxinas, que teriam a capacidade de influenciar a resposta imune de modo a alterar a prevalência da asma e da atopia 82 -86 . a sua actuação, com mais do que um tipo de consequências, dependerá da altura da exposição (importante a precoce), da dose e frequência do estímulo, de co--exposições, tudo isto dependendo de uma clara variabilidade genética. de entre as inúmeras referências a estudos epidemiológicos, avultam as que concluem que crianças, nascendo e crescendo em quintas, em contacto com currais e feno acumulado em palheiros, vêm a revelar menos asma e atopia do que populações vizinhas com estilo de vida mais próximo do urbano, efeito tanto mais nítido quanto mais precoce a exposição 85 . algumas especificidades são as de certos estilos de vida, como acontece em algumas comunidades da península hindustânica, onde é íntimo o contacto doméstico com animais, de grande porte ou gatos durante a noite, que levariam a que as crianças desen-or cats during the night, leading the children to develop less asthma, rhinitis and allergy 87, 88 . the same is seen for the habitual consumption of non-pasteurised milk 85 . while children at risk at allergic asthma have long been told to avoid contact with these animals, it is concluded that prolonged early life exposure to feld-1 induces a form of immune tolerance specific to that allergen 89 . this effect cannot be explained by an increase in the exposure to endotoxins 90 . it is evident that this does not overrule the need for avoidance in patients sensitised to these animals. here unanimous opinion states that children at risk should avoid them in early life. in addition to the lipopolysaccarides (lps) of gram negative bacteria walls (the largest component of endotoxins) other bacterial products have been responsible for this protector effect. these include muramic acid, composed of proteoglycans present in the wall of most bacteria. this influence works in proportion to the concentration, in the beds of rural houses, of lps and muramic acid 87 . explanations of this have emerged over the years but are still not totally clear. what seems clear is that they cannot reside in the now clarified th 1 /th 2 balance as children living where there is high exposure to endotoxins have a decreased secretion of both th 1 and th 2 cytokines when their leucocytes were re-stimulated with lps via the tlr 4 84 . it is natural that the regulatory t cell role emerges to the fore again, probably through a suppressor effect in the allergic response 83, 91 . repeated exposure to endotoxins and other bacterial products leads to a refractory situation in response to re-exposure. romagnani 92 argues for an effect of infecção na modulaçâo da asma j pinto mendes volvessem menos asma, rinite e atopia 87, 88 . o mesmo para o consumo habitual de leite não pasteurizado 85 . em relação aos gatos, rompendo com uma longa tradição de evicção destes animais por crianças em risco de asma atópica, concluiu--se que a elevada exposição precoce a feld -1 induz uma forma de tolerância imunitária que é específica daquele alergénio 89 , efeitos que, contudo, não podem ser explicados por um aumento da exposição a endotoxinas 90 . é evidente que tal não contraria a exigência de evicção em indivíduos tornados sensíveis a estes animais, e mesmo, aqui sem unanimidade de opiniões, em crianças de risco, passados os primeiros anos de vida. para este efeito protector, para além dos lipopolissacáridos (lps) das paredes das bactérias gram negativas (o maior componente das endotoxinas), outros produtos bacterianos também têm sido responsabilizados, como o ácido murâmico, composto de proteoglicanos presente na parede da maioria das bactérias. esta actuação moduladora exerce -se proporcionalmente à concentração, nas camas das casas rurais, de lps e ácido murâmico 87 . as explicações para este fenómeno não foram logo evidentes, nem hoje são transparentes, mas pareceu claro que não podiam estar no já desmistificado balanço th 1 /th 2 porque crianças vivendo em ambientes de elevada exposição a endotoxinas apresentavam uma secreção diminuída de citocinas, tanto th 1 como th 2 , quando os seus leucócitos eram reestimulados com lps através dos tlr 4 84 . naturalmente que o papel das células t reguladoras volta a emergir, provavelmente através de um efeito supressor na resposta atópica 83, 91 . a exposição repetida a endotoxinas e outros produtos bacterianos conduzirá a uma situação refractária na resposta às reexposições. romagnani 92 de-those cells in simultaneous suppression of th 1 and th 2 response. attention naturally returns to the cellular receptors of the bacterial products and with surprising results in the environment/genome interaction field 93, 94 . the cd14 gene is the key here. it is the gene which codifies a co-receptor for multiple tlrs which recognise in addition to the virus -as stated above -the lipopolysaccarides and proteoglycans of the bacterial membranes 95 . the white blood cells of farm born and bred children have more cd14 and tlr receptors than those of city children, in the absence of any infectious attack worth noting 96 . epidemiology studies in this field have abounded over the last few years with conclusions which are sometimes very different 97 ; different methodologies make it hard to establish cause-effect relationships. one apparent contradiction are the conclusions which in some epidemiological studies, in spite of an inverse correlation with allergy, see increased risk of wheeze 98 or non-allergic asthma 99 with exposure to endotoxins. we have known for some time of the negative impact endotoxins have on the respiratory system, particularly when exposure is occupational. this has led to the description of 'endotoxin-sensitisation asthma' 100, 101 , with neutrophil type inflammatory reaction 50 . this phenomenon has been put to the test in inhalatory challenge tests which could bring on asthma episodes or exacerbations in children and adults 82, 102 , but, to test this seeming paradox, it is not necessary to resort to these arguments as in a german study 82 , the degree of early life exposure to domestic endotoxins was in direct correla-infecção na modulaçâo da asma j pinto mendes fende um efeito daquelas células na supressão simultânea das respostas th 1 e th 2 . e a atenção voltou -se, logicamente, para os receptores celulares dos produtos bacterianos e com surpreendentes resultados no campo da interacção ambiente/genoma 93, 94 . e a chave utilizada para abrir estas portas é a do gene cd14 que codifica um co -receptor para múltiplos tlr que reconhecem, além de vírus, como já foi citado, os lipopolissacáridos e proteoglicanos das membranas bacterianas 95 . ora, os glóbulos brancos de crianças que nasceram e vivem em fazendas manifestam uma maior quantidade de receptores cd14 e tlr do que as que vivem em zonas urbanas, na ausência de agressões infecciosas dignas de registo 96 . os estudos epidemiológicos, neste campo, multiplicaram -se nestes últimos anos, com conclusões por vezes muito diferentes 97 , a que não serão estranhas vicissitudes metodológicas que tornam difícil estabelecer relações de causa -efeito. uma aparente contradição são as conclusões que, nas circunstâncias de alguns estudos epidemiológicos, apesar de uma associação inversa com a atopia, há aumento do risco de sibilâncias 98 ou de asma não atópica 99 com a exposição a endotoxinas. mas já é do nosso velho conhecimento o efeito negativo das endotoxinas sobre o aparelho respiratório, nomeadamente em meio ocupacional, que levou à descrição de uma suposta "asma por sensibilização às endotoxinas" 100,101 , com reacção inflamatórias de tipo neutrofílico 50 . este fenómeno está bem testado em provas de provocação inalatória que podem provocar episódios de asma em crianças, ou a exacerbação da síndroma, em crianças e adultos 82, 102 , mas, para testar este aparente paradoxo, não é necessário recorrer a estes argumentos de inalação de tion to the increase in the rate of respiratory and cutaneous symptoms between 6 and 12 months. another longitudinal study showed that a higher degree of exposure to endotoxins at birth was linked to a higher risk of early life asthma 103 . what is the path out of this crossroads? various research units across the world are studying endotoxin receptors and the polymorphisms of their genes. the final results of this multi-polarised scientific effort, with epidemiological studies into geographically distant populations with different ethnicities, could provide enormous advantages as it represents a wide genetic diversity. as expected, bacteria have been indicated for the polymorphisms of gene cd14 having a dominant position in the complex of lps receptors but also of rsv, particularly the tlrs, located on chromosome 5q31, a region associated with markers of asthma 84 . the relevant results in so far are particularly useful for the light they shed on this dense and vast matter which will be hard to solve and give rise to fundamentally opposing positions. mononucleotide polymorphisms of that gene are the ideal target. we will start with cd14/-260, whose c allele is associated to higher levels of total and specific ige in patients in regular contact with pets but which has an inverse correlation in patients in regular contact with farm animals 104 . another example is the tt homozygotic of cd14/-159 which correlates with a greater sensitisation to dog allergens and a lesser rate of allergic eczema 105 . another paradigmatic reference states that cd14/-1721 when in homozygotic aa, and to a lesser degree in gg, is linked to an inverse correlation between non-pasteurised infecção na modulaçâo da asma j pinto mendes doses maciças porque, num estudo alemão 82 , o grau de exposição precoce a endotoxinas no ambiente doméstico está directamente correlacionado com o aumento da prevalência de sintomas respiratórios e cutâneos entre os 6 e os 12 meses. num outro estudo longitudinal, um maior grau de exposição a endotoxinas, à nascença, estaria ligado a um maior risco de asma no primeiro ano de vida 103 . como sair desta encruzilhada? espalhados por todo o mundo, centros de investigação lançaram -se na pista dos receptores das endotoxinas e do polimorfismo dos seus genes. esta multipolarização do esforço científico, com estudos epidemiológicos em populações muito afastadas geograficamente, com distintas etnias, poderá trazer enormes vantagens quando se fizerem as contas finais, pela diversidade genética que pode representar. e, como seria de prever, as baterias foram apontadas para os polimorfismos do gene cd14 que tem uma posição dominante no complexo de receptores dos lps, mas também do vsr, com destaque para os tlr, e que está localizado no cromossoma 5q31, uma região que tem sido conotada com marcadores da asma 84 . os relevantes resultados já conseguidos valem sobretudo pelas clareiras que abrem numa densa e vasta floresta que vai custar a desbravar e que virá trazer motivos para uma infindável e salutar polémica. são alvo privilegiado os polimorfismos uninucleotídicos daquele gene e vamos apontar, como primeiro exemplo, o do cd14/ -260, cujo alelo c estará associado a níveis mais elevados de ige totais e específicas em indivíduos que têm contacto regular com animais domésticos, mas apresenta uma associação inversa nos que contactam regularmente com estábulos de animais 104 . outro exemplo é o da homozigotia tt do cd14/ -159 que milk consumption and allergic sensitisation 106 . non-treated components in milk can modify expression of cd14, at the level of position -1721. the difficulties of these genetic studies are well-known, particularly in the choice of quality phenotypes and genotypes and the impossibility of eliminating all confusing factors 107 . it is impossible to list all the studies, but mention is made of the braun-fahrlan der/von mutius and fernando martinez results. these remarkable teams have learned from the past that incongruent results often lead to the largest leaps in scientific knowledge. in 1999, the f. martinez team 108 described the existence of an oligonucleotide polymorphism at position -159 of gene cd14, located on chromosome 5q31 and to which are attributed responsibilities in asthma phenotypes. it is also of interest in that it is present in monocyte, macrophage and neutophil membrane and could be an intermediary in the performance of microbial products 109 and probably of rsv 110 . two alleles (c and t) of cd14/-159 have been studied. their homozygote could be important in allergic sensitisation ability. the early studies of the martinez team were confirmed by some but not all researchers. the braun-fahrlander team falls into the latter, with their wide-based study which cited the influence of more than a position of cd14 and various forms of environmental exposure. another example is the alex (allergy and endotoxin) study 83 . the closeness of these two groups, an example of scientific rigour in terms of protocols and the analysis of divergent results, led to understandably provisional conclusions in this thorny field 84, 104 . infecção na modulaçâo da asma j pinto mendes se correlaciona com uma menor sensibilização a alergénios de cão e uma menor prevalência de eczema atópico 105 . outra referência paradigmática reporta -se ao cd14/ -1721 que, quando em homozigotia aa, e em menor grau em gg, está ligado a uma relação inversa entre o consumo de leite não pasteurizado e a sensibilização alérgica 106 . sugere -se que componentes existentes no leite não tratado são capazes de modificar a expressão do gene cd14, a nível da posição -1721. são reconhecidas as dificuldades destes estudos genéticos, nomeadamente na escolha de fenótipos e genótipos de qualidade e na impossibilidade de eliminar todos os factores de confusão 107 , mas, na impossibilidade de citação exaustiva, ficamo -nos pela breve enunciação dos resultados dos grupos de braun -fahrlander/von mutius e de fernando martinez. estas notáveis equipas aprenderam com a história que é da incongruência dos resultados que muitas vezes se parte para as maiores conquistas científicas. em 1999, a equipa de f. martinez 108 descreve a existência de um polimorfismo oligonucleotídico na posição -159 do gene cd14, situado no cromossoma 5q31, ao qual têm sido atribuídas responsabilidades nos fenótipos da asma e igualmente interessante pelo facto de estar presente na membrana de monócitos, macrófagos e neutrófilos e poder ser intermediário da actuação dos produtos microbianos 109 e, provavelmente, do vsr 110 . para o visado cd14/ -159 estudaram -se dois alelos (c e t), cuja homozigotia pode ser relevante na capacidade de sensibilização atópica. os estudos iniciais da equipa de martinez, confirmados por alguns investigadores, não o eram por outros, nomeadamente pela equipa de braun -fahrlander no estudo de a study of peripheral leucocytes concluded that in the cc homozygote when there is a low degree of exposure to endotoxins there was a high risk of allergic sensitisation, while when there was a high degree of exposure, the risk of sensitisation was minimal. on the contrary, when there was a tt homozygote there was protection in relation to allergic sensitisation when the levels of exposure were low and a great risk when they were high. martinez 84 was the first to show a correlation between phenotypic expression and dose dependant environmental factors on gene secretion. it is believed that this type of phenomenon can have an important impact on phylogenetic evolution and the ontogenetics of the immune system 111 . we await the results of studies underway into cd14 and other gene polymorphisms which may have an influence on endotoxin receptors and other outside agents, particularly viruses, which are increasingly seen as important in the expression of allergic and asthmatic phenotypes. another strand in the argument came in a recent issue of the journal of immunology, where a korean team used a human and murine model 112 . after concluding that severe asthmas are often of neutrophilic expression, with increased ifn-γ (th 1 ) expression, they later verified in an animal model that inhalation of low endotoxin doses induces th 2 response phenotypes, bronchial hyperresponsiveness and induction of ige secretion. in contrast, high endotoxin doses induce neutrophilic inflammation and bronchial hyperresponsiveness with a th 1 profile in rats. this does not happen in animals deficient in ifn-γ. infecção na modulaçâo da asma j pinto mendes grande amplitude, incidindo sobre mais de uma posição do cd14 e vários tipos de exposição ambiental, o estudo alex (allergy and endotoxin) 83 . a aproximação destes dois grupos, um exemplo de seriedade científica no confronto de protocolos e na análise de resultados divergentes, levou a conclusões, naturalmente provisórias, neste campo de tão difícil abordagem 84, 104 . o estudo em leucócitos periféricos concluiu que, na homozigotia cc, quando havia um baixo grau de exposição a endotoxinas, era elevado o risco de sensibilização atópica, enquanto se o grau de exposição fosse elevado o risco de sensibilização era mínimo. pelo contrário, quando existia uma homozigotia tt havia uma protecção em relação à sensibilização atópica quando eram baixos os níveis de exposição e um grande risco quando esta era elevada. para martinez 84 , ter -se -á demonstrado pela primeira vez uma relação da expressão fenotípica com a influência do ambiente (dependente da dose) sobre a secreção génica. presume -se que fenómenos deste tipo poderão ter tido importante papel na evolução filogenética e na ontogenia do sistema imune 111 . aguardam -se os resultados dos estudos em curso sobre outros polimorfismos do cd14 e de outros genes que possam ter algo a ver com receptores das endotoxinas e de outros agentes externos, nomeadamente vírus, que parece estarem a ganhar grande relevância na expressão dos fenótipos atópico e asmático. uma outra acha para a fogueira foi lançada por uma publicação recente no journal of immunology por uma equipa coreana que utilizou modelos humano e murino 112 . depois de concluírem que as asmas graves são com frequência de expressão neutrofílica, com aumento da expressão de ifn -γ (th 1 ), martinez 84 stated that asthma and allergic phenotypes are only rarely purely 'genetic' or 'environmental'. he proposed that they are almost always the result of inadequate genetically determined responses to environmental situations in which, depending on the context, the latter can predispose towards disease, prevention or even neutral results in the environment/phenotype correlation. developments are eagerly awaited and will shortly cascade. there is a heavy current investment in animal research, as in addition to the difficulties in epidemiological research starting from the genome already discussed, there are important ethical barriers which will not be easily overcome. in the midst of so much confusion, is it possible to reach any conclusions on asthma and allergy prevention which are applicable to the here and now? will we have to change the way we lead our lives? it is obvious, and no one would say otherwise, that it is not possible or desirable to turn back the clock on advances in quality of life which hygiene measures have brought to populations. this is of course not a defence of those urging an obsessively sterile lifestyle, which is sometimes advocated by pressure groups with financial interests in those areas. but this is already calling into question advice to which we have all been privy, and which is sometimes taken too much to heart by parents of allergic and/or asthmatic children, or children at risk of these diseases, to keep the house clean and avoid animals in early life. can genetic studies, such as those infecção na modulaçâo da asma j pinto mendes verificam, depois, no animal, que a inalação de doses baixas de endotoxinas induzem fenótipos de resposta th 2 , hiperreactividade brônquica e indução da secreção de ige. em contraste, o uso de doses altas de endotoxinas induzem no rato inflamação neutrofílica e hiperreactividade brônquica, com um perfil th 1 , situação que não acontece no animal deficiente em ifn -γ. para martinez 84 , os fenótipos asma e atopia só raramente poderão ser "genéticos" ou "ambientais" puros. propõe que sejam, quase sempre, o resultado de respostas inadequadas, geneticamente determinadas, a situações ambienciais, onde, dependendo do contexto, estas últimas tanto podem predispor para a doença, para a prevenir, ou, ainda, para resultados neutros na correlação ambiente/fenótipo. pressente -se na literatura médica impaciência quanto aos desenvolvimentos que, neste domínio, vão surgir em catadupa e que conhecem actualmente um forte investimento na investigação animal, já que ir mais longe na avaliação de modelos humanos, para além das já referidas dificuldades na investigação epidemiológica com ponto de partida no genoma, compreende importantes obstáculos de ordem ética que dificilmente poderão ser ultrapassados. será que de tanta contradição, de que fizemos eco, é possível retirar consequências para o quotidiano na procura da prevenção da asma e da atopia? será que temos de mudar os nossos padrões de vida? é evidente, e ninguém o defende, que não é possível nem desejável voltar atrás no progresso que as medidas higiénicas trouxeram à qualidade de vida das populações. mas, claro, isto não significa apoiar certos fundamentalismos already carried out into endotoxins, provide future guidance? a somewhat logical option, part of the initial hygiene hypothesis, is the use of orally administered probiotics, something which even today provides the backbone of foodstuff industry marketing strategy. existing studies are inconclusive, however 60, 114 , and attempts to blame early life antibiotic use for the increased rate of asthma were not encouraged 115 . the synthesis of anti-viral vaccines, particularly anti-rsv and anti-rv, or anti-viruses suitable for administering in early life may be a useful way to go, and bring something to knowledge of asthma modulation by virus. while it is good in the field of asthma, as in other medical science fields, to hope for discovery of environment/genotype/phenotype correlations and easy access markers to characterise them, we are all aware that fresh scien tific knowledge does not appear at the speed we would hope. that said, hope remains of future clarification of such cloudy areas as asthma, particularly in its modulation by infections. infecção na modulaçâo da asma j pinto mendes de obsessão por uma sociedade esterilizada, com excessos normativos que, muitas vezes, não deixam de ter por detrás grupos de pressão com interesses financeiros nestas áreas. mas já são de por em causa conselhos que todos nós vimos dando, por vezes levados a um extremo de rigor pelos pais de crianças atópicas e/ou asmáticas, ou em risco de o serem, na limpeza da casa ou evicção de animais desde os primeiros meses de vida. será que os estudos genéticos, como os feitos para as endotoxinas, nos poderão orientar futuramente? uma opção mais ou menos lógica, dentro da versão inicial da hipótese higiénica, seria o uso de probióticos por via oral, visão que continua ainda hoje a orientar estratégias de marketing na indústria alimentar. mas os estudos realizados revelaram -se inconsistentes 60, 114 , nem foram encorajadoras as tentativas de responsabilizar a administração de antibióticos em idades precoces pelo aumento da prevalência da asma 115 . poderá ter interesse, e tê -lo -á por certo para o conhecimento da modulação da asma por vírus, a síntese de vacinas antivirusais, nomeadamente anti -vsr e anti -rv, ou de anti virais viáveis para administração nos primeiros tempos de vida. se bem que, no campo da asma como no de outros sectores da ciência médica, se alimentem todas as esperanças nas relações ambiente/genótipo/fenótipo e no achado de marcadores de fácil acesso para as caracterizar, todos estamos conscientes de que a passagem à prática de novos conhecimentos científicos não se faz à velocidade da nossa esperança que, no entanto, se mantém viva e confiante na clarificação futura de nebulosas tão densas como são as da asma, nomeadamente na sua modulação pelas infecções. respiratory 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polymorphism in cd14 modified the effect of farm milk consumption on allergic disease and cd14 gene expression association studies in asthma genetics a polymorphism in the 5'. flanking region of the cd14 gene is associated with circulating soluble cd14 levels and total serum ige dependent mechanisms of cell stimulation by bacterial endotoxin phenotypic evolution: a reaction norm perspective airway exposure levels of lypopolysaccharide determine type 1 versus type 2 experimental asthma probiotics and prevention of atopic disease: 4 -year follow -up of a randomized placebo. controlled study lack of association between antibiotic use in the first year of life and asthma, allergic rhinitis, or eczema at age of 5 years key: cord-332298-ig1j5z07 authors: couetil, laurent; cardwell, jacqueline m.; leguillette, renaud; mazan, melissa; richard, eric; bienzle, dorothee; bullone, michela; gerber, vinzenz; ivester, kathleen; lavoie, jean-pierre; martin, james; moran, gabriel; niedźwiedź, artur; pusterla, nicola; swiderski, cyprianna title: equine asthma: current understanding and future directions date: 2020-07-30 journal: front vet sci doi: 10.3389/fvets.2020.00450 sha: doc_id: 332298 cord_uid: ig1j5z07 the 2019 havemeyer workshop brought together researchers and clinicians to discuss the latest information on equine asthma and provide future research directions. current clinical and molecular asthma phenotypes and endotypes in humans were discussed and compared to asthma phenotypes in horses. the role of infectious and non-infectious causes of equine asthma, genetic factors and proposed disease pathophysiology were reviewed. diagnostic limitations were evident by the limited number of tests and biomarkers available to field practitioners. the participants emphasized the need for more accessible, standardized diagnostics that would help identify specific phenotypes and endotypes in order to create more targeted treatments or management strategies. one important outcome of the workshop was the creation of the equine asthma group that will facilitate communication between veterinary practice and research communities through published and easily accessible guidelines and foster research collaboration. the effort to clarify the phenotype and terminology used to characterize horses with chronic inflammatory airway disease started in 2000 with a workshop in east lansing, michigan (1) . several workshops were subsequently held with similar goals in mind with the latest hosted in cabourg, france in 2014 (2) . in the last few years, the terminology has further evolved with the term equine asthma (ea) now being recommended to describe horses with chronic respiratory signs ranging in severity from mild to severe that were previously referred as inflammatory airway disease and recurrent airway obstruction, respectively (3) . although strong evidence supports the role of exposure to environmental dust in the pathophysiology of both mild and severe ea, the potential role of infectious agents (bacterial and viral) has not been clearly established. the goal of the 2019 havemeyer workshop on equine asthma was to bring together researchers and clinicians from different disciplines who are actively investigating airway inflammation to discuss the latest information on this topic and provide some comparative perspective from human asthma. the workshop was designed to facilitate productive discussions that would inform potential future revisions of the 2016 american college of veterinary internal medicine (acvim) consensus statement on mild-moderate ea (3) and provide future research directions. the present report follows the format of the workshop. the manuscript is organized thematically starting with the recent advancements in the understanding of the classification and diagnosis of human and equine asthma. the second part is centered on the etiology and pathophysiology of ea. the third and final section of the manuscript summarizes the extensive discussions conducted during the workshop with the goal of prioritizing future directions of ea research. clinical asthma phenotypes have been recognized for many decades but were collapsed into a unified hypothesis of asthma as an allergic disease in 1989 when age adjusted levels of immunoglobulin e were associated with asthma. it has taken more than 20 years to consider the heterogeneity of asthma again with an emerging emphasis on endotypes, an intrinsically more interesting approach to understanding asthma pathobiology (4) . the term "endotype" is used to describe a subtype of disease defined by a molecular mechanism, genetic variation or by treatment response (5, 6) . cluster analyses of asthma cohorts have revealed groups with different ages of onset, lung function, concordance or lack thereof between measures of airway inflammation by sputum analysis and symptoms. a recent review of asthma by a panel of experts has focused on the need to recognize asthma in its diverse forms and to identify treatable traits. this extensive review has highlighted areas for future attention (7) . the application of the analysis of gene expression to airway epithelial cells and sputum cells from well-characterized groups of asthmatics has led to the appreciation of asthma associated with t helper 2 cytokines and non-t2 asthma (8) . the former is the more allergic subset with higher ige and peripheral and sputum eosinophilia. non-t2 asthma has fewer of these features and is less responsive to inhaled corticosteroids. t cells that express interleukin-17 have been linked to severe neutrophilic asthma. these so-called th17 cells have been shown in animal models to be associated with steroid-unresponsiveness. the th1 cytokine interferon-γ likewise has been found to be expressed in the airways of severe asthmatics. in recent years there has emerged another lymphoid cell that participates in host responses to mucosal injury. these innate lymphoid cells are lineage negative, lacking the usual lymphocyte surface markers (9) . they express similar panels of cytokines to the t helper subsets and are labeled innate lymphoid cell (ilc) 1, 2, and 3. they are rapidly activated by epithelial signals such as thymic stromal lymphopoietin (tslp), interleukins 25 and 33, molecules termed alarmins. the secretion of il-5 and il-13 by ilc2 may lead to a pattern of inflammation previously interpreted as th2. innate lymphoid cells are less steroid sensitive. additionally, alarmins prime cells such as dendritic cells and therefore may have a role in adaptive immunity as well as innate immune responses. the synthesis of amphiregulin, an epidermal growth factor receptor ligand, by ilc2s but also th2 cells, is postulated to promote mucosal integrity. one could anticipate that viral infection of epithelial cells or damage by irritants giving rise to inflammation mediated by ilcs. however, their roles have yet to be fully explored. transcriptomic analysis of sputum has revealed three patterns of inflammation and gene signatures consistent with both th2 and ilc2 driven inflammation and oxidative stress (10) . the descriptions of molecular mechanisms of inflammation may still be considered as a deeper form of phenotyping. however, the application of novel biologics to treat asthma is now implicating certain pathways in disease and therefore is providing us with true disease endotypes. most of the progress in the identification of treatable traits has related to the t2 phenotype. biologics targeting ige (omalizumab), il-5 and therefore, the eosinophil (mepolizumab, benrazilumab, rezlizumab) and the t2 cytokines (dupilumab) have all demonstrated efficacy in reducing exacerbations of asthma. recent results of studies targeting the alarmin tslp and therefore both t2 high and low asthma have confirmed efficacy against acute attacks of asthma. oxidative stress in asthma has not been specifically addressed. a problematic form of asthma is that associated with airway remodeling and fixed airway obstruction. the association with mucus plugging and eosinophilic inflammation has been recently identified as a potential factor in long term impaired airway function (11) . severe equine asthma is typically a neutrophilic form of asthma although expression of t2 cytokines has been described (12) . there is also evidence that il-17 is expressed in equine asthma and its effects on neutrophil survival are steroidinsensitive (13, 14) . although neutrophilic human asthma is less steroid-sensitive than the eosinophilic phenotype, severe equine asthma is responsive to steroid treatment despite the presence of neutrophilic inflammation. severe equine asthma shares the structural remodeling of the airways with human asthma and a part of the remodeling change is reversible with steroid treatment as well as withdrawal from the inciting stimulus (15) . studies of airway remodeling in human asthma with treatment have not addressed key components of remodeling such as increased airway smooth muscle mass. revised in 2016 and discussed the use of ea to describe these conditions (3) . the revised consensus recognized that asthmatic horses of all severities have common clinical presentations (such as chronic cough, excess mucus, poor performance) but also a wide heterogeneity in terms of triggering factors, severity, and pathologic characteristics. a phenotype is the observable physical properties of an organism, including measurable laboratory findings, which is the result of the expression of the genes in response to the environment (17) . identifying distinct phenotypes is of interest if they facilitate the diagnosis, the prognosis or allow the implementation of targeted therapy. while currently loosely defined, the ea phenotypes discussed in the 2016 consensus statements were based on clinical presentation (severe vs. mild/moderate), triggering factors (barn/hay or pasture), endoscopy findings (mucus) and bronchoalveolar cytology. from a clinical standpoint, further dividing ea as distinct "mild" and "moderate" phenotypes may promote recognition that asthma is an underdiagnosed cause of exercise intolerance in high performance horses. horses with a cough or increased respiratory rate at rest or following exercise will commonly undergo further diagnostic procedures to confirm asthma, or "anti-asthma" treatments will be implemented. however, this is generally not the case when no clinical signs suggestive of an airway disease are present. the term "mild ea" could describe the condition affecting these horses, while "moderate ea" would be used when clinical signs of airway disease (such as cough) are present, but without the periods of labored breathing at rest seen in "severe ea" (18) . the inflammatory airway cell phenotypes (neutrophils, mast cells, eosinophils) were recognized in the 2007 and 2016 consensus statements (3, 16) . future phenotypes may include the age (early or late) of appearance of clinical signs, or specific remodeling features affecting the airways, if these new features are shown to facilitate prognostication or the implementation of specific therapy. the future development of new portable and sensitive devices for measuring the lung function of horses (forced oscillation or flow interruption techniques), or the discovery of blood biomarkers for ea would help not only to facilitate the diagnosis of mild and moderate forms of ea in clinical practice, but also to possibly identify new phenotypes for these conditions. to date, different inflammatory pathways have been proposed as contributing to ea, which may eventually lead to novel therapies (19) . the discrepancies between results of the different studies may be an indication of different endotypes in ea, although future studies on large cohorts of horses from multiple sites would be required before specific endotypes can be recognized. multicenter tissue banking could facilitate these studies. in summary, the 2016 acvim consensus statement recognized the currently known distinctive features of ea. further defining "mild" and "moderate" ea based on the presence or absence of easily identified clinical signs may promote the investigation of the subclinical (mild) phenotype. the identification of novel phenotypes and endotypes may lead to "precision medicine" where treatments most likely to help equine patients would be selected. this approach is now implemented in humans and may eventually be applicable to horses if supported by scientific research. severe equine pasture asthma (epa) is characterized by episodes of reversible airway obstruction in horses grazing pasture during the summer in hot humid climates (20) . affected horses demonstrate neutrophilic airway inflammation, airway hyperresponsiveness extending throughout the season of remission, and airway remodeling (21, 22) . the author's experience is restricted to epa as first described in horses residing in louisiana, and diagnosed in states with subtropical climates (mississippi, alabama, and florida) (20) . veterinarians in regions of adjoining states and distant states (oregon) describe similar signs in horses grazing pastures during hot humid conditions. epa is described in the united kingdom where it differs in its association with hot dry weather or exposure to dust from harvest/burning of crops (23) . epa demonstrates adult onset (12 ± 6 years; range 1-29 years) without sex predilection (24) . asthma exacerbations generally begin in summer (july), persisting until temperature and humidity decrease (october/november) (25) . fewer horses experience asthma in the spring. a history of prior seasonal cough and/or exercise intolerance may be identified. improvement within hours to days of isolation from pasture particulates in a stall environment is a key diagnostic feature of epa in the southeastern usa (20) ; some severe cases necessitate isolation in a climate climate-controlled environment. in the author's experience, without adequate environmental management, disease severity is progressive and responsiveness to parenteral corticosteroids decreases. though specific agent(s) that elicit epa exacerbation are not identified, the response to stall housing implicates seasonal pasture-associated particulates. costa et al. reported increases in grass but not tree pollens were significantly associated with epa exacerbation using a pollen station ∼90 miles from affected horses (25) . in this regard, intact pollen is too large to reach the respirable zone of humans in order to elicit asthma, but moist conditions that are associated with epa exacerbations can shatter pollen and disseminate respirable particles (26) . grass pollen sensitization is classically associated with th2 responses, ige-mediated hypersensitivity, and eosinophilic inflammatory infiltrates. however, chronic exposure to th2 sensitizing antigens and to complex antigen combinations that include th2 sensitizing antigens each generate th17 responses accompanied by neutrophilic airway inflammation that typifies epa (27, 28) . subtopical grasses differ substantially from grasses in temperate and continental climates (29) . pollen from subtropical grass subfamilies is important to rhinitis and human asthma in subtropical zones of australia, asia, india, africa, and america. pollination seasons for bahia and bermuda grass (spring through september/october) align to the season of epa exacerbation (30, 31) . the pollen season for johnson grass is temperature dependent, flowering from may to july, with higher temperatures moving flowering later into autumm (32) . a role for fungal triggering in epa exacerbation is suggested by the near identical clinical picture presented by horses with epa and barn dust-associated severe asthma, wherein a role for fungal triggering is substantiated in the latter (33) . chronic neutrophilic airway inflammation characterizing both forms of severe equine asthma also aligns to th17-mediated neutrophilic inflammation in fungal asthma models (34) . of the more than 100 species of fungi that exist in biotropic relationships with bermuda, bahia, and johnson grasses, curvularia, helminthosporium, alternaria, puccinia, epicoccum, and fusarium are implicated in eliciting human asthma (35) . costa et al. identified fungal spores of the genus nigrospora, and curvularia, as well as basidiospores, as temporally associated with exacerbations of pasture asthma (25) . these findings are in agreement with reported correlations between epa exacerbation and high dew point temperature (25) . specifically, nigrospora conidia and basidiospore release increase with increasing relative humidity, resulting in a peak in spore counts during the early morning and aligning to the association of epa exacerbations with increased dew point temperature (25, 36) . in contrast, conidia of cladosporium, alternaria, epicoccum, and dreschlera spp. are released during warm, dry, windy conditions, while precipitation is required for release of many ascospores. in this way, humidity influences fungi of relevance to asthma in different locales which could influence associations of pasture asthma in the uk with hot dry conditions, rather than hot humid conditions precipitating pasture asthma in the southeastern us. as a chronic and progressive disease of undetermined etiology, epa is most effectively managed by segregation from inciting grass pastures during warm seasons. the necessity to segregate horses from pasture, particularly at a time when they are typically extensively ridden and grazed, presents a conundrum that is ultimately detrimental for most affected horses. accordingly, there is a critical need to identify the agents that trigger epa in order to improve disease management. both veterinary practitioners and researchers muse about the diagnostic armamentarium available to physicians-if only we had the chest ct, the advanced lung function testing, the biomarkers-then we would be able to have a better diagnosis. a quick search of the literature, however, shows us that our counterparts face many of the same diagnostic dilemmas that we do, albeit often with higher bills! while pulmonologists have drawn up multiple guidelines to help in the diagnosis of asthma in humans with its multiple phenotypes and endotypes, physiciandiagnosed asthma criteria often fail to be consistent with the official guidelines rendering the results of large epidemiologic studies or clinical trials fraught with the perils of resting findings on nebulous datasets. various forms of spirometry or simple pulmonary function testing are readily available in human medicine, but few non-pulmonologists avail themselves of objective data, and instead rest on reported symptoms such as difficulty breathing on exertion, cough or positive response to bronchodilation (37) . indeed, the gina toolbox identifies "lack of access to spirometry/bronchoprovocation tests" as a barrier to implementation of gina guidelines in human asthmatics (38) . moreover, the heterogeneity in published algorithms for diagnosis of asthma-more than 66 in the literature at last count-make even an algorithm-based diagnosis unsure (39) . thus, the conclusion that symptom-based diagnosis is associated with a significant risk of over-diagnosis has been reached for asthma in humans (40) . the current push in human medicine to refine both the phenotypes and endotypes for multiple different subtypes of asthmas aims to elucidate the underlying causes and thus treatments that may be very different. we are still searching for the criteria that will help us with this in equine medicine. if there are indeed mechanistically different groups of horses within the categories of mild, moderate, and severe ea that are associated with genetic differences or cellular or molecular biomarkers, then perhaps we will gain better understanding of treatment successes and failures and will be able more logically to choose clinical therapies and predict responses. the difficult case for the clinician and the researcher alike is not the horse with severe ea-because the history and clinical exam alone can often suffice to diagnose, and there is a visible relief in respiratory embarrassment with administration of bronchodilator (although it can take some time in horses with diaphragmatic exhaustion) (41) . the difficult horse is the one with moderate/severe asthma in remission and the horse with mild-moderate ea. as was recently pointed out, the biggest difference that we note in the clinical diagnosis of horses with mild-moderate ea vs. severe ea is the presence of an increased respiratory effort at rest, which is due to the underlying pathophysiology of bronchoconstriction, increased mucus, and bronchiolar inflammation (42) . the need, then, is to detect the mildly or subclinically affected horse. as veterinarians, we have at hand history, clinical signs, lung function testing, radiographs, endoscopy, analysis of airway secretions, blood biomarkers and clinical pathology which can be used in a minimum database in order to classify horses into clinically useful categories that have a pathophysiologic basis that can simultaneously allow us to diagnose, treat, and translate clinical cases into field research. a tentative diagnosis of ea in its most severe form can often be made on history alone, with the key component being the recognition of episodes of reversible respiratory embarrassment precipitated by exposure to specific triggers-namely, moldy hay in the northeast of the united states, and pasture allergens and particulates in the south. history in subclinical or mild cases is seldom of such definitive use; this does not mean that it is unimportant. such questions as parentage (43) , type of feed and how it is fed (44) , and heat and pollen counts at the time of diagnosis (45) may be important risk factors for equine asthma. while it has been proposed that coughing and poor performance may serve to define a phenotype of moderate vs. mild ea (46) , these signs are not sufficiently sensitive (47) and would misclassify a subset of horses-they alert the clinician that moderate ea is likely, but the absence of these signs does not rule out disease. the connections between ea and viral or bacterial disease are not linear, but it is becoming increasingly clear that the connection exists (48, 49) , thus a thorough history should include probing for past infectious respiratory disease. one of the best described questionnaire analysis tools for classification of horses based on history is the hoarsi index (50), developed as a means of distinguishing among normal, mild-moderate ea or severe ea phenotypes. however, clinical signs and indices are insufficiently sensitive to distinguish horses with mildmoderate ea from normal horses or horses with severe ea in remission (51) . proposed minimum database for both practitioners in the field and for research: a common history tool should be developed that addresses the main concerns of parentage if known, current and lifetime exposures to particulates and allergens including feeds and feeding practices, barn environment, vaccinations, travel history, and recent illnesses. multiple scoring systems have been shown to be useful for distinguishing healthy horses from horses with severe ea in exacerbation, but, similar to questionnaire indices, these scoring systems do not help in the more difficult problem of distinguishing horses with mild ea from healthy or severe ea in remission (52) . indeed, 19 years ago, robinson et al. found that even in horses with historical severe ea, clinical score failed to reflect low-grade airway obstruction, and suggested that without easily used, field-accessible testing equipment, lower airway disease would go underdiagnosed (53) . recently, the adapted 23-point scoring system has been shown to be the most useful in discriminating mild from severe cases, but it is unlikely to distinguish normal from subclinical disease (54) , and the ideass scoring system has recently been described as a useful scoring system for moderate-to-severe equine asthma (55) . thus, while clinical scoring is essential to a good examination and careful research, and can potentially be useful in measuring response to treatment in the individual, it is insufficient in making the phenotypic distinction between mildly affected horses and healthy horses. proposed minimum database for both practitioners in the field and for research: the 23-point modified clinical score appears to best stratify horses with obstruction ranging from mild to severe. an application suitable for smart phone use would enhance the adoption of a common scoring tool. in human asthma, the gold standard is the detection of variability in pulmonary function using spirometry or other methods of lung function testing (38) . unfortunately, lung function testing remains available only to a few specialized centers, as more recently developed portable lung function testing modalities are no longer on the market (41) . initial reports from the author's laboratory of a simple field test of respiratory resistance using the interrupter technique hold promise for increased use of lung function testing in the future. while the classic esophageal balloon/pneumotachometer method is effective in demonstrating increased maximal pleural pressure and allows for calculation of pulmonary resistance and elastance as well as dynamic compliance in severe ea, it is not sufficient for demonstrating abnormal function in mildly affected horses in which baseline lung function is rarely abnormal and histamine or other bronchoprovocation or bronchodilation must be used in order in order to detect low-grade obstruction (56) . unfortunately, in some studies, even histamine bronchoprovocation has not been sufficient to distinguish between normal horses and horses with mild asthma (52) , and a lack of concordance between histamine bronchoprovocation and bronchoalveolar lavage (bal) cytology has been noted in several studies (57, 58) . while lung function testing and histamine bronchoprovocation have shown moderate to strong correlations with bal cytology in some studies (56, 59, 60) , others have not (57, 58) . methods of performing histamine bronchoprovocation are equally important: studies in human asthmatics have shown that it is the total dose of histamine that is most important rather than the duration of exposure. a more precise method of dosing may be important to establish. in human athletes, indirect stimuli, such as cold air, hypertonic solutions such as mannitol, exercise, and amp are all considered more accurate and useful in predicting asthma than are direct stimuli such as methacholine or histamine; this is an area that requires exploration in equine pulmonology. while hay challenge is useful for research in severe ea, it is inappropriate in a clinical case, especially in a horse that is expected to do athletic work (3) . in moderate to severe ea, variability in airflow should be demonstrated not through bronchoprovocation but through bronchodilation using either systemic (buscopan tm ) or inhaled (albuterol, ipratropium bromide) drugs to assess reversibility; it is possible that a 24 h period of bronchodilation is necessary for maximum effect in horses with diaphragmatic fatigue (61) . proposed minimum database for both practitioners in the field and for research: in research, lung function should be assessed and airflow variability/changes in airway caliber should be assessed with either bronchoprovocation or bronchodilation. more research is necessary to determine if field assessment of lung function after bronchoprovocation or bronchodilation is sufficient to determine change with the 23-point scoring system. it is essential that a robust, easily used system for testing lung function in the field be developed. unlike in human pulmonology, examination of airway secretions is a primary method of diagnosis in ea, be it mild, moderate or severe. although a standard volume of between 250 and 500 ml of saline using a 2 m long endoscope or 3 m bal tube is recommended (3), this practice is not always followed, and cytology should be assessed keeping in mind that the amount of fluid infused will affect the cell percentages. the relationship between bal cytology and performance is still not clear. certainly, poor performance has been associated with what have been determined to be abnormal cell types or percentages (3) . there has been much discussion as to what is normal on bal cytology; it likely depends on a combination of technique, environment and population. even the "stringent" definition proposed by couëtil et al. (3) of <5% neutrophils, 2% mast cells, 1% eosinophils, would be considered elevated in some high-performance populations (62, 63) . although an earlier study found no evidence of a clear phenotype in mast cell vs. neutrophilic inflammation with respect to pulmonary gas exchange during exercise (64) , recently, an increase in bal mast cells or neutrophils was shown to negatively affect performance (44) . the way that cells are counted in bal cytology is also important, especially for rare cells. in our laboratory we count a minimum of 500 cells at 400x for common cells such as macrophages and lymphocytes or neutrophils in mild ea, whereas for rare cells such as mast cells we count 1,000 cells. other techniques, such as using a 5-field differential for mast cells, are only useful if the cell density is high (65) . the conundrum of whether to assess airway fluid from both lungs rather than blind sampling, or to pool samples, has also occupied attention from researchers. one group found that, depending on whether the "loose" or "stringent" categorization was used, 8-37% of horses would have been categorized as control vs. mild-moderate ea if only one lung were used (66) . as it is the rare practitioner who has a bronchoscope in the field, it is unlikely that even pooled samples (63) , which may be a better representation of overall lung inflammation, will be taken other than in referral centers or practices. the problem is most important for rare cells. more attention will need to be paid in future to morphology and perhaps typing of cells. the existence of neutrophil extracellular traps (netosis) in horses with severe ea presents an additional method to determine response to treatment (67) , and recently the presence of degenerate neutrophils has been shown to raise suspicion for bacterial infection (68) . the question of macrophage morphology as an indicator of inflammation is also an area that will profit from further investigation (69) . recently, as well, the paucigranulocytic phenotype has been described in which horses with clear signs of severe ea have low neutrophil percentages in the bal (46) . this is thought to be due to mucus plugging of small airways that essentially sequesters neutrophils. although a recent publication showed a rather shocking 81% of highperforming european horses with mild-moderate ea had fungal elements in the bal (62) , this remains to be confirmed in other populations. proposed minimum database for both practitioners in the field and for research: for the bal, at least 250-mls of saline should be used, and there is a preference for counting at least 500 cells to adequately represent rarer cells. for research purposes where rare cells are of interest (e.g., mast cells or eosinophils), sampling of both lungs appears preferable. better categorization of cells through morphological descriptions including apparent neutrophil extracellular traps and notations of fungal or birefringent elements should be done. characterization of mucus on cytology may help to elucidate the paucigranulocytic phenotype. bal in the field will usually be done blindly with a specialty tube. the debate continues to swirl around the utility of tracheal wash vs. bronchoalveolar lavage, with malikides et al. (70) finding a 37% disagreement in young racehorses, while derksen et al. (71) determining that there was no correlation between bal and tw, and others finding no relationship between tracheal neutrophil counts and racing performance (72); thus, tracheal cytology has been considered inappropriate for diagnosis of mild ea (3). recently, however, a comparison of tw and bal in 145 horses, along with evidence of mucus and endoscopy, found that only 17.5% of horses would have been classified differently if they had had the other procedure, eventually concluding that there is no gold standard-except for mast cells, which are rare in the trachea, and thus, to be found, demand that a bal be performed (73) . proposed minimum database for both practitioners in the field and for research: tracheal wash may be most practical for some practitioners in the field and has the added benefit of allowing for bacterial culture. the inability to assess mast cells adequately continues to limit this modality. in research settings, both tracheal aspirate and bal are preferable. many clinical diagnoses are made on the basis of endoscopic visualization of mucus, with strong support from the finding that tracheal mucus quite nicely correlated with racing performance or lack thereof (72) . the recent consensus statement considers that the demonstration through tracheobronchial endoscopy of mucus grade 2/5 in racehorses or 3/5 for sport/pleasure horses is sufficient to diagnose mild-moderate ea and in support of this recommendation, rossi et al. (73) found that visible mucus in the trachea is indeed likely to predict inflammation. there are varying degrees of certainty about mucus in the trachea predicting inflammation (49, 62, 74, 75) . nonetheless, other studies have shown that mucus is insufficient to parse out mild vs. unaffected cases (76) . endoscopy has also been shown to be useful in detecting an increase in upper airway abnormalities in horses with mild-moderate ea, with courouce-malblanc et al. (77) raising the chicken-and-egg question of the relationship between mild-moderate ea and dorsal displacement of the soft palate, and more recently, wysocka and klucinski (78) found that more horses with mild-moderate ea had dynamic pharyngeal abnormalities. it may be that the answer will rest in whether any of these modalities can help to define a phenotype rather than simply further describing an already understood phenotype. proposed minimum database for both practitioners in the field and for research: upper airway endoscopy should be performed to rule out upper airway cause of obstruction as a primary cause of signs or that might confound lung function testing. assessment of tracheal mucus should be performed. endobronchial biopsies offer an excellent method of sampling larger airways, although deeper layers cannot be accessed. the brass ring-being able to distinguish normal from remission or mild ea-remains elusive, however, as correlates were evident between histopathology and impulse oscillometry and showed a difference between horses in remission at pasture and those that remained stabled and treated with glucocorticoids, but did not show any difference between horses with severe ea in remission and controls (79) . proposed minimum database for both practitioners in the field and for research: at this time, brushings/biopsies are not considered part of a minimum database. imaging is considered an important ancillary diagnostic in humans, but radiographs have not been shown to be sensitive or specific in horses with ea (80) . chest ct is currently not feasible in large animals. while endobronchial ultrasound shows promise for the elucidation of airway smooth muscle thickening in severe ea, the ultimate goal of being able to detect low-grade disease in erstwhile healthy horses, or to distinguish normal from severe ea in remission remains elusive (79) . proposed minimum database for both practitioners in the field and for research: at this time, imaging is not considered part of the minimum database. equine asthma encompasses mild to severe forms of chronic airway inflammation. severe ea affects ∼14-17% of horses in countries with northern, cool climate (47, 81) . mild-moderate ea affects 68-77% of pleasure horses based on tracheal wash cytology (neutrophils > 20%) and up to 80% of racehorses based on bal cytology (44, 75) . horses affected with severe ea experience exacerbation of clinical signs when exposed to organic dust originating from hay and bedding, in particular molds present in poor quality hay. as a result, clinical signs tend to be worse during the winter when horses are housed indoors for extended periods of time (82) . some horses exhibit disease flare-ups while at pasture during summer months (epa) (25) . these horses improve clinically during winter or after being housed indoor. a small percentage of horses appear to suffer from both classic severe ea and epa. horses with severe asthma tend to be mature (>7 years) to old animals and a genetic predisposition has been identified in some families (83, 84) . the main clinical sign characteristic of severe ea is increased respiratory effort ("dyspnea") that can rapidly improve following bronchodilator administration. although the decrease in respiratory effort following bronchodilator administration can be detected within minutes of drug administration using lung function testing, clinical improvement may not be apparent to clinicians (85) . acute exacerbation is associated with increased pulmonary artery and right-heart vascular pressures as well as increased pulmonary artery diameter on ultrasound (86) . blood pressure return to baseline during clinical remission however, cardiac ultrasound abnormalities such as right ventricular wall thickness remained increased (86) . surprisingly, severe ea is rarely fatal unless complications develop such as cor pulmonale (87) . affected horses are more likely to be euthanized because owners get discouraged with the expense associated with chronic therapy and maintaining a low-dust environment (83) . coughing and nasal discharge are non-specific signs of respiratory disease commonly reported in horse with severe ea (47) . horses with a history of both coughing and mucoid nasal discharge are at increased risk of developing severe ea (88) . thoracic auscultation may reveal increased breath sounds bilaterally, extended area of auscultation, and abnormal breath sounds (i.e., crackles, wheezes). however, the thick chest wall of horses makes auscultation an insensitive indicator of pulmonary disease, with abnormal findings obtained in <50% of horses with severe ea (88) . strict management changes or medical therapy will results in rapid improvement in clinical signs however, if exposure to triggering factors is not addressed improvement will be short lived or incomplete (3, 15) . this form of mild respiratory disease is mainly subclinical with horses showing non-specific signs such as intermittent coughing and poor performance (3) . however, mild asthma should not be ruled out in horses that do not cough because coughing is reported in only 38% of horses with mild asthma (89) . coughing is associated with increased bal neutrophils (56) . poor performance and reduced willingness to perform are associated with increased tracheal mucus scores in racehorses and show-horses, respectively (72, 90) . in racehorses, poor performance has been associated with increased neutrophils and mast cells in bal fluid (44) . there is an association between nasal discharge and increased tracheal mucus in racehorses (49) . however, the association between tracheal mucus and bal cytology has not been reported yet. the term "remodeling" defines a process resulting in a tissue that is structurally and architecturally altered compared to its healthy counterpart. in asthma, structural alterations are represented by quantitative or qualitative changes of the bronchial wall components or their surrounding tissues, whilst architectural alterations refer to the skewed relationships among such structures. airway remodeling has been studied only in horses affected by severe ea. an increased expression of metalloproteinases and their tissue inhibitors has been recently reported in a group of horses with mild respiratory signs and bal cytology compatible with mild ea (91) . however, the possibility that the horses studied were horses with severe ea in remission of the disease was not excluded. almost all airway components undergo remodeling in severe ea, both in peripheral (diameter < 2 mm) and central airways. the airway smooth muscle mass as well as collagen and elastic fiber deposition are increased in the lamina propria of peripheral airways during severe ea remission compared to healthy airways (92, 93) . mucostasis, mucus cell hyperplasia, peribronchiolar metaplasia, and interstitial fibrosis are more frequently detected in horses with severe ea in remission compared to controls (94) . however, histomorphometric techniques revealed no differences in the number of mucus cells per mm of lamina reticularis or in the volume of stored mucosubstance in bronchial epithelial cells (95) . central airway remodeling during disease remission is less pronounced compared to what is observed peripherally. whether airway submucosal structures are significantly altered during severe ea remission compared to control remain to be established (79, 96, 97) . functionally, severe ea remission is associated with a normal lung function in spite of significant structural alterations of the airways. in these conditions, the respiratory resistance correlates with the amount of collagen within the lamina propria of peripheral airways (93) , indicating that, in the absence of bronchospasm, peripheral airway stiffness is the major determinant of respiratory resistance in asthmatic horses. the functional implications of peripheral remodeling become more important during disease exacerbations, when most of the changes are further accentuated and the mechanics of breathing are altered (73, 94) . there is no doubt that the major determinant of airway obstruction during severe ea exacerbations is smooth muscle contraction and that central airways play a major role (98) . by definition, the force produced by a muscle is proportional to its cross-sectional area. given the increased smooth muscle mass (and cross-sectional area) during severe ea exacerbations (79) , asthmatic muscle is "stronger" and able to contract the thickened lamina propria observed in severe ea, further reducing the airway lumen. increased mucus secretions into the airway lumen also contribute to airway occlusion (99) . these same mechanisms operate in peripheral airways, where the effects on lung function are somewhat blunted by the fact that their overall contribution to pulmonary resistance is low, due to their large cumulative cross-sectional area (100) . at this level, the more relevant functional effects of remodeling are the loss of lung elasticity and airway-parenchymal tethering. adequate small airway patency is guaranteed by their intimal connection to the lung parenchyma by elastic and connective fibers. when the lung inflates during inspiration, small airways are stretched and passively dilate. remodeling of elastic fibers and of the extracellular matrix within and around the airways and in the alveolar septa alters this mechanism, preventing the smallest airways from remaining open (101) . the effect is even worse during expiration, when the lungs physiologically recoil and the airway diameter physiologically narrows. with a significantly impaired expiratory airflow, part of the air that reaches the alveoli remains trapped. this leads horses with severe ea in exacerbation to breath at increasing lung volumes [functional residual capacity (102) ] in the attempt to maintain airway patency, which causes lung hyperinflation and enlarged fields of thoracic auscultation (103) . anecdotal evidence to date has suggested that, although bal sampling is widely accepted elsewhere as the diagnostic tool of choice for cytological assessment of equine lower airways, tracheal endoscopy and tracheal wash-based diagnostics have remained the mainstay of routine clinical lower airway investigations in british thoroughbred racehorses in training. given the emphasis on bal in research, this would present a considerable challenge to furthering evidence-based respiratory medicine in this important equine population. in a recent study we investigated british racing veterinarians' rationales for current practices, and the challenges they face in relation to diagnosing and managing racehorse airway inflammation (104) . qualitative data were gathered through semi-structured focus group discussions designed to capture current practices and opinions relating to the diagnosis and treatment of lower airway inflammation, as well as familiarity with and views on the most recent acvim consensus statement (3), in which the term "mild-moderate equine asthma" was recommended. four british veterinary practices, two primarily serving the flat racing community and two primarily serving the national hunt (jump racing) community, in different geographical regions of england, were purposively selected to participate. focus group discussions were conducted at the practice premises, moderated by one of the authors (tk), an experienced qualitative researcher who is not a veterinarian. discussions were audio-recorded and transcribed verbatim, and transcripts were analyzed using an inductive, thematic analysis. in total, 25 participants contributed to the focus group discussions (number per group ranged from 3 to11). all were veterinarians (experience ranging from recent graduate to senior partner), with the exception of one laboratory team member and one veterinary student, and five were women. discussions lasted between 46 and 74 min. three key themes were developed through analysis of focus group data: (i) an over-arching theme of serving the racing industry within which two further themes (ii) disregarding of the consensus and (iii) the pragmatic clinician were nested. (i) serving the racing industry: this was a key driver of clinical approaches to racehorse respiratory health, which were strongly trainer-influenced in particular. the trainer selects horses for endoscopic respiratory assessment, often because of training and racing schedules rather than any clinical signs, and the approach to investigation and treatment is strongly influenced by trainer expectations. this varies with trainer personality, experience and training methods, as well as stage of the racing season, signalment of the affected animal and general health on the yard, and is in turn driven by commercial pressures of the racing industry. (ii) disregard of the consensus: the unanimous view across all four groups was that the condition defined as mildmoderate ea by current concensus (3) is largely not seen in british racehorses which, in the participants' considerable collective experience, are affected predominantly with excess endoscopically-visible tracheal mucus largely attributed to bacterial infections. it was also considered unfeasible to fulfill two key aspects of the consensus case definition: waiting for chronicity of clinical signs (>3 weeks duration), and performing bal sampling. neither of these would be acceptable to trainers, according to participants, and participants themselves were not convinced of the extra value of bal sampling. the consensus statement was therefore seen as having been developed for outsiders, by outsiders without sufficient understanding of culture and practices on british racing yards. (iii) the pragmatic clinician: participants shared a strong professional identity as pragmatic clinicians often required to base clinical decision-making on direct personal or collective experience, rather than on research-based or laboratory evidence. cytological examinations of tracheal wash samples were defended as valuable when interpreted sequentially and combined with knowledge of the history and idiosyncracies of the individual horse and yard. although this approach was generally viewed positively as flexible and individualized, participants did also express some frustration with the sometimes unsatisfactory jigsaw of diagnostic information available to them, particularly in relation to discrepancies between clinical and laboratory findings. our work has highlighted a lack of alignment between clinical practice on british racing yards and international consensus on diagnosing lower airway inflammation, which constitutes a barrier to furthering development of a contextually-relevant evidence-base for this population. equine clinicians elsewhere may find themselves in disagreement with some of the opinions expressed, or practices described, by our study participants. however, these investigations were designed to understand the experiences and rationales of clinicians in the specific context of british racing practice. the strength and consistency of views expressed support the anecdotal evidence that, in this context, tracheal endoscopy and wash sampling are widely regarded as the best available means of providing the non-invasive monitoring of respiratory health expected by trainers and used to inform training-and racing-related decisions. it would be interesting to determine whether similar approaches are being taken elsewhere, particularly in populations of yearling and 2 year old thoroughbred racehorses in training. given the considerable resistance to bal sampling in british racing, development of new tracheal-based or other minimally-invasive diagnostics, including appropriate biomarkers and suitably sensitive, portable lung function tests, would be valuable. furthermore, our participants' views that mild-moderate ea as defined by current consensus is largely not seen in british racehorses suggest that research furthering our understanding of the etiology and pathogenesis of airway inflammation in this equine population is still required. the respiratory system is an interface between the outer environment and the inner body. lower airways have historically been seen as a sterile milieu, thanks to the anatomical configuration, local surface immunity and mucus production and clearance systems (105) . however, with the development of high sensitivity and high throughput technologies, the microbiota of the respiratory system has been described in healthy subjects in many species, including horses (106, 107) . further investigation of the relationship between infectious agents, lower respiratory tract microbiota and the development of mild ea is warranted. we and others have reported descriptive results about the microbiota of horses with mild ea (107, 108), but the causality between bacterial flora and the disease is far from being understood. studies on the microbiome use dna extraction followed by high throughput amplification and sequencing of the 16s amplicon (109) . the sequences are then filtered and aligned against a taxonomy database to identify and organize operational taxonomic units (otus). descriptive analysis of the phyla, otus and bacterial species are then performed, followed by statistical analysis at the community level (within and between samples; alpha and beta diversity, respectively) and at the individual level (otu diversity analysis). statistical analysis can be used to compare between groups: healthy horses vs. those with mild asthma, upper vs. lower respiratory tract (109) . the lower airways have a decreased richness (alpha diversity, corresponding to the number and proportion of each bacterial species) when compared to the upper airways in healthy horses (107) . however, a very large majority of the same otus are present in both the upper and the lower airways, showing an overlap and some continuity in the bacterial population between the two anatomical environments in healthy horses. furthermore, treatment with corticosteroids did not affect the composition of the bacterial flora in the upper airways (107) . the role of the upper airways microbiota in mild ea is unknown, but two studies did not find any difference in beta diversity of the upper airways between healthy horses and those with mild ea (107, 108) . the relationship between bacteria and the lower respiratory tract of the equine host seems to be dynamic. as an example, a change in the environmental respirable particulates has an effect on the lower respiratory tract flora in horses. furthermore, treatment with systemic or nebulized dexamethasone induces some changes in the microbiota of the lower respiratory tract in both healthy and mild asthma horses (107) . systemic dexamethasone administration decreased the evenness of the flora and increased the abundance of 9 otus. there is an agreement between studies that the lower airways microbiota between healthy and mild ea horses are clearly different (107, 108) . interestingly, streptococcus is one of the 6 otus which differed with disease status, and was the otu with the greatest increase in relative abundance in mild ea. the effect of the environment on the composition of the lower airways' microbiota is also a common finding between studies (107, 108). however, a study found that treatment with corticosteroids had more effect on the composition of the bacterial flora than changes in the environment (107) . the microbiome studies are recent in equine medicine and are limited to being descriptive. the challenge for the scientific community will be to answer the causality dilemma of the chicken or the egg regarding the role of the airway microbiota in mild ea. asthma development in humans is most probably caused by the interaction of multiple factors, including genetics, allergen exposure, microbiome and invading pathogens. human rhinovirus, human respiratory syncytial virus, human metapneumovirus, human parainfluenza virus, human enterovirus and human coronavirus are strongly associated with asthma exacerbations (110) . the association between human rhinovirus-induced wheezing and the development of childhood asthma/wheezing has been confirmed in a recent meta-analysis (111) . the risk for asthma by age 6 years has been shown to increase (odds ratio 9.8) if children have been wheezing with rhinovirus during the first 3 years of life (112) . further, many prospective long-term follow-up studies have shown that human respiratory syncytial virus-induced bronchiolitis is associated with later development of asthma (113) . however, the pathogenic role of respiratory viruses as triggers for the development and/or exacerbation in asthmatic human patients has not been fully characterized. changes in the immune response to viral infections in genetically predisposed individuals are very likely to be the main factor involved in the association between viral infection and asthma (114) . the pathogenesis of ea remains incompletely defined. however, similar to human asthma, a multifactorial process is suspected. conditions associated with exercise, feeding and housing practices, location, seasonality, infection of the upper and lower airways and genetic influences have been linked to ea (7, 8, 115, 116) and bacterial (streptococcus equi subspecies zooepidemicus, actinobacillus spp., pasteurella spp.) etiological agents have been linked to mild to moderate ea (49, 117) . it remains to be determined if these agents are triggers for the development of ea or are secondary colonizers of already compromised airways. viral respiratory infections are one of the most common health problems in horses throughout the world ( table 1 ). these infections are often self-limiting and a full recovery can be expected in most horses. young performance horses, such as racing horses, have an increased risk of respiratory viral infections. this relates to age susceptibility, commingling, stress and suboptimal biosecurity protocols (119, 122, 123) . amongst respiratory viruses, only eiv and ervs have an affinity to the lower respiratory tract, leading to airway hyperresponsiveness. clinical signs associated with eiv are usually more severe than those seen with mild to moderate ea. further, no association has been determined between mild to moderate ea and infections with eiv, ehv-1 and ehv-4 (118, 120, 121) . this is in sharp contrast to the detection of ervs (erav and erbv), known to cause subclinical or mild clinical disease (118, 120, 121) . in a recent study, horses with mild to moderate ea were significantly more likely to have a positive titer as well as higher log-transformed titers to erav when compared to control horses (120) . in another study, the detection of erbv by qpcr was significantly associated with coughing in standardbred racehorses in training (118) . subclinical respiratory viral activity in horses with poor performance has been associated with ehv-2 and ehv-5 infection (118, 120) . in a recent study, the detection of ehv-2 by qpcr in nasal secretions was significantly associated with mild to moderate ea (120) . in another study, the detection of ehv-2 by qpcr was significantly associated with coughing and excessive tracheal mucus in standardbred racing horses (118) . these results are in sharp contrast to two recent studies performed on 66 swedish standardbred trotters, which were followed for 13 months via qpcr analysis of nasal secretions and serology (121, 124) . despite occurrence of poor performance and subclinical viral activity in the swedish standardbred trotters, the authors were unable to detect associations between ehv-2/-5 and clinical respiratory disease and/or poor performance. these conflicting results reflect the ongoing challenges in establishing causality between mild to moderate ea and gamma herpesviruses, known to be ubiquitous in both healthy and clinically affected horses. in conclusion, associations between specific viruses detected via antigen or antibody detection and clinical signs of mild to moderate ea may suggest that viruses may play a role in triggering or exacerbating asthma. however, because some viruses are ubiquitous both in healthy and clinically affected horses or are often associated with subclinical disease, establishing causality is challenging and in need for further research. a growing body of research demonstrates the link between organic dust exposure and ea. introduction of horses to high dust environments not only induces profound bal fluid neutrophilia and airway obstruction in horses susceptible to severe asthma, but also significant neutrophilic airway inflammation in previously healthy horses (125, 126) . outside of the experimental exposure setting, higher dust exposure has also been associated with increased risk of tracheal mucus accumulation in racing thoroughbreds (127) . barn dust is a complex mixture, rich in potential sources of allergens as well as immunomodulators such as endotoxin and β-glucan (128, 129) . in addition to individual horse factors such as age and susceptibility, this complexity may partially account for the heterogeneity of asthma phenotypes. respirable particulates, nominally <4 µm in diameter, have been linked to eosinophilic inflammation in young thoroughbreds entering race training (130) and neutrophilic inflammation in actively racing thoroughbreds (44) . increasing respirable endotoxin exposures have been shown to provide an apparent protective effect against neutrophilic inflammation at low doses (44) , while high doses of endotoxin augment the inflammatory response to particulates (131) , suggesting a non-linear response to inhaled endotoxin in the horse. mast cell inflammation has been found to be common in both young, untrained thoroughbreds (130) and those that are actively racing (44) , but unrelated to respirable dust or respirable endotoxin exposures. instead, bal mast cell proportions are related with respirable β-glucan exposures. conversely, inhalable dust exposures have not been found to affect bal inflammatory cell proportions. thus, inhalable particulates, those nominally <100 µm in diameter, appear to be less relevant than respirable particulates in equine respiratory health. setting exposure recommendations will require better understanding of the dose-response to inhaled non-infectious agents across wider ranges of age, breed, and discipline through study designs that include both exposure and respiratory health outcome measures and utilize appropriate statistical tools to relate them. advanced characterization of respiratory health, such as investigation of alveolar macrophage function and bal fluid cytokine profiles, coupled with extensive exposure assessment is likely to offer valuable insight into ea pathophysiology and identify new targets for intervention. miniaturization of optical particle counters has rendered realtime breathing zone exposure measurements on the horse both affordable and technically feasible. finally, the equine airway is arguably most susceptible to particle penetration during athletic exertion due to large tidal volumes and extension of the head and neck, yet the exposures that horses sustain during exercise are largely unexplored. such measures of exposure are complicated by the air speed and turbulence generated at the breathing zone during such activity and will require specialized sampling strategies. neutrophils are key actors in host defense, migrating toward sites of inflammation and infection, where they act as early responder cells toward external insults (132). however, neutrophils can also mediate tissue damage in various noninfectious inflammatory processes. airway inflammation is one of the primary characteristics of an asthma-affected horse's response to aeroallergens with neutrophilic bronchiolitis being the main lesion (133) . the mechanism by which airway inflammation develops in ea is a multifaceted and dynamic process. current knowledge suggests that the inflammatory component of this disease results from a combination of both the innate and adaptive immune responses (134) . generally, airway inflammation involves activation of pathogen-specific inflammatory cells, modulation of gene transcription factors, and release of inflammatory mediators (135) . within the airways, neutrophils likely contribute to bronchoconstriction, mucus hypersecretion, and pulmonary remodeling by release of proinflammatory mediators, including the cytokines interleukins 8 and 17, neutrophil elastase, reactive oxygen species, and neutrophil extracellular traps (nets) (118) (119) (120) (121) . oxidative stress in horses with asthma is evidenced by the increase in elastase and decrease in ascorbic acid concentrations in balf associated with neutrophilia secondary to exposure to organic dust (136) . the pathogenic role of nets has been described for many infectious and non-infectious human diseases, including respiratory cases with a massive influx of neutrophils into the airways (137) . excessive net release is particularly deleterious in lung diseases because nets can expand easily in the pulmonary alveolar space and cause lung injury. furthermore, nets and their associated molecules can directly induce epithelial and endothelial cell death (138) . the mechanisms that regulate neutrophil functions in tissues are complex and incompletely understood and must be regulated with exquisite precision and timing. timely apoptosis of neutrophils is central to the resolution of inflammation; dying neutrophils are known to stimulate their own efferocytosis, inducing macrophagic transition from a pro-inflammatory to an anti-inflammatory profile (139) . thus, dysregulated apoptosis and mechanisms of inflammation may play an important role in the pathogenesis of ea. the persistence of apoptosis-resistant neutrophils in the airways of horses with asthma may also impede timely neutrophil clearance and delay the resolution of airway inflammation. the discovery and development of compounds that can help regulate ros, net formation, cytokine release and clearance of airway neutrophils would be highly beneficial in the design of therapies for ea (133) . asthma is a highly heterogeneous condition of the lung. akin to the lining of the gastrointestinal tract, the lining of the airways is also in contact with external substances throughout life. ingested substances generally pass through the gastrointestinal tract unidirectionally, and a careful balance between processing of digested food materials, nutrient absorption and limiting immunoreactivity is maintained during homeostasis, with wellknown severe consequences of deviations in this balance. the airways function differently in that only gaseous substances normally pass into the distal alveoli and are exhaled in the reverse direction. inhaled particulates also have to be expelled in reverse direction toward the nasopharynx by largely mechanical means or taken up by alveolar macrophages for disposition with minimal inflammatory evocation (140) . hence, a complex and selective epithelial barrier with differing functions characterizes both organs. the epithelium lining the airways has unique composition, morphology and function throughout the lung, and is intimately connected to subepithelial structures such as the basement membrane, mucous glands, smooth muscle, fibroblasts, endothelium and immune cells. the epithelium forms a barrier between inhaled components and the subepithelial constituents, and also has to balance efficient transfer of gases with controlled reactivity to non-gaseous components. while the lesions of severe ea manifest predominantly with inflammation, smooth muscle hyperplasia and fibrosis of the peripheral airways and surrounding tissues, the larger airways are exposed to the same inhaled substances and also have morphological, functional and molecular changes (141) . research initially focused on the role of club cell secretory protein (ccsp), a member of the secretoglobin family produced by non-ciliated epithelial cells concentrated within the epithelium at the transition from bronchi to bronchioles. club cells are recognized as epithelial progenitor cells that can differentiate into ciliated and other specialized cells of the airway epithelium, participate in reduction of reactive oxygen toxicants through cytochrome enzymes, and their hydrophobic secreted protein inactivates a range of inflammatory mediators. horses with severe asthma have fewer club cells and lower concentration of ccsp in airway fluids, which may be a function of chronic inflammation resulting in reduced regenerative capacity of the airway epithelium (142) . unique relative to other mammals, equids have two expressed ccsp genes that differ in 12 of 70 amino acids, and also in their interaction with hydrophobic molecules (143) . recombinant eccsp increased neutrophil oxidative burst, phagocytosis and extracellular trap formation, lending support to the notion that loss of club cells has deleterious effects on lung health (144) . whole transcriptomic changes in endobronchial epithelial biopsies from sites from 5th to 12th generation bronchi were investigated with next-generation sequencing. each horse served as its own control to identify changes in gene expression associated with an inhaled challenge since inter-individual variability exceeded changes attributable to the challenge. a bioinformatics pipeline including quality control measures to account for duplicates, variable sequencing depth and dispersion was implemented, results were mapped to the equine genome, and predicted proteins were procured with a combination of software and manual approaches to assign appropriate ensemble ids for analyzing interactions. an overall conservative analytic approach yielded 111 genes differentially expressed in horses with severe asthma as a result of a challenge, with the majority up-regulated (145) . not surprisingly, many up-regulated genes pertained to inflammatory mediators and effectors and were well-known members of protein interacting networks. however, somewhat more surprisingly, genes with altered expression also concerned more broadly epithelial cell formation and maintenance, and the circadian rhythm, suggesting that multiple cell properties are affected in exacerbated ea at the transcriptomic level. subsequent analysis of enriched gene sets in asthmatic horses further highlighted the importance of cell cycle regulation and repair pathways (146) . transcriptomic studies of this nature yield a great deal of information, which requires subsequent confirmation regarding cell specificity, correlation with protein expression and function, and extension to a more robust number of affected and unaffected individuals. albeit, there is strong evidence to indicate that the bronchial epithelium is profoundly altered during exacerbation of severe ea, and this insight offers new venues for investigating the role of specific proteins and for potential therapeutic targets (147, 148) . the entire spectrum of ea is influenced by interactions between the environment and genetics, but almost all research in this field has focused on the severe clinical phenotype. while no specific genetic risk factors have been reported for mild to moderate forms of ea, genetic susceptibility to certain bacterial lower airway infections could potentially be relevant (149) . furthermore, mild but persistent respiratory signs such as occasional coughing and nasal discharge may represent early phenotypic indicators for an increased risk to later development of severe ea (88) . this suggests that the genetics of milder forms of ea may be worth investigating in longitudinal studies. severe ea has been shown to be partly heritable in several breeds and has been the focus of genetic research involving family and epidemiological studies, whole-genome scans and investigation of candidate genes. reports of marked familial aggregation of severe ea date back 70 years (150) . parent, age, and stable environment have significant additive effects that increase the risk for developing severe ea as defined by a history of persistent frequent coughing and/or increased breathing effort (43, 151) . offspring of affected sires have a more than 4-fold increased risk for developing severe ea (50) . whole genome scans in high-prevalence families indicate two chromosome regions with a genome-wide significant association with severe ea (152) . importantly, the associations differ between the families: region eca13 in one family and eca15 in another family. further association and gene expression studies indicate interleukin 4 receptor as a candidate gene in a subset of ea-affected horses. molecular pathway analyses of genomic and proteomic data showed interactions between interleukin 4 receptor and socs5 upstream of an important molecular cascade involving nuclear factor κb (153) . so far, no causal genetic variant has been identified in interleukin 4. an allelic case-control genome-wide association study in the general warmblood population revealed another region on chromosome 13. the best-associated marker was located in the protein-coding gene txndc11, which may be involved in regulating hydrogen peroxide production in the respiratory tract epithelium as well as in the expression of muc5ac mucin (154) . no genomic copy number variations were found to be associated with severe ea (155) . integrative analyses combining gwas, differential expression (de), and expression quantitative trait loci (eqtls) were not able to uncover causative genetic variants that contribute to severe ea through gene expression regulation. however, results showed interesting similarities to human asthma with disease-associated genetic variants in clec16a that also regulate gene expression of dexi (156) . furthermore, global gene expression studies of mrna and mirna levels in these high-prevalence families have shown impaired cell cycle regulation and cd4 + t cell differentiation into th2/th17 cells, respectively, in severe ea (157, 158) . at present, none of these associations are useful genetic markers in the general population. most of the findings pertain to warmbloods only, or even only to certain lines and families. the fact that the chromosomal regions and the mode of inheritance do not agree between families indicates genetic heterogeneity for severe ea: depending on the genetic make-up of affected horses, different genes confer the susceptibility for the disease. it appears that the genetic basis of severe ea is robust, but remarkably complex. polygenic complexity, potentially with a larger number of genes that each may only contribute <10% to the total genetic effects, may make it difficult to discover causative variants. nevertheless, the genetics of severe ea has revealed interesting links between severe ea, allergic skin diseases and susceptibility to intestinal parasites (159, 160) . according to the national institutes of health, a biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a therapeutic intervention (161) . in practice, biomarkers include tools and technologies that can help in understanding the prediction, cause, diagnosis, progression, and outcome of treatment of a disease. although bal cytology has been recognized as the gold standard for diagnosing respiratory diseases such as ea, currently, sensitive and specific biomarker tests useful in routine laboratory diagnostics are being sought. a simple biomarker capable of distinguishing between animals with lower airway infections and those with non-infectious airway inflammation would be helpful. although the diagnosis of severe cases of ea is relatively easy, it is difficult to diagnose cases in remission or horses with a mild form of the disease. ideally, molecular biomarkers should reflect a feature of relevant pathological processes. in addition, biomarker assessment should be easy, low-cost, technically accurate, repeatable and have an acceptable risk. therefore, a measurement from easily obtainable body fluids or tissues is preferred, such as blood, urine, exhaled breath condensates, as opposed to bal, transbronchial biopsy or lung biopsy (162) . several biomarkers are present or altered in the airways or circulation of horses with asthma. inflammatory markers such as acute phase proteins and cytokines have been studied as markers of systemic inflammation. however, the available literature on markers of systemic inflammation in horses with severe ea is not well-characterized and controversial (116, (163) (164) (165) . apart from reports on differential expression of cytokines during the course of severe ea, only a few acute phase proteins have been investigated. haptoglobin is a suitable marker of both acute and chronic systemic inflammations, whereas high concentrations of serum amyloid a indicate acute inflammation. one study found no difference in the acute phase protein levels (serum amyloid a, c-reactive protein, haptoglobin) between horses with mild ea and those with other causes of exercise intolerance (166) . another study found elevated haptoglobin concentration in horses with mild ea (167) . surfactant protein d is a large multimeric collagenous glycoprotein produced mainly by type ii epithelial cells in the lungs and is also detectable in the serum. serum surfactant protein d has been identified as a potential systemic biomarker for some pulmonary diseases in humans, such as idiopathic interstitial fibrosis and acute respiratory distress syndrome. elevated serum levels of surfactant protein d have been detected in horses with mild ea (167, 168) . circulating immune complexes are proteins that result from an immune response against an organism or antigens of various origin. in humans, circulating immune complexes are detectable in a variety of systemic disorders such as autoimmune diseases, allergies and infectious diseases (169) . high levels of circulating immune complexes have been reported in horses with severe ea (165) . another study found circulating immune complexes useful for differentiating healthy vs. severe ea, and monitoring corticosteroids therapy (170) . the main group of enzymes responsible for collagen and other protein degradation in the extracellular matrix are matrix metalloproteinases (mmps), while tissue inhibitors of metalloproteinases (timps) lead to fibrosis formation. collagen is the main structural component of connective tissue and its degradation is a very important process in development, morphogenesis, tissue remodeling, and repair. in horses with severe ea, mmps, timps, and their ratios are useful in the evaluation of the severity of respiratory disease and in identifying subclinical cases (91) . furthermore, mmp-2, mmp-9, timp-1, and timp-2 are significantly decreased after therapy with inhaled glucocorticoid therapy (171) . exhaled breath condensate is a promising source of biomarkers of lung disease in humans. exhaled breath condensate hydrogen peroxide concentration and ph were higher in horses with mild ea, vs. controls (69) . additionally, both hydrogen peroxide and ph had a positive association with bal neutrophil percentage, while leukotriene b-4 demonstrated a positive association with bal eosinophil percentage. another study characterized the metabolomic profile of tracheal wash and exhaled breath condensate in healthy horses and those with severe ea (172) . higher concentrations of histamine and oxidant agents, such as glutamate, valine, leucine, and isoleucine, as well as lower levels of ascorbate, methylamine, dimethylamine and o-phosphocholine, were found in the group of severe ea, compared to healthy controls. many biomarkers of ea have been studied-some are already being used in clinical settings, while others require further studies. however, history, clinical evaluation, and bal still constitute the basis for diagnosis of ea. immune response has mainly been investigated in the airways of horses with severe ea and more recently mild-moderate ea, while still representing one of the futures direction for research stated in the 2016 acvim consensus statement (3). such characterization has mostly been performed through relative mrna expression of various cytokines in bal fluid, while several publications also reported protein concentration in bal fluid for few cytokines. various methodologies for cytokine mrna expressions have been published (e.g., sybr green or taqman technology, design of primers and probes, relative quantitation, etc.). variation in methodologies may ultimately prevent objective comparisons between reports, as well as the implementation of prospective, multicenter studies. such diversity should however not be considered as a scientific weakness, and methodological homogenization among the various research groups neither represents a prerequisite nor a final goal to be reached. however, evaluation of the methodological performances of different research laboratories might represent a relevant goal. in this manner, implementation of inter-laboratory comparisons based on international standards (e.g., iso/iec 17043 and iso 13528) warrants further consideration. let's consider for example mrna expression of two different cytokines by pcr in balf samples. as a first and informal procedure, a simple "blind test" could be performed among up to four different teams. in this procedure, the "reference lab" will provide the three other labs with aliquots of the same sample(s). each team will evaluate mrna expression for these two cytokines based on their own procedures, and comparisons of the results obtained and agreement among the teams can be evaluated. this "blind test" might then be repeated on a regular basis, systematically alternating the "reference lab" within the group. in the end, the procedure will provide an objective evaluation of the results diversity among the teams, but clearly will not determine whether several teams are more efficient than others for these specific analyses. a second and more structured procedure would require the specific synthesis of standards (mrna for two different cytokines in this case), and the development/validation of relevant conditioning and conservation procedures. a similar group of four different labs would first evaluate their ability to detect and quantify predetermined amounts of analytical standards (evaluation of the detection, not of the sample extraction, etc.). this step is a necessary preliminary, in the absence of reference methods. a panel of at least 10 samples (previously calibrated with standards) would then be tested, including several identical ones (for repeatability) and submitted to the group (including a "self-shipment") for testing and further statistical analyses (agreement, etc.). once the methodological performance of the lab is considered acceptable for this panel, the procedure might then be repeated with another two cytokines and so on. in the end, the whole panel of standardized samples might allow the establishment of a labeling, accessible to any voluntary laboratory involved in equine asthma. mandatory considerations about such comparisons are that there is no trap, and this does not represent an overall examination of laboratories, but simple evaluations of procedures. all labs are expected to use their methodologies, whether or not the technologies are similar within the group. among others, samples conditioning, conservation, shipment and their associated costs will represent major issues to be considered, and this should be more broadly associated with virtuous initiatives such as the equine respiratory tissue biobank. several group discussions were conducted during the 2019 havemeyer equine asthma workshop to identify future research priorities. initial rotating small-group topic explorations (pathophysiology, risk-factors, diagnostic methods and phenotype definition) facilitated by members of the workshop organizing team, were followed by a final large group "roundtable" discussion of key directions for future ea research. the discussion was informed by data gathered directly from ∼30 participants (i.e., all who attended the final roundtable), who were invited to propose up to three short-or long-term, focused or "big picture, " research topics or ideas that they considered to be key future research directions. these data were submitted anonymously, during the workshop, as free-text on paper and loosely arranged into broad categories for further open discussion. following the workshop, in order to present an accessible, systematic and non-selective summary of the ideas proposed by participants, the free-text data were collated in microsoft excel for content analysis using an approach based on recommended methods for quasi-qualitative data (173, 174) . the text was transcribed verbatim and coded at two levels to categorize content into (i) broad topic areas (level 1) and (ii) specific subsets of these topics (level 2). all instances of each level 1 topic code were then exported into online software (worditout) to create a word cloud (figure 1) , in which the relative frequencies of occurrence of each topic are represented by font size. overall, 62 responses were received, each proposing between 1 and 3 research ideas, resulting in a total of 117 research ideas, which were organized into the 14 broad topic codes presented in the word cloud. some research ideas encompassed more than one topic and were identified with multiple codes to reflect this. frequencies of occurrence of each code ranged from n=28 for "diagnostics" to n = 1 for "genetics." specific proposed areas of interest in the dominant "diagnostics" category were the development of improved, non-invasive field diagnostics through the identification of suitable biomarkers, development of portable lung function tests, improved understanding of relative values of tracheal wash in comparison with bal cytology, or relationships between the two, and identification of gold standards for all of these diagnostic modalities. another key topic was phenotype distinction (21 occurrences)-in particular to clarify any distinction between mild and moderate ea, and to determine whether or not such a distinction is valuable in terms of differing pathophysiology, diagnostic indicators, therapeutics or prognosis. as with many of these proposed topics, phenotype distinction rests on the back of the category "diagnostics"-pointing out a self-identified weakness on the part of ea researchers that the goal of identifying the horse with asthma so mild that it does not present as respiratory disease per se, continues in many cases to elude us and underscores a collective pragmatism that there is little benefit in understanding the fine points if we cannot definitively identify the case in the first place. ideas relating to therapeutics (18 occurrences) included investigating the efficacy of different treatments including environmental management and any evidence for the value of antibiotics, as well as the development of optimal nebulized glucocorticoids, alternatives to corticosteroids, immunological treatments, respiratory probiotics, other novel therapeutics (e.g., marcks inhibitor peptide), and individualized treatments for different endotypes and phenotypes. suggestions relating to pathophysiology (17 occurrences) included furthering our understanding of the role of environmental pollutants, of when a physiological response becomes a pathological response and of factors influencing progression from mild to severe equine asthma. standardization (11 occurrences) referred in particular to the need to develop or agree on standardized diagnostic approaches, including in relation to bal collection techniques, laboratory processing and cytological methods and threshold values, context-specific reference ranges, development of a central repository of protocols and improved quality control protocols. a central repository of standard protocols was suggested. academic-clinical communication (9 occurrences) was recognized as an area for general improvement. related research suggestions included improving our understanding of the views and practices of field clinicians, as well as their perceptions of disease progression and treatment efficacy, particularly in regions outside the uk (to build on the kinnison and cardwell uk study) (104) . this would inform the enhancement of multidirectional communication between academia, referral and first opinion clinical practice, development of guidelines and apps for field practice and overall improved dialogue and engagement. better use of collaborative, epidemiological and longitudinal studies was suggested for many topics and included multicenter, cross-country collaborations, more use of the existing tissue bank and the initiation of a new equine asthma group. it is recognized that the ideas for research directions generated through this roundtable discussion at the end of a 3 day workshop are subject to biases and influences relating to the interests, priorities and perceptions of workshop participants. however, by using and describing a systematic method of representing the ideas proposed, we have aimed at least to be transparent in our reporting of this. further, longer-term, international discussion and exchange of views will be facilitated by one of the key outcomes of this workshop, which was the development of the new equine asthma group. the aim of this group is to offer a platform of information for veterinary practitioners and horse owners as well as a resource for researchers to collaborate and exchange ideas on the understanding of ea. it was suggested that this group could lead some initiatives in line with the proposed areas of interest described above. there are plans for this group to develop some guidelines for the diagnosis and treatment of equine asthma, including for example the standardization of diagnostic methods, as mentioned above. development of an equine asthma group website and other communication tools are now underway as an internationally collaborative initiative. the 2019 havemeyer equine asthma workshop has paved the way for a better understanding of this many-faceted disease by bringing together researchers and clinicians to identify both the needs of the equine industry for effective treatments and at the 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asthma evidence for transferrin allele as a host-level risk factor in naturally occurring equine respiratory disease: a preliminary study untersuchungen über die erblichkeit und das wesen des lungendampfes beim pferd [investigation into the nature and heritability of heaves in the horse sir frederick hobday memorial lecture. the genetic basis of some equine diseases a whole-genome scan for recurrent airway obstruction in warmblood sport horses indicates two positional candidate regions comparison of genomic and proteomic data in recurrent airway obstruction affected horses using ingenuity pathway analysis r a genome-wide association study for equine recurrent airway obstruction in european warmblood horses reveals a suggestive new quantitative trait locus on chromosome 13 analysis of genomic copy number variation in equine recurrent airway obstruction (heaves) eqtl discovery and their association with severe equine asthma in european warmblood horses differential expression of serum micrornas supports cd4+ t cell differentiation into th2/th17 cells in severe equine asthma impaired cell cycle regulation in a natural equine model of asthma multiple hypersensitivities including recurrent airway obstruction, insect bite hypersensitivity, and urticaria in 2 warmblood horse populations insect bite hypersensitivity in horses is associated with airway hyperreactivity biomarkers and surrogate endpoints: preferred definitions and conceptual framework molecular biomarkers in idiopathic pulmonary fibrosis heaves, an asthmalike disease of horses markers of systemic inflammation in horses with heaves circulating immune complexes and markers of systemic inflammation in rao-affected horses acute phase proteins in racehorses with inflammatory airway disease serum surfactant protein d and haptoglobin as potential biomarkers for inflammatory airway disease in horses tests for circulating immune complexes circulating immune complexes in horses with severe equine asthma metalloproteinases and their inhibitors are influenced by inhalative glucocorticoid therapy in combination with environmental dust reduction in equine recurrent airway obstruction metabolomics of tracheal wash samples and exhaled breath condensates in healthy horses and horses affected by equine asthma is there anything else you would like to tell us" -methodological issues in the use of free-text comments from postal surveys working with words: exploring textual analysis in medical education research the authors are grateful to gene pranzo, president of the havemeyer foundation, for his support of the 2019 workshop on equine asthma. we are also thankful to boehringer ingelheim animal health, haygain, nortev, trudell medical international, and zoetis for their support of travel grants for participants and workshop activities. the workshop was made possible thanks to the generous support of the dorothy havemeyer foundation, boehringer ingelheim, haygain, nortev, trudell medical and zoetis. key: cord-023713-daz2vokz authors: devereux, graham; matsui, elizabeth c.; burney, peter g.j. title: epidemiology of asthma and allergic airway diseases date: 2013-09-06 journal: middleton's allergy doi: 10.1016/b978-0-323-08593-9.00049-8 sha: doc_id: 23713 cord_uid: daz2vokz nan epidemiology is the study of the distribution of disease in populations. it is essential for assessing the spread and burden of disease. it is the appropriate method for understanding the cause and pathogenesis of disease. research into allergy has had a long history with many changes in direction, and the language that has been developed to describe what has been found has changed over time. this can lead to confusion. in this chapter, we use the term sensitization to indicate the production of immunoglobulin e (ige) antibodies in response to allergens. we use the term allergy to refer to the presence of one or more diseases associated with ige sensitization, the most common of which are asthma, eczema, and rhinitis. the term atopy was originally introduced to account for the observation that the main allergic diseases occurred in the same families and appeared to have a common origin. however, it is often used synonymously with the term allergy. test standards. good tests should possess reliability and validity. 1 a test is reliable if it always gives the same answer when applied under similar circumstances. validity implies that the result of the test coincides well with the true condition of the person being tested. validity has two components: sensitivity, which is the ability of the test to identify an existing condition, and specificity, which is the ability to identify as normal people who are free of the condition. measuring the validity of a test for a condition that is poorly defined, such as asthma, is a problem because it presupposes a gold standard test with which the proposed test can be compared. although validity in an absolute sense may always be contested, what is as important in epidemiologic studies is standardization, meaning that the test is identical wherever and by whomever it is administered. validity is essential to the measurement of absolute prevalence, but in many epidemiologic studies, we are as interested in relative prevalence, such as relative prevalence between age groups, countries, or districts, or differences between people exposed to various environmental or genetic risks. standardization is essential for this, and considerable effort has been made to provide standardized measures, particularly for international studies. tests of sensitization. sensitization can be assessed directly by determining the presence of specific ige to allergens in serum. in many places, mites, grass, and cat allergens are among the most common allergens, and most sensitized individuals can be identified by testing for relatively few allergens. 2, 3 some test kits can identify a mixture of several allergens. in the past, they have been used to test for the occurrence of sensitization, and this may be cost-effective, but it leaves unclear which allergens are » epidemiology is the study of the distribution of disease and, by extension, its causes and consequences, mostly in general populations. » the rates of allergic sensitization and allergic diseases have been increasing, although the increase in prevalence of allergic diseases has slowed among children. » allergic disease is less common in rural parts of low-income countries, although allergic sensitization can be common in these areas. » there has been very little success in explaining the increased prevalence of allergic disease, although it has been linked to urbanization. the great changes observed in prevalence and distribution strongly suggest a major role for the environment. » factors that initiate allergy and allergic diseases should be differentiated from factors that exacerbate them after they have been established. » allergies are affected by environmental factors, including diet; exposure to a normal, diverse microflora; infections; exposure to air pollutants; and occupational exposures. » allergy is not associated with higher mortality rates or loss of lung function, but asthma is associated with both. » outcomes for asthma can be considerably improved by good management. test of whether someone had asthma. what had been provided was, in his view, no more than a description. second, he pointed out that most diseases were concepts rather than "things" and that their definitions were therefore bound to be contested. since then, there have been many attempts to define asthma (table 48-1) , although most have paid little attention to the issues raised by this led to more complicated descriptions but not to any greater clarity. some have introduced additional assumptions about mechanisms and causes. despite these strictures, asthma has been an enduring and trusted concept clinically, but a separate question remains about how the condition can be identified in epidemiologic studies. there are effectively three broad methods of identifying asthma in surveys: questionnaires asking about diagnosed asthma, questions about the symptoms of asthma, and physiologic tests of airway responsiveness. questions asking whether someone has asthma, often qualified by asking whether a doctor has ever confirmed the diagnosis, are common. they are regarded as highly specific, meaning that there are few people who answer this question in the affirmative but do not have asthma, but there are many people who may be defined as asthmatic who deny that they have the condition. the worst characteristic of these questions is the lack of standardization. the answers to the questions depend on local medical practice and the terms used by health professionals when talking to patients. variations in the use of the term asthma likely have influenced estimates of time trends and observed differences in mortality between countries. over the past 50 years, the prevalence of people with asthma has increased markedly, and there has been much debate about whether this can be explained by differences in the way the term has been used. this possibility is supported by the encouragement given to pediatricians, particularly from the 1980s onward, to diagnose all wheezy children as asthmatic because this would encourage the use of medication and was shown to enhance the quality of life of children regardless of the exact diagnosis. 15 in the 1980s, kelson and heller sent scenarios of patients who had died to a representative group of physicians signing death certificates in several european countries. 16 one scenario (box 48-1) described a person who had some symptoms of asthma but many of the features of chronic obstructive lung disease. figure 48 -1 shows the relationship between the proportion of the physicians in each country ascribing this death to asthma and the national mortality rate for asthma. 17 there is a strong suggestion that the way doctors in each country view such marginal cases may be influencing the national mortality data. whether this is still the case is uncertain. since then, there has been a major increase in international consensus documents. asking about symptoms rather than diagnosed disease avoids some of these problems, and efforts have been made to find suitable questionnaires and to standardize them across countries. the most commonly used questionnaire for children is that developed for the international study of asthma and allergies in childhood (isaac). 18 for adults, the questionnaire developed for the international union against tuberculosis and lung disease (iuatld) 19, 20 was subsequently adapted for use in the european community respiratory health survey (ecrhs) 21 and was further adapted for the world health survey. 22 responsible for symptoms. microchip technology and the development of recombinant and purified allergens have enabled testing for several allergens simultaneously and allowed more precise identification of the relevant allergens. the technology remains expensive and is not widely used in epidemiologic studies. an alternative method of identifying sensitized individuals is to undertake skin-prick tests. they do not require a laboratory and do not involve taking blood. the technique involves introducing a small amount of allergen under the outer layers of the skin using a needle or lancet and reading the size of the wheal that appears in the 15 minutes after the test is applied. 4 this is compared with the wheal produced by a control solution (usually the diluent in which the allergens have been dissolved) and with a positive (usually histamine) control that tests whether the skin is able to respond to the release of mediators that the allergen induces. skin tests have more operatordependent variation than serologic tests, because they are influenced in part by the technique of the technician, but they typically are cheap and provide an immediate answer, which can be more satisfactory for the patient or participant. the criterion for a positive test result varies according to the purpose of testing. using any test greater than the diluent control is more repeatable and less prone to observational error and reflects well the presence of allergen-specific ige. 5 however, in a clinical context, small wheals are rarely associated with allergic disease that can be ascribed to that allergen, and in a clinical context, wheals less than 3 mm in diameter usually are discounted as irrelevant. defining the prevalence of sensitization in a population depends to some extent on which allergens are tested. in western europe and the united states, there is little change in overall prevalence after five or six allergens have been included in the panel. 2, 3 although less is known about other countries, mite allergens appear to be widespread in tropical and subtropical areas. for the most part, skin tests and serologic tests for sensitization give similar results when technical failures and differences between allergens are taken into account. however, they are not equivalent. skin tests also depend on the ability of mast cells to degranulate and for the skin to respond to histamine. when skin test results are negative, clinical allergy is unlikely even in the presence of specific ige. 3 modern attempts to define asthma start with the ciba guest symposium of 1958 on the terminology, definitions, and classification of chronic pulmonary emphysema and related conditions. 6 the symposium defined asthma as "the condition of subjects with widespread narrowing of the bronchial airways, which changes its severity over time spontaneously or under treatment, and is not due to cardiovascular disease". it further identified the clinical characteristics as "abnormal breathlessness, which may be paroxysmal or persistent, wheezing, and in most cases, relief by bronchodilator drugs (including corticosteroids)." soon after the publication of this report, scadding, one of the contributors to the symposium, made two important points. 7 first, what had been described as a definition in the report was not a true definition in that it did not provide a clear year definition ciba foundation 6 1959 condition of subjects with widespread narrowing of the bronchial airways, which changes its severity over short periods spontaneously or during treatment american thoracic society 8 1962 disease characterized by increased responsiveness of the trachea and bronchi to various stimuli and manifested by widespread narrowing of the airways that changes in severity spontaneously or as a result of therapy world health organization (who) 9 1975 chronic condition characterized by recurrent bronchospasm resulting from a tendency to develop reversible narrowing of the airway lumina in response to stimuli of a level or intensity not inducing such narrowing in most individuals american thoracic society 10 1987 clinical syndrome is characterized by increased responsiveness of the tracheobronchial tree to a variety of stimuli. major symptoms are paroxysms of dyspnea, wheezing, and cough, which may vary from mild and almost undetectable to severe and unremitting (i.e., status asthmaticus). primary physiologic manifestation of this hyperresponsiveness is variable airway obstruction, occurring in the form of fluctuations in the severity of obstruction after bronchodilator or corticosteroid use, or increased obstruction caused by drugs or other stimuli, as well as evidence of mucosal edema of bronchi, infiltration of bronchial mucosa or submucosa with inflammatory cells (especially eosinophils), shedding of epithelium, and obstruction of peripheral airways with mucus. nhlbi/nih 11 1991 lung disease with the following characteristics: (1) airway obstruction that is reversible (but not completely in some patients) spontaneously or with treatment, (2) airway inflammation, and (3) increased airway responsiveness to a variety of stimuli. nhlbi/nih 12,13 1993 1995 1997 chronic inflammatory disorder of the airways in which many cells play a role, particularly mast cells, eosinophils, and t lymphocytes. in susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough in early morning. symptoms are usually associated with widespread but variable airflow limitation that is at least partly reversible spontaneously or with treatment. inflammation also causes an increase in airway responsiveness that is associated with a variety of stimuli. nih/nhlbi 14 2002 chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. the chronic inflammation causes an increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. these episodes are usually associated with widespread but variable airflow obstruction that is often reversible spontaneously or with treatment. nhlbi/nih, national heart, lung, and blood institute/national institutes of health. symptom questionnaires do not have the disadvantages of reported diagnoses, but they have problems of their own. first, used alone, symptoms are rarely diagnostic of a condition. this may not be a serious problem when there is no need for an accurate diagnosis in every case, but some symptoms are highly nonspecific. there may be considerable crossover of symptoms between different airway diseases such as asthma and bronchitis. second, the interpretation of similar symptoms may vary among different people. this may become a serious problem when making comparisons in the settings of different cultures and languages. in translating asthma questionnaires, there may be particular problems in translating terms such as wheeze when there may not be an equivalent word, and even people who speak the same language may interpret wheeze differently. given the lack of a gold standard to test these questionnaires against, their validity cannot be fully assessed, because it depends in part on whether they are seen as plausible indicators of the presence of asthma and standardization against a plausible alternative indicator. in the iuatld questionnaire, this indicator was the airway response to histamine, which usually increases tests. 24 they have some of the same limitations as reversibility testing. more promising has been the use of bronchial challenge tests, most of which use a direct bronchoconstrictor such as histamine or methacholine. lung function is assessed before and after inhaling increasing doses of the agent. the decline in lung function (usually the forced expiratory volume in 1 second [fev 1 ]) is regarded as a marker of asthma. 25, 26 this may be expressed as the dose or concentration of agent that produces a given (often 20%) fall in lung function, in which case the result usually is dichotomized as those falling by at least that amount (i.e., hyperresponsive) and those that do not (i.e., normal). alternatively, the slope of the dose-response curve has been used as a continuous measure of airway reactivity, a method that uses epidemiologic information more efficiently but may be clinically less intuitive. 27 development of these tests for use in surveys has provided a tool for assessing a physiologic measure associated with asthma. there is little difference between the use of histamine and methacholine, but methacholine is more widely used because it has fewer side effects. one disadvantage of nonspecific challenge tests is that they produce positive results for those with asthma and also with chronic obstructive pulmonary disease (copd). 28, 29 this has led to the use of alternative agents that act indirectly by releasing mediators from mast cells in the airway. challenge agents include adenosine, hypertonic solutions (e.g., saline, mannitol), exercise, and cold, dry air. these alternatives have not been used as widely as methacholine. exercise testing usually has been confined to studies of children. its effects depend on weather conditions (e.g., cold, dry conditions produce a greater stimulus than warm, moist conditions), and it requires well-motivated groups of participants. equipment to provide cold, dry air has not been widely available. use of saline and mannitol has promise, but they have not been widely used in surveys. the theoretical advantage of using these methods is that they are less likely to provoke airway constriction in those with copd. allergic rhinitis has been investigated much less frequently than asthma using epidemiologic approaches. population-based studies are made difficult by misclassification arising from reliance on questionnaires to establish the presence of allergic rhinitis. typically, the questionnaires used by epidemiologists ascertain self-reports of responders having something they call allergic rhinitis or hay fever. nonetheless, studies show that allergic rhinitis is among the most common chronic diseases. symptoms of individuals with rhinitis include sneezing, nasal irritation, rhinorrhea, and nasal blockage. 30 these symptoms can also involve the eyes, ears, and throat, including postnasal drainage. 31 allergic rhinitis is most commonly classified as seasonal, perennial, or occupational, 30 but a recent guidelines statement advocated classifying allergic rhinitis as intermittent or persistent. 32 the symptoms of allergic rhinitis are associated with exposure to allergen sources such as pollens, pets, and house-dust mites (hdms). 30 symptoms result from inflammation induced by a specific ige-mediated immune response to the allergens. 31 criteria for diagnosing chronic rhinosinusitis have been published. 33, 34 a questionnaire based on the symptomatic part of this definition has been devised and tested for epidemiologic surveys. 35 in patients with asthma. although it is not diagnostic of asthma, it is reassuring to find that answers to the questionnaires can predict the results of the alternative test 19 and that they can do this in approximately the same way in different countries and different translations. 20 for the isaac questionnaires, a video was developed that demonstrated the symptoms of asthma, and it was used to help standardize comprehension of the questionnaire in different settings. 23 although fully validated questionnaires for diagnosing asthma are not available, the current questionnaires do allow comparison of symptoms that plausibly represent conditions close to asthma in a standardized way. although cautious interpretation is always advisable, they have enabled substantial advances in our knowledge of the relative distribution of the condition. an objective test for asthma that did not depend on interpretation of questionnaires would be ideal, and several tests have been proposed. the lack of a gold standard for diagnosing asthma and the similarity of asthma to other conditions make a perfectly validated test unattainable, but tests do provide additional tools to check the findings of surveys that use questionnaires only. the physiologic tests for asthma have been based on the definition of asthma as a condition of the airways that changes its severity over time spontaneously or after treatment (box 48-2). reversibility of airway obstruction after use of a bronchodilator (i.e., reversibility testing) has been used in clinical studies to distinguish between asthma and fixed airway obstruction, and some have used it as a test in surveys to identify asthma. the difficulty lies in interpreting the results. a positive test result indicates the likely presence of asthma, but a negative test result is uninformative. because a patient with asthma who is receiving good treatment or in remission for some other reason does not respond to a bronchodilator, this approach has not found much use in surveys of the general population. spontaneous changes in airway caliber can be assessed using peak flow diaries, a clinical technique that has been commonly used in primary care in the united kingdom. although they can be difficult to use in large-scale studies, they do provide data comparable to that using more invasive bronchial challenge kingdom, and the netherlands. low prevalence rates were found in spain, iceland, and italy. the second phase of the isaac study estimated the prevalence of positive skin-prick test responses to at least one of six allergens in children between the ages of 8 and 12 years living in 18 sites, mostly in western europe. 40, 41 estimated prevalence ranged from 11.6% in tallin, estonia, and 16.5% in mumbai, india, to 39.5% in rome, italy, and 44.7% in almeira, spain. unlike in western countries, the prevalence of sensitization in africa heavily depends on the methods used to assess sensitization. in rural areas, the prevalence of positive skin-prick test results is very low, whereas the prevalence of allergen-specific ige is high. the high prevalence of allergen-specific ige in poor rural areas was first shown in zimbabwe (formerly called southern rhodesia) by merrett and associates, 42 but the dissociation in these environments between specific ige levels and skin test results also has been shown in kenya 43 and south africa. 44 where skin test results are negative, even in the presence of specific ige to aeroallergens, clinical allergy is rare. 3 asthma is a global problem. it is estimated that approximately 300 million people worldwide have asthma. 45 prevalence rates for children and adults are substantially different in countries around the world. the first phase of the isaac study provides the most extensive information on variation in childhood asthma prevalence. in 1998, the isaac steering committee reported findings for 463,801 13-to 14-year-old children (155 centers in 56 countries) and 257,800 6-to 7-yearold children (91 centers in 38 countries). 46 for the younger and older children, the prevalence of asthma symptoms was based on a positive response to this question: have you had wheezing or whistling in the chest in the past 12 months? across countries, there was an approximately twentyfold range of prevalence, with the highest rates usually found in more developed countries (figs. 48-2 and 48-3) . the countries with the highest prevalence rates (>20%) were the isle of man, the united kingdom, new zealand, ireland, australia, peru, panama, costa rica, the united states, and brazil. the ecrhs assessed geographic variation in asthma among 140,000 adults from 22 countries. a sixfold variation in the prevalence of current asthma was found among the countries. 21 a high (>7%) prevalence of asthma was found in australia, new zealand, the united states, ireland, and the united kingdom. asthma prevalence of less than 4% was found in iceland, parts of spain, germany, italy, algeria, and india. current asthma was defined in the ecrhs as "having an attack of asthma in the past 12 months or currently taking medicine for asthma." the ecrhs did not examine many sites outside the developed market economies, but the world health survey interviewed adults older than 18 years of age in six continents using questions derived from the ecrhs on wheezing and diagnosed asthma. 22 the prevalence of diagnosed asthma ranged from 1.8% in vietnam to 32.8% in australia (fig. 48-4) . a very wide variation in the prevalence of diagnosed asthma (and wheezing) was found in all countries, regardless of gross national income per capita adjusted for purchasing power parity. in countries eczema similar to allergic rhinitis, the epidemiology of eczema is less well understood than the epidemiology of asthma. eczema, also known as atopic dermatitis, is a pruritic rash characterized by chronic, recurrent papular lesions typically affecting skin at the flexor surfaces, buttocks, and back of the neck. infants frequently have involvement of the face. in its acute and subacute forms, eczema is characterized primarily by erythema and a papular eruption, but in its chronic form, it is characterized by lichenification of affected areas. allergic sensitization plays an important role in provoking eczema flares, particularly in pediatric patients. 36 some studies have relied on physician diagnosis to define eczema, but standardized questions have been developed for identifying eczema cases with or without additional information from standardized examination. 37 these questions are included in the isaac questionnaire, and they focus on the chronic and recurrent nature of the rash, its location, and the presence of pruritus. during the past 10 years, food allergy has received increased attention, and there is a growing body of literature available regarding its epidemiology. food allergy is an immune-mediated reaction to a food. it can produce a wide spectrum of clinical manifestations, including acute ige-mediated reactions, mixed ige-mediated and non-ige-mediated reactions that are often characterized by insidious gastrointestinal symptoms, and non-ige-mediated syndromes such as allergic colitis and food protein-induced enterocolitis syndrome. even among patients with acute ige-mediated types of food-allergic reactions, symptoms can vary and include one or many of the following: urticaria, angioedema, pruritus, cough, wheezing, hoarseness, vomiting, diarrhea, oral pruritus, hypotension, and rhinorrhea. because the diagnosis is based on the clinical history and diagnostic test results, with the gold standard being a double-blind, placebo-controlled food challenge, conducting large epidemiologic surveys can be difficult because of reliance on questionnairebased tools for identification of food allergy and evidence of ige sensitization. because there is no validated questionnaire for food allergy and many reported food allergies are not confirmed when a full diagnostic evaluation is completed, estimates obtained from questionnaires are likely to be inflated. 38 the prevalence of sensitization depends on the selection of allergens. for this reason, the relative prevalence of responses to a standardized panel of allergens is more informative than an absolute prevalence. the ecrhs estimated the prevalence of specific ige (≥0.35 ku/l) to mites (dermatophagoides pteronyssinus), cats, grass (timothy grass), or cladosporium among young adults between the ages of 20 and 44 years in 35 centers, mostly in western europe. 39 the prevalence of a positive response to any of the four common allergens ranged from 16.2% to 44.5% ,with a median prevalence of 33.1%. high prevalence rates were found in australia, new zealand, the united states, the united rates for different questionnaire-based indicators of asthma: physician report, current disease, and the symptom of wheezing used in the national health and nutrition survey of the united states from 1976 through 1980. 47 questions that ask about asthma or wheeze provide estimates that are almost twice those of questions asking about either alone, and this difference varies with age. for those between the ages of 3 and 17 years, with the lowest incomes (<us$3000), none of 20 sites had a prevalence of diagnosed asthma of more than 10%; among countries with intermediate incomes, 3 (19%) of 16 countries had a prevalence higher than 10%; and among counties with the highest incomes (<us$8000), 7 (26%) of 27 countries had a prevalence above 10%. the national health interview survey (nhis) and the national health and nutrition examination survey (nhanes) include random samples of the whole u.s. population. both also provide periodic prevalence estimates. standardization of the methods of prevalence surveys is essential because the wording of questions on asthma or other aspects of data collection may affect estimates based on the questionnaires. for example, table 48 -2 provides prevalence country wheeze is much more likely to be associated with a diagnosis of asthma. state-specific asthma prevalence data for adults are available from the 2010 behavioral risk factor surveillance system (brfss), a state-based, random-digit-dialed survey of noninstitutionalized u.s. adults age 18 years or older. it was conducted by the centers for disease control and prevention (cdc) and the state or territorial departments of health. information was gathered from all 50 states, puerto rico, the virgin islands, and the district of columbia. the definition for current asthma was based on providing positive answers to two questions: have you ever been told by a doctor, nurse, or other health professional that you had asthma? do you still have asthma? the overall current asthma prevalence rate was 8.6%, ranging on the mainland from 6% in tennesee to 11.1% in vermont ( fig. 48-5) . 48 asthma prevalence rates in the united states vary with demographic and social conditions. figure 48-6 gives prevalence rates from the nhis for 2008 through 2010. children have more reported asthma than adults, women have more than men, those in poverty have more asthma than those not in poverty, asian respondents reported less asthma than any other group, and all other racial groups have more asthma than white respondents. 49 estimating incidence and prevalence of allergic rhinitis is as challenging as for asthma. the diagnosis is symptom based, and there is no consensus for measurement. some attempts have been made to estimate the incidence of allergic rhinitis using cohort or longitudinal data. in a birth cohort study from germany that followed 587 children for 7 years, 50 15% of them developed seasonal allergies, defined as a combination of exposure-related symptoms and sensitization. a 23% cumulative incidence rate was determined in a 23-year longitudinal study of 738 college students. 51 the researchers also observed that regression of hay fever symptoms was inversely related to age of onset. almost 85% of those with hay fever onset before 5 years of age had improvement of their symptoms. the isaac researchers collected data on 12-month prevalence of allergic rhinoconjunctivitis for children 13 to 14 years old from 56 countries. 46 allergic rhinoconjucntivitis was defined as having a problem with sneezing or a runny or a blocked nose without a cold or flu and accompanied by itchy, watery eyes. there was a thirtyfold variation in the prevalence rate among the sites, from 1.4% to 39.7%. estimates for adults obtained in the ecrhs ranged from 9.5% in algeria to 40.9% in australia. 21 the median prevalence of nasal allergies in the ecrhs was about 21%. countries with significantly high prevalence rates were the netherlands, belgium, switzerland, france, the united kingdom, new zealand, australia, and the united states. chronic rhinosinusitis is an inflammation of the nose and paranasal sinuses lasting over 12 weeks. another multicenter european study estimated the prevalence of chronic rhinosinusitis using a questionnaire based on the european position paper on rhinosinusitis and nasal polyps (ep 3 os) on symptom criteria 35 to be about 11% among adults, ranging from 7% in helsinki, finland, to 27% in coimbra, portugal. the condition was more common in women, in younger participants, and in smokers. 52 the worldwide prevalence of eczema was best documented in isaac phase three, in which the prevalence for 6-to 7-year-old children ranged from 0.9% in india to 22.5% in ecuador. 53, 54 the worldwide prevalence of eczema in children 6 to 7 years of age has increased in most regions of the world and has remained stable only in western, northern, and eastern europe. for this younger age group, the prevalence in isaac phase three was 7.9%, an increase from the prevalence in phase one of 6.1%. the overall prevalence among 13-to 14-year-old adolescents declined to 7.3% in isaac phase three from 8.8% in phase one. the regions with the most striking increases in eczema prevalence were asia and latin america. a growing number of population-based studies have estimated food allergy prevalence and incidence. the prevalence of food allergy and the foods that are most commonly implicated in food allergy vary widely across the world. for example, a metaanalysis found that the self-reported prevalence of food allergy ranged from 3% to 35%. 55 although some of the heterogeneity observed is attributable to study methodology, other studies that have focused on specific geographic regions and populations support the notion that there is marked worldwide heterogeneity in food allergy prevalence. for example, in the united states, the estimated prevalence of food allergy is 4% to 8% among children, 56, 57 and in australia, a prevalence of more than 10% among 1-year-old children has been reported. 58 in contrast, findings from a population-based birth cohort from the united kingdom indicate that between 2.2% and 5.5% of infants have food allergy in the first year of life, 59 and in other u.k. studies, the estimated prevalence of food allergy among 6-year-old children is 1.6% to 2.5%, 60 and among adolescents, it is 2.3%. 61 an international study that used allergen-specific ige data for young adults confirmed the heterogeneity of food allergy prevalence observed in the questionnaire-based studies. 62 in this study, prevalence of sensitization to any 1 of 24 foods ranged from 7.7% in iceland to 24.6% in the united states. however, sensitization to the major foods, such as fish, egg, and milk, was uncommon (<1%). the incidence and prevalence of allergy to specific foods have been studied. a random telephone survey administered in 2002 to estimate the prevalence of seafood allergy in the united states found that 2.3% of the general population reported allergy to fish or shellfish. 63 another telephone survey was conducted in 1997 and repeated in 2002 and 2010 to estimate the prevalence and incidence of peanut and tree nut allergies. 64, 65 the prevalence rate of peanut or tree nut allergy was stable at 1.4% among adults, but it increased from 0.6% to 1.2% to 2.1% among children during this period. in contrast, data from u.k. general practices were used to estimate a prevalence rate of peanut allergy of 0.05%, and a school-based survey in singapore and the philippines estimated a prevalence rate of peanut and tree nut allergy of less than 1%. 66 in australia, the prevalence of peanut allergy may be higher than that observed in the united states or united kingdom, because the prevalence of peanut allergy among 1-year-old children was estimated to be 3%. 58 there is limited information about the epidemiology of allergic gastrointestinal diseases. however, the incidence and prevalence of eosinophilic esophagitis appear to have increased over the past decade. a range of gastrointestinal symptoms and mucosal eosinophilia characterizes eosinophilic esophagitis. approximately one half of cases demonstrate ige sensitivity to foods. 67 what was once thought to be a rare disease was found people born later in the century having a higher prevalence of disease throughout their lives. in cross-sectional surveys, this pattern of disease is indistinguishable from a decline in disease with age. in the ecrhs, there was almost no net change in the prevalence of sensitization over the 8 years between the surveys within any birth cohort, but succeeding birth cohorts had increasingly high prevalence rates. a subsequent analysis of some british data showed that this phenomenon was apparent in successive birth cohorts since at least the 1930s. 72 to evaluate changes in prevalence, repeated surveys are required for the same populations and using the same instruments for assessment. in the 1950s and 1960s, smith in birmingham, england, first observed that the prevalence of asthma was rising among schoolchildren undergoing school medical examinations. 73 since then, many studies have assessed changes in prevalence. these studies are summarized in figure 48 -7, which by one study based in switzerland to have increased in incidence from 1.2 to 7.4 per 100,000 adults from 1989 to 2009. 68, 69 in another study in hamilton county, ohio, the incidence in children younger than 19 years old has increased from 0.009 to 0.013% per year, and the prevalence has increased from 0.01% to 0.04% from 2000 to 2003. 67 a few studies have made serial assessments of the levels of ige specific to common allergens in the same populations over many years. these studies have shown a fairly consistent increase in the prevalence of sensitization over time. analysis of the data from the tucson 70 and the first and second ecrhs surveys 71 found that the apparent decline in the prevalence of sensitization with age was more easily explained as a birth cohort effect. the apparent effect of age results from 1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1986 1988 1990 1992 1994 1996 1998 2000 1984 2002 0.1 1 10 100 year of survey germany in two surveys made very close together in time and seem unlikely to represent a long-term trend. 80 the isaac reassessed prevalence of asthma and other allergic diseases by questionnaire for 6-to 7-year-old children in 66 centers in 37 countries and for 13-to 14-year-old children in 106 centers in 56 countries. 45 the results for asthma prevalence are given in figure 48 -9. among the younger children, rates were more commonly rising than declining, whereas among the older children, the rising and declining rates were more evenly balanced. among the older children in centers with a high prevalence, the rates were more likely to be declining. in the united states, the nhis, a population-based interview survey of u.s. households, is a key source of information on trends in the prevalence of asthma. 81 before 1997, prevalence estimates were based on a positive response to one question: during the past 12 months, did you have asthma? in 1997, the nchs redesigned the nhis questionnaire. consequently, answers to the nhis questionnaire after 1996 cannot be compared with those in previous surveys because the new questions assess asthma morbidity differently. 82 lifetime incidence is measured by this question: have you ever been told by a doctor or other health professional that you had asthma? the prevalence of asthma attacks is obtained by a positive response to another question: during the past 12 months, have you had an episode of asthma or asthma attack? the asthma attack prevalence in 2009 was 4.2% for all age groups. in 2001, nchs added a question (do you still have asthma?) after the lifetime incidence question to provide estimates of current asthma prevalence (table 48 -3). the 2009 estimates indicate that 8.2% of u.s. residents currently have asthma that has been diagnosed by a doctor or other health professional. 49 table 48 -3 provides the estimates for asthma prevalence before and after the revisions of the nhis questionnaire. 83 figures 48-10 and 48-11 show data from the nhis with different estimates of prevalence of asthma over time for children and adults and by race or ethnic group. for children and adults, the 12-month and lifetime prevalence rates increased over time. current and attack prevalence rates have not shown a marked trend since the use of these outcomes began. prevalence rates also vary among racial and ethnic groups; this variation likely reflects differences in genetic, environmental, social, shows the changes in prevalence over time plotted on a logarithmic scale. most of the studies surveyed children, although a few looked at military conscripts in countries with compulsory military service. the very large variations in the absolute prevalence estimates reflect differences in the definitions used and the populations examined. from the late 1950s to the mid-1990s, the values rose uniformly at a rate that represented a doubling of prevalence approximately every 14 years, and this occurred regardless of the definition used and the starting prevalence. only in the mid-1990s did reports begin to suggest that this increase had slowed down. a much smaller number of studies have assessed changes in the prevalence of airway responsiveness ( fig. 48-8 ). during the 1980s, a small number of studies showed increases in prevalence over time. [74] [75] [76] [77] the study of dubois, which showed a yearly increase in prevalence among belgian conscripts over 14 years, is particularly persuasive given the difficulties of standardizing the tests. since the 1980s, most studies have shown a flattening of or a decline in prevalence, [76] [77] [78] although increases were seen in a study from ghana, 79 and a large increase was observed in year prevalence (%) asthma period prevalence current asthma prevalence asthma attack prevalence and cultural influences among population groups. 84 between 1980 and 1996, the prevalence of asthma had increased from 3.1% to 5.4% among whites and from 3.3% to 6.5% among blacks, representing cumulative increases of approximately 4% per annum. 85 between 2001 and 2009, rates of current asthma had increased from 7.2 % to 7.8% among whites, a cumulative increase of approximately 0.8% per annum, and from 8.4% to 11.9% among blacks, a further increase of approximately 4% per annum (see fig. 48 -11). 86 many of the studies that reported changes in the prevalence of asthma and wheeze also found increased reporting of other allergic diseases, most notably allergic rhinitis and eczema in children. as for asthma, almost all studies reporting before the mid-1990s found increases in other atopic conditions with time. since then, results have been more mixed, and the isaac has provided a more representative spread of data than is possible from individual studies. (fig. 48-12 ) 53 for the 6-to 7-yearold children, most sites showed an increase in prevalence of allergic rhinoconjunctivitis and eczema in the 5 years after the baseline surveys of isaac phase one. for the 13-to 14-year-old children, the changes were more evenly distributed between increases and decreases, and the size of the annual percentage change (positive and negative) appeared to be proportional to the initial value. a follow-up of the ecrhs sample approximately 9 years later estimated an incidence rate of rhinitis of 7.5 cases per thousand people per year. males had a greater risk in childhood and a lower risk in adulthood of incident rhinitis compared with females. atopic subjects had the highest incidence of rhinitis, at more than 22 cases per thousand people per year. 87 were compared for fathers (5.4%) and sons (15.4%) and for mothers (5.8%) and daughters (20%). later findings from a u.k. study suggested that the prevalence of hay fever had been stable in the latter half of the 2000s. 95 the worldwide prevalence of eczema among 6-to 7-year-old children has increased in most regions of the world and has remained stable only in western, northern, and eastern europe. for this younger age group, the prevalence found in the isaac phase three was 7.9%, an increase from the prevalence in phase one of 6.1%. the overall prevalence among 13-to 14-year-old children declined to 7.3% in the isaac phase three from 8.8% in the isaac phase one. the regions with the most striking increases in eczema prevalence were asia and latin america. two cross-sectional chinese studies from chongqing showed a statistically significant increase in food allergy prevalence, from 3.5% in 1999 to 7.7% in 2009, among young children between the ages of 0 and 24 months. 96 these studies also showed that sensitization to food allergens assessed by positive skin-prick test results had almost doubled, rising from 9.9% to 18% during the same 10-year period. other than these studies, there is little evidence on time trends using food challenge tests in general populations, although there is more circumstantial evidence for an increase over time. the prevalence of allergic rhinitis has increased over time in the united states. the 2004 nhis estimated a seasonal allergic rhinitis prevalence of 9%, 88, 89 an increase of 66% from the prevalence estimate of 5.4% based on the 1970 nhis. 90 the 2004 nhis estimated that about 25.3 million americans, 6.7 million of them younger than age 18 years, have allergic rhinitis. 88, 89 the survey also showed geographic variation in the prevalence of seasonal allergic rhinitis, with the highest estimated prevalence for the western united states (10.8%), followed by the northeast (9.5%), south (8.0%), and midwest (7.2%). studies in other countries have also documented an increase in the prevalence of allergic rhinitis over time. von mutius and colleagues 91 observed a significant increase in hay fever prevalence among schoolchildren from leipzig, germany. the hay fever prevalence rate in the 1991-1992 survey was 2.3%; in the 1995-1996 survey, the prevalence had increased to 5.1%. an italian retrospective study compared data on allergic rhinitis prevalence among italian recruits observed in 1983 and from 1993 to 1995. 92 the investigators found a significant increase in allergic rhinitis prevalence, from 1.5% in 1983 to 2.2% in the 1993-1995 period. results from surveys conducted in 1989 and 1997 of an adult danish population showed a significant increase of 61% in the prevalence of allergic rhinitis after adjustment by age and gender. 93 a scottish study observed a threefold increase in the age-adjusted prevalence rate of hay fever between 1972 and 76 and 1996 in middle-age adults. 94 the hay fever prevalence rates change per year (%) mean prevalence (%) eczema d some genotypes were specifically associated with childhoodonset asthma. 113 gender data from epidemiologic studies consistently reveal male gender to be a risk factor for asthma among young children, whereas studies of adolescents and adults show females to be at greater risk. a review of prospective studies showed that male children were at greater risk for incident asthma or wheeze, and studies of adolescents or adults showed females to be at greater risk. 114, 115 one hypothesis explaining the excess of asthma seen in boys during childhood is the different airway geometry in boys and girls. boys have smaller airways for a given lung size than girls. lower flow rates were found for boys 4 to 6 years of age, 116 and they have higher airway resistance compared with girls of the same age. 117 this difference in airway anatomy predisposes boys to more wheezing, and they have a higher incidence of lower respiratory tract infections. 118 , 119 martinez and coworkers 120 suggested that reduced lung function was a key determinant of wheezing in boys and girls. in the tucson study, lung function was measured within weeks of birth in 124 healthy infants. the subsequent incidence of wheezing illness over the first 6 years of life was increased in boys with high respiratory resistance and in girls with low functional residual capacity. one hypothesis for females being at higher risk of developing asthma or wheeze during adolescence or adulthood is the smaller relative airway caliber in women compared with men after puberty. 121 epidemiologic studies consistently show an association between atopy and asthma, although the strength of the association varies with the index used and the study population. part of the problem lies in the ambivalent nature of the term asthma.the symptoms of asthma in older adults also can indicate copd, and the differential diagnosis may be difficult even in a clinic. a distinction used to be made between asthma and other wheezy syndromes in children. however, the management is very similar, the distinction has fallen largely into disuse, and use of the term nonatopic asthma has become common for children, whereas it was prviously reserved for a condition associated with eosinophilic inflammation but negative skin test results that predominantly presented in middle age, often among women, and had a relatively poor prognosis. the idea that atopic and airway components of asthma are distinct 101, 109 has been confirmed by genetic studies thatidentified gene polymorphisms associated with asthma but not obviously related to the regulation of ige or associated immunologic responses. isaac found little variation in the prevalence of nonatopic asthma that could be explained by the local gross income, but prevalence of asthma associated with sensitization became less common in low-income settings. 41, 122 the distinction is important, because atopic asthma in children apears to have a less benign course than nonatopic disease. 123 burrows and colleagues 124 assessed this association in a random sample selected from tucson, arizona, using skin tests with local antigens as an index of atopic status. in children 3 to 14 years old, atopy was strongly associated with attacks of wheezing and dyspnea, regardless of whether asthma had been diagnosed. later analyses of the tucson population indicated that the total serum ige level was more strongly associated with the prevalence of asthma, 125 an association that was also found in an nhanes analysis (discussed later). another study using self-reported during the 14-year period from 1990 to 2004, hospital admissions for food allergy showed continuing increases of 5 to 26 cases per million people overall and 16 to 107 cases per million children, particularly in the 14-year-old age group. hospital admissions attributed to "dermatitis due to food" increased in england and wales from 5 cases per million people in 1990 to 26 cases per million people in 2004, an increase of almost 13% per annum. 97, 98 apart from true changes in the epidemiology of food allergy, alternative explanations for this dramatic increase in health care use for presumed food allergy include changes in the coding behavior of doctors, changes in the awareness and behavior of patients, and changes in the health care system. in the united states, the nhis recorded much smaller increases in parent-reported food allergy, 99 although such reports are usually regarded as unreliable. increasing reports of more specific complaints of peanut allergy have been made for children in the united states 56 and the united kingdom. 100 a genetic component of asthma has long been recognized, based initially on the observation that asthma tends to cluster in families. familial aggregation, twin, genetic linkage, and association studies subsequently provided evidence to support this hypothesis. detailed descriptions of the molecular genetics of asthma and atopic disease are provided in chapter 22. family aggregation studies compare disease occurrences between family members. disease aggregation between siblings and between parents and children supports a hereditary component, whereas increased aggregation between spouses suggests that environment is more important. however, aggregation among related individuals may represent shared genes or a common household environment. evidence of a hereditary component of asthma has been demonstrated in numerous family-based studies. [101] [102] [103] [104] population-based studies also have shown an increased prevalence of asthma among first-degree relatives of index cases. [105] [106] [107] [108] [109] twin studies compared disease frequency in monozygotic (mz) twins, who share 100% of their genes, with dizygotic (dz) twins, who share on average 50% of their genes. this is another method to determine the relative contribution of genetic and environmental factors. a greater occurrence of disease in mz than in dz twins is evidence for a genetic component to the disease because both types of twins are assumed to share environmental factors similarly. significantly higher concordance rates for mz twins have been observed in some small studies. 110 larger studies of twin registries also suggest a significant genetic contribution to asthma. in 6996 twin pairs from the swedish twin registry, edfors-lubs found the prevalence of asthma to be 3.8%. 111 the higher concordance of asthma in mz (19.8%) over dz (4.8%) pairs suggests that genetic factors contribute to asthma. similarly, duffy and associates observed a 30% concordance in mz twins and 12% in dz twins in a total of 2902 australian pairs. 112 whole-genome association studies have identified specific loci associated with clinical asthma. the genes associated with total ige levels were not strongly associated with asthma, and many related methodologic issues complicate the study of diet and disease. 134 obtaining unbiased exposure estimates is difficult because of recall problems, difficulties in measuring intake, and limited range of variation in the western diet. 135 diet is fundamental to existence and is closely associated with many lifestyle, social, cultural, and environmental factors that may influence the development of disease. although many studies adjust for potential confounders, it has been argued that this is insufficient and that many or all of the reported associations between diet and disease are likely to be confounded by social and behavioral factors acting across the life course. 136, 137 several reviews on the topic of diet and asthma and allergic disease are available. [138] [139] [140] [141] [142] [143] [144] observational and randomized studies have directly correlated dietary sodium levels with increased bronchial responsiveness to histamine challenge. [145] [146] [147] one study showed this response occurred in males but not in females. 146 ecologic data from england and wales support these experimental findings; the purchases of table salt correlated with the regions of increased asthma mortality for men and children. 131 other population-based studies, however, have not shown a relationship between urinary sodium levels and methacholine airway responsiveness, [148] [149] [150] although two did show an association with higher levels of potassium excretion. 148, 150 britton and associates 151 found that increased magnesium intake was associated with a reduced risk of bronchial hyperresponsiveness and wheeze. because of the relationships among sodium, potassium, and magnesium, these investigators suggest the possibility that low levels of dietary magnesium may confound the association of sodium and potassium with bronchial hyperresponsiveness or asthma. 151 a systematic review of the clinical trials of dietary sodium reduction in persons with asthma concluded that dietary sodium reduction does not significantly improve asthma control. 152 dietary sodium reduction was associated with some improvement in lung function in people with exercise-induced asthma, but because extremely large reductions in sodium intake were required, the clinical utility, as distinct from the potential public health relevance of this finding, is likely to be small. a systematic review of the studies correlating asthma and allergic disease in children with dietary intake or status of vitamin a, vitamin c, vitamin e, selenium, zinc, copper, iron, fruits, vegetables, and components of the mediterranean diet identified 62 eligible reports. 138 there were no randomized, controlled trials, and all studies were judged to be at moderate to substantial risk of bias. meta-analyses demonstrated that serum vitamin a was lower in children with asthma compared with controls (odds ratio [or] = 0.25; 95% confidence interval [ci], 0.10 to 0.40). the meta-analyses also showed that high maternal dietary vitamin e intake during pregnancy was protective against development of childhood wheezing (or = 0.68; 95% ci, 0.52 to 0.88) and that maternal adherence to a mediterranean diet during pregnancy was protective against persistent wheeze (or = 0.22; 95% ci, 0.08 to 0.58) and atopy (or = 0.55; 95% ci, 0.31 to 0.97) in children. seventeen of 22 fruit and vegetable studies reported beneficial associations with asthma and allergic outcomes. although weak, the available epidemiologic evidence supports dietary intake of vitamin a, vitamin d, vitamin e, zinc, fruits, vegetables, and a mediterranean diet for the prevention of asthma. 138 the fatty acid composition of the diet, particularly the relative amounts of n-3 (ω-3) and n-6 (ω-6) polyunsaturated fatty diagnosis of hay fever in a population sample from western pennsylvania showed atopy to be more common in asthmatic than nonasthmatic children. 126 two other studies demonstrated parental atopy and asthma as risk factors for asthma in their children. 127, 128 the results also demonstrated a complex interaction between these factors and the gender of the child. a study of 525 new zealand children assessed the relationship of total serum ige levels at the age 11 years and asthma, and investigators found that the prevalence of diagnosed asthma was strongly related to the serum ige level (p trend < .0001). 129, 130 asthma was not reported for children with ige levels of less than 32 iu/ ml, whereas 36% of children with ige levels of 1000 iu/ml or higher had asthma. asthma and atopy are closely linked, and the causal nature of the factors seems to be complex and require more investigation. nonetheless, atopy in parents and children does increase the risk of asthma and can be used as an empiric predictor. 131 diet diet, including breastfeeding, food intolerance and sensitivity, and intake levels of specific micronutrients, has been investigated as a potential risk factor for asthma for over 2 decades. in 1987, burney 132 was among the first to propose diet as a potential explanation for the rising frequency of asthma, suggesting the possibility that increasing salt intake might have a role. the rationale for investigating diet as a possible risk factor for asthma and allergic disease is that diet has changed in recent decades and biologically plausible mechanisms exist. many dietary constituents have been investigated for potential involvement in the pathogenesis of asthma and allergic disease, including antioxidants (e.g., vitamin e, vitamin c, carotenoids, flavonoids), polyunsaturated fatty acids, vitamin d, folate, 122, 133 foods (e.g., fruits, vegetables), metals or trace minerals (e.g., sodium, magnesium, selenium, zinc, copper), and components of the mediterranean diet ( increased ige levels, eosinophilia, methacholine responsiveness, asthma-related hospitalization, exacerbations, use of antiinflammatory medication, and use of oral corticosteroids and with reduced asthma control scores. 169 analogous findings have been reported for adults with asthma. 170 similarly, for children with atopic dermatitis, lower serum 25-oh-d concentrations have been associated with increased severity of atopic dermatitis. 171 longitudinal cohort studies quantifying vitamin d status before the development of disease are not subject to many of the limitations of cross-sectional studies, such as reverse causation, whereby the vitamin d status of an individual is influenced by the presence of disease (e.g., children with asthma may spend more time indoors). a systematic review and metaanalysis of the longitudinal studies relating maternal vitamin d status during pregnancy to childhood outcomes concluded that high maternal dietary vitamin d intake is associated with a reduced risk of children wheezing up to the age of 5 years (or = 0.56; 95% ci, 0.42 to 0.73). 138 however, maternal dietary vitamin d intake during pregnancy is not indicative of total body vitamin d status, because 90% of vitamin d is derived from cutaneous exposure to ultraviolet light. in contrast to maternal dietary vitamin d intake, high (>75 nmol/l) maternal serum 25-oh-d levels in late pregnancy have been associated with an increased likelihood of childhood eczema at age 9 months and asthma at age 9 years. 172 during infancy, increased vitamin d intake has been associated with an increased risk of atopic dermatitis at age 6 years and an increased likelihood of allergic rhinitis and atopic sensitization at the age of 31 years. 173, 174 in later childhood, an increased serum 25-oh-d concentration at 4 years of age has been associated with a reduced likelihood of asthma at 8 years of age, 175 and an increased serum 25-oh-d concentration at 6 years of age has been associated with a reduced likelihood of asthma, rhinoconjunctivitis, and atopic sensitization at 14 years of age. 176 the epidemiologic data support the hypotheses that vitamin d may have beneficial and adverse influences on the development of asthma and allergic disease. ongoing clinical trials are clarifying the potential clinical role of vitamin d in modifying the risk of developing asthma and as an adjunct to asthma and atopic dermatitis therapy. although breastfeeding of infants is recommended because of well-documented benefits for mother and child, the effects of breastfeeding on the subsequent development of atopic dermatitis, wheezing disease, and asthma are not clear. 177, 178 conceptually, the advantageous consequences of breastfeeding for the infant include acquisition of maternal antibodies and immune-competent cells such as macrophages and leukocytes and protection against early occurrence of lower respiratory tract infections. however, breastfeeding may also be a route of exposure to a variety of immunologically active substances from the mother, such as tobacco smoke, cow's milk, eggs, wheat, maternal ige, and sensitized lymphocytes. 135 many studies have investigated the association between breastfeeding, asthma, wheezing illness, and atopic disease, and they have been subject to several systematic reviews, most of which highlight the limitations and difficulties in conducting and interpreting such studies (e.g., confounding, recruitment bias, reporting bias, reverse causation, variation in breastfeeding patterns, inability to randomize and blind). the systematic reviews have themselves been reviewed in consensus documents, which conclude that the exclusive breastfeeding for 3 to 4 months of acids (pufas) found in fish and vegetable oils, respectively, 153 affects cell functioning. fatty acids appear to have specific roles in inflammatory and immune responses, and changes in fatty acid consumption are a postulated cause of the rising incidence of asthma and other allergic diseases. 154, 155 conflicting observational data relating n-3 and n-6 pufa intake or status during pregnancy, childhood, and adulthood to asthma and allergic disease have been surpassed by intervention trials. a 2008 systematic review with meta-analysis evaluated the interventional studies of n-3 and n-6 pufa supplementation in the context of primary prevention of asthma and allergic disease. 143 ten reports from six double-blind, randomized, controlled trials were identified. four studies compared n-3 pufa supplements with placebo, and two studies compared n-6 pufa supplements with placebo. the meta-analyses failed to identify any consistent or clear benefits associated with n-3 pufa supplementation during pregnancy or infancy for atopic dermatitis two subsequent trials reported the consequences of n-3 pufa supplementation during pregnancy. in the first, highdose n-3 pufa supplementation of 117 pregnant women from 25 weeks' gestation and during breastfeeding reduced the incidence of food allergy and ige-associated atopic dermatitis in children in the first year of life compared with placebo (2% versus 15% [p < .05] and 8% versus 24% [p < .05], respectively). 156 in the second, larger study of 368 pregnant women, high-dose n-3 pufa supplementation from 21 weeks' gestation until delivery did not reduce the incidence of ige-associated disease or atopic dermatitis during the first year of life compared with placebo (rr = 0.70 [95% ci, 0.45 to 1.09] and rr = 0.64 [95% ci, 0.40 to 1.02], respectively). 157 there is insufficient evidence to recommend pufa supplementation in any period of life as a means of reducing the burden of asthma and allergic disease. the role of vitamin d in the cause asthma and allergic disease remains unclear. the increase in asthma and allergic disease in developed countries has been attributed to early-life vitamin d supplementation as rickets prophylaxis, 158 and widespread vitamin d deficiency is thought to be a consequence of more time being spent indoors and the active promotion of sun avoidance. 159 cross-sectional, observational studies have reported vitamin d status to be no different 160 or increased in adults 161 with asthma but decreased in children with asthma. 162, 163 blood levels of 25-hydroxyvitamin d (25-oh-d) concentrations were found to be lower in adults with atopic dermatitis and allergic rhinitis. 164, 165 in two studies using nhanes data, blood levels of 25-oh-d have been no different in adults with evidence of atopic sensitization; however, atopic sensitization was associated with reduced blood 25-oh-d levels in children and adolescents in one study 166 but not in adolescents in the other. 167 the effect of blood 25-oh-d levels on current wheeze depended on age and atopic status in another study using nhanes data, with nonatopic individuals and adults 50 years of age or older having a greater risk of wheeze if they had lower 25-oh-d levels. 168 in children with asthma, lower blood levels of 25-oh-d have been associated with increased asthma severity, including have reported associations between the prevalence of asthma and obesity, it is not possible to exclude reverse causation, whereby asthma may contribute to obesity through inactivity and use of oral corticosteroids. the most relevant data come from prospective cohort studies that have assessed risk for incident asthma in relation to initial weight or bmi. beuther and sutherland systematically reviewed prospective studies evaluating the association between bmi and incident asthma among adults. 190 meta-analysis of the data from 333,102 subjects participating in the seven identified studies demonstrated that being overweight or obese (bmi ≥ 25) was associated with an increase in the rate of 1-year incident asthma (or = 1.51; 95% ci, 1.27 to 1.80), with evidence of a dose effect for being overweight (or = 1.38; 95% ci, 1.17 to 1.62) or obese (or = 1.92; 95% ci, 1.43 to 2.59). there was no difference between sexes. a systematic review of similar literature for children and adolescents concluded that obesity precedes and is associated with the persistence and intensity of asthma symptoms. 191 in observational designs, a potential methodologic concern is that nonspecific respiratory symptoms resulting from cardiorespiratory loading and deconditioning may be misclassified as asthma. careful studies of children and adults suggest that asthma is not inappropriately overdiagnosed in the obese. 192, 193 observational studies have also reported adverse associations for bmi, obesity and overweight, and atopic dermatitis and atopic sensitization in children and adults. [194] [195] [196] [197] a retrospective case-control study of children with a mean age of 7.0 years confirmed an association between obesity and atopic dermatitis and reported that early-life and prolonged obesity was associated with atopic dermatitis. atopic dermatitis was more prevalent among children who were obese before 2 years of age (or = 15.1; 95% ci, 1.51 to 151) and between 2 and 5 years of age (or = 2.58; 95% ci, 1.24 to 5.41). obesity after the age of 5 years was not associated with atopic dermatitis. children who were obese for 2.5 to 5.0 years (or = 2.64; 95% ci, 1.13 to 6.18) and for more than 5 years (or = 3.40; 95% ci, 1.34 to 8.63) were more likely to be diagnosed with atopic dermatitis. 197 infants at high risk for atopic disease reduces the likelihood of atopic dermatitis and that breastfeeding beyond 3 to 4 months appears to confer no additional benefit. 179, 180 the available evidence also suggests that the breastfeeding of infants at low risk for atopic disease does not reduce the incidence of atopic dermatitis. the evidence for a protective effect of breastfeeding against respiratory disease is controversial. although breastfeeding appears to reduce the incidence of virus-associated wheezing episodes in young children (<4 years), the evidence of an effect on breastfeeding on the development of asthma is inconsistent. systematic reviews suggest that exclusive breastfeeding for 3 to 4 months is associated with a reduced risk of asthma in children 2 to 5 years old, but this beneficial effect is limited to infants at high risk for atopic disease. some systematic reviews have revisited the literature relating breastfeeding to childhood atopic dermatitis, asthma, and wheezing. a systematic review examining the association between exclusive breastfeeding for 3months or longer and the development of childhood atopic dermatitis identified 21 reports from 27 study populations and concluded that there was no strong evidence that exclusive breastfeeding confers a beneficial effect on the development of childhood atopic dermatitis (summary or = 0.89; 95% ci, 0.76 to 1.04), even in children at high familial risk (or = 0.78; 95% ci, 0.58 to 1.05). 181 another systematic review clarified the association between breastfeeding and childhood asthma and wheezing after 5 years of age. 182 it examined 31 publications and concluded that breastfeeding for 3months or longer did not confer any beneficial effect on the incidence of asthma and wheezing illness after the age of 5 years. the summary odds ratio for any breastfeeding and wheezing was 0.97 (95% ci, 0.90 to 1.04), and for exclusive breastfeeding and wheezing, it was 0.96 (95% ci, 0.86 to 1.06). the prevalence of obesity increased dramatically in many countries, particularly western and other developed countries in the latter decades of the twentieth century. in the united states, for example, the prevalence of overweight and obesity among adults rose sharply across the 1990s, such that most adults are now overweight. 183 the prevalence of childhood overweight is also rising rapidly. 183 the rise in obesity parallels the rise of asthma, and a hypothesis has been advanced that obesity could be a risk factor for asthma. 184 several mechanisms have been postulated for the association, including the mechanical effects of obesity, a higher frequency of gastric esophageal reflux, upregulation of immunologic and inflammatory correlates of obesity, and a shared genetic basis for both conditions. 185, 186 the association of obesity with asthma has been investigated in children and adults. camargo and colleagues offered one of the first reports in their 1999 paper based on the nurses' health study ii. 187 the body mass index (bmi) in 1991 was positively and strongly associated with asthma risk over the next few years (fig. 48-13) . 188 similar studies have addressed obesity and asthma in children. in a cross-sectional study using nhanes iii data, von mutius and colleagues 188 found a positive association between bmi and asthma risk (or = 1.77; 95% ci, 1.44 to 2.19) by comparing the highest and lowest quartiles of bmi. in the tucson study, girls becoming overweight or obese between the ages of 6 and 11 years had a sevenfold increased risk for asthma. 189 although many cross-sectional observational studies ≥30.0 at 7 years. because most children are not hospitalized for lower respiratory tract disease, these results apply only to the more severe infections. a population-based study of children in east boston, massachusetts, however, found that a history of bronchiolitis or croup was a predictor of increased airway responsiveness. 209 in another boston area study, children from a birth cohort with lower respiratory tract infection (i.e., croup, bronchitis, bronchiolitis, or pneumonia) in the first year of life were twice as likely to report two or more episodes of wheeze than children with no lower respiratory tract infection. 210 the tucson children's respiratory study provides relevant data on follow-up from birth to age 13 years. 158, 211 results from this longitudinal study show that rsv infection was associated with an increased risk of infrequent and frequent wheeze by age 6 years. 211 the relative risk for wheeze after 3 years of age for children with rsv infection compared with children with no rsv infection decreased over time. the relative risk decreased with age from 3.2 and 4.3 at age 6 years to no risk at age 13 years for infrequent wheeze and frequent wheeze, respectively. 198 support for the idea that severe rsv-associated respiratory disease probably does not contribute to the development of asthma has been provided by a large (8280 pairs) danish twin registry study that applied genetic variance and direction of causation models to data on rsv-associated hospitalization and the development of asthma. 212 a model in which asthma caused rsv-related hospitalization fit the data significantly better than a model in which rsv-related hospitalization caused asthma, suggesting that rsv infection does not cause asthma but reflects an underlying predisposition to asthma. the role of viruses in the natural history of asthma has been highlighted by several longitudinal cohort studies. the wisconsin childhood origins of asthma (coast) study prospectively evaluated the timing, frequency, severity, and cause of symptomatic viral infection in the first 3 years of life in relation to later wheezing illness in a cohort of 289 neonates at high familial risk for asthma. 213 by using molecular technologies to identify viral infections in nasal lavage samples collected routinely and when symptomatic, this study highlighted the prognostic importance of hrv. having one or more hrvassociated wheezing episodes during the first 3 years of life was more strongly associated with wheezing in the third year (or = 10.0; 95% ci, 4.7 to 23.0) than having one or more rsv-associated wheezing episodes during the first 3 years of life (or = 3.0; 95% ci, 1.6 to 5.8). first-year wheezing associated with hrv was the strongest predictor for third-year wheeze (or = 6.6). 213 the pattern of viral respiratory tract infection in the first 3 years was different for children with or without asthma at the age of 6 years (fig. 48-14) . 214 asthma at 6 years of age was strongly associated with hrv-associated wheeze in the first 3 years of life (or = 9.8; 95% ci, 4.3 to 22.0). the frequency of hrv-induced wheezing episodes increased in the first 3 years of life for children diagnosed with asthma by age 6, whereas for children without asthma, hrv-associated wheezing episodes declined in the first 3 years (see fig. 48-14) . almost 90% of children with hrv-associated wheezing episodes in year 3 had been diagnosed with asthma by the age of 6 years, and hrv-associated wheeze was a more robust predictor for subsequent asthma than atopic sensitization to aeroallergens. asthma at 6 years of age was also associated with rsv-associated wheezing episodes in the first 3 years (or = 2.6; 95% ci, 1.0 to 6.3). the likelihood of asthma by age 6 years being associated with rsv-induced wheeze in the first 2 years of life was increased these findings are provocative and indicate another potential risk factor for asthma and allergic disease, one that is increasingly prevalent and amenable to intervention. a better understanding of the mechanisms and potential role of intervention in the primary and secondary prevention of disease is needed. respiratory infections are common in the first years of life, and they provoke wheezing in children with or without asthma. less certain is whether viral or other respiratory infections have a direct role in the pathogenesis of asthma or they merely reveal that a child is predisposed to asthma. investigation of the association of viral infection and asthma has been limited by available technology, with culture, serology, and antigen detection having 30% to 50% detection rates. the newer molecular technologies have improved the rates of viral detection up to about 90% and have revealed the importance of previously unknown viruses, such as human rhinovirus c (hrv-c). lower respiratory tract infections in children, which are caused by hrvs, respiratory syncytial virus (rsv), parainfluenza viruses, and other pathogens, are universal in childhood. a community-based study in tecumseh, michigan, estimated that children experience, on average, 2.1 lower respiratory tract infections in the first year of life and 1.5 such infections between 1 and 2 years of age. 119 another cohort study of respiratory illnesses from birth through 18 months in albuquerque, new mexico, adapted a surveillance system similar to the one used in tecumseh and found comparable incidence rates from 1988 through 1992. 198 the incidence of severe episodes of viral respiratory infections was captured in another study using surveillance through a pediatric group practice. 118 this study showed that 25% of children were affected in the first year of life, that 12% had annual occurrences by age 5 years, and that 8% of children 6 to 8 years old experienced annual episodes of infection. follow-up studies of children with a history of hospitalization for respiratory infections suggest that these illnesses may predispose to the development of asthma. in several studies, children with past hospitalizations tended to have abnormal lung function that was indicative of airflow obstruction, including hyperinflation, increased respiratory resistance, and reduced spirometric flow rates. [199] [200] [201] [202] [203] [204] [205] [206] in children with past hospitalizations, increased airway reactivity occurred after assessment by exercise, cold air inhalation, methacholine, or histamine inhalation challenge. [201] [202] [203] infants hospitalized with rsv-associated bronchiolitis are more likely to wheeze and develop asthma later in childhood. a study of swedish children found that those who were hospitalized with rsv bronchiolitis in infancy were almost nine times more likely to have physician-diagnosed asthma at age 13 years than those without infection. 207 being hospitalized with rsv bronchiolitis in infancy was an independent risk factor for current asthma and recurring wheezing (or = 9.3; 95% ci, 3.6 to 24.5). henderson and colleagues 208 described the relationship of hospitalization for rsv bronchiolitis in infancy and asthma in a population-based birth cohort study of more than 8000 children from the united kingdom. hospitalization for rsv bronchiolitis was associated with physician-diagnosed asthma at age 7 years (or = 2.5; 95% ci, 1.4 to 4.3) only among nonatopic children. no association was observed for children with atopy type 16 (hrv-16) replicates more readily in the airway epithelial cells of people with asthma, and the airway epithelial cells are more likely to lyse and have greatly impaired interferon-λ (ifn-λ) and ifn-β responses. van der zalm and coworkers reported that increased neonatal airway resistance was related to an increased likelihood of hrv-associated wheeze in the first year of life (or = 1.77; 95% ci, 1.16 to 2.69). 218 hrv was originally classified as serotypes hrv-a and hrv-b, but in 2007, a novel hrv designated hrv-c was identified using reverse transcription-polymerase chain reaction (rt-pcr). 219 hrv-c has been implicated in the natural history of wheezing disease and asthma, and it appears to have prognostic importance. in a prospective, population-based study of 1052 children younger than 5 years of age who were hospitalized in two u.s. counties with acute respiratory illness or fever, hrv was detected in 16%, and hrv-c was isolated slightly more than 50% of them. children from whom hrv-c was isolated were significantly more likely than those with hrv-a or hrv-b to have underlying high-risk conditions such as asthma (or = 2.32; 95% ci, 1.05 to 5.23). 220 in australia, hrv serotypes were isolated from 88% of 128 children 2 to 16 years old who presented to the hospital with acute asthma. hrv-c was isolated from 59% of the children, and these children had higher asthma severity scores than those infected with hrv-a or hrv-b. 221 in a study of children hospitalized in hong kong, hrvs were isolated from 85% of 128 children admitted because of acute asthma and from 33% of 192 control, nonatopic children hospitalized with nonasthma respiratory conditions. 222 hrv-c was isolated from 70% of the children with acute asthma and 19% of the controls, and children with hrv-c were more likely to require supplemental oxygen. these studies implicate hrv-c in most episodes of acute asthma requiring hospital attention. hrv-c appears to be more virulent than other hrv serotypes, particularly in children with atopic sensitization. 223 although the major focus has been on viral respiratory tract infection, asymptomatic early-life bacterial airway colonization has also been associated with childhood wheeze and asthma. 224 in the copenhagen prospective study of asthma in childhood, 321 neonates at high familial risk for asthma had their hypopharyngeal regions sampled at 1 month of age, and the children were then followed up to 5 years of age. neonatal colonization of the hypopharyngeal region by streptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis (but not staphylococcus aureus) in isolation or in combination was associated with increased likelihood of subsequent wheeze, hospitalization with wheeze, and asthma. hypopharyngeal colonization at 1 year of age was not associated with neonatal colonization or the development of wheeze or asthma. although has been postulated that early-life bacterial colonization induced neutrophilic airway inflammation with consequent wheeze and asthma, it also has been suggested that neonatal airway colonization by these bacteria reflects defective early-life innate immune responses that predispose to asthma. 225 asthma-like symptoms, especially in young children, often are treated with antibiotics, and an association has been observed between the use of these drugs and the risk of asthma. the simultaneously increased use of antibiotics in children and the increasing prevalence of asthma in developed countries has led to the hypothesis (consistent with the hygiene hypothesis) that antibiotic use may contribute to asthma by altering the normal colonization of gut flora in infants and increasing the only for children who had also had hrv-associated wheezing episodes. measurement of lung function in the coast cohort at age 8 years demonstrated that hrv-associated wheezing episodes in the first 3 years of life were associated with reduced lung function: fev 1 of 96% of predicted for those with hrvassociated wheeze versus 102% for no hrv-associated wheeze (p < .03). similar differences were found for absolute fev 1 , forced expiratory volume in 0.5 second (fev 0.5 ), and forced expiratory flow determined over the middle 50% of a patient's expired volume (fef ). 215 lung function at age 8 was not associated with the frequency of hrv-associated wheeze nor with rsv-associated wheeze. although studies such as coast demonstrate that hrv respiratory infection is prognostically more important than rsv infection for subsequent asthma, whether virus-associated wheezing episodes (particularly hrv) contribute to the pathogenesis of asthma or are merely manifestations of infection in children predisposed to asthma remains an unanswered question. there is evidence supporting the concept that children predisposed to asthma have lung function and airway epithelial abnormalities from very early in life that increase the likelihood of virus-associated wheezing episodes. [216] [217] [218] human rhinovirus cross-sectional studies. in one of the earliest reports, northway and coworkers 234 considered the first possibility-that asthma is a long-term consequence of bronchopulmonary dysplasia (bpd). bpd is a syndrome of chronic lung disease in premature infants who are mechanically ventilated for at least 1 week as a treatment for rds. the clinical diagnosis requires the symptoms of persistent respiratory distress during infancy, dependence on supplemental oxygen, and abnormal chest radiographs. northway and colleagues 235 then studied adolescents and young adults born between 1964 and 1973 who had bpd in infancy and compared their long-term pulmonary outcomes with those of two control groups. they found that most subjects with a history of bpd in infancy had pulmonary dysfunction. moreover, the increase in airway reactivity was not associated with a more frequent family history of asthma in this sample or with an increased prevalence of atopy. these findings suggest that lung injury resulting from mechanical ventilation of premature infants has a role in the pathogenesis of persistent pulmonary dysfunction that is similar to asthma. bertrand and associates 236 investigated the role of rds in prematurity in the pathogenesis of airway hyperresponsiveness (ahr) in subjects who did not have bpd as infants. the group with a history of rds had evidence of more hyperinflation and airway obstruction compared with controls. however, results from the histamine challenge to determine ahr and familial aggregation of ahr were inconclusive. the incidence of airway reactivity was elevated among cases and controls and among the mothers and siblings of cases and controls. the investigators suggest that the elevated incidence of ahr among mothers of both groups supports the hypothesis that there may be an association between the onset of premature labor and airway reactivity. because no comparison group was established for mothers of term children, however, this assertion cannot be affirmed from the study. some researchers have investigated the effect of very low birth weight (vlbw < 1501 g) and bpd on asthma development in birth cohorts. [235] [236] [237] [238] [239] [240] [241] children with vlbw were followed for 8 years as part of the newborn lung project conducted in wisconsin and iowa. 237, 238 results at age 5 years did not show a consistent association between asthma and bpd. 237 children with diagnosed bpd and children with radiographically identified bpd had about a threefold and twofold increase, respectively, in the risk of bronchodilator use up to age 2 years, adjusted for birth weight, gestational age, gender, race, and neonatal center. among children with bpd, the prevalence of ever having asthma at age 8 years did not show a difference by the period of birth. 238 however, the prevalence of wheezing in the last year at 8 years of age decreased from 50% to 16% over time. as the researchers observed, this finding could have resulted from the introduction of surfactant therapy as a bpd treatment. prematurity as a risk factor for asthma has been explored in cross-sectional studies. [242] [243] [244] [245] [246] [247] a significant association between current asthma prevalence and premature girls was observed in a study of 5000 schoolchildren. 243 significantly more premature children had a family history of asthma than did term children, and this association was stronger among children who required mechanical ventilation as premature infants. another german study of schoolchildren did not show an association between former or current asthma and low birth weight (lbw < 2500 g) among premature children. 244 however, bronchial hyperresponsiveness was significantly increased in children born at atopic, helper t cell type 2 (th2) immune responses. 226, 227 in support of this hypothesis, humans exposed to stable and farm environments, which are rich in microbes, show significantly reduced levels of asthma and atopic disease compared with those in other rural or nonrural environments. 227 other studies have shown that the different proportion of aerobic and anaerobic gut flora in children from sweden compared with estonia parallels the difference in atopy incidence between these populations. 227, 228 animal studies also support the hypothesis. mice given oral antibiotics had altered intestinal flora and impaired helper t cell type 1 (th1) immune responses. 229 epidemiologic studies of asthma and allergic disease in relation to antibiotic use are beset by biases, including reverse causality (i.e., asthma leads to more common prescription of antibiotics) 230 and confounding by indication (i.e. respiratory infections leading to antibiotic use may be implicated in the development of asthma). to illustrate this problem, in a carefully conducted tucson birth cohort study, information on illness, antibiotic use, and physician visits was ascertained on seven occasions in the first 9 months of life and correlated with the development of asthma and allergic disease up to the age of 5 years. 231 a significant association between the number of early-life courses of antibiotics and asthma was reported. the number of physician visits was associated with the number of antibiotic courses and with asthma. however, after adjustment for the number of physician visits, antibiotic use was not associated with asthma, and it was concluded that any association between early-life antibiotic use and asthma was an artifact of the number of physician visits for illness, which was strongly associated with antibiotic use and risk of asthma. two systematic reviews have provided insight into the possible causative association between early-life antibiotic use and asthma and allergic disease. a systematic review of studies that have related antibiotic exposure during pregnancy or in the first year of life with risk of childhood asthma identified relevant 22 studies. 232 antibiotic use in the first year of life was associated with an increased likelihood of childhood asthma (or = 1.52; 95% ci, 1.30 to 1.77). stratified analysis indicated that retrospective studies reported the strongest associations (or = 2.04; 95% ci, 1.83 to 2.27) compared with database and prospective studies (or = 1.25; 95% ci, 1.08 to 1.45) . studies that addressed potential biases by adjusting for respiratory infections reported the weakest associations (or = 1.16; 95% ci, 1.08 to 1.25). a second systematic review focusing on longitudinal studies identified 18 studies, and a meta-analysis indicated that antibiotic use was associated with subsequent wheeze or asthma (or = 1.27; 95% ci, 1.12 to 1.43). 233 however, after eliminating nine studies with a high risk of bias, the magnitude of the association was reduced (or = 1.12; 95% ci, 0.98 to 1.26). both systematic reviews concluded that there might be a weak link between antibiotic use and subsequent asthma and that biases had exaggerated the strength of any association that might exist. premature birth has been associated with the development of symptoms consistent with asthma and other long-term pulmonary sequelae in a number of studies. the cause of the sequelae is uncertain. the pulmonary injury may be acquired during mechanical ventilation of preterm infants with respiratory distress syndrome (rds), from the rds itself, or from some other facet of prematurity. prematurity has been examined as a risk factor for asthma in cohort studies of affected children and in plants (e.g., grain dust, flour, latex, castor bean, green coffee bean), enzymes (e.g., subtilisin from bacillus subtilis, papain, fungal amylase), wood dust or barks (e.g., western red cedar, oak, reactive dyes), drugs (e.g., penicillin, methyldopa), metals (e.g., halogenated platinum salts, cobalt), and others such as oil mists. they have been classified according to possible pathogenetic mechanisms: high-molecular-weight agents that induce specific ige antibodies; low-molecular-weight substances, such as isocyanates, for which underlying mechanisms are largely unknown; and irritant gases, fumes, and chemicals that induce occupational asthma by nonimmunologic mechanisms. 255 more extensive coverage of these agents and the topic is available elsewhere. 256, 257 other causes of occupational asthma have been identified through clinical reports, epidemiologic investigations, and population studies. jaakkola and colleagues 258 conducted a casecontrol study in finland. risk for asthma was found to be increased for several occupational groups, including some for which occupational asthma had not been previously reported, such as being a male or female waiter. le moual and coworkers 259 explored associations for occupation and occupational exposures with asthma in 14,000 participants in a french survey conducted in 1975. several jobs were associated with an increased risk of asthma of about 50%. a similar analysis was reported for the united states based on the nhanes iii. 260 several studies provide estimates of the overall importance of occupational asthma. kogevinas and colleagues 261 analyzed data from more than 15,000 young adults participating in the ecrhs. an estimated 6.9% of asthma was attributed to occupation, with asthma defined by asthma symptoms or use of medication and assessed by questionnaire. when asthma was defined by questionnaire responses and bronchial hyperresponsiveness, the attributable risk estimated for occupation increased to 9.9%. among members of a u.s. health maintenance organization, one third of persons identified as having new or recurrent asthma were classified as having a potential association with work as the basis for asthma. 262 blanc and toren 263 conducted a meta-analysis of studies on occupational asthma from 1966 to mid-1999. the median attributable risk estimate for occupational asthma was 9% for all studies identified. when the study quality was taken into account and analyses were limited to those of higher quality, the estimate was 15%. these estimates included new-onset asthma and reactivation of preexisting asthma. outdoor air pollutants can be classified by origin as natural or manmade. among the naturally occurring air pollutants are particulate matter (including bioaerosols), volatile organic compounds, and ozone. for asthma, the key manmade pollutants result from combustion of fossil fuels in cars, power plants, heating devices, and industrial point sources and from emissions of chemicals from manufacturing facilities, storage tanks, and accidental releases. in the united states, air pollutants have been categorized on the basis of their regulation under the clean air act as criteria pollutants (e.g., lead, nitrogen dioxide [no 2 ], sulfur dioxide [so 2 ], particulate matter [pm], ozone [o 3 ], carbon monoxide [co]) and as air toxics, a specified listing of 189 chemicals that includes some irritants relevant to asthma. 264 these pollutants are a concern throughout the world's polluted cities and regions. many cities and smaller towns and term with lbw compared with children born with normal birth weight, with values adjusted for height, gender, and age. a study conducted as part of the ecrhs examined birth characteristics and asthma symptoms in young adults from norway. 245 the researchers observed a significant decrease in asthma symptoms per 500-g increase in birth weight, adjusted for gestational age, length at birth, parity, maternal age, gender, adult height, hay fever, and current smoking habits. race and socioeconomic status may be determinants of prematurity and asthma. to test the hypothesis that prematurity was a risk factor for asthma independent of race or socioeconomic status, oliveti and colleagues 248 performed a case-control study using a population restricted to african-american children from impoverished inner-city census tracts in cleveland, ohio. their findings confirmed previous findings with regard to prematurity and lbw. asthmatic children had significantly lower birth weights and gestational ages than nonasthmatic children and were more likely to have required positive-pressure ventilation (ppv) after birth. the risk of asthma was increased more than three times for children receiving ppv after birth. however, the increased risk of asthma due to lbw and prematurity was not significant when maternal history of asthma, bronchiolitis, lack of prenatal care, low maternal weight gain, and ppv were considered simultaneously. 248 this suggests that lung injury and perhaps mechanical ventilation lead to an asthma-like syndrome, rather than lbw and prematurity directly. researchers have examined the lung function of preterm children over time. koumbourlis and associates 249 followed 17 preterm children with chronic lung disease, including bpd, from 8 to 15 years of age. the investigators observed improvements in the lung volumes of these patients throughout childhood and into adolescence, and these improvements were experienced by all children, regardless of the severity of the neonatal chronic lung disease. if patients had airway obstruction, it was primarily localized to the smaller airways, associated with ahr, and relatively fixed over time. two systematic reviews have investigated the association between prematurity and childhood asthma and wheezing outcomes. patelarou and colleagues identified nine studies that had reported on the association between adverse birth outcomes (e.g., premature, lbw, vlbw, fetal growth retardation) and early (0 to 2 years) childhood wheeze. 250 they concluded that adverse birth outcomes were associated with wheezing in early life. similarly, a systematic review that identified 19 studies reported that preterm (<37 weeks' gestation) was associated with an increased likelihood of childhood asthma (or = 1.074; 95% ci, 1.072 to 1.075). 251 these results suggest that premature infants with or without neonatal respiratory disease may be at higher risk for asthma or a syndrome similar to asthma than term infants. however, the mechanistic pathways involved and the potential interactions with other asthma risk factors, such as viral respiratory infections and susceptibility genes, remain uncertain. occupational asthma is defined as variable airflow limitation or bronchial hyperresponsiveness due to exposure to a specific agent or conditions in a particular occupational setting but not to stimuli encountered outside the workplace. 252 several hundred agents have been identified as causes of occupational asthma. 253, 254 they include animal allergens (e.g., urine, dander), for children from east germany, where pollution originated from burning brown coal and industrial emissions. 290 however, living in west germany was not an independent risk factor for asthma after adjustment for sensitivity to pollen, hdms, and cat allergens. another german study conducted from 1995 through 1996 obtained similar results. 289 current asthma prevalence for children from munich was 5.1%, compared with the prevalence for their counterparts from dresden of 4.0%. significant differences in physician-diagnosed asthma prevalence were observed by comparing children in munich (10.3%) and those in dresden, former east germany (5.8%). 289 a study enrolling children 8 to 12 years of age who were living in hong kong compared physician-diagnosed asthma prevalence in a high-pollution district and a low-pollution district. 291 the researchers found that asthma prevalence was almost doubled in the high-pollution area compared with the low-pollution area. some studies have investigated the possible role of specific air pollutants in the development of asthma. in a cross-sectional study that was conducted as part of the isaac phase two and enrolled the same german children from dresden, an increase in estimated traffic-related exposure to benzene was associated with an increased prevalence in physician-diagnosed asthma after adjusting for potential confounders. 292 however, this association reached statistical significance only when the home and school addresses used as the exposure indicators were combined. the prevalence of asthma was not associated with concentrations of so 2 , no 2 , and co. an increase in the exposure to air pollutants (except ozone) was associated with an increased prevalence of physician-diagnosed asthma in 5421 nonatopic children (5 to 7 years and 9 to 11 years old). this relationship was not observed in atopic children. another cross-sectional study evaluating the effects of general air pollution was conducted among 165,173 high school students in taiwan as part of the isaac. 293 the researchers investigated the role of long-term exposure (i.e., annual average concentration) to air pollution and the prevalence of asthma. long-term exposure to total suspended particles, no 2 , co, ozone, and airborne dust was associated with increased prevalence of asthma after adjusting for exercise, smoking, alcohol consumption, incense use, and environmental tobacco exposure. a similar study of 331,686 middle school students living in 24 counties and cities in taiwan found a positive association between physician-diagnosed asthma prevalence and exposure to co and nitrogen oxides (no x ) when adjusted for age, history of atopic eczema, and parental education. 294 baldi and coworkers 295 reanalyzed data from a survey of 3193 children and 20,310 adults from seven french towns between 1974 and 1976. they estimated a significant increase (or = 1.24; 95% ci, 1.08 to 1.44) in asthma prevalence per 50 µg/m 3 in the so 2 3-year-period annual mean after adjusting for age, education, and smoking status. the association remained significant when they restricted the analysis to adults reporting their first attack after moving to the study areas. they did not observe this relationship for children. these cross-sectional studies address the prevalence of asthma, which reflects the incidence and duration of the disease. if air pollution increases the duration of asthma, the prevalence would be increased, even without an effect on incidence. the clearest evidence of a causal association between outdoor air pollution and childhood asthma comes from cohort studies. villages in the developing world have the problem of smoke from biomass fuel use for indoor cooking and heating that is emitted outdoors. 265 although it is accepted that exposure to outdoor air pollution can exacerbate existing asthma, 266-269 the role of outdoor air pollution in the development of childhood asthma is less well established. however, there is increasing evidence, especially from studies with a focus on exposure related to traffic within urban areas, that implicates outdoor air pollution in the development of childhood asthma [270] [271] [272] and lung function. 273 the outbreaks of acute asthma in barcelona illustrate the consequences of exposure to an airborne contaminant and the need to investigate asthma epidemics. during the 1980s, a remarkable series of epidemics of asthma occurred in barcelona, a port city. careful analysis of one outbreak showed spatial clustering near the harbor, and an epidemiologic investigation showed a very strong association between unloading of soybeans at the harbor and occurrence of the epidemics. 274 an antigen was identified in the soybeans that proved to be responsible for the outbreaks. 275 the outbreaks were traced to releases of dust at a particular silo, and control measures were enacted. 276 subsequently, a review of the historical record showed that there had been similar outbreaks of soybean asthma in new orleans. 277 a large body of experimental and observational evidence links outdoor air pollution to exacerbation of asthma. [266] [267] [268] [269] [278] [279] [280] [281] [282] [283] compilations of the evidence can be found in the criteria documents prepared by the u.s. environmental protection agency (epa) for particulate matter and ozone. 282, 283 human experimental studies have provided some insights, showing for example, that the oxidant pollutants nitrogen dioxide and ozone may enhance the effects of allergens, possibly by increasing the permeability of airways. 284, 285 epidemiologic data, primarily coming from studies of panels of persons with asthma or of medical morbidity, have shown that the adverse effects of air pollution on asthma are relevant clinically and are significant from a public health perspective. there is uncertainty about the relative effects of specific pollutants compared with the overall toxicity of the air pollution mixture. 286 gent and colleagues investigated the effect of exposure to ozone and particulate matter of 2.5 µm in diameter (pm 2.5 ) in a u.s. cohort study of 271 asthmatic children. 287 among children using maintenance medication, the level of ozone, but not pm 2.5 , was significantly associated with worsening of respiratory symptoms and an increase in rescue medication use. significant associations were not found for children not using maintenance medication. these findings suggest that children with asthma using maintenance medication are especially vulnerable to ozone, even after adjusting for exposure to pm 2.5 and at air pollution levels below the epa air quality standards. various lines of epidemiologic evidence continue to indicate a potential role of air pollution in the cause of asthma. crosssectional studies have investigated asthma prevalence and air pollution. after the unification of east and west germany, studies were conducted to compare respiratory diseases among children who had a relatively homogenous genetic background but had experienced exposures to air pollution at very different concentrations. [288] [289] [290] [291] in a study conducted between 1989 and 1992, children 9 to 11 years old from munich (west) had a higher prevalence of physician-diagnosed asthma than those from leipzig and halle (east). 288 current asthma prevalence among children living in west germany, an area with a greater amount of heavy road traffic, was 5.9%, compared with 3.9% also raised. the disparity between cross-sectional and prospective studies suggests that although the incidence of asthma among those living close to traffic is increased, it is not evident at a population level because of the small effect size and the lack of variation in the distance between home and traffic. cohort studies published since the comeap are consistent with its findings, but they also highlight a possible early-life effect and the importance of exposure while at school. the dutch prevention and incidence of asthma and mite allergy (piama) birth cohort study related symptom data prospectively collected annually from 3863 children up to the age of 8 years to land-use regression estimates of individual no 2 , pm 2.5 , and soot exposures at their birth addresses. 271 pm 2.5 was associated with an increased annual incidence of asthma (or 1.28; 95% ci, 1.10 to 1.49), prevalence of asthma (or = 1.26; 95% ci, 1.04 to 1.51), and asthma symptoms (or = 1.15; 95% ci, 1.02 to 1.28). the associations between outcomes and no 2 and soot exposures were similar, but there was a high correlation (r > 0.9) for pm 2.5 , no 2 , and soot exposures. only 48% of the cohort were still living at the birth address at age 8 years, and the associations between pollutants and outcomes were evident only in those who had not moved house; for the children who had moved from the birth addresses, the only significant association was between pm 2.5 and the prevalence of wheezing symptoms (or = 1.15; 95% ci, 1.00 to 1.32). the southern californian health study evaluated 2497 symptom-free children recruited in kindergarten or the first grade (≤6 years old) from 13 communities, each with continuous ambient ozone, no 2 , pm 2.5 , and pm 10 measurement. 272 the incidence of asthma in the subsequent 3 years was determined by annual questionnaires and correlated with individualized estimates of traffic-related pollution at home and at school. the incidence of asthma was increased by nonfreeway traffic-related pollution at home (hazard ratio [hr] = 1.51; 95% ci, 1.25 to 1.81) and at school (hr = 1.45; 95% ci, 1.06 to 1.98) . although the balance of evidence suggests an association between outdoor air pollution and the development of asthma in some individuals who live near busy roads, there does not appear to be an association between air pollution and the development of asthma at the population level. moreover, the welldocumented increase in asthma prevalence in the latter decades of the twentieth century cannot be readily explained by changes in levels of the major combustion pollutants. the emerging association between traffic-related emissions and asthma requires further investigation. in the home and other indoor environments, children and adults inhale diverse pollutants that may be associated with the risk for asthma. 279, 301 they include combustion-source emissions from cooking stoves and ovens, space heaters fueled by gas or kerosene, wood-burning stoves or fireplaces, and tobacco smoking; volatile and semivolatile organic compounds released from household products, furnishings, and other sources; and allergens from insects, molds, mites, rodents, and pets. 279, 301 many of these pollutants can be present in higher concentrations indoors than outdoors, providing a rationale for studies that have examined indoor pollutants as factors that may cause or exacerbate asthma. for example, in a prospective cohort study of inner-city u.s. children with asthma, indoor no 2 302 and pm 303 were associated with asthma symptoms. the associations were independent of each other and of outdoor the traffic-related air pollution and childhood asthma (trapca) study is a birth cohort study of children from the netherlands, germany, and sweden that is funded by the european union. 296 preliminary results from the 1756 german children followed for their first 2 years of life showed a 23% (95% ci, 1.00 to 1.51) increase in the risk of asthmatic, spastic, or obstructive bronchitis for those living close to major roads (<50 m) compared with children farther away. a cohort study of almost 5000 children between the ages of 5 and 7 years, who lived in nine communities surveyed in the california children's health study and four other communities, was started in 2003 to evaluate characteristics that might increase children's susceptibilities to the effects of traffic-related pollution. 297 preliminary results showed that living within 75 m of a major road was associated with an increased risk of physician-diagnosed asthma (or 1.29; 95% ci, 1.01 to 1.86), prevalent asthma (or = 1.50; 95% ci, 1.16 to 1.95), and wheeze (or = 1.40; 95% ci, 1.09 to 1.78). among long-term residents (i.e., living in the same home since the child was 2 years old or younger) with no parental history of asthma, an increased risk of physician-diagnosed asthma (or = 1.85; 95% ci, 1.11 to 3.09), prevalent asthma (or = 2.46; 95% ci, 1.48 to 4.09), and wheeze (or = 2.74; 95% ci, 1.71 to 4.39) was associated with living within 75 m of a major road. increased risk was not associated with the exposure for children with a parental history of asthma and for short-term residents. the adventist health study on smog (ahsmog) is a prospective cohort study that enrolled more than 3000 nonsmoking adults (27 to 87 years old) living in california in 1977. 298 in the first 10 years of follow-up, abbey and colleagues 298 examined 79 incident asthma cases in relation to pm and found a 30% increased risk of asthma for a 1000 hr/yr exposure to concentrations of pm 10 that exceeded 100 µg/m 3 . a later report on the ahsmog participants used the 1973-1992 8-hour mean ozone concentration as the exposure and found that the risk of developing asthma doubled per 27 parts per billion increase for males but not in females after adjusting for age, education, respiratory infection before age 16 years, and smoking status. 299 a systematic review commissioned by the u.k. committee on the medical effects of air pollution (comeap) was established to investigate whether outdoor air pollution causes asthma. 300 this 2010 review identified 14 cross-sectional studies relating asthma prevalence in more than four cities to quantitative pollution measures; the number of cities ranged from 6 to 62 and covered europe, north america, and asia. a metaanalysis revealed no significant associations between no 2 , pm 10 , or so 2 and period prevalence of wheeze and lifetime prevalence of asthma. the review also identified 14 studies of 10 birth cohorts and 11 studies of cohorts recruited during child or adulthood. in these studies, exposures were individualized by modeling, usually to the individual's home address. in contrast to the cross-sectional studies, meta-analysis revealed associations between no 2 and the incidence of asthma (or = 1.07; 95% ci, 1.01 to 1.14; 11 studies) and between pm 2.5 and the incidence of asthma (or = 1.43; 95% ci, 1.01 to 2.02; 5 studies). the comeap systematic review concluded that the evidence from the cohort studies is consistent with a significant increase in the incidence of asthma associated with no 2 and pm from traffic sources. the possibilities of air pollution aggravating existing subclinical asthma and residual confounding by factors associated with asthma and residential proximity to traffic were assessed early indoor allergen exposure and physician-diagnosed asthma or wheeze and did not find an association. they concluded that their results did not support the hypothesis that allergen exposure causes asthma. prospective cohort studies have studied the relationship between exposure to mold and the risk of asthma. a study of 1916 finnish children 1 to 7 years old used parents' reports of mold and dampness as a surrogate for exposure to aeroallergens in the home. 320 after 6 years of follow-up, exposure to mold was found to be an independent risk factor for asthma among finnish children. the incidence of physician-diagnosed asthma was double for children in homes with reported mold odor compared with those that did not. jaakkola and jaakkola reviewed the literature on indoor molds and asthma, and they concluded that exposure to molds at home increases the risk of asthma among adults and that exposure to molds at work increases the risk of wheezing. 321 they observed that exposure to indoor molds increases the severity of asthma and that removing the source relieves or eliminates symptoms and signs of asthma. sensitization to mold has been linked to the presence, persistence, and severity of asthma. 322, 323 a review of housing interventions designed to improve outcomes concluded that asthma symptoms could be reduced by removing moldy items and eliminating leaks and other moisture sources in homes. 324 intervention studies with avoidance of aeroallergens and food allergens have not consistently found a reduction of asthma risk among children. the canadian childhood asthma primary prevention study included 545 high-risk children who were randomized to intervention (i.e., avoidance of hdm by use of mattress covers and acaricides, pets, and passive smoking and encouragement of breastfeeding with delayed introduction of solid foods) or to control groups before birth. 325 for 380 children at 7 years of age, the prevalence of physician-diagnosed asthma was significantly lower for the intervention group (15%) than for the control group (23%). another intervention study of a birth cohort of 110 high-risk children living on the isle of wight assessed asthma (i.e., wheeze and bronchial hyperresponsiveness) prevalence at age 8 years and found that the asthma risk was ninefold higher for the control group than the intervention group. 326 intervention included breastfeeding by a mother on a low-allergen diet or giving a hydrolyzed formula and reducing hdm exposure with an acaricide and mattress covers. however, the australian childhood asthma prevention study, which included 516 highrisk children randomized to an hdm avoidance intervention group or control group, did not find a significant reduction in the prevalence of current asthma at age 8 years for the intervention group compared with the control group. 327 a systematic review and meta-analysis of prospective birth cohort studies evaluating the effects of allergen (i.e., hdm or dietary) avoidance during pregnancy concluded that early-life allergen avoidance in isolation does not reduce the likelihood of asthma in children at age 5 years (or = 1.22; 95% ci, 0.83 to 1.78). however, multifaceted antenatal intervention that combines breastfeeding with allergen avoidance and maternal smoking cessation does reduce the likelihood of asthma in children at age 5 years (or = 0.73; 95% ci, 0.55 to 0.97). 328 exposure to tobacco smoke has serious adverse effects on the respiratory tract. perhaps because of the sensitivity of the concentrations of the pollutant. a full examination of this literature is beyond the scope of this chapter, but reviews of indoor air pollution are available. 279 whether these exposures by themselves, in the absence of underlying genetic susceptibility, can cause asthma is uncertain. 301 however, mounting evidence indicates that maternal smoking is associated with an increased risk for asthma in offspring and later exacerbations of asthma (see "involuntary or passive smoking") and that levels of allergen exposure are associated with the incidence of asthma and wheezing. however, there have been only limited investigations of indoor air pollution and the incidence of asthma linked to risk factors other than passive exposure to tobacco smoke. an institute of medicine committee reviewed the evidence on indoor air pollution and childhood asthma and derived conclusions regarding causation and exacerbation. 301 this topic also has been reviewed elsewhere. 304, 305 several investigations have addressed the prevalence of asthma and exposure to nitrogen oxides from cooking stoves. homes with natural gas-fueled or propane-fueled cooking stoves tend to have no 2 levels substantially above those of homes with electric stoves. 306 some investigations indicate a general increased risk of respiratory symptoms, including wheezing, in households with gas stoves, but the data are inconsistent and not indicative of increased asthma incidence caused by nitrogen oxides. 31, 307 the myriad exposures to volatile and semivolatile organic compounds that can occur in homes and other locales have been investigated as risk factors for childhood asthma. although many cross-sectional studies report an association between volatile organic compound exposure and asthma in children 308, 309 and adults, 310, 311 these studies cannot establish causality and are beset by the problem of reverse causality, whereby parents modify their houses (e.g., laminate flooring) as a consequence of their children developing asthma. 312 cohort studies suggest that maternal volatile organic compound exposure during pregnancy can influence the development of childhood allergic disease. 313 this is an area of ongoing research because of the potential for intervention by behavioral modification and low volatile organic compound technology. studies of indoor allergens have largely focused on the status of children with asthma in relation to levels of allergen rather than considering the levels of allergens as predictors of asthma. 314 a prospective cohort study conducted in the united kingdom found levels of hdms in the home to predict later development of asthma, and children with higher levels of hdm antigen in their homes tended to wheeze at a younger age. 315 the german multicentre allergy study followed 1314 children from birth to 13 years of age and found that sensitization to perennial allergens such as hdms, cat hair, and dog hair that developed before 3 years of age was associated with a loss of lung function at school age. 316 a u.s. study of 474 children indicated that exposure to two or more dogs or cats in the first year of life might reduce subsequent allergic sensitization risk to multiple allergens during childhood. 317 not all studies support the conclusion that allergen exposure causes asthma. a british cohort study did not find a significant association between levels of hdm exposure and sensitization or wheeze. 318 results from a german birth cohort of 939 children followed until age 7 years showed a strong association between sensitivity to hdm allergens or cat allergens and wheezing from 3 years of age. 319 however, the investigators also during pregnancy has also been associated with increased in vitro cord blood mononuclear cell proliferative and cytokine responses after stimulation with allergens. 339, 340 there is extensive literature on the relationship between passive smoking and childhood wheeze and asthma. a systematic review identified 79 relevant prospective cohort studies. 341 exposure to maternal (prenatal and postnatal), paternal, and household sources of cigarette smoke was associated with an increased likelihood of children wheezing up to the age of 18 years. the strongest associations for childhood wheeze were for postnatal exposure to maternal cigarette smoking: wheeze at 2 years or younger (or = 1.70; 95% ci, 1.24 to 2.35), 3 to 4 years (or = 1.65; 95% ci, 1.20 to 2.68), and 5 to 18 years (or = 1.18; 95% ci, 0.99 to 1.40). the associations between exposure to maternal, paternal and household cigarette smoke and childhood asthma were not as strong as for wheeze, but they were most noticeable for maternal smoking during pregnancy: childhood asthma at 2 years or younger (or = 1.85; 95% ci, 1.35 to 2.53) and 5 to 18 years (or = 1.23; 95% ci, 1.12 to 1.36). paternal smoking was associated with an increase in childhood asthma between 3 and 4 years, and household smoking was associated with an increase in childhood asthma after the age of 3 years. the children's health study based in california reported a transgenerational association, suggesting that exposure to cigarette smoke in utero may have epigenetic effects. 329 in a nested case-control study of children at 5 years of age (279 with asthma and 412 controls), the likelihood of childhood asthma was increased if the mother (or = 1.5; 95% ci, 1.0 to 2.3) or the maternal grandmother (or = 2.1; 95% ci, 1.4 to 3.2) smoked during pregnancy. 342 if the mother and grandmother smoked during pregnancy, the likelihood of childhood asthma was increased further (or = 2.6; 95% ci, 1.6 to 4.5). although allergic rhinitis is common, few epidemiologic studies have focused on this disease. the most frequently cited risk factors include increasing age, atopy, and high socioeconomic status. 343 parental history is positively associated with the development of allergic rhinitis in offspring. in the tucson birth cohort study, a maternal history of physician-diagnosed allergy was significantly associated with a diagnosis of rhinitis by age 6 years (or = 2.2; 95% ci, 1.35 to 3.54). 344 perinatal and infant risk factors have been examined. for example, younger gestational age at birth has been associated with a decreased risk of allergic rhinitis. 345, 346 some researchers have postulated that early-life exposures to microbes may modulate risk of allergic rhinitis, and this hypothesis has been supported by the observations that birth by cesarean section is a risk factor for allergic rhinitis, 347 as is reduced diversity of the intestinal microbiota in infancy. 348 other risk factors under investigation include genetics, 349 early-life exposure to infections, acetaminophen use, 350 oral contraceptive use, 351 and indoor and outdoor air pollution exposure. 352 risk factors for eczema include gender, race or ethnicity, family history, early-life antibiotic use, environmental exposures, and dietary factors, including breastfeeding, timing of the introduction of solids, and inclusion of probiotics. family history of asthmatic lung to cigarette smoke, young smokers tend to have somewhat greater lung function and less underlying airway responsiveness than nonsmokers-a phenomenon sometimes referred to as the healthy smoker effect. 329 nonetheless, substantial data show that active smoking increases nonspecific responsiveness of the airways, perhaps by inducing inflammation 329 or by narrowing baseline airway caliber in older people. 28 smokers also tend to report wheezing more frequently than nonsmokers, and wheezing tends to decline after cessation of smoking. increased airway responsiveness in active smokers also tends to abate after smoking cessation. 329, 330 a systematic review of studies exploring the temporal association between active smoking and asthma reported that most studies indicated that people who smoked were at increased risk for asthma. 331 these studies evaluated diverse sample populations and used different methods, and the review highlighted the potential for residual confounding by health behaviors (e.g., physical exercise). the review concluded that although active smoking might be a risk factor for asthma, the evidence was insufficient to conclusively state whether smoking was a causal or proxy risk factor for asthma. the nonsmoking child is exposed to second-hand smoke, a name given to the mixture of sidestream smoke released by a burning cigarette and the mainstream smoke exhaled into the air by the smoker. this mixture has also been called environmental tobacco smoke. smoking adds respirable particles and irritant gases to indoor air, and it represents one of the major sources of fine particles in the air of u.s. homes. 332 exposure of children to particles and gases in tobacco smoke has been documented by measuring personal exposures and using biomarkers that indicate the levels of tobacco smoke components absorbed into the body. 333 cotinine, a major metabolite of nicotine, has been extensively investigated in children in relation to parental smoking. compared with children living in households in which there is no smoking, children living with smokers tend to have substantially higher cotinine levels. 332, 333 in the past, exposure to second-hand smoke was widespread. almost all participants, including nonsmokers, in the 1988-1990 nhanes iii had detectable serum cotinine levels. 334 ten years later, nhanes iv showed a dramatic reduction in cotinine levels, 335 a trend that has continued. 331 exposure to second-hand smoke contributes to both the causation and the exacerbation of asthma. first, passive smoking may increase the risk of more severe lower respiratory tract infections during the early years of life. 336 second, the direct toxic effects of second-hand smoke may induce and maintain the heightened nonspecific responsiveness of airways found in asthmatic children. third, many children have secondhand smoke exposure during gestation and after birth. substantial evidence suggests that in utero exposure to tobacco smoke components affects fetal airway and immune system development. young and associates assessed nonspecific airway responsiveness using a histamine challenge for 63 normal infants at a mean age of 4.5 weeks. 337 even at this young age, parental smoking and a family history of asthma were associated with an increased level of airway responsiveness. in a similar prospective investigation, hanrahan and colleagues found that children whose mothers smoked during pregnancy had a lower level of airway function soon after birth. 338 maternal smoking later epidemiologic studies provided a deeper understanding of the physiologic consequences of having childhood asthma and indicated that the lungs of these children might already have heightened airway responsiveness at birth. birth cohort studies that include indices of ventilatory function and airway responsiveness during the first weeks of life indicate that infants at risk for asthma because of a parental history of asthma and atopy already have heightened responsiveness to a challenge. 337 the tucson study clarified the early natural history of wheezing. 120,372 martinez and colleagues described the natural history of wheezing beginning before 3 years of age and found that some children had only transient early wheezing. children who continued to wheeze up to 6 years of age were more likely to have mothers with a history of asthma and to have an elevated serum ige levels, suggesting that the early wheezing represented asthma. children whose wheezing did not persist had diminished airway function in early life but did not tend to have mothers with asthma or elevated ige levels. the pattern of persistence of wheezing during childhood and into adulthood was similar in a smaller cohort study of 100 children in england, who were followed from birth to age 22 years. 373 in this highrisk cohort, early wheezing was not likely to persist, but wheezing at 11 years of age did tend to persist. the results of these studies imply that clinicians should be cautious in labeling all early childhood illnesses with wheezing as asthma, because some children are predisposed to wheeze with respiratory infections because of reduced airway function. population-based groups of children have been followed over time in prospective cohort studies (table 48 -5) . because most of these studies have drawn participants from defined populations, there is less potential for bias by the selection process, and the children with asthma are more likely to be representative. information collected from childhood to early adulthood is available from several investigations, including two particularly large studies involving lengthy follow-up: the cohort study in australia and the 1958 birth cohort study in the united kingdom. 374, 375 findings of a number of smaller studies have been similar (see table 48 -5). one of the first studies using a birth cohort design was conducted in australia, initially by williams and mcnicol. 374, [376] [377] [378] on enrollment in 1964, the children were 7 years of age, and after 35 years of follow-up, they were 42 years old. [376] [377] [378] wheezing tended to track over time, but 43% were no longer wheezing at 28 years of age, and only 32% had wheezing at least weekly. those with more severe wheezing at age 28 years tended to have a lower level of lung function tested by spirometry and to have a higher degree of airway responsiveness to a methacholine challenge. over time, some improved, but an approximately equal proportion worsened. at age 42 years, 60% of the group with wheezy bronchitis at baseline was free of wheeze, and only 5% of this group had persistent asthma. 378 symptoms continued in 70% of the original asthma group and in 90% of the severe asthma group. almost one half of the severe asthma group continued to have persistent asthma at age 42 years. those with severe asthma had suffered a loss in lung function by 14 years of age, but this loss did not progress in adulthood. children with milder symptoms did not have a significant loss of lung function. in another large, long-term study, members of the 1958 birth cohort in the united kingdom were followed up to age 33 years. 375, 379, 380 parents were interviewed when the participants eczema has been identified as a risk factor for eczema in several studies, 353 pointing to genetic determinants of eczema. loss-offunction mutations in the filaggrin gene (flg), which encodes a protein critical to skin barrier function, have been directly linked to eczema, and approximately 42% of people heterozygous for these mutations develop eczema. 354 black and asian race or ethnicity is a risk factor, along with male gender, 353, 355 although isaac phase three found that worldwide, boys were less likely to have eczema than girls. earlylife exposure to endotoxin appears to protect against the development of eczema, as reported in several studies. 356, 357 dietary factors, including breastfeeding, infant formulas, timing of solid food introduction, and supplementation with probiotics, have been studied. neither breastfeeding nor timing of solid food introduction has been associated with protection against eczema. [358] [359] [360] [361] [362] [363] evidence suggests that hydrolyzed infant formulas and supplementation with probiotics may afford some protection against eczema, 364, 365 but study results are mixed, and infection by the probiotic organism has been reported in infants receiving probiotic supplementation. established risk factors for food allergy include male gender for children, eczema, and an atopic family history. [366] [367] [368] other possible risk factors are diet and feeding practices during early childhood. controversy exists about whether early allergen introduction or allergen avoidance may predispose to the development of food allergy. the natural history of asthma is a concern for affected children, their parents, the clinicians providing care, and researchers. parents ask whether the child will outgrow asthma, and clinicians should be able to answer this question. researchers have studied the natural history of asthma and searched for factors that determine prognosis. during adulthood, the former asthmatic child may be exposed to environmental agents, including cigarette smoke, which may adversely affect respiratory health. childhood asthma has been postulated to increase the likely adverse effects of these exposures and other long-term consequences, such as persistent physiologic impairment from airway remodeling. 369, 370 initial information on the natural history of childhood asthma largely came from cohort studies of children attending general practices or clinics. 140, 371 these studies, some dating to the 1930s, were a principal source of data on the natural history of asthma until population-based investigations were implemented beginning in the 1960s. these early studies provided evidence of waning of clinical symptoms over time in a substantial proportion of children with asthma. however, most children tended to remain symptomatic. interpretation of these data is constrained by differences between past and current therapeutic approaches, possible lack of representativeness of children receiving care at a particular clinical facility, and by diversity of the research methods. 140 these studies drew the participants from general practices and clinics, and presumably, more severe asthma was represented. nevertheless, they provide evidence that the prognosis is favorable for some children with asthma, even in an era antedating contemporary therapeutic approaches. bronchial challenge testing, and allergy testing. of the 613 participants with complete data for the follow-up period, 14.5% had persistent wheezing into adulthood, and only 27.4% never reported wheezing. the remainder had various patterns of intermittent wheezing. predictors of persistent wheezing included sensitization to hdms, female sex, and smoking at age 21 years. pulmonary function was reduced in those with persistent wheezing. evaluation of the natural history of asthma in adults is complicated by the occurrence of copd and the potential difficulty of separating copd from asthma. in adults, asthma includes disease originating in childhood and following its natural course into adulthood and asthma developing during the adult years. these natural histories have not been carefully delineated, although the lengthier studies of childhood asthma can provide information on its course into adulthood. there is less information on asthma in adulthood that is comparable to that on childhood asthma, such as the longitudinal picture of symptoms and clinical status. however, the effect of having asthma on the decline of lung function has been assessed, and there is limited information on the development of irreversible airflow obstruction in persons with asthma (table 48-6 ). the evidence on asthma and change in lung function over time is inconsistent with some studies showing were 7, 11, and 16 years of age, and the participants themselves were interviewed at age 23 and 33 years. asthma tended to remit over time; of the children with a report of asthma or wheezy bronchitis before 7 years of age, only 10% had wheezing in the last year at age 23 years, although this figure increased to 27% at age 33 years. 375 lung function was evaluated in a sample of 1060 of the participants with a history of asthma or wheezy bronchitis and 275 controls. 380 for those not reporting wheezing at age 33 years, lung function was only slightly reduced compared with controls. for those with wheezing, fev 1 was reduced by approximately 10% compared with controls. similar results were found in a 1994 follow-up study of 181 dutch individuals. 381 subjects were extensively tested as children 25 years earlier and reexamined as adults. the data revealed that 11% of persons were no longer considered asthmatic, 25% had an fev 1 greater than 90% of predicted, 21% were no longer bronchial hyperresponsive, and 40% did not report asthmatic symptoms. results of these studies support the hypothesis that early intervention in mild asthma may lead to improved outcomes. in a longitudinal, population-based, cohort study carried out in dunedin, new zealand, 382 1139 children were enrolled, and a substantial proportion was followed to age 26 years with repeated assessment by questionnaires, lung function testing, in the copd group and a 20-ml loss in the intermediate group. the balance of the evidence indicates that a diagnosis of asthma is associated with an increased rate of fev 1 decline (see table 48 -6). perhaps reflecting this excess decline, many elderly persons with asthma have fixed airflow obstruction. 389 there are few studies on the clinical course of asthma in adults (table 48-7) , and as airway obstruction becomes fixed with advancing age, separating asthma from copd becomes increasingly difficult. in the study by schachter and coworkers, 384 of the male participants age 18 years or older with asthma, 75% improved and only 1% worsened during follow-up. among female participants, 58% improved and none worsened during follow-up. bronniman and burrows 390 followed 136 asthmatics, who were drawn from the general population sample in tucson, arizona, of 2300 persons, over a 9-year period. participants were classified as in remission if they had active disease at baseline and on follow-up denied medication use, asthma attacks, and frequent attacks of shortness of breath with wheezing during the preceding year. after 9 years of follow-up, 22% were in remission, with the highest rate found among those between 10 and 19 years of age at enrollment (65%) and the lowest rate found for those between 40 and 49 years of age (6%). remission was more common in those with less frequent wheezing, less frequent asthma attacks, and less frequent attacks of shortness of breath with wheezing. remission was significantly less likely increased decline in persons with asthma compared with controls and others showing no difference between asthmatics and controls. peat and woolcock followed 92 persons with asthma, who were 22 to 69 years old on enrollment, and 186 control participants from busselton, australia. 383 the asthmatic individuals had lower lung function values at enrollment and the fev 1 declined at 15 ml/yr more in the persons with asthma compared with the controls. schachter and colleagues 384 followed the lung function of 73 persons with asthma and 278 with wheezing. over a 6-year interval, there was a similar excess loss of fev 1 in the persons with asthma. ulrik and lange 385 followed subjects over a 5-year period and found that asthmatic subjects had lower baseline lung function values and an excess annual decline in fev 1 compared with nonasthmatics; the excess annual decline was 39 ml in asthmatic men and 11 ml in asthmatic women. some individuals with asthma appear to eventually develop irreversible airflow obstruction, which has been related to duration and severity of asthma. 356, 387 a continuing effect of asthma was found when follow-up was extended to 15 years. 388 other studies have not shown increased loss of function associated with having a diagnosis of asthma. burrows and colleagues 389 examined the course of asthma over 10 years in 27 asthmatics from the general population and compared them with two other groups: 45 copd subjects and 45 subjects who did not fit clearly into either group. the asthmatic subjects had a 5 ml/yr decline in fev 1 , compared with a 70-ml decline years. this was a highly selected group with many comorbidities, which probably influenced the eventual outcome. unfortunately, little is known about the outcome of elderly asthmatics that are not as ill. panhuysen and colleagues 104 followed 181 persons with asthma over 25 years. the participants had been comprehensively evaluated in an asthma clinic in the netherlands between 1962 and 1970 at the ages of 13 to 44 years (mean, 24 years). on retesting, 38% no longer showed bronchial hyperresponsiveness on histamine challenge, and based on a lack of bronchial hyperresponsiveness, symptoms, and lung function level, 11% were considered to no longer have asthma. settipane and colleagues 393 followed a group of college students over 23 years. half of those with asthma on follow-up reported the disease as inactive, although about 50% of the new cases occurred during follow-up. in those with chronic productive cough or a coexisting diagnosis of chronic bronchitis or emphysema. a normal level of percent predicted fev 1 at baseline was the most powerful predictor of remission. persons 30 to 60 years old with active symptoms had only a 10% remission rate over 9 years. broder and colleagues 391 reported similar findings, with a remission rate of 16.7% for patients between 16 and 44 years of age and 21% in those 45 years of age or older. all relapse rates increased with age. braman and coworkers 392 investigated the outcomes of 25 nonsmoking asthmatics older than 70 years of age. all had moderately severe asthma requiring daily bronchodilators, and 22 of the 25 needed daily glucocorticoids. over 7 years, dependency on those drugs and complications of therapy were common. no patients died of acute asthma, but two died of chronic respiratory failure. mortality was not related to the level of pulmonary function or duration of asthma in philadelphia: wb saunders number of allergens to be tested to assess allergenic sensitization in epidemiologic studies: results of the european community respiratory health 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distinct clinical entity with lifelong significance? the state of childhood asthma in young adulthood decline in lung function in the busselton health study: the effects of asthma and cigarette smoking the characteristics of bronchial asthma among a young adult population mortality and decline in lung function in 213 adults with bronchial asthma: a ten year follow up key: cord-023331-jrvmgnu3 authors: nan title: asthma & allergy sig: poster session 3. physiology, environment, investigation and management date: 2008-03-12 journal: respirology doi: 10.1111/j.1440-1843.2008.01252_3.x sha: doc_id: 23331 cord_uid: jrvmgnu3 nan increased airway smooth muscle (asm) in asthma may be due to hyperplasia or hypertrophy of asm cells. the contribution of extracellular matrix (ecm) within asm bundles has not previously been accounted for when estimating asm cell volume. aim to estimate the mean asm cell volume in asm bundles in asthma. methods post-mortem tissues from control subjects (c n = 9); nonfatal (nfa n = 11) and fatal (fa n = 10) cases of asthma were studied. on 30 mm transverse airway sections stained with haematoxylin, the volume density (nv) of asm cell nuclei was estimated using an optical disector (¥1000). the mean cell volume (vc = 1/nv) was calculated, correcting for the volume fraction of asm (fasm) within the asm bundle (corrected vc = 1/(nv ¥ fasm)). fasm was estimated on 0.5 mm thick sections of the same airway stained with masson's trichrome. basement membrane perimeter (pbm) was used to indicate airway size. results table shows mean ϯ sd. (one-way anova) *p < 0.05 for c v fa, nfa v fa. conclusion these data suggest that although asm area is increased in asthma, mean asm cell volume is unchanged. therefore hyperplasia, not hypertrophy, of asm cells is present in both mild and severe asthma. these results were similar for both large and small airways. asthma is characterized by airway inflammation and remodelling which contribute to airway hyperresponsiveness and episodic airflow obstruction. mast cell (mc) densities are higher on the smooth muscle (asm) in asthma so their mediators may modulate other asm functions as well as cause contraction. aim to investigate the effect of mc mediators on chemokine and extracellular matrix (ecm) production by asm cells from donors with and without asthma. methods mc were isolated from the resected lung samples of 6 patients, resuspended at 10 6 cells/ml in dmem + 10% fbs and stimulated with ige/anti-ige. supernatants (sn) were collected after 2 and 24 h and the mc lysed. sub-confluent asm cells from 6 donors with and without asthma were serum deprived for 72 h before mc sn/lysates were added in dmem + 10%fbs for 48 h. il-8 and eotaxin levels in all asm sn and mc sn/lysates were measured by elisa. fibronectin and collagen iv deposition was measured in situ by immunoassay following asm cell lysis. results in asthmatic and non-asthmatic asm cells all mc sn and lysates reduced eotaxin release by up to 47% and 58%, whereas the 0-2 h mc sn significantly increased il-8 release to 178 ϯ 35.9% (p = 0.0339) and 169 ϯ 49% (p = 0.0445) of the fbs control respectively. however, only nonasthmatic asm cell il-8 release was increased by the mc 2-24 h sn (216 ϯ 85%; p = 0.0421) and cell lysates (215 ϯ 47%; p = 0.0421). the 0-2 h mc sn also increased fibronectin deposition to 143 ϯ 16% (p = 0.008) by asthmatic asm cells only. mc sn and lysates had no effect on collagen iv deposition. conclusions activated mast cell mediators differentially modulated chemokine and ecm secretion by asm cells from donors with and without asthma. thus mast cells may modulate their own recruitment to the smooth muscle and remodelling locally in the airways in asthma. supported by nhmrc. the technique of ige passive sensitization reproduces ige-related allergic responses in vitro and studies have validated this technique for investigations modelling allergic smooth muscle responses. there are no studies investigating effects of ige sensitization on rhinovirus (rv) infection. we hypothesized that rv infection is enhanced by ige sensitization, a consequence of diminished early innate immune responses. methods beas-2b epithelial cells and primary culture airway fibroblasts were sensitized with ige 24 h-7 d prior to infection with rv16. samples of tissue culture supernatant and cell lysates were collected over a 12 h period after infection for analysis. viral replication was measured by real-time rt-qpcr and viral titration and type i interferon mrna by rt-qpcr. ige receptor mrna expression was examined using rt-pcr. results initial studies to establish the model used human serum high in ige (>1000 iu/ml), this yielded inconsistent results and it was found that purified ige (1000 iu/ml) provided more reliable responses. sensitization was established after 24 h ige incubation and was comparable with up to 7 d. rt-pcr detected mrna for the ige low affinity receptor only after sensitization. following rv16 infection, vrna was increased after 24 h in ige sensitized cells (p < 0.05), but this effect varied noticeably between and within cell lines. cellular expression of ifn-b mrna increased with viral infection but in cells sensitized with ige lower levels of expression were noted (p < 0.05). conclusions ige passive sensitization enhanced rv replication in vitro but the model is constrained by significant variability between and within cell lines. the effect of sensitization on rv replication may occur through the low affinity ige receptor. activated mast cells (mc) are present in higher numbers on the airway smooth muscle (asm) in asthma compared with other inflammatory airway diseases. matrix metallo-proteinases (mmps) cleave chemokines and alter chemokine gradients by degrading the extracellular matrix and thus may modulate mc migration to the asm. aim to determine the levels of mmp-2, mmp-9 and their inhibitors, timp-1 and timp-2, secreted by asm cells from donors with and without asthma. method confluent asm cells were washed, serum-starved for 48 h and then stimulated with th1 (il-1, tnf and ifn) or th2 (il-1, il-4 and il-13) cytokines or left unstimulated. after 4 and 24 h,the sn were collected. the relative amount of pro and active forms of mmp-2 and mmp-9 in sn were determined by gelatine zymography. timp-1 and timp-2 levels in the sn were measured by elisa. results pro-and active mmp-9 were not detected. however, pro-mmp-2 levels were high in sn of asm cells from donors with (195.6 ϯ 47.2 % positive control/10 5 cells) and without (226.5 ϯ 49.2 % positive control/10 5 cells) asthma. a trend to increased active mmp-2 production by asm cells from donors with (7.3 ϯ 2.7 % positive control/10 5 cells, n = 9) compared to without (2.9 ϯ 0.7 % positive control/10 5 cells, n = 11) asthma after 24 h was not significant (p = 0.101). timp-1 and timp-2 levels respectively were high in the sn of cells from donors with (69.4 ϯ 19.6 and 21.3 ϯ 4.7 ng/10 5 cells, n = 5) and without (57.3 ϯ 13.7 and 16.6 ϯ 3.5 ng/10 5 cells, n = 5) asthma. th1 and th2 cytokine stimulation did not affect mmp or timp release. conclusions th1 and th2 cytokines did not regulate asm cell production of mmp-2, timp-1 and timp-2. altered asm mmp-2 activity is unlikely to play a role in mc chemotaxis to asm cells from donors with asthma in vitro or their presence on the asm in asthma. there has been a marked increase in the prevalence of asthma and other allergic diseases in the last few decades. one of the explanations for this is the change in our diet. one of the characteristics of the "western diet" is a high intake of both saturated and polyunsaturated fat. this prompted us to compare the effects of high fat and low fat meals on the numbers of circulating eosinophils and other leukocytes. methods we studied 12 volunteers who had allergic rhinitis and/or asthma and a peripheral eosinophil count at baseline of ն200 ¥ 10 7 /l. this was a randomized, crossover trial with participants studied on two different days. on each occasion they arrived fasting and after bloods were drawn consumed a 3000 calorie meal. one of the meals was high in saturated fat and refined carbohydrate. the other meal was low in saturated fat and high in fruit and fibre. bloods were drawn postprandially every hour for five hours. results eosinophil counts were highest in the early morning and fell over the course of the day but the decrease was less with the high fat meal (p = 0.03). over the same period of time the increase in lymphocytes (p = 0.016) was greater with the high fat meal. the high fat meal was also associated with greater increases in triglycerides (p < 0.0001) and cholesterol (0.004). conclusions in atopic individuals a high fat meal was associated with higher circulating numbers of eosinophils and lymphocytes than an isocaloric meal that was low in fat. further studies of the effect of dietary fat on eosinophilic inflammation are warranted. supported by the university of auckland research committeee. intravenous gamma globulin therapy (ivig), which is therapeutic in a variety of immune diseases, has been reported to be effective on patients with severe steroid-dependent asthma. although fcer are known to play important roles in asthma, there are few reports about the role of fcg?receptors in asthma. fcg receptor iib (fcgriib) is unique inhibitory receptor, which suppresses immune response. in this study, we evaluated the effect of ivig in allergic airway inflammation in ova-challenged mice and the mechanism of the inhibitory effects of ivig and fcgriib. method c57bl/6 mice (wt) and fcgriib deficient mice (ko) were sensitized with ovalbumin (ova) and alum and subsequently challenged with nebulized ova. before ova challenge rabbit igg was administered intravenously. the airway inflammation and effects of igg were assessed by histology, cell counts of bal fluid and airway hyperresponsiveness. result histology showed that igg treatment ameliorated the inflammation around the airway and the vessels and hypertrophy of goblet cells induced by ova challenge. the migratory activity of dcs is modulated in inflammatory diseases such as asthma. recently, we reported that immature dcs express kinin receptors and that bradykinin (bk) significantly enhances the migration of immature dc in vitro. as kinins mediate many of the pathophysiological effects associated with asthma, we hypothesized that lys-des[arg 9 ]-bk, which is produced during inflammation and acts via the b1 receptor (b1r), would inhibit migration of mature dcs. methods day 7 cultured human monocyte-derived dcs were matured with lps, tnfa +il-1b or cd40l in the absence or presence of lys-des[arg 9 ]-bk. maturation of dc was analysed by flow cytometry (facs). b1r expression was assessed by reverse-transcriptase pcr and quantitative confocal microscopy. migration of mature dc was assessed in transwell chambers with lysdes [arg 9 ]-bk and the chemokine ccl19 used as chemoattractants. results maturation of dcs was found to result in down-regulation of b1r expression to varying degrees depending upon the maturation stimulus used. mature dcs all demonstrated an ability to migrate toward lys-des[arg 9 ]-bk and ccl19. however pre-treatment with lys-des[arg 9 ]-bk decreased the migratory ability of all mature dcs to both chemoattractants. conclusions along with chemokines, lys-des[arg 9 ]-bk is likely to play a crucial role in regulating the in vivo migration of mature dc during inflammation. the production of lys-des [arg 9 ]-bk during inflammation potentially immobilizes mature dcs thereby facilitating locally-mediated immune responses within inflamed tissues. supported by the asthma foundation of western australia. introduction alternative or aberrant splicing is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms. the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to use a new and innovative approach involving the use of the genechip (r) exon array system together with real-time quantitative pcr to study asthma candidate genes in human monocyte-derived dendritic cells. asthmatic and non-asthmatic subjects provided 20 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method, and differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data indicate splice variant expression in dendritic cells from asthmatic patients is influenced by asthma severity. conclusion exon expression array analysis has generated a number of asthma candidate genes with alternative splice variants. further studies to validate these data in a replicate data set and establish the functional significance of our findings in asthma are underway. alternative or aberrant splicing occurs in more than 70% of genes and is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms 1 . the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to study one asthma candidate gene in human stimulated and unstimulated: (1) monocytes, (2) monocytederived dendritic cells and (3) lung smooth muscle cells. methods asthmatic and non-asthmatic subjects provided 40 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method. up to 50% of the monocytes were then differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. induction experiments used 1 mg/ml lps and cells were stimulated for an optimal period of 24 hrs. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data from stimulation experiments indicate splice variant production can be regulated by the inflammatory response and that this response is influenced by asthma status. conclusion preliminary experiments have confirmed the presence of an aberrant splice variant for an asthma candidate gene in the primary cells studied. further studies to confirm these data and establish the functional significance of our findings in asthma are underway. exposure to environmental factors, such as environmental tobacco smoke (ets), plays a significant role in modulating pre-existing genetic susceptibilities to diseases including asthma. the glutathione s-transferase enzymes (gsts) play an important role in the detoxification of ets. there are several gst isoforms and gstp1 codes for the gst pi isoform, which is the primary gst isoform expressed in human lung tissue. two single nucleotide polymorphisms (snps) at positions 105 and 114 have been reported in gstp1 and associated with asthma and atopy. the aim of this study was to examine the effect of these snps in combination with ets, on asthma phenotypes in a cohort of asthmatic children. children were recruited during an acute episode requiring presentation at an emergency department. genotyping using pcr-rflp was completed on 218 children and ets exposure was determined by parental questionnaire. urinary cotinine was measured in the children and was in agreement with questionnaire responses. statistical analyses were performed using spss. there were no significant associations between the genotypes and asthma severity during acute exacerbations. significant associations were found between the snps and atopy in this population with an odds ratio of 2.77 for the 105aa genotype (p = 0.029) and or of 5.47 for the 114cc genotype (p = 0.002). however, when an interaction with ets was included, the odds ratios increased to 9.02 for 105aa (p = 0.05) and 9.17 for 114cc (p = 0.020). these results suggest that there is a significant gene/environment interaction impacting on atopy in this cohort. the rage gene encodes the receptor for advanced glycation end-products (rage), a member of the immunoglobulin superfamily. rage activation by ligands, including amphoterin and s100/calgranulins, leads to prolonged nf-kb signalling and has been associated with chronic inflammation. despite high levels of rage expression in lung tissue, little research has been undertaken into the role of rage in the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. objective determine genetic associations between functional polymorphisms in the rage promoter and severe and aspirin-sensitive asthma phenotypes. methods pcr and restriction fragment length polymorphism (rflp) were used to genotype three rage promoter polymorphisms, -429t>c, -374t>a and a 63 bp deletion from -407 to -345, in a large case-control asthma population phenotyped for asthma severity, atopy and aspirin sensitivity. results no associations were identified between any of the polymorphisms and the occurrence of asthma. however, the -374a allele was linked with both severe asthma (p = 0.013) and aspirin-sensitive asthma (p < 0.001). likewise, genotypes containing the -374a allele were strongly associated with both severe asthma (or 2.10, 95% ci 1.32-3.36) and aspirin-sensitive asthma (or 3.13, 95% ci 1.45-6.77). conclusions the -374a allele of the rage gene, previously shown to lead to a 3-fold increase in promoter activity, is associated with the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. these results suggest that increased rage expression, with a concomitant increase in nf-kb signalling, may in part contribute to the inflammatory response seen in these conditions. the global prevalence of allergic diseases is rising and australia has one of the highest prevalence rates in the world. the role of early childhood infections in the development of allergic disease remains controversial. objective to examine the association between early childhood infections and the development of allergic diseases in later childhood, in high risk children. methods data were analysed from the melbourne atopic cohort study (macs) of 620 infants with 1 or more first-degree family members with atopic disease. primary risk factors assessed were otitis media, bronchitis and gastroenteritis reported in the first two years of life. outcomes were current asthma, hay fever and eczema at 6 years of age. logistic regression was used to estimate crude and adjusted odds ratios. results asthma was the most common allergic condition (25.4%, 95% ci 21.6-29.5%), followed by eczema (24.9%, 95% ci 21.1-29.0%) and hayfever (15.6%, 95% ci 12.5-19.1%). the most commonly reported infection was otitis media (58.9%, 95% ci 54.9-62.8%), then gastroenteritis (37.7%, 95% ci 33.9-41.7%) and then bronchitis (19.4%, 95% ci 16. [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] .7%). all 3 types of infection within the first 2 years of life were associated with increased risk of asthma. an increased risk of asthma at 6 years was seen with otitis media (or = 1.14, 95% ci 1.02-1.3), bronchitis (or = 1.34, 95% ci 1.0-1.8) and gastroenteritis (or = 1.23, 95% ci 0.96-1.6). when the frequency of infection was examined, those who reported at least 3 episodes of gastroenteritis had a 3-4-fold increased risk and an almost 30% absolute increased risk (rd 0.34, 95% ci 0.08-0.59). conclusion these findings appear to contradict the hygiene hypothesis. the findings for gastroenteritis are novel. further examination of these associations and possible underlying mechanisms is warranted. grant support asthma foundation of victoria, nestle. background knowledge about incident cases of asthma in australia is limited because they are not routinely reported. the ability to predict the number of new cases of asthma would be helpful in allocating resources for asthma education, management and care. data on first use of medications for asthma gives an indication of the incidence of asthma. the objective of this study was to estimate the incidence rate of asthma by investigating asthma medication use in individuals. methods pharmaceutical benefits scheme (pbs) records for all prescriptions filled for inhaled corticosteroids (alone or combined formulation), cromones and leukotriene receptor antagonists from july 2002 to june 2005 were included. using a 2-year look back window, any persons who had their first prescription for any of these drugs dispensed between july 2004 and june 2005 were assumed to be incident cases. overall and age-specific incidence rates were calculated per 100 asthma-medication-free individuals. results there were 352,082 individuals who had their first asthma medication dispensed between july 2004 and june 2005, which equates to an overall incidence rate for asthma of 1.89 per 100. the incidence was higher among children aged 0-14 years (2.07) and adults aged 65 years and over (2.45) . conclusions our estimated incidence rates were consistent with those reported by others in the literature. while the pbs database was designed for administrative purposes, it can be used to estimate incidence rates for asthma. support acam is a collaborating unit of the australian institute of health and welfare and is funded by the department of health and ageing (doha). we acknowledge the pharmaceutical pricing and estimates section of doha for provision of pbs data. keywords asthma incidence, pharmaceutical benefits scheme. rosario ampon 1 , guy marks 1 , teresa to 2 , leanne poulos 1 , anne-marie waters 1 1 australian centre for asthma monitoring (acam), sydney, australia, and 2 hospital for sick children, toronto, canada background the ability to assess individual patterns of asthma medication use would have clinical relevance in targeting effective asthma education and management for this common condition. to describe longitudinal patterns of asthma medication use, we used a population-based prescription database to follow individuals from the first time they filled an asthma prescription. asthma is more commonly listed on death certificates as an associated cause of death, in people whose deaths are attributed to other causes, than as an underlying cause of death. understanding the importance of these associations would contribute towards an overall appreciation of the impact of asthma on mortality. the objective of this analysis was to estimate the prevalence of asthma as an associated cause of death when various other diseases were attributed as the underlying cause of death. background acam currently recommend 24 indicators to measure population-level asthma health and outcomes. we examined correlations among several asthma indicators covering prevalence, morbidity and mortality to try and produce a condensed set of indicators which minimized redundancy. methods seven of the 24 indicators were included in this study: prevalence of ever having doctor diagnosed asthma, prevalence of current asthma, asthma-related general practice (gp) encounters, proportion of people with asthma with an asthma action plan (aap), hospitalizations for asthma, hospital patient days for asthma, and deaths due to asthma. a correlation matrix was created for these indicators by age groups. pearson correlation coefficients ն0.7 or յ-0.7 were considered strong. results there were strong positive correlations between prevalence of ever asthma and current asthma (r = 1.0); gp visits and aap possession (r = 0.74), hospitalization (r = 0.91) and patient days (r = 0.95); and hospitalization and patient days (r = 0.90) and aap possession (r = 0.73). recent australian reports have shown that the prevalence of asthma and respiratory symptoms has decreased over the last 10-15 years. as part of a larger study investigating child health and air quality we have collected nationwide data from schoolchildren living in act, victoria, queensland, wa and sa. methods schools were selected based on proximity to air quality monitoring stations. classes from years 3 to 6 were randomly selected and all children were invited to participate. parents self completed a questionnaire that included questions about diagnosed asthma and respiratory symptoms. results a total of 1989 children provided questionnaires for analysis. the response rate varied between states and territories and ranged from 30% to 42%. the sample comprised 51.9% girls and the mean age of children was 10.2 years. ever diagnosed asthma 27.9 current asthma ('does he/she still have asthma? ') 13.8 wheeze in the past 12 months 16.1 respiratory symptoms limiting activities 11.8 missed school due to asthma or wheezing 8.8 conclusions despite the relatively low participation rate, the prevalence estimates for current asthma are similar to those reported in the national health survey 2004-05 [1] . there is no evidence of any recent increase in the prevalence of childhood asthma. methods tahs is a longitudinal population-based respiratory study of 8583 subjects which commenced in 1968 when they were 7 years of age. since the initial study another 4 follow-ups have been conducted, including the most recent follow-up when subjects were 44 years of age. lung function of the total sample was measured at baseline and in sub-samples in 3 subsequent followups. asthma was categorized as persistent, frequent or episodic when participants reported asthma symptoms in at least 3 follow-ups, in 2 follow-ups or in 1 follow-up respectively. results by age 7 years ever asthma prevalence was 16%. at age 44, 10% of those who had not reported asthma by age 7 had asthma symptoms while 75% of those who reported asthma by age 7 had no asthma symptoms. hence over all only 25% of the asthma symptoms at age 44 were attributable to asthma developed by age 7. in contrast, 91% of the persistent and frequent asthmatics had developed their asthma by age 7. persistent and frequent asthmatics had more symptoms and poorer lung function at age 7, 14 and 44 as well as more reversibility at age 44 (p < 0.05). childhood asthmatics who also had a productive cough by age 7 were more likely to have persistent asthma than those without a cough (p < 0.05). conclusions although the majority of middle-age asthma is related to postchildhood onset asthma, most severe middle-age asthma has its origin in persistent childhood disease. having productive cough in childhood may identify high risk asthmatics who require especially rigorous management in early life. one third of women experience an improvement in asthma during pregnancy, and symptoms improve in most women in the late third trimester. we hypothesized that the exacerbation rate would be reduced and that symptoms during exacerbations would be less severe in the third trimester compared to the second trimester. methods pregnant women with asthma (n = 81) were prospectively followed from recruitment (14.8 weeks (3 sd) ) to delivery at clinic visits (18, 30, 36 weeks and during exacerbation), and fortnightly phone calls. the asthma control questionnaire (acq) was administered at each contact and exacerbations classified as severe (requiring medical intervention) or mild (selfmanaged). lung function, medication use, fractional exhaled nitric oxide (feno) and full blood counts were assessed. paracetamol is commonly used in infants as an analgesic and antipyretic. it has been hypothesized that frequent paracetamol consumption may result in reduced lung capacity to cope with oxidative stress and increase risk of respiratory disease. to date, no study has examined exposure to paracetamol during infancy, when lungs are still developing, and risk of childhood asthma. method a birth cohort of 620 infants with an atopic family history was recruited. frequency of paracetamol exposure was prospectively documented up to 2 years of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results paracetamol exposure in infancy was common (97% exposed by two years of age), with some infants receiving paracetamol on up to 77 days. it has been hypothesized that mucosal immune response requires a particular micro-flora milieu in the infant's gastro-intestinal tract, and that early life antibiotic exposure may disrupt this process and increase risk of allergic disease. method a birth cohort of 620 infants with an atopic family history was recruited. exposure to oral antibiotics was prospectively documented up to 12 months of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results by one year of age, approximately 80% of infants had received at least one course of oral antibiotics. the prevalence of current asthma in childhood was approximately 30% (148/495). frequent use of antibiotics (more than 20 days exposure during first year of life) was associated with increased risk of childhood asthma (or = 2.52, 95% ci = 1.40-4.54) when compared to infant who had not been exposed. excluding infants with a diagnosis of asthma within the first two years of life, reduced this association by about 30% (or = 1.80, 95% ci = 0.90-3.57) and adjustment for gender, parental history of asthma and number of infections in the first year of life further reduced this association (or = 1.60, 95% ci = 0.79-3.22). the increased risk of childhood asthma associated with antibiotic exposure in the first year of life is, at least in part, due to confounding with early life wheeze and infections. if real, the independent effect of antibiotic exposure on risk of childhood asthma is likely to be minimal in this high risk cohort. support dairy australia, crc for asthma and airways, vichealth, nestle. the epidemiological data on asthma suggest a gender difference that varies with age. hormonal effects have been suggested as a possible explanation for these differences. the aim of this study was to examine reproductive factors and risk of asthma among the females of the tasmanian longitudinal health study (tahs). methods the tahs is a longitudinal population-based cohort study of respiratory disease which commenced in 1968 when subjects were 7 years of age. four follow-up studies have been conducted including the current most comprehensive follow-up with subjects at 44 years of age. information has now been collected on reproductive factors such as number of pregnancies, age at pregnancies, age at menarche and contraceptive pill use as well as on asthma status. reproductive factors were examined as risk factors for asthma using multiple logistic regression to adjust for all likely confounders. results a total of 2,776 women completed the most recent postal survey. of these 355 (12.8%) had current asthma, and of these women with current asthma 73.5% (261) developed asthma after childhood. on average these women were in their mid-twenties when they developed asthma (mean ϯ sd age = 26.6 ϯ 12.5 yrs). we found with increasing age at first birth an approxi-mate~30% reduced risk of current asthma in women who developed their asthma post-childhood (trend p = 0.04). we did not observe any other associations between reproductive factors and risk of asthma. conclusions our results are consistent with the hypothesis that early pregnancy may promote asthma development by altering the immune response favouring a th2 pathway. a delay in the age of first pregnancy reduces this risk of asthma. grant support nhmrc, clifford craig foundation, victorian & tasmanian asthma foundations. introduction the association between exposure to pets in early life and subsequent development of sensitization and allergic disease remains controversial. the objective of this analysis was to examine the relationship between cat exposure before birth and development of cat sensitization over time within the melbourne atopic cohort study (macs). methods the macs is a prospective longitudinal cohort study that initially recruited 620 women antenatal in melbourne from february 1990 to november 1994. detailed information on cat exposure was collected at recruitment and frequently until two years of age. skin prick test (spt) were conducted at 6, 12, 24 months and 10 years. the data were analysed by logistic regression and using generalized estimating equations (gee) for the repeated measures design. results among 620 subjects, 169 (28.8%) had a cat before birth. at 6 months, 1.9% (n = 11) of subjects were sensitized to cat and by 10 years of age 18.8% (n = 68) were sensitized. those who did not have cat before birth belong to a higher social class, and were more likely to have a father with allergic disease than those with a cat. those who developed sensitization to cat were more likely to have a paternal family history of allergic disease and more likely to be sensitized to other allergens. we did not observe any association between exposure to cat before birth and the development of sensitization to cat at 6 months (or = 0.7, 95% ci 0. 1-3.3) , 12 months (or = 1.4, 0.5-3.9), 24 months (or = 0.76, 0.2-2.5) or 10 years (or = 0.6, 0. 2-1.4) . these crosssectional results were confirmed by the gee analysis. conclusion our results fail to show an association between cat exposure before birth and development of sensitization to cat. furthermore exposure after birth in the first 18months of life was not associated with an increased or decrease risk of sensitization to cat. our results do not support either a benefit or risk associated with cat ownership and sensitization. introduction peri-natal events influence the development of asthma and atopic diseases in childhood but the current literature is contradictory on the effect of low birth weight, small for gestational age and prematurity on asthma risk. the aim of this study was to assess the relationship between these three exposures and asthma from childhood to adulthood. aim to assess the current prevalence of dda, wheeze (<12 months), atopy and ahr in children and adults in busselton. methods an age-and sex-stratified random sample of adults, selected from the electoral roll, was invited to complete a questionnaire and attend the local study centre for assessment of atopy (allergen skin tests) and ahr (methacholine). all children from participating primary and secondary schools were also invited to attend. the prevalences of dda, wheeze, atopy, ahr and "current asthma" (wheeze + ahr) were calculated. background asthma is often associated with comorbidity, however few studies have investigated comorbidities among people with this common condition. the objective of this analysis was to describe patterns of non-respiratory comorbidity among adults hospitalized with asthma in australia. methods data on hospitalizations for people aged 15 years and over with a principal diagnosis of asthma (j45, j46) were obtained from the australian institute of health and welfare's (aihw) national hospital morbidity database for the period 2005-06. patterns of comorbidity were examined by investigating additional diagnoses for non-respiratory disease according to icd-10 diseasespecific chapters. results among people aged 15 years and over hospitalized in 2005-06 with a principal diagnosis of asthma (16,566 hospitalizations; 70% female; 47% aged 35-64 years), 33% had at least one non-respiratory comorbidity. median length of stay was higher among those with at least one comorbidity (4 days) than among those with no comorbidities (2 days). among people aged 15-64 years, the most common comorbid condition was endocrine, nutritional and metabolic diseases (19%), while among those aged 65 years and over it was diseases of the circulatory system (32%). conclusions a large proportion of asthma hospitalizations in australia are associated with non-respiratory comorbidity and a longer length of stay. further, the pattern of non-respiratory comorbidity associated with asthma hospitalizations varies by age. given our rapidly ageing population, the level of comorbidity associated with asthma has implications for coordinated health care and demand on health services. support acam is a collaborating unit of the aihw and is funded by the department of health and ageing. keywords comorbidity, hospitalization, asthma. background asthma exacerbations are often triggered by viral respiratory infections, yet the influence of respiratory infections on the morbidity of acute asthma beyond the immediate period is unknown. we examined the influence of nasopharyngeal (npa) respiratory viral, chlamydia and mycoplasma detection on asthma morbidity in children presenting to the emergency department for an acute exacerbation of asthma. methods a subset (n = 78) of the 201 children enrolled for a randomized controlled trial (rct) on the efficacy of 5 vs 3 days of oral prednisolone had an npa taken at presentation. npa were examined for chlamydia, mycoplasma and respiratory viruses (enteroviruses, coronaviruses, human metapneumovirus, adenovirus, parainfluenza, influenza, rsv, rhinoviruses) by pcr. enrolled children were aged 2-16 years with recurrent wheeze and required ն600 ?g (mdi/spacer) or ն2.5 mg (nebulized) of salbutamol to reduce tachypnoea. parents filled validated diary cards for cough and asthma severity, and completed asthma qol data at enrolment and end of weeks 1 and 2. results pcr for various viruses was positive in 42 (53.8%) children, with no significant difference in the groups the children were randomized into. rhinovirus pcr was positive in the npa of 32 children, rsv in 7, hmpv in 2, adenovirus, parainfluenza, influenza a and b in one each. specimens were negative for the other micro-organisms listed above. children with a npa viral positive state were significantly (p = 0.002) younger than those with a negative state. however, there was no difference in the any of the asthma outcomes of children whose npa was positive or negative for the micro-organisms tested. conclusions in children with an acute asthma exacerbation presenting to emergency health facilities, a respiratory virus could be identified in >50% but the presence of a respiratory virus did not influence the morbidity of the asthma exacerbation at presentation or at the end of week-1 and week-2. the university of sydney, nsw 2006, and 3 royal north shore hospital, st leonards, nsw 2065 airway wall thickness measured using hrct is reported to be increased in asthmatic compared with control subjects. however, it is unknown whether wall thickness is a fixed structural characteristic of the airways or if it responds to transient changes in bronchomotor tone or airway size. aim to determine the effects of bronchomotor tone and lung volume on airway wall area measured by hrct. methods 8 patients with doctor-diagnosed asthma had partial chest hrct scans, before and after bronchodilator (bd), at frc, tlc and a volume midway between (mid-volume). airway segments were identified between branch points and matched between consecutive lung volumes both before and after bd, and also at constant lung volume before and after bd. mean lumen areas and wall areas for each airway segment at each volume were measured using automated analysis software. paired t-tests were used to determine changes due to bd and lung inflation. results 44 airways were matched before and after bd at frc. absolute airway wall area (wa) was related to airway lumen diameter (di wood smoke air pollution is of concern with respect to respiratory health due to its complex chemical composition and potential to carry air toxics into the lower respiratory system. launceston has a long history of poor winter air quality, primarily due to use of domestic wood heaters. participants in hobart had a similar prevalence of wood heater use, but hobart does not experience the same wood smoke pollution (due to differences in regional geography , asthma control and anxiety and depression were completed at baseline, immediately following (6 wks), and 3 mths after the intervention period. results clinically and statistically (p < 0.05) significant improvements in qol were observed in the exercise group at 6 wks compared to the control group. this difference was not maintained at 3 mths. 6mwd improved at 6 wks and 3 mths in the exercise group (p < 0.01), however the difference between groups was not significant. in the exercise group there was a trend towards improved asthma control and a reduction in anxiety and depression that was not observed in the control group. *p < 0.05, change at 6 wks vs baseline; home asthma monitoring is important for measuring day-to-day variation in lung function and symptoms. this approach requires the availability of complete diaries for a comprehensive assessment. we assessed the completeness of written diaries collected as part of a nation wide study of air quality and child health. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified from a cross-sectional study. these children were asked to record symptom scores and peak expiratory flows twice daily in diaries for a five week period. the diaries and peak flow devices were explained at a face-to-face meeting with parents and children. each week diaries were mailed back and parents received a phone call to encourage completion. completeness was defined as no missing responses to symptom questions or peak flow measurements in diaries from week two to week five. results data from the first 36 children (822 day records) were available for analysis. the sample included (53%) girls, mean age 10 yrs. the overall frequencies for complete records were; morning symptoms 85%, morning peak flow 85%, evening symptoms 83% and evening peak flow 82%. there was a significant trend for more complete morning peak flow records over the four weeks (cochrane-armitage trend test p < 0.007). agreement between morning and evening symptom completeness and between morning and evening peak flow completeness was fairly poor (kappa < 0.30). conclusions the completeness of symptom and peak flow records collected in this study was very high. the comprehensive follow-up protocol implemented is likely to have had an important impact on the completeness of asthma diaries. daily peak expiratory flow (pef) monitoring has been used in epidemiological studies to assess changes in lung function over time. the value of written pef diaries has been questioned because of problems with completeness and validity. this study aimed to compare stored electronic pef data and a written diary record of those data in a panel study in children with weekly reminders to aid adherence. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified in a population study. they were given electronic pef devices with a digital readout (miniwright digital, mwd, clement clarke, uk) and written symptom and peak flow diaries and instructed in their use at a meeting with parents and children. each child was asked to complete three pef manoeuvres every morning and evening for five weeks and to record these in the written diary. background previous research suggests that comorbid anxiety is associated with lower asthma-related quality of life (aqol) in adults with asthma. however, research is scant on the role of psychological interventions in these patients. aim to evaluate the effectiveness of a four-session cognitive-behavioural therapy (cbt) intervention, in improving the aqol, in participants with anxiety and asthma. method participants identified with comorbid anxiety and asthma were randomly assigned to the cbt intervention group (n = 10) and the asthma monitoring control group (n = 8) and evaluated on aqol measures, at various intervals. results nine participants, in the cbt group, completed the study. seven participants showed a clinically significant improvement in asthma-related emotional functioning (ef) and six participants in total aqol scores, at the 5-week post-intervention assessment. additionally, six participants in the cbt group indicated clinically significant improvement in ef and five participants in total aqol scores, at the 3-month follow-up assessment. only three participants in the control group completed the study. none of these participants showed any improvement in aqol scores at the 5-week or 3-month assessment. conclusion this pilot study suggests that a higher number of participants in the cbt group showed clinically significant improvement in ef and total aqol scores with higher retention rates. further research needs to confirm these findings in a larger group, identifying the elements of a successful cbt intervention and characteristics of participants who respond to the cbt intervention. gastro-oesophageal reflux disease (gord) is a risk factor for uncontrolled asthma. we conducted an update of a systematic review to assess whether treatment of gastro-oesophageal reflux in subjects with asthma improved asthma outcomes. methods randomized controlled trials (rcts) of gord treatment in adults or children that reported asthma health outcomes and had symptomatic gord were included and assessed in accordance with the standard cochrane systematic review process. subjects received pharmacological therapies compared with conservative management. results from 261 potentially relevant studies, 19 rcts were included in the review. when compared to placebo, morning peak expiratory flow did not significantly improve (change from baseline wmd 10.43, 95% ci: -9.55 to 30.42) with proton pump inhibitor treatment (n = 7 trials involving 739 participants). asthma exacerbations were not significantly less in the intervention groups compared with the control groups (odds ratio 0.66; 0.41-1.08; n = 557). conclusions while some trials reported evidence of asthma improvement with gord therapy, overall there appears to be no statistically significant evidence of a beneficial effect. it is clear that not all persons with gord and asthma will gain improved control over their asthma with gord therapy; this may be due to the heterogeneous pathophysiology of asthma. future large-scale trials would be required to demonstrate an effect on asthma exacerbations. kel and brd were supported by a cochrane airways group scholarship. background the ats/ers task force recommend the use of metered dose inhaler (mdi) and spacer for airflow limitation reversibility testing. salbutamol given via mdi & spacer has been shown to be equivalent to a nebulizer in the clinical setting. this has not been well studied in respiratory laboratory setting. aim to compare the 2 methods of reversibility testing in a laboratory setting. methods we conducted a laboratory based crossover study in a secondary hospital. patients with asthma or copd were eligible. the patients firstly underwent spirometry and reversibility testing following a standard dose of nebulized salbutamol. they were asked to return for a second set of spirometry within the same week and at the same time of day when reversibility with an mdi and spacer was recorded. we used an incremental dose of salbutamol starting from 2 puffs and up to 8 puffs. spirometry parameters were recorded 10 minutes after each intervention. the primary outcome was the percentage change in fev1 after each intervention. side effects were monitored for. results nine patients with asthma were recruited. the mean percentage change in fev1 was higher in the nebulizer group than after only 2 puffs via mdi & spacer (15.4 ϯ 7.4 vs 6.2 ϯ 8 [mean ϯ sd], p = 0.67). however, there were no differences between the 2 arms following higher doses of bronchodilator via mdi & spacer. the mean percentage change in fev1 after 4, 6 and 8 puffs were 12.6 ϯ 11.3, 15.4 ϯ 12.3, and 17.7 ϯ 13.6 respectively (p = 0.09, 0.05 and 0.07 respectively when compared to the nebulizer group). conclusion using an mdi and spacer for bronchodilator reversibility is equivalent to that of a nebulizer and should be the standard method of testing. the dose of bronchodilator needs to be at least 4 puffs as recommended by the ats/ers; however 6 puffs correlated best with a standard nebulizer route. further increments in bronchodilator dose provided little additional bronchodilatation. the study was limited by the small number of patients. asthma guidelines recommend a stepwise approach to treatment. the role of inhaled corticosteroid (ics) and long-acting beta-agonist (laba) combination therapy in asthma written action plans is not clear. objective to assess the efficacy of adjusting ics/laba combination therapy in a written action plan compared to fixed dosing in people with asthma requiring maintenance ics. methods cochrane systematic review of randomized controlled trials comparing ics/laba combination therapy in a single inhaler that is adjusted up or down according to a written action plan (wap) to comparison 1: budesonide/ formoterol given as a fixed maintenance dose (fd) (n = 9) or comparison 2: fluticasone/salmeterol fd (n = 2). results 10 parallel randomized controlled trials describing 11 interventions met the inclusion criteria. for the trials that compared wap to fd budesonide/ formoterol there were significant reductions for the wap group in exacerbations, (rr (95%ci): 0.82 (0.70 to 0.97)), severe exacerbations (rr (95%ci): 0.61 (0.37 to 0.99)) and study medications (wmd (95%ci): -1.18 (-1.23 to -1.14)) with no difference in asthma control or adverse events. the results for the two trials reporting wap budesonide/formoterol to fd fluticasone/ salmeterol were discordant and a homogenous pooled result could not be determined. of the 318 australians who died from asthma in 2005, over two thirds were over 50 years of age. this trend resulted in the national asthma council of australia (nac) calling for better management of asthma in the elderly. we designed an educational intervention using evidence based educational strategies to improve the content and style of general practice consultations for older people with asthma. methods randomized controlled trial of a multi-faceted program consisting of a group educational session, a videotaped standardized simulated patient consultation, followed by an academic detailing session. forty-two gps were randomized into an active or a control group. gps provided the names of patients who would be happy to participate in the study and the program was evaluated by patient and gp outcomes. results gps recruited into our program reported improvements in a range of clinical areas. one hundred and ten patients were recruited, their outcomes are under analysis. conclusion gps were overwhelmingly positive about participation in this trial and our intervention successfully improved the capacity and confidence of gp's to deliver care to older people with asthma. our study also developed several tools that would enable dissemination of our findings. supported by an asthma targeted in studies where direct clinical assessment is not possible, urgent health care utilization (hcu) is often used as an indirect measure of asthma control. this study aimed to identify factors predicting urgent hcu and asthma control. methods patients in nsw with a doctor diagnosis of asthma were recruited from community pharmacies, a research volunteer database, and databases of asthma foundation nsw, to complete a questionnaire about asthma. poor asthma control was defined as asthma control questionnaire (acq) score ն1.5. urgent hcu was defined as hospitalization, ed visit, or urgent doctor visit due to asthma. multiple logistic regression was used to identify predictors of poor control and urgent hcu. results questionnaires were completed by 608 adults (61% female) with a doctor diagnosis of asthma (pharmacy 260, woolcock 299, asthma foundation 87). 87% used inhaled corticosteroid (ics) ϯ long-acting b2-agonist in the last 4 wks. median age was 56 yrs (range 12-87), and 9% were current smokers. mean acq score was 1.4 (95% ci 1.3-1.5), with 40% of participants having poor asthma control (acq ն 1.5). 28% had urgent hcu for asthma in the previous year. significant independent predictors for poor asthma control were younger age, current smoking, living in more disadvantaged areas, being retired, having only primary education, and holding a concession card. predictors for urgent hcu were younger age, being in full-time employment, having only primary education, and being of non-english speaking background. neither ics use nor possession of a written asthma action plan was associated with lower risk for either poor asthma control or hcu. conclusions poor asthma control is common in nsw even in patients using inhaled corticosteroids. although urgent hcu is often used as an indirect measure of poor asthma control, it is affected by different factors, perhaps because health care utilization represents a more complex balance between need and access. bronchial challenge tests with mannitol, to measure airway hyperresponsiveness, can take up to 30 minutes and require inhalation of up to 635 mg of mannitol. our aim was to determine if positive mannitol challenges can be detected after half the maximal dose (315 mg) using the forced oscillation technique (fot) to measure response. methods 15 non-asthmatic subjects and 52 asthmatic subjects underwent standard mannitol challenge, up to 635 mg mannitol. respiratory system conductance (grs) and reactance (xrs) was measured by fot at 6 hz during 40 sec tidal breathing immediately after each dose of mannitol. fev1 was measured after fot, within 90 sec of mannitol administration. two point dose response slope (drs), was calculated for grs (drsgrs) and xrs (drsxrs) for standard tests, up to 635 mg, and for short tests by excluding data from doses above 315 mg. ability to detect a positive test, defined as pd15fev1 < 635 mg, was determined by the area under the roc curve (auc) and repeatability by intra-class correlation coefficient (icc). results 32 asthmatic and 2 non-asthmatic subjects had positive tests, with pd15 fev1 values from 9.2 to 622 mg. auc (95%ci) did not differ between standard (std) and short tests for drsgrs (p = 0.14) or drsxrs ( combined use of inhaled steroids (ics) and long acting beta-agonists (laba) have an important role in asthma management. we used data from a 2006 population sample to examine medication use in adults and children. methods all adults (18-75 years) and children (2-17 years) from within four discrete zones in northern sydney were eligible for an interview survey, as part of a study investigating health effects associated with traffic-related air pollution. the prevalence of use of short-acting beta-agonists (saba), any ics (alone or combination) and combined formulations of ics/laba in the previous three months was estimated for the study population and those with diagnosed asthma. results there were 806 children [mean (sd) age 8.7 (4.6) years and 50% female] and 2184 adults [mean (sd) age 45.6 (14.9) years and 56% female] interviewed in 1843 households, representing an overall response rate of 33%. the prevalence of ever diagnosed asthma was 16.1% in children and 17.4% in adults. medication data were missing for 301 subjects. background asthma affects 1:9 adult australians and is a leading cause of rejection for recruitment into the australian defence force (adf). within this diagnosis there is a wide spectrum of disease activity and clinical outcomes. also asthma assessment and management has improved so that many asthmatics are now fully active without any significant disruption or risk to their lives. hypothesis: there is a subgroup of asthmatics who are at very low risk from significant adverse effects from asthma and who could be considered for recruitment to the adf. aims 1. to identify the subgroup of asthmatics who could be considered for recruitment to the adf. 2. to develop an assessment process to identify this subgroup (screening). 3. to develop a process to evaluate the outcomes of any change to the recruitment standard for asthma (evaluation). methods 1. a literature review of the natural history, assessment, management and response to treatment of mild episodic and mild persistent asthma. 2. a literature review of asthma in the military. 3. a clinical review of the outcomes of known asthmatics in the adf. 4. an expert group to review the above and to develop a screening process and an evaluation of the program. the literature review identified a subgroup of asthmatics, defined as mild episodic and mild persistent, who with appropriate management, have a low risk of significant adverse asthma outcomes. they can be identified by a combination of questionnaire, spirometry and bronchial provocation testing. a screening process has been developed which allows asthmatics to be recruited with a negative mannitol or hypertonic saline challenge on 400 mg/day or less of budesonide (or equivalent) without laba. a methodology to evaluate the impact of these changes on the recruitment standard has also been developed. alexithymia is a personality trait associated with difficulty identifying and communicating emotional and physical feelings. it has been associated with poor control of asthma and near fatal asthma. the primary objectives of this study were to: (1) identify alexithymia in a cohort of australian asthma patients; (2) investigate the relationship between alexithymia and asthma control; (3) investigate the relationship between alexithymia and asthma management. methods cross sectional study of 25 moderate to severe asthma patients recruited from royal adelaide hospital outpatients. participants were either mailed the questionnaire pack or completed it after a clinic appointment. existing validated questionnaires were used. statistical analyses were performed using spss. results 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years, sd = 11) participated. alexithymia scores ranged from 23.0 to 76.0 (x = 48.3, sd = 13.2). 12% (n = 3) of participants could be classified high alexithymia, 32% (n = 8) borderline alexithymia and 56% (n = 14) were low alexithymia. alexithymia mean scores were not statistically different across sociodemographic variables. a positive correlation/association was found between alexithymia score and asthma control score (r = 0.57, p < 0.01), quality of life (r = -0.65, p < 0.01), and adherence (p = 0.03) but not satisfaction with communication (r = -0.27, p = 0.2) or number of hospitalizations (p = 0.25). conclusions this is the first australian study to identify alexithymia among asthma patients and investigate relationship to control as well as management and communication. associations between alexithymia and asthma control were confirmed. a larger sample size is needed to determine impact of alexithymia on self-management and provision of clinical care for asthma. port hedland is impacted by iron-containing dust particles (pm10) that may activate lung cells when inhaled. furthermore, the effects of port hedland pm10 may differ from the effects of urban pm10 impacting metropolitan areas. the aim of this study was to assess the effects of port hedland pm10 on production and release of the inflammatory cytokines, il-6 and il-8, by human airway epithelial (a549) cells, and to compare these with the effects urban pm10 from metropolitan areas. methods human airway epithelial (a549) cells were exposed to pm10 collected at port hedland and at urban locations (sydney, perth). a549 cells were exposed to a range of pm10 concentrations (20-200 mg/ml) for 24 h. lipopolysaccharide (lps) and phorbol myristate acetate (pma) were used as positive controls. supernatants from cell cultures were assayed for il-6 and il-8 using specific elisa kits. rna was extracted and reverse transcribed to cdna. il-6 and il-8 mrna expression was quantified by duplex real-time pcr using taqman primer/probes. results lps stimulated a 2.7-fold increase in il-8 release and pma stimulated a 3-fold increase in il-8 release and a 30-fold increase in il-6 release. however, neither port hedland pm10 nor urban pm10 stimulated concentration dependent release of il-6 or il-8 by a549 cells. expression of il-6 or il-8 mrna was also not altered by port hedland or urban dust. cd8+ t-cells may cause airway epithelial cell apoptosis via the granzyme pathway. we have reported increased apoptosis of airway epithelial cells and increased bal t-cell expression of granzyme b in copd, and a positive correlation between the two. we hypothesized that the increased granzyme b would also be related to smoking history (pack years -pk/y), age and severity of airflow obstruction (fev1 %pred) in patients with copd. we further hypothesized that the t-cell granzyme b expression would be higher in the airway than the peripheral blood. methods we investigated t-cell intracellular granzyme b expression in blood from copd subjects (33 current and 24 ex-smokers) and 12 never-smoker controls, and bronchoalveolar lavage (bal) and bronchial brushing (intraepithelial t-cells) from a cohort of these subjects using flow cytometry. correlations between granzyme b and pk/y, age or fev1 were performed using spearman's rank correlation. granzyme b in t-cells from blood, bal and bronchial brushings were compared. results there were significant correlations between fev1 and granzyme b expression in blood and bal (blood: r -0.444, p = 0.002; bal: r -0.368, p = 0.029). there was a significant correlation between pk/y and granzyme b expression in blood (r 0.362, p = 0.002), but not in bal. there were no significant correlations between granzyme b and age. there were no significant differences in granzyme b expression in blood, bal or intra-epithelial compartments. conclusion granzyme b is expressed at similar levels in blood, bal and intra-epithelial compartments, supporting recent opinion that copd is a systemic disease. t-cell granzyme b is related to severity of airflow obstruction and smoking history in patients with copd and may be one mechanism of apoptosis leading to lung injury and airflow obstruction in copd. jc allen 1 , t schlosser, ee ramsay 1 , q ge 2 , aj ammit 1 as development of remodelled airways is correlated with deterioration of lung function, we require therapies that reduce and reverse structural changes in remodelled airways. in asthma, corticosteroids can halt some, but not all, aspects of airway remodelling. therefore, in order to aid future design of efficacious anti-remodelling agents we need a better understanding of the molecular mechanism/s underlying the development of airway remodelling and the effectiveness of corticosteroids. hyperplasia of airway smooth muscle (asm) is a feature of the remodelled airway in asthmatics. in this study we examined the effect of corticosteroids on a key regulator of g1 progressioncyclin d1. asm cells from n = 8 non-asthmatics and n = 7 asthmatics were pretreated for 1 h with vehicle or dexamethasone (0.1 mm). the temporal kinetics of cyclin d1 mrna and protein expression were measured up to 24 h after stimulation with the mitogen platelet-derived growth factor-bb (pdgf-bb). pdgf-bb induced a significant increase in cyclin d1 mrna expression in asm from non-asthmatics (2.6 ϯ 0.3-fold) and asthmatics (2.9 ϯ 0.3-fold) after 24 h stimulation. in non-asthmatics, the corticosteroid dexamethasone significantly (p < 0.05) reduced the amount of cyclin d1 mrna expressed (to 1.6 ϯ 0.2-fold). in contrast, cyclin d1 expression in asthmatics was relatively resistant to inhibition by dexamethasone; the amount of pdgf-bb-induced cyclin d1 expression in the absence or presence of dexamethasone was not significantly different ( sphingosine 1-phosphate (s1p), a bioactive sphingolipid found elevated in the airways of asthmatics, modulates myriad airway smooth muscle (asm) functions that promote inflammation and remodelling in asthma. in this study, we uncover the molecular pathway/s underlying s1p-induced secretion of il-6, and investigate if, and how, corticosteroids inhibit il-6 secretion. using cultured asm cells from non-asthmatics, we found that s1p induces il-6 secretion from asm cells via cre, but not ap-1, c/ebp or nf-kb, transcriptional regulation of il-6 gene expression. cre-dependence was supported by s1p-induced creb phosphorylation. although the corticosteroid dexamethasone reduced s1p-induced il-6 secretion in a dose-dependant manner, this inhibition appeared to occur via a pathway independent of creb/cre, suggesting the existence of a parallel pathway. as we recently discovered that the antiinflammatory actions of corticosteroids in asm can be mediated via the induction of the endogenous mitogen-activated protein kinase (mapk) inhibitor, mapk phosphatase-1 (mkp-1), we investigated whether mapk represents the parallel pathway targeted by corticosteroids. we found that s1p can induce activation of a variety of mapk, however, only p38 mapk phosphorylation was inhibited by dexamethasone; importantly, the increase in mkp-1 after corticosteroid treatment appeared to mirror the decrease in s1p-induced p38 mapk phosphorylation. furthermore, exogenous expression of mkp-1 inhibited s1pinduced il-6 secretion. taken together, these results suggest that parallel pathways exist to induce il-6 secretion (transcriptional via creb/cre and possibly post-transcriptional via p38 mapk) and serve to underscore the importance of mkp-1 upregulation as a mechanism of action of corticocosteroids in asm. angiogenesis is a hallmark feature of asthma. angiogenic promoters, such as vegf and tgfb are reported to be increased in airways of asthmatics. tumstatin, an endogenous angiogenic inhibitor, is the non-collagenous domain-1 (nc1) of the alpha3 chain of collagen iv. decreased levels of collagen iv have been reported in the airways of asthmatics. we investigated the presence of tumstatin in the airway of asthmatics and its potential role as an angiogenic inhibitor. we detected the six a chain nc1domains of col iv and the 7s domain of the a3 chain using immunohistochemistry. the level of tumstatin in serum and bal-f was measured by dot blot. western blots were used to identify the association with the rest of the collagen iv molecule. a tube formation assay using primary pulmonary endothelial cells (ppec) was performed to evaluate the role of tumstatin in the airway. the effect of intranasal tumstatin on airway hyperresponsiveness and angiogenesis was studied in an ovalbumin mouse model. tumstatin was absent in the airways of asthmatics (n = 14) while the remaining six collagen iv a chains were present. the 7s domain of the a3 chain was present in the asthmatic airway (n = 6). tumstatin was detected in both serum and bal-f samples from asthmatic volunteers (n = 10), however the level of expression was not significantly different from that in nonasthmatics (n = 7). in asthmatic serum tumstatin was part of the whole collagen iv a3 chain. tumstatin was able to inhibit ppec tube formation in a dose related manner. tumstatin inhibited angiogenesis in the mice airways and was associated with an improvement in ahr. the fact that tumstatin is absent from asthmatic airways and inhibited airway hyperresponsiveness and angiogenesis may indicate potential for therapeutic intervention in airway remodelling. this work was supported by the crc for asthma and airways and nh&mrc. introduction epithelial egfr (epidermal growth factor receptor) expression correlates with disease severity and neutrophil infiltration in asthmatic airways. acute exacerbations of asthma and copd are also associated with steroid refractory neutrophilic inflammation, with rhinoviruses being the most common trigger. .7 mg/l and il-6: 5.8 vs. 3.6 ng/l). since il-6 stimulates the acute phase response, we correlated its levels with the other markers. only crp was strongly correlated with il-6 (spearman r = 0.58, p < 0.0001), suggesting differential regulation of saa and ip10. saa discriminated between non-pathogen (n = 10) vs. pathogen-associated (n = 41) events (saa: 9.4 vs. 44.1 mg/l p = 0.005), whereas no significant change was observed in the other markers (ip-10: 139.8 vs. 170.5 ng/l, crp: 4 vs. 10 mg/l, il-6: 4.6 vs. 7.2 ng/ l). however when aecopd marker levels were stratified on the basis of pathogen type (viral = 12, bacterial = 21, viral and bacterial = 8), none of the markers were significantly altered. conclusions ip-10 is significantly elevated during an aecopd, however only saa differentiated non-pathogen from pathogen associated events. background severe persistent asthma is characterized by structural changes in the airways-airway remodelling. airway smooth muscle (asm) cells have the potential to play a key role in these processes through the release of growth factors, cytokines and extracellular matrix (ecm) proteins. we have previously studied the effects of budesonide and formoterol individually however, the effect of their combination on these characteristics of asm cells is not known. methods asm cells from asthmatic (n = 6) and nonasthmatic (n = 6) individuals were stimulated with transforming growth factor ß (tgfß) (1 ng/ml) with or without budesonide (10 -8 m) and formoterol (10 -10 and 10 -8 m) and fibronectin levels and interleukin-6 (il-6) release were measured by elisa. bronchial rings from nonasthmatic individuals (n = 2) were incubated with tgfß with or without the drugs and ecm protein expression (fibronectin and collagen i) measured using immunohistochemistry. results in nonasthmatic cells, budesonide alone induced fibronectin deposition whether tgfß was present or not. formoterol decreased fibronectin induced by tgfß and, when combined with budesonide, reversed the increase in fibronectin. a similar pattern was observed in asthmatic cells, except that budesonide did not further increase the tgfß mediated fibronectin release. as before [1] , il-6 was induced by formoterol but inhibited by budesonide. tgfßinduced il-6 was inhibited by both drugs and their combination in both cell types. in bronchial rings the presence of either drug did not affect tgfßinduced fibronectin or collagen i. severe combined immune deficiency (scid) spontaneous mutation specifically impairs differentiation of stem cells into mature lymphocytes. nod-cb17prkd scid (known as nod-scid) lacked nk cells, hence is commonly used in cell transfer experiments for transferring tissue and haematological xenografts. the aim of this study was to establish lung inflamamtory model in nod-scid strain. methods balb/c and nod-scid balb/c mice (n = 8) were exposed to cigarette smoke for 4 days, 2 and 4 weeks (9 cigarettes/day; 5 days/week). bronchoalveolar lavage fluid (balf) and lung tissue were collected for inflammatory profiling and analysis for cytokines, chemokines and protease expression and/or activity. results nod-scid have significant accumulation of macrophages in lung after 4 days, 2 and 4 weeks smoking as compared to no smoke control (p < 0.001) that was not different to balb/c (p > 0.05). nod-scid also have increased neutrophil number after 2 and 4 weeks smoking (p < 0.001). even though myeloid cell differentiation isn't affected by scid phenotype, nod-scid have one fold less neutrophil than balb/c mice (p < 0.001) that is also reflected in the reduced expression of matrix metalloproteinase-9. consistent with the known lymphopenic phenotype, nod-scid have significant but less lymphocytes recruitment as compared to balb/c mice after 4 weeks smoking (p < 0.001) despite the enhanced expression of inteferon inducible protein 10 (lymphocytes specific chemokine) in lung. both mouse strains showed the same elevation of net gelatinase and serine protease activity in lung. nodscid mice also demonstrated comparable transcriptional induction of proinflammatory cytokines (tnfa, il-6), growth factors (gm-csf, g-csf) and chemokines (mcp-1, mip-2), indicating susceptibility to smoke-induced injury. conclusions nod-scid mice are capable to mount smoke induced inflammatory response. this model may be useful to study localization and role of immunocytes, including adoptively transfer human cells in the pathogenesis of copd. supported by the nhmrc. rhinovirus (rv) is the cause of most common colds and up to 80% of asthma attacks. in our previous studies, plasminogen activator inhibitor 2 (pai-2) was expressed at high levels and was induced in vivo and in vitro by rv infection. pai-2 may have antiviral properties suggested by antiviral activity in some models, high pai-2 expression levels and further upregulation by rv infection. methods to determine whether pai-2 has antiviral activities following rv infection, o-hela, pai-2 expression-deficient cells were first transfected with pai-2 or control genes. this was followed by infection with rv and effects on viral replication were assessed by rt-qpcr for vrna and by viral titration for virus release. ifn expression was assessed by rt-qpcr. results ifn-a and -b mrna expression were induced in response to rv infection and to pai-2 expression in cells. pai-2 expression followed by rv infection elicited a synergistic response and pai-2 over-expression reduced vrna by >5 fold and viral titre by >3 log (p < 0.05). however, this effect was not specific to pai-2, as transfection of cells with control genes/plasmids reduced viral titre to a comparableextent. one of the pathological findings in idiopathic pulmonary fibrosis (ipf) is the presence on fibroblastic foci comprising cells which exhibit mesenchymal phenotypic features such as myofibroblast-like morphology, increased asma expression and collagen deposition. currently steroid treatment in ipf has shown limited efficacy. the cellular origins of these mesenchymal cells remain unclear, but evidence from other studies suggests that epithelial cells may undergo a transition to a mesenchymal cell phenotype (emt). transforming growth factor ß has been implicated in promoting this emt. in this study we have induced a morphological change in a549 cells using tgf-ß1 and assessed the influence of glucocorticoids, and the changes to the extracellular environment of the cells, on emt. methods a549 cells were grown on uncoated plastic cultures plates or those coated with monomeric or fibrillar collagen and treated with 200-500 pm tgf-ß1. the influence of the glucocorticoid, dexamethasone (dex, 1-1000 nm), or collagen type, on emt was assessed by microscopy, rt-pcr and western blotting for markers of myofibroblast phenotype. results tgf-ß1 induced an increase in mrna expression of asma (1.5 fold), collagen (7.0 fold) and fibronectin (2.0 fold). dex (100 nm) partially inhibited the expression of collagen, but had no effect on asma levels. however, dex (100 nm) reduced asma and ctgf protein levels. dex (100 nm) also prevented the tgf-ß1-induced morphological changes, regardless of ecm matrix. conclusion glucocorticoids appear to control some of the emt phenotype changes induced by tgf-ß1. however, the inability to fully inhibit these changes may contribute to the resistance of ipf to glucocorticoids. the extracellular environment may also play a role in the development of fibroblastic foci and their pharmacological responses. defective alveolar macrophage (am) phagocytic function in the airway may perpetuate inflammation via secondary necrosis of uncleared apoptotic cells in copd. we have previously reported that low-dose azithromycin improved macrophage function in vitro, although the mechanisms for this effect were not identified. we explored the possible role of the collectin pathway in the azithromycin-mediated improvement in phagocytosis as well as possible defects in this pathway in copd subjects. methods (1) mannose binding lectin (mbl), mannose receptor (mr), surfactant protein d (sp-d) were measured in copd subjects and controls. (2) the in vitro effects of addition of rhmbl, and blocking mr with a specific antibody, on am phagocytic ability were assessed. in vitro effects of azithromycin on am expression of mr were also investigated. (3) azithromycin (250 mg orally 2¥ weekly/12 weeks) was administered to 11 copd subjects. bronchoscopies were performed prior to and 12 weeks following therapy. ex vivo assessments included am phagocytic ability, levels of mbl, sp-d and mr and apoptosis of bronchial epithelial cells. results am mr expression and levels of mbl and sp-d were significantly reduced in copd subjects vs controls. azithomycin (500 ng/ml) increased mr expression by 31% in vitro. rhmbl induced a dose-dependent increase in am phagocytic ability (up to 148%). blocking mr significantly decreased am phagocytic ability by 60%. in copd patients following azithromycin therapy, we observed improved am phagcocytic ability, increased levels of mr and reduced levels of bronchial epithelial cell apoptosis. conclusions these findings strongly implicate the mr in both the defective phagocytic function of am in copd and as a target for the azithromycinmediated improvement in phagocytic ability. obstructive sleep apnea (osa) is associated with hypoxia and increased cardiovascular morbidity. t cells and monocytes play a significant role in atherogenesis via cytokine production. there have been reports of benefits of continuous positive airway pressure (cpap) therapy in osa. the purpose of this study was to characterize leucocyte inflammatory cytokine/chemokine production by t cells and monocytes in a group of osa patients and to investigate the therapeutic effects of cpap therapy. methods a comprehensive range of intracellular t-cell and monocyte proand anti-inflammatory cytokines/chemokines was investigated in peripheral blood from 5 osa patients and 5 aged-matched control subjects (with no evidence of sleep problems) using multiparameter flow cytometry. osa patients were again studied following 7 days of cpap therapy. results in osa patients there was an increase in intracellular t-cell ifng and tnfa production but no change in il-2, il-4 or tgfb compared with control. there was an increase in intracellular monocyte il-1a, il-8, tnfa, mcp-1 and mcp-3 in osa patients but no change in il-10 or il-12. following cpap therapy, t-cell ifng and tnfa production returned to 'normal' levels. however, although intracellular monocyte cytokine/chemokine production was decreased following cpap, levels were significantly elevated compared with control. conclusions osa is associated with increased intracellular proinflammatory cytokine/chemokines, many of which are increased in atherosclerotic plaques. although one week of cpap therapy resulted in amelioration of t-cell pro-inflammatory cytokines, longer cpap use or alternative therapy may be required to reduce monocyte pro-inflammatory mediators associated with atherosclerosis in patients with osa. gp130 has been associated with the progression of fibrosis especially in patients with idiopathic pulmonary fibrosis (ipf). gp130 is the common subunit of the receptor complexes for the il-6 family of cytokines including il-11 and oncostatin m (osm), where gp130-mediated signalling leads to activation of the erk or stat pathways. we have previously demonstrated exaggerated gp130-stat signalling to be fundamental to the development of pulmonary fibrosis in a murine model of bleomycin-induced lung fibrosis. the aim of this study was to elucidate the role of the il-6 cytokine family in the development of pulmonary fibrosis by identifying which il-6 family cytokines regulate fibrosis in bleomycin treated mice, and determine the effects of these cytokines on cell function. bleomycin (0.05 u/mouse) or control saline was administered intranasally to wildtype mice (wt), genetically engineered mice containing point mutations to prevent gp130 erk signalling (gp130 757f ) or gp130 stat signalling (gp130 dstat ), and duel il-6 and il-11 a-receptor knockout mice (il-6 -/-;il-11ar -/-). the effect of bleomycin on collagen production was examined in lung tissue 30 days post treatment by hplc. there was a significant increase in collagen levels in bleomycin treated wt lungs which was further increased in gp130 757f lungs. the lungs of gp130 dstat and il-6 -/-;il-11ar -/mice were protected from fibrosis suggesting that gp130-stat signalling is important in inducing lung fibrosis which may be mediated through il-6 and/or il-11. cell proliferation was examined in lung fibroblasts isolated from wt, gp130 dstat and gp130 757f mice. il-6, il-11 and osm were significantly mitogenic for gp130 dstat cells but not for wt or gp130 757f cells, reflecting different responses to the different signalling pathways. changes in cytokine profiles are currently being examined in lung tissue and serum of control and bleomycin treated mice 0-30 days after treatment. in conclusion, il-6 and il-11 are likely to play a role in bleomycin-induced fibrosis via the gp130-stat-mediated pathway, however this may not be due to regulation of proliferation induced by these cytokines. supported by the nhmrc. mimicking viral infection by application of various toll-like receptor ligands has shown clinical promise in the treatment of persistent viral infections and more recently with malignant tumours. commercially available toll-like receptor 7 ligands (tlr7l), such as those of the imidazoquinoline family have been applied clinically for the treatment of a number of conditions including basal cell carcinoma and hpv-induced genital warts. these compounds are known to retard tumour growth indirectly by promoting activation and migration of dcs, leading to a strong th1 cellular response, and directly via release of proinflammatory cytokines and promotion of tumour cell apoptosis. malignant mesothelioma (mm), an aggressive tumour with a mean survival of 9 months, is highly resistant to chemotherapy, radiotherapy and surgery and is therefore an interesting candidate for immunotherapy in the form of tlr7 ligand treatment. whilst tlr7 is known to be selectively expressed in immune cells and its relative expression low amongst other cell and tissue types in mammals, its expression on tumour cells and the consequences of such expression on tumour growth are unknown. here we describe the presence of tlr7 (mrna and protein) directly in a range of different tumours, including several murine and human mm cell lines. reactive oxygen species (ros) produced during the innate immune response are important agents of anti-pathogen defense but may also cause oxidative lung damage. glutathione peroxidase-1 (gpx-1) is a detoxifying enzyme that may protect lungs from such damage. methods wild-type (wt) or mice deficient in glutathione peroxidase-1 (gpx-1 -/-) were placed in a perspex chamber and exposed to cigarette (cig) smoke generated from 9 cigs per day for 4 days. on the fifth day, mice were killed, the lungs lavaged with pbs and then harvested for proteomic and genomic analysis. results wt mice exposed to cig smoke for 4 days had significantly more macrophages (3.1 ϯ 0.1(sem) ¥ 10 5 ) and neutrophils (4.9 ϯ 0.4 ¥ 10 5 ) than sham-exposed mice (2.2 ϯ 0.2 ¥ 10 5 and 0, respectively) (n = 6, p < 0.05). however, gpx-1mice exposed to cig smoke had significantly greater macrophages (5.4 ϯ 0.3 ¥ 10 5 ) and neutrophils (1.2 ϯ 0.1 ¥ 10 6 ) than smokeexposed wt mice (n = 6, p < 0.001). macrophage and neutrophil numbers in sham-exposed gpx-1 -/mice (1.7 ϯ 0.3 ¥ 10 5 and 0.5 ϯ 0.4 ¥ 10 3 ) were similar to those of sham-exposed wt mice (2.2 ϯ 0.2 ¥ 10 5 and 0). in addition, we found that balf of gpx1 -/mice exposed to cig smoke had an increased proteolytic burden compared with smoke-exposed wt mice as assessed by zymography and net gelatinase activity assay. conclusions these data suggest that gpx-1 protects the lung from cigarette smoke-induced inflammation and that targeting gpx-1 may have therapeutic utility in inflammatory lung diseases where cigarette smoke plays a role. funded by nhmrc. the becs from subjects with chronic obstructive pulmonary disease (copd) are exposed to frequent infectious and inflammatory stimuli. infection with rv is known to trigger acute exacerbations and subjects with copd are particularly susceptible. we hypothesized that exposure of copd becs to these stimuli would alter their response to rv infection. methods bec were obtained by endobronchial brushing from subjects with gold stage 3 copd (n = 4, all ex-smokers), subjects with mild persistent asthma (n = 4) and healthy controls (hc, n = 4). becs were cultured and then treated with tumour necrosis factor (tnf)a 10 ng/ml or lps 100 mg/ml for 24 hrs and then infected with rv-43, rv-1b. response was measured by release of il-8, il-6 and ip-10 mrna and by elisa. virus replication measured by cell titration assay. results infection with both rv strains led to increased release of il-8 and ip-10 in all groups. exposure of hc and asthma becs to both lps and tnf led to increased release of il-8. in these becs there was no increase in release of il-8 exposed to lps and tnf and then infected with either rv. becs from subjects with copd released significantly less il-8 in response to all conditions and rv infection compared to hcs and asthma. no differences were seen in rv replication. the aim of this study was to determine opinions and attitudes to exercise from chronic obstructive pulmonary disease (copd) subjects after completion of a 12-month maintenance exercise program. methods following completion of a 12-month exercise study, which included a supervised program (intervention, n = 18) and control group (control, n = 17), copd subjects [mean age (sd): 66 (8); mean fev1 (% predicted) = 56% (19)] were asked to complete a questionnaire. the questionnaire included closedended questions using visual analogue scales (100 mm). in copd the 6 minute walk distance (6mwd) is known to increase with test repetition (familiarization) and in response to exercise training. it is unknown whether the magnitudes of these increases are related to the degree of disability of the individual patient. methods 6mwd was measured twice before and once after an 8 week out-patient exercise program in 121 patients (82 males) aged 67ϯ8.6 yrs, fev1 37ϯ15% predicted (meanϯsd) with stable copd. the changes in 6mwd following a familiarization test and following training were compared between patients grouped according to their degree of disability (defined as the pre-training 6mwd [best of 2 tests] expressed as %predicted 6mwd). *p < 0.05 gp 3 vs gp 1. conclusions before training, 6mwd increases following a familiarization test irrespective of the level of disability. the magnitude of this increase is similar in all groups when normalized for their pre-training 6mwd. following training, the increase in 6mwd is greatest in patients with the greatest disability (lowest pre-training 6mwd). in less disabled patients, the relatively smaller increase in 6mwd following training may reflect an inability to further increase stride length, thereby reducing the responsiveness of the 6mwt in this group. supported by nhmrc. endotoxin is a stimulant of the innate immune system and is a major component of cigarette smoke. smokers have evidence of increased airway neutrophils and inflammation. we hypothesized that endotoxin levels would be higher in the bronchial lavage (bl) of subjects who were former smokers and subjects with chronic obstructive pulmonary disease (copd). methods subjects were all ex-smokers for at least 5 years (n = 10, 5 copd, 5 healthy controls) or never smokers (n = 12, 6 asthma, 6 healthy controls). bl was collected and analysed for cell count and differential, culture for microbiology. the supernatant was analysed for il-8 by elisa and endotoxin by quantitative kinetic lal assay. results median endotoxin levels were significantly higher in ex-smokers 101 compared to never smokers 6.3 u/ml (p < 0.001). there were no differences between subjects with copd and hs. subjects with copd had higher median endotoxin levels (80 u/ml), compared to asthma (5.2 u/ml) and hc (6.3 u/ml, p = 0.03). there was no correlation between endotoxin levels and bl total cell count, neutrophils (%) or fev1 % predicted. there was a strong correlation with previous packet years smoked and endotoxin levels (r = 0.72, p < 0.01). conclusions bl endotoxin levels are higher in ex-smokers, including subjects with copd. despite this there is no relationship to increased neutrophilic inflammation. copd is associated with inflammation associated with ineffective repair of the injured epithelium and loss of structural integrity. we have shown that these changes may result from dysregulated 'efferocytosis' (increased apoptosis of bronchial epithelial cells and defective clearance of these cells by alveolar macrophages (am)). we have also reported that azithromycin, at subbactericidal dose, improved am phagocytic function ex vivo. methods we administered azithromycin at low dose (250 mg/ twice weekly for 12 weeks) to 10 copd subjects (7 male, age: 62 ϯ 8 yr, 5 current/ 5 ex-smokers, fev1: 63 ϯ 9% pred, fev1/fvc: 48 ϯ 9%). the study was openlabel, uncontrolled and primarily focused on objective biological responses obtained from the bronchoscopy samples taken. phagocytic ability of am (from bal), apoptosis of bronchial epithelial cells (from bronchial brushing), markers of inflammation in blood, bal and breath condensate (crp, wcc and inflammatory cytokines), health status (st. george's respiratory questionnaire), ecg and lung function were assessed pre and post-administration of azithromycin. results azithromycin significantly improved phagocytic ability of am (by 37%) and reduced bronchial epithelial cell apoptosis (by 34%). antiinflammatory effects of azithromycin included significantly reduced blood wcc and crp. there were non-significant reductions in levels of pro-inflammatory cytokines il-8, il-6 and tnf-a in blood, bal and breath condensate, and a trend for improved health status. conclusions our findings indicate a novel approach to supplement existing therapies in copd that may improve clearance of accumulated apoptotic material and reduce the risk of secondary necrosis and release of toxic cell contents that perpetuate inflammation. background the prevalence of gastro-oesophageal reflux disease (gord) across the disease spectrum in copd and bronchiectasis is not well described. the aim of this study was to determine the prevalence of symptomatic and silent gord in copd and bronchiectasis and its effect on lung function and quality of life (qol 4] ) and 18 healthy controls were recruited. the prevalence of gord in bronchiectasis was 33%; 37% in copd; 17% in controls. in copd and bronchiectasis, total nre and ri were increased in those with distal and proximal gord compared to those without gord (all p < 0.05). there was no difference in extent or severity of bronchiectasis in patients with or without gord (all p > 0.05). in copd, the relationship between proximal gord and fev1 was small to moderate (r = 0.383). sgrq symptom scores were higher in patients with bronchiectasis with increased ri (p = 0.02). increased proximal nre was associated with reduced physical (p = 0.03) and mental health (p = 0.02) in the sf-36 in copd. conclusions gord is a co-morbidity in patients with copd and bronchiectasis. the impact of gord on disease severity requires further evaluation. funding source nhmrc, the university of melbourne, monash university, physiotherapy research foundation. chronic obstructive pulmonary disease (copd) is prevalent among older people, however little is known about the influence of ageing on airway inflammation. the aim of this study was to compare airway inflammation in older people with obstructive airway disease to groups of older and younger healthy controls. methods participants (>55 years of age) with stable airway disease and incomplete reversibility (fev1% predicted <80% and fev1/fvc < 70%; copd n = 71) and healthy controls (n = 45, 35 older >55 years and 10 younger <55 years) were recruited from the respiratory ambulatory care clinic or by advertisement. participants underwent a clinical assessment, skin allergy test, hypertonic saline challenge, sputum induction and gas diffusion studies. results participants with copd had moderate airflow obstruction (mean (sd) fev1% predicted 56 (19)) and 45 (63%) were current or ex-smokers with a median (iqr) pack year history of 36 (20-54) pack years. ageing was associated with an increase in airway neutrophils (p = 0.0001). compared to older controls, participants with copd had increased airway eosinophils and lymphopenia (p = 0.004, p = 0.003 respectively), but no difference in airway neutrophils. conclusion airway neutrophilia is a feature of ageing and is not further increased in the presence of copd. copd is associated increased numbers of airway eosinophils with reduced lymphocytes which may impact on the ability of the immune system to combat infection. supported by nhmrc, the university of newcastle. chronic obstructive pulmonary disease (copd) is third leading cause of death and fourth leading cause of disease burden in australia. mechanisms involved in emphysema severity have not been fully understood. micrornas are noncoding rnas that regulate gene expression. we hypothesize that microrna expression differs between emphysema severity in copd patients. methods mirna profiling was performed using 15k agilent human oligo mirna microarrays on total rna extracted from non-tumour lung tissue from 30 copd patients undergoing resection for lung cancer. the mirnas were quantile normalized and anova was used to find differentially expressed genes. results demographic characteristics of the copd patients (mean (sd)) were age 69 (6) years, fev1 72 (17) % predicted and fev1/fvc ratio (<70%). anova identified 31 mirnas that were differentially expressed when stratified into two classes according to kco % predicted > or <75% (t-test, p < 0.05). discussion this mirna analysis has identified mirnas that may be important in emphysema severity in copd patients. further validation will be performed using qrt-pcr and mirna assays on the training set and an independent set, and target prediction and validation. t-helper type 1 (th1) and type 2 (th2) lymphocyte responses have been well recognized as being important pathways in inflammation. recently another form of inflammatory lymphocyte response has been described, the th17 pathway. th17 cells produce cytokines such as il-17a to clear extra-cellular bacteria and fungi and have been implicated in autoimmune and chronic inflammatory diseases. the th17 response in copd is unknown. methods subjects were patients with copd (ex-smokers, fev1 < 70% predicted who had not had an exacerbation for at least 1 month) and control subjects (ex-smokers and normal spirometry). serum samples were obtained for measurement of c reactive protein (crp) and il-17a, the latter measured using enzyme-linked immunosorbent assay (elisa). production of il-17a by t-cell subsets was also identified by intra-cellular cytokine staining and measured by flow cytometry. the mean fev1 of copd subjects was 42 % predicted (6.1 sem, n = 6) and mean fev1 of controls was 112 % predicted (3.0 sem, n = 4). the copd group had a higher mean level of crp 9.5 mg/l (3.9 sem) compared to the control group mean level of 4.6 mg/l (0.6 sem). the mean level of the il-17 in the copd group as measured by elisa was 22.3 pg/ml (16.9 sem, range 0-87) whilst no il-17 was measured in any of the control subjects. conclusions the findings of this pilot study suggest that il-17 may be elevated in association with crp in stable copd. airway obstruction is defined as a fev1/fvc ratio below the lower limit of normal. airway obstruction may prolong the forced expiratory time (fet). method spirometry results from 467 patients were categorized as obstructive, restrictive or normal. the mean, range and coefficient of variation were determined for fet in each diagnostic group. receiver operator characteristic (roc) curves were used to determine if fet could predict a low fev1/fvc. the number of patients with airway obstruction in five fet groups: <9; 9; 10-12; 13-14; and >14 seconds were determined. results the coefficient of variation was high for all groups. pair-wise comparisons showed a difference in mean fet between patients with normal lung function versus those with airway obstruction (p < 0.001). the best cut-point in the roc analysis of 9.895 seconds had a sensitivity of 0.66, specificity 0.77 and area under the curve of 0.743 for predicting obstruction. the technique of skeletal muscle microbiopsy has previously been validated [1] and shown to be minimally invasive and well tolerated in participants with stable copd. aim a study was undertaken to determine the feasibility and tolerability of obtaining microbiopsy muscle samples from the patient admitted for acute exacerbation of copd patient. methods written informed consent was obtained to collect the muscle, blood and sputum samples for research purposes. local anaesthetic was injected prior to the insertion of a 16 gauge bard max core disposable biopsy instrument through the associated guide needle. multiple passes (up to 6) were obtained. the patient was asked to evaluate the experience by rating it on the modified borg scale 0-10. results to date 5 patients and 3 controls have participated in this study. the gold severity ranged from 2-4 and ats exacerbation severity 2-3. the mean age 75 years (range 68-83 years), bmi mean 23.6 kg m -2 (range 17.2-27.1 kg m -2 ) and fat free mass was determined using single frequency bioimpedance. the sample mass obtained ranged from 27.2-104.1 mg, with an increasing yield occurring with increased experience of the operator. the procedure has been well tolerated, the borg scale rating ranged from 1-2/10. all patients were ambulant post procedure; no haematoma or bruising was observed in any of the subjects. conclusion the microbiopsy technique allows the collection of muscle tissue with minimal discomfort to the participant. small tissue masses such as these are sufficient to obtain measures of local markers of wasting and may prove to be a useful adjunct to the collection of sputum and blood for the measure of biomarkers in copd research. introduction older people (op) with obstructive airways disease (oad) experience multiple problems that may impact on their quality of life (qol) and disease management. these problems may relate to pathophysiology, symptoms, self management skills, psychological issues, lifestyle or other problems identified as important by the patient. aim the aim of this study was to determine the frequency of clinical problems associated with oad and to determine if a problem based assessment (pba) could adequately identify these problems. methods a multidimensional assessment tool was developed and the content compared to clinical practice guidelines. participants over 55 years with diagnosed oad underwent this assessment. results sixty-one consecutive patients, aged 59-87 years, with mean (sd) fev1 of 51.4 (17.85) % predicted were assessed. the assessment tool identified a mean (sd) of 3.03 (2.13) current and significant co morbidities with an additional 11 (3.37) clinical problems per patient. qol was increasingly impaired with an increasing number of problems (p < 0.0001). regression modelling identified that the number of identified clinical problems accounted for 55% of the qol impairment. the model demonstrated that every additional patient problem was associated with a clinically significant change in qol impairment (4.22 units) . conclusions op with oad experience multiple clinical problems and co morbidities that adversely impact their qol. a pba of op with oad identifies significant problems that may not be addressed in a diagnosis centred approach. there is a need to identify and effectively manage this array of problems in clinical practice. discussion in this diverse group of copd patients, there was a positive correlation between dlco and fev1, but not kco and fev1. the fev1/ kco plot identifies substantial numbers of patients with the potential ad and e phenotypes defined above. we intend to study inflammatory biomarkers in these groups. fat free mass index (ffmi) is a marker of morbidity and mortality in copd. measurement of ffm in the out-patient population is commonly undertaken using single frequency bioelectrical impedance analysis (bia). however the formulae to convert measured values to ffm are population dependent. schols et al (am j clin nutr, 1991) suggested that formula used for the general population may be inappropriate for patients with copd, and derived a specific formula from total body water (tbw) as measured by deuterium dilution. we compare this method of measuring ffm with 5 others, along with tbw and ffm hydration. methods tbw was measured in 31 outpatients with copd by bia and a difference method (weight-(protein+bone mineral+fat+non-bone mineral+ glycogen)) and ffm hydration was calculated. ffmi was measured by skin fold anthropometry (sfa), bia (3 separate formulae), dual energy x-ray absorptiometry (dexa) and total body potassium by g-counter (tbk). comparison between methods for tbw and ffmi was made by bland-altman analysis and between methods of calculation of ffm hydration by paired t-test. the two methods of assessment of tbw showed little difference (bias -0.04, 95% limits of agreement -5.40 to 5.31). however there was a significant difference in calculation of hydration of ffm (p = 0.0001). sfa, bia (lukaski), bia (tanita) and tbk underestimated ffmi when compared to bia (schols), with bias of -1.24, -3.87, -1.06 and -2.76 respectively. dexa however had a bias of only 0.05 and 95% loa of -3.09 to 3.21. conclusions there are differences between methods of assessment of tbw and ffmi and comparing values between methods must be done with caution. this has implications for assessment of morbidity and mortality in copd. chronic obstructive pulmonary disease (copd) has been identified as a major health problem in australia. recent studies have suggested that respiratory viral infections are the major cause of a worsening of copd; however this has not been studied in australia. aim to characterize pef changes and identify viruses during copd exacerbations. methods a pilot prospective longitudinal cohort study was done. patients had confirmed copd with fev1 <70% predicted and reversibility <10% and/or 200 ml. patients recorded daily peak expiratory flow (pef) measurements and daily chest and cold scores over a period of 2 years. sputum samples and nasal aspirates were taken at 6-month review (control visit) and whenever they had symptoms of an exacerbation (worsening of copd symptoms -seemungal et. al. am j resp crit care med, 2001). nasal aspirates and sputum samples were obtained and analysed by rt-pcr for rhinovirus (rv). result five patients have finished 2 years of study. a total of 12 exacerbations were reported based on patient symptoms. only 3 exacerbations were associated with significant reductions in pef and only one was linked to increases in nasal cold scores. all samples taken at control visits and nasal aspirates and sputum samples during exacerbations were negative for rv by rt-pcr. positive controls confirmed the accuracy of the assay. conclusion our data suggest that a symptom-based definition of copd exacerbation is not always accompanied by significant reductions in lung function parameters. these 'exacerbations' are also not associated with the commonest reported viral cause. our findings suggest that variability of copd may mimic. bronchiectasis is characterized by hypersecretion of mucus and impaired clearance that results in mucus accumulation, chronic cough, sputum production and recurrent infections. inhaled mannitol (400 mg) improves clearance of mucus by increasing the airway hydration and by reducing the viscoelastic and surface properties of mucus. however, the effect of other doses of mannitol on the clearance of mucus in patients with bronchiectasis is unknown. methods fourteen patients, age: 63.3 ϯ 5.7 yr, were studied on 5 visits. clearance of mucus was measured using 99m tc-sulphur colloid and imaging with a gamma camera at baseline and with mannitol ( weight loss and skeletal muscle atrophy are major determinants of morbidity in chronic obstructive pulmonary disease (copd), which are independent of lung function impairment. thus, we examined if a high-fat diet (hfd) protected against the wasting associated with prolonged cigarette smoke exposure (se) in mice. methods male balb/c mice were exposed to the smoke of 4 cigarettes/day, 6 days/week for 7 weeks. sham mice were handled identically without smoke exposure. mice consumed either standard laboratory chow (3.5 kcal/g, consisting of 12 % fat) or a hfd (4.3 kcal/g, 32% consisting of fat). we examined the effect of se and hfd on hind limb skeletal muscles, lung (tissue & bronchoalveolar lavage (balf)) and systemic inflammation in the 4 groups of mice (n = 8/ group). results after 7 weeks of hfd, sham and se mice were 12 and 13% heavier (respectively, p < 0.05) than chow fed animals. conversely, se significantly decreased body weight of chow and hfd fed mice by 16 and 15%, respectively, compared to sham animals (p < 0.05). the hfd did not protect against the decrease in soleus, tibialis anterior and gastrocnemius skeletal muscle weights induced by se (p < 0.05). se altered the mrna expression of a number of genes associated with the regulation of skeletal muscle mass including insulin-like growth factor-i (igf-i), atrogin-1 and interleukin (il)-6. the mrna expression of pro-inflammatory cytokines and chemokines was significantly increased by se in the lung, as were the number of inflammatory cells in balf (p < 0.05). on the other hand, although obesity has been linked to systemic inflammation, the hfd exerted little direct effect on the skeletal muscle and lung parameters measured. se and hfd had no effect on two markers of systemic inflammation, il-6 and serum amyloid a, whereas se tended to reduce circulating igf-i, an anabolic hormone. conclusions the hfd was not protective against the weight loss and skeletal muscle wasting associated with cigarette smoke exposure. supported by the nhmrc and crc for chronic inflammatory diseases. background patients with copd and bronchiectasis undertake airway clearance therapy (act) and exercise as part of physiotherapy management but it is unknown whether these treatments provoke gastro-oesophageal reflux (gor). this study aimed to determine the impact of positive expiratory pressure (pep) therapy and exercise on gastro-oesophageal function. p. aeruginosa is a significant opportunistic lung pathogen in individuals with cystic fibrosis (cf) and is associated with increased lung disease and morbidity. early intervention is beneficial for the effective clearance of p. aeruginosa and better long-term health outcomes. currently, lung flora of cf patients is monitored by regular culturing of sputum, however, children unable to expectorate are limited to annual bronchoalveolar lavages (bal), which is invasive and requires general anaesthesia. saliva is useful for clinical assays as collection is simple, non-invasive. we are developing a standardized enzymelinked immunosorbent assay (elisa) to detect respiratory infection of p. aeruginosa in cf children who cannot expectorate. methods 18 children (7-18 years) with cf and recent p. aeruginosa lung infection history and 16 non cf children (1-6 years) with no previous p. aeruginosa infection history provided saliva as positive, negative controls respectively. saliva was obtained by spitting, or absorbed using cellulose swabs and later extracted. these cell-free supernatant samples were used in an elisa anti-p. aeruginosa iga using commercial antigen. all results were standardized to account for flow using total iga expression. results median value was increased 9 fold in the recent p. aeruginosa lung infection group (mann-whitney test, n = 34, p յ 0.001). there was no significance between mucoid and non mucoid samples, and detection was independent of cfu/ml. discussion early findings support that p. aeruginosa respiratory infection can be detected through specific analysis of salivary iga expression. larger population sampling (30 positive, 90 negative) will aid selection of cut-off values for specificity and sensitivity testing in the future to objectively determine the utility of this assay as a means of monitoring for p. aeruginosa and for determining effectiveness of treatment. medical thoracoscopy is utilized widely throughout europe and northern america by thoracic physicians for the management of pleural disease, including the undiagnosed pleural effusion, malignant effusions and less commonly pneumothorax (ptx). australia has limited experience in this modality. we report the success of medical thoracoscopy in both primary and secondary ptx requiring intervention. methods data were collected from 2001 to 2007 in patients treated with medical thoracoscopy for the treatment of ptx. results 11 patients, 7 male, 4 female. average age 48 (range 19-86). 1 first episode primary spontaneous (ps) ptx, 2 third episodes of ps, 5 first secondary spontaneous (ss), 1 second ssptx, 2 third ssptx. underlying pulmonary disease in secondary ptx included: 4 chronic obstructive pulmonary disease, 1 lymphangioleiomyomatosis, 1 mesothelioma, 1 metastatic angiosarcoma and 1 was secondary to a motor vehicle accident. 7 had a history of smoking, 5 were former smokers and 2 were current smokers, with a mean 24 pack year history (range 5-45). 7 ptx were large, 4 moderate. 5 patients had an intercostal catheter (icc) inserted prior to thoracoscopy, 1 had failed pleural aspirate. there was evidence of bronchopleural fistula in 7 patients prior to the procedure. there was a median of 9 days from ptx to thoracoscopy. light sedation was used for the procedure in 10 patients, 1 required a general anaesthesia with a double lumen endotracheal tube due to anxiety. single port entry, dry talc poudrage and a 16 gauge french icc was used for all procedures. icc was removed a mean of 2 days following thoracoscopy and patients discharged on day 4. pain was the most common complication, requiring narcotic analgesia. one patient died on day 7, secondary to metastatic angiosarcoma. there has been no recurrence of ptx in any patient. conclusion medical thoracoscopy, performed by thoracic physicians is an effective procedure for the treatment of pneumothorax requiring intervention, including selected patients with evidence of bronchopleural fistula. funding nil. conflict of interest nil. nomination for young investigator award no. background lung cancer incidence and mortality are high in tasmania. australia (aihw 2003) 85/100 000 72/100 000 tasmania (cancer registry 2003) 102/100 000 89/100 000 aims and objectives (a) to determine patient demographics in southern tasmania, (b) to determine compliance to identified measures of best practice and (c) assess referral rates, clinical utility and potential delay to positron emission tomography (pet) in a regional setting. methods a prospective database collected information on local clinical practice. cases presented at a multidisciplinary lung cancer meeting over a 12 month period (march 2006 -april 2007 were analysed. data were available for n = 121/161 (75%). results are shown as mean ϯ sd. results 113 primary lung cancer cases were identified. the mean age was 71 ϯ 11 years. 58% of patients were male and 95% were current or ex-smokers. 81% were non-small cell lung cancers (nsclc). tissue diagnosis 93% time from diagnosis to surgery (27 ϯ 15 days) 82% < 42 days macroscopically complete surgical resection (9/11) 82% pet for stage iiib before radical chemoradiotherapy 75% 62% of patients presenting with early or locally advanced disease underwent further staging with pet (n = 34/55). management was changed in 50% of cases (17/34). the average time from pet referral to scan was 11 ϯ 5 days. conclusion a disproportionate number of lung cancers occurred in women. although surgery was performed within recognized timeframes, 2 of 11 patients had incomplete resections. pet influenced management decisions and was performed in a timely fashion. hp chan 1,2 , v tran 1,2 , c lewis 1,3 , p thomas exhaled breath condensate (ebc) is a simple, safe and non-invasive method of sampling breath and has the potential to investigate lung cancer and the associated neoplastic process in the lungs. increased oxidative stress has been implicated in the pathogenesis of lung cancer, and is characterized by elevated hydrogen ions, and hydrogen peroxide (h2o2), which is formed from the conversion of superoxide anions by superoxide dismutase. airway ph has already been shown to be decreased in ebc of patients with other respiratory conditions, but not in lung cancer. therefore the concentration of h2o2 and hydrogen ions in the ebc of lung cancer subjects was compared with matched controls. methods six subjects with newly diagnosed lung cancer were recruited and matched with control subjects: non-smokers, ex-smokers and smokers. ebc was collected and h2o2 was then measured by an assay method based on oxidation of 3,3',5,5'-tetramethybenzidine by horseradish peroxidase and h2o2 while ph was measured using a ph meter. results there was a significant difference (p = 0.033, anova) in h2o2 concentration between the 4 groups with the lung cancer group having elevated mean h2o2 concentration of 23.68 mm (9.15 (sem) compared to the controls: non-smokers, 17.59 mm (6.53 (sem); ex-smokers, 14.35 mm (3.79 (sem); and smokers, 5.21mm (0.69 (sem). ph did not differ significantly (p = 0.659, kruskal-wallis test) between the groups. conclusion these preliminary data suggest that there is significant difference in h2o2 concentration between the groups. the demonstration of an elevated h2o2 level in those with lung cancer indicates an increase in oxidative stress which implies that this may be part of the pathogenesis or response to neoplasia. supported by none. conflict of interest none. pro-inflammatory th1 cytokines produced by t cells and monocytes play an important role in the immune response to malignant cells. however, tumours may escape immune surveillance by inhibiting th1 response and promoting chronic inflammation at the tumour site. methods to investigate the effect of soluble factors released by lung cancer cells on t cell and monocyte pro-and anti-inflammatory cytokines, culture supernatants from several lung cancer cell lines and a normal epithelial cell line (16hbe) were cultured with whole blood for 24 hours, then for a further 16 hrs with and without stimuli. intracellular cytokine / chemokine production was determined using multiparameter flow cytometry. results in stimulated cultures, there was a significant decrease in t cell th1 pro-inflammatory cytokines ifng, tnfa and il-2 and a decrease in monocyte il-1a, il-8, il-12, tnfa, mcp-1 and mcp-3 but an increase in antiinflammatory cytokine il-10 compared with 16hbe and control media. in non-stimulated blood cultures there was an increase in all monocyte inflammatory cytokines / chemokines in the presence of lung cancer supernatants. conclusions lung cancers secrete soluble factors that inhibit the antitumour pro-inflammatory th1 response by t cells and monocytes and upregulate monocyte anti-inflammatory cytokine il-10 following "antigenic challenge". lung cancer cells may also escape immune surveillance by secreting soluble factors that cause newly recruited monocytes to release inflammatory cytokines promoting chronic inflammation at the tumour site. cytotoxic t-cells (ctl's) are important barriers against tumour cells. ctl's induce apoptosis of target cells by mechanisms that include the release of pore-forming perforin and granule associated enzymes, such as granzyme b and granulysin. proteinase inhibitor-9 (pi-9) is the only known granzyme b inhibitor and its expression has been observed in some cancers. we hypothesized that pi-9 would be differentially expressed in lung cancer cells and may inhibit granzyme b-induced apoptosis in these cells. methods we investigated pi-9, granulysin and granzyme b expression in various lung cancer cell lines (1299 ( , 1466 ( , 2009 and normal epithelial cells obtained from bronchial brushing using flow cytometry. peripheral bloodderived t-cells were then incubated with lung cancer cell line supernatants and levels of pi-9, granzyme b and t-cell reactive oxygen species (ros) were assessed. results pi-9 expression was detected in all lung cancer cell lines, (1299 (54.2%), 1466 (90.2%), 2009 (85%), sbc-1 (81%)), at much higher levels than in normal bronchial epithelial cells (8.5%). granzyme b and granulysin levels were undetectable or low in cancer cells (0-9.2%). increased expression of pi-9 and reduced levels of granzyme b were observed in cd8+ t-cells in the presence of all cancer cell supernatants tested (p < 0.05). interestingly, t-cell ros levels were significantly increased in cd8+ t-cells after incubation with cancer cell supernatants (p < 0.05). conclusions high pi-9 expression in lung cancer cells combined with a reduction in t-cell granzyme b expression and enhanced intracellular t-cell ros levels may be a mechanism of immune evasion of lung cancer cells to granzyme b-induced cytotoxicity. immunotherapy for lung malignancies such as lung cancer and mesothelioma is most likely to be successful it it can be combined with conventional tumour debulking approaches such as chemotherapy and surgery. but they scientific basis of such combinations is yet to be determined. to study this we evaluated (1) the capacity of different lung chemotherapy drugs to alter tumour antigen cross-presentation and immunogencity, (2) duration of antigen presentation and responsiveness to immunotherapy after debulking surgery with/without lymphadenectomy, and (3) the pattern of tlr agonism which best synergized with chemotherapy and surgery. we used the ab1-ha murine model of lung malignancy in balb/c mice. results (1) the antimetabolite drugs gemcitabine and pemetrexed were most immunogenic compared to the cytotoxic antibiotics doxorubicin and mitomycin c and the alkylating agent cisplatin. gemcitabine delived large amounts of tumour antigen into the cross-presentation pathway. (2) tumour antigen cross-presentation persisted for only 10 days following resection. the optimal window for immunotherapy following cancer surgery is 1 week for effector ctl stimulation and 2-4 weeks for memory ctl stimulation. (3) the viral-like tlr agonists tlr 3, 7 and 9 were the most effective adjuvant tlr molecules, with tlr 7 agonists generating the strongest systemic anti-tumour responses. conclusion these results help explain previous lung immunotherapy failures and will inform new clinical trials. background mesothelioma is a highly aggressive tumour with an increasing world wide incidence. the serum biomarker mesothelin is elevated in some individuals prior to development of clinical symptoms of the disease and may be useful for screening. we therefore studied the sensitivity and specificity of urinary versus serum levels of mesothelin for mesothelioma patients and evaluated the influence if renal function on the biomarker level. materials and methods concurrent sera and urine samples collected from patients with and control populations. mesothelin concentrations were determined by double-determinant elisa using the mesomark tm assay (fdi, pa). their estimated glomerular filtration rate (egfr) was also calculated. results mesothelin levels correlated between serum and urine samples (pearson's correlation 0.791; p < 0.0001). mesothelin levels were significantly higher in patients with mesothelioma compared to those with asbestosis and/or pleural plaques in serum (4 ϯ 0.9 versus 0.9 ϯ 0.05 nm; p < 0.0001, respectively), in urine (1.9 ϯ 0.5 versus 0.3 ϯ 0.03; p < 0.0001) and in urine following normalization using creatine levels (0.2 ϯ 0.05 versus 0.04 ϯ 0.01). age and egfr were significantly associated with mesothelin levels. conclusion the sensitivity and specificity of mesothelin in urine and in serum were comparable. urine mesothelin may prove to be a useful alternative to serum mesothelin for mass screening of asbestos-exposed individuals. patients undergoing ct coronary angiogram (cta) are often former or current smokers with a high incidence of asymptomatic lung disease. overseas reports show a rate of lung abnormalities ranging from 6.7% to 19%. there are no studies from australia and local factors such as the higher incidence of atypical mycobacteria may influence the rate of benign findings. we are therefore performing a prospective observational study to identify the prevalence and characteristics of incidental lung findings in people undergoing routine cta. methods population: 100 patients undergoing routine cta after informed consent. intervention: radiologist evaluation of lung windows on diagnostic standard workstations. comparator: uncontrolled observational study of consecutive patients. outcomes: primary: prevalence and characteristics of abnormal findings, final diagnosis (clinical judgment, biopsy or long term followup). secondary: number of downstream investigations and costs. results 25 ctas have been studied to date. in 8/25 (32%), abnormalities were noted on lung windows. in 2/25 (8%), there were lung nodules, in 2/25 (8%) there were hilar lymph node abnormalities, in 1/25 (4%), there was hemidiaphragm elevation and in 3/25 (12%) there were pleural plaques (data collection ongoing with study closure expected in february 2008). conclusions preliminary data indicate a substantial number of incidental pulmonary findings from cta; full results will be presented. further analysis is required to determine the impact (benefits, costs and harms) that may result from the concurrent examination of lung windows at routine cta. aim increased levels of nitrogen oxides (nox) and inflammatory markers have been found in bronchoalveolar fluid of lung cancer (lc) patients, but have not been investigated in exhaled breath condensate (ebc).the aim of this study was to compare nox and total protein levels in ebc of lc patients with control subjects. methods ebc was collected during tidal breathing through a glass collection device cooled to 4°c. ebc nox concentrations were measured by a fluorescent modification of the greiss method. total protein in ebc was determined employing the bicinchoninic acid (bca) assay. ebc nox data were log transformed. all data were analysed using anova and expressed as mean ϯ sem. results a total of 88 control subjects and 54 patients with primary lc were recruited. nox and protein concentrations are shown in table 1 . there was no significant difference in ebc nox levels (p > 0.05), but in total protein there was a significant difference between lung cancer patients and all control groups (p = 0.04). conclusion significantly increased ebc total protein levels were found in patients with lung cancer. these data suggest that protein mediator secretion or vascular leak may be present in those with lung cancer. future studies will focus upon the identification of these proteins. methods in this two stage case-control study 446 lung cancer cases and 484 healthy smoker controls were recruited. 180 genetic markers (snps) implicated in lung cancer were screened in our test cohort of 439 smokers and ex-smokers. 30 snps whose genotypes (co-dominant or recessive model) were associated with either the healthy smokers (protective) or lung cancer (susceptibility) phenotype were identified. after genotyping this 30 snp panel in a second cohort of 491 subjects 19 snps were chosen and assigned a simple composite genetic score that was combined with scores for age, history of copd and family history of lung cancer, weighted according to our multivariate regression analysis (n = 930 total subjects). the lung cancer risk score was linearly related to the likelihood of lung cancer with odds ratios (referenced against the lowest score quintile) ranging from 1 to 29 in the highest quintile. on receiver operator curve analyses, the auc was 0.78 and the frequency distribution showed bimodal separation between healthy smokers and lung cancer cases. utility of the score was not affected by effects of age, smoking history or lung function. we suggest that genetic data may be combined with other risk variables to define smokers or ex-smokers at risk of lung cancer for targeted interventions such as smoking cessation and early detection of lung cancer. supported by health research council, nz. conflict of interest yes. tp 144 v aiyappan 1 , a graham 2 1 department of medicine, maroondah hospital, melbourne, australia, and 2 the new disease-modifying anti-rheumatic drug (dmard) leflunomide is being used increasingly to treat inflammatory arthritis. its association with interstitial lung disease needs to be considered before combining it with methotrexate. case report a 73-year-old male who was known to have rheumatoid arthritis and was on methotrexate was admitted with progressive dyspnoea and malaise. he had been recently started on leflunomide. investigations revealed interstitial lung disease and acute renal failure. he improved on conservative treatment (stoppage of disease modifying drugs (dmard), iv fluids and steroids). review of literature an epidemiological study by suissa et al has suggested that there is increased risk of ild associated with leflunomide in patients with a history of ild or methotrexate use but they attributed this to channelling bias. there has also been a report of leflunomide associated with iga glomerulonephritis.by this presentation we aim to increase the awareness of this entity. we also suggest that any patient who is started on combination dmard (i.e. methotrexate and leflunomide) should have a baseline chest x-ray and be monitored for development of interstitial lung disease. conclusion we are reporting the first ever case of interstitial lung disease and glomerulonephritis (in the same patient), due to usage of leflunomide. this entity needs to be thought about in any patient on combination dmards. background bone morphogenic protein receptor ii (bmpr-ii) mutations are associated with pulmonary artery hypertension. failure of the growth inhibitory effects of bmp may contribute to vascular obliteration and remodelling leading to pulmonary artery hypertension (pah) [1] . pah has been observed following venous thrombembolic disease (vte), including pulmonary embolism (pe) and deep venous thrombosis (dvt) [2] . local markers of the pulmonary vascular endothelium rather than traditional markers of thromobophilia are thought to be involved [3] . methods plasma was collected from age and gender matched participants within 24 hours of diagnosis of vte and prior to commencement of warfarin therapy. plasma samples were hybridized to individual human cytokine antibody arrays, to detect protein levels of bmp2, bmp4 and bmpr-ii. results bmp2 and bmp4 levels were higher in patients with dvt than pe. no difference in the bmp level was observed between patients with pe and controls. soluble bmpr-ii receptor was lower in patients with pe than in controls or patients with dvt. conclusion in patients with pulmonary artery stress during the time of a pe the bmpr-ii receptor is reduced, which may predispose patients to vascular remodelling and obliteration. the bmp 2 and 4 levels are reduced at the same time, suggesting a possible overriding regulatory mechanism. the physiological role of bmp's and bmp receptors in patients with vte warrants further investigation. historically, cyclophosphamide has had a variable role in interstitial lung disease (ild), the rationale for its use based on the benefit seen in vasculitis and scleroderma, its rapid effect and low toxicity profile. in patients with severe progressive ild a rapidly effective, well-tolerated agent is desirable. for this reason a treatment protocol for the use of intravenous (iv) cyclophosphamide was implemented at our hospital. aim to review the indications, duration, tolerability and effect of intravenous cyclophosphamide in ild patients following the introduction of a treatment protocol. methods records of 92 patients [dlco was 40 ϯ 15% and fvc 61 ϯ 20%] completing a course of iv cyclophosphamide during 2005-6 were reviewed (excluding patients with systemic sclerosis). data covering 18 months prior to and following treatment were collected. comparative analysis of paired pulmonary function data 6 months before and after treatment was performed. 61% had underlying autoimmune disease. results primary treatment indications included progressive disease(n = 67); severe disease (n = 16); suspected vasculopathy (n = 11); bridging therapy to transplantation (n = 10); and accelerated decline (n = 5). patients received 600 mg/m 2 [mean dose 1152 ϯ 165 mg, median number of pulses 6 (1-12)]. patients with paired pulmonary function data had a difference in median change in dlco% predicted from -15.6% (-95.4 to 29.9%) before treatment to +4.25% (-17.3 to 73.9%) following treatment (p < 0.0001). this remained significant with exclusion of vasculitis, or any autoimmune disease, and independent of prior immunosuppression. therapy was well tolerated (4 withdrew from treatment, 5 deaths within 1yr, none directly related to treatment). conclusion iv cyclophosphamide is well tolerated, and associated with functional stability or improvement in the majority of patients. it remains a viable treatment alternative for consideration. pulmonary hypertension is common in interstitial lung disease (ild) and associated with a poor prognosis. as the gold-standard test, right-heart catheterization (rhc) is invasive, and resource-limited, reliable non-invasive measures of ph are needed. methods all ild patients referred for rhc during 1997-2007 were included (n = 95; 54 male; age 56.5 ϯ 12 yrs). all patients had concurrent echocardiography (tte) and pulmonary function. the relationship of rhc mean pulmonary artery pressure (mpap) to tte variables, pulmonary function, exercise capacity, as measured by six minute walk testing (6mwt, n = 58) and brain natriuretic peptide (bnp, n = 36), was examined. case a 65 year old male, non-smoker for 25 years, retired professor of anatomy (had chronic exposure to embalming fluids, formaldehyde, phenol, antifungal and other solvents, for 20 years) presented with chronic cough and phlegm production. these symptoms were worse at night (waking him several times) and early morning. his pulmonary tests were stopped due to persistent cough. a chest x-ray revealed features of longstanding interstitial lung disease. the hrct revealed widespread subpleural interlobular thickening, worse at bases, in keeping with idiopathic pulmonary fibrosis (ipf). there was minimal fibrosis and honeycombing, but no groundglass opacification, large bullae, pleural calcification or pleural plaques. however, there was associated bronchiectasis at the lung bases considered to be due to traction. the ba lavage showed 50% macrophages, 7% neutrophils, 3% lymphocytes, and 40%, eosinophils and no infection. the patient declined to have a lung biopsy. as per his past x-rays, the duration of his ipf is a little over one year. he maintains that his symptoms started only after starting irbesartan (irb). introduction transbronchial lung biopsy (tbb) has a variable and unpredictable diagnostic yield in sarcoidosis. we hypothesized that the extent and pattern of parenchymal disease on ct would predict the likelihood of a positive tbb. methods data relating to ethnicity, symptoms, pulmonary function and site and results of tbb and bronchoalveolar lavage (bal) from 70 sarcoidosis patients were recorded. all had a ct scan within 6 weeks prior to the tbb procedure. cxr stage was determined from radiology report. ct scans were scored quantitatively for patterns of parenchymal disease (nodular, reticular, consolidation, ground glass and mosaic attenuation) on a lobar basis. results 50% patients had a positive tbb (total 67% of cohort had histological confirmation). symptoms, ethnicity, treatment, lung function and cxr stage were not predictors of a positive biopsy. positive biopsy was associated with higher bal lymphocyte count (p < 0.05) and female gender (p < 0.01). a reticular pattern (p < 0.05) and higher total lung score (excluding da) (p < 0.05) on ct scan predicted a positive biopsy. in those patients with tbb from right lower lobe (53/70) the total rll score on ct was predictive of positive biopsy (p < 0.05). on multivariate analysis gender, bal lymphocytosis and total lung score were independent predictors of a positive tbb (area under roc 0.82). pulmonary arterial hypertension has two histological variants; 'arterial-only pulmonary arterial hypertension' (artpah) and 'pulmonary veno-occlusive disease' (pvod). bosentan, a dual endothelin receptor antagonist, has been found to improve haemodynamics, functional capacity and survival in artpah. however, the response to bosentan in clinically diagnosed artpah is often variable. it was hypothesized that a lack of response to bosentan therapy in clinically diagnosed artpah can be explained by misdiagnosed pvod. aims included to: (1) perform morphometric and qualitative pulmonary vessel analysis on normal controls and cases clinically diagnosed with artpah who had failed bosentan therapy; (2) ascertain if pvod is present within the case group; (3) correlate clinical variables and vessel microanatomy to identify the pathologies driving pulmonary pressure elevation. this study reviewed 14 cases of clinically diagnosed artpah (idiopathic n = 12, associated with scleroderma n = 2), who had failed bosentan therapy and had available lung tissue. controls (n = 6) were obtained from explanted lungs for other causes and a prior transthoracic echocardiogram excluded pulmonary hypertension. vessel morphometry and qualitative analysis was performed with a novel technique of smooth muscle actin immunohistochemistry counterstained with verhoeff's elastin. baseline clinical data were retrieved. we found 86% of cases had pathology confirmed pvod. only 14% of cases had artpah, the original clinical diagnosis. in pvod, significant pathology was present in all vessel types. all vessels had significant smooth muscle hypertrophy. the obstructive, collagenous, pauci-cellular intimal fibrosis of the venules (p < 0.0001) and arterioles (p < 0.0001) was considerably different to the concentric laminar proliferation of smooth muscle observed in the muscular arteries (p < 0.0001) and arterioles (p = 0.001) in artpah. artpah also had muscular artery smooth muscle hypertrophy (p = 0.007). the median time to bosentan failure was shorter in pvod than artpah (290 vs. 657 days). in conclusion, pvod is an under-diagnosed cause of pulmonary hypertension, is commonly clinically misdiagnosed as artpah and may present with a poor bosentan therapy response. finally, pvod is a vaso-occlusive, not a veno-occlusive disease, and is an independent type of pulmonary hypertension, not a subtype of pulmonary arterial hypertension. cutaneous t cell lymphomas (ctcl) are a heterogenous group of lymphoproliferative disorders. they show various clinical manifestations and diverse morphological, histological and immunological characteristics of the malignant cells. they are caused by clonally derived, skin invasive t cells. peripheral t cell lymphomas (ptcl) are generally more aggressive and have one of the lowest overall and failure-free survival rates. because of the rarity of these disorders, diagnosis and treatment remain challenging. this case report describes a 69-year-old woman presenting with progressive dyspnoea and cough, together with a distressing generalized pruritic rash. she was initially treated as left ventricular failure with the rash ascribed to a drug reaction as suggested by initial skin biopsies. the diagnosis was made on a third skin biopsy and flow cytometry of lymphocytes obtained by broncho-alveolar lavage 6 months after presentation. despite an initial response to chemotherapy she succumbed to the disease 20 months after diagnosis. clinical pathways to guide the investigation of suspected pulmonary embolism (pe) have been increasingly adopted by emergency departments (ed) worldwide. compliance with these diagnostic algorithms is critical in ensuring good patient outcomes. this study evaluated the compliance to the clinical pathway used in our ed that combines risk assessment (wells scoring system) with d-dimer test, vq scan or ctpa. the main objectives of this study were to identify those factors which contributed to compliance and to assess patient outcomes. methods a prospective observational study of 239 consecutive patients who underwent investigation for pe in our ed. patient demographics, pathway parameters and patient outcomes at 3-month follow-up were collected. case we report the case of a 37 year old woman who presented to the emergency department with a three day history of dry cough and dyspnoea. the patient was in her third pregnancy at 30 weeks gestation. she had no fever, chest pain or coryzal symptoms. the patient had presented with a right sided spontaneous pneumothorax seven months prior to the current presentation. her past medical history included placental abruption, complicating her previous two pregnancies. her second pregnancy was complicated by placental abruption at 27 weeks and the foetus had not survived. her first pregnancy was complicated by placental abruption at 36 weeks with successful delivery of the foetus. at presentation, significant findings included tachycardia, hypoxemia, tachypnoea and reduced breath sounds over the right side of the chest. chest x-ray demonstrated a large right pneumothorax. a right intercostal catheter was inserted resulting in right lung re-expansion. the catheter was removed three days later. the patient returned to hospital twenty four hours after catheter removal with a recurrent right sided pneumothorax. the patient agreed to surgical intervention involving video-assisted thoracotomy and talc pleurodesis. the patient had no further complications with the pregnancy. she delivered a healthy baby at 38 weeks gestation. discussion spontaneous pneumothorax in pregnancy is rare and there is little evidence to provide guidelines for the management of recurrent pneumothorax in high risk pregnancy. our case illustrates a successful outcome for mother and foetus with surgical intervention at 32 weeks gestation. folfox is currently the standard adjuvant treatment for locally advanced (stage iii) colon cancer and increases disease free survival. its toxicity is well tolerated with common adverse effects being paraesthesia, bone marrow suppression and gastrointestinal disturbance. pulmonary toxicity has rarely been reported. three clinical cases of acute dyspnoea following folfox therapy (2005) (2006) (2007) for stage iii colon cancer are reported. all had an anterior resection followed by 11-12 cycles of folfox. each developed rapidly progressive dyspnoea requiring hospital admission within one week of their last cycle. one patient required invasive ventilation in icu. high resolution computed tomography (hrct) showed bilateral widespread honeycomb pattern with associated ground glass opacification consistent with pulmonary fibrosis. they had reduced lung volumes and gas transfer. transbronchial biopsy and bronchoalveolar lavage in one patient showed an acute eosinophilic pneumonitis. other causes of interstitial lung disease were carefully excluded. all three patients received high dose corticosteroids with one receiving additional cyclophosphamide. the first patient showed complete recovery following an eight week course of corticosteroids, with resolution of the hrct changes and improvement in lung function. the second had symptomatic improvement of dyspnoea, but a persistent moderate reduction in gas transfer. the final patient had persisting radiographic changes and a reduced gas transfer. he remained dependant on ambulatory oxygen 6 months after his initial presentation. these patients' interstitial lung disease appears due to folfox with oxaliplatin being the most likely causative agent. the use of oxaliplatin chemotherapy has increased markedly over the last 3 years and although rare, physicians should be aware of its potential for lung toxicity. lung function testing at baseline, during and towards the end of oxaliplatin treatment should be undertaken and may allow early detection and intervention in cases of pulmonary toxicity. the forced oscillation technique (fot) with broadband signals has been employed relatively rarely in the studies on respiratory mechanics. recent work from our laboratory [1] indicated that the cheek support and the neck angle have minor influence on the impedance spectra around the first antiresonance (far,1), which makes the use of the broadband fot especially attractive in young children. methods we studied 7 healthy children (c; female: 4) and 8 children with bronchopulmonary dysplasia (bpd; female: 3), using multiple-frequency fot between 8 and 256 hz superimposed on spontaneous breathing. results groups c and bpd did not differ in age ( lung function impairment is common in children with cardiac defects associated with increases in pulmonary blood flow/pressure. to investigate the development of bronchial hyperreactivity (bhr), an aorto-caval shunt was created in a model of precapillary pulmonary hypertension. surgical shunt repair was performed to assess the reversibility of bhr. methods 26 rats were divided into 3 groups: group c (n = 10) with sham surgery, group s (n = 8) where an aorto-caval shunt was created (follow-up 4 wks), group r (n = 8) with aorto-caval shunt but surgical correction of the shunt at 4 wks (follow-up 8 wks). in all animals, respiratory input impedance (zrs) was measured at baseline and following increasing doses of methacholine (mch 2, 4, 8, 12 mcg/kg). airway resistance (raw), inertance, tissue damping (g) and elastance were estimated from the zrs spectra by model fitting. measurements were repeated in all animals at 4 wks and at 8 wks for groups r and c. results there was a significant increase in raw and g in group s and rat 4 wks at baseline and following mch ( fig.) which was reversed after surgery. to characterize the factors contributing to lung function impairment following cardiopulmonary bypass (cpb), functional residual capacity (frc), lung clearance index (lci) and respiratory mechanics were measured in children with pulmonary hypoperfusion (tetralogy of fallot, tof n = 12) and hyperperfusion (ventricular septal defect, vsd n = 12) undergoing surgical repair of congenital heart disease. methods frc and lci were measured using a sf6 washout technique and respiratory mechanics using a low frequency oscillation technique in the perioperative period. results while chest opening led to a significant improvement of lung volumes and respiratory mechanics in all patients (p < 0.001), a reduction in pulmonary blood flow during cpb decreased lung volumes and airway resistance in parallel but significantly more in children with tof compared with those with vsd. re-establishing pulmonary blood flow during cpb improved respiratory function particularly in children with tof ( figure) . conclusions sternotomy had a great impact on lung function with parallel improvement in alveolar recruitment, ventilation inhomogeneity and airway resistance. in contrast, onset of cpb led to lung function impairment with a significant drop in frc especially in children with pre-existing hypoperfused lungs. this suggest that pulmonary blood flow enhances alveolar stability through a tethering effect on the alveolar walls. children with advanced lung disease being considered for lung transplantation are likely to spend disproportionately longer periods on transplant waiting lists before appropriately sized donor organs become available. these longer waiting times reflect the lower organ donation rates seen in children; rates that are significantly lower than those reported in the adult population. we describe two children with advanced lung disease who deteriorated whilst on the waiting list for lung transplantation, and in the absence of appropriately sized donor lungs, underwent lobar lung transplantation. methods we describe the clinical course of two children, aged 9 and 13 years old, with advanced lung disease secondary to post-mycoplasma obliterative bronchiolitis and cystic fibrosis-associated bronchiectasis, respectively. results both children received a "cutdown" bilateral lobar transplant from two oversized adult brain-dead organ donors. in both cases the transplant operation involved implantation of the right middle and upper lobes, and of the left upper lobe from the donor. conclusion given the low organ donation rates in children, and in the absence of appropriately sized donor lungs, novel strategies such as lobar transplantation must be considered, particularly when children continue to clinically deteriorate whilst on the lung transplant waiting list. data from the west australian adult outcomes of extreme preterm birth study suggest that adult survivors of bronchopulmonary dysplasia (bpd) may be left with functional and structural pulmonary abnormalities, most notably emphysema. animal data suggest that the antenatal administration of corticosteroids may adversely affect lung development. we therefore sought to determine if maternal variables, including administration of corticosteroid, could predict emphysema severity in adulthood. methods bpd subjects (birthweight < 1500 g and oxygen dependence at 36 weeks post-menstrual age) born prior to 1988 were identified and recruited prospectively via the statewide neonatal follow up program as previously described. pulmonary function tests and thin selective inspiratory and expiratory computerised (ct) images were acquired and scored for emphysema severity (voxel index (%)). the obstetric history was obtained from retrospective review of case notes. results 21 adults (12 females, aged 18-34) were studied, 2 declined ct. all subjects had abnormal ct findings. fifteen (79%) had areas of emphysema. emphysema score and fev1 were not influenced by the administration of antenatal corticosteroids, indication for delivery, maternal age or presence or absence of chorioamnionitis. conclusion maternal factors, including the administration of antenatal corticosteroids, do not predict the long term respiratory outcome of bpd. the factors determining the severity of emphysema in this group remain unknown. the prevalence of childhood asthma is high in the torres strait. children have generally more severe asthma and asthma knowledge is poor. however, there is no culturally appropriate asthma education program for these children. we are conducting a randomized controlled trial to examine the additional benefits of an education intervention by indigenous health care workers (hcw) on asthma outcomes. we describe the study's objectives, design and baseline measurements. methods children with wheeze were reviewed by two paediatric respiratory physicians using a standardized protocol; children with asthma were eligible. after obtaining informed consent children were randomly allocated to: (1) three additional asthma education sessions with a hcw; or (2) no additional education from a hcw. trained hcws carried out the education sessions using culturally appropriate tools. primary outcome was the number of unscheduled hospital/doctor visits due to asthma exacerbation. all children were re-assessed at 12 months. results we enrolled 113 children aged 1 to 17 years, 81% were torres strait islanders and 12% aboriginal and torres strait islanders. the clinical spectrum of asthma was: 51% infrequent episodic asthma, 22% frequent episodic asthma and 27% chronic asthma. eighteen percent of the children knew what a written asthma action plan was; 8.5% had one. carers' assessment of knowledge of medications showed that 52% could not name any asthma medication used by their child, 40% could not explain dosage, and 67% could not explain how beta2 agonists worked. conclusions asthma knowledge and possession of asthma action plans in this cohort is poor at baseline. there is substantial room for improvement and additional asthma education by hcws potentially has significant benefits. impulse oscillometry system (ios) measures respiratory function during normal breathing by transmitting mixed frequency rectangular pressure impulses down the airways and measuring reflected pressure. computer analysis calculates respiratory impedance and its components, airways resistance and reactance, at a range of frequencies from 0.1 hz to 150 hz. no previous australian normative data exists. the ios software generates predictive normal values for each of the parameters measured including total airway resistance (r5), the proximal airway resistance (r20) as well as peripheral capacitive reactance (x5). however, they are based on german data. methods cross-sectional study of 100 community dwelling adults, with 10 males and females per 10-year cohort. inclusion criteria: age range 25-74 years, apparently good respiratory health. exclusion criteria: smokers, asthmatics and others with acute or chronic respiratory disease. both ios and spirometry were conducted on all participants. results australian predictive normal equations have been generated and compared to the current published equations. the ios parameters have been correlated with the spirometric data. results have been analysed by gender, age, height and weight and compared with the predictive normal values for each parameter provided by the german manufacturer of the ios instrument. analysis includes calculation of mean range, and lower limit of normal. conclusions a preliminary set of australian predictive equations have now been produced for the ios. these have been compared with international equations. ios has potential application in a range of respiratory disease states and in population screening for occupational health (e.g. mining, & high dust load environments). supported by phc red. rationale although clinical practice guidelines for both asthma and copd recommend spirometry for diagnosis and monitoring, beneficial effects on the management of chronic respiratory diseases in general practice have not been established. we hypothesized that spirometry would improve health outcomes compared to usual care. methods we are conducting a single masked rct with 3 arms: group a receive 3 monthly spirometry and followup, group b receive spirometry before and after the trial and group c usual care. 45 general practices were recruited though divisions of general practice in melbourne. invitations were mailed by 31 of these practices to patients who had been prescribed inhaled medications during the previous 6 months. participants returned respiratory and generic quality of life questionnaires and an asthma score card. groups a and b were tested on a micromedical turbine spirometer following ats/ers guidelines. results 351 eligible patients (275 adults, 50 children aged 8-13 and 26 youths aged 14-17 years) entered the trial. 122 were randomized to group a, 134 to group b and 95 to group c. the mean (sd) age of adult participants was 54.3 (12.7), children 10.3 (1.7) and youths 15 (1.1) years. there were 130 males and 221 females. the adults were highly symptomatic in the previous 12 months: 82% reporting wheeze, 50% chest tightness on waking, 74% shortness of breath on exertion, 61% nocturnal cough, 46% morning cough and 75% sputum. symptoms of chronic bronchitis were reported by 39% of adults and a diagnosis of copd by 19%. asthma was reported by 84%, confirmed by a doctor in 96% and 55% had experienced an attack in the last 12 months. only 35% had a written asthma action plan. 37% of adults had ever visited a hospital ed and 28% had been admitted. conclusion it is possible to recruit asthma and copd patients from general practice and to randomize them to spirometry or usual care. whether spirometry is associated with fewer symptoms, changes in medication, uptake of action plans or improvement in lung function or quality of life requires further followup. supported by nhmrc. s shah 1 , jk roydhouse 1 , b toelle 2 , s sawyer 3 , c jenkins 2 for the pace australia management committee 1 university of sydney, 2 woolcock institute of medical research, sydney, nsw 2006, and 3 royal children's hospital, melbourne, vic 3052 it is widely held that recruitment of general practitioners for research can be challenging. in this paper, we discuss the recruitment experience from a current study evaluating the impact of an educational asthma intervention on patient outcomes. our aim is to describe the two different strategies utilized to date: (1) in-house through an academic department of gp and (2) outsourced to a private gp organization. methods initial interest was generated through faxes, presentations at gp divisional meetings and newsletter advertisements. gps who expressed interest were visited by project staff to discuss the study further. a major difference was recruiting one gp per practice in the first strategy versus multiple gps per practice in the second strategy. to assess the strategies, we examined participant characteristics, number of gps recruited and number retained. results participant characteristics: under both strategies, 30% of recruits had trained in asia and 54% were women. the first strategy recruited more gps who spoke at least two languages at home (85% vs 42%) and the second strategy recruited more recently graduated gps (58% vs 50%). recruitment: the first strategy recruited 35 gps over 6 months and the second recruited 34 gps over 3 months. retention: 19 gps (54%) from the first strategy stayed in, compared to 29 (85%) from the second. conclusions whilst absolute numbers of gps recruited were similar, retention was much higher under the second strategy. recruitment in primary care is difficult and requires a range of approaches which need to be re-evaluated and adapted as necessary during the course of the study. supported by the australian government department of health and ageing. bronchiectasis is a heterogeneous condition with a large number of causative factors and range of symptoms. the classification of this condition is often confusing and hard to remember. the aim of this study was to classify non-cf bronchiectasis into different clinical phenotypes. methods 178 consecutive patients with non-cf bronchiectasis confirmed on high resolution ct scanning had a detailed clinical, spirometric and laboratory assessment performed by a respiratory physician (pk/mf/pw) and were then followed up for an average of 9 ϯ 4 years (mean and sd) for a total of over 2000 reviews. results 160 of the 178 patients (90%) could be classified as belonging to 3 phenotypic groups; 1) bronchiectasis arising in childhood, 2) bronchiectasis occurring in smokers and 3) bronchiectasis occurring in the elderly. each group had different features which are listed in the there are few data on the long term outcomes of treatment for tuberculosis (tb) by directly observed therapy (dot) in low-incidence settings. the aim of this study was to assess the incidence of recurrent tb in nsw. methods data linkage was performed within the nsw department of health tb notifications database to identify cases that had more than one tb notification between 1994 and 2006. recurrent tuberculosis was defined to include all patients with two or more culture positive episodes at least 6 months apart, where patients had received at least six months treatment for the initial episode. in cases where data contained within the notification details was not sufficient to allow us to distinguish between true cases of recurrent disease, duplication notification for the same episode or persistent disease after incomplete treatment, additional information was obtained from the area tb coordinator. results there were 5723 tb notifications between 1994 and 2006 with 3731 being culture positive. 15 cases of recurrent culture positive disease after completed treatment for the first episode were identified (recurrence rate: 0.4%). conclusions in a population with a low tb incidence, treatment of active tuberculosis with dot results in a very low rate of disease recurrence over a long period of follow-up. support nhmrc ccre in respiratory and sleep medicine. introduction rhinoviruses (rvs) are the major cause of viral-induced exacerbation of asthma. to date, the molecular mechanisms of rv pathogenesis are not understood. recent findings suggest that rv pathology may involve host cell nucleocytoplasmic trafficking, inhibiting key cell functions such as transcription and translation. the study aims to investigate the mechanism of rv 3c protease nuclear trafficking. methods hela cells were infected with rv or transfected with plasmids and cellular localization of 3c analysed at various times thereafter using immunofluorescent confocal microscopy and western blotting with specific antibodies. results 3c protease was predominantly present in nuclei of rv infected cells up to 6 hours after infection, becoming increasingly cytoplasmic thereafter. the nuclear membrane of infected cells became progressively indistinct with time. using a specific inhibitor we also found that 3c utilizes the crm-1 nuclear export pathway. 3c was predominantly in the form of 3cd in both cytoplasm and nucleus of infected cells; mature 3c protease was also detected from 6 hours after infection. deletion analysis indicats that the nuclear localization domain and a nuclear export signal are most likely to be present within the n terminal 64 amino acids. the nuclear export signal is inhibited in the full length protein, via an unknown mechanism. conclusion our data suggest that 3c and 3cd proteins localize to the nucleus in infected cells where they may play a key role in rv pathogenesis by disrupting cellular transcription and the nuclear transport machinery. chronic necrotizing pulmonary aspergillosis (cnpa) is a relatively uncommon, sub-acute, locally destructive process due to aspergillus invasion of the lung. the incidence and prognosis of cnpa are poorly described. case report we present a case of cnpa in a patient on intermittent low dose steroid therapy and recurrent refractory exacerbations of chronic obstructive pulmonary disease (copd).the patient presented with worsening shortness of breath and productive cough requiring recurrent inpatient admissions. human influenza virus is found to bind preferentially to saa2,6gal receptors found in the upper respiratory tract, while avian viruses bind to saa2,3gal receptors expressed in lower airways. this is thought to affect the ability of transmission to humans. our aim was to study the ability of avian and human influenza strains to infect bronchial epithelial cells and relate this to levels of the sialic acid receptor expression. methods calu-3 cells were used as a proximal airway cell and a549 were used as distal airway cell. human primary bronchial epithelial cells (pbecs) were obtained from healthy, asthmatic, and copd volunteers by endobronchial brushing. epithelial cells were stained with sambucus nigra lectin that binds saa2,6gal receptor, and maackia amurensis lectin ii that binds to saa2,3gal. the cells was analysed by flow cytometry. human influenza a/h3n2/wellington strain and low pathogenic avian influenza a/h11n9/sandpiper were chosen and were used at an moi of 0.005 to infect cells. the supernatants were harvested at 48 hr post infection, of which was then analysed by plaque assay for virus replication. results the calu-3 showed greater expression of saa2,6gal linkage than saa2,3gal linkage, and a549 displayed slightly higher expression of both receptors compared to pbecs. despite this human and avian influenza virus replicated to similar titre at 15,000 pfu/ml in both cell lines, but showed low replication in pbecs. background treatment of community-acquired pneumonia remains based on 'best guess' empiric algorithms because of the poor utility of current pathogen tests. furthermore our ability to stratify patients into risk groups is crude at best, relying on scores such as the pneumonia severity index or the curb-65 have major limitations. we have been slowly improving real-time pcr assays for pneumococcus as a clinical tool in patients with pneumonia. methods building on previous research we assesed two targets in the autolysin (lyta) gene and the pneumolysin (ply) gene of s.pneumoniae using the lightcycler instrument and fluorescence resonance energy transfer (fret) probes. all common s. pneumoniae serotypes were detected while other bacteria and viruses were not. the lyta target had the best sensitivity with a detection range between 21 ng to 21 fg. both assays were then applied to whole blood samples from 400 adult patients with community-acquired pneumonia, all of whom had blood cultures prior to antibiotic administration and urinary antigen testing for s.pneumoniae. the lyta pcr had the best performance characteristics with a sensitivity more than twice that of blood cultures in the clinical samples. most pcr+ve/culture -ve patients had positive urinary antigen tests. there was clinical evidence that urinary antigen +ve/ pcr -ve patients were false +ves. most significantly there was a strong correlation between quantitative bacterial count and clinical outcome. conclusions real-time quantitative pcr for pneumococcus has significant potential as both a diagnostic and therapeutic tool in patients with pneumonia. the pitjantjatjara lands are situated in the north-western corner of south australia, occupying an area of over 120 000 square kilometres with a population of approximately 3000. the population lives in small communities or homelands, and there is a high level of mobility between this region and other aboriginal communities in south australia and the northern territory. nganampa health council provides all health care services to the region. specialized support for tb control comes from both the south australia tb service based at royal adelaide hospital as well as a centre for disease control in alice springs. the prevalence of tuberculosis (tb) in this predominantly indigenous community is thought to be significantly higher than the national rate. there are considerable challenges in detecting and managing tuberculosis, relating to the community's geographical remoteness, migration of populations and access to health services. the aims of this study are to quantify the prevalence of tuberculosis in the pitjantjatjara lands, and describe the significant barriers to tb diagnosis and treatment. methods a retrospective study of all diagnoses of tuberculosis within the pitjantjatjara lands in the period 1995-2006. outcomes include measures of tuberculosis diagnosis, the rates of completed tb treatment and rates of tuberculosis drug resistance. the study will draw conclusions about the reasons for high levels of tb prevalence in this community and identify barriers to effective tuberculosis treatment. conflict of interest no. patients admitted to hospital with a diagnosis of community-acquired pneumonia (cap) are usually treated with intravenous (iv) antibiotics irrespective of pneumonia severity. available guidelines vary in recommended timing and indications for switching to oral antibiotics. aim to examine the patterns of antibiotic choice and delivery method (iv, oral and time to switch) in patients admitted with cap. methods a retrospective chart review of admissions to the respiratory unit over a 12-month period with a diagnostic-related group (drg) coding of pneumonia. 41 charts were reviewed. data collected included patient demographics, clinical features at presentation (temperature, pulse rate, respiratory rate, bp, oxygenation), initial investigations, initial antibiotic regime, time to change (iv to oral), subsequent antibiotic regime and duration, time to defervescence, length of stay and outcome. pneumonia severity was calculated using the revised british thoracic society system (curb-65), score ն 2 = severe. results 3 patients were excluded due to incorrect coding. of the 38 patients, age was 50 ϯ 21 (mean ϯ sd) yrs and 25 (66%) were male. 28 patients (74%) were febrile at presentation and the median curb-65 score was 1 (range 0-4). 37 patients (97%) received iv antibiotics. the curb-65 score was 0 or 1 (non-severe) in 25 patients and 22 of these patients received a combination of iv ceftriaxone and a macrolide. time to defervescence was 2.9 ϯ 2.3 days. time from defervescence to switching to oral therapy was 3.4 ϯ 2.8 days. in non-febrile patients, time to switch was 4.7ϯ4.3 days. length of stay was 8.7ϯ13.0 days. conclusions the time between defervescence and switch to an oral regime was relatively long, possibly contributing to an increased length of stay. many patients received ceftriaxone even with a curb-65 severity rating of 0 or 1. implementing local guideline-based treatment protocols may reduce length of stay. ultrasonic flow sensors can determine flow, volume and molar mass (mm) of the gas flow simultaneously. during tidal breathing the expired molar mass curve can be used to compute co2 over expired volume and a capnography index (cpi) can be computed. the relationship between cpi and copd classification according to gold was investigated. methods prospective, controlled trial. consecutive patients who underwent routine lung function were enrolled to participate in a tidal breathing test using an ultrasonic flow sensor. each test consisted of three tidal breathing recordings of 60 sec. flow, volume and molar mass were measured at 200 hz and data were acquired using prototype wbreath data acquisition software. mean expirograms (mm over volume) were computed and the measurements were analyzed to determine the slope of exhaled phase ii (s2), the slope of phase iii (s3) and the relationship between s2 and s3 (cpi = s3/s2). gold stages were determined from the lung function results and the ers predicted values. results 53 volunteers participated in the study with a mean age of 62 (sd 14), 23 were male, mean bmi 26 (sd 5), 17 had never smoked. the mean pack/year smoking history was 38. there was a clear relationship between gold stage and cpi: gold stage 'normal' had a mean cpi of 5.5 (sd 3.7, n = 21), stage 'severe' had a mean cpi of 13.7(sd = 3.9, n = 7). conclusion computation of cpi based on tidal breathing analysis using an ultrasonic flow and mm sensor correlates well with gold stages. it may therefore be possible to use a simple tidal breathing test to determine the severity of airways disease. background osa is common in tetraplegia and appears within weeks of injury. although cpap treatment is efficacious in able-bodied subjects, case series suggest that cpap is poorly tolerated in tetraplegia. no prospective study has examined cpap efficacy or adherence in tetraplegia. aim to determine the feasibility of cpap use to treat osa following acute tetraplegia. methods all acute admissions who consented and fulfilled the inclusion and exclusion criteria underwent full, portable polysomnography. those found to have an apnoea hypopnoea index of >10 events per hour (osa) were offered cpap, delivered via an auto-titrating device. results to date, 25 patients have been admitted (11 excluded, 3 refused consent). no significant, adverse events have been observed. two patients did not have osa. of the nine with osa, four are mid-study, two had incomplete follow-up (1 returned to uk and 1 refused 3 month assessment), two adhered with cpap and one did not due to severe, pre-existing nasal obstruction. preliminary analyses suggest that those who adhered to cpap had a marked reduction (80% compared with 10-40%) in sleepiness and a greater reduction in the functional outcomes of sleepiness compared to either those without osa or who were unable to use cpap. patient accrual, recruitment and completion rates are consistent with our initial estimates. study recruitment will be completed by end-october 2007. conclusion initial data suggest that auto-titrating cpap is a feasible treatment for osa in acute tetraplegia. these data will be used to finalize planning for a multi-national, multi-centre randomized controlled of therapy. this research was supported by the transport accident commission. visual recognition of cyanosis is an important clinical activity. cyanosis recognition is affected by lighting colour and there is anecdotal evidence that people with significant colour vision deficiencies (cvds) have particular difficulty. studies to date have centred on the colour change with oxygenation of isolated blood but it is not clear how this extrapolates to cyanotic patients in vivo. methods ten patients known to be chronically hypoxaemic and showing signs of cyanosis were recruited from the chronic respiratory program. ten normal subjects were recruited as controls. the spectral reflectances of their lips, nail beds and palm creases were measured using a topcon sr-3 telespectroradiometer. the patients were measured at rest and after exercise to lower their saturation by 5-10%. the chromaticities were calculated and plotted. results both groups showed a spread of colours but they fell into two distinct ranges. the colour difference between the groups lies very close to the colour confusions made by congenital cvds. within the cyanosed group, the colour shift was not tightly related to decreasing oxygen saturation. this is most likely due to interpersonal factors such as pigmentation and vascular perfusion that affect colour and the difficulties in measuring the colour of heterogeneous anatomical features. conclusions these results quantify the anecdotal difficulties in detecting cyanosis and suggest that observers with cvd would have problems recognizing the condition. the photographs obtained from this study will be used to compare the ability of subjects with and without cvd to detect cyanosis. supported by the nsw ambulance service. baroreflex sensitivity is depressed in osa patients during sleep but effects during wakefulness are less clear. we have now examined relationships between awake brs and severity of sleep disordered breathing (sdb). methods immediately prior to overnight polysomnography, continuous (5 min) beat-to-beat arterial blood pressure was measured via finger plethysmography (portapres) and heart rate via ecg in 20, supine, normotensive, untreated osa patients (17 males; age: 49 ϯ 15 years (mean ϯ sd); bmi: 26 ϯ 11 kg/m 2 ). spontaneous baroreflex sensitivity (brs) was calculated using the sequence technique. sdb was characterized as apnoea hyponoea index (events/hour) and arousal index (ai). data were analysed via mathematical modelling and unpaired t test. results brs fell with increasing ahi. patients with ahi > 30 events/hour (n = 9) had a significantly lower brs (8.1 ϯ 1.5 ms/mmhg) than those with ahi < 30 events/hour (19.8 ϯ 8.7 ms/mmhg, p < 0.001). brs was negatively related to both ahi and ai via fitted exponential functions (r 2 = 0.45 and 0.70, respectively). it is hypothesized that the analysis of morphology of the ecg waveform in combination with the heart rate patterns could lead to the possibility of detection of the start and duration of apnoea/hypopnoea events and consequently estimation of the apnoea-hypopnoea index (ahi). to the authors' knowledge the published ecg based algorithms for detecting sleep disordered breathing are only capable of minute by minute analysis rather than detection of individual respiratory events. methods changes to ecg parameters were investigated during respiratory events with no distinction made between apnoea and hypopnoea events. 632 isolated respiratory events and 1264 controls of identical duration were obtained from 7 polysomnographic studies, using a randomized procedure. features such as the r wave amplitude, t wave amplitude, qrs area and the r-r interval were extracted from the 2 lead ecg. a number of physiological predictors based on these features were generated. a logistic regression model was used to investigate the association between the predictors and true events, using the statistical software, stata. results univariate and multivariate analyses were performed. three multivariate models were developed; heart parameters only, ecg waveform morphology parameters only and the combinations of the two. the area under the receiver operator characteristic curves (auc) for these models were compared. the best results were obtained with the combination of morphology and heart rate parameters (auc = 0.8858 (0.0078 (sd))) compared to the morphology (auc = 0.8169 (0.0121 (sd))) and heart rate (auc = 0.7195 (0.0103 (sd))) models. the multivariate analysis has shown encouraging results indicating that an algorithm using a combination of heart rate and ecg morphological parameters could potentially be constructed that would enable the determination of individual respiratory events and subsequently an ahi. supported by the arc. introduction sacin and scond are measures of ventilation heterogeneity in acinar and conducting airways, derived from analysis of mbnw. maintaining tidal volumes of 1 l at 9-11 breaths/minute (bpm) is impossible for some. our aim was to examine the effect of different tidal volumes on sacin and scond in normals and asthmatics. methods 10 normals (23-41 yrs) and 12 asthmatics (21-63 yrs) underwent mbnw at tidal volumes of 500 ml at 20-23 bpm, 1 l at 9-11 bpm, and 2 l at 5-7 bpm. scond and sacin, were determined from the normalized phase iii slopes of breaths between turnovers (cumulative ventilation/frc) 1.5 & 6. results the mean ϯ sd %predicted fev1 was 97.3 ϯ 17% in normals and 88 ϯ 11% in asthmatics. in normals, sacin at tv of 0.5, 1 and 2 l were 0.195 ϯ 0.105 l -1 , 0.095 ϯ 0.036 l -1 and 0.058 ϯ 0.031 l -1 , respectively (p = 0.0003, anova), while scond were 0.098 ϯ 0.047 l -1 , 0.042 ϯ 0.021 l -1 and 0.029 ϯ 0.014 l -1 (p = 0.0002), respectively. in asthmatics, sacin were 0.440 ϯ 0.195 l -1 , 0.181 ϯ 0.087 l -1 and 0.100 ϯ 0.047 l -1 , respectively (p < 0.01), while scond were 0.204 ϯ 0.111 l -1 , 0.068 ϯ 0.037 l -1 and 0.031 ϯ 0.013 l -1 , respectively (p < 0.0001). conclusion increasing tidal volume while maintaining the same minute ventilation during mbnw led to large decreases in scond and sacin in both asthmatics and normals. this may be due to reduced inter-regional differences in specific ventilation with greater tv. the log-log relationship between sacin and tv allows an adjustment to be made for variations in tidal volume. funding crc for asthma and airways and nhmrc project grant #547346. dj smith 1 , k bowden 2 , t lloyd 2 , j coucher 2 , l garske 1 1 respiratory medicine, and 2 radiology, princess alexandra hospital, brisbane, australia introduction we have shown diaphragmatic flattening and decreased diaphragmatic excursion qualitatively assessed on ultrasound is strongly predictive of dyspnea severity and lower lung inflation in patients with pleural effusion. we sought to quantitatively measure diaphragm length and movement and determine how closely these are related to dyspnea severity and lung inflation. methods patients with unilateral pleural effusions had ct imaging of their diaphragm during a measured inspiratory capacity manoeuvre. maximal sagittal length was measured at tlc, and frc. patients had a baseline dyspnea index (bdi: 0-12) and respiratory function measured. results 4 patients with unilateral effusion (all right side; 3 malignant mesothelioma, 1 inflammatory) had a mean (sd) bdi of 5.5 (2.89), and tlc of 74% (3.91) predicted. the right diaphragm on the side of the effusion tended to be shorter than the left at frc (p = 0.08), and had a trend to reduced shortening with inspiration (p = 0.08). conclusions the right diaphragm is known to be longer than the left in health. the strong trend to a shorter and less mobile right diaphragm associated with effusion suggests this is a potential mechanism for dyspnea. further recruitment will enable correlation between bdi, tlc and diaphragm length and mobility. 4) ) that was slightly worse than an able bodied, control population (17.9 (3.1)), but better than an able-bodied population with untreated osa (14.5 (3.6)). the mapi predicted that 14% of the sample were likely to have osa. these data will be complimented by full sleep studies to be performed at the participants' homes in late 2007, early 2008. conclusion our interim data suggest that the rate of subjective sleep complaints are not substantially different in the population with tetraplegia compared with the able-bodied. this research was supported by the victorian neurotrauma initiative. it has long been assumed that the ventilation heterogeneity associated with lung disease could in itself affect the measurement of carbon monoxide transfer factor. the aim of this study was to investigate the potential estimation errors of carbon monoxide diffusing capacity (tlco) measurement that are specifically due to conductive ventilation heterogeneity. we induced conductive airway ventilation heterogeneity in 35 never-smoker normal subjects by histamine provocation, and related the resulting changes in ventilation heterogeneity (derived from the multiple breath washout test) to corresponding changes in diffusing capacity, alveolar volume and inspired vital capacity (derived from the single breath tlco method). average conductive ventilation heterogeneity doubled (p < 0.001), while tlco decreased by 6% (p < 0.001), with no correlation between individual data (p > 0.1). when dividing diffusing capacity by alveolar volume, the resulting transfer coefficient was not significantly different pre versus post histamine (p = 0.074). these findings can be brought in agreement with recent modelling work, where specific ventilation heterogeneity resulting from different distributions of either inspired volume or end-expiratory lung volume have been shown to affect tlco estimation errors in opposite ways. the combination of these errors appears to largely cancel out in our experimental situation of induced ventilation heterogeneity comparable to that observed in lung disease. we conclude that conductive ventilation heterogeneity per se has a negligible effect on diffusing capacity measurement. an important determinant of airway function in humans is vagal-mediated cholinergic tone in airway smooth muscle (asm). this airway tone may be altered in disease states. the use of mouse models for the study of airway diseases, including asthma, pulmonary fibrosis and copd is well established. however, it is not known whether mice actually possess basal asm tone or, if it does exist, how this tone changes in disease models. this study was undertaken to determine whether mice have detectable asm tone in vivo. methods respiratory system impedance (zrs) was measured in female adult balb/c mice using a wave-tube modification of the forced oscillation technique. zrs was measured during slow (~35 s) inflation-deflation manoeuvres between the transrespiratory pressures of 0 and 20 cmh2o. baseline lung mechanics and thoracic lung volumes (tgv) were measured before and after each mouse was allocated to one of four treatment groups: 'saline' mice received an i.p injection of saline, 'atropine' mice received i.p. atropine sulphate, 'vagotomy' mice had their left and right cervical vagus nerves isolated by blunt dissection and cut, and 'sham' mice had the area of the vagus nerves exposed but the nerves were not cut. results there were no post-treatment changes in tgv, airway resistance, tissue damping, tissue elastance, inertance or tissue hysteresivity in any of the four groups. conclusions the lack of change in lung mechanics post-atropine or postvagotomy in balb/c mice suggests that, unlike humans and many other species, the airways of mice have no baseline asm tone. supported by nhmrc grant#11488. nomination none. conflict of interest none. both male gender and increased mandibular enclosure volume predict more severe sleep disordered breathing in obstructive sleep apnoea patients. we now examine gender/body size/mandibular enclosure volume relationships for normal subjects stepwise multiple linear regression analysis was used to model body size/enclosure volume interactions. results for the whole group, mv was 261.1 ϯ 6.0 ml (mean ϯ se) while rmv was 205.1 ϯ 4.9 ml. head circumference (positive) and forehead height (negative) were both independent predictors for mv and rmv (both p < 0.02), while hip circumference was an additional positive predictive factor for rmv (p < 0.04). after adjusting for these parameters, male mv and rmv were larger than for females conclusion these findings suggest that mandibular enclosure volumes are relatively larger in males, even after adjusting for body size/cranial dimension. differing body size/mandibular enclosure volume interactions may contribute to gender influences on the severity of sleep disordered breathing. supported by nhmrc of australia nomination john read prize for sleep and physiological research tp 027 audit of ctpa in a regional hospital y raje, s vincent, g simpson department of thoracic medicine, cairns base hospital, cairns, qld 4870 since the introduction of computerized tomographic pulmonary angiograms (ctpa) at our institution the number of requests for this investigation at our institution has grown at an alarming rate. the purpose of this study was to evaluate the clinical assessment of suspected pulmonary embolism (pe). methods 50 ctpa were reviewed. results 31 female, 19 male. mean age 50 yrs (range 21-87). 26 ctpa requests came from department of medicine, 21 from emergency department, 2 from surgical teams and 1 from oncology outpatients. 36 patients presented with chest pain (pleuritic in 20 cases), 25 had dyspnea, 7 presented with collapse. 4 patients had haemoptysis. hypoxaemia was recorded in 7. none were clinically shocked and only one had a recorded tachycardia. d-dimer requested in 10 patients and was elevated in 9. arterial blood gases performed in only 10 patients (20%). 47 patients had prior chest x-ray which was normal in 24 (48%). 8 patients had consolidation on chest x-ray, 2 pleural effusions, 2 atelectasis and 1 fractured ribs. recorded risk factors included 4 patients with previous dvt or pe, 4 patients with malignancy and 6 patients were immediately post-operative. only 6 ctpas (12%) demonstrated evidence of pe. of these 2 had recent dvt and 2 were post-operative. 1 had a history of bowel cancer. there was no formal record of pre-test clinical probability of pe (eg wells' score) for any of the 50 cases. retrospective calculation of the cases of pe, 4 had a wells' score of 4.5 and 1 of 4 with the remaining patient with wells' score of under 2. only 3 patients (one with clinically probable pe) had received fractionated heparin prior to the ctpa. conclusion (1) ctpas performed at our institution have a low yield (12%).(2) pre-investigation clinical assessment was poor and there was poor adherence to published guidelines, (3) this results in many unnecessary ctpa examinations generating increased work and expense for the medical imaging department and exposes many patients to unnecessary and potentially harmful radiation exposure. the evaluation and management of hereditary hemorrhagic telangiectasia involves a multidisciplinary approach according to international guidelines. the aim of this audit was to compare the assessment process in one centre with that of the international recommendations. methods retrospective comparison was made by medical chart review of all patients with a diagnosis of hht between the years 1994 to 2006. demographic along with clinical data with diagnostic investigations, complications, treatment and genetic evaluation, including family screening was collected. the proportion of patients evaluated and managed as per the international recommendations was determined. results the audit identified 26 patients with the diagnosis of hht, with the mean age 58 years. diagnostic criteria were met in 77% of the cohort. of the known clinical features, 54% had a family history, and 81% epistaxis. cutaneous telangiectasia was present in 85% and visceral involvement in 92%. pulmonary arterio-venous malformations (pavm) were seen in 16 patients, cerebral avm in 4, gastrointestinal telangiectasia was documented in 8. one patient had a spinal (cervical) avm, and another had pulmonary hypertension in association with this condition. only 8 patients underwent diagnostic or screening investigations in accordance with the international recommendations. furthermore, one patient was referred for a genetic evaluation. conclusions this clinical audit found that 31% of patients referred to this centre were evaluated in accordance with the international recommendations. genetic assessment was lacking. the study supports the need for a coordinated, multidisciplinary approach to the evaluation and management of hht in this centre. lm young 1 , n good 1 , d milne 2 , w fergusson 1 , i zeng 1 , j kolbe 1 , ml wilsher 1 background while airflow limitation is the most common physiological impairment in sarcoidosis, there are limited data on airway hyperresponsiveness (ahr). understanding the role of ahr in sarcoidosis, if any, may help to identify individuals who might benefit from inhaled therapies. aims (1) to determine the prevalence of ahr in sarcoidosis. (2) to determine the correlation between responses to direct (using histamine) and indirect (using hypertonic saline) bronchial challenge. (3) to determine the clinical, physiological and radiological predictors of ahr. methods subjects with a diagnosis of sarcoidosis based on typical clinical presentation and compatible hrct features and/or tissue biopsy and with a baseline fev1>35% predicted were recruited. subjects underwent standard hypertonic (15% fall in fev1) and histamine (20% fall in fev1) challenge (>1 day but <7 days apart), lung function testing and high resolution computed tomography (hrct) of the chest. results the 52 subjects (48 ϯ 11 years, 35% female, 92% european, 35% stage i, 25% stage ii, 40% stage iii, 0% stage iv) had well preserved lung function overall (fev1 = 2.8l ϯ 0.7.87% predicted). ahr was detected in 5/47 (11%) to hypertonic saline and 19/43 (44%) to histamine challenge. on univariate analysis, response to histamine challenge was predicted by conglomerate fibrosis (p = 0.002) and reticular pattern (p = 0.05) on hrct. the baseline % predicted fev1 was significantly associated with ahr on univariate (p = 0.004), and multivariate analysis (p = 0.01) when adjusted by hrct patterns. conclusions there is a high prevalence of ahr using histamine challenge in this study of sarcoidosis subjects. ahr most strongly associates with baseline % predicted fev1 but also conglomerate fibrosis and reticular pattern on hrct. these findings may reflect the consequence of airway remodelling following inflammation. further studies are warranted to confirm these findings. background upper airway shunt represents a significant source of measurement artefact in the use of the forced oscillation technique (fot), with increasing importance in young children. changes in respiratory system admittance, ars (or zrs -1 ), are theoretically independent of the upper airway shunt. this study examines the possible clinical benefit of ars in preschool children by assessing any increased ability to differentiate responses to bronchial challenges in the routine clinical setting. we hypothesized the use of ars would provide improved sensitivity to clinically relevant obstruction, bronchodilator responsiveness (bdr) and airway hyper-responsiveness (ahr) in young children with respiratory disease. method previous fot measurements were re-analysed and ars calculated to derive: (1) ars reference equations in healthy young children (n = 158); (2) bdr in ars, respiratory system resistance (rrs) and reactance (xrs) in healthy children (n = 78), children with cystic fibrosis (n = 39), neonatal chronic lung disease (n = 49), asthma (n = 56) and wheeze (n = 66); (3) ahr to inhaled adenosine-5′-monosphate (amp) in 19 children. fisher's exact tests were used to assess changes in diagnostic outcomes between ars and conventional fot outcomes (rrs and xrs). results ars was no more sensitive to bronchodilator induced changes than conventional fot outcomes. amp challenges resulted in equivalent responses measured by relative changes in rrs and ars while absolute changes in ars were the least sensitive variable. conclusion this study does not support a clinical advantage in using ars in measuring responses to either inhaled bronchodilator or amp. c hollier 1,2 , c menadue 1,2 , d flunt 1,2 , aj piper 1,2 1 department of respiratory and sleep medicine, royal prince alfred hospital, nsw 2050, and 2 woolcock institute of medical research, nsw 2050 serial measurement of arterial carbon dioxide (paco2), ph and bicarbonate (hco3 -) is essential in the management of patients with hypercapnic respiratory failure (hrf). this information is usually obtained from a sample of arterial blood (abg). the procedure can be painful and distressing for patients, and is sometimes technically difficult due to obesity or contractures. our aim was to determine the validity and feasibility of arterialized venous blood (av) sampling as an alternative to abgs in measuring paco2, ph and hco3levels in patients with chronic hrf. method eighteen patients completed the study. venous blood was arterialized by heating forearm skin to a temperature of 42-45°c with an electric heating pad. an av sample was taken from a cannula positioned in a vein of the heated forearm simultaneously with an abg. in addition, the reliability of av sampling within the recommended temperature range (42-45°c) was investigated in ten healthy volunteers placed on volume cycled ventilation in order to maintain constant ventilation. av samples were taken at 0.5°c temperature intervals from 42.5-45°c results the table below summarizes results for validation of av sampling: based on the evidence that cardiovascular dynamics are altered due to obstructive sleep apnea, this study aims to identify the onset and termination of each apnea event using power spectral density (psd) and morphological features of single lead ecg signal over 5 second period. methods ecgs from 4 patients overnight sleep studies were examined for location of the pre-scored apnea events. onset (n = 1995), maximum (n = 6751) and termination (n = 1996) of each apnea event and normal events (n = 11219) were annotated on 5 second windows. features extracted were psd, amplitudes of r and t wave of 5 second ecgs. receiver operating characteristics (roc) analysis was used to gauge the event recognition ability of all features. weight loss causes an improvement in the severity of osa, however substantial weight loss is very difficult for obese patients. the very low caloric diet (vlcd) has been shown to be successful in causing significant weight loss in obese patients. this is a pilot study on the use of a formal screening protocol to identify osa patients who are potentially eligible for the supervised vlcd program offered by the endocrinology department at auckland city hospital. method 344 consecutive patients who attended the sleep laboratory at ach between june to december 2006 were screened using the protocol. patients who are eligible to be considered for the vlcd program are identified as having a combination of obesity (bmi > 30), osa (ahi > 5 on sleep study) and being residents within the auckland district healthboard region. results 243/ 344 patients screened did not fulfil the inclusion criteria: 171 lived outside the adhb region; 71 had bmi < 30; 7 patients did not have osa (ahi < 5). 101 patients fulfilled the inclusion criteria. 54/101 patients (54%) were excluded due to medical or psychiatric contraindications to vlcd.47 patients (47%) who did not have contraindications to vlcd were contacted. 33 patients were contacted successfully. 14 patients were either unavailable to phone contacts on 3 separate days or were disconnected. 12/101 patients consented to being referred (12%). 21/101 patients declined referral (21%). conclusion this pilot study is the first study using a formal comprehensive screening protocol in the recruitment of obese osa patients into a medically supervised vlcd program. only a small proportion (12%) of patients proceeded to being referred to the vlcd program. key: cord-023288-sqr33y72 authors: nan title: paediatric sig: poster session date: 2008-03-12 journal: respirology doi: 10.1111/j.1440-1843.2008.01252_11.x sha: doc_id: 23288 cord_uid: sqr33y72 nan increased airway smooth muscle (asm) in asthma may be due to hyperplasia or hypertrophy of asm cells. the contribution of extracellular matrix (ecm) within asm bundles has not previously been accounted for when estimating asm cell volume. aim to estimate the mean asm cell volume in asm bundles in asthma. methods post-mortem tissues from control subjects (c n = 9); nonfatal (nfa n = 11) and fatal (fa n = 10) cases of asthma were studied. on 30 mm transverse airway sections stained with haematoxylin, the volume density (nv) of asm cell nuclei was estimated using an optical disector (¥1000). the mean cell volume (vc = 1/nv) was calculated, correcting for the volume fraction of asm (fasm) within the asm bundle (corrected vc = 1/(nv ¥ fasm)). fasm was estimated on 0.5 mm thick sections of the same airway stained with masson's trichrome. basement membrane perimeter (pbm) was used to indicate airway size. results table shows mean ϯ sd. (one-way anova) *p < 0.05 for c v fa, nfa v fa. conclusion these data suggest that although asm area is increased in asthma, mean asm cell volume is unchanged. therefore hyperplasia, not hypertrophy, of asm cells is present in both mild and severe asthma. these results were similar for both large and small airways. asthma is characterized by airway inflammation and remodelling which contribute to airway hyperresponsiveness and episodic airflow obstruction. mast cell (mc) densities are higher on the smooth muscle (asm) in asthma so their mediators may modulate other asm functions as well as cause contraction. aim to investigate the effect of mc mediators on chemokine and extracellular matrix (ecm) production by asm cells from donors with and without asthma. methods mc were isolated from the resected lung samples of 6 patients, resuspended at 10 6 cells/ml in dmem + 10% fbs and stimulated with ige/anti-ige. supernatants (sn) were collected after 2 and 24 h and the mc lysed. sub-confluent asm cells from 6 donors with and without asthma were serum deprived for 72 h before mc sn/lysates were added in dmem + 10%fbs for 48 h. il-8 and eotaxin levels in all asm sn and mc sn/lysates were measured by elisa. fibronectin and collagen iv deposition was measured in situ by immunoassay following asm cell lysis. results in asthmatic and non-asthmatic asm cells all mc sn and lysates reduced eotaxin release by up to 47% and 58%, whereas the 0-2 h mc sn significantly increased il-8 release to 178 ϯ 35.9% (p = 0.0339) and 169 ϯ 49% (p = 0.0445) of the fbs control respectively. however, only nonasthmatic asm cell il-8 release was increased by the mc 2-24 h sn (216 ϯ 85%; p = 0.0421) and cell lysates (215 ϯ 47%; p = 0.0421). the 0-2 h mc sn also increased fibronectin deposition to 143 ϯ 16% (p = 0.008) by asthmatic asm cells only. mc sn and lysates had no effect on collagen iv deposition. conclusions activated mast cell mediators differentially modulated chemokine and ecm secretion by asm cells from donors with and without asthma. thus mast cells may modulate their own recruitment to the smooth muscle and remodelling locally in the airways in asthma. supported by nhmrc. the technique of ige passive sensitization reproduces ige-related allergic responses in vitro and studies have validated this technique for investigations modelling allergic smooth muscle responses. there are no studies investigating effects of ige sensitization on rhinovirus (rv) infection. we hypothesized that rv infection is enhanced by ige sensitization, a consequence of diminished early innate immune responses. methods beas-2b epithelial cells and primary culture airway fibroblasts were sensitized with ige 24 h-7 d prior to infection with rv16. samples of tissue culture supernatant and cell lysates were collected over a 12 h period after infection for analysis. viral replication was measured by real-time rt-qpcr and viral titration and type i interferon mrna by rt-qpcr. ige receptor mrna expression was examined using rt-pcr. results initial studies to establish the model used human serum high in ige (>1000 iu/ml), this yielded inconsistent results and it was found that purified ige (1000 iu/ml) provided more reliable responses. sensitization was established after 24 h ige incubation and was comparable with up to 7 d. rt-pcr detected mrna for the ige low affinity receptor only after sensitization. following rv16 infection, vrna was increased after 24 h in ige sensitized cells (p < 0.05), but this effect varied noticeably between and within cell lines. cellular expression of ifn-b mrna increased with viral infection but in cells sensitized with ige lower levels of expression were noted (p < 0.05). conclusions ige passive sensitization enhanced rv replication in vitro but the model is constrained by significant variability between and within cell lines. the effect of sensitization on rv replication may occur through the low affinity ige receptor. activated mast cells (mc) are present in higher numbers on the airway smooth muscle (asm) in asthma compared with other inflammatory airway diseases. matrix metallo-proteinases (mmps) cleave chemokines and alter chemokine gradients by degrading the extracellular matrix and thus may modulate mc migration to the asm. aim to determine the levels of mmp-2, mmp-9 and their inhibitors, timp-1 and timp-2, secreted by asm cells from donors with and without asthma. method confluent asm cells were washed, serum-starved for 48 h and then stimulated with th1 (il-1, tnf and ifn) or th2 (il-1, il-4 and il-13) cytokines or left unstimulated. after 4 and 24 h,the sn were collected. the relative amount of pro and active forms of mmp-2 and mmp-9 in sn were determined by gelatine zymography. timp-1 and timp-2 levels in the sn were measured by elisa. results pro-and active mmp-9 were not detected. however, pro-mmp-2 levels were high in sn of asm cells from donors with (195.6 ϯ 47.2 % positive control/10 5 cells) and without (226.5 ϯ 49.2 % positive control/10 5 cells) asthma. a trend to increased active mmp-2 production by asm cells from donors with (7.3 ϯ 2.7 % positive control/10 5 cells, n = 9) compared to without (2.9 ϯ 0.7 % positive control/10 5 cells, n = 11) asthma after 24 h was not significant (p = 0.101). timp-1 and timp-2 levels respectively were high in the sn of cells from donors with (69.4 ϯ 19.6 and 21.3 ϯ 4.7 ng/10 5 cells, n = 5) and without (57.3 ϯ 13.7 and 16.6 ϯ 3.5 ng/10 5 cells, n = 5) asthma. th1 and th2 cytokine stimulation did not affect mmp or timp release. conclusions th1 and th2 cytokines did not regulate asm cell production of mmp-2, timp-1 and timp-2. altered asm mmp-2 activity is unlikely to play a role in mc chemotaxis to asm cells from donors with asthma in vitro or their presence on the asm in asthma. there has been a marked increase in the prevalence of asthma and other allergic diseases in the last few decades. one of the explanations for this is the change in our diet. one of the characteristics of the "western diet" is a high intake of both saturated and polyunsaturated fat. this prompted us to compare the effects of high fat and low fat meals on the numbers of circulating eosinophils and other leukocytes. methods we studied 12 volunteers who had allergic rhinitis and/or asthma and a peripheral eosinophil count at baseline of ն200 ¥ 10 7 /l. this was a randomized, crossover trial with participants studied on two different days. on each occasion they arrived fasting and after bloods were drawn consumed a 3000 calorie meal. one of the meals was high in saturated fat and refined carbohydrate. the other meal was low in saturated fat and high in fruit and fibre. bloods were drawn postprandially every hour for five hours. results eosinophil counts were highest in the early morning and fell over the course of the day but the decrease was less with the high fat meal (p = 0.03). over the same period of time the increase in lymphocytes (p = 0.016) was greater with the high fat meal. the high fat meal was also associated with greater increases in triglycerides (p < 0.0001) and cholesterol (0.004). conclusions in atopic individuals a high fat meal was associated with higher circulating numbers of eosinophils and lymphocytes than an isocaloric meal that was low in fat. further studies of the effect of dietary fat on eosinophilic inflammation are warranted. supported by the university of auckland research committeee. intravenous gamma globulin therapy (ivig), which is therapeutic in a variety of immune diseases, has been reported to be effective on patients with severe steroid-dependent asthma. although fcer are known to play important roles in asthma, there are few reports about the role of fcg?receptors in asthma. fcg receptor iib (fcgriib) is unique inhibitory receptor, which suppresses immune response. in this study, we evaluated the effect of ivig in allergic airway inflammation in ova-challenged mice and the mechanism of the inhibitory effects of ivig and fcgriib. method c57bl/6 mice (wt) and fcgriib deficient mice (ko) were sensitized with ovalbumin (ova) and alum and subsequently challenged with nebulized ova. before ova challenge rabbit igg was administered intravenously. the airway inflammation and effects of igg were assessed by histology, cell counts of bal fluid and airway hyperresponsiveness. result histology showed that igg treatment ameliorated the inflammation around the airway and the vessels and hypertrophy of goblet cells induced by ova challenge. the migratory activity of dcs is modulated in inflammatory diseases such as asthma. recently, we reported that immature dcs express kinin receptors and that bradykinin (bk) significantly enhances the migration of immature dc in vitro. as kinins mediate many of the pathophysiological effects associated with asthma, we hypothesized that lys-des[arg 9 ]-bk, which is produced during inflammation and acts via the b1 receptor (b1r), would inhibit migration of mature dcs. methods day 7 cultured human monocyte-derived dcs were matured with lps, tnfa +il-1b or cd40l in the absence or presence of lys-des[arg 9 ]-bk. maturation of dc was analysed by flow cytometry (facs). b1r expression was assessed by reverse-transcriptase pcr and quantitative confocal microscopy. migration of mature dc was assessed in transwell chambers with lysdes [arg 9 ]-bk and the chemokine ccl19 used as chemoattractants. results maturation of dcs was found to result in down-regulation of b1r expression to varying degrees depending upon the maturation stimulus used. mature dcs all demonstrated an ability to migrate toward lys-des[arg 9 ]-bk and ccl19. however pre-treatment with lys-des[arg 9 ]-bk decreased the migratory ability of all mature dcs to both chemoattractants. conclusions along with chemokines, lys-des[arg 9 ]-bk is likely to play a crucial role in regulating the in vivo migration of mature dc during inflammation. the production of lys-des [arg 9 ]-bk during inflammation potentially immobilizes mature dcs thereby facilitating locally-mediated immune responses within inflamed tissues. supported by the asthma foundation of western australia. introduction alternative or aberrant splicing is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms. the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to use a new and innovative approach involving the use of the genechip (r) exon array system together with real-time quantitative pcr to study asthma candidate genes in human monocyte-derived dendritic cells. asthmatic and non-asthmatic subjects provided 20 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method, and differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data indicate splice variant expression in dendritic cells from asthmatic patients is influenced by asthma severity. conclusion exon expression array analysis has generated a number of asthma candidate genes with alternative splice variants. further studies to validate these data in a replicate data set and establish the functional significance of our findings in asthma are underway. alternative or aberrant splicing occurs in more than 70% of genes and is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms 1 . the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to study one asthma candidate gene in human stimulated and unstimulated: (1) monocytes, (2) monocytederived dendritic cells and (3) lung smooth muscle cells. methods asthmatic and non-asthmatic subjects provided 40 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method. up to 50% of the monocytes were then differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. induction experiments used 1 mg/ml lps and cells were stimulated for an optimal period of 24 hrs. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data from stimulation experiments indicate splice variant production can be regulated by the inflammatory response and that this response is influenced by asthma status. conclusion preliminary experiments have confirmed the presence of an aberrant splice variant for an asthma candidate gene in the primary cells studied. further studies to confirm these data and establish the functional significance of our findings in asthma are underway. exposure to environmental factors, such as environmental tobacco smoke (ets), plays a significant role in modulating pre-existing genetic susceptibilities to diseases including asthma. the glutathione s-transferase enzymes (gsts) play an important role in the detoxification of ets. there are several gst isoforms and gstp1 codes for the gst pi isoform, which is the primary gst isoform expressed in human lung tissue. two single nucleotide polymorphisms (snps) at positions 105 and 114 have been reported in gstp1 and associated with asthma and atopy. the aim of this study was to examine the effect of these snps in combination with ets, on asthma phenotypes in a cohort of asthmatic children. children were recruited during an acute episode requiring presentation at an emergency department. genotyping using pcr-rflp was completed on 218 children and ets exposure was determined by parental questionnaire. urinary cotinine was measured in the children and was in agreement with questionnaire responses. statistical analyses were performed using spss. there were no significant associations between the genotypes and asthma severity during acute exacerbations. significant associations were found between the snps and atopy in this population with an odds ratio of 2.77 for the 105aa genotype (p = 0.029) and or of 5.47 for the 114cc genotype (p = 0.002). however, when an interaction with ets was included, the odds ratios increased to 9.02 for 105aa (p = 0.05) and 9.17 for 114cc (p = 0.020). these results suggest that there is a significant gene/environment interaction impacting on atopy in this cohort. the rage gene encodes the receptor for advanced glycation end-products (rage), a member of the immunoglobulin superfamily. rage activation by ligands, including amphoterin and s100/calgranulins, leads to prolonged nf-kb signalling and has been associated with chronic inflammation. despite high levels of rage expression in lung tissue, little research has been undertaken into the role of rage in the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. objective determine genetic associations between functional polymorphisms in the rage promoter and severe and aspirin-sensitive asthma phenotypes. methods pcr and restriction fragment length polymorphism (rflp) were used to genotype three rage promoter polymorphisms, -429t>c, -374t>a and a 63 bp deletion from -407 to -345, in a large case-control asthma population phenotyped for asthma severity, atopy and aspirin sensitivity. results no associations were identified between any of the polymorphisms and the occurrence of asthma. however, the -374a allele was linked with both severe asthma (p = 0.013) and aspirin-sensitive asthma (p < 0.001). likewise, genotypes containing the -374a allele were strongly associated with both severe asthma (or 2.10, 95% ci 1.32-3.36) and aspirin-sensitive asthma (or 3.13, 95% ci 1.45-6.77). conclusions the -374a allele of the rage gene, previously shown to lead to a 3-fold increase in promoter activity, is associated with the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. these results suggest that increased rage expression, with a concomitant increase in nf-kb signalling, may in part contribute to the inflammatory response seen in these conditions. the global prevalence of allergic diseases is rising and australia has one of the highest prevalence rates in the world. the role of early childhood infections in the development of allergic disease remains controversial. objective to examine the association between early childhood infections and the development of allergic diseases in later childhood, in high risk children. methods data were analysed from the melbourne atopic cohort study (macs) of 620 infants with 1 or more first-degree family members with atopic disease. primary risk factors assessed were otitis media, bronchitis and gastroenteritis reported in the first two years of life. outcomes were current asthma, hay fever and eczema at 6 years of age. logistic regression was used to estimate crude and adjusted odds ratios. results asthma was the most common allergic condition (25.4%, 95% ci 21.6-29.5%), followed by eczema (24.9%, 95% ci 21.1-29.0%) and hayfever (15.6%, 95% ci 12.5-19.1%). the most commonly reported infection was otitis media (58.9%, 95% ci 54.9-62.8%), then gastroenteritis (37.7%, 95% ci 33.9-41.7%) and then bronchitis (19.4%, 95% ci 16. [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] .7%). all 3 types of infection within the first 2 years of life were associated with increased risk of asthma. an increased risk of asthma at 6 years was seen with otitis media (or = 1.14, 95% ci 1.02-1.3), bronchitis (or = 1.34, 95% ci 1.0-1.8) and gastroenteritis (or = 1.23, 95% ci 0.96-1.6). when the frequency of infection was examined, those who reported at least 3 episodes of gastroenteritis had a 3-4-fold increased risk and an almost 30% absolute increased risk (rd 0.34, 95% ci 0.08-0.59). conclusion these findings appear to contradict the hygiene hypothesis. the findings for gastroenteritis are novel. further examination of these associations and possible underlying mechanisms is warranted. grant support asthma foundation of victoria, nestle. background knowledge about incident cases of asthma in australia is limited because they are not routinely reported. the ability to predict the number of new cases of asthma would be helpful in allocating resources for asthma education, management and care. data on first use of medications for asthma gives an indication of the incidence of asthma. the objective of this study was to estimate the incidence rate of asthma by investigating asthma medication use in individuals. methods pharmaceutical benefits scheme (pbs) records for all prescriptions filled for inhaled corticosteroids (alone or combined formulation), cromones and leukotriene receptor antagonists from july 2002 to june 2005 were included. using a 2-year look back window, any persons who had their first prescription for any of these drugs dispensed between july 2004 and june 2005 were assumed to be incident cases. overall and age-specific incidence rates were calculated per 100 asthma-medication-free individuals. results there were 352,082 individuals who had their first asthma medication dispensed between july 2004 and june 2005, which equates to an overall incidence rate for asthma of 1.89 per 100. the incidence was higher among children aged 0-14 years (2.07) and adults aged 65 years and over (2.45) . conclusions our estimated incidence rates were consistent with those reported by others in the literature. while the pbs database was designed for administrative purposes, it can be used to estimate incidence rates for asthma. support acam is a collaborating unit of the australian institute of health and welfare and is funded by the department of health and ageing (doha). we acknowledge the pharmaceutical pricing and estimates section of doha for provision of pbs data. keywords asthma incidence, pharmaceutical benefits scheme. rosario ampon 1 , guy marks 1 , teresa to 2 , leanne poulos 1 , anne-marie waters 1 1 australian centre for asthma monitoring (acam), sydney, australia, and 2 hospital for sick children, toronto, canada background the ability to assess individual patterns of asthma medication use would have clinical relevance in targeting effective asthma education and management for this common condition. to describe longitudinal patterns of asthma medication use, we used a population-based prescription database to follow individuals from the first time they filled an asthma prescription. asthma is more commonly listed on death certificates as an associated cause of death, in people whose deaths are attributed to other causes, than as an underlying cause of death. understanding the importance of these associations would contribute towards an overall appreciation of the impact of asthma on mortality. the objective of this analysis was to estimate the prevalence of asthma as an associated cause of death when various other diseases were attributed as the underlying cause of death. background acam currently recommend 24 indicators to measure population-level asthma health and outcomes. we examined correlations among several asthma indicators covering prevalence, morbidity and mortality to try and produce a condensed set of indicators which minimized redundancy. methods seven of the 24 indicators were included in this study: prevalence of ever having doctor diagnosed asthma, prevalence of current asthma, asthma-related general practice (gp) encounters, proportion of people with asthma with an asthma action plan (aap), hospitalizations for asthma, hospital patient days for asthma, and deaths due to asthma. a correlation matrix was created for these indicators by age groups. pearson correlation coefficients ն0.7 or յ-0.7 were considered strong. results there were strong positive correlations between prevalence of ever asthma and current asthma (r = 1.0); gp visits and aap possession (r = 0.74), hospitalization (r = 0.91) and patient days (r = 0.95); and hospitalization and patient days (r = 0.90) and aap possession (r = 0.73). recent australian reports have shown that the prevalence of asthma and respiratory symptoms has decreased over the last 10-15 years. as part of a larger study investigating child health and air quality we have collected nationwide data from schoolchildren living in act, victoria, queensland, wa and sa. methods schools were selected based on proximity to air quality monitoring stations. classes from years 3 to 6 were randomly selected and all children were invited to participate. parents self completed a questionnaire that included questions about diagnosed asthma and respiratory symptoms. results a total of 1989 children provided questionnaires for analysis. the response rate varied between states and territories and ranged from 30% to 42%. the sample comprised 51.9% girls and the mean age of children was 10.2 years. ever diagnosed asthma 27.9 current asthma ('does he/she still have asthma? ') 13.8 wheeze in the past 12 months 16.1 respiratory symptoms limiting activities 11.8 missed school due to asthma or wheezing 8.8 conclusions despite the relatively low participation rate, the prevalence estimates for current asthma are similar to those reported in the national health survey 2004-05 [1] . there is no evidence of any recent increase in the prevalence of childhood asthma. methods tahs is a longitudinal population-based respiratory study of 8583 subjects which commenced in 1968 when they were 7 years of age. since the initial study another 4 follow-ups have been conducted, including the most recent follow-up when subjects were 44 years of age. lung function of the total sample was measured at baseline and in sub-samples in 3 subsequent followups. asthma was categorized as persistent, frequent or episodic when participants reported asthma symptoms in at least 3 follow-ups, in 2 follow-ups or in 1 follow-up respectively. results by age 7 years ever asthma prevalence was 16%. at age 44, 10% of those who had not reported asthma by age 7 had asthma symptoms while 75% of those who reported asthma by age 7 had no asthma symptoms. hence over all only 25% of the asthma symptoms at age 44 were attributable to asthma developed by age 7. in contrast, 91% of the persistent and frequent asthmatics had developed their asthma by age 7. persistent and frequent asthmatics had more symptoms and poorer lung function at age 7, 14 and 44 as well as more reversibility at age 44 (p < 0.05). childhood asthmatics who also had a productive cough by age 7 were more likely to have persistent asthma than those without a cough (p < 0.05). conclusions although the majority of middle-age asthma is related to postchildhood onset asthma, most severe middle-age asthma has its origin in persistent childhood disease. having productive cough in childhood may identify high risk asthmatics who require especially rigorous management in early life. one third of women experience an improvement in asthma during pregnancy, and symptoms improve in most women in the late third trimester. we hypothesized that the exacerbation rate would be reduced and that symptoms during exacerbations would be less severe in the third trimester compared to the second trimester. methods pregnant women with asthma (n = 81) were prospectively followed from recruitment (14.8 weeks (3 sd) ) to delivery at clinic visits (18, 30, 36 weeks and during exacerbation), and fortnightly phone calls. the asthma control questionnaire (acq) was administered at each contact and exacerbations classified as severe (requiring medical intervention) or mild (selfmanaged). lung function, medication use, fractional exhaled nitric oxide (feno) and full blood counts were assessed. paracetamol is commonly used in infants as an analgesic and antipyretic. it has been hypothesized that frequent paracetamol consumption may result in reduced lung capacity to cope with oxidative stress and increase risk of respiratory disease. to date, no study has examined exposure to paracetamol during infancy, when lungs are still developing, and risk of childhood asthma. method a birth cohort of 620 infants with an atopic family history was recruited. frequency of paracetamol exposure was prospectively documented up to 2 years of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results paracetamol exposure in infancy was common (97% exposed by two years of age), with some infants receiving paracetamol on up to 77 days. it has been hypothesized that mucosal immune response requires a particular micro-flora milieu in the infant's gastro-intestinal tract, and that early life antibiotic exposure may disrupt this process and increase risk of allergic disease. method a birth cohort of 620 infants with an atopic family history was recruited. exposure to oral antibiotics was prospectively documented up to 12 months of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results by one year of age, approximately 80% of infants had received at least one course of oral antibiotics. the prevalence of current asthma in childhood was approximately 30% (148/495). frequent use of antibiotics (more than 20 days exposure during first year of life) was associated with increased risk of childhood asthma (or = 2.52, 95% ci = 1.40-4.54) when compared to infant who had not been exposed. excluding infants with a diagnosis of asthma within the first two years of life, reduced this association by about 30% (or = 1.80, 95% ci = 0.90-3.57) and adjustment for gender, parental history of asthma and number of infections in the first year of life further reduced this association (or = 1.60, 95% ci = 0.79-3.22). the increased risk of childhood asthma associated with antibiotic exposure in the first year of life is, at least in part, due to confounding with early life wheeze and infections. if real, the independent effect of antibiotic exposure on risk of childhood asthma is likely to be minimal in this high risk cohort. support dairy australia, crc for asthma and airways, vichealth, nestle. the epidemiological data on asthma suggest a gender difference that varies with age. hormonal effects have been suggested as a possible explanation for these differences. the aim of this study was to examine reproductive factors and risk of asthma among the females of the tasmanian longitudinal health study (tahs). methods the tahs is a longitudinal population-based cohort study of respiratory disease which commenced in 1968 when subjects were 7 years of age. four follow-up studies have been conducted including the current most comprehensive follow-up with subjects at 44 years of age. information has now been collected on reproductive factors such as number of pregnancies, age at pregnancies, age at menarche and contraceptive pill use as well as on asthma status. reproductive factors were examined as risk factors for asthma using multiple logistic regression to adjust for all likely confounders. results a total of 2,776 women completed the most recent postal survey. of these 355 (12.8%) had current asthma, and of these women with current asthma 73.5% (261) developed asthma after childhood. on average these women were in their mid-twenties when they developed asthma (mean ϯ sd age = 26.6 ϯ 12.5 yrs). we found with increasing age at first birth an approxi-mate~30% reduced risk of current asthma in women who developed their asthma post-childhood (trend p = 0.04). we did not observe any other associations between reproductive factors and risk of asthma. conclusions our results are consistent with the hypothesis that early pregnancy may promote asthma development by altering the immune response favouring a th2 pathway. a delay in the age of first pregnancy reduces this risk of asthma. grant support nhmrc, clifford craig foundation, victorian & tasmanian asthma foundations. introduction the association between exposure to pets in early life and subsequent development of sensitization and allergic disease remains controversial. the objective of this analysis was to examine the relationship between cat exposure before birth and development of cat sensitization over time within the melbourne atopic cohort study (macs). methods the macs is a prospective longitudinal cohort study that initially recruited 620 women antenatal in melbourne from february 1990 to november 1994. detailed information on cat exposure was collected at recruitment and frequently until two years of age. skin prick test (spt) were conducted at 6, 12, 24 months and 10 years. the data were analysed by logistic regression and using generalized estimating equations (gee) for the repeated measures design. results among 620 subjects, 169 (28.8%) had a cat before birth. at 6 months, 1.9% (n = 11) of subjects were sensitized to cat and by 10 years of age 18.8% (n = 68) were sensitized. those who did not have cat before birth belong to a higher social class, and were more likely to have a father with allergic disease than those with a cat. those who developed sensitization to cat were more likely to have a paternal family history of allergic disease and more likely to be sensitized to other allergens. we did not observe any association between exposure to cat before birth and the development of sensitization to cat at 6 months (or = 0.7, 95% ci 0. 1-3.3) , 12 months (or = 1.4, 0.5-3.9), 24 months (or = 0.76, 0.2-2.5) or 10 years (or = 0.6, 0. 2-1.4) . these crosssectional results were confirmed by the gee analysis. conclusion our results fail to show an association between cat exposure before birth and development of sensitization to cat. furthermore exposure after birth in the first 18months of life was not associated with an increased or decrease risk of sensitization to cat. our results do not support either a benefit or risk associated with cat ownership and sensitization. introduction peri-natal events influence the development of asthma and atopic diseases in childhood but the current literature is contradictory on the effect of low birth weight, small for gestational age and prematurity on asthma risk. the aim of this study was to assess the relationship between these three exposures and asthma from childhood to adulthood. aim to assess the current prevalence of dda, wheeze (<12 months), atopy and ahr in children and adults in busselton. methods an age-and sex-stratified random sample of adults, selected from the electoral roll, was invited to complete a questionnaire and attend the local study centre for assessment of atopy (allergen skin tests) and ahr (methacholine). all children from participating primary and secondary schools were also invited to attend. the prevalences of dda, wheeze, atopy, ahr and "current asthma" (wheeze + ahr) were calculated. background asthma is often associated with comorbidity, however few studies have investigated comorbidities among people with this common condition. the objective of this analysis was to describe patterns of non-respiratory comorbidity among adults hospitalized with asthma in australia. methods data on hospitalizations for people aged 15 years and over with a principal diagnosis of asthma (j45, j46) were obtained from the australian institute of health and welfare's (aihw) national hospital morbidity database for the period 2005-06. patterns of comorbidity were examined by investigating additional diagnoses for non-respiratory disease according to icd-10 diseasespecific chapters. results among people aged 15 years and over hospitalized in 2005-06 with a principal diagnosis of asthma (16,566 hospitalizations; 70% female; 47% aged 35-64 years), 33% had at least one non-respiratory comorbidity. median length of stay was higher among those with at least one comorbidity (4 days) than among those with no comorbidities (2 days). among people aged 15-64 years, the most common comorbid condition was endocrine, nutritional and metabolic diseases (19%), while among those aged 65 years and over it was diseases of the circulatory system (32%). conclusions a large proportion of asthma hospitalizations in australia are associated with non-respiratory comorbidity and a longer length of stay. further, the pattern of non-respiratory comorbidity associated with asthma hospitalizations varies by age. given our rapidly ageing population, the level of comorbidity associated with asthma has implications for coordinated health care and demand on health services. support acam is a collaborating unit of the aihw and is funded by the department of health and ageing. keywords comorbidity, hospitalization, asthma. background asthma exacerbations are often triggered by viral respiratory infections, yet the influence of respiratory infections on the morbidity of acute asthma beyond the immediate period is unknown. we examined the influence of nasopharyngeal (npa) respiratory viral, chlamydia and mycoplasma detection on asthma morbidity in children presenting to the emergency department for an acute exacerbation of asthma. methods a subset (n = 78) of the 201 children enrolled for a randomized controlled trial (rct) on the efficacy of 5 vs 3 days of oral prednisolone had an npa taken at presentation. npa were examined for chlamydia, mycoplasma and respiratory viruses (enteroviruses, coronaviruses, human metapneumovirus, adenovirus, parainfluenza, influenza, rsv, rhinoviruses) by pcr. enrolled children were aged 2-16 years with recurrent wheeze and required ն600 ?g (mdi/spacer) or ն2.5 mg (nebulized) of salbutamol to reduce tachypnoea. parents filled validated diary cards for cough and asthma severity, and completed asthma qol data at enrolment and end of weeks 1 and 2. results pcr for various viruses was positive in 42 (53.8%) children, with no significant difference in the groups the children were randomized into. rhinovirus pcr was positive in the npa of 32 children, rsv in 7, hmpv in 2, adenovirus, parainfluenza, influenza a and b in one each. specimens were negative for the other micro-organisms listed above. children with a npa viral positive state were significantly (p = 0.002) younger than those with a negative state. however, there was no difference in the any of the asthma outcomes of children whose npa was positive or negative for the micro-organisms tested. conclusions in children with an acute asthma exacerbation presenting to emergency health facilities, a respiratory virus could be identified in >50% but the presence of a respiratory virus did not influence the morbidity of the asthma exacerbation at presentation or at the end of week-1 and week-2. the university of sydney, nsw 2006, and 3 royal north shore hospital, st leonards, nsw 2065 airway wall thickness measured using hrct is reported to be increased in asthmatic compared with control subjects. however, it is unknown whether wall thickness is a fixed structural characteristic of the airways or if it responds to transient changes in bronchomotor tone or airway size. aim to determine the effects of bronchomotor tone and lung volume on airway wall area measured by hrct. methods 8 patients with doctor-diagnosed asthma had partial chest hrct scans, before and after bronchodilator (bd), at frc, tlc and a volume midway between (mid-volume). airway segments were identified between branch points and matched between consecutive lung volumes both before and after bd, and also at constant lung volume before and after bd. mean lumen areas and wall areas for each airway segment at each volume were measured using automated analysis software. paired t-tests were used to determine changes due to bd and lung inflation. results 44 airways were matched before and after bd at frc. absolute airway wall area (wa) was related to airway lumen diameter (di wood smoke air pollution is of concern with respect to respiratory health due to its complex chemical composition and potential to carry air toxics into the lower respiratory system. launceston has a long history of poor winter air quality, primarily due to use of domestic wood heaters. participants in hobart had a similar prevalence of wood heater use, but hobart does not experience the same wood smoke pollution (due to differences in regional geography , asthma control and anxiety and depression were completed at baseline, immediately following (6 wks), and 3 mths after the intervention period. results clinically and statistically (p < 0.05) significant improvements in qol were observed in the exercise group at 6 wks compared to the control group. this difference was not maintained at 3 mths. 6mwd improved at 6 wks and 3 mths in the exercise group (p < 0.01), however the difference between groups was not significant. in the exercise group there was a trend towards improved asthma control and a reduction in anxiety and depression that was not observed in the control group. *p < 0.05, change at 6 wks vs baseline; home asthma monitoring is important for measuring day-to-day variation in lung function and symptoms. this approach requires the availability of complete diaries for a comprehensive assessment. we assessed the completeness of written diaries collected as part of a nation wide study of air quality and child health. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified from a cross-sectional study. these children were asked to record symptom scores and peak expiratory flows twice daily in diaries for a five week period. the diaries and peak flow devices were explained at a face-to-face meeting with parents and children. each week diaries were mailed back and parents received a phone call to encourage completion. completeness was defined as no missing responses to symptom questions or peak flow measurements in diaries from week two to week five. results data from the first 36 children (822 day records) were available for analysis. the sample included (53%) girls, mean age 10 yrs. the overall frequencies for complete records were; morning symptoms 85%, morning peak flow 85%, evening symptoms 83% and evening peak flow 82%. there was a significant trend for more complete morning peak flow records over the four weeks (cochrane-armitage trend test p < 0.007). agreement between morning and evening symptom completeness and between morning and evening peak flow completeness was fairly poor (kappa < 0.30). conclusions the completeness of symptom and peak flow records collected in this study was very high. the comprehensive follow-up protocol implemented is likely to have had an important impact on the completeness of asthma diaries. daily peak expiratory flow (pef) monitoring has been used in epidemiological studies to assess changes in lung function over time. the value of written pef diaries has been questioned because of problems with completeness and validity. this study aimed to compare stored electronic pef data and a written diary record of those data in a panel study in children with weekly reminders to aid adherence. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified in a population study. they were given electronic pef devices with a digital readout (miniwright digital, mwd, clement clarke, uk) and written symptom and peak flow diaries and instructed in their use at a meeting with parents and children. each child was asked to complete three pef manoeuvres every morning and evening for five weeks and to record these in the written diary. background previous research suggests that comorbid anxiety is associated with lower asthma-related quality of life (aqol) in adults with asthma. however, research is scant on the role of psychological interventions in these patients. aim to evaluate the effectiveness of a four-session cognitive-behavioural therapy (cbt) intervention, in improving the aqol, in participants with anxiety and asthma. method participants identified with comorbid anxiety and asthma were randomly assigned to the cbt intervention group (n = 10) and the asthma monitoring control group (n = 8) and evaluated on aqol measures, at various intervals. results nine participants, in the cbt group, completed the study. seven participants showed a clinically significant improvement in asthma-related emotional functioning (ef) and six participants in total aqol scores, at the 5-week post-intervention assessment. additionally, six participants in the cbt group indicated clinically significant improvement in ef and five participants in total aqol scores, at the 3-month follow-up assessment. only three participants in the control group completed the study. none of these participants showed any improvement in aqol scores at the 5-week or 3-month assessment. conclusion this pilot study suggests that a higher number of participants in the cbt group showed clinically significant improvement in ef and total aqol scores with higher retention rates. further research needs to confirm these findings in a larger group, identifying the elements of a successful cbt intervention and characteristics of participants who respond to the cbt intervention. gastro-oesophageal reflux disease (gord) is a risk factor for uncontrolled asthma. we conducted an update of a systematic review to assess whether treatment of gastro-oesophageal reflux in subjects with asthma improved asthma outcomes. methods randomized controlled trials (rcts) of gord treatment in adults or children that reported asthma health outcomes and had symptomatic gord were included and assessed in accordance with the standard cochrane systematic review process. subjects received pharmacological therapies compared with conservative management. results from 261 potentially relevant studies, 19 rcts were included in the review. when compared to placebo, morning peak expiratory flow did not significantly improve (change from baseline wmd 10.43, 95% ci: -9.55 to 30.42) with proton pump inhibitor treatment (n = 7 trials involving 739 participants). asthma exacerbations were not significantly less in the intervention groups compared with the control groups (odds ratio 0.66; 0.41-1.08; n = 557). conclusions while some trials reported evidence of asthma improvement with gord therapy, overall there appears to be no statistically significant evidence of a beneficial effect. it is clear that not all persons with gord and asthma will gain improved control over their asthma with gord therapy; this may be due to the heterogeneous pathophysiology of asthma. future large-scale trials would be required to demonstrate an effect on asthma exacerbations. kel and brd were supported by a cochrane airways group scholarship. background the ats/ers task force recommend the use of metered dose inhaler (mdi) and spacer for airflow limitation reversibility testing. salbutamol given via mdi & spacer has been shown to be equivalent to a nebulizer in the clinical setting. this has not been well studied in respiratory laboratory setting. aim to compare the 2 methods of reversibility testing in a laboratory setting. methods we conducted a laboratory based crossover study in a secondary hospital. patients with asthma or copd were eligible. the patients firstly underwent spirometry and reversibility testing following a standard dose of nebulized salbutamol. they were asked to return for a second set of spirometry within the same week and at the same time of day when reversibility with an mdi and spacer was recorded. we used an incremental dose of salbutamol starting from 2 puffs and up to 8 puffs. spirometry parameters were recorded 10 minutes after each intervention. the primary outcome was the percentage change in fev1 after each intervention. side effects were monitored for. results nine patients with asthma were recruited. the mean percentage change in fev1 was higher in the nebulizer group than after only 2 puffs via mdi & spacer (15.4 ϯ 7.4 vs 6.2 ϯ 8 [mean ϯ sd], p = 0.67). however, there were no differences between the 2 arms following higher doses of bronchodilator via mdi & spacer. the mean percentage change in fev1 after 4, 6 and 8 puffs were 12.6 ϯ 11.3, 15.4 ϯ 12.3, and 17.7 ϯ 13.6 respectively (p = 0.09, 0.05 and 0.07 respectively when compared to the nebulizer group). conclusion using an mdi and spacer for bronchodilator reversibility is equivalent to that of a nebulizer and should be the standard method of testing. the dose of bronchodilator needs to be at least 4 puffs as recommended by the ats/ers; however 6 puffs correlated best with a standard nebulizer route. further increments in bronchodilator dose provided little additional bronchodilatation. the study was limited by the small number of patients. asthma guidelines recommend a stepwise approach to treatment. the role of inhaled corticosteroid (ics) and long-acting beta-agonist (laba) combination therapy in asthma written action plans is not clear. objective to assess the efficacy of adjusting ics/laba combination therapy in a written action plan compared to fixed dosing in people with asthma requiring maintenance ics. methods cochrane systematic review of randomized controlled trials comparing ics/laba combination therapy in a single inhaler that is adjusted up or down according to a written action plan (wap) to comparison 1: budesonide/ formoterol given as a fixed maintenance dose (fd) (n = 9) or comparison 2: fluticasone/salmeterol fd (n = 2). results 10 parallel randomized controlled trials describing 11 interventions met the inclusion criteria. for the trials that compared wap to fd budesonide/ formoterol there were significant reductions for the wap group in exacerbations, (rr (95%ci): 0.82 (0.70 to 0.97)), severe exacerbations (rr (95%ci): 0.61 (0.37 to 0.99)) and study medications (wmd (95%ci): -1.18 (-1.23 to -1.14)) with no difference in asthma control or adverse events. the results for the two trials reporting wap budesonide/formoterol to fd fluticasone/ salmeterol were discordant and a homogenous pooled result could not be determined. of the 318 australians who died from asthma in 2005, over two thirds were over 50 years of age. this trend resulted in the national asthma council of australia (nac) calling for better management of asthma in the elderly. we designed an educational intervention using evidence based educational strategies to improve the content and style of general practice consultations for older people with asthma. methods randomized controlled trial of a multi-faceted program consisting of a group educational session, a videotaped standardized simulated patient consultation, followed by an academic detailing session. forty-two gps were randomized into an active or a control group. gps provided the names of patients who would be happy to participate in the study and the program was evaluated by patient and gp outcomes. results gps recruited into our program reported improvements in a range of clinical areas. one hundred and ten patients were recruited, their outcomes are under analysis. conclusion gps were overwhelmingly positive about participation in this trial and our intervention successfully improved the capacity and confidence of gp's to deliver care to older people with asthma. our study also developed several tools that would enable dissemination of our findings. supported by an asthma targeted in studies where direct clinical assessment is not possible, urgent health care utilization (hcu) is often used as an indirect measure of asthma control. this study aimed to identify factors predicting urgent hcu and asthma control. methods patients in nsw with a doctor diagnosis of asthma were recruited from community pharmacies, a research volunteer database, and databases of asthma foundation nsw, to complete a questionnaire about asthma. poor asthma control was defined as asthma control questionnaire (acq) score ն1.5. urgent hcu was defined as hospitalization, ed visit, or urgent doctor visit due to asthma. multiple logistic regression was used to identify predictors of poor control and urgent hcu. results questionnaires were completed by 608 adults (61% female) with a doctor diagnosis of asthma (pharmacy 260, woolcock 299, asthma foundation 87). 87% used inhaled corticosteroid (ics) ϯ long-acting b2-agonist in the last 4 wks. median age was 56 yrs (range 12-87), and 9% were current smokers. mean acq score was 1.4 (95% ci 1.3-1.5), with 40% of participants having poor asthma control (acq ն 1.5). 28% had urgent hcu for asthma in the previous year. significant independent predictors for poor asthma control were younger age, current smoking, living in more disadvantaged areas, being retired, having only primary education, and holding a concession card. predictors for urgent hcu were younger age, being in full-time employment, having only primary education, and being of non-english speaking background. neither ics use nor possession of a written asthma action plan was associated with lower risk for either poor asthma control or hcu. conclusions poor asthma control is common in nsw even in patients using inhaled corticosteroids. although urgent hcu is often used as an indirect measure of poor asthma control, it is affected by different factors, perhaps because health care utilization represents a more complex balance between need and access. bronchial challenge tests with mannitol, to measure airway hyperresponsiveness, can take up to 30 minutes and require inhalation of up to 635 mg of mannitol. our aim was to determine if positive mannitol challenges can be detected after half the maximal dose (315 mg) using the forced oscillation technique (fot) to measure response. methods 15 non-asthmatic subjects and 52 asthmatic subjects underwent standard mannitol challenge, up to 635 mg mannitol. respiratory system conductance (grs) and reactance (xrs) was measured by fot at 6 hz during 40 sec tidal breathing immediately after each dose of mannitol. fev1 was measured after fot, within 90 sec of mannitol administration. two point dose response slope (drs), was calculated for grs (drsgrs) and xrs (drsxrs) for standard tests, up to 635 mg, and for short tests by excluding data from doses above 315 mg. ability to detect a positive test, defined as pd15fev1 < 635 mg, was determined by the area under the roc curve (auc) and repeatability by intra-class correlation coefficient (icc). results 32 asthmatic and 2 non-asthmatic subjects had positive tests, with pd15 fev1 values from 9.2 to 622 mg. auc (95%ci) did not differ between standard (std) and short tests for drsgrs (p = 0.14) or drsxrs ( combined use of inhaled steroids (ics) and long acting beta-agonists (laba) have an important role in asthma management. we used data from a 2006 population sample to examine medication use in adults and children. methods all adults (18-75 years) and children (2-17 years) from within four discrete zones in northern sydney were eligible for an interview survey, as part of a study investigating health effects associated with traffic-related air pollution. the prevalence of use of short-acting beta-agonists (saba), any ics (alone or combination) and combined formulations of ics/laba in the previous three months was estimated for the study population and those with diagnosed asthma. results there were 806 children [mean (sd) age 8.7 (4.6) years and 50% female] and 2184 adults [mean (sd) age 45.6 (14.9) years and 56% female] interviewed in 1843 households, representing an overall response rate of 33%. the prevalence of ever diagnosed asthma was 16.1% in children and 17.4% in adults. medication data were missing for 301 subjects. background asthma affects 1:9 adult australians and is a leading cause of rejection for recruitment into the australian defence force (adf). within this diagnosis there is a wide spectrum of disease activity and clinical outcomes. also asthma assessment and management has improved so that many asthmatics are now fully active without any significant disruption or risk to their lives. hypothesis: there is a subgroup of asthmatics who are at very low risk from significant adverse effects from asthma and who could be considered for recruitment to the adf. aims 1. to identify the subgroup of asthmatics who could be considered for recruitment to the adf. 2. to develop an assessment process to identify this subgroup (screening). 3. to develop a process to evaluate the outcomes of any change to the recruitment standard for asthma (evaluation). methods 1. a literature review of the natural history, assessment, management and response to treatment of mild episodic and mild persistent asthma. 2. a literature review of asthma in the military. 3. a clinical review of the outcomes of known asthmatics in the adf. 4. an expert group to review the above and to develop a screening process and an evaluation of the program. the literature review identified a subgroup of asthmatics, defined as mild episodic and mild persistent, who with appropriate management, have a low risk of significant adverse asthma outcomes. they can be identified by a combination of questionnaire, spirometry and bronchial provocation testing. a screening process has been developed which allows asthmatics to be recruited with a negative mannitol or hypertonic saline challenge on 400 mg/day or less of budesonide (or equivalent) without laba. a methodology to evaluate the impact of these changes on the recruitment standard has also been developed. alexithymia is a personality trait associated with difficulty identifying and communicating emotional and physical feelings. it has been associated with poor control of asthma and near fatal asthma. the primary objectives of this study were to: (1) identify alexithymia in a cohort of australian asthma patients; (2) investigate the relationship between alexithymia and asthma control; (3) investigate the relationship between alexithymia and asthma management. methods cross sectional study of 25 moderate to severe asthma patients recruited from royal adelaide hospital outpatients. participants were either mailed the questionnaire pack or completed it after a clinic appointment. existing validated questionnaires were used. statistical analyses were performed using spss. results 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years, sd = 11) participated. alexithymia scores ranged from 23.0 to 76.0 (x = 48.3, sd = 13.2). 12% (n = 3) of participants could be classified high alexithymia, 32% (n = 8) borderline alexithymia and 56% (n = 14) were low alexithymia. alexithymia mean scores were not statistically different across sociodemographic variables. a positive correlation/association was found between alexithymia score and asthma control score (r = 0.57, p < 0.01), quality of life (r = -0.65, p < 0.01), and adherence (p = 0.03) but not satisfaction with communication (r = -0.27, p = 0.2) or number of hospitalizations (p = 0.25). conclusions this is the first australian study to identify alexithymia among asthma patients and investigate relationship to control as well as management and communication. associations between alexithymia and asthma control were confirmed. a larger sample size is needed to determine impact of alexithymia on self-management and provision of clinical care for asthma. port hedland is impacted by iron-containing dust particles (pm10) that may activate lung cells when inhaled. furthermore, the effects of port hedland pm10 may differ from the effects of urban pm10 impacting metropolitan areas. the aim of this study was to assess the effects of port hedland pm10 on production and release of the inflammatory cytokines, il-6 and il-8, by human airway epithelial (a549) cells, and to compare these with the effects urban pm10 from metropolitan areas. methods human airway epithelial (a549) cells were exposed to pm10 collected at port hedland and at urban locations (sydney, perth). a549 cells were exposed to a range of pm10 concentrations (20-200 mg/ml) for 24 h. lipopolysaccharide (lps) and phorbol myristate acetate (pma) were used as positive controls. supernatants from cell cultures were assayed for il-6 and il-8 using specific elisa kits. rna was extracted and reverse transcribed to cdna. il-6 and il-8 mrna expression was quantified by duplex real-time pcr using taqman primer/probes. results lps stimulated a 2.7-fold increase in il-8 release and pma stimulated a 3-fold increase in il-8 release and a 30-fold increase in il-6 release. however, neither port hedland pm10 nor urban pm10 stimulated concentration dependent release of il-6 or il-8 by a549 cells. expression of il-6 or il-8 mrna was also not altered by port hedland or urban dust. cd8+ t-cells may cause airway epithelial cell apoptosis via the granzyme pathway. we have reported increased apoptosis of airway epithelial cells and increased bal t-cell expression of granzyme b in copd, and a positive correlation between the two. we hypothesized that the increased granzyme b would also be related to smoking history (pack years -pk/y), age and severity of airflow obstruction (fev1 %pred) in patients with copd. we further hypothesized that the t-cell granzyme b expression would be higher in the airway than the peripheral blood. methods we investigated t-cell intracellular granzyme b expression in blood from copd subjects (33 current and 24 ex-smokers) and 12 never-smoker controls, and bronchoalveolar lavage (bal) and bronchial brushing (intraepithelial t-cells) from a cohort of these subjects using flow cytometry. correlations between granzyme b and pk/y, age or fev1 were performed using spearman's rank correlation. granzyme b in t-cells from blood, bal and bronchial brushings were compared. results there were significant correlations between fev1 and granzyme b expression in blood and bal (blood: r -0.444, p = 0.002; bal: r -0.368, p = 0.029). there was a significant correlation between pk/y and granzyme b expression in blood (r 0.362, p = 0.002), but not in bal. there were no significant correlations between granzyme b and age. there were no significant differences in granzyme b expression in blood, bal or intra-epithelial compartments. conclusion granzyme b is expressed at similar levels in blood, bal and intra-epithelial compartments, supporting recent opinion that copd is a systemic disease. t-cell granzyme b is related to severity of airflow obstruction and smoking history in patients with copd and may be one mechanism of apoptosis leading to lung injury and airflow obstruction in copd. jc allen 1 , t schlosser, ee ramsay 1 , q ge 2 , aj ammit 1 as development of remodelled airways is correlated with deterioration of lung function, we require therapies that reduce and reverse structural changes in remodelled airways. in asthma, corticosteroids can halt some, but not all, aspects of airway remodelling. therefore, in order to aid future design of efficacious anti-remodelling agents we need a better understanding of the molecular mechanism/s underlying the development of airway remodelling and the effectiveness of corticosteroids. hyperplasia of airway smooth muscle (asm) is a feature of the remodelled airway in asthmatics. in this study we examined the effect of corticosteroids on a key regulator of g1 progressioncyclin d1. asm cells from n = 8 non-asthmatics and n = 7 asthmatics were pretreated for 1 h with vehicle or dexamethasone (0.1 mm). the temporal kinetics of cyclin d1 mrna and protein expression were measured up to 24 h after stimulation with the mitogen platelet-derived growth factor-bb (pdgf-bb). pdgf-bb induced a significant increase in cyclin d1 mrna expression in asm from non-asthmatics (2.6 ϯ 0.3-fold) and asthmatics (2.9 ϯ 0.3-fold) after 24 h stimulation. in non-asthmatics, the corticosteroid dexamethasone significantly (p < 0.05) reduced the amount of cyclin d1 mrna expressed (to 1.6 ϯ 0.2-fold). in contrast, cyclin d1 expression in asthmatics was relatively resistant to inhibition by dexamethasone; the amount of pdgf-bb-induced cyclin d1 expression in the absence or presence of dexamethasone was not significantly different ( sphingosine 1-phosphate (s1p), a bioactive sphingolipid found elevated in the airways of asthmatics, modulates myriad airway smooth muscle (asm) functions that promote inflammation and remodelling in asthma. in this study, we uncover the molecular pathway/s underlying s1p-induced secretion of il-6, and investigate if, and how, corticosteroids inhibit il-6 secretion. using cultured asm cells from non-asthmatics, we found that s1p induces il-6 secretion from asm cells via cre, but not ap-1, c/ebp or nf-kb, transcriptional regulation of il-6 gene expression. cre-dependence was supported by s1p-induced creb phosphorylation. although the corticosteroid dexamethasone reduced s1p-induced il-6 secretion in a dose-dependant manner, this inhibition appeared to occur via a pathway independent of creb/cre, suggesting the existence of a parallel pathway. as we recently discovered that the antiinflammatory actions of corticosteroids in asm can be mediated via the induction of the endogenous mitogen-activated protein kinase (mapk) inhibitor, mapk phosphatase-1 (mkp-1), we investigated whether mapk represents the parallel pathway targeted by corticosteroids. we found that s1p can induce activation of a variety of mapk, however, only p38 mapk phosphorylation was inhibited by dexamethasone; importantly, the increase in mkp-1 after corticosteroid treatment appeared to mirror the decrease in s1p-induced p38 mapk phosphorylation. furthermore, exogenous expression of mkp-1 inhibited s1pinduced il-6 secretion. taken together, these results suggest that parallel pathways exist to induce il-6 secretion (transcriptional via creb/cre and possibly post-transcriptional via p38 mapk) and serve to underscore the importance of mkp-1 upregulation as a mechanism of action of corticocosteroids in asm. angiogenesis is a hallmark feature of asthma. angiogenic promoters, such as vegf and tgfb are reported to be increased in airways of asthmatics. tumstatin, an endogenous angiogenic inhibitor, is the non-collagenous domain-1 (nc1) of the alpha3 chain of collagen iv. decreased levels of collagen iv have been reported in the airways of asthmatics. we investigated the presence of tumstatin in the airway of asthmatics and its potential role as an angiogenic inhibitor. we detected the six a chain nc1domains of col iv and the 7s domain of the a3 chain using immunohistochemistry. the level of tumstatin in serum and bal-f was measured by dot blot. western blots were used to identify the association with the rest of the collagen iv molecule. a tube formation assay using primary pulmonary endothelial cells (ppec) was performed to evaluate the role of tumstatin in the airway. the effect of intranasal tumstatin on airway hyperresponsiveness and angiogenesis was studied in an ovalbumin mouse model. tumstatin was absent in the airways of asthmatics (n = 14) while the remaining six collagen iv a chains were present. the 7s domain of the a3 chain was present in the asthmatic airway (n = 6). tumstatin was detected in both serum and bal-f samples from asthmatic volunteers (n = 10), however the level of expression was not significantly different from that in nonasthmatics (n = 7). in asthmatic serum tumstatin was part of the whole collagen iv a3 chain. tumstatin was able to inhibit ppec tube formation in a dose related manner. tumstatin inhibited angiogenesis in the mice airways and was associated with an improvement in ahr. the fact that tumstatin is absent from asthmatic airways and inhibited airway hyperresponsiveness and angiogenesis may indicate potential for therapeutic intervention in airway remodelling. this work was supported by the crc for asthma and airways and nh&mrc. introduction epithelial egfr (epidermal growth factor receptor) expression correlates with disease severity and neutrophil infiltration in asthmatic airways. acute exacerbations of asthma and copd are also associated with steroid refractory neutrophilic inflammation, with rhinoviruses being the most common trigger. .7 mg/l and il-6: 5.8 vs. 3.6 ng/l). since il-6 stimulates the acute phase response, we correlated its levels with the other markers. only crp was strongly correlated with il-6 (spearman r = 0.58, p < 0.0001), suggesting differential regulation of saa and ip10. saa discriminated between non-pathogen (n = 10) vs. pathogen-associated (n = 41) events (saa: 9.4 vs. 44.1 mg/l p = 0.005), whereas no significant change was observed in the other markers (ip-10: 139.8 vs. 170.5 ng/l, crp: 4 vs. 10 mg/l, il-6: 4.6 vs. 7.2 ng/ l). however when aecopd marker levels were stratified on the basis of pathogen type (viral = 12, bacterial = 21, viral and bacterial = 8), none of the markers were significantly altered. conclusions ip-10 is significantly elevated during an aecopd, however only saa differentiated non-pathogen from pathogen associated events. background severe persistent asthma is characterized by structural changes in the airways-airway remodelling. airway smooth muscle (asm) cells have the potential to play a key role in these processes through the release of growth factors, cytokines and extracellular matrix (ecm) proteins. we have previously studied the effects of budesonide and formoterol individually however, the effect of their combination on these characteristics of asm cells is not known. methods asm cells from asthmatic (n = 6) and nonasthmatic (n = 6) individuals were stimulated with transforming growth factor ß (tgfß) (1 ng/ml) with or without budesonide (10 -8 m) and formoterol (10 -10 and 10 -8 m) and fibronectin levels and interleukin-6 (il-6) release were measured by elisa. bronchial rings from nonasthmatic individuals (n = 2) were incubated with tgfß with or without the drugs and ecm protein expression (fibronectin and collagen i) measured using immunohistochemistry. results in nonasthmatic cells, budesonide alone induced fibronectin deposition whether tgfß was present or not. formoterol decreased fibronectin induced by tgfß and, when combined with budesonide, reversed the increase in fibronectin. a similar pattern was observed in asthmatic cells, except that budesonide did not further increase the tgfß mediated fibronectin release. as before [1] , il-6 was induced by formoterol but inhibited by budesonide. tgfßinduced il-6 was inhibited by both drugs and their combination in both cell types. in bronchial rings the presence of either drug did not affect tgfßinduced fibronectin or collagen i. severe combined immune deficiency (scid) spontaneous mutation specifically impairs differentiation of stem cells into mature lymphocytes. nod-cb17prkd scid (known as nod-scid) lacked nk cells, hence is commonly used in cell transfer experiments for transferring tissue and haematological xenografts. the aim of this study was to establish lung inflamamtory model in nod-scid strain. methods balb/c and nod-scid balb/c mice (n = 8) were exposed to cigarette smoke for 4 days, 2 and 4 weeks (9 cigarettes/day; 5 days/week). bronchoalveolar lavage fluid (balf) and lung tissue were collected for inflammatory profiling and analysis for cytokines, chemokines and protease expression and/or activity. results nod-scid have significant accumulation of macrophages in lung after 4 days, 2 and 4 weeks smoking as compared to no smoke control (p < 0.001) that was not different to balb/c (p > 0.05). nod-scid also have increased neutrophil number after 2 and 4 weeks smoking (p < 0.001). even though myeloid cell differentiation isn't affected by scid phenotype, nod-scid have one fold less neutrophil than balb/c mice (p < 0.001) that is also reflected in the reduced expression of matrix metalloproteinase-9. consistent with the known lymphopenic phenotype, nod-scid have significant but less lymphocytes recruitment as compared to balb/c mice after 4 weeks smoking (p < 0.001) despite the enhanced expression of inteferon inducible protein 10 (lymphocytes specific chemokine) in lung. both mouse strains showed the same elevation of net gelatinase and serine protease activity in lung. nodscid mice also demonstrated comparable transcriptional induction of proinflammatory cytokines (tnfa, il-6), growth factors (gm-csf, g-csf) and chemokines (mcp-1, mip-2), indicating susceptibility to smoke-induced injury. conclusions nod-scid mice are capable to mount smoke induced inflammatory response. this model may be useful to study localization and role of immunocytes, including adoptively transfer human cells in the pathogenesis of copd. supported by the nhmrc. rhinovirus (rv) is the cause of most common colds and up to 80% of asthma attacks. in our previous studies, plasminogen activator inhibitor 2 (pai-2) was expressed at high levels and was induced in vivo and in vitro by rv infection. pai-2 may have antiviral properties suggested by antiviral activity in some models, high pai-2 expression levels and further upregulation by rv infection. methods to determine whether pai-2 has antiviral activities following rv infection, o-hela, pai-2 expression-deficient cells were first transfected with pai-2 or control genes. this was followed by infection with rv and effects on viral replication were assessed by rt-qpcr for vrna and by viral titration for virus release. ifn expression was assessed by rt-qpcr. results ifn-a and -b mrna expression were induced in response to rv infection and to pai-2 expression in cells. pai-2 expression followed by rv infection elicited a synergistic response and pai-2 over-expression reduced vrna by >5 fold and viral titre by >3 log (p < 0.05). however, this effect was not specific to pai-2, as transfection of cells with control genes/plasmids reduced viral titre to a comparableextent. one of the pathological findings in idiopathic pulmonary fibrosis (ipf) is the presence on fibroblastic foci comprising cells which exhibit mesenchymal phenotypic features such as myofibroblast-like morphology, increased asma expression and collagen deposition. currently steroid treatment in ipf has shown limited efficacy. the cellular origins of these mesenchymal cells remain unclear, but evidence from other studies suggests that epithelial cells may undergo a transition to a mesenchymal cell phenotype (emt). transforming growth factor ß has been implicated in promoting this emt. in this study we have induced a morphological change in a549 cells using tgf-ß1 and assessed the influence of glucocorticoids, and the changes to the extracellular environment of the cells, on emt. methods a549 cells were grown on uncoated plastic cultures plates or those coated with monomeric or fibrillar collagen and treated with 200-500 pm tgf-ß1. the influence of the glucocorticoid, dexamethasone (dex, 1-1000 nm), or collagen type, on emt was assessed by microscopy, rt-pcr and western blotting for markers of myofibroblast phenotype. results tgf-ß1 induced an increase in mrna expression of asma (1.5 fold), collagen (7.0 fold) and fibronectin (2.0 fold). dex (100 nm) partially inhibited the expression of collagen, but had no effect on asma levels. however, dex (100 nm) reduced asma and ctgf protein levels. dex (100 nm) also prevented the tgf-ß1-induced morphological changes, regardless of ecm matrix. conclusion glucocorticoids appear to control some of the emt phenotype changes induced by tgf-ß1. however, the inability to fully inhibit these changes may contribute to the resistance of ipf to glucocorticoids. the extracellular environment may also play a role in the development of fibroblastic foci and their pharmacological responses. defective alveolar macrophage (am) phagocytic function in the airway may perpetuate inflammation via secondary necrosis of uncleared apoptotic cells in copd. we have previously reported that low-dose azithromycin improved macrophage function in vitro, although the mechanisms for this effect were not identified. we explored the possible role of the collectin pathway in the azithromycin-mediated improvement in phagocytosis as well as possible defects in this pathway in copd subjects. methods (1) mannose binding lectin (mbl), mannose receptor (mr), surfactant protein d (sp-d) were measured in copd subjects and controls. (2) the in vitro effects of addition of rhmbl, and blocking mr with a specific antibody, on am phagocytic ability were assessed. in vitro effects of azithromycin on am expression of mr were also investigated. (3) azithromycin (250 mg orally 2¥ weekly/12 weeks) was administered to 11 copd subjects. bronchoscopies were performed prior to and 12 weeks following therapy. ex vivo assessments included am phagocytic ability, levels of mbl, sp-d and mr and apoptosis of bronchial epithelial cells. results am mr expression and levels of mbl and sp-d were significantly reduced in copd subjects vs controls. azithomycin (500 ng/ml) increased mr expression by 31% in vitro. rhmbl induced a dose-dependent increase in am phagocytic ability (up to 148%). blocking mr significantly decreased am phagocytic ability by 60%. in copd patients following azithromycin therapy, we observed improved am phagcocytic ability, increased levels of mr and reduced levels of bronchial epithelial cell apoptosis. conclusions these findings strongly implicate the mr in both the defective phagocytic function of am in copd and as a target for the azithromycinmediated improvement in phagocytic ability. obstructive sleep apnea (osa) is associated with hypoxia and increased cardiovascular morbidity. t cells and monocytes play a significant role in atherogenesis via cytokine production. there have been reports of benefits of continuous positive airway pressure (cpap) therapy in osa. the purpose of this study was to characterize leucocyte inflammatory cytokine/chemokine production by t cells and monocytes in a group of osa patients and to investigate the therapeutic effects of cpap therapy. methods a comprehensive range of intracellular t-cell and monocyte proand anti-inflammatory cytokines/chemokines was investigated in peripheral blood from 5 osa patients and 5 aged-matched control subjects (with no evidence of sleep problems) using multiparameter flow cytometry. osa patients were again studied following 7 days of cpap therapy. results in osa patients there was an increase in intracellular t-cell ifng and tnfa production but no change in il-2, il-4 or tgfb compared with control. there was an increase in intracellular monocyte il-1a, il-8, tnfa, mcp-1 and mcp-3 in osa patients but no change in il-10 or il-12. following cpap therapy, t-cell ifng and tnfa production returned to 'normal' levels. however, although intracellular monocyte cytokine/chemokine production was decreased following cpap, levels were significantly elevated compared with control. conclusions osa is associated with increased intracellular proinflammatory cytokine/chemokines, many of which are increased in atherosclerotic plaques. although one week of cpap therapy resulted in amelioration of t-cell pro-inflammatory cytokines, longer cpap use or alternative therapy may be required to reduce monocyte pro-inflammatory mediators associated with atherosclerosis in patients with osa. gp130 has been associated with the progression of fibrosis especially in patients with idiopathic pulmonary fibrosis (ipf). gp130 is the common subunit of the receptor complexes for the il-6 family of cytokines including il-11 and oncostatin m (osm), where gp130-mediated signalling leads to activation of the erk or stat pathways. we have previously demonstrated exaggerated gp130-stat signalling to be fundamental to the development of pulmonary fibrosis in a murine model of bleomycin-induced lung fibrosis. the aim of this study was to elucidate the role of the il-6 cytokine family in the development of pulmonary fibrosis by identifying which il-6 family cytokines regulate fibrosis in bleomycin treated mice, and determine the effects of these cytokines on cell function. bleomycin (0.05 u/mouse) or control saline was administered intranasally to wildtype mice (wt), genetically engineered mice containing point mutations to prevent gp130 erk signalling (gp130 757f ) or gp130 stat signalling (gp130 dstat ), and duel il-6 and il-11 a-receptor knockout mice (il-6 -/-;il-11ar -/-). the effect of bleomycin on collagen production was examined in lung tissue 30 days post treatment by hplc. there was a significant increase in collagen levels in bleomycin treated wt lungs which was further increased in gp130 757f lungs. the lungs of gp130 dstat and il-6 -/-;il-11ar -/mice were protected from fibrosis suggesting that gp130-stat signalling is important in inducing lung fibrosis which may be mediated through il-6 and/or il-11. cell proliferation was examined in lung fibroblasts isolated from wt, gp130 dstat and gp130 757f mice. il-6, il-11 and osm were significantly mitogenic for gp130 dstat cells but not for wt or gp130 757f cells, reflecting different responses to the different signalling pathways. changes in cytokine profiles are currently being examined in lung tissue and serum of control and bleomycin treated mice 0-30 days after treatment. in conclusion, il-6 and il-11 are likely to play a role in bleomycin-induced fibrosis via the gp130-stat-mediated pathway, however this may not be due to regulation of proliferation induced by these cytokines. supported by the nhmrc. mimicking viral infection by application of various toll-like receptor ligands has shown clinical promise in the treatment of persistent viral infections and more recently with malignant tumours. commercially available toll-like receptor 7 ligands (tlr7l), such as those of the imidazoquinoline family have been applied clinically for the treatment of a number of conditions including basal cell carcinoma and hpv-induced genital warts. these compounds are known to retard tumour growth indirectly by promoting activation and migration of dcs, leading to a strong th1 cellular response, and directly via release of proinflammatory cytokines and promotion of tumour cell apoptosis. malignant mesothelioma (mm), an aggressive tumour with a mean survival of 9 months, is highly resistant to chemotherapy, radiotherapy and surgery and is therefore an interesting candidate for immunotherapy in the form of tlr7 ligand treatment. whilst tlr7 is known to be selectively expressed in immune cells and its relative expression low amongst other cell and tissue types in mammals, its expression on tumour cells and the consequences of such expression on tumour growth are unknown. here we describe the presence of tlr7 (mrna and protein) directly in a range of different tumours, including several murine and human mm cell lines. reactive oxygen species (ros) produced during the innate immune response are important agents of anti-pathogen defense but may also cause oxidative lung damage. glutathione peroxidase-1 (gpx-1) is a detoxifying enzyme that may protect lungs from such damage. methods wild-type (wt) or mice deficient in glutathione peroxidase-1 (gpx-1 -/-) were placed in a perspex chamber and exposed to cigarette (cig) smoke generated from 9 cigs per day for 4 days. on the fifth day, mice were killed, the lungs lavaged with pbs and then harvested for proteomic and genomic analysis. results wt mice exposed to cig smoke for 4 days had significantly more macrophages (3.1 ϯ 0.1(sem) ¥ 10 5 ) and neutrophils (4.9 ϯ 0.4 ¥ 10 5 ) than sham-exposed mice (2.2 ϯ 0.2 ¥ 10 5 and 0, respectively) (n = 6, p < 0.05). however, gpx-1mice exposed to cig smoke had significantly greater macrophages (5.4 ϯ 0.3 ¥ 10 5 ) and neutrophils (1.2 ϯ 0.1 ¥ 10 6 ) than smokeexposed wt mice (n = 6, p < 0.001). macrophage and neutrophil numbers in sham-exposed gpx-1 -/mice (1.7 ϯ 0.3 ¥ 10 5 and 0.5 ϯ 0.4 ¥ 10 3 ) were similar to those of sham-exposed wt mice (2.2 ϯ 0.2 ¥ 10 5 and 0). in addition, we found that balf of gpx1 -/mice exposed to cig smoke had an increased proteolytic burden compared with smoke-exposed wt mice as assessed by zymography and net gelatinase activity assay. conclusions these data suggest that gpx-1 protects the lung from cigarette smoke-induced inflammation and that targeting gpx-1 may have therapeutic utility in inflammatory lung diseases where cigarette smoke plays a role. funded by nhmrc. the becs from subjects with chronic obstructive pulmonary disease (copd) are exposed to frequent infectious and inflammatory stimuli. infection with rv is known to trigger acute exacerbations and subjects with copd are particularly susceptible. we hypothesized that exposure of copd becs to these stimuli would alter their response to rv infection. methods bec were obtained by endobronchial brushing from subjects with gold stage 3 copd (n = 4, all ex-smokers), subjects with mild persistent asthma (n = 4) and healthy controls (hc, n = 4). becs were cultured and then treated with tumour necrosis factor (tnf)a 10 ng/ml or lps 100 mg/ml for 24 hrs and then infected with rv-43, rv-1b. response was measured by release of il-8, il-6 and ip-10 mrna and by elisa. virus replication measured by cell titration assay. results infection with both rv strains led to increased release of il-8 and ip-10 in all groups. exposure of hc and asthma becs to both lps and tnf led to increased release of il-8. in these becs there was no increase in release of il-8 exposed to lps and tnf and then infected with either rv. becs from subjects with copd released significantly less il-8 in response to all conditions and rv infection compared to hcs and asthma. no differences were seen in rv replication. the aim of this study was to determine opinions and attitudes to exercise from chronic obstructive pulmonary disease (copd) subjects after completion of a 12-month maintenance exercise program. methods following completion of a 12-month exercise study, which included a supervised program (intervention, n = 18) and control group (control, n = 17), copd subjects [mean age (sd): 66 (8); mean fev1 (% predicted) = 56% (19)] were asked to complete a questionnaire. the questionnaire included closedended questions using visual analogue scales (100 mm). in copd the 6 minute walk distance (6mwd) is known to increase with test repetition (familiarization) and in response to exercise training. it is unknown whether the magnitudes of these increases are related to the degree of disability of the individual patient. methods 6mwd was measured twice before and once after an 8 week out-patient exercise program in 121 patients (82 males) aged 67ϯ8.6 yrs, fev1 37ϯ15% predicted (meanϯsd) with stable copd. the changes in 6mwd following a familiarization test and following training were compared between patients grouped according to their degree of disability (defined as the pre-training 6mwd [best of 2 tests] expressed as %predicted 6mwd). *p < 0.05 gp 3 vs gp 1. conclusions before training, 6mwd increases following a familiarization test irrespective of the level of disability. the magnitude of this increase is similar in all groups when normalized for their pre-training 6mwd. following training, the increase in 6mwd is greatest in patients with the greatest disability (lowest pre-training 6mwd). in less disabled patients, the relatively smaller increase in 6mwd following training may reflect an inability to further increase stride length, thereby reducing the responsiveness of the 6mwt in this group. supported by nhmrc. endotoxin is a stimulant of the innate immune system and is a major component of cigarette smoke. smokers have evidence of increased airway neutrophils and inflammation. we hypothesized that endotoxin levels would be higher in the bronchial lavage (bl) of subjects who were former smokers and subjects with chronic obstructive pulmonary disease (copd). methods subjects were all ex-smokers for at least 5 years (n = 10, 5 copd, 5 healthy controls) or never smokers (n = 12, 6 asthma, 6 healthy controls). bl was collected and analysed for cell count and differential, culture for microbiology. the supernatant was analysed for il-8 by elisa and endotoxin by quantitative kinetic lal assay. results median endotoxin levels were significantly higher in ex-smokers 101 compared to never smokers 6.3 u/ml (p < 0.001). there were no differences between subjects with copd and hs. subjects with copd had higher median endotoxin levels (80 u/ml), compared to asthma (5.2 u/ml) and hc (6.3 u/ml, p = 0.03). there was no correlation between endotoxin levels and bl total cell count, neutrophils (%) or fev1 % predicted. there was a strong correlation with previous packet years smoked and endotoxin levels (r = 0.72, p < 0.01). conclusions bl endotoxin levels are higher in ex-smokers, including subjects with copd. despite this there is no relationship to increased neutrophilic inflammation. copd is associated with inflammation associated with ineffective repair of the injured epithelium and loss of structural integrity. we have shown that these changes may result from dysregulated 'efferocytosis' (increased apoptosis of bronchial epithelial cells and defective clearance of these cells by alveolar macrophages (am)). we have also reported that azithromycin, at subbactericidal dose, improved am phagocytic function ex vivo. methods we administered azithromycin at low dose (250 mg/ twice weekly for 12 weeks) to 10 copd subjects (7 male, age: 62 ϯ 8 yr, 5 current/ 5 ex-smokers, fev1: 63 ϯ 9% pred, fev1/fvc: 48 ϯ 9%). the study was openlabel, uncontrolled and primarily focused on objective biological responses obtained from the bronchoscopy samples taken. phagocytic ability of am (from bal), apoptosis of bronchial epithelial cells (from bronchial brushing), markers of inflammation in blood, bal and breath condensate (crp, wcc and inflammatory cytokines), health status (st. george's respiratory questionnaire), ecg and lung function were assessed pre and post-administration of azithromycin. results azithromycin significantly improved phagocytic ability of am (by 37%) and reduced bronchial epithelial cell apoptosis (by 34%). antiinflammatory effects of azithromycin included significantly reduced blood wcc and crp. there were non-significant reductions in levels of pro-inflammatory cytokines il-8, il-6 and tnf-a in blood, bal and breath condensate, and a trend for improved health status. conclusions our findings indicate a novel approach to supplement existing therapies in copd that may improve clearance of accumulated apoptotic material and reduce the risk of secondary necrosis and release of toxic cell contents that perpetuate inflammation. background the prevalence of gastro-oesophageal reflux disease (gord) across the disease spectrum in copd and bronchiectasis is not well described. the aim of this study was to determine the prevalence of symptomatic and silent gord in copd and bronchiectasis and its effect on lung function and quality of life (qol 4] ) and 18 healthy controls were recruited. the prevalence of gord in bronchiectasis was 33%; 37% in copd; 17% in controls. in copd and bronchiectasis, total nre and ri were increased in those with distal and proximal gord compared to those without gord (all p < 0.05). there was no difference in extent or severity of bronchiectasis in patients with or without gord (all p > 0.05). in copd, the relationship between proximal gord and fev1 was small to moderate (r = 0.383). sgrq symptom scores were higher in patients with bronchiectasis with increased ri (p = 0.02). increased proximal nre was associated with reduced physical (p = 0.03) and mental health (p = 0.02) in the sf-36 in copd. conclusions gord is a co-morbidity in patients with copd and bronchiectasis. the impact of gord on disease severity requires further evaluation. funding source nhmrc, the university of melbourne, monash university, physiotherapy research foundation. chronic obstructive pulmonary disease (copd) is prevalent among older people, however little is known about the influence of ageing on airway inflammation. the aim of this study was to compare airway inflammation in older people with obstructive airway disease to groups of older and younger healthy controls. methods participants (>55 years of age) with stable airway disease and incomplete reversibility (fev1% predicted <80% and fev1/fvc < 70%; copd n = 71) and healthy controls (n = 45, 35 older >55 years and 10 younger <55 years) were recruited from the respiratory ambulatory care clinic or by advertisement. participants underwent a clinical assessment, skin allergy test, hypertonic saline challenge, sputum induction and gas diffusion studies. results participants with copd had moderate airflow obstruction (mean (sd) fev1% predicted 56 (19)) and 45 (63%) were current or ex-smokers with a median (iqr) pack year history of 36 (20-54) pack years. ageing was associated with an increase in airway neutrophils (p = 0.0001). compared to older controls, participants with copd had increased airway eosinophils and lymphopenia (p = 0.004, p = 0.003 respectively), but no difference in airway neutrophils. conclusion airway neutrophilia is a feature of ageing and is not further increased in the presence of copd. copd is associated increased numbers of airway eosinophils with reduced lymphocytes which may impact on the ability of the immune system to combat infection. supported by nhmrc, the university of newcastle. chronic obstructive pulmonary disease (copd) is third leading cause of death and fourth leading cause of disease burden in australia. mechanisms involved in emphysema severity have not been fully understood. micrornas are noncoding rnas that regulate gene expression. we hypothesize that microrna expression differs between emphysema severity in copd patients. methods mirna profiling was performed using 15k agilent human oligo mirna microarrays on total rna extracted from non-tumour lung tissue from 30 copd patients undergoing resection for lung cancer. the mirnas were quantile normalized and anova was used to find differentially expressed genes. results demographic characteristics of the copd patients (mean (sd)) were age 69 (6) years, fev1 72 (17) % predicted and fev1/fvc ratio (<70%). anova identified 31 mirnas that were differentially expressed when stratified into two classes according to kco % predicted > or <75% (t-test, p < 0.05). discussion this mirna analysis has identified mirnas that may be important in emphysema severity in copd patients. further validation will be performed using qrt-pcr and mirna assays on the training set and an independent set, and target prediction and validation. t-helper type 1 (th1) and type 2 (th2) lymphocyte responses have been well recognized as being important pathways in inflammation. recently another form of inflammatory lymphocyte response has been described, the th17 pathway. th17 cells produce cytokines such as il-17a to clear extra-cellular bacteria and fungi and have been implicated in autoimmune and chronic inflammatory diseases. the th17 response in copd is unknown. methods subjects were patients with copd (ex-smokers, fev1 < 70% predicted who had not had an exacerbation for at least 1 month) and control subjects (ex-smokers and normal spirometry). serum samples were obtained for measurement of c reactive protein (crp) and il-17a, the latter measured using enzyme-linked immunosorbent assay (elisa). production of il-17a by t-cell subsets was also identified by intra-cellular cytokine staining and measured by flow cytometry. the mean fev1 of copd subjects was 42 % predicted (6.1 sem, n = 6) and mean fev1 of controls was 112 % predicted (3.0 sem, n = 4). the copd group had a higher mean level of crp 9.5 mg/l (3.9 sem) compared to the control group mean level of 4.6 mg/l (0.6 sem). the mean level of the il-17 in the copd group as measured by elisa was 22.3 pg/ml (16.9 sem, range 0-87) whilst no il-17 was measured in any of the control subjects. conclusions the findings of this pilot study suggest that il-17 may be elevated in association with crp in stable copd. airway obstruction is defined as a fev1/fvc ratio below the lower limit of normal. airway obstruction may prolong the forced expiratory time (fet). method spirometry results from 467 patients were categorized as obstructive, restrictive or normal. the mean, range and coefficient of variation were determined for fet in each diagnostic group. receiver operator characteristic (roc) curves were used to determine if fet could predict a low fev1/fvc. the number of patients with airway obstruction in five fet groups: <9; 9; 10-12; 13-14; and >14 seconds were determined. results the coefficient of variation was high for all groups. pair-wise comparisons showed a difference in mean fet between patients with normal lung function versus those with airway obstruction (p < 0.001). the best cut-point in the roc analysis of 9.895 seconds had a sensitivity of 0.66, specificity 0.77 and area under the curve of 0.743 for predicting obstruction. the technique of skeletal muscle microbiopsy has previously been validated [1] and shown to be minimally invasive and well tolerated in participants with stable copd. aim a study was undertaken to determine the feasibility and tolerability of obtaining microbiopsy muscle samples from the patient admitted for acute exacerbation of copd patient. methods written informed consent was obtained to collect the muscle, blood and sputum samples for research purposes. local anaesthetic was injected prior to the insertion of a 16 gauge bard max core disposable biopsy instrument through the associated guide needle. multiple passes (up to 6) were obtained. the patient was asked to evaluate the experience by rating it on the modified borg scale 0-10. results to date 5 patients and 3 controls have participated in this study. the gold severity ranged from 2-4 and ats exacerbation severity 2-3. the mean age 75 years (range 68-83 years), bmi mean 23.6 kg m -2 (range 17.2-27.1 kg m -2 ) and fat free mass was determined using single frequency bioimpedance. the sample mass obtained ranged from 27.2-104.1 mg, with an increasing yield occurring with increased experience of the operator. the procedure has been well tolerated, the borg scale rating ranged from 1-2/10. all patients were ambulant post procedure; no haematoma or bruising was observed in any of the subjects. conclusion the microbiopsy technique allows the collection of muscle tissue with minimal discomfort to the participant. small tissue masses such as these are sufficient to obtain measures of local markers of wasting and may prove to be a useful adjunct to the collection of sputum and blood for the measure of biomarkers in copd research. introduction older people (op) with obstructive airways disease (oad) experience multiple problems that may impact on their quality of life (qol) and disease management. these problems may relate to pathophysiology, symptoms, self management skills, psychological issues, lifestyle or other problems identified as important by the patient. aim the aim of this study was to determine the frequency of clinical problems associated with oad and to determine if a problem based assessment (pba) could adequately identify these problems. methods a multidimensional assessment tool was developed and the content compared to clinical practice guidelines. participants over 55 years with diagnosed oad underwent this assessment. results sixty-one consecutive patients, aged 59-87 years, with mean (sd) fev1 of 51.4 (17.85) % predicted were assessed. the assessment tool identified a mean (sd) of 3.03 (2.13) current and significant co morbidities with an additional 11 (3.37) clinical problems per patient. qol was increasingly impaired with an increasing number of problems (p < 0.0001). regression modelling identified that the number of identified clinical problems accounted for 55% of the qol impairment. the model demonstrated that every additional patient problem was associated with a clinically significant change in qol impairment (4.22 units) . conclusions op with oad experience multiple clinical problems and co morbidities that adversely impact their qol. a pba of op with oad identifies significant problems that may not be addressed in a diagnosis centred approach. there is a need to identify and effectively manage this array of problems in clinical practice. discussion in this diverse group of copd patients, there was a positive correlation between dlco and fev1, but not kco and fev1. the fev1/ kco plot identifies substantial numbers of patients with the potential ad and e phenotypes defined above. we intend to study inflammatory biomarkers in these groups. fat free mass index (ffmi) is a marker of morbidity and mortality in copd. measurement of ffm in the out-patient population is commonly undertaken using single frequency bioelectrical impedance analysis (bia). however the formulae to convert measured values to ffm are population dependent. schols et al (am j clin nutr, 1991) suggested that formula used for the general population may be inappropriate for patients with copd, and derived a specific formula from total body water (tbw) as measured by deuterium dilution. we compare this method of measuring ffm with 5 others, along with tbw and ffm hydration. methods tbw was measured in 31 outpatients with copd by bia and a difference method (weight-(protein+bone mineral+fat+non-bone mineral+ glycogen)) and ffm hydration was calculated. ffmi was measured by skin fold anthropometry (sfa), bia (3 separate formulae), dual energy x-ray absorptiometry (dexa) and total body potassium by g-counter (tbk). comparison between methods for tbw and ffmi was made by bland-altman analysis and between methods of calculation of ffm hydration by paired t-test. the two methods of assessment of tbw showed little difference (bias -0.04, 95% limits of agreement -5.40 to 5.31). however there was a significant difference in calculation of hydration of ffm (p = 0.0001). sfa, bia (lukaski), bia (tanita) and tbk underestimated ffmi when compared to bia (schols), with bias of -1.24, -3.87, -1.06 and -2.76 respectively. dexa however had a bias of only 0.05 and 95% loa of -3.09 to 3.21. conclusions there are differences between methods of assessment of tbw and ffmi and comparing values between methods must be done with caution. this has implications for assessment of morbidity and mortality in copd. chronic obstructive pulmonary disease (copd) has been identified as a major health problem in australia. recent studies have suggested that respiratory viral infections are the major cause of a worsening of copd; however this has not been studied in australia. aim to characterize pef changes and identify viruses during copd exacerbations. methods a pilot prospective longitudinal cohort study was done. patients had confirmed copd with fev1 <70% predicted and reversibility <10% and/or 200 ml. patients recorded daily peak expiratory flow (pef) measurements and daily chest and cold scores over a period of 2 years. sputum samples and nasal aspirates were taken at 6-month review (control visit) and whenever they had symptoms of an exacerbation (worsening of copd symptoms -seemungal et. al. am j resp crit care med, 2001). nasal aspirates and sputum samples were obtained and analysed by rt-pcr for rhinovirus (rv). result five patients have finished 2 years of study. a total of 12 exacerbations were reported based on patient symptoms. only 3 exacerbations were associated with significant reductions in pef and only one was linked to increases in nasal cold scores. all samples taken at control visits and nasal aspirates and sputum samples during exacerbations were negative for rv by rt-pcr. positive controls confirmed the accuracy of the assay. conclusion our data suggest that a symptom-based definition of copd exacerbation is not always accompanied by significant reductions in lung function parameters. these 'exacerbations' are also not associated with the commonest reported viral cause. our findings suggest that variability of copd may mimic. bronchiectasis is characterized by hypersecretion of mucus and impaired clearance that results in mucus accumulation, chronic cough, sputum production and recurrent infections. inhaled mannitol (400 mg) improves clearance of mucus by increasing the airway hydration and by reducing the viscoelastic and surface properties of mucus. however, the effect of other doses of mannitol on the clearance of mucus in patients with bronchiectasis is unknown. methods fourteen patients, age: 63.3 ϯ 5.7 yr, were studied on 5 visits. clearance of mucus was measured using 99m tc-sulphur colloid and imaging with a gamma camera at baseline and with mannitol ( weight loss and skeletal muscle atrophy are major determinants of morbidity in chronic obstructive pulmonary disease (copd), which are independent of lung function impairment. thus, we examined if a high-fat diet (hfd) protected against the wasting associated with prolonged cigarette smoke exposure (se) in mice. methods male balb/c mice were exposed to the smoke of 4 cigarettes/day, 6 days/week for 7 weeks. sham mice were handled identically without smoke exposure. mice consumed either standard laboratory chow (3.5 kcal/g, consisting of 12 % fat) or a hfd (4.3 kcal/g, 32% consisting of fat). we examined the effect of se and hfd on hind limb skeletal muscles, lung (tissue & bronchoalveolar lavage (balf)) and systemic inflammation in the 4 groups of mice (n = 8/ group). results after 7 weeks of hfd, sham and se mice were 12 and 13% heavier (respectively, p < 0.05) than chow fed animals. conversely, se significantly decreased body weight of chow and hfd fed mice by 16 and 15%, respectively, compared to sham animals (p < 0.05). the hfd did not protect against the decrease in soleus, tibialis anterior and gastrocnemius skeletal muscle weights induced by se (p < 0.05). se altered the mrna expression of a number of genes associated with the regulation of skeletal muscle mass including insulin-like growth factor-i (igf-i), atrogin-1 and interleukin (il)-6. the mrna expression of pro-inflammatory cytokines and chemokines was significantly increased by se in the lung, as were the number of inflammatory cells in balf (p < 0.05). on the other hand, although obesity has been linked to systemic inflammation, the hfd exerted little direct effect on the skeletal muscle and lung parameters measured. se and hfd had no effect on two markers of systemic inflammation, il-6 and serum amyloid a, whereas se tended to reduce circulating igf-i, an anabolic hormone. conclusions the hfd was not protective against the weight loss and skeletal muscle wasting associated with cigarette smoke exposure. supported by the nhmrc and crc for chronic inflammatory diseases. background patients with copd and bronchiectasis undertake airway clearance therapy (act) and exercise as part of physiotherapy management but it is unknown whether these treatments provoke gastro-oesophageal reflux (gor). this study aimed to determine the impact of positive expiratory pressure (pep) therapy and exercise on gastro-oesophageal function. p. aeruginosa is a significant opportunistic lung pathogen in individuals with cystic fibrosis (cf) and is associated with increased lung disease and morbidity. early intervention is beneficial for the effective clearance of p. aeruginosa and better long-term health outcomes. currently, lung flora of cf patients is monitored by regular culturing of sputum, however, children unable to expectorate are limited to annual bronchoalveolar lavages (bal), which is invasive and requires general anaesthesia. saliva is useful for clinical assays as collection is simple, non-invasive. we are developing a standardized enzymelinked immunosorbent assay (elisa) to detect respiratory infection of p. aeruginosa in cf children who cannot expectorate. methods 18 children (7-18 years) with cf and recent p. aeruginosa lung infection history and 16 non cf children (1-6 years) with no previous p. aeruginosa infection history provided saliva as positive, negative controls respectively. saliva was obtained by spitting, or absorbed using cellulose swabs and later extracted. these cell-free supernatant samples were used in an elisa anti-p. aeruginosa iga using commercial antigen. all results were standardized to account for flow using total iga expression. results median value was increased 9 fold in the recent p. aeruginosa lung infection group (mann-whitney test, n = 34, p յ 0.001). there was no significance between mucoid and non mucoid samples, and detection was independent of cfu/ml. discussion early findings support that p. aeruginosa respiratory infection can be detected through specific analysis of salivary iga expression. larger population sampling (30 positive, 90 negative) will aid selection of cut-off values for specificity and sensitivity testing in the future to objectively determine the utility of this assay as a means of monitoring for p. aeruginosa and for determining effectiveness of treatment. medical thoracoscopy is utilized widely throughout europe and northern america by thoracic physicians for the management of pleural disease, including the undiagnosed pleural effusion, malignant effusions and less commonly pneumothorax (ptx). australia has limited experience in this modality. we report the success of medical thoracoscopy in both primary and secondary ptx requiring intervention. methods data were collected from 2001 to 2007 in patients treated with medical thoracoscopy for the treatment of ptx. results 11 patients, 7 male, 4 female. average age 48 (range 19-86). 1 first episode primary spontaneous (ps) ptx, 2 third episodes of ps, 5 first secondary spontaneous (ss), 1 second ssptx, 2 third ssptx. underlying pulmonary disease in secondary ptx included: 4 chronic obstructive pulmonary disease, 1 lymphangioleiomyomatosis, 1 mesothelioma, 1 metastatic angiosarcoma and 1 was secondary to a motor vehicle accident. 7 had a history of smoking, 5 were former smokers and 2 were current smokers, with a mean 24 pack year history (range 5-45). 7 ptx were large, 4 moderate. 5 patients had an intercostal catheter (icc) inserted prior to thoracoscopy, 1 had failed pleural aspirate. there was evidence of bronchopleural fistula in 7 patients prior to the procedure. there was a median of 9 days from ptx to thoracoscopy. light sedation was used for the procedure in 10 patients, 1 required a general anaesthesia with a double lumen endotracheal tube due to anxiety. single port entry, dry talc poudrage and a 16 gauge french icc was used for all procedures. icc was removed a mean of 2 days following thoracoscopy and patients discharged on day 4. pain was the most common complication, requiring narcotic analgesia. one patient died on day 7, secondary to metastatic angiosarcoma. there has been no recurrence of ptx in any patient. conclusion medical thoracoscopy, performed by thoracic physicians is an effective procedure for the treatment of pneumothorax requiring intervention, including selected patients with evidence of bronchopleural fistula. funding nil. conflict of interest nil. nomination for young investigator award no. background lung cancer incidence and mortality are high in tasmania. australia (aihw 2003) 85/100 000 72/100 000 tasmania (cancer registry 2003) 102/100 000 89/100 000 aims and objectives (a) to determine patient demographics in southern tasmania, (b) to determine compliance to identified measures of best practice and (c) assess referral rates, clinical utility and potential delay to positron emission tomography (pet) in a regional setting. methods a prospective database collected information on local clinical practice. cases presented at a multidisciplinary lung cancer meeting over a 12 month period (march 2006 -april 2007 were analysed. data were available for n = 121/161 (75%). results are shown as mean ϯ sd. results 113 primary lung cancer cases were identified. the mean age was 71 ϯ 11 years. 58% of patients were male and 95% were current or ex-smokers. 81% were non-small cell lung cancers (nsclc). tissue diagnosis 93% time from diagnosis to surgery (27 ϯ 15 days) 82% < 42 days macroscopically complete surgical resection (9/11) 82% pet for stage iiib before radical chemoradiotherapy 75% 62% of patients presenting with early or locally advanced disease underwent further staging with pet (n = 34/55). management was changed in 50% of cases (17/34). the average time from pet referral to scan was 11 ϯ 5 days. conclusion a disproportionate number of lung cancers occurred in women. although surgery was performed within recognized timeframes, 2 of 11 patients had incomplete resections. pet influenced management decisions and was performed in a timely fashion. hp chan 1,2 , v tran 1,2 , c lewis 1,3 , p thomas exhaled breath condensate (ebc) is a simple, safe and non-invasive method of sampling breath and has the potential to investigate lung cancer and the associated neoplastic process in the lungs. increased oxidative stress has been implicated in the pathogenesis of lung cancer, and is characterized by elevated hydrogen ions, and hydrogen peroxide (h2o2), which is formed from the conversion of superoxide anions by superoxide dismutase. airway ph has already been shown to be decreased in ebc of patients with other respiratory conditions, but not in lung cancer. therefore the concentration of h2o2 and hydrogen ions in the ebc of lung cancer subjects was compared with matched controls. methods six subjects with newly diagnosed lung cancer were recruited and matched with control subjects: non-smokers, ex-smokers and smokers. ebc was collected and h2o2 was then measured by an assay method based on oxidation of 3,3',5,5'-tetramethybenzidine by horseradish peroxidase and h2o2 while ph was measured using a ph meter. results there was a significant difference (p = 0.033, anova) in h2o2 concentration between the 4 groups with the lung cancer group having elevated mean h2o2 concentration of 23.68 mm (9.15 (sem) compared to the controls: non-smokers, 17.59 mm (6.53 (sem); ex-smokers, 14.35 mm (3.79 (sem); and smokers, 5.21mm (0.69 (sem). ph did not differ significantly (p = 0.659, kruskal-wallis test) between the groups. conclusion these preliminary data suggest that there is significant difference in h2o2 concentration between the groups. the demonstration of an elevated h2o2 level in those with lung cancer indicates an increase in oxidative stress which implies that this may be part of the pathogenesis or response to neoplasia. supported by none. conflict of interest none. pro-inflammatory th1 cytokines produced by t cells and monocytes play an important role in the immune response to malignant cells. however, tumours may escape immune surveillance by inhibiting th1 response and promoting chronic inflammation at the tumour site. methods to investigate the effect of soluble factors released by lung cancer cells on t cell and monocyte pro-and anti-inflammatory cytokines, culture supernatants from several lung cancer cell lines and a normal epithelial cell line (16hbe) were cultured with whole blood for 24 hours, then for a further 16 hrs with and without stimuli. intracellular cytokine / chemokine production was determined using multiparameter flow cytometry. results in stimulated cultures, there was a significant decrease in t cell th1 pro-inflammatory cytokines ifng, tnfa and il-2 and a decrease in monocyte il-1a, il-8, il-12, tnfa, mcp-1 and mcp-3 but an increase in antiinflammatory cytokine il-10 compared with 16hbe and control media. in non-stimulated blood cultures there was an increase in all monocyte inflammatory cytokines / chemokines in the presence of lung cancer supernatants. conclusions lung cancers secrete soluble factors that inhibit the antitumour pro-inflammatory th1 response by t cells and monocytes and upregulate monocyte anti-inflammatory cytokine il-10 following "antigenic challenge". lung cancer cells may also escape immune surveillance by secreting soluble factors that cause newly recruited monocytes to release inflammatory cytokines promoting chronic inflammation at the tumour site. cytotoxic t-cells (ctl's) are important barriers against tumour cells. ctl's induce apoptosis of target cells by mechanisms that include the release of pore-forming perforin and granule associated enzymes, such as granzyme b and granulysin. proteinase inhibitor-9 (pi-9) is the only known granzyme b inhibitor and its expression has been observed in some cancers. we hypothesized that pi-9 would be differentially expressed in lung cancer cells and may inhibit granzyme b-induced apoptosis in these cells. methods we investigated pi-9, granulysin and granzyme b expression in various lung cancer cell lines (1299 ( , 1466 ( , 2009 and normal epithelial cells obtained from bronchial brushing using flow cytometry. peripheral bloodderived t-cells were then incubated with lung cancer cell line supernatants and levels of pi-9, granzyme b and t-cell reactive oxygen species (ros) were assessed. results pi-9 expression was detected in all lung cancer cell lines, (1299 (54.2%), 1466 (90.2%), 2009 (85%), sbc-1 (81%)), at much higher levels than in normal bronchial epithelial cells (8.5%). granzyme b and granulysin levels were undetectable or low in cancer cells (0-9.2%). increased expression of pi-9 and reduced levels of granzyme b were observed in cd8+ t-cells in the presence of all cancer cell supernatants tested (p < 0.05). interestingly, t-cell ros levels were significantly increased in cd8+ t-cells after incubation with cancer cell supernatants (p < 0.05). conclusions high pi-9 expression in lung cancer cells combined with a reduction in t-cell granzyme b expression and enhanced intracellular t-cell ros levels may be a mechanism of immune evasion of lung cancer cells to granzyme b-induced cytotoxicity. immunotherapy for lung malignancies such as lung cancer and mesothelioma is most likely to be successful it it can be combined with conventional tumour debulking approaches such as chemotherapy and surgery. but they scientific basis of such combinations is yet to be determined. to study this we evaluated (1) the capacity of different lung chemotherapy drugs to alter tumour antigen cross-presentation and immunogencity, (2) duration of antigen presentation and responsiveness to immunotherapy after debulking surgery with/without lymphadenectomy, and (3) the pattern of tlr agonism which best synergized with chemotherapy and surgery. we used the ab1-ha murine model of lung malignancy in balb/c mice. results (1) the antimetabolite drugs gemcitabine and pemetrexed were most immunogenic compared to the cytotoxic antibiotics doxorubicin and mitomycin c and the alkylating agent cisplatin. gemcitabine delived large amounts of tumour antigen into the cross-presentation pathway. (2) tumour antigen cross-presentation persisted for only 10 days following resection. the optimal window for immunotherapy following cancer surgery is 1 week for effector ctl stimulation and 2-4 weeks for memory ctl stimulation. (3) the viral-like tlr agonists tlr 3, 7 and 9 were the most effective adjuvant tlr molecules, with tlr 7 agonists generating the strongest systemic anti-tumour responses. conclusion these results help explain previous lung immunotherapy failures and will inform new clinical trials. background mesothelioma is a highly aggressive tumour with an increasing world wide incidence. the serum biomarker mesothelin is elevated in some individuals prior to development of clinical symptoms of the disease and may be useful for screening. we therefore studied the sensitivity and specificity of urinary versus serum levels of mesothelin for mesothelioma patients and evaluated the influence if renal function on the biomarker level. materials and methods concurrent sera and urine samples collected from patients with and control populations. mesothelin concentrations were determined by double-determinant elisa using the mesomark tm assay (fdi, pa). their estimated glomerular filtration rate (egfr) was also calculated. results mesothelin levels correlated between serum and urine samples (pearson's correlation 0.791; p < 0.0001). mesothelin levels were significantly higher in patients with mesothelioma compared to those with asbestosis and/or pleural plaques in serum (4 ϯ 0.9 versus 0.9 ϯ 0.05 nm; p < 0.0001, respectively), in urine (1.9 ϯ 0.5 versus 0.3 ϯ 0.03; p < 0.0001) and in urine following normalization using creatine levels (0.2 ϯ 0.05 versus 0.04 ϯ 0.01). age and egfr were significantly associated with mesothelin levels. conclusion the sensitivity and specificity of mesothelin in urine and in serum were comparable. urine mesothelin may prove to be a useful alternative to serum mesothelin for mass screening of asbestos-exposed individuals. patients undergoing ct coronary angiogram (cta) are often former or current smokers with a high incidence of asymptomatic lung disease. overseas reports show a rate of lung abnormalities ranging from 6.7% to 19%. there are no studies from australia and local factors such as the higher incidence of atypical mycobacteria may influence the rate of benign findings. we are therefore performing a prospective observational study to identify the prevalence and characteristics of incidental lung findings in people undergoing routine cta. methods population: 100 patients undergoing routine cta after informed consent. intervention: radiologist evaluation of lung windows on diagnostic standard workstations. comparator: uncontrolled observational study of consecutive patients. outcomes: primary: prevalence and characteristics of abnormal findings, final diagnosis (clinical judgment, biopsy or long term followup). secondary: number of downstream investigations and costs. results 25 ctas have been studied to date. in 8/25 (32%), abnormalities were noted on lung windows. in 2/25 (8%), there were lung nodules, in 2/25 (8%) there were hilar lymph node abnormalities, in 1/25 (4%), there was hemidiaphragm elevation and in 3/25 (12%) there were pleural plaques (data collection ongoing with study closure expected in february 2008). conclusions preliminary data indicate a substantial number of incidental pulmonary findings from cta; full results will be presented. further analysis is required to determine the impact (benefits, costs and harms) that may result from the concurrent examination of lung windows at routine cta. aim increased levels of nitrogen oxides (nox) and inflammatory markers have been found in bronchoalveolar fluid of lung cancer (lc) patients, but have not been investigated in exhaled breath condensate (ebc).the aim of this study was to compare nox and total protein levels in ebc of lc patients with control subjects. methods ebc was collected during tidal breathing through a glass collection device cooled to 4°c. ebc nox concentrations were measured by a fluorescent modification of the greiss method. total protein in ebc was determined employing the bicinchoninic acid (bca) assay. ebc nox data were log transformed. all data were analysed using anova and expressed as mean ϯ sem. results a total of 88 control subjects and 54 patients with primary lc were recruited. nox and protein concentrations are shown in table 1 . there was no significant difference in ebc nox levels (p > 0.05), but in total protein there was a significant difference between lung cancer patients and all control groups (p = 0.04). conclusion significantly increased ebc total protein levels were found in patients with lung cancer. these data suggest that protein mediator secretion or vascular leak may be present in those with lung cancer. future studies will focus upon the identification of these proteins. methods in this two stage case-control study 446 lung cancer cases and 484 healthy smoker controls were recruited. 180 genetic markers (snps) implicated in lung cancer were screened in our test cohort of 439 smokers and ex-smokers. 30 snps whose genotypes (co-dominant or recessive model) were associated with either the healthy smokers (protective) or lung cancer (susceptibility) phenotype were identified. after genotyping this 30 snp panel in a second cohort of 491 subjects 19 snps were chosen and assigned a simple composite genetic score that was combined with scores for age, history of copd and family history of lung cancer, weighted according to our multivariate regression analysis (n = 930 total subjects). the lung cancer risk score was linearly related to the likelihood of lung cancer with odds ratios (referenced against the lowest score quintile) ranging from 1 to 29 in the highest quintile. on receiver operator curve analyses, the auc was 0.78 and the frequency distribution showed bimodal separation between healthy smokers and lung cancer cases. utility of the score was not affected by effects of age, smoking history or lung function. we suggest that genetic data may be combined with other risk variables to define smokers or ex-smokers at risk of lung cancer for targeted interventions such as smoking cessation and early detection of lung cancer. supported by health research council, nz. conflict of interest yes. tp 144 v aiyappan 1 , a graham 2 1 department of medicine, maroondah hospital, melbourne, australia, and 2 the new disease-modifying anti-rheumatic drug (dmard) leflunomide is being used increasingly to treat inflammatory arthritis. its association with interstitial lung disease needs to be considered before combining it with methotrexate. case report a 73-year-old male who was known to have rheumatoid arthritis and was on methotrexate was admitted with progressive dyspnoea and malaise. he had been recently started on leflunomide. investigations revealed interstitial lung disease and acute renal failure. he improved on conservative treatment (stoppage of disease modifying drugs (dmard), iv fluids and steroids). review of literature an epidemiological study by suissa et al has suggested that there is increased risk of ild associated with leflunomide in patients with a history of ild or methotrexate use but they attributed this to channelling bias. there has also been a report of leflunomide associated with iga glomerulonephritis.by this presentation we aim to increase the awareness of this entity. we also suggest that any patient who is started on combination dmard (i.e. methotrexate and leflunomide) should have a baseline chest x-ray and be monitored for development of interstitial lung disease. conclusion we are reporting the first ever case of interstitial lung disease and glomerulonephritis (in the same patient), due to usage of leflunomide. this entity needs to be thought about in any patient on combination dmards. background bone morphogenic protein receptor ii (bmpr-ii) mutations are associated with pulmonary artery hypertension. failure of the growth inhibitory effects of bmp may contribute to vascular obliteration and remodelling leading to pulmonary artery hypertension (pah) [1] . pah has been observed following venous thrombembolic disease (vte), including pulmonary embolism (pe) and deep venous thrombosis (dvt) [2] . local markers of the pulmonary vascular endothelium rather than traditional markers of thromobophilia are thought to be involved [3] . methods plasma was collected from age and gender matched participants within 24 hours of diagnosis of vte and prior to commencement of warfarin therapy. plasma samples were hybridized to individual human cytokine antibody arrays, to detect protein levels of bmp2, bmp4 and bmpr-ii. results bmp2 and bmp4 levels were higher in patients with dvt than pe. no difference in the bmp level was observed between patients with pe and controls. soluble bmpr-ii receptor was lower in patients with pe than in controls or patients with dvt. conclusion in patients with pulmonary artery stress during the time of a pe the bmpr-ii receptor is reduced, which may predispose patients to vascular remodelling and obliteration. the bmp 2 and 4 levels are reduced at the same time, suggesting a possible overriding regulatory mechanism. the physiological role of bmp's and bmp receptors in patients with vte warrants further investigation. historically, cyclophosphamide has had a variable role in interstitial lung disease (ild), the rationale for its use based on the benefit seen in vasculitis and scleroderma, its rapid effect and low toxicity profile. in patients with severe progressive ild a rapidly effective, well-tolerated agent is desirable. for this reason a treatment protocol for the use of intravenous (iv) cyclophosphamide was implemented at our hospital. aim to review the indications, duration, tolerability and effect of intravenous cyclophosphamide in ild patients following the introduction of a treatment protocol. methods records of 92 patients [dlco was 40 ϯ 15% and fvc 61 ϯ 20%] completing a course of iv cyclophosphamide during 2005-6 were reviewed (excluding patients with systemic sclerosis). data covering 18 months prior to and following treatment were collected. comparative analysis of paired pulmonary function data 6 months before and after treatment was performed. 61% had underlying autoimmune disease. results primary treatment indications included progressive disease(n = 67); severe disease (n = 16); suspected vasculopathy (n = 11); bridging therapy to transplantation (n = 10); and accelerated decline (n = 5). patients received 600 mg/m 2 [mean dose 1152 ϯ 165 mg, median number of pulses 6 (1-12)]. patients with paired pulmonary function data had a difference in median change in dlco% predicted from -15.6% (-95.4 to 29.9%) before treatment to +4.25% (-17.3 to 73.9%) following treatment (p < 0.0001). this remained significant with exclusion of vasculitis, or any autoimmune disease, and independent of prior immunosuppression. therapy was well tolerated (4 withdrew from treatment, 5 deaths within 1yr, none directly related to treatment). conclusion iv cyclophosphamide is well tolerated, and associated with functional stability or improvement in the majority of patients. it remains a viable treatment alternative for consideration. pulmonary hypertension is common in interstitial lung disease (ild) and associated with a poor prognosis. as the gold-standard test, right-heart catheterization (rhc) is invasive, and resource-limited, reliable non-invasive measures of ph are needed. methods all ild patients referred for rhc during 1997-2007 were included (n = 95; 54 male; age 56.5 ϯ 12 yrs). all patients had concurrent echocardiography (tte) and pulmonary function. the relationship of rhc mean pulmonary artery pressure (mpap) to tte variables, pulmonary function, exercise capacity, as measured by six minute walk testing (6mwt, n = 58) and brain natriuretic peptide (bnp, n = 36), was examined. case a 65 year old male, non-smoker for 25 years, retired professor of anatomy (had chronic exposure to embalming fluids, formaldehyde, phenol, antifungal and other solvents, for 20 years) presented with chronic cough and phlegm production. these symptoms were worse at night (waking him several times) and early morning. his pulmonary tests were stopped due to persistent cough. a chest x-ray revealed features of longstanding interstitial lung disease. the hrct revealed widespread subpleural interlobular thickening, worse at bases, in keeping with idiopathic pulmonary fibrosis (ipf). there was minimal fibrosis and honeycombing, but no groundglass opacification, large bullae, pleural calcification or pleural plaques. however, there was associated bronchiectasis at the lung bases considered to be due to traction. the ba lavage showed 50% macrophages, 7% neutrophils, 3% lymphocytes, and 40%, eosinophils and no infection. the patient declined to have a lung biopsy. as per his past x-rays, the duration of his ipf is a little over one year. he maintains that his symptoms started only after starting irbesartan (irb). introduction transbronchial lung biopsy (tbb) has a variable and unpredictable diagnostic yield in sarcoidosis. we hypothesized that the extent and pattern of parenchymal disease on ct would predict the likelihood of a positive tbb. methods data relating to ethnicity, symptoms, pulmonary function and site and results of tbb and bronchoalveolar lavage (bal) from 70 sarcoidosis patients were recorded. all had a ct scan within 6 weeks prior to the tbb procedure. cxr stage was determined from radiology report. ct scans were scored quantitatively for patterns of parenchymal disease (nodular, reticular, consolidation, ground glass and mosaic attenuation) on a lobar basis. results 50% patients had a positive tbb (total 67% of cohort had histological confirmation). symptoms, ethnicity, treatment, lung function and cxr stage were not predictors of a positive biopsy. positive biopsy was associated with higher bal lymphocyte count (p < 0.05) and female gender (p < 0.01). a reticular pattern (p < 0.05) and higher total lung score (excluding da) (p < 0.05) on ct scan predicted a positive biopsy. in those patients with tbb from right lower lobe (53/70) the total rll score on ct was predictive of positive biopsy (p < 0.05). on multivariate analysis gender, bal lymphocytosis and total lung score were independent predictors of a positive tbb (area under roc 0.82). pulmonary arterial hypertension has two histological variants; 'arterial-only pulmonary arterial hypertension' (artpah) and 'pulmonary veno-occlusive disease' (pvod). bosentan, a dual endothelin receptor antagonist, has been found to improve haemodynamics, functional capacity and survival in artpah. however, the response to bosentan in clinically diagnosed artpah is often variable. it was hypothesized that a lack of response to bosentan therapy in clinically diagnosed artpah can be explained by misdiagnosed pvod. aims included to: (1) perform morphometric and qualitative pulmonary vessel analysis on normal controls and cases clinically diagnosed with artpah who had failed bosentan therapy; (2) ascertain if pvod is present within the case group; (3) correlate clinical variables and vessel microanatomy to identify the pathologies driving pulmonary pressure elevation. this study reviewed 14 cases of clinically diagnosed artpah (idiopathic n = 12, associated with scleroderma n = 2), who had failed bosentan therapy and had available lung tissue. controls (n = 6) were obtained from explanted lungs for other causes and a prior transthoracic echocardiogram excluded pulmonary hypertension. vessel morphometry and qualitative analysis was performed with a novel technique of smooth muscle actin immunohistochemistry counterstained with verhoeff's elastin. baseline clinical data were retrieved. we found 86% of cases had pathology confirmed pvod. only 14% of cases had artpah, the original clinical diagnosis. in pvod, significant pathology was present in all vessel types. all vessels had significant smooth muscle hypertrophy. the obstructive, collagenous, pauci-cellular intimal fibrosis of the venules (p < 0.0001) and arterioles (p < 0.0001) was considerably different to the concentric laminar proliferation of smooth muscle observed in the muscular arteries (p < 0.0001) and arterioles (p = 0.001) in artpah. artpah also had muscular artery smooth muscle hypertrophy (p = 0.007). the median time to bosentan failure was shorter in pvod than artpah (290 vs. 657 days). in conclusion, pvod is an under-diagnosed cause of pulmonary hypertension, is commonly clinically misdiagnosed as artpah and may present with a poor bosentan therapy response. finally, pvod is a vaso-occlusive, not a veno-occlusive disease, and is an independent type of pulmonary hypertension, not a subtype of pulmonary arterial hypertension. cutaneous t cell lymphomas (ctcl) are a heterogenous group of lymphoproliferative disorders. they show various clinical manifestations and diverse morphological, histological and immunological characteristics of the malignant cells. they are caused by clonally derived, skin invasive t cells. peripheral t cell lymphomas (ptcl) are generally more aggressive and have one of the lowest overall and failure-free survival rates. because of the rarity of these disorders, diagnosis and treatment remain challenging. this case report describes a 69-year-old woman presenting with progressive dyspnoea and cough, together with a distressing generalized pruritic rash. she was initially treated as left ventricular failure with the rash ascribed to a drug reaction as suggested by initial skin biopsies. the diagnosis was made on a third skin biopsy and flow cytometry of lymphocytes obtained by broncho-alveolar lavage 6 months after presentation. despite an initial response to chemotherapy she succumbed to the disease 20 months after diagnosis. clinical pathways to guide the investigation of suspected pulmonary embolism (pe) have been increasingly adopted by emergency departments (ed) worldwide. compliance with these diagnostic algorithms is critical in ensuring good patient outcomes. this study evaluated the compliance to the clinical pathway used in our ed that combines risk assessment (wells scoring system) with d-dimer test, vq scan or ctpa. the main objectives of this study were to identify those factors which contributed to compliance and to assess patient outcomes. methods a prospective observational study of 239 consecutive patients who underwent investigation for pe in our ed. patient demographics, pathway parameters and patient outcomes at 3-month follow-up were collected. case we report the case of a 37 year old woman who presented to the emergency department with a three day history of dry cough and dyspnoea. the patient was in her third pregnancy at 30 weeks gestation. she had no fever, chest pain or coryzal symptoms. the patient had presented with a right sided spontaneous pneumothorax seven months prior to the current presentation. her past medical history included placental abruption, complicating her previous two pregnancies. her second pregnancy was complicated by placental abruption at 27 weeks and the foetus had not survived. her first pregnancy was complicated by placental abruption at 36 weeks with successful delivery of the foetus. at presentation, significant findings included tachycardia, hypoxemia, tachypnoea and reduced breath sounds over the right side of the chest. chest x-ray demonstrated a large right pneumothorax. a right intercostal catheter was inserted resulting in right lung re-expansion. the catheter was removed three days later. the patient returned to hospital twenty four hours after catheter removal with a recurrent right sided pneumothorax. the patient agreed to surgical intervention involving video-assisted thoracotomy and talc pleurodesis. the patient had no further complications with the pregnancy. she delivered a healthy baby at 38 weeks gestation. discussion spontaneous pneumothorax in pregnancy is rare and there is little evidence to provide guidelines for the management of recurrent pneumothorax in high risk pregnancy. our case illustrates a successful outcome for mother and foetus with surgical intervention at 32 weeks gestation. folfox is currently the standard adjuvant treatment for locally advanced (stage iii) colon cancer and increases disease free survival. its toxicity is well tolerated with common adverse effects being paraesthesia, bone marrow suppression and gastrointestinal disturbance. pulmonary toxicity has rarely been reported. three clinical cases of acute dyspnoea following folfox therapy (2005) (2006) (2007) for stage iii colon cancer are reported. all had an anterior resection followed by 11-12 cycles of folfox. each developed rapidly progressive dyspnoea requiring hospital admission within one week of their last cycle. one patient required invasive ventilation in icu. high resolution computed tomography (hrct) showed bilateral widespread honeycomb pattern with associated ground glass opacification consistent with pulmonary fibrosis. they had reduced lung volumes and gas transfer. transbronchial biopsy and bronchoalveolar lavage in one patient showed an acute eosinophilic pneumonitis. other causes of interstitial lung disease were carefully excluded. all three patients received high dose corticosteroids with one receiving additional cyclophosphamide. the first patient showed complete recovery following an eight week course of corticosteroids, with resolution of the hrct changes and improvement in lung function. the second had symptomatic improvement of dyspnoea, but a persistent moderate reduction in gas transfer. the final patient had persisting radiographic changes and a reduced gas transfer. he remained dependant on ambulatory oxygen 6 months after his initial presentation. these patients' interstitial lung disease appears due to folfox with oxaliplatin being the most likely causative agent. the use of oxaliplatin chemotherapy has increased markedly over the last 3 years and although rare, physicians should be aware of its potential for lung toxicity. lung function testing at baseline, during and towards the end of oxaliplatin treatment should be undertaken and may allow early detection and intervention in cases of pulmonary toxicity. the forced oscillation technique (fot) with broadband signals has been employed relatively rarely in the studies on respiratory mechanics. recent work from our laboratory [1] indicated that the cheek support and the neck angle have minor influence on the impedance spectra around the first antiresonance (far,1), which makes the use of the broadband fot especially attractive in young children. methods we studied 7 healthy children (c; female: 4) and 8 children with bronchopulmonary dysplasia (bpd; female: 3), using multiple-frequency fot between 8 and 256 hz superimposed on spontaneous breathing. results groups c and bpd did not differ in age ( lung function impairment is common in children with cardiac defects associated with increases in pulmonary blood flow/pressure. to investigate the development of bronchial hyperreactivity (bhr), an aorto-caval shunt was created in a model of precapillary pulmonary hypertension. surgical shunt repair was performed to assess the reversibility of bhr. methods 26 rats were divided into 3 groups: group c (n = 10) with sham surgery, group s (n = 8) where an aorto-caval shunt was created (follow-up 4 wks), group r (n = 8) with aorto-caval shunt but surgical correction of the shunt at 4 wks (follow-up 8 wks). in all animals, respiratory input impedance (zrs) was measured at baseline and following increasing doses of methacholine (mch 2, 4, 8, 12 mcg/kg). airway resistance (raw), inertance, tissue damping (g) and elastance were estimated from the zrs spectra by model fitting. measurements were repeated in all animals at 4 wks and at 8 wks for groups r and c. results there was a significant increase in raw and g in group s and rat 4 wks at baseline and following mch ( fig.) which was reversed after surgery. to characterize the factors contributing to lung function impairment following cardiopulmonary bypass (cpb), functional residual capacity (frc), lung clearance index (lci) and respiratory mechanics were measured in children with pulmonary hypoperfusion (tetralogy of fallot, tof n = 12) and hyperperfusion (ventricular septal defect, vsd n = 12) undergoing surgical repair of congenital heart disease. methods frc and lci were measured using a sf6 washout technique and respiratory mechanics using a low frequency oscillation technique in the perioperative period. results while chest opening led to a significant improvement of lung volumes and respiratory mechanics in all patients (p < 0.001), a reduction in pulmonary blood flow during cpb decreased lung volumes and airway resistance in parallel but significantly more in children with tof compared with those with vsd. re-establishing pulmonary blood flow during cpb improved respiratory function particularly in children with tof ( figure) . conclusions sternotomy had a great impact on lung function with parallel improvement in alveolar recruitment, ventilation inhomogeneity and airway resistance. in contrast, onset of cpb led to lung function impairment with a significant drop in frc especially in children with pre-existing hypoperfused lungs. this suggest that pulmonary blood flow enhances alveolar stability through a tethering effect on the alveolar walls. children with advanced lung disease being considered for lung transplantation are likely to spend disproportionately longer periods on transplant waiting lists before appropriately sized donor organs become available. these longer waiting times reflect the lower organ donation rates seen in children; rates that are significantly lower than those reported in the adult population. we describe two children with advanced lung disease who deteriorated whilst on the waiting list for lung transplantation, and in the absence of appropriately sized donor lungs, underwent lobar lung transplantation. methods we describe the clinical course of two children, aged 9 and 13 years old, with advanced lung disease secondary to post-mycoplasma obliterative bronchiolitis and cystic fibrosis-associated bronchiectasis, respectively. results both children received a "cutdown" bilateral lobar transplant from two oversized adult brain-dead organ donors. in both cases the transplant operation involved implantation of the right middle and upper lobes, and of the left upper lobe from the donor. conclusion given the low organ donation rates in children, and in the absence of appropriately sized donor lungs, novel strategies such as lobar transplantation must be considered, particularly when children continue to clinically deteriorate whilst on the lung transplant waiting list. data from the west australian adult outcomes of extreme preterm birth study suggest that adult survivors of bronchopulmonary dysplasia (bpd) may be left with functional and structural pulmonary abnormalities, most notably emphysema. animal data suggest that the antenatal administration of corticosteroids may adversely affect lung development. we therefore sought to determine if maternal variables, including administration of corticosteroid, could predict emphysema severity in adulthood. methods bpd subjects (birthweight < 1500 g and oxygen dependence at 36 weeks post-menstrual age) born prior to 1988 were identified and recruited prospectively via the statewide neonatal follow up program as previously described. pulmonary function tests and thin selective inspiratory and expiratory computerised (ct) images were acquired and scored for emphysema severity (voxel index (%)). the obstetric history was obtained from retrospective review of case notes. results 21 adults (12 females, aged 18-34) were studied, 2 declined ct. all subjects had abnormal ct findings. fifteen (79%) had areas of emphysema. emphysema score and fev1 were not influenced by the administration of antenatal corticosteroids, indication for delivery, maternal age or presence or absence of chorioamnionitis. conclusion maternal factors, including the administration of antenatal corticosteroids, do not predict the long term respiratory outcome of bpd. the factors determining the severity of emphysema in this group remain unknown. the prevalence of childhood asthma is high in the torres strait. children have generally more severe asthma and asthma knowledge is poor. however, there is no culturally appropriate asthma education program for these children. we are conducting a randomized controlled trial to examine the additional benefits of an education intervention by indigenous health care workers (hcw) on asthma outcomes. we describe the study's objectives, design and baseline measurements. methods children with wheeze were reviewed by two paediatric respiratory physicians using a standardized protocol; children with asthma were eligible. after obtaining informed consent children were randomly allocated to: (1) three additional asthma education sessions with a hcw; or (2) no additional education from a hcw. trained hcws carried out the education sessions using culturally appropriate tools. primary outcome was the number of unscheduled hospital/doctor visits due to asthma exacerbation. all children were re-assessed at 12 months. results we enrolled 113 children aged 1 to 17 years, 81% were torres strait islanders and 12% aboriginal and torres strait islanders. the clinical spectrum of asthma was: 51% infrequent episodic asthma, 22% frequent episodic asthma and 27% chronic asthma. eighteen percent of the children knew what a written asthma action plan was; 8.5% had one. carers' assessment of knowledge of medications showed that 52% could not name any asthma medication used by their child, 40% could not explain dosage, and 67% could not explain how beta2 agonists worked. conclusions asthma knowledge and possession of asthma action plans in this cohort is poor at baseline. there is substantial room for improvement and additional asthma education by hcws potentially has significant benefits. impulse oscillometry system (ios) measures respiratory function during normal breathing by transmitting mixed frequency rectangular pressure impulses down the airways and measuring reflected pressure. computer analysis calculates respiratory impedance and its components, airways resistance and reactance, at a range of frequencies from 0.1 hz to 150 hz. no previous australian normative data exists. the ios software generates predictive normal values for each of the parameters measured including total airway resistance (r5), the proximal airway resistance (r20) as well as peripheral capacitive reactance (x5). however, they are based on german data. methods cross-sectional study of 100 community dwelling adults, with 10 males and females per 10-year cohort. inclusion criteria: age range 25-74 years, apparently good respiratory health. exclusion criteria: smokers, asthmatics and others with acute or chronic respiratory disease. both ios and spirometry were conducted on all participants. results australian predictive normal equations have been generated and compared to the current published equations. the ios parameters have been correlated with the spirometric data. results have been analysed by gender, age, height and weight and compared with the predictive normal values for each parameter provided by the german manufacturer of the ios instrument. analysis includes calculation of mean range, and lower limit of normal. conclusions a preliminary set of australian predictive equations have now been produced for the ios. these have been compared with international equations. ios has potential application in a range of respiratory disease states and in population screening for occupational health (e.g. mining, & high dust load environments). supported by phc red. rationale although clinical practice guidelines for both asthma and copd recommend spirometry for diagnosis and monitoring, beneficial effects on the management of chronic respiratory diseases in general practice have not been established. we hypothesized that spirometry would improve health outcomes compared to usual care. methods we are conducting a single masked rct with 3 arms: group a receive 3 monthly spirometry and followup, group b receive spirometry before and after the trial and group c usual care. 45 general practices were recruited though divisions of general practice in melbourne. invitations were mailed by 31 of these practices to patients who had been prescribed inhaled medications during the previous 6 months. participants returned respiratory and generic quality of life questionnaires and an asthma score card. groups a and b were tested on a micromedical turbine spirometer following ats/ers guidelines. results 351 eligible patients (275 adults, 50 children aged 8-13 and 26 youths aged 14-17 years) entered the trial. 122 were randomized to group a, 134 to group b and 95 to group c. the mean (sd) age of adult participants was 54.3 (12.7), children 10.3 (1.7) and youths 15 (1.1) years. there were 130 males and 221 females. the adults were highly symptomatic in the previous 12 months: 82% reporting wheeze, 50% chest tightness on waking, 74% shortness of breath on exertion, 61% nocturnal cough, 46% morning cough and 75% sputum. symptoms of chronic bronchitis were reported by 39% of adults and a diagnosis of copd by 19%. asthma was reported by 84%, confirmed by a doctor in 96% and 55% had experienced an attack in the last 12 months. only 35% had a written asthma action plan. 37% of adults had ever visited a hospital ed and 28% had been admitted. conclusion it is possible to recruit asthma and copd patients from general practice and to randomize them to spirometry or usual care. whether spirometry is associated with fewer symptoms, changes in medication, uptake of action plans or improvement in lung function or quality of life requires further followup. supported by nhmrc. s shah 1 , jk roydhouse 1 , b toelle 2 , s sawyer 3 , c jenkins 2 for the pace australia management committee 1 university of sydney, 2 woolcock institute of medical research, sydney, nsw 2006, and 3 royal children's hospital, melbourne, vic 3052 it is widely held that recruitment of general practitioners for research can be challenging. in this paper, we discuss the recruitment experience from a current study evaluating the impact of an educational asthma intervention on patient outcomes. our aim is to describe the two different strategies utilized to date: (1) in-house through an academic department of gp and (2) outsourced to a private gp organization. methods initial interest was generated through faxes, presentations at gp divisional meetings and newsletter advertisements. gps who expressed interest were visited by project staff to discuss the study further. a major difference was recruiting one gp per practice in the first strategy versus multiple gps per practice in the second strategy. to assess the strategies, we examined participant characteristics, number of gps recruited and number retained. results participant characteristics: under both strategies, 30% of recruits had trained in asia and 54% were women. the first strategy recruited more gps who spoke at least two languages at home (85% vs 42%) and the second strategy recruited more recently graduated gps (58% vs 50%). recruitment: the first strategy recruited 35 gps over 6 months and the second recruited 34 gps over 3 months. retention: 19 gps (54%) from the first strategy stayed in, compared to 29 (85%) from the second. conclusions whilst absolute numbers of gps recruited were similar, retention was much higher under the second strategy. recruitment in primary care is difficult and requires a range of approaches which need to be re-evaluated and adapted as necessary during the course of the study. supported by the australian government department of health and ageing. bronchiectasis is a heterogeneous condition with a large number of causative factors and range of symptoms. the classification of this condition is often confusing and hard to remember. the aim of this study was to classify non-cf bronchiectasis into different clinical phenotypes. methods 178 consecutive patients with non-cf bronchiectasis confirmed on high resolution ct scanning had a detailed clinical, spirometric and laboratory assessment performed by a respiratory physician (pk/mf/pw) and were then followed up for an average of 9 ϯ 4 years (mean and sd) for a total of over 2000 reviews. results 160 of the 178 patients (90%) could be classified as belonging to 3 phenotypic groups; 1) bronchiectasis arising in childhood, 2) bronchiectasis occurring in smokers and 3) bronchiectasis occurring in the elderly. each group had different features which are listed in the there are few data on the long term outcomes of treatment for tuberculosis (tb) by directly observed therapy (dot) in low-incidence settings. the aim of this study was to assess the incidence of recurrent tb in nsw. methods data linkage was performed within the nsw department of health tb notifications database to identify cases that had more than one tb notification between 1994 and 2006. recurrent tuberculosis was defined to include all patients with two or more culture positive episodes at least 6 months apart, where patients had received at least six months treatment for the initial episode. in cases where data contained within the notification details was not sufficient to allow us to distinguish between true cases of recurrent disease, duplication notification for the same episode or persistent disease after incomplete treatment, additional information was obtained from the area tb coordinator. results there were 5723 tb notifications between 1994 and 2006 with 3731 being culture positive. 15 cases of recurrent culture positive disease after completed treatment for the first episode were identified (recurrence rate: 0.4%). conclusions in a population with a low tb incidence, treatment of active tuberculosis with dot results in a very low rate of disease recurrence over a long period of follow-up. support nhmrc ccre in respiratory and sleep medicine. introduction rhinoviruses (rvs) are the major cause of viral-induced exacerbation of asthma. to date, the molecular mechanisms of rv pathogenesis are not understood. recent findings suggest that rv pathology may involve host cell nucleocytoplasmic trafficking, inhibiting key cell functions such as transcription and translation. the study aims to investigate the mechanism of rv 3c protease nuclear trafficking. methods hela cells were infected with rv or transfected with plasmids and cellular localization of 3c analysed at various times thereafter using immunofluorescent confocal microscopy and western blotting with specific antibodies. results 3c protease was predominantly present in nuclei of rv infected cells up to 6 hours after infection, becoming increasingly cytoplasmic thereafter. the nuclear membrane of infected cells became progressively indistinct with time. using a specific inhibitor we also found that 3c utilizes the crm-1 nuclear export pathway. 3c was predominantly in the form of 3cd in both cytoplasm and nucleus of infected cells; mature 3c protease was also detected from 6 hours after infection. deletion analysis indicats that the nuclear localization domain and a nuclear export signal are most likely to be present within the n terminal 64 amino acids. the nuclear export signal is inhibited in the full length protein, via an unknown mechanism. conclusion our data suggest that 3c and 3cd proteins localize to the nucleus in infected cells where they may play a key role in rv pathogenesis by disrupting cellular transcription and the nuclear transport machinery. chronic necrotizing pulmonary aspergillosis (cnpa) is a relatively uncommon, sub-acute, locally destructive process due to aspergillus invasion of the lung. the incidence and prognosis of cnpa are poorly described. case report we present a case of cnpa in a patient on intermittent low dose steroid therapy and recurrent refractory exacerbations of chronic obstructive pulmonary disease (copd).the patient presented with worsening shortness of breath and productive cough requiring recurrent inpatient admissions. human influenza virus is found to bind preferentially to saa2,6gal receptors found in the upper respiratory tract, while avian viruses bind to saa2,3gal receptors expressed in lower airways. this is thought to affect the ability of transmission to humans. our aim was to study the ability of avian and human influenza strains to infect bronchial epithelial cells and relate this to levels of the sialic acid receptor expression. methods calu-3 cells were used as a proximal airway cell and a549 were used as distal airway cell. human primary bronchial epithelial cells (pbecs) were obtained from healthy, asthmatic, and copd volunteers by endobronchial brushing. epithelial cells were stained with sambucus nigra lectin that binds saa2,6gal receptor, and maackia amurensis lectin ii that binds to saa2,3gal. the cells was analysed by flow cytometry. human influenza a/h3n2/wellington strain and low pathogenic avian influenza a/h11n9/sandpiper were chosen and were used at an moi of 0.005 to infect cells. the supernatants were harvested at 48 hr post infection, of which was then analysed by plaque assay for virus replication. results the calu-3 showed greater expression of saa2,6gal linkage than saa2,3gal linkage, and a549 displayed slightly higher expression of both receptors compared to pbecs. despite this human and avian influenza virus replicated to similar titre at 15,000 pfu/ml in both cell lines, but showed low replication in pbecs. background treatment of community-acquired pneumonia remains based on 'best guess' empiric algorithms because of the poor utility of current pathogen tests. furthermore our ability to stratify patients into risk groups is crude at best, relying on scores such as the pneumonia severity index or the curb-65 have major limitations. we have been slowly improving real-time pcr assays for pneumococcus as a clinical tool in patients with pneumonia. methods building on previous research we assesed two targets in the autolysin (lyta) gene and the pneumolysin (ply) gene of s.pneumoniae using the lightcycler instrument and fluorescence resonance energy transfer (fret) probes. all common s. pneumoniae serotypes were detected while other bacteria and viruses were not. the lyta target had the best sensitivity with a detection range between 21 ng to 21 fg. both assays were then applied to whole blood samples from 400 adult patients with community-acquired pneumonia, all of whom had blood cultures prior to antibiotic administration and urinary antigen testing for s.pneumoniae. the lyta pcr had the best performance characteristics with a sensitivity more than twice that of blood cultures in the clinical samples. most pcr+ve/culture -ve patients had positive urinary antigen tests. there was clinical evidence that urinary antigen +ve/ pcr -ve patients were false +ves. most significantly there was a strong correlation between quantitative bacterial count and clinical outcome. conclusions real-time quantitative pcr for pneumococcus has significant potential as both a diagnostic and therapeutic tool in patients with pneumonia. the pitjantjatjara lands are situated in the north-western corner of south australia, occupying an area of over 120 000 square kilometres with a population of approximately 3000. the population lives in small communities or homelands, and there is a high level of mobility between this region and other aboriginal communities in south australia and the northern territory. nganampa health council provides all health care services to the region. specialized support for tb control comes from both the south australia tb service based at royal adelaide hospital as well as a centre for disease control in alice springs. the prevalence of tuberculosis (tb) in this predominantly indigenous community is thought to be significantly higher than the national rate. there are considerable challenges in detecting and managing tuberculosis, relating to the community's geographical remoteness, migration of populations and access to health services. the aims of this study are to quantify the prevalence of tuberculosis in the pitjantjatjara lands, and describe the significant barriers to tb diagnosis and treatment. methods a retrospective study of all diagnoses of tuberculosis within the pitjantjatjara lands in the period 1995-2006. outcomes include measures of tuberculosis diagnosis, the rates of completed tb treatment and rates of tuberculosis drug resistance. the study will draw conclusions about the reasons for high levels of tb prevalence in this community and identify barriers to effective tuberculosis treatment. conflict of interest no. patients admitted to hospital with a diagnosis of community-acquired pneumonia (cap) are usually treated with intravenous (iv) antibiotics irrespective of pneumonia severity. available guidelines vary in recommended timing and indications for switching to oral antibiotics. aim to examine the patterns of antibiotic choice and delivery method (iv, oral and time to switch) in patients admitted with cap. methods a retrospective chart review of admissions to the respiratory unit over a 12-month period with a diagnostic-related group (drg) coding of pneumonia. 41 charts were reviewed. data collected included patient demographics, clinical features at presentation (temperature, pulse rate, respiratory rate, bp, oxygenation), initial investigations, initial antibiotic regime, time to change (iv to oral), subsequent antibiotic regime and duration, time to defervescence, length of stay and outcome. pneumonia severity was calculated using the revised british thoracic society system (curb-65), score ն 2 = severe. results 3 patients were excluded due to incorrect coding. of the 38 patients, age was 50 ϯ 21 (mean ϯ sd) yrs and 25 (66%) were male. 28 patients (74%) were febrile at presentation and the median curb-65 score was 1 (range 0-4). 37 patients (97%) received iv antibiotics. the curb-65 score was 0 or 1 (non-severe) in 25 patients and 22 of these patients received a combination of iv ceftriaxone and a macrolide. time to defervescence was 2.9 ϯ 2.3 days. time from defervescence to switching to oral therapy was 3.4 ϯ 2.8 days. in non-febrile patients, time to switch was 4.7ϯ4.3 days. length of stay was 8.7ϯ13.0 days. conclusions the time between defervescence and switch to an oral regime was relatively long, possibly contributing to an increased length of stay. many patients received ceftriaxone even with a curb-65 severity rating of 0 or 1. implementing local guideline-based treatment protocols may reduce length of stay. ultrasonic flow sensors can determine flow, volume and molar mass (mm) of the gas flow simultaneously. during tidal breathing the expired molar mass curve can be used to compute co2 over expired volume and a capnography index (cpi) can be computed. the relationship between cpi and copd classification according to gold was investigated. methods prospective, controlled trial. consecutive patients who underwent routine lung function were enrolled to participate in a tidal breathing test using an ultrasonic flow sensor. each test consisted of three tidal breathing recordings of 60 sec. flow, volume and molar mass were measured at 200 hz and data were acquired using prototype wbreath data acquisition software. mean expirograms (mm over volume) were computed and the measurements were analyzed to determine the slope of exhaled phase ii (s2), the slope of phase iii (s3) and the relationship between s2 and s3 (cpi = s3/s2). gold stages were determined from the lung function results and the ers predicted values. results 53 volunteers participated in the study with a mean age of 62 (sd 14), 23 were male, mean bmi 26 (sd 5), 17 had never smoked. the mean pack/year smoking history was 38. there was a clear relationship between gold stage and cpi: gold stage 'normal' had a mean cpi of 5.5 (sd 3.7, n = 21), stage 'severe' had a mean cpi of 13.7(sd = 3.9, n = 7). conclusion computation of cpi based on tidal breathing analysis using an ultrasonic flow and mm sensor correlates well with gold stages. it may therefore be possible to use a simple tidal breathing test to determine the severity of airways disease. background osa is common in tetraplegia and appears within weeks of injury. although cpap treatment is efficacious in able-bodied subjects, case series suggest that cpap is poorly tolerated in tetraplegia. no prospective study has examined cpap efficacy or adherence in tetraplegia. aim to determine the feasibility of cpap use to treat osa following acute tetraplegia. methods all acute admissions who consented and fulfilled the inclusion and exclusion criteria underwent full, portable polysomnography. those found to have an apnoea hypopnoea index of >10 events per hour (osa) were offered cpap, delivered via an auto-titrating device. results to date, 25 patients have been admitted (11 excluded, 3 refused consent). no significant, adverse events have been observed. two patients did not have osa. of the nine with osa, four are mid-study, two had incomplete follow-up (1 returned to uk and 1 refused 3 month assessment), two adhered with cpap and one did not due to severe, pre-existing nasal obstruction. preliminary analyses suggest that those who adhered to cpap had a marked reduction (80% compared with 10-40%) in sleepiness and a greater reduction in the functional outcomes of sleepiness compared to either those without osa or who were unable to use cpap. patient accrual, recruitment and completion rates are consistent with our initial estimates. study recruitment will be completed by end-october 2007. conclusion initial data suggest that auto-titrating cpap is a feasible treatment for osa in acute tetraplegia. these data will be used to finalize planning for a multi-national, multi-centre randomized controlled of therapy. this research was supported by the transport accident commission. visual recognition of cyanosis is an important clinical activity. cyanosis recognition is affected by lighting colour and there is anecdotal evidence that people with significant colour vision deficiencies (cvds) have particular difficulty. studies to date have centred on the colour change with oxygenation of isolated blood but it is not clear how this extrapolates to cyanotic patients in vivo. methods ten patients known to be chronically hypoxaemic and showing signs of cyanosis were recruited from the chronic respiratory program. ten normal subjects were recruited as controls. the spectral reflectances of their lips, nail beds and palm creases were measured using a topcon sr-3 telespectroradiometer. the patients were measured at rest and after exercise to lower their saturation by 5-10%. the chromaticities were calculated and plotted. results both groups showed a spread of colours but they fell into two distinct ranges. the colour difference between the groups lies very close to the colour confusions made by congenital cvds. within the cyanosed group, the colour shift was not tightly related to decreasing oxygen saturation. this is most likely due to interpersonal factors such as pigmentation and vascular perfusion that affect colour and the difficulties in measuring the colour of heterogeneous anatomical features. conclusions these results quantify the anecdotal difficulties in detecting cyanosis and suggest that observers with cvd would have problems recognizing the condition. the photographs obtained from this study will be used to compare the ability of subjects with and without cvd to detect cyanosis. supported by the nsw ambulance service. baroreflex sensitivity is depressed in osa patients during sleep but effects during wakefulness are less clear. we have now examined relationships between awake brs and severity of sleep disordered breathing (sdb). methods immediately prior to overnight polysomnography, continuous (5 min) beat-to-beat arterial blood pressure was measured via finger plethysmography (portapres) and heart rate via ecg in 20, supine, normotensive, untreated osa patients (17 males; age: 49 ϯ 15 years (mean ϯ sd); bmi: 26 ϯ 11 kg/m 2 ). spontaneous baroreflex sensitivity (brs) was calculated using the sequence technique. sdb was characterized as apnoea hyponoea index (events/hour) and arousal index (ai). data were analysed via mathematical modelling and unpaired t test. results brs fell with increasing ahi. patients with ahi > 30 events/hour (n = 9) had a significantly lower brs (8.1 ϯ 1.5 ms/mmhg) than those with ahi < 30 events/hour (19.8 ϯ 8.7 ms/mmhg, p < 0.001). brs was negatively related to both ahi and ai via fitted exponential functions (r 2 = 0.45 and 0.70, respectively). it is hypothesized that the analysis of morphology of the ecg waveform in combination with the heart rate patterns could lead to the possibility of detection of the start and duration of apnoea/hypopnoea events and consequently estimation of the apnoea-hypopnoea index (ahi). to the authors' knowledge the published ecg based algorithms for detecting sleep disordered breathing are only capable of minute by minute analysis rather than detection of individual respiratory events. methods changes to ecg parameters were investigated during respiratory events with no distinction made between apnoea and hypopnoea events. 632 isolated respiratory events and 1264 controls of identical duration were obtained from 7 polysomnographic studies, using a randomized procedure. features such as the r wave amplitude, t wave amplitude, qrs area and the r-r interval were extracted from the 2 lead ecg. a number of physiological predictors based on these features were generated. a logistic regression model was used to investigate the association between the predictors and true events, using the statistical software, stata. results univariate and multivariate analyses were performed. three multivariate models were developed; heart parameters only, ecg waveform morphology parameters only and the combinations of the two. the area under the receiver operator characteristic curves (auc) for these models were compared. the best results were obtained with the combination of morphology and heart rate parameters (auc = 0.8858 (0.0078 (sd))) compared to the morphology (auc = 0.8169 (0.0121 (sd))) and heart rate (auc = 0.7195 (0.0103 (sd))) models. the multivariate analysis has shown encouraging results indicating that an algorithm using a combination of heart rate and ecg morphological parameters could potentially be constructed that would enable the determination of individual respiratory events and subsequently an ahi. supported by the arc. introduction sacin and scond are measures of ventilation heterogeneity in acinar and conducting airways, derived from analysis of mbnw. maintaining tidal volumes of 1 l at 9-11 breaths/minute (bpm) is impossible for some. our aim was to examine the effect of different tidal volumes on sacin and scond in normals and asthmatics. methods 10 normals (23-41 yrs) and 12 asthmatics (21-63 yrs) underwent mbnw at tidal volumes of 500 ml at 20-23 bpm, 1 l at 9-11 bpm, and 2 l at 5-7 bpm. scond and sacin, were determined from the normalized phase iii slopes of breaths between turnovers (cumulative ventilation/frc) 1.5 & 6. results the mean ϯ sd %predicted fev1 was 97.3 ϯ 17% in normals and 88 ϯ 11% in asthmatics. in normals, sacin at tv of 0.5, 1 and 2 l were 0.195 ϯ 0.105 l -1 , 0.095 ϯ 0.036 l -1 and 0.058 ϯ 0.031 l -1 , respectively (p = 0.0003, anova), while scond were 0.098 ϯ 0.047 l -1 , 0.042 ϯ 0.021 l -1 and 0.029 ϯ 0.014 l -1 (p = 0.0002), respectively. in asthmatics, sacin were 0.440 ϯ 0.195 l -1 , 0.181 ϯ 0.087 l -1 and 0.100 ϯ 0.047 l -1 , respectively (p < 0.01), while scond were 0.204 ϯ 0.111 l -1 , 0.068 ϯ 0.037 l -1 and 0.031 ϯ 0.013 l -1 , respectively (p < 0.0001). conclusion increasing tidal volume while maintaining the same minute ventilation during mbnw led to large decreases in scond and sacin in both asthmatics and normals. this may be due to reduced inter-regional differences in specific ventilation with greater tv. the log-log relationship between sacin and tv allows an adjustment to be made for variations in tidal volume. funding crc for asthma and airways and nhmrc project grant #547346. dj smith 1 , k bowden 2 , t lloyd 2 , j coucher 2 , l garske 1 1 respiratory medicine, and 2 radiology, princess alexandra hospital, brisbane, australia introduction we have shown diaphragmatic flattening and decreased diaphragmatic excursion qualitatively assessed on ultrasound is strongly predictive of dyspnea severity and lower lung inflation in patients with pleural effusion. we sought to quantitatively measure diaphragm length and movement and determine how closely these are related to dyspnea severity and lung inflation. methods patients with unilateral pleural effusions had ct imaging of their diaphragm during a measured inspiratory capacity manoeuvre. maximal sagittal length was measured at tlc, and frc. patients had a baseline dyspnea index (bdi: 0-12) and respiratory function measured. results 4 patients with unilateral effusion (all right side; 3 malignant mesothelioma, 1 inflammatory) had a mean (sd) bdi of 5.5 (2.89), and tlc of 74% (3.91) predicted. the right diaphragm on the side of the effusion tended to be shorter than the left at frc (p = 0.08), and had a trend to reduced shortening with inspiration (p = 0.08). conclusions the right diaphragm is known to be longer than the left in health. the strong trend to a shorter and less mobile right diaphragm associated with effusion suggests this is a potential mechanism for dyspnea. further recruitment will enable correlation between bdi, tlc and diaphragm length and mobility. 4) ) that was slightly worse than an able bodied, control population (17.9 (3.1)), but better than an able-bodied population with untreated osa (14.5 (3.6)). the mapi predicted that 14% of the sample were likely to have osa. these data will be complimented by full sleep studies to be performed at the participants' homes in late 2007, early 2008. conclusion our interim data suggest that the rate of subjective sleep complaints are not substantially different in the population with tetraplegia compared with the able-bodied. this research was supported by the victorian neurotrauma initiative. it has long been assumed that the ventilation heterogeneity associated with lung disease could in itself affect the measurement of carbon monoxide transfer factor. the aim of this study was to investigate the potential estimation errors of carbon monoxide diffusing capacity (tlco) measurement that are specifically due to conductive ventilation heterogeneity. we induced conductive airway ventilation heterogeneity in 35 never-smoker normal subjects by histamine provocation, and related the resulting changes in ventilation heterogeneity (derived from the multiple breath washout test) to corresponding changes in diffusing capacity, alveolar volume and inspired vital capacity (derived from the single breath tlco method). average conductive ventilation heterogeneity doubled (p < 0.001), while tlco decreased by 6% (p < 0.001), with no correlation between individual data (p > 0.1). when dividing diffusing capacity by alveolar volume, the resulting transfer coefficient was not significantly different pre versus post histamine (p = 0.074). these findings can be brought in agreement with recent modelling work, where specific ventilation heterogeneity resulting from different distributions of either inspired volume or end-expiratory lung volume have been shown to affect tlco estimation errors in opposite ways. the combination of these errors appears to largely cancel out in our experimental situation of induced ventilation heterogeneity comparable to that observed in lung disease. we conclude that conductive ventilation heterogeneity per se has a negligible effect on diffusing capacity measurement. an important determinant of airway function in humans is vagal-mediated cholinergic tone in airway smooth muscle (asm). this airway tone may be altered in disease states. the use of mouse models for the study of airway diseases, including asthma, pulmonary fibrosis and copd is well established. however, it is not known whether mice actually possess basal asm tone or, if it does exist, how this tone changes in disease models. this study was undertaken to determine whether mice have detectable asm tone in vivo. methods respiratory system impedance (zrs) was measured in female adult balb/c mice using a wave-tube modification of the forced oscillation technique. zrs was measured during slow (~35 s) inflation-deflation manoeuvres between the transrespiratory pressures of 0 and 20 cmh2o. baseline lung mechanics and thoracic lung volumes (tgv) were measured before and after each mouse was allocated to one of four treatment groups: 'saline' mice received an i.p injection of saline, 'atropine' mice received i.p. atropine sulphate, 'vagotomy' mice had their left and right cervical vagus nerves isolated by blunt dissection and cut, and 'sham' mice had the area of the vagus nerves exposed but the nerves were not cut. results there were no post-treatment changes in tgv, airway resistance, tissue damping, tissue elastance, inertance or tissue hysteresivity in any of the four groups. conclusions the lack of change in lung mechanics post-atropine or postvagotomy in balb/c mice suggests that, unlike humans and many other species, the airways of mice have no baseline asm tone. supported by nhmrc grant#11488. nomination none. conflict of interest none. both male gender and increased mandibular enclosure volume predict more severe sleep disordered breathing in obstructive sleep apnoea patients. we now examine gender/body size/mandibular enclosure volume relationships for normal subjects stepwise multiple linear regression analysis was used to model body size/enclosure volume interactions. results for the whole group, mv was 261.1 ϯ 6.0 ml (mean ϯ se) while rmv was 205.1 ϯ 4.9 ml. head circumference (positive) and forehead height (negative) were both independent predictors for mv and rmv (both p < 0.02), while hip circumference was an additional positive predictive factor for rmv (p < 0.04). after adjusting for these parameters, male mv and rmv were larger than for females conclusion these findings suggest that mandibular enclosure volumes are relatively larger in males, even after adjusting for body size/cranial dimension. differing body size/mandibular enclosure volume interactions may contribute to gender influences on the severity of sleep disordered breathing. supported by nhmrc of australia nomination john read prize for sleep and physiological research tp 027 audit of ctpa in a regional hospital y raje, s vincent, g simpson department of thoracic medicine, cairns base hospital, cairns, qld 4870 since the introduction of computerized tomographic pulmonary angiograms (ctpa) at our institution the number of requests for this investigation at our institution has grown at an alarming rate. the purpose of this study was to evaluate the clinical assessment of suspected pulmonary embolism (pe). methods 50 ctpa were reviewed. results 31 female, 19 male. mean age 50 yrs (range 21-87). 26 ctpa requests came from department of medicine, 21 from emergency department, 2 from surgical teams and 1 from oncology outpatients. 36 patients presented with chest pain (pleuritic in 20 cases), 25 had dyspnea, 7 presented with collapse. 4 patients had haemoptysis. hypoxaemia was recorded in 7. none were clinically shocked and only one had a recorded tachycardia. d-dimer requested in 10 patients and was elevated in 9. arterial blood gases performed in only 10 patients (20%). 47 patients had prior chest x-ray which was normal in 24 (48%). 8 patients had consolidation on chest x-ray, 2 pleural effusions, 2 atelectasis and 1 fractured ribs. recorded risk factors included 4 patients with previous dvt or pe, 4 patients with malignancy and 6 patients were immediately post-operative. only 6 ctpas (12%) demonstrated evidence of pe. of these 2 had recent dvt and 2 were post-operative. 1 had a history of bowel cancer. there was no formal record of pre-test clinical probability of pe (eg wells' score) for any of the 50 cases. retrospective calculation of the cases of pe, 4 had a wells' score of 4.5 and 1 of 4 with the remaining patient with wells' score of under 2. only 3 patients (one with clinically probable pe) had received fractionated heparin prior to the ctpa. conclusion (1) ctpas performed at our institution have a low yield (12%).(2) pre-investigation clinical assessment was poor and there was poor adherence to published guidelines, (3) this results in many unnecessary ctpa examinations generating increased work and expense for the medical imaging department and exposes many patients to unnecessary and potentially harmful radiation exposure. the evaluation and management of hereditary hemorrhagic telangiectasia involves a multidisciplinary approach according to international guidelines. the aim of this audit was to compare the assessment process in one centre with that of the international recommendations. methods retrospective comparison was made by medical chart review of all patients with a diagnosis of hht between the years 1994 to 2006. demographic along with clinical data with diagnostic investigations, complications, treatment and genetic evaluation, including family screening was collected. the proportion of patients evaluated and managed as per the international recommendations was determined. results the audit identified 26 patients with the diagnosis of hht, with the mean age 58 years. diagnostic criteria were met in 77% of the cohort. of the known clinical features, 54% had a family history, and 81% epistaxis. cutaneous telangiectasia was present in 85% and visceral involvement in 92%. pulmonary arterio-venous malformations (pavm) were seen in 16 patients, cerebral avm in 4, gastrointestinal telangiectasia was documented in 8. one patient had a spinal (cervical) avm, and another had pulmonary hypertension in association with this condition. only 8 patients underwent diagnostic or screening investigations in accordance with the international recommendations. furthermore, one patient was referred for a genetic evaluation. conclusions this clinical audit found that 31% of patients referred to this centre were evaluated in accordance with the international recommendations. genetic assessment was lacking. the study supports the need for a coordinated, multidisciplinary approach to the evaluation and management of hht in this centre. lm young 1 , n good 1 , d milne 2 , w fergusson 1 , i zeng 1 , j kolbe 1 , ml wilsher 1 background while airflow limitation is the most common physiological impairment in sarcoidosis, there are limited data on airway hyperresponsiveness (ahr). understanding the role of ahr in sarcoidosis, if any, may help to identify individuals who might benefit from inhaled therapies. aims (1) to determine the prevalence of ahr in sarcoidosis. (2) to determine the correlation between responses to direct (using histamine) and indirect (using hypertonic saline) bronchial challenge. (3) to determine the clinical, physiological and radiological predictors of ahr. methods subjects with a diagnosis of sarcoidosis based on typical clinical presentation and compatible hrct features and/or tissue biopsy and with a baseline fev1>35% predicted were recruited. subjects underwent standard hypertonic (15% fall in fev1) and histamine (20% fall in fev1) challenge (>1 day but <7 days apart), lung function testing and high resolution computed tomography (hrct) of the chest. results the 52 subjects (48 ϯ 11 years, 35% female, 92% european, 35% stage i, 25% stage ii, 40% stage iii, 0% stage iv) had well preserved lung function overall (fev1 = 2.8l ϯ 0.7.87% predicted). ahr was detected in 5/47 (11%) to hypertonic saline and 19/43 (44%) to histamine challenge. on univariate analysis, response to histamine challenge was predicted by conglomerate fibrosis (p = 0.002) and reticular pattern (p = 0.05) on hrct. the baseline % predicted fev1 was significantly associated with ahr on univariate (p = 0.004), and multivariate analysis (p = 0.01) when adjusted by hrct patterns. conclusions there is a high prevalence of ahr using histamine challenge in this study of sarcoidosis subjects. ahr most strongly associates with baseline % predicted fev1 but also conglomerate fibrosis and reticular pattern on hrct. these findings may reflect the consequence of airway remodelling following inflammation. further studies are warranted to confirm these findings. background upper airway shunt represents a significant source of measurement artefact in the use of the forced oscillation technique (fot), with increasing importance in young children. changes in respiratory system admittance, ars (or zrs -1 ), are theoretically independent of the upper airway shunt. this study examines the possible clinical benefit of ars in preschool children by assessing any increased ability to differentiate responses to bronchial challenges in the routine clinical setting. we hypothesized the use of ars would provide improved sensitivity to clinically relevant obstruction, bronchodilator responsiveness (bdr) and airway hyper-responsiveness (ahr) in young children with respiratory disease. method previous fot measurements were re-analysed and ars calculated to derive: (1) ars reference equations in healthy young children (n = 158); (2) bdr in ars, respiratory system resistance (rrs) and reactance (xrs) in healthy children (n = 78), children with cystic fibrosis (n = 39), neonatal chronic lung disease (n = 49), asthma (n = 56) and wheeze (n = 66); (3) ahr to inhaled adenosine-5′-monosphate (amp) in 19 children. fisher's exact tests were used to assess changes in diagnostic outcomes between ars and conventional fot outcomes (rrs and xrs). results ars was no more sensitive to bronchodilator induced changes than conventional fot outcomes. amp challenges resulted in equivalent responses measured by relative changes in rrs and ars while absolute changes in ars were the least sensitive variable. conclusion this study does not support a clinical advantage in using ars in measuring responses to either inhaled bronchodilator or amp. c hollier 1,2 , c menadue 1,2 , d flunt 1,2 , aj piper 1,2 1 department of respiratory and sleep medicine, royal prince alfred hospital, nsw 2050, and 2 woolcock institute of medical research, nsw 2050 serial measurement of arterial carbon dioxide (paco2), ph and bicarbonate (hco3 -) is essential in the management of patients with hypercapnic respiratory failure (hrf). this information is usually obtained from a sample of arterial blood (abg). the procedure can be painful and distressing for patients, and is sometimes technically difficult due to obesity or contractures. our aim was to determine the validity and feasibility of arterialized venous blood (av) sampling as an alternative to abgs in measuring paco2, ph and hco3levels in patients with chronic hrf. method eighteen patients completed the study. venous blood was arterialized by heating forearm skin to a temperature of 42-45°c with an electric heating pad. an av sample was taken from a cannula positioned in a vein of the heated forearm simultaneously with an abg. in addition, the reliability of av sampling within the recommended temperature range (42-45°c) was investigated in ten healthy volunteers placed on volume cycled ventilation in order to maintain constant ventilation. av samples were taken at 0.5°c temperature intervals from 42.5-45°c results the table below summarizes results for validation of av sampling: based on the evidence that cardiovascular dynamics are altered due to obstructive sleep apnea, this study aims to identify the onset and termination of each apnea event using power spectral density (psd) and morphological features of single lead ecg signal over 5 second period. methods ecgs from 4 patients overnight sleep studies were examined for location of the pre-scored apnea events. onset (n = 1995), maximum (n = 6751) and termination (n = 1996) of each apnea event and normal events (n = 11219) were annotated on 5 second windows. features extracted were psd, amplitudes of r and t wave of 5 second ecgs. receiver operating characteristics (roc) analysis was used to gauge the event recognition ability of all features. weight loss causes an improvement in the severity of osa, however substantial weight loss is very difficult for obese patients. the very low caloric diet (vlcd) has been shown to be successful in causing significant weight loss in obese patients. this is a pilot study on the use of a formal screening protocol to identify osa patients who are potentially eligible for the supervised vlcd program offered by the endocrinology department at auckland city hospital. method 344 consecutive patients who attended the sleep laboratory at ach between june to december 2006 were screened using the protocol. patients who are eligible to be considered for the vlcd program are identified as having a combination of obesity (bmi > 30), osa (ahi > 5 on sleep study) and being residents within the auckland district healthboard region. results 243/ 344 patients screened did not fulfil the inclusion criteria: 171 lived outside the adhb region; 71 had bmi < 30; 7 patients did not have osa (ahi < 5). 101 patients fulfilled the inclusion criteria. 54/101 patients (54%) were excluded due to medical or psychiatric contraindications to vlcd.47 patients (47%) who did not have contraindications to vlcd were contacted. 33 patients were contacted successfully. 14 patients were either unavailable to phone contacts on 3 separate days or were disconnected. 12/101 patients consented to being referred (12%). 21/101 patients declined referral (21%). conclusion this pilot study is the first study using a formal comprehensive screening protocol in the recruitment of obese osa patients into a medically supervised vlcd program. only a small proportion (12%) of patients proceeded to being referred to the vlcd program. key: cord-023308-af5nihyi authors: nan title: copd sig: poster session 2 date: 2008-03-12 journal: respirology doi: 10.1111/j.1440-1843.2008.01252_6.x sha: doc_id: 23308 cord_uid: af5nihyi nan increased airway smooth muscle (asm) in asthma may be due to hyperplasia or hypertrophy of asm cells. the contribution of extracellular matrix (ecm) within asm bundles has not previously been accounted for when estimating asm cell volume. aim to estimate the mean asm cell volume in asm bundles in asthma. methods post-mortem tissues from control subjects (c n = 9); nonfatal (nfa n = 11) and fatal (fa n = 10) cases of asthma were studied. on 30 mm transverse airway sections stained with haematoxylin, the volume density (nv) of asm cell nuclei was estimated using an optical disector (¥1000). the mean cell volume (vc = 1/nv) was calculated, correcting for the volume fraction of asm (fasm) within the asm bundle (corrected vc = 1/(nv ¥ fasm)). fasm was estimated on 0.5 mm thick sections of the same airway stained with masson's trichrome. basement membrane perimeter (pbm) was used to indicate airway size. results table shows mean ϯ sd. (one-way anova) *p < 0.05 for c v fa, nfa v fa. conclusion these data suggest that although asm area is increased in asthma, mean asm cell volume is unchanged. therefore hyperplasia, not hypertrophy, of asm cells is present in both mild and severe asthma. these results were similar for both large and small airways. asthma is characterized by airway inflammation and remodelling which contribute to airway hyperresponsiveness and episodic airflow obstruction. mast cell (mc) densities are higher on the smooth muscle (asm) in asthma so their mediators may modulate other asm functions as well as cause contraction. aim to investigate the effect of mc mediators on chemokine and extracellular matrix (ecm) production by asm cells from donors with and without asthma. methods mc were isolated from the resected lung samples of 6 patients, resuspended at 10 6 cells/ml in dmem + 10% fbs and stimulated with ige/anti-ige. supernatants (sn) were collected after 2 and 24 h and the mc lysed. sub-confluent asm cells from 6 donors with and without asthma were serum deprived for 72 h before mc sn/lysates were added in dmem + 10%fbs for 48 h. il-8 and eotaxin levels in all asm sn and mc sn/lysates were measured by elisa. fibronectin and collagen iv deposition was measured in situ by immunoassay following asm cell lysis. results in asthmatic and non-asthmatic asm cells all mc sn and lysates reduced eotaxin release by up to 47% and 58%, whereas the 0-2 h mc sn significantly increased il-8 release to 178 ϯ 35.9% (p = 0.0339) and 169 ϯ 49% (p = 0.0445) of the fbs control respectively. however, only nonasthmatic asm cell il-8 release was increased by the mc 2-24 h sn (216 ϯ 85%; p = 0.0421) and cell lysates (215 ϯ 47%; p = 0.0421). the 0-2 h mc sn also increased fibronectin deposition to 143 ϯ 16% (p = 0.008) by asthmatic asm cells only. mc sn and lysates had no effect on collagen iv deposition. conclusions activated mast cell mediators differentially modulated chemokine and ecm secretion by asm cells from donors with and without asthma. thus mast cells may modulate their own recruitment to the smooth muscle and remodelling locally in the airways in asthma. supported by nhmrc. the technique of ige passive sensitization reproduces ige-related allergic responses in vitro and studies have validated this technique for investigations modelling allergic smooth muscle responses. there are no studies investigating effects of ige sensitization on rhinovirus (rv) infection. we hypothesized that rv infection is enhanced by ige sensitization, a consequence of diminished early innate immune responses. methods beas-2b epithelial cells and primary culture airway fibroblasts were sensitized with ige 24 h-7 d prior to infection with rv16. samples of tissue culture supernatant and cell lysates were collected over a 12 h period after infection for analysis. viral replication was measured by real-time rt-qpcr and viral titration and type i interferon mrna by rt-qpcr. ige receptor mrna expression was examined using rt-pcr. results initial studies to establish the model used human serum high in ige (>1000 iu/ml), this yielded inconsistent results and it was found that purified ige (1000 iu/ml) provided more reliable responses. sensitization was established after 24 h ige incubation and was comparable with up to 7 d. rt-pcr detected mrna for the ige low affinity receptor only after sensitization. following rv16 infection, vrna was increased after 24 h in ige sensitized cells (p < 0.05), but this effect varied noticeably between and within cell lines. cellular expression of ifn-b mrna increased with viral infection but in cells sensitized with ige lower levels of expression were noted (p < 0.05). conclusions ige passive sensitization enhanced rv replication in vitro but the model is constrained by significant variability between and within cell lines. the effect of sensitization on rv replication may occur through the low affinity ige receptor. activated mast cells (mc) are present in higher numbers on the airway smooth muscle (asm) in asthma compared with other inflammatory airway diseases. matrix metallo-proteinases (mmps) cleave chemokines and alter chemokine gradients by degrading the extracellular matrix and thus may modulate mc migration to the asm. aim to determine the levels of mmp-2, mmp-9 and their inhibitors, timp-1 and timp-2, secreted by asm cells from donors with and without asthma. method confluent asm cells were washed, serum-starved for 48 h and then stimulated with th1 (il-1, tnf and ifn) or th2 (il-1, il-4 and il-13) cytokines or left unstimulated. after 4 and 24 h,the sn were collected. the relative amount of pro and active forms of mmp-2 and mmp-9 in sn were determined by gelatine zymography. timp-1 and timp-2 levels in the sn were measured by elisa. results pro-and active mmp-9 were not detected. however, pro-mmp-2 levels were high in sn of asm cells from donors with (195.6 ϯ 47.2 % positive control/10 5 cells) and without (226.5 ϯ 49.2 % positive control/10 5 cells) asthma. a trend to increased active mmp-2 production by asm cells from donors with (7.3 ϯ 2.7 % positive control/10 5 cells, n = 9) compared to without (2.9 ϯ 0.7 % positive control/10 5 cells, n = 11) asthma after 24 h was not significant (p = 0.101). timp-1 and timp-2 levels respectively were high in the sn of cells from donors with (69.4 ϯ 19.6 and 21.3 ϯ 4.7 ng/10 5 cells, n = 5) and without (57.3 ϯ 13.7 and 16.6 ϯ 3.5 ng/10 5 cells, n = 5) asthma. th1 and th2 cytokine stimulation did not affect mmp or timp release. conclusions th1 and th2 cytokines did not regulate asm cell production of mmp-2, timp-1 and timp-2. altered asm mmp-2 activity is unlikely to play a role in mc chemotaxis to asm cells from donors with asthma in vitro or their presence on the asm in asthma. there has been a marked increase in the prevalence of asthma and other allergic diseases in the last few decades. one of the explanations for this is the change in our diet. one of the characteristics of the "western diet" is a high intake of both saturated and polyunsaturated fat. this prompted us to compare the effects of high fat and low fat meals on the numbers of circulating eosinophils and other leukocytes. methods we studied 12 volunteers who had allergic rhinitis and/or asthma and a peripheral eosinophil count at baseline of ն200 ¥ 10 7 /l. this was a randomized, crossover trial with participants studied on two different days. on each occasion they arrived fasting and after bloods were drawn consumed a 3000 calorie meal. one of the meals was high in saturated fat and refined carbohydrate. the other meal was low in saturated fat and high in fruit and fibre. bloods were drawn postprandially every hour for five hours. results eosinophil counts were highest in the early morning and fell over the course of the day but the decrease was less with the high fat meal (p = 0.03). over the same period of time the increase in lymphocytes (p = 0.016) was greater with the high fat meal. the high fat meal was also associated with greater increases in triglycerides (p < 0.0001) and cholesterol (0.004). conclusions in atopic individuals a high fat meal was associated with higher circulating numbers of eosinophils and lymphocytes than an isocaloric meal that was low in fat. further studies of the effect of dietary fat on eosinophilic inflammation are warranted. supported by the university of auckland research committeee. intravenous gamma globulin therapy (ivig), which is therapeutic in a variety of immune diseases, has been reported to be effective on patients with severe steroid-dependent asthma. although fcer are known to play important roles in asthma, there are few reports about the role of fcg?receptors in asthma. fcg receptor iib (fcgriib) is unique inhibitory receptor, which suppresses immune response. in this study, we evaluated the effect of ivig in allergic airway inflammation in ova-challenged mice and the mechanism of the inhibitory effects of ivig and fcgriib. method c57bl/6 mice (wt) and fcgriib deficient mice (ko) were sensitized with ovalbumin (ova) and alum and subsequently challenged with nebulized ova. before ova challenge rabbit igg was administered intravenously. the airway inflammation and effects of igg were assessed by histology, cell counts of bal fluid and airway hyperresponsiveness. result histology showed that igg treatment ameliorated the inflammation around the airway and the vessels and hypertrophy of goblet cells induced by ova challenge. the migratory activity of dcs is modulated in inflammatory diseases such as asthma. recently, we reported that immature dcs express kinin receptors and that bradykinin (bk) significantly enhances the migration of immature dc in vitro. as kinins mediate many of the pathophysiological effects associated with asthma, we hypothesized that lys-des[arg 9 ]-bk, which is produced during inflammation and acts via the b1 receptor (b1r), would inhibit migration of mature dcs. methods day 7 cultured human monocyte-derived dcs were matured with lps, tnfa +il-1b or cd40l in the absence or presence of lys-des[arg 9 ]-bk. maturation of dc was analysed by flow cytometry (facs). b1r expression was assessed by reverse-transcriptase pcr and quantitative confocal microscopy. migration of mature dc was assessed in transwell chambers with lysdes [arg 9 ]-bk and the chemokine ccl19 used as chemoattractants. results maturation of dcs was found to result in down-regulation of b1r expression to varying degrees depending upon the maturation stimulus used. mature dcs all demonstrated an ability to migrate toward lys-des[arg 9 ]-bk and ccl19. however pre-treatment with lys-des[arg 9 ]-bk decreased the migratory ability of all mature dcs to both chemoattractants. conclusions along with chemokines, lys-des[arg 9 ]-bk is likely to play a crucial role in regulating the in vivo migration of mature dc during inflammation. the production of lys-des [arg 9 ]-bk during inflammation potentially immobilizes mature dcs thereby facilitating locally-mediated immune responses within inflamed tissues. supported by the asthma foundation of western australia. introduction alternative or aberrant splicing is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms. the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to use a new and innovative approach involving the use of the genechip (r) exon array system together with real-time quantitative pcr to study asthma candidate genes in human monocyte-derived dendritic cells. asthmatic and non-asthmatic subjects provided 20 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method, and differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data indicate splice variant expression in dendritic cells from asthmatic patients is influenced by asthma severity. conclusion exon expression array analysis has generated a number of asthma candidate genes with alternative splice variants. further studies to validate these data in a replicate data set and establish the functional significance of our findings in asthma are underway. alternative or aberrant splicing occurs in more than 70% of genes and is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms 1 . the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to study one asthma candidate gene in human stimulated and unstimulated: (1) monocytes, (2) monocytederived dendritic cells and (3) lung smooth muscle cells. methods asthmatic and non-asthmatic subjects provided 40 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method. up to 50% of the monocytes were then differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. induction experiments used 1 mg/ml lps and cells were stimulated for an optimal period of 24 hrs. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data from stimulation experiments indicate splice variant production can be regulated by the inflammatory response and that this response is influenced by asthma status. conclusion preliminary experiments have confirmed the presence of an aberrant splice variant for an asthma candidate gene in the primary cells studied. further studies to confirm these data and establish the functional significance of our findings in asthma are underway. exposure to environmental factors, such as environmental tobacco smoke (ets), plays a significant role in modulating pre-existing genetic susceptibilities to diseases including asthma. the glutathione s-transferase enzymes (gsts) play an important role in the detoxification of ets. there are several gst isoforms and gstp1 codes for the gst pi isoform, which is the primary gst isoform expressed in human lung tissue. two single nucleotide polymorphisms (snps) at positions 105 and 114 have been reported in gstp1 and associated with asthma and atopy. the aim of this study was to examine the effect of these snps in combination with ets, on asthma phenotypes in a cohort of asthmatic children. children were recruited during an acute episode requiring presentation at an emergency department. genotyping using pcr-rflp was completed on 218 children and ets exposure was determined by parental questionnaire. urinary cotinine was measured in the children and was in agreement with questionnaire responses. statistical analyses were performed using spss. there were no significant associations between the genotypes and asthma severity during acute exacerbations. significant associations were found between the snps and atopy in this population with an odds ratio of 2.77 for the 105aa genotype (p = 0.029) and or of 5.47 for the 114cc genotype (p = 0.002). however, when an interaction with ets was included, the odds ratios increased to 9.02 for 105aa (p = 0.05) and 9.17 for 114cc (p = 0.020). these results suggest that there is a significant gene/environment interaction impacting on atopy in this cohort. the rage gene encodes the receptor for advanced glycation end-products (rage), a member of the immunoglobulin superfamily. rage activation by ligands, including amphoterin and s100/calgranulins, leads to prolonged nf-kb signalling and has been associated with chronic inflammation. despite high levels of rage expression in lung tissue, little research has been undertaken into the role of rage in the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. objective determine genetic associations between functional polymorphisms in the rage promoter and severe and aspirin-sensitive asthma phenotypes. methods pcr and restriction fragment length polymorphism (rflp) were used to genotype three rage promoter polymorphisms, -429t>c, -374t>a and a 63 bp deletion from -407 to -345, in a large case-control asthma population phenotyped for asthma severity, atopy and aspirin sensitivity. results no associations were identified between any of the polymorphisms and the occurrence of asthma. however, the -374a allele was linked with both severe asthma (p = 0.013) and aspirin-sensitive asthma (p < 0.001). likewise, genotypes containing the -374a allele were strongly associated with both severe asthma (or 2.10, 95% ci 1.32-3.36) and aspirin-sensitive asthma (or 3.13, 95% ci 1.45-6.77). conclusions the -374a allele of the rage gene, previously shown to lead to a 3-fold increase in promoter activity, is associated with the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. these results suggest that increased rage expression, with a concomitant increase in nf-kb signalling, may in part contribute to the inflammatory response seen in these conditions. the global prevalence of allergic diseases is rising and australia has one of the highest prevalence rates in the world. the role of early childhood infections in the development of allergic disease remains controversial. objective to examine the association between early childhood infections and the development of allergic diseases in later childhood, in high risk children. methods data were analysed from the melbourne atopic cohort study (macs) of 620 infants with 1 or more first-degree family members with atopic disease. primary risk factors assessed were otitis media, bronchitis and gastroenteritis reported in the first two years of life. outcomes were current asthma, hay fever and eczema at 6 years of age. logistic regression was used to estimate crude and adjusted odds ratios. results asthma was the most common allergic condition (25.4%, 95% ci 21.6-29.5%), followed by eczema (24.9%, 95% ci 21.1-29.0%) and hayfever (15.6%, 95% ci 12.5-19.1%). the most commonly reported infection was otitis media (58.9%, 95% ci 54.9-62.8%), then gastroenteritis (37.7%, 95% ci 33.9-41.7%) and then bronchitis (19.4%, 95% ci 16. [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] .7%). all 3 types of infection within the first 2 years of life were associated with increased risk of asthma. an increased risk of asthma at 6 years was seen with otitis media (or = 1.14, 95% ci 1.02-1.3), bronchitis (or = 1.34, 95% ci 1.0-1.8) and gastroenteritis (or = 1.23, 95% ci 0.96-1.6). when the frequency of infection was examined, those who reported at least 3 episodes of gastroenteritis had a 3-4-fold increased risk and an almost 30% absolute increased risk (rd 0.34, 95% ci 0.08-0.59). conclusion these findings appear to contradict the hygiene hypothesis. the findings for gastroenteritis are novel. further examination of these associations and possible underlying mechanisms is warranted. grant support asthma foundation of victoria, nestle. background knowledge about incident cases of asthma in australia is limited because they are not routinely reported. the ability to predict the number of new cases of asthma would be helpful in allocating resources for asthma education, management and care. data on first use of medications for asthma gives an indication of the incidence of asthma. the objective of this study was to estimate the incidence rate of asthma by investigating asthma medication use in individuals. methods pharmaceutical benefits scheme (pbs) records for all prescriptions filled for inhaled corticosteroids (alone or combined formulation), cromones and leukotriene receptor antagonists from july 2002 to june 2005 were included. using a 2-year look back window, any persons who had their first prescription for any of these drugs dispensed between july 2004 and june 2005 were assumed to be incident cases. overall and age-specific incidence rates were calculated per 100 asthma-medication-free individuals. results there were 352,082 individuals who had their first asthma medication dispensed between july 2004 and june 2005, which equates to an overall incidence rate for asthma of 1.89 per 100. the incidence was higher among children aged 0-14 years (2.07) and adults aged 65 years and over (2.45) . conclusions our estimated incidence rates were consistent with those reported by others in the literature. while the pbs database was designed for administrative purposes, it can be used to estimate incidence rates for asthma. support acam is a collaborating unit of the australian institute of health and welfare and is funded by the department of health and ageing (doha). we acknowledge the pharmaceutical pricing and estimates section of doha for provision of pbs data. keywords asthma incidence, pharmaceutical benefits scheme. rosario ampon 1 , guy marks 1 , teresa to 2 , leanne poulos 1 , anne-marie waters 1 1 australian centre for asthma monitoring (acam), sydney, australia, and 2 hospital for sick children, toronto, canada background the ability to assess individual patterns of asthma medication use would have clinical relevance in targeting effective asthma education and management for this common condition. to describe longitudinal patterns of asthma medication use, we used a population-based prescription database to follow individuals from the first time they filled an asthma prescription. asthma is more commonly listed on death certificates as an associated cause of death, in people whose deaths are attributed to other causes, than as an underlying cause of death. understanding the importance of these associations would contribute towards an overall appreciation of the impact of asthma on mortality. the objective of this analysis was to estimate the prevalence of asthma as an associated cause of death when various other diseases were attributed as the underlying cause of death. background acam currently recommend 24 indicators to measure population-level asthma health and outcomes. we examined correlations among several asthma indicators covering prevalence, morbidity and mortality to try and produce a condensed set of indicators which minimized redundancy. methods seven of the 24 indicators were included in this study: prevalence of ever having doctor diagnosed asthma, prevalence of current asthma, asthma-related general practice (gp) encounters, proportion of people with asthma with an asthma action plan (aap), hospitalizations for asthma, hospital patient days for asthma, and deaths due to asthma. a correlation matrix was created for these indicators by age groups. pearson correlation coefficients ն0.7 or յ-0.7 were considered strong. results there were strong positive correlations between prevalence of ever asthma and current asthma (r = 1.0); gp visits and aap possession (r = 0.74), hospitalization (r = 0.91) and patient days (r = 0.95); and hospitalization and patient days (r = 0.90) and aap possession (r = 0.73). recent australian reports have shown that the prevalence of asthma and respiratory symptoms has decreased over the last 10-15 years. as part of a larger study investigating child health and air quality we have collected nationwide data from schoolchildren living in act, victoria, queensland, wa and sa. methods schools were selected based on proximity to air quality monitoring stations. classes from years 3 to 6 were randomly selected and all children were invited to participate. parents self completed a questionnaire that included questions about diagnosed asthma and respiratory symptoms. results a total of 1989 children provided questionnaires for analysis. the response rate varied between states and territories and ranged from 30% to 42%. the sample comprised 51.9% girls and the mean age of children was 10.2 years. ever diagnosed asthma 27.9 current asthma ('does he/she still have asthma? ') 13.8 wheeze in the past 12 months 16.1 respiratory symptoms limiting activities 11.8 missed school due to asthma or wheezing 8.8 conclusions despite the relatively low participation rate, the prevalence estimates for current asthma are similar to those reported in the national health survey 2004-05 [1] . there is no evidence of any recent increase in the prevalence of childhood asthma. methods tahs is a longitudinal population-based respiratory study of 8583 subjects which commenced in 1968 when they were 7 years of age. since the initial study another 4 follow-ups have been conducted, including the most recent follow-up when subjects were 44 years of age. lung function of the total sample was measured at baseline and in sub-samples in 3 subsequent followups. asthma was categorized as persistent, frequent or episodic when participants reported asthma symptoms in at least 3 follow-ups, in 2 follow-ups or in 1 follow-up respectively. results by age 7 years ever asthma prevalence was 16%. at age 44, 10% of those who had not reported asthma by age 7 had asthma symptoms while 75% of those who reported asthma by age 7 had no asthma symptoms. hence over all only 25% of the asthma symptoms at age 44 were attributable to asthma developed by age 7. in contrast, 91% of the persistent and frequent asthmatics had developed their asthma by age 7. persistent and frequent asthmatics had more symptoms and poorer lung function at age 7, 14 and 44 as well as more reversibility at age 44 (p < 0.05). childhood asthmatics who also had a productive cough by age 7 were more likely to have persistent asthma than those without a cough (p < 0.05). conclusions although the majority of middle-age asthma is related to postchildhood onset asthma, most severe middle-age asthma has its origin in persistent childhood disease. having productive cough in childhood may identify high risk asthmatics who require especially rigorous management in early life. one third of women experience an improvement in asthma during pregnancy, and symptoms improve in most women in the late third trimester. we hypothesized that the exacerbation rate would be reduced and that symptoms during exacerbations would be less severe in the third trimester compared to the second trimester. methods pregnant women with asthma (n = 81) were prospectively followed from recruitment (14.8 weeks (3 sd) ) to delivery at clinic visits (18, 30, 36 weeks and during exacerbation), and fortnightly phone calls. the asthma control questionnaire (acq) was administered at each contact and exacerbations classified as severe (requiring medical intervention) or mild (selfmanaged). lung function, medication use, fractional exhaled nitric oxide (feno) and full blood counts were assessed. paracetamol is commonly used in infants as an analgesic and antipyretic. it has been hypothesized that frequent paracetamol consumption may result in reduced lung capacity to cope with oxidative stress and increase risk of respiratory disease. to date, no study has examined exposure to paracetamol during infancy, when lungs are still developing, and risk of childhood asthma. method a birth cohort of 620 infants with an atopic family history was recruited. frequency of paracetamol exposure was prospectively documented up to 2 years of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results paracetamol exposure in infancy was common (97% exposed by two years of age), with some infants receiving paracetamol on up to 77 days. it has been hypothesized that mucosal immune response requires a particular micro-flora milieu in the infant's gastro-intestinal tract, and that early life antibiotic exposure may disrupt this process and increase risk of allergic disease. method a birth cohort of 620 infants with an atopic family history was recruited. exposure to oral antibiotics was prospectively documented up to 12 months of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results by one year of age, approximately 80% of infants had received at least one course of oral antibiotics. the prevalence of current asthma in childhood was approximately 30% (148/495). frequent use of antibiotics (more than 20 days exposure during first year of life) was associated with increased risk of childhood asthma (or = 2.52, 95% ci = 1.40-4.54) when compared to infant who had not been exposed. excluding infants with a diagnosis of asthma within the first two years of life, reduced this association by about 30% (or = 1.80, 95% ci = 0.90-3.57) and adjustment for gender, parental history of asthma and number of infections in the first year of life further reduced this association (or = 1.60, 95% ci = 0.79-3.22). the increased risk of childhood asthma associated with antibiotic exposure in the first year of life is, at least in part, due to confounding with early life wheeze and infections. if real, the independent effect of antibiotic exposure on risk of childhood asthma is likely to be minimal in this high risk cohort. support dairy australia, crc for asthma and airways, vichealth, nestle. the epidemiological data on asthma suggest a gender difference that varies with age. hormonal effects have been suggested as a possible explanation for these differences. the aim of this study was to examine reproductive factors and risk of asthma among the females of the tasmanian longitudinal health study (tahs). methods the tahs is a longitudinal population-based cohort study of respiratory disease which commenced in 1968 when subjects were 7 years of age. four follow-up studies have been conducted including the current most comprehensive follow-up with subjects at 44 years of age. information has now been collected on reproductive factors such as number of pregnancies, age at pregnancies, age at menarche and contraceptive pill use as well as on asthma status. reproductive factors were examined as risk factors for asthma using multiple logistic regression to adjust for all likely confounders. results a total of 2,776 women completed the most recent postal survey. of these 355 (12.8%) had current asthma, and of these women with current asthma 73.5% (261) developed asthma after childhood. on average these women were in their mid-twenties when they developed asthma (mean ϯ sd age = 26.6 ϯ 12.5 yrs). we found with increasing age at first birth an approxi-mate~30% reduced risk of current asthma in women who developed their asthma post-childhood (trend p = 0.04). we did not observe any other associations between reproductive factors and risk of asthma. conclusions our results are consistent with the hypothesis that early pregnancy may promote asthma development by altering the immune response favouring a th2 pathway. a delay in the age of first pregnancy reduces this risk of asthma. grant support nhmrc, clifford craig foundation, victorian & tasmanian asthma foundations. introduction the association between exposure to pets in early life and subsequent development of sensitization and allergic disease remains controversial. the objective of this analysis was to examine the relationship between cat exposure before birth and development of cat sensitization over time within the melbourne atopic cohort study (macs). methods the macs is a prospective longitudinal cohort study that initially recruited 620 women antenatal in melbourne from february 1990 to november 1994. detailed information on cat exposure was collected at recruitment and frequently until two years of age. skin prick test (spt) were conducted at 6, 12, 24 months and 10 years. the data were analysed by logistic regression and using generalized estimating equations (gee) for the repeated measures design. results among 620 subjects, 169 (28.8%) had a cat before birth. at 6 months, 1.9% (n = 11) of subjects were sensitized to cat and by 10 years of age 18.8% (n = 68) were sensitized. those who did not have cat before birth belong to a higher social class, and were more likely to have a father with allergic disease than those with a cat. those who developed sensitization to cat were more likely to have a paternal family history of allergic disease and more likely to be sensitized to other allergens. we did not observe any association between exposure to cat before birth and the development of sensitization to cat at 6 months (or = 0.7, 95% ci 0. 1-3.3) , 12 months (or = 1.4, 0.5-3.9), 24 months (or = 0.76, 0.2-2.5) or 10 years (or = 0.6, 0. 2-1.4) . these crosssectional results were confirmed by the gee analysis. conclusion our results fail to show an association between cat exposure before birth and development of sensitization to cat. furthermore exposure after birth in the first 18months of life was not associated with an increased or decrease risk of sensitization to cat. our results do not support either a benefit or risk associated with cat ownership and sensitization. introduction peri-natal events influence the development of asthma and atopic diseases in childhood but the current literature is contradictory on the effect of low birth weight, small for gestational age and prematurity on asthma risk. the aim of this study was to assess the relationship between these three exposures and asthma from childhood to adulthood. aim to assess the current prevalence of dda, wheeze (<12 months), atopy and ahr in children and adults in busselton. methods an age-and sex-stratified random sample of adults, selected from the electoral roll, was invited to complete a questionnaire and attend the local study centre for assessment of atopy (allergen skin tests) and ahr (methacholine). all children from participating primary and secondary schools were also invited to attend. the prevalences of dda, wheeze, atopy, ahr and "current asthma" (wheeze + ahr) were calculated. background asthma is often associated with comorbidity, however few studies have investigated comorbidities among people with this common condition. the objective of this analysis was to describe patterns of non-respiratory comorbidity among adults hospitalized with asthma in australia. methods data on hospitalizations for people aged 15 years and over with a principal diagnosis of asthma (j45, j46) were obtained from the australian institute of health and welfare's (aihw) national hospital morbidity database for the period 2005-06. patterns of comorbidity were examined by investigating additional diagnoses for non-respiratory disease according to icd-10 diseasespecific chapters. results among people aged 15 years and over hospitalized in 2005-06 with a principal diagnosis of asthma (16,566 hospitalizations; 70% female; 47% aged 35-64 years), 33% had at least one non-respiratory comorbidity. median length of stay was higher among those with at least one comorbidity (4 days) than among those with no comorbidities (2 days). among people aged 15-64 years, the most common comorbid condition was endocrine, nutritional and metabolic diseases (19%), while among those aged 65 years and over it was diseases of the circulatory system (32%). conclusions a large proportion of asthma hospitalizations in australia are associated with non-respiratory comorbidity and a longer length of stay. further, the pattern of non-respiratory comorbidity associated with asthma hospitalizations varies by age. given our rapidly ageing population, the level of comorbidity associated with asthma has implications for coordinated health care and demand on health services. support acam is a collaborating unit of the aihw and is funded by the department of health and ageing. keywords comorbidity, hospitalization, asthma. background asthma exacerbations are often triggered by viral respiratory infections, yet the influence of respiratory infections on the morbidity of acute asthma beyond the immediate period is unknown. we examined the influence of nasopharyngeal (npa) respiratory viral, chlamydia and mycoplasma detection on asthma morbidity in children presenting to the emergency department for an acute exacerbation of asthma. methods a subset (n = 78) of the 201 children enrolled for a randomized controlled trial (rct) on the efficacy of 5 vs 3 days of oral prednisolone had an npa taken at presentation. npa were examined for chlamydia, mycoplasma and respiratory viruses (enteroviruses, coronaviruses, human metapneumovirus, adenovirus, parainfluenza, influenza, rsv, rhinoviruses) by pcr. enrolled children were aged 2-16 years with recurrent wheeze and required ն600 ?g (mdi/spacer) or ն2.5 mg (nebulized) of salbutamol to reduce tachypnoea. parents filled validated diary cards for cough and asthma severity, and completed asthma qol data at enrolment and end of weeks 1 and 2. results pcr for various viruses was positive in 42 (53.8%) children, with no significant difference in the groups the children were randomized into. rhinovirus pcr was positive in the npa of 32 children, rsv in 7, hmpv in 2, adenovirus, parainfluenza, influenza a and b in one each. specimens were negative for the other micro-organisms listed above. children with a npa viral positive state were significantly (p = 0.002) younger than those with a negative state. however, there was no difference in the any of the asthma outcomes of children whose npa was positive or negative for the micro-organisms tested. conclusions in children with an acute asthma exacerbation presenting to emergency health facilities, a respiratory virus could be identified in >50% but the presence of a respiratory virus did not influence the morbidity of the asthma exacerbation at presentation or at the end of week-1 and week-2. the university of sydney, nsw 2006, and 3 royal north shore hospital, st leonards, nsw 2065 airway wall thickness measured using hrct is reported to be increased in asthmatic compared with control subjects. however, it is unknown whether wall thickness is a fixed structural characteristic of the airways or if it responds to transient changes in bronchomotor tone or airway size. aim to determine the effects of bronchomotor tone and lung volume on airway wall area measured by hrct. methods 8 patients with doctor-diagnosed asthma had partial chest hrct scans, before and after bronchodilator (bd), at frc, tlc and a volume midway between (mid-volume). airway segments were identified between branch points and matched between consecutive lung volumes both before and after bd, and also at constant lung volume before and after bd. mean lumen areas and wall areas for each airway segment at each volume were measured using automated analysis software. paired t-tests were used to determine changes due to bd and lung inflation. results 44 airways were matched before and after bd at frc. absolute airway wall area (wa) was related to airway lumen diameter (di wood smoke air pollution is of concern with respect to respiratory health due to its complex chemical composition and potential to carry air toxics into the lower respiratory system. launceston has a long history of poor winter air quality, primarily due to use of domestic wood heaters. participants in hobart had a similar prevalence of wood heater use, but hobart does not experience the same wood smoke pollution (due to differences in regional geography , asthma control and anxiety and depression were completed at baseline, immediately following (6 wks), and 3 mths after the intervention period. results clinically and statistically (p < 0.05) significant improvements in qol were observed in the exercise group at 6 wks compared to the control group. this difference was not maintained at 3 mths. 6mwd improved at 6 wks and 3 mths in the exercise group (p < 0.01), however the difference between groups was not significant. in the exercise group there was a trend towards improved asthma control and a reduction in anxiety and depression that was not observed in the control group. *p < 0.05, change at 6 wks vs baseline; home asthma monitoring is important for measuring day-to-day variation in lung function and symptoms. this approach requires the availability of complete diaries for a comprehensive assessment. we assessed the completeness of written diaries collected as part of a nation wide study of air quality and child health. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified from a cross-sectional study. these children were asked to record symptom scores and peak expiratory flows twice daily in diaries for a five week period. the diaries and peak flow devices were explained at a face-to-face meeting with parents and children. each week diaries were mailed back and parents received a phone call to encourage completion. completeness was defined as no missing responses to symptom questions or peak flow measurements in diaries from week two to week five. results data from the first 36 children (822 day records) were available for analysis. the sample included (53%) girls, mean age 10 yrs. the overall frequencies for complete records were; morning symptoms 85%, morning peak flow 85%, evening symptoms 83% and evening peak flow 82%. there was a significant trend for more complete morning peak flow records over the four weeks (cochrane-armitage trend test p < 0.007). agreement between morning and evening symptom completeness and between morning and evening peak flow completeness was fairly poor (kappa < 0.30). conclusions the completeness of symptom and peak flow records collected in this study was very high. the comprehensive follow-up protocol implemented is likely to have had an important impact on the completeness of asthma diaries. daily peak expiratory flow (pef) monitoring has been used in epidemiological studies to assess changes in lung function over time. the value of written pef diaries has been questioned because of problems with completeness and validity. this study aimed to compare stored electronic pef data and a written diary record of those data in a panel study in children with weekly reminders to aid adherence. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified in a population study. they were given electronic pef devices with a digital readout (miniwright digital, mwd, clement clarke, uk) and written symptom and peak flow diaries and instructed in their use at a meeting with parents and children. each child was asked to complete three pef manoeuvres every morning and evening for five weeks and to record these in the written diary. background previous research suggests that comorbid anxiety is associated with lower asthma-related quality of life (aqol) in adults with asthma. however, research is scant on the role of psychological interventions in these patients. aim to evaluate the effectiveness of a four-session cognitive-behavioural therapy (cbt) intervention, in improving the aqol, in participants with anxiety and asthma. method participants identified with comorbid anxiety and asthma were randomly assigned to the cbt intervention group (n = 10) and the asthma monitoring control group (n = 8) and evaluated on aqol measures, at various intervals. results nine participants, in the cbt group, completed the study. seven participants showed a clinically significant improvement in asthma-related emotional functioning (ef) and six participants in total aqol scores, at the 5-week post-intervention assessment. additionally, six participants in the cbt group indicated clinically significant improvement in ef and five participants in total aqol scores, at the 3-month follow-up assessment. only three participants in the control group completed the study. none of these participants showed any improvement in aqol scores at the 5-week or 3-month assessment. conclusion this pilot study suggests that a higher number of participants in the cbt group showed clinically significant improvement in ef and total aqol scores with higher retention rates. further research needs to confirm these findings in a larger group, identifying the elements of a successful cbt intervention and characteristics of participants who respond to the cbt intervention. gastro-oesophageal reflux disease (gord) is a risk factor for uncontrolled asthma. we conducted an update of a systematic review to assess whether treatment of gastro-oesophageal reflux in subjects with asthma improved asthma outcomes. methods randomized controlled trials (rcts) of gord treatment in adults or children that reported asthma health outcomes and had symptomatic gord were included and assessed in accordance with the standard cochrane systematic review process. subjects received pharmacological therapies compared with conservative management. results from 261 potentially relevant studies, 19 rcts were included in the review. when compared to placebo, morning peak expiratory flow did not significantly improve (change from baseline wmd 10.43, 95% ci: -9.55 to 30.42) with proton pump inhibitor treatment (n = 7 trials involving 739 participants). asthma exacerbations were not significantly less in the intervention groups compared with the control groups (odds ratio 0.66; 0.41-1.08; n = 557). conclusions while some trials reported evidence of asthma improvement with gord therapy, overall there appears to be no statistically significant evidence of a beneficial effect. it is clear that not all persons with gord and asthma will gain improved control over their asthma with gord therapy; this may be due to the heterogeneous pathophysiology of asthma. future large-scale trials would be required to demonstrate an effect on asthma exacerbations. kel and brd were supported by a cochrane airways group scholarship. background the ats/ers task force recommend the use of metered dose inhaler (mdi) and spacer for airflow limitation reversibility testing. salbutamol given via mdi & spacer has been shown to be equivalent to a nebulizer in the clinical setting. this has not been well studied in respiratory laboratory setting. aim to compare the 2 methods of reversibility testing in a laboratory setting. methods we conducted a laboratory based crossover study in a secondary hospital. patients with asthma or copd were eligible. the patients firstly underwent spirometry and reversibility testing following a standard dose of nebulized salbutamol. they were asked to return for a second set of spirometry within the same week and at the same time of day when reversibility with an mdi and spacer was recorded. we used an incremental dose of salbutamol starting from 2 puffs and up to 8 puffs. spirometry parameters were recorded 10 minutes after each intervention. the primary outcome was the percentage change in fev1 after each intervention. side effects were monitored for. results nine patients with asthma were recruited. the mean percentage change in fev1 was higher in the nebulizer group than after only 2 puffs via mdi & spacer (15.4 ϯ 7.4 vs 6.2 ϯ 8 [mean ϯ sd], p = 0.67). however, there were no differences between the 2 arms following higher doses of bronchodilator via mdi & spacer. the mean percentage change in fev1 after 4, 6 and 8 puffs were 12.6 ϯ 11.3, 15.4 ϯ 12.3, and 17.7 ϯ 13.6 respectively (p = 0.09, 0.05 and 0.07 respectively when compared to the nebulizer group). conclusion using an mdi and spacer for bronchodilator reversibility is equivalent to that of a nebulizer and should be the standard method of testing. the dose of bronchodilator needs to be at least 4 puffs as recommended by the ats/ers; however 6 puffs correlated best with a standard nebulizer route. further increments in bronchodilator dose provided little additional bronchodilatation. the study was limited by the small number of patients. asthma guidelines recommend a stepwise approach to treatment. the role of inhaled corticosteroid (ics) and long-acting beta-agonist (laba) combination therapy in asthma written action plans is not clear. objective to assess the efficacy of adjusting ics/laba combination therapy in a written action plan compared to fixed dosing in people with asthma requiring maintenance ics. methods cochrane systematic review of randomized controlled trials comparing ics/laba combination therapy in a single inhaler that is adjusted up or down according to a written action plan (wap) to comparison 1: budesonide/ formoterol given as a fixed maintenance dose (fd) (n = 9) or comparison 2: fluticasone/salmeterol fd (n = 2). results 10 parallel randomized controlled trials describing 11 interventions met the inclusion criteria. for the trials that compared wap to fd budesonide/ formoterol there were significant reductions for the wap group in exacerbations, (rr (95%ci): 0.82 (0.70 to 0.97)), severe exacerbations (rr (95%ci): 0.61 (0.37 to 0.99)) and study medications (wmd (95%ci): -1.18 (-1.23 to -1.14)) with no difference in asthma control or adverse events. the results for the two trials reporting wap budesonide/formoterol to fd fluticasone/ salmeterol were discordant and a homogenous pooled result could not be determined. of the 318 australians who died from asthma in 2005, over two thirds were over 50 years of age. this trend resulted in the national asthma council of australia (nac) calling for better management of asthma in the elderly. we designed an educational intervention using evidence based educational strategies to improve the content and style of general practice consultations for older people with asthma. methods randomized controlled trial of a multi-faceted program consisting of a group educational session, a videotaped standardized simulated patient consultation, followed by an academic detailing session. forty-two gps were randomized into an active or a control group. gps provided the names of patients who would be happy to participate in the study and the program was evaluated by patient and gp outcomes. results gps recruited into our program reported improvements in a range of clinical areas. one hundred and ten patients were recruited, their outcomes are under analysis. conclusion gps were overwhelmingly positive about participation in this trial and our intervention successfully improved the capacity and confidence of gp's to deliver care to older people with asthma. our study also developed several tools that would enable dissemination of our findings. supported by an asthma targeted in studies where direct clinical assessment is not possible, urgent health care utilization (hcu) is often used as an indirect measure of asthma control. this study aimed to identify factors predicting urgent hcu and asthma control. methods patients in nsw with a doctor diagnosis of asthma were recruited from community pharmacies, a research volunteer database, and databases of asthma foundation nsw, to complete a questionnaire about asthma. poor asthma control was defined as asthma control questionnaire (acq) score ն1.5. urgent hcu was defined as hospitalization, ed visit, or urgent doctor visit due to asthma. multiple logistic regression was used to identify predictors of poor control and urgent hcu. results questionnaires were completed by 608 adults (61% female) with a doctor diagnosis of asthma (pharmacy 260, woolcock 299, asthma foundation 87). 87% used inhaled corticosteroid (ics) ϯ long-acting b2-agonist in the last 4 wks. median age was 56 yrs (range 12-87), and 9% were current smokers. mean acq score was 1.4 (95% ci 1.3-1.5), with 40% of participants having poor asthma control (acq ն 1.5). 28% had urgent hcu for asthma in the previous year. significant independent predictors for poor asthma control were younger age, current smoking, living in more disadvantaged areas, being retired, having only primary education, and holding a concession card. predictors for urgent hcu were younger age, being in full-time employment, having only primary education, and being of non-english speaking background. neither ics use nor possession of a written asthma action plan was associated with lower risk for either poor asthma control or hcu. conclusions poor asthma control is common in nsw even in patients using inhaled corticosteroids. although urgent hcu is often used as an indirect measure of poor asthma control, it is affected by different factors, perhaps because health care utilization represents a more complex balance between need and access. bronchial challenge tests with mannitol, to measure airway hyperresponsiveness, can take up to 30 minutes and require inhalation of up to 635 mg of mannitol. our aim was to determine if positive mannitol challenges can be detected after half the maximal dose (315 mg) using the forced oscillation technique (fot) to measure response. methods 15 non-asthmatic subjects and 52 asthmatic subjects underwent standard mannitol challenge, up to 635 mg mannitol. respiratory system conductance (grs) and reactance (xrs) was measured by fot at 6 hz during 40 sec tidal breathing immediately after each dose of mannitol. fev1 was measured after fot, within 90 sec of mannitol administration. two point dose response slope (drs), was calculated for grs (drsgrs) and xrs (drsxrs) for standard tests, up to 635 mg, and for short tests by excluding data from doses above 315 mg. ability to detect a positive test, defined as pd15fev1 < 635 mg, was determined by the area under the roc curve (auc) and repeatability by intra-class correlation coefficient (icc). results 32 asthmatic and 2 non-asthmatic subjects had positive tests, with pd15 fev1 values from 9.2 to 622 mg. auc (95%ci) did not differ between standard (std) and short tests for drsgrs (p = 0.14) or drsxrs ( combined use of inhaled steroids (ics) and long acting beta-agonists (laba) have an important role in asthma management. we used data from a 2006 population sample to examine medication use in adults and children. methods all adults (18-75 years) and children (2-17 years) from within four discrete zones in northern sydney were eligible for an interview survey, as part of a study investigating health effects associated with traffic-related air pollution. the prevalence of use of short-acting beta-agonists (saba), any ics (alone or combination) and combined formulations of ics/laba in the previous three months was estimated for the study population and those with diagnosed asthma. results there were 806 children [mean (sd) age 8.7 (4.6) years and 50% female] and 2184 adults [mean (sd) age 45.6 (14.9) years and 56% female] interviewed in 1843 households, representing an overall response rate of 33%. the prevalence of ever diagnosed asthma was 16.1% in children and 17.4% in adults. medication data were missing for 301 subjects. background asthma affects 1:9 adult australians and is a leading cause of rejection for recruitment into the australian defence force (adf). within this diagnosis there is a wide spectrum of disease activity and clinical outcomes. also asthma assessment and management has improved so that many asthmatics are now fully active without any significant disruption or risk to their lives. hypothesis: there is a subgroup of asthmatics who are at very low risk from significant adverse effects from asthma and who could be considered for recruitment to the adf. aims 1. to identify the subgroup of asthmatics who could be considered for recruitment to the adf. 2. to develop an assessment process to identify this subgroup (screening). 3. to develop a process to evaluate the outcomes of any change to the recruitment standard for asthma (evaluation). methods 1. a literature review of the natural history, assessment, management and response to treatment of mild episodic and mild persistent asthma. 2. a literature review of asthma in the military. 3. a clinical review of the outcomes of known asthmatics in the adf. 4. an expert group to review the above and to develop a screening process and an evaluation of the program. the literature review identified a subgroup of asthmatics, defined as mild episodic and mild persistent, who with appropriate management, have a low risk of significant adverse asthma outcomes. they can be identified by a combination of questionnaire, spirometry and bronchial provocation testing. a screening process has been developed which allows asthmatics to be recruited with a negative mannitol or hypertonic saline challenge on 400 mg/day or less of budesonide (or equivalent) without laba. a methodology to evaluate the impact of these changes on the recruitment standard has also been developed. alexithymia is a personality trait associated with difficulty identifying and communicating emotional and physical feelings. it has been associated with poor control of asthma and near fatal asthma. the primary objectives of this study were to: (1) identify alexithymia in a cohort of australian asthma patients; (2) investigate the relationship between alexithymia and asthma control; (3) investigate the relationship between alexithymia and asthma management. methods cross sectional study of 25 moderate to severe asthma patients recruited from royal adelaide hospital outpatients. participants were either mailed the questionnaire pack or completed it after a clinic appointment. existing validated questionnaires were used. statistical analyses were performed using spss. results 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years, sd = 11) participated. alexithymia scores ranged from 23.0 to 76.0 (x = 48.3, sd = 13.2). 12% (n = 3) of participants could be classified high alexithymia, 32% (n = 8) borderline alexithymia and 56% (n = 14) were low alexithymia. alexithymia mean scores were not statistically different across sociodemographic variables. a positive correlation/association was found between alexithymia score and asthma control score (r = 0.57, p < 0.01), quality of life (r = -0.65, p < 0.01), and adherence (p = 0.03) but not satisfaction with communication (r = -0.27, p = 0.2) or number of hospitalizations (p = 0.25). conclusions this is the first australian study to identify alexithymia among asthma patients and investigate relationship to control as well as management and communication. associations between alexithymia and asthma control were confirmed. a larger sample size is needed to determine impact of alexithymia on self-management and provision of clinical care for asthma. port hedland is impacted by iron-containing dust particles (pm10) that may activate lung cells when inhaled. furthermore, the effects of port hedland pm10 may differ from the effects of urban pm10 impacting metropolitan areas. the aim of this study was to assess the effects of port hedland pm10 on production and release of the inflammatory cytokines, il-6 and il-8, by human airway epithelial (a549) cells, and to compare these with the effects urban pm10 from metropolitan areas. methods human airway epithelial (a549) cells were exposed to pm10 collected at port hedland and at urban locations (sydney, perth). a549 cells were exposed to a range of pm10 concentrations (20-200 mg/ml) for 24 h. lipopolysaccharide (lps) and phorbol myristate acetate (pma) were used as positive controls. supernatants from cell cultures were assayed for il-6 and il-8 using specific elisa kits. rna was extracted and reverse transcribed to cdna. il-6 and il-8 mrna expression was quantified by duplex real-time pcr using taqman primer/probes. results lps stimulated a 2.7-fold increase in il-8 release and pma stimulated a 3-fold increase in il-8 release and a 30-fold increase in il-6 release. however, neither port hedland pm10 nor urban pm10 stimulated concentration dependent release of il-6 or il-8 by a549 cells. expression of il-6 or il-8 mrna was also not altered by port hedland or urban dust. cd8+ t-cells may cause airway epithelial cell apoptosis via the granzyme pathway. we have reported increased apoptosis of airway epithelial cells and increased bal t-cell expression of granzyme b in copd, and a positive correlation between the two. we hypothesized that the increased granzyme b would also be related to smoking history (pack years -pk/y), age and severity of airflow obstruction (fev1 %pred) in patients with copd. we further hypothesized that the t-cell granzyme b expression would be higher in the airway than the peripheral blood. methods we investigated t-cell intracellular granzyme b expression in blood from copd subjects (33 current and 24 ex-smokers) and 12 never-smoker controls, and bronchoalveolar lavage (bal) and bronchial brushing (intraepithelial t-cells) from a cohort of these subjects using flow cytometry. correlations between granzyme b and pk/y, age or fev1 were performed using spearman's rank correlation. granzyme b in t-cells from blood, bal and bronchial brushings were compared. results there were significant correlations between fev1 and granzyme b expression in blood and bal (blood: r -0.444, p = 0.002; bal: r -0.368, p = 0.029). there was a significant correlation between pk/y and granzyme b expression in blood (r 0.362, p = 0.002), but not in bal. there were no significant correlations between granzyme b and age. there were no significant differences in granzyme b expression in blood, bal or intra-epithelial compartments. conclusion granzyme b is expressed at similar levels in blood, bal and intra-epithelial compartments, supporting recent opinion that copd is a systemic disease. t-cell granzyme b is related to severity of airflow obstruction and smoking history in patients with copd and may be one mechanism of apoptosis leading to lung injury and airflow obstruction in copd. jc allen 1 , t schlosser, ee ramsay 1 , q ge 2 , aj ammit 1 as development of remodelled airways is correlated with deterioration of lung function, we require therapies that reduce and reverse structural changes in remodelled airways. in asthma, corticosteroids can halt some, but not all, aspects of airway remodelling. therefore, in order to aid future design of efficacious anti-remodelling agents we need a better understanding of the molecular mechanism/s underlying the development of airway remodelling and the effectiveness of corticosteroids. hyperplasia of airway smooth muscle (asm) is a feature of the remodelled airway in asthmatics. in this study we examined the effect of corticosteroids on a key regulator of g1 progressioncyclin d1. asm cells from n = 8 non-asthmatics and n = 7 asthmatics were pretreated for 1 h with vehicle or dexamethasone (0.1 mm). the temporal kinetics of cyclin d1 mrna and protein expression were measured up to 24 h after stimulation with the mitogen platelet-derived growth factor-bb (pdgf-bb). pdgf-bb induced a significant increase in cyclin d1 mrna expression in asm from non-asthmatics (2.6 ϯ 0.3-fold) and asthmatics (2.9 ϯ 0.3-fold) after 24 h stimulation. in non-asthmatics, the corticosteroid dexamethasone significantly (p < 0.05) reduced the amount of cyclin d1 mrna expressed (to 1.6 ϯ 0.2-fold). in contrast, cyclin d1 expression in asthmatics was relatively resistant to inhibition by dexamethasone; the amount of pdgf-bb-induced cyclin d1 expression in the absence or presence of dexamethasone was not significantly different ( sphingosine 1-phosphate (s1p), a bioactive sphingolipid found elevated in the airways of asthmatics, modulates myriad airway smooth muscle (asm) functions that promote inflammation and remodelling in asthma. in this study, we uncover the molecular pathway/s underlying s1p-induced secretion of il-6, and investigate if, and how, corticosteroids inhibit il-6 secretion. using cultured asm cells from non-asthmatics, we found that s1p induces il-6 secretion from asm cells via cre, but not ap-1, c/ebp or nf-kb, transcriptional regulation of il-6 gene expression. cre-dependence was supported by s1p-induced creb phosphorylation. although the corticosteroid dexamethasone reduced s1p-induced il-6 secretion in a dose-dependant manner, this inhibition appeared to occur via a pathway independent of creb/cre, suggesting the existence of a parallel pathway. as we recently discovered that the antiinflammatory actions of corticosteroids in asm can be mediated via the induction of the endogenous mitogen-activated protein kinase (mapk) inhibitor, mapk phosphatase-1 (mkp-1), we investigated whether mapk represents the parallel pathway targeted by corticosteroids. we found that s1p can induce activation of a variety of mapk, however, only p38 mapk phosphorylation was inhibited by dexamethasone; importantly, the increase in mkp-1 after corticosteroid treatment appeared to mirror the decrease in s1p-induced p38 mapk phosphorylation. furthermore, exogenous expression of mkp-1 inhibited s1pinduced il-6 secretion. taken together, these results suggest that parallel pathways exist to induce il-6 secretion (transcriptional via creb/cre and possibly post-transcriptional via p38 mapk) and serve to underscore the importance of mkp-1 upregulation as a mechanism of action of corticocosteroids in asm. angiogenesis is a hallmark feature of asthma. angiogenic promoters, such as vegf and tgfb are reported to be increased in airways of asthmatics. tumstatin, an endogenous angiogenic inhibitor, is the non-collagenous domain-1 (nc1) of the alpha3 chain of collagen iv. decreased levels of collagen iv have been reported in the airways of asthmatics. we investigated the presence of tumstatin in the airway of asthmatics and its potential role as an angiogenic inhibitor. we detected the six a chain nc1domains of col iv and the 7s domain of the a3 chain using immunohistochemistry. the level of tumstatin in serum and bal-f was measured by dot blot. western blots were used to identify the association with the rest of the collagen iv molecule. a tube formation assay using primary pulmonary endothelial cells (ppec) was performed to evaluate the role of tumstatin in the airway. the effect of intranasal tumstatin on airway hyperresponsiveness and angiogenesis was studied in an ovalbumin mouse model. tumstatin was absent in the airways of asthmatics (n = 14) while the remaining six collagen iv a chains were present. the 7s domain of the a3 chain was present in the asthmatic airway (n = 6). tumstatin was detected in both serum and bal-f samples from asthmatic volunteers (n = 10), however the level of expression was not significantly different from that in nonasthmatics (n = 7). in asthmatic serum tumstatin was part of the whole collagen iv a3 chain. tumstatin was able to inhibit ppec tube formation in a dose related manner. tumstatin inhibited angiogenesis in the mice airways and was associated with an improvement in ahr. the fact that tumstatin is absent from asthmatic airways and inhibited airway hyperresponsiveness and angiogenesis may indicate potential for therapeutic intervention in airway remodelling. this work was supported by the crc for asthma and airways and nh&mrc. introduction epithelial egfr (epidermal growth factor receptor) expression correlates with disease severity and neutrophil infiltration in asthmatic airways. acute exacerbations of asthma and copd are also associated with steroid refractory neutrophilic inflammation, with rhinoviruses being the most common trigger. .7 mg/l and il-6: 5.8 vs. 3.6 ng/l). since il-6 stimulates the acute phase response, we correlated its levels with the other markers. only crp was strongly correlated with il-6 (spearman r = 0.58, p < 0.0001), suggesting differential regulation of saa and ip10. saa discriminated between non-pathogen (n = 10) vs. pathogen-associated (n = 41) events (saa: 9.4 vs. 44.1 mg/l p = 0.005), whereas no significant change was observed in the other markers (ip-10: 139.8 vs. 170.5 ng/l, crp: 4 vs. 10 mg/l, il-6: 4.6 vs. 7.2 ng/ l). however when aecopd marker levels were stratified on the basis of pathogen type (viral = 12, bacterial = 21, viral and bacterial = 8), none of the markers were significantly altered. conclusions ip-10 is significantly elevated during an aecopd, however only saa differentiated non-pathogen from pathogen associated events. background severe persistent asthma is characterized by structural changes in the airways-airway remodelling. airway smooth muscle (asm) cells have the potential to play a key role in these processes through the release of growth factors, cytokines and extracellular matrix (ecm) proteins. we have previously studied the effects of budesonide and formoterol individually however, the effect of their combination on these characteristics of asm cells is not known. methods asm cells from asthmatic (n = 6) and nonasthmatic (n = 6) individuals were stimulated with transforming growth factor ß (tgfß) (1 ng/ml) with or without budesonide (10 -8 m) and formoterol (10 -10 and 10 -8 m) and fibronectin levels and interleukin-6 (il-6) release were measured by elisa. bronchial rings from nonasthmatic individuals (n = 2) were incubated with tgfß with or without the drugs and ecm protein expression (fibronectin and collagen i) measured using immunohistochemistry. results in nonasthmatic cells, budesonide alone induced fibronectin deposition whether tgfß was present or not. formoterol decreased fibronectin induced by tgfß and, when combined with budesonide, reversed the increase in fibronectin. a similar pattern was observed in asthmatic cells, except that budesonide did not further increase the tgfß mediated fibronectin release. as before [1] , il-6 was induced by formoterol but inhibited by budesonide. tgfßinduced il-6 was inhibited by both drugs and their combination in both cell types. in bronchial rings the presence of either drug did not affect tgfßinduced fibronectin or collagen i. severe combined immune deficiency (scid) spontaneous mutation specifically impairs differentiation of stem cells into mature lymphocytes. nod-cb17prkd scid (known as nod-scid) lacked nk cells, hence is commonly used in cell transfer experiments for transferring tissue and haematological xenografts. the aim of this study was to establish lung inflamamtory model in nod-scid strain. methods balb/c and nod-scid balb/c mice (n = 8) were exposed to cigarette smoke for 4 days, 2 and 4 weeks (9 cigarettes/day; 5 days/week). bronchoalveolar lavage fluid (balf) and lung tissue were collected for inflammatory profiling and analysis for cytokines, chemokines and protease expression and/or activity. results nod-scid have significant accumulation of macrophages in lung after 4 days, 2 and 4 weeks smoking as compared to no smoke control (p < 0.001) that was not different to balb/c (p > 0.05). nod-scid also have increased neutrophil number after 2 and 4 weeks smoking (p < 0.001). even though myeloid cell differentiation isn't affected by scid phenotype, nod-scid have one fold less neutrophil than balb/c mice (p < 0.001) that is also reflected in the reduced expression of matrix metalloproteinase-9. consistent with the known lymphopenic phenotype, nod-scid have significant but less lymphocytes recruitment as compared to balb/c mice after 4 weeks smoking (p < 0.001) despite the enhanced expression of inteferon inducible protein 10 (lymphocytes specific chemokine) in lung. both mouse strains showed the same elevation of net gelatinase and serine protease activity in lung. nodscid mice also demonstrated comparable transcriptional induction of proinflammatory cytokines (tnfa, il-6), growth factors (gm-csf, g-csf) and chemokines (mcp-1, mip-2), indicating susceptibility to smoke-induced injury. conclusions nod-scid mice are capable to mount smoke induced inflammatory response. this model may be useful to study localization and role of immunocytes, including adoptively transfer human cells in the pathogenesis of copd. supported by the nhmrc. rhinovirus (rv) is the cause of most common colds and up to 80% of asthma attacks. in our previous studies, plasminogen activator inhibitor 2 (pai-2) was expressed at high levels and was induced in vivo and in vitro by rv infection. pai-2 may have antiviral properties suggested by antiviral activity in some models, high pai-2 expression levels and further upregulation by rv infection. methods to determine whether pai-2 has antiviral activities following rv infection, o-hela, pai-2 expression-deficient cells were first transfected with pai-2 or control genes. this was followed by infection with rv and effects on viral replication were assessed by rt-qpcr for vrna and by viral titration for virus release. ifn expression was assessed by rt-qpcr. results ifn-a and -b mrna expression were induced in response to rv infection and to pai-2 expression in cells. pai-2 expression followed by rv infection elicited a synergistic response and pai-2 over-expression reduced vrna by >5 fold and viral titre by >3 log (p < 0.05). however, this effect was not specific to pai-2, as transfection of cells with control genes/plasmids reduced viral titre to a comparableextent. one of the pathological findings in idiopathic pulmonary fibrosis (ipf) is the presence on fibroblastic foci comprising cells which exhibit mesenchymal phenotypic features such as myofibroblast-like morphology, increased asma expression and collagen deposition. currently steroid treatment in ipf has shown limited efficacy. the cellular origins of these mesenchymal cells remain unclear, but evidence from other studies suggests that epithelial cells may undergo a transition to a mesenchymal cell phenotype (emt). transforming growth factor ß has been implicated in promoting this emt. in this study we have induced a morphological change in a549 cells using tgf-ß1 and assessed the influence of glucocorticoids, and the changes to the extracellular environment of the cells, on emt. methods a549 cells were grown on uncoated plastic cultures plates or those coated with monomeric or fibrillar collagen and treated with 200-500 pm tgf-ß1. the influence of the glucocorticoid, dexamethasone (dex, 1-1000 nm), or collagen type, on emt was assessed by microscopy, rt-pcr and western blotting for markers of myofibroblast phenotype. results tgf-ß1 induced an increase in mrna expression of asma (1.5 fold), collagen (7.0 fold) and fibronectin (2.0 fold). dex (100 nm) partially inhibited the expression of collagen, but had no effect on asma levels. however, dex (100 nm) reduced asma and ctgf protein levels. dex (100 nm) also prevented the tgf-ß1-induced morphological changes, regardless of ecm matrix. conclusion glucocorticoids appear to control some of the emt phenotype changes induced by tgf-ß1. however, the inability to fully inhibit these changes may contribute to the resistance of ipf to glucocorticoids. the extracellular environment may also play a role in the development of fibroblastic foci and their pharmacological responses. defective alveolar macrophage (am) phagocytic function in the airway may perpetuate inflammation via secondary necrosis of uncleared apoptotic cells in copd. we have previously reported that low-dose azithromycin improved macrophage function in vitro, although the mechanisms for this effect were not identified. we explored the possible role of the collectin pathway in the azithromycin-mediated improvement in phagocytosis as well as possible defects in this pathway in copd subjects. methods (1) mannose binding lectin (mbl), mannose receptor (mr), surfactant protein d (sp-d) were measured in copd subjects and controls. (2) the in vitro effects of addition of rhmbl, and blocking mr with a specific antibody, on am phagocytic ability were assessed. in vitro effects of azithromycin on am expression of mr were also investigated. (3) azithromycin (250 mg orally 2¥ weekly/12 weeks) was administered to 11 copd subjects. bronchoscopies were performed prior to and 12 weeks following therapy. ex vivo assessments included am phagocytic ability, levels of mbl, sp-d and mr and apoptosis of bronchial epithelial cells. results am mr expression and levels of mbl and sp-d were significantly reduced in copd subjects vs controls. azithomycin (500 ng/ml) increased mr expression by 31% in vitro. rhmbl induced a dose-dependent increase in am phagocytic ability (up to 148%). blocking mr significantly decreased am phagocytic ability by 60%. in copd patients following azithromycin therapy, we observed improved am phagcocytic ability, increased levels of mr and reduced levels of bronchial epithelial cell apoptosis. conclusions these findings strongly implicate the mr in both the defective phagocytic function of am in copd and as a target for the azithromycinmediated improvement in phagocytic ability. obstructive sleep apnea (osa) is associated with hypoxia and increased cardiovascular morbidity. t cells and monocytes play a significant role in atherogenesis via cytokine production. there have been reports of benefits of continuous positive airway pressure (cpap) therapy in osa. the purpose of this study was to characterize leucocyte inflammatory cytokine/chemokine production by t cells and monocytes in a group of osa patients and to investigate the therapeutic effects of cpap therapy. methods a comprehensive range of intracellular t-cell and monocyte proand anti-inflammatory cytokines/chemokines was investigated in peripheral blood from 5 osa patients and 5 aged-matched control subjects (with no evidence of sleep problems) using multiparameter flow cytometry. osa patients were again studied following 7 days of cpap therapy. results in osa patients there was an increase in intracellular t-cell ifng and tnfa production but no change in il-2, il-4 or tgfb compared with control. there was an increase in intracellular monocyte il-1a, il-8, tnfa, mcp-1 and mcp-3 in osa patients but no change in il-10 or il-12. following cpap therapy, t-cell ifng and tnfa production returned to 'normal' levels. however, although intracellular monocyte cytokine/chemokine production was decreased following cpap, levels were significantly elevated compared with control. conclusions osa is associated with increased intracellular proinflammatory cytokine/chemokines, many of which are increased in atherosclerotic plaques. although one week of cpap therapy resulted in amelioration of t-cell pro-inflammatory cytokines, longer cpap use or alternative therapy may be required to reduce monocyte pro-inflammatory mediators associated with atherosclerosis in patients with osa. gp130 has been associated with the progression of fibrosis especially in patients with idiopathic pulmonary fibrosis (ipf). gp130 is the common subunit of the receptor complexes for the il-6 family of cytokines including il-11 and oncostatin m (osm), where gp130-mediated signalling leads to activation of the erk or stat pathways. we have previously demonstrated exaggerated gp130-stat signalling to be fundamental to the development of pulmonary fibrosis in a murine model of bleomycin-induced lung fibrosis. the aim of this study was to elucidate the role of the il-6 cytokine family in the development of pulmonary fibrosis by identifying which il-6 family cytokines regulate fibrosis in bleomycin treated mice, and determine the effects of these cytokines on cell function. bleomycin (0.05 u/mouse) or control saline was administered intranasally to wildtype mice (wt), genetically engineered mice containing point mutations to prevent gp130 erk signalling (gp130 757f ) or gp130 stat signalling (gp130 dstat ), and duel il-6 and il-11 a-receptor knockout mice (il-6 -/-;il-11ar -/-). the effect of bleomycin on collagen production was examined in lung tissue 30 days post treatment by hplc. there was a significant increase in collagen levels in bleomycin treated wt lungs which was further increased in gp130 757f lungs. the lungs of gp130 dstat and il-6 -/-;il-11ar -/mice were protected from fibrosis suggesting that gp130-stat signalling is important in inducing lung fibrosis which may be mediated through il-6 and/or il-11. cell proliferation was examined in lung fibroblasts isolated from wt, gp130 dstat and gp130 757f mice. il-6, il-11 and osm were significantly mitogenic for gp130 dstat cells but not for wt or gp130 757f cells, reflecting different responses to the different signalling pathways. changes in cytokine profiles are currently being examined in lung tissue and serum of control and bleomycin treated mice 0-30 days after treatment. in conclusion, il-6 and il-11 are likely to play a role in bleomycin-induced fibrosis via the gp130-stat-mediated pathway, however this may not be due to regulation of proliferation induced by these cytokines. supported by the nhmrc. mimicking viral infection by application of various toll-like receptor ligands has shown clinical promise in the treatment of persistent viral infections and more recently with malignant tumours. commercially available toll-like receptor 7 ligands (tlr7l), such as those of the imidazoquinoline family have been applied clinically for the treatment of a number of conditions including basal cell carcinoma and hpv-induced genital warts. these compounds are known to retard tumour growth indirectly by promoting activation and migration of dcs, leading to a strong th1 cellular response, and directly via release of proinflammatory cytokines and promotion of tumour cell apoptosis. malignant mesothelioma (mm), an aggressive tumour with a mean survival of 9 months, is highly resistant to chemotherapy, radiotherapy and surgery and is therefore an interesting candidate for immunotherapy in the form of tlr7 ligand treatment. whilst tlr7 is known to be selectively expressed in immune cells and its relative expression low amongst other cell and tissue types in mammals, its expression on tumour cells and the consequences of such expression on tumour growth are unknown. here we describe the presence of tlr7 (mrna and protein) directly in a range of different tumours, including several murine and human mm cell lines. reactive oxygen species (ros) produced during the innate immune response are important agents of anti-pathogen defense but may also cause oxidative lung damage. glutathione peroxidase-1 (gpx-1) is a detoxifying enzyme that may protect lungs from such damage. methods wild-type (wt) or mice deficient in glutathione peroxidase-1 (gpx-1 -/-) were placed in a perspex chamber and exposed to cigarette (cig) smoke generated from 9 cigs per day for 4 days. on the fifth day, mice were killed, the lungs lavaged with pbs and then harvested for proteomic and genomic analysis. results wt mice exposed to cig smoke for 4 days had significantly more macrophages (3.1 ϯ 0.1(sem) ¥ 10 5 ) and neutrophils (4.9 ϯ 0.4 ¥ 10 5 ) than sham-exposed mice (2.2 ϯ 0.2 ¥ 10 5 and 0, respectively) (n = 6, p < 0.05). however, gpx-1mice exposed to cig smoke had significantly greater macrophages (5.4 ϯ 0.3 ¥ 10 5 ) and neutrophils (1.2 ϯ 0.1 ¥ 10 6 ) than smokeexposed wt mice (n = 6, p < 0.001). macrophage and neutrophil numbers in sham-exposed gpx-1 -/mice (1.7 ϯ 0.3 ¥ 10 5 and 0.5 ϯ 0.4 ¥ 10 3 ) were similar to those of sham-exposed wt mice (2.2 ϯ 0.2 ¥ 10 5 and 0). in addition, we found that balf of gpx1 -/mice exposed to cig smoke had an increased proteolytic burden compared with smoke-exposed wt mice as assessed by zymography and net gelatinase activity assay. conclusions these data suggest that gpx-1 protects the lung from cigarette smoke-induced inflammation and that targeting gpx-1 may have therapeutic utility in inflammatory lung diseases where cigarette smoke plays a role. funded by nhmrc. the becs from subjects with chronic obstructive pulmonary disease (copd) are exposed to frequent infectious and inflammatory stimuli. infection with rv is known to trigger acute exacerbations and subjects with copd are particularly susceptible. we hypothesized that exposure of copd becs to these stimuli would alter their response to rv infection. methods bec were obtained by endobronchial brushing from subjects with gold stage 3 copd (n = 4, all ex-smokers), subjects with mild persistent asthma (n = 4) and healthy controls (hc, n = 4). becs were cultured and then treated with tumour necrosis factor (tnf)a 10 ng/ml or lps 100 mg/ml for 24 hrs and then infected with rv-43, rv-1b. response was measured by release of il-8, il-6 and ip-10 mrna and by elisa. virus replication measured by cell titration assay. results infection with both rv strains led to increased release of il-8 and ip-10 in all groups. exposure of hc and asthma becs to both lps and tnf led to increased release of il-8. in these becs there was no increase in release of il-8 exposed to lps and tnf and then infected with either rv. becs from subjects with copd released significantly less il-8 in response to all conditions and rv infection compared to hcs and asthma. no differences were seen in rv replication. the aim of this study was to determine opinions and attitudes to exercise from chronic obstructive pulmonary disease (copd) subjects after completion of a 12-month maintenance exercise program. methods following completion of a 12-month exercise study, which included a supervised program (intervention, n = 18) and control group (control, n = 17), copd subjects [mean age (sd): 66 (8); mean fev1 (% predicted) = 56% (19)] were asked to complete a questionnaire. the questionnaire included closedended questions using visual analogue scales (100 mm). in copd the 6 minute walk distance (6mwd) is known to increase with test repetition (familiarization) and in response to exercise training. it is unknown whether the magnitudes of these increases are related to the degree of disability of the individual patient. methods 6mwd was measured twice before and once after an 8 week out-patient exercise program in 121 patients (82 males) aged 67ϯ8.6 yrs, fev1 37ϯ15% predicted (meanϯsd) with stable copd. the changes in 6mwd following a familiarization test and following training were compared between patients grouped according to their degree of disability (defined as the pre-training 6mwd [best of 2 tests] expressed as %predicted 6mwd). *p < 0.05 gp 3 vs gp 1. conclusions before training, 6mwd increases following a familiarization test irrespective of the level of disability. the magnitude of this increase is similar in all groups when normalized for their pre-training 6mwd. following training, the increase in 6mwd is greatest in patients with the greatest disability (lowest pre-training 6mwd). in less disabled patients, the relatively smaller increase in 6mwd following training may reflect an inability to further increase stride length, thereby reducing the responsiveness of the 6mwt in this group. supported by nhmrc. endotoxin is a stimulant of the innate immune system and is a major component of cigarette smoke. smokers have evidence of increased airway neutrophils and inflammation. we hypothesized that endotoxin levels would be higher in the bronchial lavage (bl) of subjects who were former smokers and subjects with chronic obstructive pulmonary disease (copd). methods subjects were all ex-smokers for at least 5 years (n = 10, 5 copd, 5 healthy controls) or never smokers (n = 12, 6 asthma, 6 healthy controls). bl was collected and analysed for cell count and differential, culture for microbiology. the supernatant was analysed for il-8 by elisa and endotoxin by quantitative kinetic lal assay. results median endotoxin levels were significantly higher in ex-smokers 101 compared to never smokers 6.3 u/ml (p < 0.001). there were no differences between subjects with copd and hs. subjects with copd had higher median endotoxin levels (80 u/ml), compared to asthma (5.2 u/ml) and hc (6.3 u/ml, p = 0.03). there was no correlation between endotoxin levels and bl total cell count, neutrophils (%) or fev1 % predicted. there was a strong correlation with previous packet years smoked and endotoxin levels (r = 0.72, p < 0.01). conclusions bl endotoxin levels are higher in ex-smokers, including subjects with copd. despite this there is no relationship to increased neutrophilic inflammation. copd is associated with inflammation associated with ineffective repair of the injured epithelium and loss of structural integrity. we have shown that these changes may result from dysregulated 'efferocytosis' (increased apoptosis of bronchial epithelial cells and defective clearance of these cells by alveolar macrophages (am)). we have also reported that azithromycin, at subbactericidal dose, improved am phagocytic function ex vivo. methods we administered azithromycin at low dose (250 mg/ twice weekly for 12 weeks) to 10 copd subjects (7 male, age: 62 ϯ 8 yr, 5 current/ 5 ex-smokers, fev1: 63 ϯ 9% pred, fev1/fvc: 48 ϯ 9%). the study was openlabel, uncontrolled and primarily focused on objective biological responses obtained from the bronchoscopy samples taken. phagocytic ability of am (from bal), apoptosis of bronchial epithelial cells (from bronchial brushing), markers of inflammation in blood, bal and breath condensate (crp, wcc and inflammatory cytokines), health status (st. george's respiratory questionnaire), ecg and lung function were assessed pre and post-administration of azithromycin. results azithromycin significantly improved phagocytic ability of am (by 37%) and reduced bronchial epithelial cell apoptosis (by 34%). antiinflammatory effects of azithromycin included significantly reduced blood wcc and crp. there were non-significant reductions in levels of pro-inflammatory cytokines il-8, il-6 and tnf-a in blood, bal and breath condensate, and a trend for improved health status. conclusions our findings indicate a novel approach to supplement existing therapies in copd that may improve clearance of accumulated apoptotic material and reduce the risk of secondary necrosis and release of toxic cell contents that perpetuate inflammation. background the prevalence of gastro-oesophageal reflux disease (gord) across the disease spectrum in copd and bronchiectasis is not well described. the aim of this study was to determine the prevalence of symptomatic and silent gord in copd and bronchiectasis and its effect on lung function and quality of life (qol 4] ) and 18 healthy controls were recruited. the prevalence of gord in bronchiectasis was 33%; 37% in copd; 17% in controls. in copd and bronchiectasis, total nre and ri were increased in those with distal and proximal gord compared to those without gord (all p < 0.05). there was no difference in extent or severity of bronchiectasis in patients with or without gord (all p > 0.05). in copd, the relationship between proximal gord and fev1 was small to moderate (r = 0.383). sgrq symptom scores were higher in patients with bronchiectasis with increased ri (p = 0.02). increased proximal nre was associated with reduced physical (p = 0.03) and mental health (p = 0.02) in the sf-36 in copd. conclusions gord is a co-morbidity in patients with copd and bronchiectasis. the impact of gord on disease severity requires further evaluation. funding source nhmrc, the university of melbourne, monash university, physiotherapy research foundation. chronic obstructive pulmonary disease (copd) is prevalent among older people, however little is known about the influence of ageing on airway inflammation. the aim of this study was to compare airway inflammation in older people with obstructive airway disease to groups of older and younger healthy controls. methods participants (>55 years of age) with stable airway disease and incomplete reversibility (fev1% predicted <80% and fev1/fvc < 70%; copd n = 71) and healthy controls (n = 45, 35 older >55 years and 10 younger <55 years) were recruited from the respiratory ambulatory care clinic or by advertisement. participants underwent a clinical assessment, skin allergy test, hypertonic saline challenge, sputum induction and gas diffusion studies. results participants with copd had moderate airflow obstruction (mean (sd) fev1% predicted 56 (19)) and 45 (63%) were current or ex-smokers with a median (iqr) pack year history of 36 (20-54) pack years. ageing was associated with an increase in airway neutrophils (p = 0.0001). compared to older controls, participants with copd had increased airway eosinophils and lymphopenia (p = 0.004, p = 0.003 respectively), but no difference in airway neutrophils. conclusion airway neutrophilia is a feature of ageing and is not further increased in the presence of copd. copd is associated increased numbers of airway eosinophils with reduced lymphocytes which may impact on the ability of the immune system to combat infection. supported by nhmrc, the university of newcastle. chronic obstructive pulmonary disease (copd) is third leading cause of death and fourth leading cause of disease burden in australia. mechanisms involved in emphysema severity have not been fully understood. micrornas are noncoding rnas that regulate gene expression. we hypothesize that microrna expression differs between emphysema severity in copd patients. methods mirna profiling was performed using 15k agilent human oligo mirna microarrays on total rna extracted from non-tumour lung tissue from 30 copd patients undergoing resection for lung cancer. the mirnas were quantile normalized and anova was used to find differentially expressed genes. results demographic characteristics of the copd patients (mean (sd)) were age 69 (6) years, fev1 72 (17) % predicted and fev1/fvc ratio (<70%). anova identified 31 mirnas that were differentially expressed when stratified into two classes according to kco % predicted > or <75% (t-test, p < 0.05). discussion this mirna analysis has identified mirnas that may be important in emphysema severity in copd patients. further validation will be performed using qrt-pcr and mirna assays on the training set and an independent set, and target prediction and validation. t-helper type 1 (th1) and type 2 (th2) lymphocyte responses have been well recognized as being important pathways in inflammation. recently another form of inflammatory lymphocyte response has been described, the th17 pathway. th17 cells produce cytokines such as il-17a to clear extra-cellular bacteria and fungi and have been implicated in autoimmune and chronic inflammatory diseases. the th17 response in copd is unknown. methods subjects were patients with copd (ex-smokers, fev1 < 70% predicted who had not had an exacerbation for at least 1 month) and control subjects (ex-smokers and normal spirometry). serum samples were obtained for measurement of c reactive protein (crp) and il-17a, the latter measured using enzyme-linked immunosorbent assay (elisa). production of il-17a by t-cell subsets was also identified by intra-cellular cytokine staining and measured by flow cytometry. the mean fev1 of copd subjects was 42 % predicted (6.1 sem, n = 6) and mean fev1 of controls was 112 % predicted (3.0 sem, n = 4). the copd group had a higher mean level of crp 9.5 mg/l (3.9 sem) compared to the control group mean level of 4.6 mg/l (0.6 sem). the mean level of the il-17 in the copd group as measured by elisa was 22.3 pg/ml (16.9 sem, range 0-87) whilst no il-17 was measured in any of the control subjects. conclusions the findings of this pilot study suggest that il-17 may be elevated in association with crp in stable copd. airway obstruction is defined as a fev1/fvc ratio below the lower limit of normal. airway obstruction may prolong the forced expiratory time (fet). method spirometry results from 467 patients were categorized as obstructive, restrictive or normal. the mean, range and coefficient of variation were determined for fet in each diagnostic group. receiver operator characteristic (roc) curves were used to determine if fet could predict a low fev1/fvc. the number of patients with airway obstruction in five fet groups: <9; 9; 10-12; 13-14; and >14 seconds were determined. results the coefficient of variation was high for all groups. pair-wise comparisons showed a difference in mean fet between patients with normal lung function versus those with airway obstruction (p < 0.001). the best cut-point in the roc analysis of 9.895 seconds had a sensitivity of 0.66, specificity 0.77 and area under the curve of 0.743 for predicting obstruction. the technique of skeletal muscle microbiopsy has previously been validated [1] and shown to be minimally invasive and well tolerated in participants with stable copd. aim a study was undertaken to determine the feasibility and tolerability of obtaining microbiopsy muscle samples from the patient admitted for acute exacerbation of copd patient. methods written informed consent was obtained to collect the muscle, blood and sputum samples for research purposes. local anaesthetic was injected prior to the insertion of a 16 gauge bard max core disposable biopsy instrument through the associated guide needle. multiple passes (up to 6) were obtained. the patient was asked to evaluate the experience by rating it on the modified borg scale 0-10. results to date 5 patients and 3 controls have participated in this study. the gold severity ranged from 2-4 and ats exacerbation severity 2-3. the mean age 75 years (range 68-83 years), bmi mean 23.6 kg m -2 (range 17.2-27.1 kg m -2 ) and fat free mass was determined using single frequency bioimpedance. the sample mass obtained ranged from 27.2-104.1 mg, with an increasing yield occurring with increased experience of the operator. the procedure has been well tolerated, the borg scale rating ranged from 1-2/10. all patients were ambulant post procedure; no haematoma or bruising was observed in any of the subjects. conclusion the microbiopsy technique allows the collection of muscle tissue with minimal discomfort to the participant. small tissue masses such as these are sufficient to obtain measures of local markers of wasting and may prove to be a useful adjunct to the collection of sputum and blood for the measure of biomarkers in copd research. introduction older people (op) with obstructive airways disease (oad) experience multiple problems that may impact on their quality of life (qol) and disease management. these problems may relate to pathophysiology, symptoms, self management skills, psychological issues, lifestyle or other problems identified as important by the patient. aim the aim of this study was to determine the frequency of clinical problems associated with oad and to determine if a problem based assessment (pba) could adequately identify these problems. methods a multidimensional assessment tool was developed and the content compared to clinical practice guidelines. participants over 55 years with diagnosed oad underwent this assessment. results sixty-one consecutive patients, aged 59-87 years, with mean (sd) fev1 of 51.4 (17.85) % predicted were assessed. the assessment tool identified a mean (sd) of 3.03 (2.13) current and significant co morbidities with an additional 11 (3.37) clinical problems per patient. qol was increasingly impaired with an increasing number of problems (p < 0.0001). regression modelling identified that the number of identified clinical problems accounted for 55% of the qol impairment. the model demonstrated that every additional patient problem was associated with a clinically significant change in qol impairment (4.22 units) . conclusions op with oad experience multiple clinical problems and co morbidities that adversely impact their qol. a pba of op with oad identifies significant problems that may not be addressed in a diagnosis centred approach. there is a need to identify and effectively manage this array of problems in clinical practice. discussion in this diverse group of copd patients, there was a positive correlation between dlco and fev1, but not kco and fev1. the fev1/ kco plot identifies substantial numbers of patients with the potential ad and e phenotypes defined above. we intend to study inflammatory biomarkers in these groups. fat free mass index (ffmi) is a marker of morbidity and mortality in copd. measurement of ffm in the out-patient population is commonly undertaken using single frequency bioelectrical impedance analysis (bia). however the formulae to convert measured values to ffm are population dependent. schols et al (am j clin nutr, 1991) suggested that formula used for the general population may be inappropriate for patients with copd, and derived a specific formula from total body water (tbw) as measured by deuterium dilution. we compare this method of measuring ffm with 5 others, along with tbw and ffm hydration. methods tbw was measured in 31 outpatients with copd by bia and a difference method (weight-(protein+bone mineral+fat+non-bone mineral+ glycogen)) and ffm hydration was calculated. ffmi was measured by skin fold anthropometry (sfa), bia (3 separate formulae), dual energy x-ray absorptiometry (dexa) and total body potassium by g-counter (tbk). comparison between methods for tbw and ffmi was made by bland-altman analysis and between methods of calculation of ffm hydration by paired t-test. the two methods of assessment of tbw showed little difference (bias -0.04, 95% limits of agreement -5.40 to 5.31). however there was a significant difference in calculation of hydration of ffm (p = 0.0001). sfa, bia (lukaski), bia (tanita) and tbk underestimated ffmi when compared to bia (schols), with bias of -1.24, -3.87, -1.06 and -2.76 respectively. dexa however had a bias of only 0.05 and 95% loa of -3.09 to 3.21. conclusions there are differences between methods of assessment of tbw and ffmi and comparing values between methods must be done with caution. this has implications for assessment of morbidity and mortality in copd. chronic obstructive pulmonary disease (copd) has been identified as a major health problem in australia. recent studies have suggested that respiratory viral infections are the major cause of a worsening of copd; however this has not been studied in australia. aim to characterize pef changes and identify viruses during copd exacerbations. methods a pilot prospective longitudinal cohort study was done. patients had confirmed copd with fev1 <70% predicted and reversibility <10% and/or 200 ml. patients recorded daily peak expiratory flow (pef) measurements and daily chest and cold scores over a period of 2 years. sputum samples and nasal aspirates were taken at 6-month review (control visit) and whenever they had symptoms of an exacerbation (worsening of copd symptoms -seemungal et. al. am j resp crit care med, 2001). nasal aspirates and sputum samples were obtained and analysed by rt-pcr for rhinovirus (rv). result five patients have finished 2 years of study. a total of 12 exacerbations were reported based on patient symptoms. only 3 exacerbations were associated with significant reductions in pef and only one was linked to increases in nasal cold scores. all samples taken at control visits and nasal aspirates and sputum samples during exacerbations were negative for rv by rt-pcr. positive controls confirmed the accuracy of the assay. conclusion our data suggest that a symptom-based definition of copd exacerbation is not always accompanied by significant reductions in lung function parameters. these 'exacerbations' are also not associated with the commonest reported viral cause. our findings suggest that variability of copd may mimic. bronchiectasis is characterized by hypersecretion of mucus and impaired clearance that results in mucus accumulation, chronic cough, sputum production and recurrent infections. inhaled mannitol (400 mg) improves clearance of mucus by increasing the airway hydration and by reducing the viscoelastic and surface properties of mucus. however, the effect of other doses of mannitol on the clearance of mucus in patients with bronchiectasis is unknown. methods fourteen patients, age: 63.3 ϯ 5.7 yr, were studied on 5 visits. clearance of mucus was measured using 99m tc-sulphur colloid and imaging with a gamma camera at baseline and with mannitol ( weight loss and skeletal muscle atrophy are major determinants of morbidity in chronic obstructive pulmonary disease (copd), which are independent of lung function impairment. thus, we examined if a high-fat diet (hfd) protected against the wasting associated with prolonged cigarette smoke exposure (se) in mice. methods male balb/c mice were exposed to the smoke of 4 cigarettes/day, 6 days/week for 7 weeks. sham mice were handled identically without smoke exposure. mice consumed either standard laboratory chow (3.5 kcal/g, consisting of 12 % fat) or a hfd (4.3 kcal/g, 32% consisting of fat). we examined the effect of se and hfd on hind limb skeletal muscles, lung (tissue & bronchoalveolar lavage (balf)) and systemic inflammation in the 4 groups of mice (n = 8/ group). results after 7 weeks of hfd, sham and se mice were 12 and 13% heavier (respectively, p < 0.05) than chow fed animals. conversely, se significantly decreased body weight of chow and hfd fed mice by 16 and 15%, respectively, compared to sham animals (p < 0.05). the hfd did not protect against the decrease in soleus, tibialis anterior and gastrocnemius skeletal muscle weights induced by se (p < 0.05). se altered the mrna expression of a number of genes associated with the regulation of skeletal muscle mass including insulin-like growth factor-i (igf-i), atrogin-1 and interleukin (il)-6. the mrna expression of pro-inflammatory cytokines and chemokines was significantly increased by se in the lung, as were the number of inflammatory cells in balf (p < 0.05). on the other hand, although obesity has been linked to systemic inflammation, the hfd exerted little direct effect on the skeletal muscle and lung parameters measured. se and hfd had no effect on two markers of systemic inflammation, il-6 and serum amyloid a, whereas se tended to reduce circulating igf-i, an anabolic hormone. conclusions the hfd was not protective against the weight loss and skeletal muscle wasting associated with cigarette smoke exposure. supported by the nhmrc and crc for chronic inflammatory diseases. background patients with copd and bronchiectasis undertake airway clearance therapy (act) and exercise as part of physiotherapy management but it is unknown whether these treatments provoke gastro-oesophageal reflux (gor). this study aimed to determine the impact of positive expiratory pressure (pep) therapy and exercise on gastro-oesophageal function. p. aeruginosa is a significant opportunistic lung pathogen in individuals with cystic fibrosis (cf) and is associated with increased lung disease and morbidity. early intervention is beneficial for the effective clearance of p. aeruginosa and better long-term health outcomes. currently, lung flora of cf patients is monitored by regular culturing of sputum, however, children unable to expectorate are limited to annual bronchoalveolar lavages (bal), which is invasive and requires general anaesthesia. saliva is useful for clinical assays as collection is simple, non-invasive. we are developing a standardized enzymelinked immunosorbent assay (elisa) to detect respiratory infection of p. aeruginosa in cf children who cannot expectorate. methods 18 children (7-18 years) with cf and recent p. aeruginosa lung infection history and 16 non cf children (1-6 years) with no previous p. aeruginosa infection history provided saliva as positive, negative controls respectively. saliva was obtained by spitting, or absorbed using cellulose swabs and later extracted. these cell-free supernatant samples were used in an elisa anti-p. aeruginosa iga using commercial antigen. all results were standardized to account for flow using total iga expression. results median value was increased 9 fold in the recent p. aeruginosa lung infection group (mann-whitney test, n = 34, p յ 0.001). there was no significance between mucoid and non mucoid samples, and detection was independent of cfu/ml. discussion early findings support that p. aeruginosa respiratory infection can be detected through specific analysis of salivary iga expression. larger population sampling (30 positive, 90 negative) will aid selection of cut-off values for specificity and sensitivity testing in the future to objectively determine the utility of this assay as a means of monitoring for p. aeruginosa and for determining effectiveness of treatment. medical thoracoscopy is utilized widely throughout europe and northern america by thoracic physicians for the management of pleural disease, including the undiagnosed pleural effusion, malignant effusions and less commonly pneumothorax (ptx). australia has limited experience in this modality. we report the success of medical thoracoscopy in both primary and secondary ptx requiring intervention. methods data were collected from 2001 to 2007 in patients treated with medical thoracoscopy for the treatment of ptx. results 11 patients, 7 male, 4 female. average age 48 (range 19-86). 1 first episode primary spontaneous (ps) ptx, 2 third episodes of ps, 5 first secondary spontaneous (ss), 1 second ssptx, 2 third ssptx. underlying pulmonary disease in secondary ptx included: 4 chronic obstructive pulmonary disease, 1 lymphangioleiomyomatosis, 1 mesothelioma, 1 metastatic angiosarcoma and 1 was secondary to a motor vehicle accident. 7 had a history of smoking, 5 were former smokers and 2 were current smokers, with a mean 24 pack year history (range 5-45). 7 ptx were large, 4 moderate. 5 patients had an intercostal catheter (icc) inserted prior to thoracoscopy, 1 had failed pleural aspirate. there was evidence of bronchopleural fistula in 7 patients prior to the procedure. there was a median of 9 days from ptx to thoracoscopy. light sedation was used for the procedure in 10 patients, 1 required a general anaesthesia with a double lumen endotracheal tube due to anxiety. single port entry, dry talc poudrage and a 16 gauge french icc was used for all procedures. icc was removed a mean of 2 days following thoracoscopy and patients discharged on day 4. pain was the most common complication, requiring narcotic analgesia. one patient died on day 7, secondary to metastatic angiosarcoma. there has been no recurrence of ptx in any patient. conclusion medical thoracoscopy, performed by thoracic physicians is an effective procedure for the treatment of pneumothorax requiring intervention, including selected patients with evidence of bronchopleural fistula. funding nil. conflict of interest nil. nomination for young investigator award no. background lung cancer incidence and mortality are high in tasmania. australia (aihw 2003) 85/100 000 72/100 000 tasmania (cancer registry 2003) 102/100 000 89/100 000 aims and objectives (a) to determine patient demographics in southern tasmania, (b) to determine compliance to identified measures of best practice and (c) assess referral rates, clinical utility and potential delay to positron emission tomography (pet) in a regional setting. methods a prospective database collected information on local clinical practice. cases presented at a multidisciplinary lung cancer meeting over a 12 month period (march 2006 -april 2007 were analysed. data were available for n = 121/161 (75%). results are shown as mean ϯ sd. results 113 primary lung cancer cases were identified. the mean age was 71 ϯ 11 years. 58% of patients were male and 95% were current or ex-smokers. 81% were non-small cell lung cancers (nsclc). tissue diagnosis 93% time from diagnosis to surgery (27 ϯ 15 days) 82% < 42 days macroscopically complete surgical resection (9/11) 82% pet for stage iiib before radical chemoradiotherapy 75% 62% of patients presenting with early or locally advanced disease underwent further staging with pet (n = 34/55). management was changed in 50% of cases (17/34). the average time from pet referral to scan was 11 ϯ 5 days. conclusion a disproportionate number of lung cancers occurred in women. although surgery was performed within recognized timeframes, 2 of 11 patients had incomplete resections. pet influenced management decisions and was performed in a timely fashion. hp chan 1,2 , v tran 1,2 , c lewis 1,3 , p thomas exhaled breath condensate (ebc) is a simple, safe and non-invasive method of sampling breath and has the potential to investigate lung cancer and the associated neoplastic process in the lungs. increased oxidative stress has been implicated in the pathogenesis of lung cancer, and is characterized by elevated hydrogen ions, and hydrogen peroxide (h2o2), which is formed from the conversion of superoxide anions by superoxide dismutase. airway ph has already been shown to be decreased in ebc of patients with other respiratory conditions, but not in lung cancer. therefore the concentration of h2o2 and hydrogen ions in the ebc of lung cancer subjects was compared with matched controls. methods six subjects with newly diagnosed lung cancer were recruited and matched with control subjects: non-smokers, ex-smokers and smokers. ebc was collected and h2o2 was then measured by an assay method based on oxidation of 3,3',5,5'-tetramethybenzidine by horseradish peroxidase and h2o2 while ph was measured using a ph meter. results there was a significant difference (p = 0.033, anova) in h2o2 concentration between the 4 groups with the lung cancer group having elevated mean h2o2 concentration of 23.68 mm (9.15 (sem) compared to the controls: non-smokers, 17.59 mm (6.53 (sem); ex-smokers, 14.35 mm (3.79 (sem); and smokers, 5.21mm (0.69 (sem). ph did not differ significantly (p = 0.659, kruskal-wallis test) between the groups. conclusion these preliminary data suggest that there is significant difference in h2o2 concentration between the groups. the demonstration of an elevated h2o2 level in those with lung cancer indicates an increase in oxidative stress which implies that this may be part of the pathogenesis or response to neoplasia. supported by none. conflict of interest none. pro-inflammatory th1 cytokines produced by t cells and monocytes play an important role in the immune response to malignant cells. however, tumours may escape immune surveillance by inhibiting th1 response and promoting chronic inflammation at the tumour site. methods to investigate the effect of soluble factors released by lung cancer cells on t cell and monocyte pro-and anti-inflammatory cytokines, culture supernatants from several lung cancer cell lines and a normal epithelial cell line (16hbe) were cultured with whole blood for 24 hours, then for a further 16 hrs with and without stimuli. intracellular cytokine / chemokine production was determined using multiparameter flow cytometry. results in stimulated cultures, there was a significant decrease in t cell th1 pro-inflammatory cytokines ifng, tnfa and il-2 and a decrease in monocyte il-1a, il-8, il-12, tnfa, mcp-1 and mcp-3 but an increase in antiinflammatory cytokine il-10 compared with 16hbe and control media. in non-stimulated blood cultures there was an increase in all monocyte inflammatory cytokines / chemokines in the presence of lung cancer supernatants. conclusions lung cancers secrete soluble factors that inhibit the antitumour pro-inflammatory th1 response by t cells and monocytes and upregulate monocyte anti-inflammatory cytokine il-10 following "antigenic challenge". lung cancer cells may also escape immune surveillance by secreting soluble factors that cause newly recruited monocytes to release inflammatory cytokines promoting chronic inflammation at the tumour site. cytotoxic t-cells (ctl's) are important barriers against tumour cells. ctl's induce apoptosis of target cells by mechanisms that include the release of pore-forming perforin and granule associated enzymes, such as granzyme b and granulysin. proteinase inhibitor-9 (pi-9) is the only known granzyme b inhibitor and its expression has been observed in some cancers. we hypothesized that pi-9 would be differentially expressed in lung cancer cells and may inhibit granzyme b-induced apoptosis in these cells. methods we investigated pi-9, granulysin and granzyme b expression in various lung cancer cell lines (1299 ( , 1466 ( , 2009 and normal epithelial cells obtained from bronchial brushing using flow cytometry. peripheral bloodderived t-cells were then incubated with lung cancer cell line supernatants and levels of pi-9, granzyme b and t-cell reactive oxygen species (ros) were assessed. results pi-9 expression was detected in all lung cancer cell lines, (1299 (54.2%), 1466 (90.2%), 2009 (85%), sbc-1 (81%)), at much higher levels than in normal bronchial epithelial cells (8.5%). granzyme b and granulysin levels were undetectable or low in cancer cells (0-9.2%). increased expression of pi-9 and reduced levels of granzyme b were observed in cd8+ t-cells in the presence of all cancer cell supernatants tested (p < 0.05). interestingly, t-cell ros levels were significantly increased in cd8+ t-cells after incubation with cancer cell supernatants (p < 0.05). conclusions high pi-9 expression in lung cancer cells combined with a reduction in t-cell granzyme b expression and enhanced intracellular t-cell ros levels may be a mechanism of immune evasion of lung cancer cells to granzyme b-induced cytotoxicity. immunotherapy for lung malignancies such as lung cancer and mesothelioma is most likely to be successful it it can be combined with conventional tumour debulking approaches such as chemotherapy and surgery. but they scientific basis of such combinations is yet to be determined. to study this we evaluated (1) the capacity of different lung chemotherapy drugs to alter tumour antigen cross-presentation and immunogencity, (2) duration of antigen presentation and responsiveness to immunotherapy after debulking surgery with/without lymphadenectomy, and (3) the pattern of tlr agonism which best synergized with chemotherapy and surgery. we used the ab1-ha murine model of lung malignancy in balb/c mice. results (1) the antimetabolite drugs gemcitabine and pemetrexed were most immunogenic compared to the cytotoxic antibiotics doxorubicin and mitomycin c and the alkylating agent cisplatin. gemcitabine delived large amounts of tumour antigen into the cross-presentation pathway. (2) tumour antigen cross-presentation persisted for only 10 days following resection. the optimal window for immunotherapy following cancer surgery is 1 week for effector ctl stimulation and 2-4 weeks for memory ctl stimulation. (3) the viral-like tlr agonists tlr 3, 7 and 9 were the most effective adjuvant tlr molecules, with tlr 7 agonists generating the strongest systemic anti-tumour responses. conclusion these results help explain previous lung immunotherapy failures and will inform new clinical trials. background mesothelioma is a highly aggressive tumour with an increasing world wide incidence. the serum biomarker mesothelin is elevated in some individuals prior to development of clinical symptoms of the disease and may be useful for screening. we therefore studied the sensitivity and specificity of urinary versus serum levels of mesothelin for mesothelioma patients and evaluated the influence if renal function on the biomarker level. materials and methods concurrent sera and urine samples collected from patients with and control populations. mesothelin concentrations were determined by double-determinant elisa using the mesomark tm assay (fdi, pa). their estimated glomerular filtration rate (egfr) was also calculated. results mesothelin levels correlated between serum and urine samples (pearson's correlation 0.791; p < 0.0001). mesothelin levels were significantly higher in patients with mesothelioma compared to those with asbestosis and/or pleural plaques in serum (4 ϯ 0.9 versus 0.9 ϯ 0.05 nm; p < 0.0001, respectively), in urine (1.9 ϯ 0.5 versus 0.3 ϯ 0.03; p < 0.0001) and in urine following normalization using creatine levels (0.2 ϯ 0.05 versus 0.04 ϯ 0.01). age and egfr were significantly associated with mesothelin levels. conclusion the sensitivity and specificity of mesothelin in urine and in serum were comparable. urine mesothelin may prove to be a useful alternative to serum mesothelin for mass screening of asbestos-exposed individuals. patients undergoing ct coronary angiogram (cta) are often former or current smokers with a high incidence of asymptomatic lung disease. overseas reports show a rate of lung abnormalities ranging from 6.7% to 19%. there are no studies from australia and local factors such as the higher incidence of atypical mycobacteria may influence the rate of benign findings. we are therefore performing a prospective observational study to identify the prevalence and characteristics of incidental lung findings in people undergoing routine cta. methods population: 100 patients undergoing routine cta after informed consent. intervention: radiologist evaluation of lung windows on diagnostic standard workstations. comparator: uncontrolled observational study of consecutive patients. outcomes: primary: prevalence and characteristics of abnormal findings, final diagnosis (clinical judgment, biopsy or long term followup). secondary: number of downstream investigations and costs. results 25 ctas have been studied to date. in 8/25 (32%), abnormalities were noted on lung windows. in 2/25 (8%), there were lung nodules, in 2/25 (8%) there were hilar lymph node abnormalities, in 1/25 (4%), there was hemidiaphragm elevation and in 3/25 (12%) there were pleural plaques (data collection ongoing with study closure expected in february 2008). conclusions preliminary data indicate a substantial number of incidental pulmonary findings from cta; full results will be presented. further analysis is required to determine the impact (benefits, costs and harms) that may result from the concurrent examination of lung windows at routine cta. aim increased levels of nitrogen oxides (nox) and inflammatory markers have been found in bronchoalveolar fluid of lung cancer (lc) patients, but have not been investigated in exhaled breath condensate (ebc).the aim of this study was to compare nox and total protein levels in ebc of lc patients with control subjects. methods ebc was collected during tidal breathing through a glass collection device cooled to 4°c. ebc nox concentrations were measured by a fluorescent modification of the greiss method. total protein in ebc was determined employing the bicinchoninic acid (bca) assay. ebc nox data were log transformed. all data were analysed using anova and expressed as mean ϯ sem. results a total of 88 control subjects and 54 patients with primary lc were recruited. nox and protein concentrations are shown in table 1 . there was no significant difference in ebc nox levels (p > 0.05), but in total protein there was a significant difference between lung cancer patients and all control groups (p = 0.04). conclusion significantly increased ebc total protein levels were found in patients with lung cancer. these data suggest that protein mediator secretion or vascular leak may be present in those with lung cancer. future studies will focus upon the identification of these proteins. methods in this two stage case-control study 446 lung cancer cases and 484 healthy smoker controls were recruited. 180 genetic markers (snps) implicated in lung cancer were screened in our test cohort of 439 smokers and ex-smokers. 30 snps whose genotypes (co-dominant or recessive model) were associated with either the healthy smokers (protective) or lung cancer (susceptibility) phenotype were identified. after genotyping this 30 snp panel in a second cohort of 491 subjects 19 snps were chosen and assigned a simple composite genetic score that was combined with scores for age, history of copd and family history of lung cancer, weighted according to our multivariate regression analysis (n = 930 total subjects). the lung cancer risk score was linearly related to the likelihood of lung cancer with odds ratios (referenced against the lowest score quintile) ranging from 1 to 29 in the highest quintile. on receiver operator curve analyses, the auc was 0.78 and the frequency distribution showed bimodal separation between healthy smokers and lung cancer cases. utility of the score was not affected by effects of age, smoking history or lung function. we suggest that genetic data may be combined with other risk variables to define smokers or ex-smokers at risk of lung cancer for targeted interventions such as smoking cessation and early detection of lung cancer. supported by health research council, nz. conflict of interest yes. tp 144 v aiyappan 1 , a graham 2 1 department of medicine, maroondah hospital, melbourne, australia, and 2 the new disease-modifying anti-rheumatic drug (dmard) leflunomide is being used increasingly to treat inflammatory arthritis. its association with interstitial lung disease needs to be considered before combining it with methotrexate. case report a 73-year-old male who was known to have rheumatoid arthritis and was on methotrexate was admitted with progressive dyspnoea and malaise. he had been recently started on leflunomide. investigations revealed interstitial lung disease and acute renal failure. he improved on conservative treatment (stoppage of disease modifying drugs (dmard), iv fluids and steroids). review of literature an epidemiological study by suissa et al has suggested that there is increased risk of ild associated with leflunomide in patients with a history of ild or methotrexate use but they attributed this to channelling bias. there has also been a report of leflunomide associated with iga glomerulonephritis.by this presentation we aim to increase the awareness of this entity. we also suggest that any patient who is started on combination dmard (i.e. methotrexate and leflunomide) should have a baseline chest x-ray and be monitored for development of interstitial lung disease. conclusion we are reporting the first ever case of interstitial lung disease and glomerulonephritis (in the same patient), due to usage of leflunomide. this entity needs to be thought about in any patient on combination dmards. background bone morphogenic protein receptor ii (bmpr-ii) mutations are associated with pulmonary artery hypertension. failure of the growth inhibitory effects of bmp may contribute to vascular obliteration and remodelling leading to pulmonary artery hypertension (pah) [1] . pah has been observed following venous thrombembolic disease (vte), including pulmonary embolism (pe) and deep venous thrombosis (dvt) [2] . local markers of the pulmonary vascular endothelium rather than traditional markers of thromobophilia are thought to be involved [3] . methods plasma was collected from age and gender matched participants within 24 hours of diagnosis of vte and prior to commencement of warfarin therapy. plasma samples were hybridized to individual human cytokine antibody arrays, to detect protein levels of bmp2, bmp4 and bmpr-ii. results bmp2 and bmp4 levels were higher in patients with dvt than pe. no difference in the bmp level was observed between patients with pe and controls. soluble bmpr-ii receptor was lower in patients with pe than in controls or patients with dvt. conclusion in patients with pulmonary artery stress during the time of a pe the bmpr-ii receptor is reduced, which may predispose patients to vascular remodelling and obliteration. the bmp 2 and 4 levels are reduced at the same time, suggesting a possible overriding regulatory mechanism. the physiological role of bmp's and bmp receptors in patients with vte warrants further investigation. historically, cyclophosphamide has had a variable role in interstitial lung disease (ild), the rationale for its use based on the benefit seen in vasculitis and scleroderma, its rapid effect and low toxicity profile. in patients with severe progressive ild a rapidly effective, well-tolerated agent is desirable. for this reason a treatment protocol for the use of intravenous (iv) cyclophosphamide was implemented at our hospital. aim to review the indications, duration, tolerability and effect of intravenous cyclophosphamide in ild patients following the introduction of a treatment protocol. methods records of 92 patients [dlco was 40 ϯ 15% and fvc 61 ϯ 20%] completing a course of iv cyclophosphamide during 2005-6 were reviewed (excluding patients with systemic sclerosis). data covering 18 months prior to and following treatment were collected. comparative analysis of paired pulmonary function data 6 months before and after treatment was performed. 61% had underlying autoimmune disease. results primary treatment indications included progressive disease(n = 67); severe disease (n = 16); suspected vasculopathy (n = 11); bridging therapy to transplantation (n = 10); and accelerated decline (n = 5). patients received 600 mg/m 2 [mean dose 1152 ϯ 165 mg, median number of pulses 6 (1-12)]. patients with paired pulmonary function data had a difference in median change in dlco% predicted from -15.6% (-95.4 to 29.9%) before treatment to +4.25% (-17.3 to 73.9%) following treatment (p < 0.0001). this remained significant with exclusion of vasculitis, or any autoimmune disease, and independent of prior immunosuppression. therapy was well tolerated (4 withdrew from treatment, 5 deaths within 1yr, none directly related to treatment). conclusion iv cyclophosphamide is well tolerated, and associated with functional stability or improvement in the majority of patients. it remains a viable treatment alternative for consideration. pulmonary hypertension is common in interstitial lung disease (ild) and associated with a poor prognosis. as the gold-standard test, right-heart catheterization (rhc) is invasive, and resource-limited, reliable non-invasive measures of ph are needed. methods all ild patients referred for rhc during 1997-2007 were included (n = 95; 54 male; age 56.5 ϯ 12 yrs). all patients had concurrent echocardiography (tte) and pulmonary function. the relationship of rhc mean pulmonary artery pressure (mpap) to tte variables, pulmonary function, exercise capacity, as measured by six minute walk testing (6mwt, n = 58) and brain natriuretic peptide (bnp, n = 36), was examined. case a 65 year old male, non-smoker for 25 years, retired professor of anatomy (had chronic exposure to embalming fluids, formaldehyde, phenol, antifungal and other solvents, for 20 years) presented with chronic cough and phlegm production. these symptoms were worse at night (waking him several times) and early morning. his pulmonary tests were stopped due to persistent cough. a chest x-ray revealed features of longstanding interstitial lung disease. the hrct revealed widespread subpleural interlobular thickening, worse at bases, in keeping with idiopathic pulmonary fibrosis (ipf). there was minimal fibrosis and honeycombing, but no groundglass opacification, large bullae, pleural calcification or pleural plaques. however, there was associated bronchiectasis at the lung bases considered to be due to traction. the ba lavage showed 50% macrophages, 7% neutrophils, 3% lymphocytes, and 40%, eosinophils and no infection. the patient declined to have a lung biopsy. as per his past x-rays, the duration of his ipf is a little over one year. he maintains that his symptoms started only after starting irbesartan (irb). introduction transbronchial lung biopsy (tbb) has a variable and unpredictable diagnostic yield in sarcoidosis. we hypothesized that the extent and pattern of parenchymal disease on ct would predict the likelihood of a positive tbb. methods data relating to ethnicity, symptoms, pulmonary function and site and results of tbb and bronchoalveolar lavage (bal) from 70 sarcoidosis patients were recorded. all had a ct scan within 6 weeks prior to the tbb procedure. cxr stage was determined from radiology report. ct scans were scored quantitatively for patterns of parenchymal disease (nodular, reticular, consolidation, ground glass and mosaic attenuation) on a lobar basis. results 50% patients had a positive tbb (total 67% of cohort had histological confirmation). symptoms, ethnicity, treatment, lung function and cxr stage were not predictors of a positive biopsy. positive biopsy was associated with higher bal lymphocyte count (p < 0.05) and female gender (p < 0.01). a reticular pattern (p < 0.05) and higher total lung score (excluding da) (p < 0.05) on ct scan predicted a positive biopsy. in those patients with tbb from right lower lobe (53/70) the total rll score on ct was predictive of positive biopsy (p < 0.05). on multivariate analysis gender, bal lymphocytosis and total lung score were independent predictors of a positive tbb (area under roc 0.82). pulmonary arterial hypertension has two histological variants; 'arterial-only pulmonary arterial hypertension' (artpah) and 'pulmonary veno-occlusive disease' (pvod). bosentan, a dual endothelin receptor antagonist, has been found to improve haemodynamics, functional capacity and survival in artpah. however, the response to bosentan in clinically diagnosed artpah is often variable. it was hypothesized that a lack of response to bosentan therapy in clinically diagnosed artpah can be explained by misdiagnosed pvod. aims included to: (1) perform morphometric and qualitative pulmonary vessel analysis on normal controls and cases clinically diagnosed with artpah who had failed bosentan therapy; (2) ascertain if pvod is present within the case group; (3) correlate clinical variables and vessel microanatomy to identify the pathologies driving pulmonary pressure elevation. this study reviewed 14 cases of clinically diagnosed artpah (idiopathic n = 12, associated with scleroderma n = 2), who had failed bosentan therapy and had available lung tissue. controls (n = 6) were obtained from explanted lungs for other causes and a prior transthoracic echocardiogram excluded pulmonary hypertension. vessel morphometry and qualitative analysis was performed with a novel technique of smooth muscle actin immunohistochemistry counterstained with verhoeff's elastin. baseline clinical data were retrieved. we found 86% of cases had pathology confirmed pvod. only 14% of cases had artpah, the original clinical diagnosis. in pvod, significant pathology was present in all vessel types. all vessels had significant smooth muscle hypertrophy. the obstructive, collagenous, pauci-cellular intimal fibrosis of the venules (p < 0.0001) and arterioles (p < 0.0001) was considerably different to the concentric laminar proliferation of smooth muscle observed in the muscular arteries (p < 0.0001) and arterioles (p = 0.001) in artpah. artpah also had muscular artery smooth muscle hypertrophy (p = 0.007). the median time to bosentan failure was shorter in pvod than artpah (290 vs. 657 days). in conclusion, pvod is an under-diagnosed cause of pulmonary hypertension, is commonly clinically misdiagnosed as artpah and may present with a poor bosentan therapy response. finally, pvod is a vaso-occlusive, not a veno-occlusive disease, and is an independent type of pulmonary hypertension, not a subtype of pulmonary arterial hypertension. cutaneous t cell lymphomas (ctcl) are a heterogenous group of lymphoproliferative disorders. they show various clinical manifestations and diverse morphological, histological and immunological characteristics of the malignant cells. they are caused by clonally derived, skin invasive t cells. peripheral t cell lymphomas (ptcl) are generally more aggressive and have one of the lowest overall and failure-free survival rates. because of the rarity of these disorders, diagnosis and treatment remain challenging. this case report describes a 69-year-old woman presenting with progressive dyspnoea and cough, together with a distressing generalized pruritic rash. she was initially treated as left ventricular failure with the rash ascribed to a drug reaction as suggested by initial skin biopsies. the diagnosis was made on a third skin biopsy and flow cytometry of lymphocytes obtained by broncho-alveolar lavage 6 months after presentation. despite an initial response to chemotherapy she succumbed to the disease 20 months after diagnosis. clinical pathways to guide the investigation of suspected pulmonary embolism (pe) have been increasingly adopted by emergency departments (ed) worldwide. compliance with these diagnostic algorithms is critical in ensuring good patient outcomes. this study evaluated the compliance to the clinical pathway used in our ed that combines risk assessment (wells scoring system) with d-dimer test, vq scan or ctpa. the main objectives of this study were to identify those factors which contributed to compliance and to assess patient outcomes. methods a prospective observational study of 239 consecutive patients who underwent investigation for pe in our ed. patient demographics, pathway parameters and patient outcomes at 3-month follow-up were collected. case we report the case of a 37 year old woman who presented to the emergency department with a three day history of dry cough and dyspnoea. the patient was in her third pregnancy at 30 weeks gestation. she had no fever, chest pain or coryzal symptoms. the patient had presented with a right sided spontaneous pneumothorax seven months prior to the current presentation. her past medical history included placental abruption, complicating her previous two pregnancies. her second pregnancy was complicated by placental abruption at 27 weeks and the foetus had not survived. her first pregnancy was complicated by placental abruption at 36 weeks with successful delivery of the foetus. at presentation, significant findings included tachycardia, hypoxemia, tachypnoea and reduced breath sounds over the right side of the chest. chest x-ray demonstrated a large right pneumothorax. a right intercostal catheter was inserted resulting in right lung re-expansion. the catheter was removed three days later. the patient returned to hospital twenty four hours after catheter removal with a recurrent right sided pneumothorax. the patient agreed to surgical intervention involving video-assisted thoracotomy and talc pleurodesis. the patient had no further complications with the pregnancy. she delivered a healthy baby at 38 weeks gestation. discussion spontaneous pneumothorax in pregnancy is rare and there is little evidence to provide guidelines for the management of recurrent pneumothorax in high risk pregnancy. our case illustrates a successful outcome for mother and foetus with surgical intervention at 32 weeks gestation. folfox is currently the standard adjuvant treatment for locally advanced (stage iii) colon cancer and increases disease free survival. its toxicity is well tolerated with common adverse effects being paraesthesia, bone marrow suppression and gastrointestinal disturbance. pulmonary toxicity has rarely been reported. three clinical cases of acute dyspnoea following folfox therapy (2005) (2006) (2007) for stage iii colon cancer are reported. all had an anterior resection followed by 11-12 cycles of folfox. each developed rapidly progressive dyspnoea requiring hospital admission within one week of their last cycle. one patient required invasive ventilation in icu. high resolution computed tomography (hrct) showed bilateral widespread honeycomb pattern with associated ground glass opacification consistent with pulmonary fibrosis. they had reduced lung volumes and gas transfer. transbronchial biopsy and bronchoalveolar lavage in one patient showed an acute eosinophilic pneumonitis. other causes of interstitial lung disease were carefully excluded. all three patients received high dose corticosteroids with one receiving additional cyclophosphamide. the first patient showed complete recovery following an eight week course of corticosteroids, with resolution of the hrct changes and improvement in lung function. the second had symptomatic improvement of dyspnoea, but a persistent moderate reduction in gas transfer. the final patient had persisting radiographic changes and a reduced gas transfer. he remained dependant on ambulatory oxygen 6 months after his initial presentation. these patients' interstitial lung disease appears due to folfox with oxaliplatin being the most likely causative agent. the use of oxaliplatin chemotherapy has increased markedly over the last 3 years and although rare, physicians should be aware of its potential for lung toxicity. lung function testing at baseline, during and towards the end of oxaliplatin treatment should be undertaken and may allow early detection and intervention in cases of pulmonary toxicity. the forced oscillation technique (fot) with broadband signals has been employed relatively rarely in the studies on respiratory mechanics. recent work from our laboratory [1] indicated that the cheek support and the neck angle have minor influence on the impedance spectra around the first antiresonance (far,1), which makes the use of the broadband fot especially attractive in young children. methods we studied 7 healthy children (c; female: 4) and 8 children with bronchopulmonary dysplasia (bpd; female: 3), using multiple-frequency fot between 8 and 256 hz superimposed on spontaneous breathing. results groups c and bpd did not differ in age ( lung function impairment is common in children with cardiac defects associated with increases in pulmonary blood flow/pressure. to investigate the development of bronchial hyperreactivity (bhr), an aorto-caval shunt was created in a model of precapillary pulmonary hypertension. surgical shunt repair was performed to assess the reversibility of bhr. methods 26 rats were divided into 3 groups: group c (n = 10) with sham surgery, group s (n = 8) where an aorto-caval shunt was created (follow-up 4 wks), group r (n = 8) with aorto-caval shunt but surgical correction of the shunt at 4 wks (follow-up 8 wks). in all animals, respiratory input impedance (zrs) was measured at baseline and following increasing doses of methacholine (mch 2, 4, 8, 12 mcg/kg). airway resistance (raw), inertance, tissue damping (g) and elastance were estimated from the zrs spectra by model fitting. measurements were repeated in all animals at 4 wks and at 8 wks for groups r and c. results there was a significant increase in raw and g in group s and rat 4 wks at baseline and following mch ( fig.) which was reversed after surgery. to characterize the factors contributing to lung function impairment following cardiopulmonary bypass (cpb), functional residual capacity (frc), lung clearance index (lci) and respiratory mechanics were measured in children with pulmonary hypoperfusion (tetralogy of fallot, tof n = 12) and hyperperfusion (ventricular septal defect, vsd n = 12) undergoing surgical repair of congenital heart disease. methods frc and lci were measured using a sf6 washout technique and respiratory mechanics using a low frequency oscillation technique in the perioperative period. results while chest opening led to a significant improvement of lung volumes and respiratory mechanics in all patients (p < 0.001), a reduction in pulmonary blood flow during cpb decreased lung volumes and airway resistance in parallel but significantly more in children with tof compared with those with vsd. re-establishing pulmonary blood flow during cpb improved respiratory function particularly in children with tof ( figure) . conclusions sternotomy had a great impact on lung function with parallel improvement in alveolar recruitment, ventilation inhomogeneity and airway resistance. in contrast, onset of cpb led to lung function impairment with a significant drop in frc especially in children with pre-existing hypoperfused lungs. this suggest that pulmonary blood flow enhances alveolar stability through a tethering effect on the alveolar walls. children with advanced lung disease being considered for lung transplantation are likely to spend disproportionately longer periods on transplant waiting lists before appropriately sized donor organs become available. these longer waiting times reflect the lower organ donation rates seen in children; rates that are significantly lower than those reported in the adult population. we describe two children with advanced lung disease who deteriorated whilst on the waiting list for lung transplantation, and in the absence of appropriately sized donor lungs, underwent lobar lung transplantation. methods we describe the clinical course of two children, aged 9 and 13 years old, with advanced lung disease secondary to post-mycoplasma obliterative bronchiolitis and cystic fibrosis-associated bronchiectasis, respectively. results both children received a "cutdown" bilateral lobar transplant from two oversized adult brain-dead organ donors. in both cases the transplant operation involved implantation of the right middle and upper lobes, and of the left upper lobe from the donor. conclusion given the low organ donation rates in children, and in the absence of appropriately sized donor lungs, novel strategies such as lobar transplantation must be considered, particularly when children continue to clinically deteriorate whilst on the lung transplant waiting list. data from the west australian adult outcomes of extreme preterm birth study suggest that adult survivors of bronchopulmonary dysplasia (bpd) may be left with functional and structural pulmonary abnormalities, most notably emphysema. animal data suggest that the antenatal administration of corticosteroids may adversely affect lung development. we therefore sought to determine if maternal variables, including administration of corticosteroid, could predict emphysema severity in adulthood. methods bpd subjects (birthweight < 1500 g and oxygen dependence at 36 weeks post-menstrual age) born prior to 1988 were identified and recruited prospectively via the statewide neonatal follow up program as previously described. pulmonary function tests and thin selective inspiratory and expiratory computerised (ct) images were acquired and scored for emphysema severity (voxel index (%)). the obstetric history was obtained from retrospective review of case notes. results 21 adults (12 females, aged 18-34) were studied, 2 declined ct. all subjects had abnormal ct findings. fifteen (79%) had areas of emphysema. emphysema score and fev1 were not influenced by the administration of antenatal corticosteroids, indication for delivery, maternal age or presence or absence of chorioamnionitis. conclusion maternal factors, including the administration of antenatal corticosteroids, do not predict the long term respiratory outcome of bpd. the factors determining the severity of emphysema in this group remain unknown. the prevalence of childhood asthma is high in the torres strait. children have generally more severe asthma and asthma knowledge is poor. however, there is no culturally appropriate asthma education program for these children. we are conducting a randomized controlled trial to examine the additional benefits of an education intervention by indigenous health care workers (hcw) on asthma outcomes. we describe the study's objectives, design and baseline measurements. methods children with wheeze were reviewed by two paediatric respiratory physicians using a standardized protocol; children with asthma were eligible. after obtaining informed consent children were randomly allocated to: (1) three additional asthma education sessions with a hcw; or (2) no additional education from a hcw. trained hcws carried out the education sessions using culturally appropriate tools. primary outcome was the number of unscheduled hospital/doctor visits due to asthma exacerbation. all children were re-assessed at 12 months. results we enrolled 113 children aged 1 to 17 years, 81% were torres strait islanders and 12% aboriginal and torres strait islanders. the clinical spectrum of asthma was: 51% infrequent episodic asthma, 22% frequent episodic asthma and 27% chronic asthma. eighteen percent of the children knew what a written asthma action plan was; 8.5% had one. carers' assessment of knowledge of medications showed that 52% could not name any asthma medication used by their child, 40% could not explain dosage, and 67% could not explain how beta2 agonists worked. conclusions asthma knowledge and possession of asthma action plans in this cohort is poor at baseline. there is substantial room for improvement and additional asthma education by hcws potentially has significant benefits. impulse oscillometry system (ios) measures respiratory function during normal breathing by transmitting mixed frequency rectangular pressure impulses down the airways and measuring reflected pressure. computer analysis calculates respiratory impedance and its components, airways resistance and reactance, at a range of frequencies from 0.1 hz to 150 hz. no previous australian normative data exists. the ios software generates predictive normal values for each of the parameters measured including total airway resistance (r5), the proximal airway resistance (r20) as well as peripheral capacitive reactance (x5). however, they are based on german data. methods cross-sectional study of 100 community dwelling adults, with 10 males and females per 10-year cohort. inclusion criteria: age range 25-74 years, apparently good respiratory health. exclusion criteria: smokers, asthmatics and others with acute or chronic respiratory disease. both ios and spirometry were conducted on all participants. results australian predictive normal equations have been generated and compared to the current published equations. the ios parameters have been correlated with the spirometric data. results have been analysed by gender, age, height and weight and compared with the predictive normal values for each parameter provided by the german manufacturer of the ios instrument. analysis includes calculation of mean range, and lower limit of normal. conclusions a preliminary set of australian predictive equations have now been produced for the ios. these have been compared with international equations. ios has potential application in a range of respiratory disease states and in population screening for occupational health (e.g. mining, & high dust load environments). supported by phc red. rationale although clinical practice guidelines for both asthma and copd recommend spirometry for diagnosis and monitoring, beneficial effects on the management of chronic respiratory diseases in general practice have not been established. we hypothesized that spirometry would improve health outcomes compared to usual care. methods we are conducting a single masked rct with 3 arms: group a receive 3 monthly spirometry and followup, group b receive spirometry before and after the trial and group c usual care. 45 general practices were recruited though divisions of general practice in melbourne. invitations were mailed by 31 of these practices to patients who had been prescribed inhaled medications during the previous 6 months. participants returned respiratory and generic quality of life questionnaires and an asthma score card. groups a and b were tested on a micromedical turbine spirometer following ats/ers guidelines. results 351 eligible patients (275 adults, 50 children aged 8-13 and 26 youths aged 14-17 years) entered the trial. 122 were randomized to group a, 134 to group b and 95 to group c. the mean (sd) age of adult participants was 54.3 (12.7), children 10.3 (1.7) and youths 15 (1.1) years. there were 130 males and 221 females. the adults were highly symptomatic in the previous 12 months: 82% reporting wheeze, 50% chest tightness on waking, 74% shortness of breath on exertion, 61% nocturnal cough, 46% morning cough and 75% sputum. symptoms of chronic bronchitis were reported by 39% of adults and a diagnosis of copd by 19%. asthma was reported by 84%, confirmed by a doctor in 96% and 55% had experienced an attack in the last 12 months. only 35% had a written asthma action plan. 37% of adults had ever visited a hospital ed and 28% had been admitted. conclusion it is possible to recruit asthma and copd patients from general practice and to randomize them to spirometry or usual care. whether spirometry is associated with fewer symptoms, changes in medication, uptake of action plans or improvement in lung function or quality of life requires further followup. supported by nhmrc. s shah 1 , jk roydhouse 1 , b toelle 2 , s sawyer 3 , c jenkins 2 for the pace australia management committee 1 university of sydney, 2 woolcock institute of medical research, sydney, nsw 2006, and 3 royal children's hospital, melbourne, vic 3052 it is widely held that recruitment of general practitioners for research can be challenging. in this paper, we discuss the recruitment experience from a current study evaluating the impact of an educational asthma intervention on patient outcomes. our aim is to describe the two different strategies utilized to date: (1) in-house through an academic department of gp and (2) outsourced to a private gp organization. methods initial interest was generated through faxes, presentations at gp divisional meetings and newsletter advertisements. gps who expressed interest were visited by project staff to discuss the study further. a major difference was recruiting one gp per practice in the first strategy versus multiple gps per practice in the second strategy. to assess the strategies, we examined participant characteristics, number of gps recruited and number retained. results participant characteristics: under both strategies, 30% of recruits had trained in asia and 54% were women. the first strategy recruited more gps who spoke at least two languages at home (85% vs 42%) and the second strategy recruited more recently graduated gps (58% vs 50%). recruitment: the first strategy recruited 35 gps over 6 months and the second recruited 34 gps over 3 months. retention: 19 gps (54%) from the first strategy stayed in, compared to 29 (85%) from the second. conclusions whilst absolute numbers of gps recruited were similar, retention was much higher under the second strategy. recruitment in primary care is difficult and requires a range of approaches which need to be re-evaluated and adapted as necessary during the course of the study. supported by the australian government department of health and ageing. bronchiectasis is a heterogeneous condition with a large number of causative factors and range of symptoms. the classification of this condition is often confusing and hard to remember. the aim of this study was to classify non-cf bronchiectasis into different clinical phenotypes. methods 178 consecutive patients with non-cf bronchiectasis confirmed on high resolution ct scanning had a detailed clinical, spirometric and laboratory assessment performed by a respiratory physician (pk/mf/pw) and were then followed up for an average of 9 ϯ 4 years (mean and sd) for a total of over 2000 reviews. results 160 of the 178 patients (90%) could be classified as belonging to 3 phenotypic groups; 1) bronchiectasis arising in childhood, 2) bronchiectasis occurring in smokers and 3) bronchiectasis occurring in the elderly. each group had different features which are listed in the there are few data on the long term outcomes of treatment for tuberculosis (tb) by directly observed therapy (dot) in low-incidence settings. the aim of this study was to assess the incidence of recurrent tb in nsw. methods data linkage was performed within the nsw department of health tb notifications database to identify cases that had more than one tb notification between 1994 and 2006. recurrent tuberculosis was defined to include all patients with two or more culture positive episodes at least 6 months apart, where patients had received at least six months treatment for the initial episode. in cases where data contained within the notification details was not sufficient to allow us to distinguish between true cases of recurrent disease, duplication notification for the same episode or persistent disease after incomplete treatment, additional information was obtained from the area tb coordinator. results there were 5723 tb notifications between 1994 and 2006 with 3731 being culture positive. 15 cases of recurrent culture positive disease after completed treatment for the first episode were identified (recurrence rate: 0.4%). conclusions in a population with a low tb incidence, treatment of active tuberculosis with dot results in a very low rate of disease recurrence over a long period of follow-up. support nhmrc ccre in respiratory and sleep medicine. introduction rhinoviruses (rvs) are the major cause of viral-induced exacerbation of asthma. to date, the molecular mechanisms of rv pathogenesis are not understood. recent findings suggest that rv pathology may involve host cell nucleocytoplasmic trafficking, inhibiting key cell functions such as transcription and translation. the study aims to investigate the mechanism of rv 3c protease nuclear trafficking. methods hela cells were infected with rv or transfected with plasmids and cellular localization of 3c analysed at various times thereafter using immunofluorescent confocal microscopy and western blotting with specific antibodies. results 3c protease was predominantly present in nuclei of rv infected cells up to 6 hours after infection, becoming increasingly cytoplasmic thereafter. the nuclear membrane of infected cells became progressively indistinct with time. using a specific inhibitor we also found that 3c utilizes the crm-1 nuclear export pathway. 3c was predominantly in the form of 3cd in both cytoplasm and nucleus of infected cells; mature 3c protease was also detected from 6 hours after infection. deletion analysis indicats that the nuclear localization domain and a nuclear export signal are most likely to be present within the n terminal 64 amino acids. the nuclear export signal is inhibited in the full length protein, via an unknown mechanism. conclusion our data suggest that 3c and 3cd proteins localize to the nucleus in infected cells where they may play a key role in rv pathogenesis by disrupting cellular transcription and the nuclear transport machinery. chronic necrotizing pulmonary aspergillosis (cnpa) is a relatively uncommon, sub-acute, locally destructive process due to aspergillus invasion of the lung. the incidence and prognosis of cnpa are poorly described. case report we present a case of cnpa in a patient on intermittent low dose steroid therapy and recurrent refractory exacerbations of chronic obstructive pulmonary disease (copd).the patient presented with worsening shortness of breath and productive cough requiring recurrent inpatient admissions. human influenza virus is found to bind preferentially to saa2,6gal receptors found in the upper respiratory tract, while avian viruses bind to saa2,3gal receptors expressed in lower airways. this is thought to affect the ability of transmission to humans. our aim was to study the ability of avian and human influenza strains to infect bronchial epithelial cells and relate this to levels of the sialic acid receptor expression. methods calu-3 cells were used as a proximal airway cell and a549 were used as distal airway cell. human primary bronchial epithelial cells (pbecs) were obtained from healthy, asthmatic, and copd volunteers by endobronchial brushing. epithelial cells were stained with sambucus nigra lectin that binds saa2,6gal receptor, and maackia amurensis lectin ii that binds to saa2,3gal. the cells was analysed by flow cytometry. human influenza a/h3n2/wellington strain and low pathogenic avian influenza a/h11n9/sandpiper were chosen and were used at an moi of 0.005 to infect cells. the supernatants were harvested at 48 hr post infection, of which was then analysed by plaque assay for virus replication. results the calu-3 showed greater expression of saa2,6gal linkage than saa2,3gal linkage, and a549 displayed slightly higher expression of both receptors compared to pbecs. despite this human and avian influenza virus replicated to similar titre at 15,000 pfu/ml in both cell lines, but showed low replication in pbecs. background treatment of community-acquired pneumonia remains based on 'best guess' empiric algorithms because of the poor utility of current pathogen tests. furthermore our ability to stratify patients into risk groups is crude at best, relying on scores such as the pneumonia severity index or the curb-65 have major limitations. we have been slowly improving real-time pcr assays for pneumococcus as a clinical tool in patients with pneumonia. methods building on previous research we assesed two targets in the autolysin (lyta) gene and the pneumolysin (ply) gene of s.pneumoniae using the lightcycler instrument and fluorescence resonance energy transfer (fret) probes. all common s. pneumoniae serotypes were detected while other bacteria and viruses were not. the lyta target had the best sensitivity with a detection range between 21 ng to 21 fg. both assays were then applied to whole blood samples from 400 adult patients with community-acquired pneumonia, all of whom had blood cultures prior to antibiotic administration and urinary antigen testing for s.pneumoniae. the lyta pcr had the best performance characteristics with a sensitivity more than twice that of blood cultures in the clinical samples. most pcr+ve/culture -ve patients had positive urinary antigen tests. there was clinical evidence that urinary antigen +ve/ pcr -ve patients were false +ves. most significantly there was a strong correlation between quantitative bacterial count and clinical outcome. conclusions real-time quantitative pcr for pneumococcus has significant potential as both a diagnostic and therapeutic tool in patients with pneumonia. the pitjantjatjara lands are situated in the north-western corner of south australia, occupying an area of over 120 000 square kilometres with a population of approximately 3000. the population lives in small communities or homelands, and there is a high level of mobility between this region and other aboriginal communities in south australia and the northern territory. nganampa health council provides all health care services to the region. specialized support for tb control comes from both the south australia tb service based at royal adelaide hospital as well as a centre for disease control in alice springs. the prevalence of tuberculosis (tb) in this predominantly indigenous community is thought to be significantly higher than the national rate. there are considerable challenges in detecting and managing tuberculosis, relating to the community's geographical remoteness, migration of populations and access to health services. the aims of this study are to quantify the prevalence of tuberculosis in the pitjantjatjara lands, and describe the significant barriers to tb diagnosis and treatment. methods a retrospective study of all diagnoses of tuberculosis within the pitjantjatjara lands in the period 1995-2006. outcomes include measures of tuberculosis diagnosis, the rates of completed tb treatment and rates of tuberculosis drug resistance. the study will draw conclusions about the reasons for high levels of tb prevalence in this community and identify barriers to effective tuberculosis treatment. conflict of interest no. patients admitted to hospital with a diagnosis of community-acquired pneumonia (cap) are usually treated with intravenous (iv) antibiotics irrespective of pneumonia severity. available guidelines vary in recommended timing and indications for switching to oral antibiotics. aim to examine the patterns of antibiotic choice and delivery method (iv, oral and time to switch) in patients admitted with cap. methods a retrospective chart review of admissions to the respiratory unit over a 12-month period with a diagnostic-related group (drg) coding of pneumonia. 41 charts were reviewed. data collected included patient demographics, clinical features at presentation (temperature, pulse rate, respiratory rate, bp, oxygenation), initial investigations, initial antibiotic regime, time to change (iv to oral), subsequent antibiotic regime and duration, time to defervescence, length of stay and outcome. pneumonia severity was calculated using the revised british thoracic society system (curb-65), score ն 2 = severe. results 3 patients were excluded due to incorrect coding. of the 38 patients, age was 50 ϯ 21 (mean ϯ sd) yrs and 25 (66%) were male. 28 patients (74%) were febrile at presentation and the median curb-65 score was 1 (range 0-4). 37 patients (97%) received iv antibiotics. the curb-65 score was 0 or 1 (non-severe) in 25 patients and 22 of these patients received a combination of iv ceftriaxone and a macrolide. time to defervescence was 2.9 ϯ 2.3 days. time from defervescence to switching to oral therapy was 3.4 ϯ 2.8 days. in non-febrile patients, time to switch was 4.7ϯ4.3 days. length of stay was 8.7ϯ13.0 days. conclusions the time between defervescence and switch to an oral regime was relatively long, possibly contributing to an increased length of stay. many patients received ceftriaxone even with a curb-65 severity rating of 0 or 1. implementing local guideline-based treatment protocols may reduce length of stay. ultrasonic flow sensors can determine flow, volume and molar mass (mm) of the gas flow simultaneously. during tidal breathing the expired molar mass curve can be used to compute co2 over expired volume and a capnography index (cpi) can be computed. the relationship between cpi and copd classification according to gold was investigated. methods prospective, controlled trial. consecutive patients who underwent routine lung function were enrolled to participate in a tidal breathing test using an ultrasonic flow sensor. each test consisted of three tidal breathing recordings of 60 sec. flow, volume and molar mass were measured at 200 hz and data were acquired using prototype wbreath data acquisition software. mean expirograms (mm over volume) were computed and the measurements were analyzed to determine the slope of exhaled phase ii (s2), the slope of phase iii (s3) and the relationship between s2 and s3 (cpi = s3/s2). gold stages were determined from the lung function results and the ers predicted values. results 53 volunteers participated in the study with a mean age of 62 (sd 14), 23 were male, mean bmi 26 (sd 5), 17 had never smoked. the mean pack/year smoking history was 38. there was a clear relationship between gold stage and cpi: gold stage 'normal' had a mean cpi of 5.5 (sd 3.7, n = 21), stage 'severe' had a mean cpi of 13.7(sd = 3.9, n = 7). conclusion computation of cpi based on tidal breathing analysis using an ultrasonic flow and mm sensor correlates well with gold stages. it may therefore be possible to use a simple tidal breathing test to determine the severity of airways disease. background osa is common in tetraplegia and appears within weeks of injury. although cpap treatment is efficacious in able-bodied subjects, case series suggest that cpap is poorly tolerated in tetraplegia. no prospective study has examined cpap efficacy or adherence in tetraplegia. aim to determine the feasibility of cpap use to treat osa following acute tetraplegia. methods all acute admissions who consented and fulfilled the inclusion and exclusion criteria underwent full, portable polysomnography. those found to have an apnoea hypopnoea index of >10 events per hour (osa) were offered cpap, delivered via an auto-titrating device. results to date, 25 patients have been admitted (11 excluded, 3 refused consent). no significant, adverse events have been observed. two patients did not have osa. of the nine with osa, four are mid-study, two had incomplete follow-up (1 returned to uk and 1 refused 3 month assessment), two adhered with cpap and one did not due to severe, pre-existing nasal obstruction. preliminary analyses suggest that those who adhered to cpap had a marked reduction (80% compared with 10-40%) in sleepiness and a greater reduction in the functional outcomes of sleepiness compared to either those without osa or who were unable to use cpap. patient accrual, recruitment and completion rates are consistent with our initial estimates. study recruitment will be completed by end-october 2007. conclusion initial data suggest that auto-titrating cpap is a feasible treatment for osa in acute tetraplegia. these data will be used to finalize planning for a multi-national, multi-centre randomized controlled of therapy. this research was supported by the transport accident commission. visual recognition of cyanosis is an important clinical activity. cyanosis recognition is affected by lighting colour and there is anecdotal evidence that people with significant colour vision deficiencies (cvds) have particular difficulty. studies to date have centred on the colour change with oxygenation of isolated blood but it is not clear how this extrapolates to cyanotic patients in vivo. methods ten patients known to be chronically hypoxaemic and showing signs of cyanosis were recruited from the chronic respiratory program. ten normal subjects were recruited as controls. the spectral reflectances of their lips, nail beds and palm creases were measured using a topcon sr-3 telespectroradiometer. the patients were measured at rest and after exercise to lower their saturation by 5-10%. the chromaticities were calculated and plotted. results both groups showed a spread of colours but they fell into two distinct ranges. the colour difference between the groups lies very close to the colour confusions made by congenital cvds. within the cyanosed group, the colour shift was not tightly related to decreasing oxygen saturation. this is most likely due to interpersonal factors such as pigmentation and vascular perfusion that affect colour and the difficulties in measuring the colour of heterogeneous anatomical features. conclusions these results quantify the anecdotal difficulties in detecting cyanosis and suggest that observers with cvd would have problems recognizing the condition. the photographs obtained from this study will be used to compare the ability of subjects with and without cvd to detect cyanosis. supported by the nsw ambulance service. baroreflex sensitivity is depressed in osa patients during sleep but effects during wakefulness are less clear. we have now examined relationships between awake brs and severity of sleep disordered breathing (sdb). methods immediately prior to overnight polysomnography, continuous (5 min) beat-to-beat arterial blood pressure was measured via finger plethysmography (portapres) and heart rate via ecg in 20, supine, normotensive, untreated osa patients (17 males; age: 49 ϯ 15 years (mean ϯ sd); bmi: 26 ϯ 11 kg/m 2 ). spontaneous baroreflex sensitivity (brs) was calculated using the sequence technique. sdb was characterized as apnoea hyponoea index (events/hour) and arousal index (ai). data were analysed via mathematical modelling and unpaired t test. results brs fell with increasing ahi. patients with ahi > 30 events/hour (n = 9) had a significantly lower brs (8.1 ϯ 1.5 ms/mmhg) than those with ahi < 30 events/hour (19.8 ϯ 8.7 ms/mmhg, p < 0.001). brs was negatively related to both ahi and ai via fitted exponential functions (r 2 = 0.45 and 0.70, respectively). it is hypothesized that the analysis of morphology of the ecg waveform in combination with the heart rate patterns could lead to the possibility of detection of the start and duration of apnoea/hypopnoea events and consequently estimation of the apnoea-hypopnoea index (ahi). to the authors' knowledge the published ecg based algorithms for detecting sleep disordered breathing are only capable of minute by minute analysis rather than detection of individual respiratory events. methods changes to ecg parameters were investigated during respiratory events with no distinction made between apnoea and hypopnoea events. 632 isolated respiratory events and 1264 controls of identical duration were obtained from 7 polysomnographic studies, using a randomized procedure. features such as the r wave amplitude, t wave amplitude, qrs area and the r-r interval were extracted from the 2 lead ecg. a number of physiological predictors based on these features were generated. a logistic regression model was used to investigate the association between the predictors and true events, using the statistical software, stata. results univariate and multivariate analyses were performed. three multivariate models were developed; heart parameters only, ecg waveform morphology parameters only and the combinations of the two. the area under the receiver operator characteristic curves (auc) for these models were compared. the best results were obtained with the combination of morphology and heart rate parameters (auc = 0.8858 (0.0078 (sd))) compared to the morphology (auc = 0.8169 (0.0121 (sd))) and heart rate (auc = 0.7195 (0.0103 (sd))) models. the multivariate analysis has shown encouraging results indicating that an algorithm using a combination of heart rate and ecg morphological parameters could potentially be constructed that would enable the determination of individual respiratory events and subsequently an ahi. supported by the arc. introduction sacin and scond are measures of ventilation heterogeneity in acinar and conducting airways, derived from analysis of mbnw. maintaining tidal volumes of 1 l at 9-11 breaths/minute (bpm) is impossible for some. our aim was to examine the effect of different tidal volumes on sacin and scond in normals and asthmatics. methods 10 normals (23-41 yrs) and 12 asthmatics (21-63 yrs) underwent mbnw at tidal volumes of 500 ml at 20-23 bpm, 1 l at 9-11 bpm, and 2 l at 5-7 bpm. scond and sacin, were determined from the normalized phase iii slopes of breaths between turnovers (cumulative ventilation/frc) 1.5 & 6. results the mean ϯ sd %predicted fev1 was 97.3 ϯ 17% in normals and 88 ϯ 11% in asthmatics. in normals, sacin at tv of 0.5, 1 and 2 l were 0.195 ϯ 0.105 l -1 , 0.095 ϯ 0.036 l -1 and 0.058 ϯ 0.031 l -1 , respectively (p = 0.0003, anova), while scond were 0.098 ϯ 0.047 l -1 , 0.042 ϯ 0.021 l -1 and 0.029 ϯ 0.014 l -1 (p = 0.0002), respectively. in asthmatics, sacin were 0.440 ϯ 0.195 l -1 , 0.181 ϯ 0.087 l -1 and 0.100 ϯ 0.047 l -1 , respectively (p < 0.01), while scond were 0.204 ϯ 0.111 l -1 , 0.068 ϯ 0.037 l -1 and 0.031 ϯ 0.013 l -1 , respectively (p < 0.0001). conclusion increasing tidal volume while maintaining the same minute ventilation during mbnw led to large decreases in scond and sacin in both asthmatics and normals. this may be due to reduced inter-regional differences in specific ventilation with greater tv. the log-log relationship between sacin and tv allows an adjustment to be made for variations in tidal volume. funding crc for asthma and airways and nhmrc project grant #547346. dj smith 1 , k bowden 2 , t lloyd 2 , j coucher 2 , l garske 1 1 respiratory medicine, and 2 radiology, princess alexandra hospital, brisbane, australia introduction we have shown diaphragmatic flattening and decreased diaphragmatic excursion qualitatively assessed on ultrasound is strongly predictive of dyspnea severity and lower lung inflation in patients with pleural effusion. we sought to quantitatively measure diaphragm length and movement and determine how closely these are related to dyspnea severity and lung inflation. methods patients with unilateral pleural effusions had ct imaging of their diaphragm during a measured inspiratory capacity manoeuvre. maximal sagittal length was measured at tlc, and frc. patients had a baseline dyspnea index (bdi: 0-12) and respiratory function measured. results 4 patients with unilateral effusion (all right side; 3 malignant mesothelioma, 1 inflammatory) had a mean (sd) bdi of 5.5 (2.89), and tlc of 74% (3.91) predicted. the right diaphragm on the side of the effusion tended to be shorter than the left at frc (p = 0.08), and had a trend to reduced shortening with inspiration (p = 0.08). conclusions the right diaphragm is known to be longer than the left in health. the strong trend to a shorter and less mobile right diaphragm associated with effusion suggests this is a potential mechanism for dyspnea. further recruitment will enable correlation between bdi, tlc and diaphragm length and mobility. 4) ) that was slightly worse than an able bodied, control population (17.9 (3.1)), but better than an able-bodied population with untreated osa (14.5 (3.6)). the mapi predicted that 14% of the sample were likely to have osa. these data will be complimented by full sleep studies to be performed at the participants' homes in late 2007, early 2008. conclusion our interim data suggest that the rate of subjective sleep complaints are not substantially different in the population with tetraplegia compared with the able-bodied. this research was supported by the victorian neurotrauma initiative. it has long been assumed that the ventilation heterogeneity associated with lung disease could in itself affect the measurement of carbon monoxide transfer factor. the aim of this study was to investigate the potential estimation errors of carbon monoxide diffusing capacity (tlco) measurement that are specifically due to conductive ventilation heterogeneity. we induced conductive airway ventilation heterogeneity in 35 never-smoker normal subjects by histamine provocation, and related the resulting changes in ventilation heterogeneity (derived from the multiple breath washout test) to corresponding changes in diffusing capacity, alveolar volume and inspired vital capacity (derived from the single breath tlco method). average conductive ventilation heterogeneity doubled (p < 0.001), while tlco decreased by 6% (p < 0.001), with no correlation between individual data (p > 0.1). when dividing diffusing capacity by alveolar volume, the resulting transfer coefficient was not significantly different pre versus post histamine (p = 0.074). these findings can be brought in agreement with recent modelling work, where specific ventilation heterogeneity resulting from different distributions of either inspired volume or end-expiratory lung volume have been shown to affect tlco estimation errors in opposite ways. the combination of these errors appears to largely cancel out in our experimental situation of induced ventilation heterogeneity comparable to that observed in lung disease. we conclude that conductive ventilation heterogeneity per se has a negligible effect on diffusing capacity measurement. an important determinant of airway function in humans is vagal-mediated cholinergic tone in airway smooth muscle (asm). this airway tone may be altered in disease states. the use of mouse models for the study of airway diseases, including asthma, pulmonary fibrosis and copd is well established. however, it is not known whether mice actually possess basal asm tone or, if it does exist, how this tone changes in disease models. this study was undertaken to determine whether mice have detectable asm tone in vivo. methods respiratory system impedance (zrs) was measured in female adult balb/c mice using a wave-tube modification of the forced oscillation technique. zrs was measured during slow (~35 s) inflation-deflation manoeuvres between the transrespiratory pressures of 0 and 20 cmh2o. baseline lung mechanics and thoracic lung volumes (tgv) were measured before and after each mouse was allocated to one of four treatment groups: 'saline' mice received an i.p injection of saline, 'atropine' mice received i.p. atropine sulphate, 'vagotomy' mice had their left and right cervical vagus nerves isolated by blunt dissection and cut, and 'sham' mice had the area of the vagus nerves exposed but the nerves were not cut. results there were no post-treatment changes in tgv, airway resistance, tissue damping, tissue elastance, inertance or tissue hysteresivity in any of the four groups. conclusions the lack of change in lung mechanics post-atropine or postvagotomy in balb/c mice suggests that, unlike humans and many other species, the airways of mice have no baseline asm tone. supported by nhmrc grant#11488. nomination none. conflict of interest none. both male gender and increased mandibular enclosure volume predict more severe sleep disordered breathing in obstructive sleep apnoea patients. we now examine gender/body size/mandibular enclosure volume relationships for normal subjects stepwise multiple linear regression analysis was used to model body size/enclosure volume interactions. results for the whole group, mv was 261.1 ϯ 6.0 ml (mean ϯ se) while rmv was 205.1 ϯ 4.9 ml. head circumference (positive) and forehead height (negative) were both independent predictors for mv and rmv (both p < 0.02), while hip circumference was an additional positive predictive factor for rmv (p < 0.04). after adjusting for these parameters, male mv and rmv were larger than for females conclusion these findings suggest that mandibular enclosure volumes are relatively larger in males, even after adjusting for body size/cranial dimension. differing body size/mandibular enclosure volume interactions may contribute to gender influences on the severity of sleep disordered breathing. supported by nhmrc of australia nomination john read prize for sleep and physiological research tp 027 audit of ctpa in a regional hospital y raje, s vincent, g simpson department of thoracic medicine, cairns base hospital, cairns, qld 4870 since the introduction of computerized tomographic pulmonary angiograms (ctpa) at our institution the number of requests for this investigation at our institution has grown at an alarming rate. the purpose of this study was to evaluate the clinical assessment of suspected pulmonary embolism (pe). methods 50 ctpa were reviewed. results 31 female, 19 male. mean age 50 yrs (range 21-87). 26 ctpa requests came from department of medicine, 21 from emergency department, 2 from surgical teams and 1 from oncology outpatients. 36 patients presented with chest pain (pleuritic in 20 cases), 25 had dyspnea, 7 presented with collapse. 4 patients had haemoptysis. hypoxaemia was recorded in 7. none were clinically shocked and only one had a recorded tachycardia. d-dimer requested in 10 patients and was elevated in 9. arterial blood gases performed in only 10 patients (20%). 47 patients had prior chest x-ray which was normal in 24 (48%). 8 patients had consolidation on chest x-ray, 2 pleural effusions, 2 atelectasis and 1 fractured ribs. recorded risk factors included 4 patients with previous dvt or pe, 4 patients with malignancy and 6 patients were immediately post-operative. only 6 ctpas (12%) demonstrated evidence of pe. of these 2 had recent dvt and 2 were post-operative. 1 had a history of bowel cancer. there was no formal record of pre-test clinical probability of pe (eg wells' score) for any of the 50 cases. retrospective calculation of the cases of pe, 4 had a wells' score of 4.5 and 1 of 4 with the remaining patient with wells' score of under 2. only 3 patients (one with clinically probable pe) had received fractionated heparin prior to the ctpa. conclusion (1) ctpas performed at our institution have a low yield (12%).(2) pre-investigation clinical assessment was poor and there was poor adherence to published guidelines, (3) this results in many unnecessary ctpa examinations generating increased work and expense for the medical imaging department and exposes many patients to unnecessary and potentially harmful radiation exposure. the evaluation and management of hereditary hemorrhagic telangiectasia involves a multidisciplinary approach according to international guidelines. the aim of this audit was to compare the assessment process in one centre with that of the international recommendations. methods retrospective comparison was made by medical chart review of all patients with a diagnosis of hht between the years 1994 to 2006. demographic along with clinical data with diagnostic investigations, complications, treatment and genetic evaluation, including family screening was collected. the proportion of patients evaluated and managed as per the international recommendations was determined. results the audit identified 26 patients with the diagnosis of hht, with the mean age 58 years. diagnostic criteria were met in 77% of the cohort. of the known clinical features, 54% had a family history, and 81% epistaxis. cutaneous telangiectasia was present in 85% and visceral involvement in 92%. pulmonary arterio-venous malformations (pavm) were seen in 16 patients, cerebral avm in 4, gastrointestinal telangiectasia was documented in 8. one patient had a spinal (cervical) avm, and another had pulmonary hypertension in association with this condition. only 8 patients underwent diagnostic or screening investigations in accordance with the international recommendations. furthermore, one patient was referred for a genetic evaluation. conclusions this clinical audit found that 31% of patients referred to this centre were evaluated in accordance with the international recommendations. genetic assessment was lacking. the study supports the need for a coordinated, multidisciplinary approach to the evaluation and management of hht in this centre. lm young 1 , n good 1 , d milne 2 , w fergusson 1 , i zeng 1 , j kolbe 1 , ml wilsher 1 background while airflow limitation is the most common physiological impairment in sarcoidosis, there are limited data on airway hyperresponsiveness (ahr). understanding the role of ahr in sarcoidosis, if any, may help to identify individuals who might benefit from inhaled therapies. aims (1) to determine the prevalence of ahr in sarcoidosis. (2) to determine the correlation between responses to direct (using histamine) and indirect (using hypertonic saline) bronchial challenge. (3) to determine the clinical, physiological and radiological predictors of ahr. methods subjects with a diagnosis of sarcoidosis based on typical clinical presentation and compatible hrct features and/or tissue biopsy and with a baseline fev1>35% predicted were recruited. subjects underwent standard hypertonic (15% fall in fev1) and histamine (20% fall in fev1) challenge (>1 day but <7 days apart), lung function testing and high resolution computed tomography (hrct) of the chest. results the 52 subjects (48 ϯ 11 years, 35% female, 92% european, 35% stage i, 25% stage ii, 40% stage iii, 0% stage iv) had well preserved lung function overall (fev1 = 2.8l ϯ 0.7.87% predicted). ahr was detected in 5/47 (11%) to hypertonic saline and 19/43 (44%) to histamine challenge. on univariate analysis, response to histamine challenge was predicted by conglomerate fibrosis (p = 0.002) and reticular pattern (p = 0.05) on hrct. the baseline % predicted fev1 was significantly associated with ahr on univariate (p = 0.004), and multivariate analysis (p = 0.01) when adjusted by hrct patterns. conclusions there is a high prevalence of ahr using histamine challenge in this study of sarcoidosis subjects. ahr most strongly associates with baseline % predicted fev1 but also conglomerate fibrosis and reticular pattern on hrct. these findings may reflect the consequence of airway remodelling following inflammation. further studies are warranted to confirm these findings. background upper airway shunt represents a significant source of measurement artefact in the use of the forced oscillation technique (fot), with increasing importance in young children. changes in respiratory system admittance, ars (or zrs -1 ), are theoretically independent of the upper airway shunt. this study examines the possible clinical benefit of ars in preschool children by assessing any increased ability to differentiate responses to bronchial challenges in the routine clinical setting. we hypothesized the use of ars would provide improved sensitivity to clinically relevant obstruction, bronchodilator responsiveness (bdr) and airway hyper-responsiveness (ahr) in young children with respiratory disease. method previous fot measurements were re-analysed and ars calculated to derive: (1) ars reference equations in healthy young children (n = 158); (2) bdr in ars, respiratory system resistance (rrs) and reactance (xrs) in healthy children (n = 78), children with cystic fibrosis (n = 39), neonatal chronic lung disease (n = 49), asthma (n = 56) and wheeze (n = 66); (3) ahr to inhaled adenosine-5′-monosphate (amp) in 19 children. fisher's exact tests were used to assess changes in diagnostic outcomes between ars and conventional fot outcomes (rrs and xrs). results ars was no more sensitive to bronchodilator induced changes than conventional fot outcomes. amp challenges resulted in equivalent responses measured by relative changes in rrs and ars while absolute changes in ars were the least sensitive variable. conclusion this study does not support a clinical advantage in using ars in measuring responses to either inhaled bronchodilator or amp. c hollier 1,2 , c menadue 1,2 , d flunt 1,2 , aj piper 1,2 1 department of respiratory and sleep medicine, royal prince alfred hospital, nsw 2050, and 2 woolcock institute of medical research, nsw 2050 serial measurement of arterial carbon dioxide (paco2), ph and bicarbonate (hco3 -) is essential in the management of patients with hypercapnic respiratory failure (hrf). this information is usually obtained from a sample of arterial blood (abg). the procedure can be painful and distressing for patients, and is sometimes technically difficult due to obesity or contractures. our aim was to determine the validity and feasibility of arterialized venous blood (av) sampling as an alternative to abgs in measuring paco2, ph and hco3levels in patients with chronic hrf. method eighteen patients completed the study. venous blood was arterialized by heating forearm skin to a temperature of 42-45°c with an electric heating pad. an av sample was taken from a cannula positioned in a vein of the heated forearm simultaneously with an abg. in addition, the reliability of av sampling within the recommended temperature range (42-45°c) was investigated in ten healthy volunteers placed on volume cycled ventilation in order to maintain constant ventilation. av samples were taken at 0.5°c temperature intervals from 42.5-45°c results the table below summarizes results for validation of av sampling: based on the evidence that cardiovascular dynamics are altered due to obstructive sleep apnea, this study aims to identify the onset and termination of each apnea event using power spectral density (psd) and morphological features of single lead ecg signal over 5 second period. methods ecgs from 4 patients overnight sleep studies were examined for location of the pre-scored apnea events. onset (n = 1995), maximum (n = 6751) and termination (n = 1996) of each apnea event and normal events (n = 11219) were annotated on 5 second windows. features extracted were psd, amplitudes of r and t wave of 5 second ecgs. receiver operating characteristics (roc) analysis was used to gauge the event recognition ability of all features. weight loss causes an improvement in the severity of osa, however substantial weight loss is very difficult for obese patients. the very low caloric diet (vlcd) has been shown to be successful in causing significant weight loss in obese patients. this is a pilot study on the use of a formal screening protocol to identify osa patients who are potentially eligible for the supervised vlcd program offered by the endocrinology department at auckland city hospital. method 344 consecutive patients who attended the sleep laboratory at ach between june to december 2006 were screened using the protocol. patients who are eligible to be considered for the vlcd program are identified as having a combination of obesity (bmi > 30), osa (ahi > 5 on sleep study) and being residents within the auckland district healthboard region. results 243/ 344 patients screened did not fulfil the inclusion criteria: 171 lived outside the adhb region; 71 had bmi < 30; 7 patients did not have osa (ahi < 5). 101 patients fulfilled the inclusion criteria. 54/101 patients (54%) were excluded due to medical or psychiatric contraindications to vlcd.47 patients (47%) who did not have contraindications to vlcd were contacted. 33 patients were contacted successfully. 14 patients were either unavailable to phone contacts on 3 separate days or were disconnected. 12/101 patients consented to being referred (12%). 21/101 patients declined referral (21%). conclusion this pilot study is the first study using a formal comprehensive screening protocol in the recruitment of obese osa patients into a medically supervised vlcd program. only a small proportion (12%) of patients proceeded to being referred to the vlcd program. key: cord-023303-fxus38mp authors: nan title: lung cancer/bronchology sigs: combined poster session date: 2008-03-12 journal: respirology doi: 10.1111/j.1440-1843.2008.01252_8.x sha: doc_id: 23303 cord_uid: fxus38mp nan increased airway smooth muscle (asm) in asthma may be due to hyperplasia or hypertrophy of asm cells. the contribution of extracellular matrix (ecm) within asm bundles has not previously been accounted for when estimating asm cell volume. aim to estimate the mean asm cell volume in asm bundles in asthma. methods post-mortem tissues from control subjects (c n = 9); nonfatal (nfa n = 11) and fatal (fa n = 10) cases of asthma were studied. on 30 mm transverse airway sections stained with haematoxylin, the volume density (nv) of asm cell nuclei was estimated using an optical disector (¥1000). the mean cell volume (vc = 1/nv) was calculated, correcting for the volume fraction of asm (fasm) within the asm bundle (corrected vc = 1/(nv ¥ fasm)). fasm was estimated on 0.5 mm thick sections of the same airway stained with masson's trichrome. basement membrane perimeter (pbm) was used to indicate airway size. results table shows mean ϯ sd. (one-way anova) *p < 0.05 for c v fa, nfa v fa. conclusion these data suggest that although asm area is increased in asthma, mean asm cell volume is unchanged. therefore hyperplasia, not hypertrophy, of asm cells is present in both mild and severe asthma. these results were similar for both large and small airways. asthma is characterized by airway inflammation and remodelling which contribute to airway hyperresponsiveness and episodic airflow obstruction. mast cell (mc) densities are higher on the smooth muscle (asm) in asthma so their mediators may modulate other asm functions as well as cause contraction. aim to investigate the effect of mc mediators on chemokine and extracellular matrix (ecm) production by asm cells from donors with and without asthma. methods mc were isolated from the resected lung samples of 6 patients, resuspended at 10 6 cells/ml in dmem + 10% fbs and stimulated with ige/anti-ige. supernatants (sn) were collected after 2 and 24 h and the mc lysed. sub-confluent asm cells from 6 donors with and without asthma were serum deprived for 72 h before mc sn/lysates were added in dmem + 10%fbs for 48 h. il-8 and eotaxin levels in all asm sn and mc sn/lysates were measured by elisa. fibronectin and collagen iv deposition was measured in situ by immunoassay following asm cell lysis. results in asthmatic and non-asthmatic asm cells all mc sn and lysates reduced eotaxin release by up to 47% and 58%, whereas the 0-2 h mc sn significantly increased il-8 release to 178 ϯ 35.9% (p = 0.0339) and 169 ϯ 49% (p = 0.0445) of the fbs control respectively. however, only nonasthmatic asm cell il-8 release was increased by the mc 2-24 h sn (216 ϯ 85%; p = 0.0421) and cell lysates (215 ϯ 47%; p = 0.0421). the 0-2 h mc sn also increased fibronectin deposition to 143 ϯ 16% (p = 0.008) by asthmatic asm cells only. mc sn and lysates had no effect on collagen iv deposition. conclusions activated mast cell mediators differentially modulated chemokine and ecm secretion by asm cells from donors with and without asthma. thus mast cells may modulate their own recruitment to the smooth muscle and remodelling locally in the airways in asthma. supported by nhmrc. the technique of ige passive sensitization reproduces ige-related allergic responses in vitro and studies have validated this technique for investigations modelling allergic smooth muscle responses. there are no studies investigating effects of ige sensitization on rhinovirus (rv) infection. we hypothesized that rv infection is enhanced by ige sensitization, a consequence of diminished early innate immune responses. methods beas-2b epithelial cells and primary culture airway fibroblasts were sensitized with ige 24 h-7 d prior to infection with rv16. samples of tissue culture supernatant and cell lysates were collected over a 12 h period after infection for analysis. viral replication was measured by real-time rt-qpcr and viral titration and type i interferon mrna by rt-qpcr. ige receptor mrna expression was examined using rt-pcr. results initial studies to establish the model used human serum high in ige (>1000 iu/ml), this yielded inconsistent results and it was found that purified ige (1000 iu/ml) provided more reliable responses. sensitization was established after 24 h ige incubation and was comparable with up to 7 d. rt-pcr detected mrna for the ige low affinity receptor only after sensitization. following rv16 infection, vrna was increased after 24 h in ige sensitized cells (p < 0.05), but this effect varied noticeably between and within cell lines. cellular expression of ifn-b mrna increased with viral infection but in cells sensitized with ige lower levels of expression were noted (p < 0.05). conclusions ige passive sensitization enhanced rv replication in vitro but the model is constrained by significant variability between and within cell lines. the effect of sensitization on rv replication may occur through the low affinity ige receptor. activated mast cells (mc) are present in higher numbers on the airway smooth muscle (asm) in asthma compared with other inflammatory airway diseases. matrix metallo-proteinases (mmps) cleave chemokines and alter chemokine gradients by degrading the extracellular matrix and thus may modulate mc migration to the asm. aim to determine the levels of mmp-2, mmp-9 and their inhibitors, timp-1 and timp-2, secreted by asm cells from donors with and without asthma. method confluent asm cells were washed, serum-starved for 48 h and then stimulated with th1 (il-1, tnf and ifn) or th2 (il-1, il-4 and il-13) cytokines or left unstimulated. after 4 and 24 h,the sn were collected. the relative amount of pro and active forms of mmp-2 and mmp-9 in sn were determined by gelatine zymography. timp-1 and timp-2 levels in the sn were measured by elisa. results pro-and active mmp-9 were not detected. however, pro-mmp-2 levels were high in sn of asm cells from donors with (195.6 ϯ 47.2 % positive control/10 5 cells) and without (226.5 ϯ 49.2 % positive control/10 5 cells) asthma. a trend to increased active mmp-2 production by asm cells from donors with (7.3 ϯ 2.7 % positive control/10 5 cells, n = 9) compared to without (2.9 ϯ 0.7 % positive control/10 5 cells, n = 11) asthma after 24 h was not significant (p = 0.101). timp-1 and timp-2 levels respectively were high in the sn of cells from donors with (69.4 ϯ 19.6 and 21.3 ϯ 4.7 ng/10 5 cells, n = 5) and without (57.3 ϯ 13.7 and 16.6 ϯ 3.5 ng/10 5 cells, n = 5) asthma. th1 and th2 cytokine stimulation did not affect mmp or timp release. conclusions th1 and th2 cytokines did not regulate asm cell production of mmp-2, timp-1 and timp-2. altered asm mmp-2 activity is unlikely to play a role in mc chemotaxis to asm cells from donors with asthma in vitro or their presence on the asm in asthma. there has been a marked increase in the prevalence of asthma and other allergic diseases in the last few decades. one of the explanations for this is the change in our diet. one of the characteristics of the "western diet" is a high intake of both saturated and polyunsaturated fat. this prompted us to compare the effects of high fat and low fat meals on the numbers of circulating eosinophils and other leukocytes. methods we studied 12 volunteers who had allergic rhinitis and/or asthma and a peripheral eosinophil count at baseline of ն200 ¥ 10 7 /l. this was a randomized, crossover trial with participants studied on two different days. on each occasion they arrived fasting and after bloods were drawn consumed a 3000 calorie meal. one of the meals was high in saturated fat and refined carbohydrate. the other meal was low in saturated fat and high in fruit and fibre. bloods were drawn postprandially every hour for five hours. results eosinophil counts were highest in the early morning and fell over the course of the day but the decrease was less with the high fat meal (p = 0.03). over the same period of time the increase in lymphocytes (p = 0.016) was greater with the high fat meal. the high fat meal was also associated with greater increases in triglycerides (p < 0.0001) and cholesterol (0.004). conclusions in atopic individuals a high fat meal was associated with higher circulating numbers of eosinophils and lymphocytes than an isocaloric meal that was low in fat. further studies of the effect of dietary fat on eosinophilic inflammation are warranted. supported by the university of auckland research committeee. intravenous gamma globulin therapy (ivig), which is therapeutic in a variety of immune diseases, has been reported to be effective on patients with severe steroid-dependent asthma. although fcer are known to play important roles in asthma, there are few reports about the role of fcg?receptors in asthma. fcg receptor iib (fcgriib) is unique inhibitory receptor, which suppresses immune response. in this study, we evaluated the effect of ivig in allergic airway inflammation in ova-challenged mice and the mechanism of the inhibitory effects of ivig and fcgriib. method c57bl/6 mice (wt) and fcgriib deficient mice (ko) were sensitized with ovalbumin (ova) and alum and subsequently challenged with nebulized ova. before ova challenge rabbit igg was administered intravenously. the airway inflammation and effects of igg were assessed by histology, cell counts of bal fluid and airway hyperresponsiveness. result histology showed that igg treatment ameliorated the inflammation around the airway and the vessels and hypertrophy of goblet cells induced by ova challenge. the migratory activity of dcs is modulated in inflammatory diseases such as asthma. recently, we reported that immature dcs express kinin receptors and that bradykinin (bk) significantly enhances the migration of immature dc in vitro. as kinins mediate many of the pathophysiological effects associated with asthma, we hypothesized that lys-des[arg 9 ]-bk, which is produced during inflammation and acts via the b1 receptor (b1r), would inhibit migration of mature dcs. methods day 7 cultured human monocyte-derived dcs were matured with lps, tnfa +il-1b or cd40l in the absence or presence of lys-des[arg 9 ]-bk. maturation of dc was analysed by flow cytometry (facs). b1r expression was assessed by reverse-transcriptase pcr and quantitative confocal microscopy. migration of mature dc was assessed in transwell chambers with lysdes [arg 9 ]-bk and the chemokine ccl19 used as chemoattractants. results maturation of dcs was found to result in down-regulation of b1r expression to varying degrees depending upon the maturation stimulus used. mature dcs all demonstrated an ability to migrate toward lys-des[arg 9 ]-bk and ccl19. however pre-treatment with lys-des[arg 9 ]-bk decreased the migratory ability of all mature dcs to both chemoattractants. conclusions along with chemokines, lys-des[arg 9 ]-bk is likely to play a crucial role in regulating the in vivo migration of mature dc during inflammation. the production of lys-des [arg 9 ]-bk during inflammation potentially immobilizes mature dcs thereby facilitating locally-mediated immune responses within inflamed tissues. supported by the asthma foundation of western australia. introduction alternative or aberrant splicing is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms. the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to use a new and innovative approach involving the use of the genechip (r) exon array system together with real-time quantitative pcr to study asthma candidate genes in human monocyte-derived dendritic cells. asthmatic and non-asthmatic subjects provided 20 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method, and differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data indicate splice variant expression in dendritic cells from asthmatic patients is influenced by asthma severity. conclusion exon expression array analysis has generated a number of asthma candidate genes with alternative splice variants. further studies to validate these data in a replicate data set and establish the functional significance of our findings in asthma are underway. alternative or aberrant splicing occurs in more than 70% of genes and is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms 1 . the role of alternative splicing in asthma pathogenesis has not been previously investigated. we hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. we chose to study one asthma candidate gene in human stimulated and unstimulated: (1) monocytes, (2) monocytederived dendritic cells and (3) lung smooth muscle cells. methods asthmatic and non-asthmatic subjects provided 40 ml of blood from which peripheral blood mononuclear cells (pbmc) were isolated by ficoll-paque gradient centrifugation. monocytes were separated from other leukocytes by adherence method. up to 50% of the monocytes were then differentiated into dendritic cells following incubation with defined concentrations of gm-csf and il-4. induction experiments used 1 mg/ml lps and cells were stimulated for an optimal period of 24 hrs. rna was isolated and reverse transcribed for real-time semi-quantitative pcr and densitometry. chi squared test was used to assess associations between alternative splicing and asthma. results data from stimulation experiments indicate splice variant production can be regulated by the inflammatory response and that this response is influenced by asthma status. conclusion preliminary experiments have confirmed the presence of an aberrant splice variant for an asthma candidate gene in the primary cells studied. further studies to confirm these data and establish the functional significance of our findings in asthma are underway. exposure to environmental factors, such as environmental tobacco smoke (ets), plays a significant role in modulating pre-existing genetic susceptibilities to diseases including asthma. the glutathione s-transferase enzymes (gsts) play an important role in the detoxification of ets. there are several gst isoforms and gstp1 codes for the gst pi isoform, which is the primary gst isoform expressed in human lung tissue. two single nucleotide polymorphisms (snps) at positions 105 and 114 have been reported in gstp1 and associated with asthma and atopy. the aim of this study was to examine the effect of these snps in combination with ets, on asthma phenotypes in a cohort of asthmatic children. children were recruited during an acute episode requiring presentation at an emergency department. genotyping using pcr-rflp was completed on 218 children and ets exposure was determined by parental questionnaire. urinary cotinine was measured in the children and was in agreement with questionnaire responses. statistical analyses were performed using spss. there were no significant associations between the genotypes and asthma severity during acute exacerbations. significant associations were found between the snps and atopy in this population with an odds ratio of 2.77 for the 105aa genotype (p = 0.029) and or of 5.47 for the 114cc genotype (p = 0.002). however, when an interaction with ets was included, the odds ratios increased to 9.02 for 105aa (p = 0.05) and 9.17 for 114cc (p = 0.020). these results suggest that there is a significant gene/environment interaction impacting on atopy in this cohort. the rage gene encodes the receptor for advanced glycation end-products (rage), a member of the immunoglobulin superfamily. rage activation by ligands, including amphoterin and s100/calgranulins, leads to prolonged nf-kb signalling and has been associated with chronic inflammation. despite high levels of rage expression in lung tissue, little research has been undertaken into the role of rage in the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. objective determine genetic associations between functional polymorphisms in the rage promoter and severe and aspirin-sensitive asthma phenotypes. methods pcr and restriction fragment length polymorphism (rflp) were used to genotype three rage promoter polymorphisms, -429t>c, -374t>a and a 63 bp deletion from -407 to -345, in a large case-control asthma population phenotyped for asthma severity, atopy and aspirin sensitivity. results no associations were identified between any of the polymorphisms and the occurrence of asthma. however, the -374a allele was linked with both severe asthma (p = 0.013) and aspirin-sensitive asthma (p < 0.001). likewise, genotypes containing the -374a allele were strongly associated with both severe asthma (or 2.10, 95% ci 1.32-3.36) and aspirin-sensitive asthma (or 3.13, 95% ci 1.45-6.77). conclusions the -374a allele of the rage gene, previously shown to lead to a 3-fold increase in promoter activity, is associated with the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. these results suggest that increased rage expression, with a concomitant increase in nf-kb signalling, may in part contribute to the inflammatory response seen in these conditions. the global prevalence of allergic diseases is rising and australia has one of the highest prevalence rates in the world. the role of early childhood infections in the development of allergic disease remains controversial. objective to examine the association between early childhood infections and the development of allergic diseases in later childhood, in high risk children. methods data were analysed from the melbourne atopic cohort study (macs) of 620 infants with 1 or more first-degree family members with atopic disease. primary risk factors assessed were otitis media, bronchitis and gastroenteritis reported in the first two years of life. outcomes were current asthma, hay fever and eczema at 6 years of age. logistic regression was used to estimate crude and adjusted odds ratios. results asthma was the most common allergic condition (25.4%, 95% ci 21.6-29.5%), followed by eczema (24.9%, 95% ci 21.1-29.0%) and hayfever (15.6%, 95% ci 12.5-19.1%). the most commonly reported infection was otitis media (58.9%, 95% ci 54.9-62.8%), then gastroenteritis (37.7%, 95% ci 33.9-41.7%) and then bronchitis (19.4%, 95% ci 16. [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] .7%). all 3 types of infection within the first 2 years of life were associated with increased risk of asthma. an increased risk of asthma at 6 years was seen with otitis media (or = 1.14, 95% ci 1.02-1.3), bronchitis (or = 1.34, 95% ci 1.0-1.8) and gastroenteritis (or = 1.23, 95% ci 0.96-1.6). when the frequency of infection was examined, those who reported at least 3 episodes of gastroenteritis had a 3-4-fold increased risk and an almost 30% absolute increased risk (rd 0.34, 95% ci 0.08-0.59). conclusion these findings appear to contradict the hygiene hypothesis. the findings for gastroenteritis are novel. further examination of these associations and possible underlying mechanisms is warranted. grant support asthma foundation of victoria, nestle. background knowledge about incident cases of asthma in australia is limited because they are not routinely reported. the ability to predict the number of new cases of asthma would be helpful in allocating resources for asthma education, management and care. data on first use of medications for asthma gives an indication of the incidence of asthma. the objective of this study was to estimate the incidence rate of asthma by investigating asthma medication use in individuals. methods pharmaceutical benefits scheme (pbs) records for all prescriptions filled for inhaled corticosteroids (alone or combined formulation), cromones and leukotriene receptor antagonists from july 2002 to june 2005 were included. using a 2-year look back window, any persons who had their first prescription for any of these drugs dispensed between july 2004 and june 2005 were assumed to be incident cases. overall and age-specific incidence rates were calculated per 100 asthma-medication-free individuals. results there were 352,082 individuals who had their first asthma medication dispensed between july 2004 and june 2005, which equates to an overall incidence rate for asthma of 1.89 per 100. the incidence was higher among children aged 0-14 years (2.07) and adults aged 65 years and over (2.45) . conclusions our estimated incidence rates were consistent with those reported by others in the literature. while the pbs database was designed for administrative purposes, it can be used to estimate incidence rates for asthma. support acam is a collaborating unit of the australian institute of health and welfare and is funded by the department of health and ageing (doha). we acknowledge the pharmaceutical pricing and estimates section of doha for provision of pbs data. keywords asthma incidence, pharmaceutical benefits scheme. rosario ampon 1 , guy marks 1 , teresa to 2 , leanne poulos 1 , anne-marie waters 1 1 australian centre for asthma monitoring (acam), sydney, australia, and 2 hospital for sick children, toronto, canada background the ability to assess individual patterns of asthma medication use would have clinical relevance in targeting effective asthma education and management for this common condition. to describe longitudinal patterns of asthma medication use, we used a population-based prescription database to follow individuals from the first time they filled an asthma prescription. asthma is more commonly listed on death certificates as an associated cause of death, in people whose deaths are attributed to other causes, than as an underlying cause of death. understanding the importance of these associations would contribute towards an overall appreciation of the impact of asthma on mortality. the objective of this analysis was to estimate the prevalence of asthma as an associated cause of death when various other diseases were attributed as the underlying cause of death. background acam currently recommend 24 indicators to measure population-level asthma health and outcomes. we examined correlations among several asthma indicators covering prevalence, morbidity and mortality to try and produce a condensed set of indicators which minimized redundancy. methods seven of the 24 indicators were included in this study: prevalence of ever having doctor diagnosed asthma, prevalence of current asthma, asthma-related general practice (gp) encounters, proportion of people with asthma with an asthma action plan (aap), hospitalizations for asthma, hospital patient days for asthma, and deaths due to asthma. a correlation matrix was created for these indicators by age groups. pearson correlation coefficients ն0.7 or յ-0.7 were considered strong. results there were strong positive correlations between prevalence of ever asthma and current asthma (r = 1.0); gp visits and aap possession (r = 0.74), hospitalization (r = 0.91) and patient days (r = 0.95); and hospitalization and patient days (r = 0.90) and aap possession (r = 0.73). recent australian reports have shown that the prevalence of asthma and respiratory symptoms has decreased over the last 10-15 years. as part of a larger study investigating child health and air quality we have collected nationwide data from schoolchildren living in act, victoria, queensland, wa and sa. methods schools were selected based on proximity to air quality monitoring stations. classes from years 3 to 6 were randomly selected and all children were invited to participate. parents self completed a questionnaire that included questions about diagnosed asthma and respiratory symptoms. results a total of 1989 children provided questionnaires for analysis. the response rate varied between states and territories and ranged from 30% to 42%. the sample comprised 51.9% girls and the mean age of children was 10.2 years. ever diagnosed asthma 27.9 current asthma ('does he/she still have asthma? ') 13.8 wheeze in the past 12 months 16.1 respiratory symptoms limiting activities 11.8 missed school due to asthma or wheezing 8.8 conclusions despite the relatively low participation rate, the prevalence estimates for current asthma are similar to those reported in the national health survey 2004-05 [1] . there is no evidence of any recent increase in the prevalence of childhood asthma. methods tahs is a longitudinal population-based respiratory study of 8583 subjects which commenced in 1968 when they were 7 years of age. since the initial study another 4 follow-ups have been conducted, including the most recent follow-up when subjects were 44 years of age. lung function of the total sample was measured at baseline and in sub-samples in 3 subsequent followups. asthma was categorized as persistent, frequent or episodic when participants reported asthma symptoms in at least 3 follow-ups, in 2 follow-ups or in 1 follow-up respectively. results by age 7 years ever asthma prevalence was 16%. at age 44, 10% of those who had not reported asthma by age 7 had asthma symptoms while 75% of those who reported asthma by age 7 had no asthma symptoms. hence over all only 25% of the asthma symptoms at age 44 were attributable to asthma developed by age 7. in contrast, 91% of the persistent and frequent asthmatics had developed their asthma by age 7. persistent and frequent asthmatics had more symptoms and poorer lung function at age 7, 14 and 44 as well as more reversibility at age 44 (p < 0.05). childhood asthmatics who also had a productive cough by age 7 were more likely to have persistent asthma than those without a cough (p < 0.05). conclusions although the majority of middle-age asthma is related to postchildhood onset asthma, most severe middle-age asthma has its origin in persistent childhood disease. having productive cough in childhood may identify high risk asthmatics who require especially rigorous management in early life. one third of women experience an improvement in asthma during pregnancy, and symptoms improve in most women in the late third trimester. we hypothesized that the exacerbation rate would be reduced and that symptoms during exacerbations would be less severe in the third trimester compared to the second trimester. methods pregnant women with asthma (n = 81) were prospectively followed from recruitment (14.8 weeks (3 sd) ) to delivery at clinic visits (18, 30, 36 weeks and during exacerbation), and fortnightly phone calls. the asthma control questionnaire (acq) was administered at each contact and exacerbations classified as severe (requiring medical intervention) or mild (selfmanaged). lung function, medication use, fractional exhaled nitric oxide (feno) and full blood counts were assessed. paracetamol is commonly used in infants as an analgesic and antipyretic. it has been hypothesized that frequent paracetamol consumption may result in reduced lung capacity to cope with oxidative stress and increase risk of respiratory disease. to date, no study has examined exposure to paracetamol during infancy, when lungs are still developing, and risk of childhood asthma. method a birth cohort of 620 infants with an atopic family history was recruited. frequency of paracetamol exposure was prospectively documented up to 2 years of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results paracetamol exposure in infancy was common (97% exposed by two years of age), with some infants receiving paracetamol on up to 77 days. it has been hypothesized that mucosal immune response requires a particular micro-flora milieu in the infant's gastro-intestinal tract, and that early life antibiotic exposure may disrupt this process and increase risk of allergic disease. method a birth cohort of 620 infants with an atopic family history was recruited. exposure to oral antibiotics was prospectively documented up to 12 months of age. interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. results by one year of age, approximately 80% of infants had received at least one course of oral antibiotics. the prevalence of current asthma in childhood was approximately 30% (148/495). frequent use of antibiotics (more than 20 days exposure during first year of life) was associated with increased risk of childhood asthma (or = 2.52, 95% ci = 1.40-4.54) when compared to infant who had not been exposed. excluding infants with a diagnosis of asthma within the first two years of life, reduced this association by about 30% (or = 1.80, 95% ci = 0.90-3.57) and adjustment for gender, parental history of asthma and number of infections in the first year of life further reduced this association (or = 1.60, 95% ci = 0.79-3.22). the increased risk of childhood asthma associated with antibiotic exposure in the first year of life is, at least in part, due to confounding with early life wheeze and infections. if real, the independent effect of antibiotic exposure on risk of childhood asthma is likely to be minimal in this high risk cohort. support dairy australia, crc for asthma and airways, vichealth, nestle. the epidemiological data on asthma suggest a gender difference that varies with age. hormonal effects have been suggested as a possible explanation for these differences. the aim of this study was to examine reproductive factors and risk of asthma among the females of the tasmanian longitudinal health study (tahs). methods the tahs is a longitudinal population-based cohort study of respiratory disease which commenced in 1968 when subjects were 7 years of age. four follow-up studies have been conducted including the current most comprehensive follow-up with subjects at 44 years of age. information has now been collected on reproductive factors such as number of pregnancies, age at pregnancies, age at menarche and contraceptive pill use as well as on asthma status. reproductive factors were examined as risk factors for asthma using multiple logistic regression to adjust for all likely confounders. results a total of 2,776 women completed the most recent postal survey. of these 355 (12.8%) had current asthma, and of these women with current asthma 73.5% (261) developed asthma after childhood. on average these women were in their mid-twenties when they developed asthma (mean ϯ sd age = 26.6 ϯ 12.5 yrs). we found with increasing age at first birth an approxi-mate~30% reduced risk of current asthma in women who developed their asthma post-childhood (trend p = 0.04). we did not observe any other associations between reproductive factors and risk of asthma. conclusions our results are consistent with the hypothesis that early pregnancy may promote asthma development by altering the immune response favouring a th2 pathway. a delay in the age of first pregnancy reduces this risk of asthma. grant support nhmrc, clifford craig foundation, victorian & tasmanian asthma foundations. introduction the association between exposure to pets in early life and subsequent development of sensitization and allergic disease remains controversial. the objective of this analysis was to examine the relationship between cat exposure before birth and development of cat sensitization over time within the melbourne atopic cohort study (macs). methods the macs is a prospective longitudinal cohort study that initially recruited 620 women antenatal in melbourne from february 1990 to november 1994. detailed information on cat exposure was collected at recruitment and frequently until two years of age. skin prick test (spt) were conducted at 6, 12, 24 months and 10 years. the data were analysed by logistic regression and using generalized estimating equations (gee) for the repeated measures design. results among 620 subjects, 169 (28.8%) had a cat before birth. at 6 months, 1.9% (n = 11) of subjects were sensitized to cat and by 10 years of age 18.8% (n = 68) were sensitized. those who did not have cat before birth belong to a higher social class, and were more likely to have a father with allergic disease than those with a cat. those who developed sensitization to cat were more likely to have a paternal family history of allergic disease and more likely to be sensitized to other allergens. we did not observe any association between exposure to cat before birth and the development of sensitization to cat at 6 months (or = 0.7, 95% ci 0. 1-3.3) , 12 months (or = 1.4, 0.5-3.9), 24 months (or = 0.76, 0.2-2.5) or 10 years (or = 0.6, 0. 2-1.4) . these crosssectional results were confirmed by the gee analysis. conclusion our results fail to show an association between cat exposure before birth and development of sensitization to cat. furthermore exposure after birth in the first 18months of life was not associated with an increased or decrease risk of sensitization to cat. our results do not support either a benefit or risk associated with cat ownership and sensitization. introduction peri-natal events influence the development of asthma and atopic diseases in childhood but the current literature is contradictory on the effect of low birth weight, small for gestational age and prematurity on asthma risk. the aim of this study was to assess the relationship between these three exposures and asthma from childhood to adulthood. aim to assess the current prevalence of dda, wheeze (<12 months), atopy and ahr in children and adults in busselton. methods an age-and sex-stratified random sample of adults, selected from the electoral roll, was invited to complete a questionnaire and attend the local study centre for assessment of atopy (allergen skin tests) and ahr (methacholine). all children from participating primary and secondary schools were also invited to attend. the prevalences of dda, wheeze, atopy, ahr and "current asthma" (wheeze + ahr) were calculated. background asthma is often associated with comorbidity, however few studies have investigated comorbidities among people with this common condition. the objective of this analysis was to describe patterns of non-respiratory comorbidity among adults hospitalized with asthma in australia. methods data on hospitalizations for people aged 15 years and over with a principal diagnosis of asthma (j45, j46) were obtained from the australian institute of health and welfare's (aihw) national hospital morbidity database for the period 2005-06. patterns of comorbidity were examined by investigating additional diagnoses for non-respiratory disease according to icd-10 diseasespecific chapters. results among people aged 15 years and over hospitalized in 2005-06 with a principal diagnosis of asthma (16,566 hospitalizations; 70% female; 47% aged 35-64 years), 33% had at least one non-respiratory comorbidity. median length of stay was higher among those with at least one comorbidity (4 days) than among those with no comorbidities (2 days). among people aged 15-64 years, the most common comorbid condition was endocrine, nutritional and metabolic diseases (19%), while among those aged 65 years and over it was diseases of the circulatory system (32%). conclusions a large proportion of asthma hospitalizations in australia are associated with non-respiratory comorbidity and a longer length of stay. further, the pattern of non-respiratory comorbidity associated with asthma hospitalizations varies by age. given our rapidly ageing population, the level of comorbidity associated with asthma has implications for coordinated health care and demand on health services. support acam is a collaborating unit of the aihw and is funded by the department of health and ageing. keywords comorbidity, hospitalization, asthma. background asthma exacerbations are often triggered by viral respiratory infections, yet the influence of respiratory infections on the morbidity of acute asthma beyond the immediate period is unknown. we examined the influence of nasopharyngeal (npa) respiratory viral, chlamydia and mycoplasma detection on asthma morbidity in children presenting to the emergency department for an acute exacerbation of asthma. methods a subset (n = 78) of the 201 children enrolled for a randomized controlled trial (rct) on the efficacy of 5 vs 3 days of oral prednisolone had an npa taken at presentation. npa were examined for chlamydia, mycoplasma and respiratory viruses (enteroviruses, coronaviruses, human metapneumovirus, adenovirus, parainfluenza, influenza, rsv, rhinoviruses) by pcr. enrolled children were aged 2-16 years with recurrent wheeze and required ն600 ?g (mdi/spacer) or ն2.5 mg (nebulized) of salbutamol to reduce tachypnoea. parents filled validated diary cards for cough and asthma severity, and completed asthma qol data at enrolment and end of weeks 1 and 2. results pcr for various viruses was positive in 42 (53.8%) children, with no significant difference in the groups the children were randomized into. rhinovirus pcr was positive in the npa of 32 children, rsv in 7, hmpv in 2, adenovirus, parainfluenza, influenza a and b in one each. specimens were negative for the other micro-organisms listed above. children with a npa viral positive state were significantly (p = 0.002) younger than those with a negative state. however, there was no difference in the any of the asthma outcomes of children whose npa was positive or negative for the micro-organisms tested. conclusions in children with an acute asthma exacerbation presenting to emergency health facilities, a respiratory virus could be identified in >50% but the presence of a respiratory virus did not influence the morbidity of the asthma exacerbation at presentation or at the end of week-1 and week-2. the university of sydney, nsw 2006, and 3 royal north shore hospital, st leonards, nsw 2065 airway wall thickness measured using hrct is reported to be increased in asthmatic compared with control subjects. however, it is unknown whether wall thickness is a fixed structural characteristic of the airways or if it responds to transient changes in bronchomotor tone or airway size. aim to determine the effects of bronchomotor tone and lung volume on airway wall area measured by hrct. methods 8 patients with doctor-diagnosed asthma had partial chest hrct scans, before and after bronchodilator (bd), at frc, tlc and a volume midway between (mid-volume). airway segments were identified between branch points and matched between consecutive lung volumes both before and after bd, and also at constant lung volume before and after bd. mean lumen areas and wall areas for each airway segment at each volume were measured using automated analysis software. paired t-tests were used to determine changes due to bd and lung inflation. results 44 airways were matched before and after bd at frc. absolute airway wall area (wa) was related to airway lumen diameter (di wood smoke air pollution is of concern with respect to respiratory health due to its complex chemical composition and potential to carry air toxics into the lower respiratory system. launceston has a long history of poor winter air quality, primarily due to use of domestic wood heaters. participants in hobart had a similar prevalence of wood heater use, but hobart does not experience the same wood smoke pollution (due to differences in regional geography , asthma control and anxiety and depression were completed at baseline, immediately following (6 wks), and 3 mths after the intervention period. results clinically and statistically (p < 0.05) significant improvements in qol were observed in the exercise group at 6 wks compared to the control group. this difference was not maintained at 3 mths. 6mwd improved at 6 wks and 3 mths in the exercise group (p < 0.01), however the difference between groups was not significant. in the exercise group there was a trend towards improved asthma control and a reduction in anxiety and depression that was not observed in the control group. *p < 0.05, change at 6 wks vs baseline; home asthma monitoring is important for measuring day-to-day variation in lung function and symptoms. this approach requires the availability of complete diaries for a comprehensive assessment. we assessed the completeness of written diaries collected as part of a nation wide study of air quality and child health. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified from a cross-sectional study. these children were asked to record symptom scores and peak expiratory flows twice daily in diaries for a five week period. the diaries and peak flow devices were explained at a face-to-face meeting with parents and children. each week diaries were mailed back and parents received a phone call to encourage completion. completeness was defined as no missing responses to symptom questions or peak flow measurements in diaries from week two to week five. results data from the first 36 children (822 day records) were available for analysis. the sample included (53%) girls, mean age 10 yrs. the overall frequencies for complete records were; morning symptoms 85%, morning peak flow 85%, evening symptoms 83% and evening peak flow 82%. there was a significant trend for more complete morning peak flow records over the four weeks (cochrane-armitage trend test p < 0.007). agreement between morning and evening symptom completeness and between morning and evening peak flow completeness was fairly poor (kappa < 0.30). conclusions the completeness of symptom and peak flow records collected in this study was very high. the comprehensive follow-up protocol implemented is likely to have had an important impact on the completeness of asthma diaries. daily peak expiratory flow (pef) monitoring has been used in epidemiological studies to assess changes in lung function over time. the value of written pef diaries has been questioned because of problems with completeness and validity. this study aimed to compare stored electronic pef data and a written diary record of those data in a panel study in children with weekly reminders to aid adherence. methods children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified in a population study. they were given electronic pef devices with a digital readout (miniwright digital, mwd, clement clarke, uk) and written symptom and peak flow diaries and instructed in their use at a meeting with parents and children. each child was asked to complete three pef manoeuvres every morning and evening for five weeks and to record these in the written diary. background previous research suggests that comorbid anxiety is associated with lower asthma-related quality of life (aqol) in adults with asthma. however, research is scant on the role of psychological interventions in these patients. aim to evaluate the effectiveness of a four-session cognitive-behavioural therapy (cbt) intervention, in improving the aqol, in participants with anxiety and asthma. method participants identified with comorbid anxiety and asthma were randomly assigned to the cbt intervention group (n = 10) and the asthma monitoring control group (n = 8) and evaluated on aqol measures, at various intervals. results nine participants, in the cbt group, completed the study. seven participants showed a clinically significant improvement in asthma-related emotional functioning (ef) and six participants in total aqol scores, at the 5-week post-intervention assessment. additionally, six participants in the cbt group indicated clinically significant improvement in ef and five participants in total aqol scores, at the 3-month follow-up assessment. only three participants in the control group completed the study. none of these participants showed any improvement in aqol scores at the 5-week or 3-month assessment. conclusion this pilot study suggests that a higher number of participants in the cbt group showed clinically significant improvement in ef and total aqol scores with higher retention rates. further research needs to confirm these findings in a larger group, identifying the elements of a successful cbt intervention and characteristics of participants who respond to the cbt intervention. gastro-oesophageal reflux disease (gord) is a risk factor for uncontrolled asthma. we conducted an update of a systematic review to assess whether treatment of gastro-oesophageal reflux in subjects with asthma improved asthma outcomes. methods randomized controlled trials (rcts) of gord treatment in adults or children that reported asthma health outcomes and had symptomatic gord were included and assessed in accordance with the standard cochrane systematic review process. subjects received pharmacological therapies compared with conservative management. results from 261 potentially relevant studies, 19 rcts were included in the review. when compared to placebo, morning peak expiratory flow did not significantly improve (change from baseline wmd 10.43, 95% ci: -9.55 to 30.42) with proton pump inhibitor treatment (n = 7 trials involving 739 participants). asthma exacerbations were not significantly less in the intervention groups compared with the control groups (odds ratio 0.66; 0.41-1.08; n = 557). conclusions while some trials reported evidence of asthma improvement with gord therapy, overall there appears to be no statistically significant evidence of a beneficial effect. it is clear that not all persons with gord and asthma will gain improved control over their asthma with gord therapy; this may be due to the heterogeneous pathophysiology of asthma. future large-scale trials would be required to demonstrate an effect on asthma exacerbations. kel and brd were supported by a cochrane airways group scholarship. background the ats/ers task force recommend the use of metered dose inhaler (mdi) and spacer for airflow limitation reversibility testing. salbutamol given via mdi & spacer has been shown to be equivalent to a nebulizer in the clinical setting. this has not been well studied in respiratory laboratory setting. aim to compare the 2 methods of reversibility testing in a laboratory setting. methods we conducted a laboratory based crossover study in a secondary hospital. patients with asthma or copd were eligible. the patients firstly underwent spirometry and reversibility testing following a standard dose of nebulized salbutamol. they were asked to return for a second set of spirometry within the same week and at the same time of day when reversibility with an mdi and spacer was recorded. we used an incremental dose of salbutamol starting from 2 puffs and up to 8 puffs. spirometry parameters were recorded 10 minutes after each intervention. the primary outcome was the percentage change in fev1 after each intervention. side effects were monitored for. results nine patients with asthma were recruited. the mean percentage change in fev1 was higher in the nebulizer group than after only 2 puffs via mdi & spacer (15.4 ϯ 7.4 vs 6.2 ϯ 8 [mean ϯ sd], p = 0.67). however, there were no differences between the 2 arms following higher doses of bronchodilator via mdi & spacer. the mean percentage change in fev1 after 4, 6 and 8 puffs were 12.6 ϯ 11.3, 15.4 ϯ 12.3, and 17.7 ϯ 13.6 respectively (p = 0.09, 0.05 and 0.07 respectively when compared to the nebulizer group). conclusion using an mdi and spacer for bronchodilator reversibility is equivalent to that of a nebulizer and should be the standard method of testing. the dose of bronchodilator needs to be at least 4 puffs as recommended by the ats/ers; however 6 puffs correlated best with a standard nebulizer route. further increments in bronchodilator dose provided little additional bronchodilatation. the study was limited by the small number of patients. asthma guidelines recommend a stepwise approach to treatment. the role of inhaled corticosteroid (ics) and long-acting beta-agonist (laba) combination therapy in asthma written action plans is not clear. objective to assess the efficacy of adjusting ics/laba combination therapy in a written action plan compared to fixed dosing in people with asthma requiring maintenance ics. methods cochrane systematic review of randomized controlled trials comparing ics/laba combination therapy in a single inhaler that is adjusted up or down according to a written action plan (wap) to comparison 1: budesonide/ formoterol given as a fixed maintenance dose (fd) (n = 9) or comparison 2: fluticasone/salmeterol fd (n = 2). results 10 parallel randomized controlled trials describing 11 interventions met the inclusion criteria. for the trials that compared wap to fd budesonide/ formoterol there were significant reductions for the wap group in exacerbations, (rr (95%ci): 0.82 (0.70 to 0.97)), severe exacerbations (rr (95%ci): 0.61 (0.37 to 0.99)) and study medications (wmd (95%ci): -1.18 (-1.23 to -1.14)) with no difference in asthma control or adverse events. the results for the two trials reporting wap budesonide/formoterol to fd fluticasone/ salmeterol were discordant and a homogenous pooled result could not be determined. of the 318 australians who died from asthma in 2005, over two thirds were over 50 years of age. this trend resulted in the national asthma council of australia (nac) calling for better management of asthma in the elderly. we designed an educational intervention using evidence based educational strategies to improve the content and style of general practice consultations for older people with asthma. methods randomized controlled trial of a multi-faceted program consisting of a group educational session, a videotaped standardized simulated patient consultation, followed by an academic detailing session. forty-two gps were randomized into an active or a control group. gps provided the names of patients who would be happy to participate in the study and the program was evaluated by patient and gp outcomes. results gps recruited into our program reported improvements in a range of clinical areas. one hundred and ten patients were recruited, their outcomes are under analysis. conclusion gps were overwhelmingly positive about participation in this trial and our intervention successfully improved the capacity and confidence of gp's to deliver care to older people with asthma. our study also developed several tools that would enable dissemination of our findings. supported by an asthma targeted in studies where direct clinical assessment is not possible, urgent health care utilization (hcu) is often used as an indirect measure of asthma control. this study aimed to identify factors predicting urgent hcu and asthma control. methods patients in nsw with a doctor diagnosis of asthma were recruited from community pharmacies, a research volunteer database, and databases of asthma foundation nsw, to complete a questionnaire about asthma. poor asthma control was defined as asthma control questionnaire (acq) score ն1.5. urgent hcu was defined as hospitalization, ed visit, or urgent doctor visit due to asthma. multiple logistic regression was used to identify predictors of poor control and urgent hcu. results questionnaires were completed by 608 adults (61% female) with a doctor diagnosis of asthma (pharmacy 260, woolcock 299, asthma foundation 87). 87% used inhaled corticosteroid (ics) ϯ long-acting b2-agonist in the last 4 wks. median age was 56 yrs (range 12-87), and 9% were current smokers. mean acq score was 1.4 (95% ci 1.3-1.5), with 40% of participants having poor asthma control (acq ն 1.5). 28% had urgent hcu for asthma in the previous year. significant independent predictors for poor asthma control were younger age, current smoking, living in more disadvantaged areas, being retired, having only primary education, and holding a concession card. predictors for urgent hcu were younger age, being in full-time employment, having only primary education, and being of non-english speaking background. neither ics use nor possession of a written asthma action plan was associated with lower risk for either poor asthma control or hcu. conclusions poor asthma control is common in nsw even in patients using inhaled corticosteroids. although urgent hcu is often used as an indirect measure of poor asthma control, it is affected by different factors, perhaps because health care utilization represents a more complex balance between need and access. bronchial challenge tests with mannitol, to measure airway hyperresponsiveness, can take up to 30 minutes and require inhalation of up to 635 mg of mannitol. our aim was to determine if positive mannitol challenges can be detected after half the maximal dose (315 mg) using the forced oscillation technique (fot) to measure response. methods 15 non-asthmatic subjects and 52 asthmatic subjects underwent standard mannitol challenge, up to 635 mg mannitol. respiratory system conductance (grs) and reactance (xrs) was measured by fot at 6 hz during 40 sec tidal breathing immediately after each dose of mannitol. fev1 was measured after fot, within 90 sec of mannitol administration. two point dose response slope (drs), was calculated for grs (drsgrs) and xrs (drsxrs) for standard tests, up to 635 mg, and for short tests by excluding data from doses above 315 mg. ability to detect a positive test, defined as pd15fev1 < 635 mg, was determined by the area under the roc curve (auc) and repeatability by intra-class correlation coefficient (icc). results 32 asthmatic and 2 non-asthmatic subjects had positive tests, with pd15 fev1 values from 9.2 to 622 mg. auc (95%ci) did not differ between standard (std) and short tests for drsgrs (p = 0.14) or drsxrs ( combined use of inhaled steroids (ics) and long acting beta-agonists (laba) have an important role in asthma management. we used data from a 2006 population sample to examine medication use in adults and children. methods all adults (18-75 years) and children (2-17 years) from within four discrete zones in northern sydney were eligible for an interview survey, as part of a study investigating health effects associated with traffic-related air pollution. the prevalence of use of short-acting beta-agonists (saba), any ics (alone or combination) and combined formulations of ics/laba in the previous three months was estimated for the study population and those with diagnosed asthma. results there were 806 children [mean (sd) age 8.7 (4.6) years and 50% female] and 2184 adults [mean (sd) age 45.6 (14.9) years and 56% female] interviewed in 1843 households, representing an overall response rate of 33%. the prevalence of ever diagnosed asthma was 16.1% in children and 17.4% in adults. medication data were missing for 301 subjects. background asthma affects 1:9 adult australians and is a leading cause of rejection for recruitment into the australian defence force (adf). within this diagnosis there is a wide spectrum of disease activity and clinical outcomes. also asthma assessment and management has improved so that many asthmatics are now fully active without any significant disruption or risk to their lives. hypothesis: there is a subgroup of asthmatics who are at very low risk from significant adverse effects from asthma and who could be considered for recruitment to the adf. aims 1. to identify the subgroup of asthmatics who could be considered for recruitment to the adf. 2. to develop an assessment process to identify this subgroup (screening). 3. to develop a process to evaluate the outcomes of any change to the recruitment standard for asthma (evaluation). methods 1. a literature review of the natural history, assessment, management and response to treatment of mild episodic and mild persistent asthma. 2. a literature review of asthma in the military. 3. a clinical review of the outcomes of known asthmatics in the adf. 4. an expert group to review the above and to develop a screening process and an evaluation of the program. the literature review identified a subgroup of asthmatics, defined as mild episodic and mild persistent, who with appropriate management, have a low risk of significant adverse asthma outcomes. they can be identified by a combination of questionnaire, spirometry and bronchial provocation testing. a screening process has been developed which allows asthmatics to be recruited with a negative mannitol or hypertonic saline challenge on 400 mg/day or less of budesonide (or equivalent) without laba. a methodology to evaluate the impact of these changes on the recruitment standard has also been developed. alexithymia is a personality trait associated with difficulty identifying and communicating emotional and physical feelings. it has been associated with poor control of asthma and near fatal asthma. the primary objectives of this study were to: (1) identify alexithymia in a cohort of australian asthma patients; (2) investigate the relationship between alexithymia and asthma control; (3) investigate the relationship between alexithymia and asthma management. methods cross sectional study of 25 moderate to severe asthma patients recruited from royal adelaide hospital outpatients. participants were either mailed the questionnaire pack or completed it after a clinic appointment. existing validated questionnaires were used. statistical analyses were performed using spss. results 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years, sd = 11) participated. alexithymia scores ranged from 23.0 to 76.0 (x = 48.3, sd = 13.2). 12% (n = 3) of participants could be classified high alexithymia, 32% (n = 8) borderline alexithymia and 56% (n = 14) were low alexithymia. alexithymia mean scores were not statistically different across sociodemographic variables. a positive correlation/association was found between alexithymia score and asthma control score (r = 0.57, p < 0.01), quality of life (r = -0.65, p < 0.01), and adherence (p = 0.03) but not satisfaction with communication (r = -0.27, p = 0.2) or number of hospitalizations (p = 0.25). conclusions this is the first australian study to identify alexithymia among asthma patients and investigate relationship to control as well as management and communication. associations between alexithymia and asthma control were confirmed. a larger sample size is needed to determine impact of alexithymia on self-management and provision of clinical care for asthma. port hedland is impacted by iron-containing dust particles (pm10) that may activate lung cells when inhaled. furthermore, the effects of port hedland pm10 may differ from the effects of urban pm10 impacting metropolitan areas. the aim of this study was to assess the effects of port hedland pm10 on production and release of the inflammatory cytokines, il-6 and il-8, by human airway epithelial (a549) cells, and to compare these with the effects urban pm10 from metropolitan areas. methods human airway epithelial (a549) cells were exposed to pm10 collected at port hedland and at urban locations (sydney, perth). a549 cells were exposed to a range of pm10 concentrations (20-200 mg/ml) for 24 h. lipopolysaccharide (lps) and phorbol myristate acetate (pma) were used as positive controls. supernatants from cell cultures were assayed for il-6 and il-8 using specific elisa kits. rna was extracted and reverse transcribed to cdna. il-6 and il-8 mrna expression was quantified by duplex real-time pcr using taqman primer/probes. results lps stimulated a 2.7-fold increase in il-8 release and pma stimulated a 3-fold increase in il-8 release and a 30-fold increase in il-6 release. however, neither port hedland pm10 nor urban pm10 stimulated concentration dependent release of il-6 or il-8 by a549 cells. expression of il-6 or il-8 mrna was also not altered by port hedland or urban dust. cd8+ t-cells may cause airway epithelial cell apoptosis via the granzyme pathway. we have reported increased apoptosis of airway epithelial cells and increased bal t-cell expression of granzyme b in copd, and a positive correlation between the two. we hypothesized that the increased granzyme b would also be related to smoking history (pack years -pk/y), age and severity of airflow obstruction (fev1 %pred) in patients with copd. we further hypothesized that the t-cell granzyme b expression would be higher in the airway than the peripheral blood. methods we investigated t-cell intracellular granzyme b expression in blood from copd subjects (33 current and 24 ex-smokers) and 12 never-smoker controls, and bronchoalveolar lavage (bal) and bronchial brushing (intraepithelial t-cells) from a cohort of these subjects using flow cytometry. correlations between granzyme b and pk/y, age or fev1 were performed using spearman's rank correlation. granzyme b in t-cells from blood, bal and bronchial brushings were compared. results there were significant correlations between fev1 and granzyme b expression in blood and bal (blood: r -0.444, p = 0.002; bal: r -0.368, p = 0.029). there was a significant correlation between pk/y and granzyme b expression in blood (r 0.362, p = 0.002), but not in bal. there were no significant correlations between granzyme b and age. there were no significant differences in granzyme b expression in blood, bal or intra-epithelial compartments. conclusion granzyme b is expressed at similar levels in blood, bal and intra-epithelial compartments, supporting recent opinion that copd is a systemic disease. t-cell granzyme b is related to severity of airflow obstruction and smoking history in patients with copd and may be one mechanism of apoptosis leading to lung injury and airflow obstruction in copd. jc allen 1 , t schlosser, ee ramsay 1 , q ge 2 , aj ammit 1 as development of remodelled airways is correlated with deterioration of lung function, we require therapies that reduce and reverse structural changes in remodelled airways. in asthma, corticosteroids can halt some, but not all, aspects of airway remodelling. therefore, in order to aid future design of efficacious anti-remodelling agents we need a better understanding of the molecular mechanism/s underlying the development of airway remodelling and the effectiveness of corticosteroids. hyperplasia of airway smooth muscle (asm) is a feature of the remodelled airway in asthmatics. in this study we examined the effect of corticosteroids on a key regulator of g1 progressioncyclin d1. asm cells from n = 8 non-asthmatics and n = 7 asthmatics were pretreated for 1 h with vehicle or dexamethasone (0.1 mm). the temporal kinetics of cyclin d1 mrna and protein expression were measured up to 24 h after stimulation with the mitogen platelet-derived growth factor-bb (pdgf-bb). pdgf-bb induced a significant increase in cyclin d1 mrna expression in asm from non-asthmatics (2.6 ϯ 0.3-fold) and asthmatics (2.9 ϯ 0.3-fold) after 24 h stimulation. in non-asthmatics, the corticosteroid dexamethasone significantly (p < 0.05) reduced the amount of cyclin d1 mrna expressed (to 1.6 ϯ 0.2-fold). in contrast, cyclin d1 expression in asthmatics was relatively resistant to inhibition by dexamethasone; the amount of pdgf-bb-induced cyclin d1 expression in the absence or presence of dexamethasone was not significantly different ( sphingosine 1-phosphate (s1p), a bioactive sphingolipid found elevated in the airways of asthmatics, modulates myriad airway smooth muscle (asm) functions that promote inflammation and remodelling in asthma. in this study, we uncover the molecular pathway/s underlying s1p-induced secretion of il-6, and investigate if, and how, corticosteroids inhibit il-6 secretion. using cultured asm cells from non-asthmatics, we found that s1p induces il-6 secretion from asm cells via cre, but not ap-1, c/ebp or nf-kb, transcriptional regulation of il-6 gene expression. cre-dependence was supported by s1p-induced creb phosphorylation. although the corticosteroid dexamethasone reduced s1p-induced il-6 secretion in a dose-dependant manner, this inhibition appeared to occur via a pathway independent of creb/cre, suggesting the existence of a parallel pathway. as we recently discovered that the antiinflammatory actions of corticosteroids in asm can be mediated via the induction of the endogenous mitogen-activated protein kinase (mapk) inhibitor, mapk phosphatase-1 (mkp-1), we investigated whether mapk represents the parallel pathway targeted by corticosteroids. we found that s1p can induce activation of a variety of mapk, however, only p38 mapk phosphorylation was inhibited by dexamethasone; importantly, the increase in mkp-1 after corticosteroid treatment appeared to mirror the decrease in s1p-induced p38 mapk phosphorylation. furthermore, exogenous expression of mkp-1 inhibited s1pinduced il-6 secretion. taken together, these results suggest that parallel pathways exist to induce il-6 secretion (transcriptional via creb/cre and possibly post-transcriptional via p38 mapk) and serve to underscore the importance of mkp-1 upregulation as a mechanism of action of corticocosteroids in asm. angiogenesis is a hallmark feature of asthma. angiogenic promoters, such as vegf and tgfb are reported to be increased in airways of asthmatics. tumstatin, an endogenous angiogenic inhibitor, is the non-collagenous domain-1 (nc1) of the alpha3 chain of collagen iv. decreased levels of collagen iv have been reported in the airways of asthmatics. we investigated the presence of tumstatin in the airway of asthmatics and its potential role as an angiogenic inhibitor. we detected the six a chain nc1domains of col iv and the 7s domain of the a3 chain using immunohistochemistry. the level of tumstatin in serum and bal-f was measured by dot blot. western blots were used to identify the association with the rest of the collagen iv molecule. a tube formation assay using primary pulmonary endothelial cells (ppec) was performed to evaluate the role of tumstatin in the airway. the effect of intranasal tumstatin on airway hyperresponsiveness and angiogenesis was studied in an ovalbumin mouse model. tumstatin was absent in the airways of asthmatics (n = 14) while the remaining six collagen iv a chains were present. the 7s domain of the a3 chain was present in the asthmatic airway (n = 6). tumstatin was detected in both serum and bal-f samples from asthmatic volunteers (n = 10), however the level of expression was not significantly different from that in nonasthmatics (n = 7). in asthmatic serum tumstatin was part of the whole collagen iv a3 chain. tumstatin was able to inhibit ppec tube formation in a dose related manner. tumstatin inhibited angiogenesis in the mice airways and was associated with an improvement in ahr. the fact that tumstatin is absent from asthmatic airways and inhibited airway hyperresponsiveness and angiogenesis may indicate potential for therapeutic intervention in airway remodelling. this work was supported by the crc for asthma and airways and nh&mrc. introduction epithelial egfr (epidermal growth factor receptor) expression correlates with disease severity and neutrophil infiltration in asthmatic airways. acute exacerbations of asthma and copd are also associated with steroid refractory neutrophilic inflammation, with rhinoviruses being the most common trigger. .7 mg/l and il-6: 5.8 vs. 3.6 ng/l). since il-6 stimulates the acute phase response, we correlated its levels with the other markers. only crp was strongly correlated with il-6 (spearman r = 0.58, p < 0.0001), suggesting differential regulation of saa and ip10. saa discriminated between non-pathogen (n = 10) vs. pathogen-associated (n = 41) events (saa: 9.4 vs. 44.1 mg/l p = 0.005), whereas no significant change was observed in the other markers (ip-10: 139.8 vs. 170.5 ng/l, crp: 4 vs. 10 mg/l, il-6: 4.6 vs. 7.2 ng/ l). however when aecopd marker levels were stratified on the basis of pathogen type (viral = 12, bacterial = 21, viral and bacterial = 8), none of the markers were significantly altered. conclusions ip-10 is significantly elevated during an aecopd, however only saa differentiated non-pathogen from pathogen associated events. background severe persistent asthma is characterized by structural changes in the airways-airway remodelling. airway smooth muscle (asm) cells have the potential to play a key role in these processes through the release of growth factors, cytokines and extracellular matrix (ecm) proteins. we have previously studied the effects of budesonide and formoterol individually however, the effect of their combination on these characteristics of asm cells is not known. methods asm cells from asthmatic (n = 6) and nonasthmatic (n = 6) individuals were stimulated with transforming growth factor ß (tgfß) (1 ng/ml) with or without budesonide (10 -8 m) and formoterol (10 -10 and 10 -8 m) and fibronectin levels and interleukin-6 (il-6) release were measured by elisa. bronchial rings from nonasthmatic individuals (n = 2) were incubated with tgfß with or without the drugs and ecm protein expression (fibronectin and collagen i) measured using immunohistochemistry. results in nonasthmatic cells, budesonide alone induced fibronectin deposition whether tgfß was present or not. formoterol decreased fibronectin induced by tgfß and, when combined with budesonide, reversed the increase in fibronectin. a similar pattern was observed in asthmatic cells, except that budesonide did not further increase the tgfß mediated fibronectin release. as before [1] , il-6 was induced by formoterol but inhibited by budesonide. tgfßinduced il-6 was inhibited by both drugs and their combination in both cell types. in bronchial rings the presence of either drug did not affect tgfßinduced fibronectin or collagen i. severe combined immune deficiency (scid) spontaneous mutation specifically impairs differentiation of stem cells into mature lymphocytes. nod-cb17prkd scid (known as nod-scid) lacked nk cells, hence is commonly used in cell transfer experiments for transferring tissue and haematological xenografts. the aim of this study was to establish lung inflamamtory model in nod-scid strain. methods balb/c and nod-scid balb/c mice (n = 8) were exposed to cigarette smoke for 4 days, 2 and 4 weeks (9 cigarettes/day; 5 days/week). bronchoalveolar lavage fluid (balf) and lung tissue were collected for inflammatory profiling and analysis for cytokines, chemokines and protease expression and/or activity. results nod-scid have significant accumulation of macrophages in lung after 4 days, 2 and 4 weeks smoking as compared to no smoke control (p < 0.001) that was not different to balb/c (p > 0.05). nod-scid also have increased neutrophil number after 2 and 4 weeks smoking (p < 0.001). even though myeloid cell differentiation isn't affected by scid phenotype, nod-scid have one fold less neutrophil than balb/c mice (p < 0.001) that is also reflected in the reduced expression of matrix metalloproteinase-9. consistent with the known lymphopenic phenotype, nod-scid have significant but less lymphocytes recruitment as compared to balb/c mice after 4 weeks smoking (p < 0.001) despite the enhanced expression of inteferon inducible protein 10 (lymphocytes specific chemokine) in lung. both mouse strains showed the same elevation of net gelatinase and serine protease activity in lung. nodscid mice also demonstrated comparable transcriptional induction of proinflammatory cytokines (tnfa, il-6), growth factors (gm-csf, g-csf) and chemokines (mcp-1, mip-2), indicating susceptibility to smoke-induced injury. conclusions nod-scid mice are capable to mount smoke induced inflammatory response. this model may be useful to study localization and role of immunocytes, including adoptively transfer human cells in the pathogenesis of copd. supported by the nhmrc. rhinovirus (rv) is the cause of most common colds and up to 80% of asthma attacks. in our previous studies, plasminogen activator inhibitor 2 (pai-2) was expressed at high levels and was induced in vivo and in vitro by rv infection. pai-2 may have antiviral properties suggested by antiviral activity in some models, high pai-2 expression levels and further upregulation by rv infection. methods to determine whether pai-2 has antiviral activities following rv infection, o-hela, pai-2 expression-deficient cells were first transfected with pai-2 or control genes. this was followed by infection with rv and effects on viral replication were assessed by rt-qpcr for vrna and by viral titration for virus release. ifn expression was assessed by rt-qpcr. results ifn-a and -b mrna expression were induced in response to rv infection and to pai-2 expression in cells. pai-2 expression followed by rv infection elicited a synergistic response and pai-2 over-expression reduced vrna by >5 fold and viral titre by >3 log (p < 0.05). however, this effect was not specific to pai-2, as transfection of cells with control genes/plasmids reduced viral titre to a comparableextent. one of the pathological findings in idiopathic pulmonary fibrosis (ipf) is the presence on fibroblastic foci comprising cells which exhibit mesenchymal phenotypic features such as myofibroblast-like morphology, increased asma expression and collagen deposition. currently steroid treatment in ipf has shown limited efficacy. the cellular origins of these mesenchymal cells remain unclear, but evidence from other studies suggests that epithelial cells may undergo a transition to a mesenchymal cell phenotype (emt). transforming growth factor ß has been implicated in promoting this emt. in this study we have induced a morphological change in a549 cells using tgf-ß1 and assessed the influence of glucocorticoids, and the changes to the extracellular environment of the cells, on emt. methods a549 cells were grown on uncoated plastic cultures plates or those coated with monomeric or fibrillar collagen and treated with 200-500 pm tgf-ß1. the influence of the glucocorticoid, dexamethasone (dex, 1-1000 nm), or collagen type, on emt was assessed by microscopy, rt-pcr and western blotting for markers of myofibroblast phenotype. results tgf-ß1 induced an increase in mrna expression of asma (1.5 fold), collagen (7.0 fold) and fibronectin (2.0 fold). dex (100 nm) partially inhibited the expression of collagen, but had no effect on asma levels. however, dex (100 nm) reduced asma and ctgf protein levels. dex (100 nm) also prevented the tgf-ß1-induced morphological changes, regardless of ecm matrix. conclusion glucocorticoids appear to control some of the emt phenotype changes induced by tgf-ß1. however, the inability to fully inhibit these changes may contribute to the resistance of ipf to glucocorticoids. the extracellular environment may also play a role in the development of fibroblastic foci and their pharmacological responses. defective alveolar macrophage (am) phagocytic function in the airway may perpetuate inflammation via secondary necrosis of uncleared apoptotic cells in copd. we have previously reported that low-dose azithromycin improved macrophage function in vitro, although the mechanisms for this effect were not identified. we explored the possible role of the collectin pathway in the azithromycin-mediated improvement in phagocytosis as well as possible defects in this pathway in copd subjects. methods (1) mannose binding lectin (mbl), mannose receptor (mr), surfactant protein d (sp-d) were measured in copd subjects and controls. (2) the in vitro effects of addition of rhmbl, and blocking mr with a specific antibody, on am phagocytic ability were assessed. in vitro effects of azithromycin on am expression of mr were also investigated. (3) azithromycin (250 mg orally 2¥ weekly/12 weeks) was administered to 11 copd subjects. bronchoscopies were performed prior to and 12 weeks following therapy. ex vivo assessments included am phagocytic ability, levels of mbl, sp-d and mr and apoptosis of bronchial epithelial cells. results am mr expression and levels of mbl and sp-d were significantly reduced in copd subjects vs controls. azithomycin (500 ng/ml) increased mr expression by 31% in vitro. rhmbl induced a dose-dependent increase in am phagocytic ability (up to 148%). blocking mr significantly decreased am phagocytic ability by 60%. in copd patients following azithromycin therapy, we observed improved am phagcocytic ability, increased levels of mr and reduced levels of bronchial epithelial cell apoptosis. conclusions these findings strongly implicate the mr in both the defective phagocytic function of am in copd and as a target for the azithromycinmediated improvement in phagocytic ability. obstructive sleep apnea (osa) is associated with hypoxia and increased cardiovascular morbidity. t cells and monocytes play a significant role in atherogenesis via cytokine production. there have been reports of benefits of continuous positive airway pressure (cpap) therapy in osa. the purpose of this study was to characterize leucocyte inflammatory cytokine/chemokine production by t cells and monocytes in a group of osa patients and to investigate the therapeutic effects of cpap therapy. methods a comprehensive range of intracellular t-cell and monocyte proand anti-inflammatory cytokines/chemokines was investigated in peripheral blood from 5 osa patients and 5 aged-matched control subjects (with no evidence of sleep problems) using multiparameter flow cytometry. osa patients were again studied following 7 days of cpap therapy. results in osa patients there was an increase in intracellular t-cell ifng and tnfa production but no change in il-2, il-4 or tgfb compared with control. there was an increase in intracellular monocyte il-1a, il-8, tnfa, mcp-1 and mcp-3 in osa patients but no change in il-10 or il-12. following cpap therapy, t-cell ifng and tnfa production returned to 'normal' levels. however, although intracellular monocyte cytokine/chemokine production was decreased following cpap, levels were significantly elevated compared with control. conclusions osa is associated with increased intracellular proinflammatory cytokine/chemokines, many of which are increased in atherosclerotic plaques. although one week of cpap therapy resulted in amelioration of t-cell pro-inflammatory cytokines, longer cpap use or alternative therapy may be required to reduce monocyte pro-inflammatory mediators associated with atherosclerosis in patients with osa. gp130 has been associated with the progression of fibrosis especially in patients with idiopathic pulmonary fibrosis (ipf). gp130 is the common subunit of the receptor complexes for the il-6 family of cytokines including il-11 and oncostatin m (osm), where gp130-mediated signalling leads to activation of the erk or stat pathways. we have previously demonstrated exaggerated gp130-stat signalling to be fundamental to the development of pulmonary fibrosis in a murine model of bleomycin-induced lung fibrosis. the aim of this study was to elucidate the role of the il-6 cytokine family in the development of pulmonary fibrosis by identifying which il-6 family cytokines regulate fibrosis in bleomycin treated mice, and determine the effects of these cytokines on cell function. bleomycin (0.05 u/mouse) or control saline was administered intranasally to wildtype mice (wt), genetically engineered mice containing point mutations to prevent gp130 erk signalling (gp130 757f ) or gp130 stat signalling (gp130 dstat ), and duel il-6 and il-11 a-receptor knockout mice (il-6 -/-;il-11ar -/-). the effect of bleomycin on collagen production was examined in lung tissue 30 days post treatment by hplc. there was a significant increase in collagen levels in bleomycin treated wt lungs which was further increased in gp130 757f lungs. the lungs of gp130 dstat and il-6 -/-;il-11ar -/mice were protected from fibrosis suggesting that gp130-stat signalling is important in inducing lung fibrosis which may be mediated through il-6 and/or il-11. cell proliferation was examined in lung fibroblasts isolated from wt, gp130 dstat and gp130 757f mice. il-6, il-11 and osm were significantly mitogenic for gp130 dstat cells but not for wt or gp130 757f cells, reflecting different responses to the different signalling pathways. changes in cytokine profiles are currently being examined in lung tissue and serum of control and bleomycin treated mice 0-30 days after treatment. in conclusion, il-6 and il-11 are likely to play a role in bleomycin-induced fibrosis via the gp130-stat-mediated pathway, however this may not be due to regulation of proliferation induced by these cytokines. supported by the nhmrc. mimicking viral infection by application of various toll-like receptor ligands has shown clinical promise in the treatment of persistent viral infections and more recently with malignant tumours. commercially available toll-like receptor 7 ligands (tlr7l), such as those of the imidazoquinoline family have been applied clinically for the treatment of a number of conditions including basal cell carcinoma and hpv-induced genital warts. these compounds are known to retard tumour growth indirectly by promoting activation and migration of dcs, leading to a strong th1 cellular response, and directly via release of proinflammatory cytokines and promotion of tumour cell apoptosis. malignant mesothelioma (mm), an aggressive tumour with a mean survival of 9 months, is highly resistant to chemotherapy, radiotherapy and surgery and is therefore an interesting candidate for immunotherapy in the form of tlr7 ligand treatment. whilst tlr7 is known to be selectively expressed in immune cells and its relative expression low amongst other cell and tissue types in mammals, its expression on tumour cells and the consequences of such expression on tumour growth are unknown. here we describe the presence of tlr7 (mrna and protein) directly in a range of different tumours, including several murine and human mm cell lines. reactive oxygen species (ros) produced during the innate immune response are important agents of anti-pathogen defense but may also cause oxidative lung damage. glutathione peroxidase-1 (gpx-1) is a detoxifying enzyme that may protect lungs from such damage. methods wild-type (wt) or mice deficient in glutathione peroxidase-1 (gpx-1 -/-) were placed in a perspex chamber and exposed to cigarette (cig) smoke generated from 9 cigs per day for 4 days. on the fifth day, mice were killed, the lungs lavaged with pbs and then harvested for proteomic and genomic analysis. results wt mice exposed to cig smoke for 4 days had significantly more macrophages (3.1 ϯ 0.1(sem) ¥ 10 5 ) and neutrophils (4.9 ϯ 0.4 ¥ 10 5 ) than sham-exposed mice (2.2 ϯ 0.2 ¥ 10 5 and 0, respectively) (n = 6, p < 0.05). however, gpx-1mice exposed to cig smoke had significantly greater macrophages (5.4 ϯ 0.3 ¥ 10 5 ) and neutrophils (1.2 ϯ 0.1 ¥ 10 6 ) than smokeexposed wt mice (n = 6, p < 0.001). macrophage and neutrophil numbers in sham-exposed gpx-1 -/mice (1.7 ϯ 0.3 ¥ 10 5 and 0.5 ϯ 0.4 ¥ 10 3 ) were similar to those of sham-exposed wt mice (2.2 ϯ 0.2 ¥ 10 5 and 0). in addition, we found that balf of gpx1 -/mice exposed to cig smoke had an increased proteolytic burden compared with smoke-exposed wt mice as assessed by zymography and net gelatinase activity assay. conclusions these data suggest that gpx-1 protects the lung from cigarette smoke-induced inflammation and that targeting gpx-1 may have therapeutic utility in inflammatory lung diseases where cigarette smoke plays a role. funded by nhmrc. the becs from subjects with chronic obstructive pulmonary disease (copd) are exposed to frequent infectious and inflammatory stimuli. infection with rv is known to trigger acute exacerbations and subjects with copd are particularly susceptible. we hypothesized that exposure of copd becs to these stimuli would alter their response to rv infection. methods bec were obtained by endobronchial brushing from subjects with gold stage 3 copd (n = 4, all ex-smokers), subjects with mild persistent asthma (n = 4) and healthy controls (hc, n = 4). becs were cultured and then treated with tumour necrosis factor (tnf)a 10 ng/ml or lps 100 mg/ml for 24 hrs and then infected with rv-43, rv-1b. response was measured by release of il-8, il-6 and ip-10 mrna and by elisa. virus replication measured by cell titration assay. results infection with both rv strains led to increased release of il-8 and ip-10 in all groups. exposure of hc and asthma becs to both lps and tnf led to increased release of il-8. in these becs there was no increase in release of il-8 exposed to lps and tnf and then infected with either rv. becs from subjects with copd released significantly less il-8 in response to all conditions and rv infection compared to hcs and asthma. no differences were seen in rv replication. the aim of this study was to determine opinions and attitudes to exercise from chronic obstructive pulmonary disease (copd) subjects after completion of a 12-month maintenance exercise program. methods following completion of a 12-month exercise study, which included a supervised program (intervention, n = 18) and control group (control, n = 17), copd subjects [mean age (sd): 66 (8); mean fev1 (% predicted) = 56% (19)] were asked to complete a questionnaire. the questionnaire included closedended questions using visual analogue scales (100 mm). in copd the 6 minute walk distance (6mwd) is known to increase with test repetition (familiarization) and in response to exercise training. it is unknown whether the magnitudes of these increases are related to the degree of disability of the individual patient. methods 6mwd was measured twice before and once after an 8 week out-patient exercise program in 121 patients (82 males) aged 67ϯ8.6 yrs, fev1 37ϯ15% predicted (meanϯsd) with stable copd. the changes in 6mwd following a familiarization test and following training were compared between patients grouped according to their degree of disability (defined as the pre-training 6mwd [best of 2 tests] expressed as %predicted 6mwd). *p < 0.05 gp 3 vs gp 1. conclusions before training, 6mwd increases following a familiarization test irrespective of the level of disability. the magnitude of this increase is similar in all groups when normalized for their pre-training 6mwd. following training, the increase in 6mwd is greatest in patients with the greatest disability (lowest pre-training 6mwd). in less disabled patients, the relatively smaller increase in 6mwd following training may reflect an inability to further increase stride length, thereby reducing the responsiveness of the 6mwt in this group. supported by nhmrc. endotoxin is a stimulant of the innate immune system and is a major component of cigarette smoke. smokers have evidence of increased airway neutrophils and inflammation. we hypothesized that endotoxin levels would be higher in the bronchial lavage (bl) of subjects who were former smokers and subjects with chronic obstructive pulmonary disease (copd). methods subjects were all ex-smokers for at least 5 years (n = 10, 5 copd, 5 healthy controls) or never smokers (n = 12, 6 asthma, 6 healthy controls). bl was collected and analysed for cell count and differential, culture for microbiology. the supernatant was analysed for il-8 by elisa and endotoxin by quantitative kinetic lal assay. results median endotoxin levels were significantly higher in ex-smokers 101 compared to never smokers 6.3 u/ml (p < 0.001). there were no differences between subjects with copd and hs. subjects with copd had higher median endotoxin levels (80 u/ml), compared to asthma (5.2 u/ml) and hc (6.3 u/ml, p = 0.03). there was no correlation between endotoxin levels and bl total cell count, neutrophils (%) or fev1 % predicted. there was a strong correlation with previous packet years smoked and endotoxin levels (r = 0.72, p < 0.01). conclusions bl endotoxin levels are higher in ex-smokers, including subjects with copd. despite this there is no relationship to increased neutrophilic inflammation. copd is associated with inflammation associated with ineffective repair of the injured epithelium and loss of structural integrity. we have shown that these changes may result from dysregulated 'efferocytosis' (increased apoptosis of bronchial epithelial cells and defective clearance of these cells by alveolar macrophages (am)). we have also reported that azithromycin, at subbactericidal dose, improved am phagocytic function ex vivo. methods we administered azithromycin at low dose (250 mg/ twice weekly for 12 weeks) to 10 copd subjects (7 male, age: 62 ϯ 8 yr, 5 current/ 5 ex-smokers, fev1: 63 ϯ 9% pred, fev1/fvc: 48 ϯ 9%). the study was openlabel, uncontrolled and primarily focused on objective biological responses obtained from the bronchoscopy samples taken. phagocytic ability of am (from bal), apoptosis of bronchial epithelial cells (from bronchial brushing), markers of inflammation in blood, bal and breath condensate (crp, wcc and inflammatory cytokines), health status (st. george's respiratory questionnaire), ecg and lung function were assessed pre and post-administration of azithromycin. results azithromycin significantly improved phagocytic ability of am (by 37%) and reduced bronchial epithelial cell apoptosis (by 34%). antiinflammatory effects of azithromycin included significantly reduced blood wcc and crp. there were non-significant reductions in levels of pro-inflammatory cytokines il-8, il-6 and tnf-a in blood, bal and breath condensate, and a trend for improved health status. conclusions our findings indicate a novel approach to supplement existing therapies in copd that may improve clearance of accumulated apoptotic material and reduce the risk of secondary necrosis and release of toxic cell contents that perpetuate inflammation. background the prevalence of gastro-oesophageal reflux disease (gord) across the disease spectrum in copd and bronchiectasis is not well described. the aim of this study was to determine the prevalence of symptomatic and silent gord in copd and bronchiectasis and its effect on lung function and quality of life (qol 4] ) and 18 healthy controls were recruited. the prevalence of gord in bronchiectasis was 33%; 37% in copd; 17% in controls. in copd and bronchiectasis, total nre and ri were increased in those with distal and proximal gord compared to those without gord (all p < 0.05). there was no difference in extent or severity of bronchiectasis in patients with or without gord (all p > 0.05). in copd, the relationship between proximal gord and fev1 was small to moderate (r = 0.383). sgrq symptom scores were higher in patients with bronchiectasis with increased ri (p = 0.02). increased proximal nre was associated with reduced physical (p = 0.03) and mental health (p = 0.02) in the sf-36 in copd. conclusions gord is a co-morbidity in patients with copd and bronchiectasis. the impact of gord on disease severity requires further evaluation. funding source nhmrc, the university of melbourne, monash university, physiotherapy research foundation. chronic obstructive pulmonary disease (copd) is prevalent among older people, however little is known about the influence of ageing on airway inflammation. the aim of this study was to compare airway inflammation in older people with obstructive airway disease to groups of older and younger healthy controls. methods participants (>55 years of age) with stable airway disease and incomplete reversibility (fev1% predicted <80% and fev1/fvc < 70%; copd n = 71) and healthy controls (n = 45, 35 older >55 years and 10 younger <55 years) were recruited from the respiratory ambulatory care clinic or by advertisement. participants underwent a clinical assessment, skin allergy test, hypertonic saline challenge, sputum induction and gas diffusion studies. results participants with copd had moderate airflow obstruction (mean (sd) fev1% predicted 56 (19)) and 45 (63%) were current or ex-smokers with a median (iqr) pack year history of 36 (20-54) pack years. ageing was associated with an increase in airway neutrophils (p = 0.0001). compared to older controls, participants with copd had increased airway eosinophils and lymphopenia (p = 0.004, p = 0.003 respectively), but no difference in airway neutrophils. conclusion airway neutrophilia is a feature of ageing and is not further increased in the presence of copd. copd is associated increased numbers of airway eosinophils with reduced lymphocytes which may impact on the ability of the immune system to combat infection. supported by nhmrc, the university of newcastle. chronic obstructive pulmonary disease (copd) is third leading cause of death and fourth leading cause of disease burden in australia. mechanisms involved in emphysema severity have not been fully understood. micrornas are noncoding rnas that regulate gene expression. we hypothesize that microrna expression differs between emphysema severity in copd patients. methods mirna profiling was performed using 15k agilent human oligo mirna microarrays on total rna extracted from non-tumour lung tissue from 30 copd patients undergoing resection for lung cancer. the mirnas were quantile normalized and anova was used to find differentially expressed genes. results demographic characteristics of the copd patients (mean (sd)) were age 69 (6) years, fev1 72 (17) % predicted and fev1/fvc ratio (<70%). anova identified 31 mirnas that were differentially expressed when stratified into two classes according to kco % predicted > or <75% (t-test, p < 0.05). discussion this mirna analysis has identified mirnas that may be important in emphysema severity in copd patients. further validation will be performed using qrt-pcr and mirna assays on the training set and an independent set, and target prediction and validation. t-helper type 1 (th1) and type 2 (th2) lymphocyte responses have been well recognized as being important pathways in inflammation. recently another form of inflammatory lymphocyte response has been described, the th17 pathway. th17 cells produce cytokines such as il-17a to clear extra-cellular bacteria and fungi and have been implicated in autoimmune and chronic inflammatory diseases. the th17 response in copd is unknown. methods subjects were patients with copd (ex-smokers, fev1 < 70% predicted who had not had an exacerbation for at least 1 month) and control subjects (ex-smokers and normal spirometry). serum samples were obtained for measurement of c reactive protein (crp) and il-17a, the latter measured using enzyme-linked immunosorbent assay (elisa). production of il-17a by t-cell subsets was also identified by intra-cellular cytokine staining and measured by flow cytometry. the mean fev1 of copd subjects was 42 % predicted (6.1 sem, n = 6) and mean fev1 of controls was 112 % predicted (3.0 sem, n = 4). the copd group had a higher mean level of crp 9.5 mg/l (3.9 sem) compared to the control group mean level of 4.6 mg/l (0.6 sem). the mean level of the il-17 in the copd group as measured by elisa was 22.3 pg/ml (16.9 sem, range 0-87) whilst no il-17 was measured in any of the control subjects. conclusions the findings of this pilot study suggest that il-17 may be elevated in association with crp in stable copd. airway obstruction is defined as a fev1/fvc ratio below the lower limit of normal. airway obstruction may prolong the forced expiratory time (fet). method spirometry results from 467 patients were categorized as obstructive, restrictive or normal. the mean, range and coefficient of variation were determined for fet in each diagnostic group. receiver operator characteristic (roc) curves were used to determine if fet could predict a low fev1/fvc. the number of patients with airway obstruction in five fet groups: <9; 9; 10-12; 13-14; and >14 seconds were determined. results the coefficient of variation was high for all groups. pair-wise comparisons showed a difference in mean fet between patients with normal lung function versus those with airway obstruction (p < 0.001). the best cut-point in the roc analysis of 9.895 seconds had a sensitivity of 0.66, specificity 0.77 and area under the curve of 0.743 for predicting obstruction. the technique of skeletal muscle microbiopsy has previously been validated [1] and shown to be minimally invasive and well tolerated in participants with stable copd. aim a study was undertaken to determine the feasibility and tolerability of obtaining microbiopsy muscle samples from the patient admitted for acute exacerbation of copd patient. methods written informed consent was obtained to collect the muscle, blood and sputum samples for research purposes. local anaesthetic was injected prior to the insertion of a 16 gauge bard max core disposable biopsy instrument through the associated guide needle. multiple passes (up to 6) were obtained. the patient was asked to evaluate the experience by rating it on the modified borg scale 0-10. results to date 5 patients and 3 controls have participated in this study. the gold severity ranged from 2-4 and ats exacerbation severity 2-3. the mean age 75 years (range 68-83 years), bmi mean 23.6 kg m -2 (range 17.2-27.1 kg m -2 ) and fat free mass was determined using single frequency bioimpedance. the sample mass obtained ranged from 27.2-104.1 mg, with an increasing yield occurring with increased experience of the operator. the procedure has been well tolerated, the borg scale rating ranged from 1-2/10. all patients were ambulant post procedure; no haematoma or bruising was observed in any of the subjects. conclusion the microbiopsy technique allows the collection of muscle tissue with minimal discomfort to the participant. small tissue masses such as these are sufficient to obtain measures of local markers of wasting and may prove to be a useful adjunct to the collection of sputum and blood for the measure of biomarkers in copd research. introduction older people (op) with obstructive airways disease (oad) experience multiple problems that may impact on their quality of life (qol) and disease management. these problems may relate to pathophysiology, symptoms, self management skills, psychological issues, lifestyle or other problems identified as important by the patient. aim the aim of this study was to determine the frequency of clinical problems associated with oad and to determine if a problem based assessment (pba) could adequately identify these problems. methods a multidimensional assessment tool was developed and the content compared to clinical practice guidelines. participants over 55 years with diagnosed oad underwent this assessment. results sixty-one consecutive patients, aged 59-87 years, with mean (sd) fev1 of 51.4 (17.85) % predicted were assessed. the assessment tool identified a mean (sd) of 3.03 (2.13) current and significant co morbidities with an additional 11 (3.37) clinical problems per patient. qol was increasingly impaired with an increasing number of problems (p < 0.0001). regression modelling identified that the number of identified clinical problems accounted for 55% of the qol impairment. the model demonstrated that every additional patient problem was associated with a clinically significant change in qol impairment (4.22 units) . conclusions op with oad experience multiple clinical problems and co morbidities that adversely impact their qol. a pba of op with oad identifies significant problems that may not be addressed in a diagnosis centred approach. there is a need to identify and effectively manage this array of problems in clinical practice. discussion in this diverse group of copd patients, there was a positive correlation between dlco and fev1, but not kco and fev1. the fev1/ kco plot identifies substantial numbers of patients with the potential ad and e phenotypes defined above. we intend to study inflammatory biomarkers in these groups. fat free mass index (ffmi) is a marker of morbidity and mortality in copd. measurement of ffm in the out-patient population is commonly undertaken using single frequency bioelectrical impedance analysis (bia). however the formulae to convert measured values to ffm are population dependent. schols et al (am j clin nutr, 1991) suggested that formula used for the general population may be inappropriate for patients with copd, and derived a specific formula from total body water (tbw) as measured by deuterium dilution. we compare this method of measuring ffm with 5 others, along with tbw and ffm hydration. methods tbw was measured in 31 outpatients with copd by bia and a difference method (weight-(protein+bone mineral+fat+non-bone mineral+ glycogen)) and ffm hydration was calculated. ffmi was measured by skin fold anthropometry (sfa), bia (3 separate formulae), dual energy x-ray absorptiometry (dexa) and total body potassium by g-counter (tbk). comparison between methods for tbw and ffmi was made by bland-altman analysis and between methods of calculation of ffm hydration by paired t-test. the two methods of assessment of tbw showed little difference (bias -0.04, 95% limits of agreement -5.40 to 5.31). however there was a significant difference in calculation of hydration of ffm (p = 0.0001). sfa, bia (lukaski), bia (tanita) and tbk underestimated ffmi when compared to bia (schols), with bias of -1.24, -3.87, -1.06 and -2.76 respectively. dexa however had a bias of only 0.05 and 95% loa of -3.09 to 3.21. conclusions there are differences between methods of assessment of tbw and ffmi and comparing values between methods must be done with caution. this has implications for assessment of morbidity and mortality in copd. chronic obstructive pulmonary disease (copd) has been identified as a major health problem in australia. recent studies have suggested that respiratory viral infections are the major cause of a worsening of copd; however this has not been studied in australia. aim to characterize pef changes and identify viruses during copd exacerbations. methods a pilot prospective longitudinal cohort study was done. patients had confirmed copd with fev1 <70% predicted and reversibility <10% and/or 200 ml. patients recorded daily peak expiratory flow (pef) measurements and daily chest and cold scores over a period of 2 years. sputum samples and nasal aspirates were taken at 6-month review (control visit) and whenever they had symptoms of an exacerbation (worsening of copd symptoms -seemungal et. al. am j resp crit care med, 2001). nasal aspirates and sputum samples were obtained and analysed by rt-pcr for rhinovirus (rv). result five patients have finished 2 years of study. a total of 12 exacerbations were reported based on patient symptoms. only 3 exacerbations were associated with significant reductions in pef and only one was linked to increases in nasal cold scores. all samples taken at control visits and nasal aspirates and sputum samples during exacerbations were negative for rv by rt-pcr. positive controls confirmed the accuracy of the assay. conclusion our data suggest that a symptom-based definition of copd exacerbation is not always accompanied by significant reductions in lung function parameters. these 'exacerbations' are also not associated with the commonest reported viral cause. our findings suggest that variability of copd may mimic. bronchiectasis is characterized by hypersecretion of mucus and impaired clearance that results in mucus accumulation, chronic cough, sputum production and recurrent infections. inhaled mannitol (400 mg) improves clearance of mucus by increasing the airway hydration and by reducing the viscoelastic and surface properties of mucus. however, the effect of other doses of mannitol on the clearance of mucus in patients with bronchiectasis is unknown. methods fourteen patients, age: 63.3 ϯ 5.7 yr, were studied on 5 visits. clearance of mucus was measured using 99m tc-sulphur colloid and imaging with a gamma camera at baseline and with mannitol ( weight loss and skeletal muscle atrophy are major determinants of morbidity in chronic obstructive pulmonary disease (copd), which are independent of lung function impairment. thus, we examined if a high-fat diet (hfd) protected against the wasting associated with prolonged cigarette smoke exposure (se) in mice. methods male balb/c mice were exposed to the smoke of 4 cigarettes/day, 6 days/week for 7 weeks. sham mice were handled identically without smoke exposure. mice consumed either standard laboratory chow (3.5 kcal/g, consisting of 12 % fat) or a hfd (4.3 kcal/g, 32% consisting of fat). we examined the effect of se and hfd on hind limb skeletal muscles, lung (tissue & bronchoalveolar lavage (balf)) and systemic inflammation in the 4 groups of mice (n = 8/ group). results after 7 weeks of hfd, sham and se mice were 12 and 13% heavier (respectively, p < 0.05) than chow fed animals. conversely, se significantly decreased body weight of chow and hfd fed mice by 16 and 15%, respectively, compared to sham animals (p < 0.05). the hfd did not protect against the decrease in soleus, tibialis anterior and gastrocnemius skeletal muscle weights induced by se (p < 0.05). se altered the mrna expression of a number of genes associated with the regulation of skeletal muscle mass including insulin-like growth factor-i (igf-i), atrogin-1 and interleukin (il)-6. the mrna expression of pro-inflammatory cytokines and chemokines was significantly increased by se in the lung, as were the number of inflammatory cells in balf (p < 0.05). on the other hand, although obesity has been linked to systemic inflammation, the hfd exerted little direct effect on the skeletal muscle and lung parameters measured. se and hfd had no effect on two markers of systemic inflammation, il-6 and serum amyloid a, whereas se tended to reduce circulating igf-i, an anabolic hormone. conclusions the hfd was not protective against the weight loss and skeletal muscle wasting associated with cigarette smoke exposure. supported by the nhmrc and crc for chronic inflammatory diseases. background patients with copd and bronchiectasis undertake airway clearance therapy (act) and exercise as part of physiotherapy management but it is unknown whether these treatments provoke gastro-oesophageal reflux (gor). this study aimed to determine the impact of positive expiratory pressure (pep) therapy and exercise on gastro-oesophageal function. p. aeruginosa is a significant opportunistic lung pathogen in individuals with cystic fibrosis (cf) and is associated with increased lung disease and morbidity. early intervention is beneficial for the effective clearance of p. aeruginosa and better long-term health outcomes. currently, lung flora of cf patients is monitored by regular culturing of sputum, however, children unable to expectorate are limited to annual bronchoalveolar lavages (bal), which is invasive and requires general anaesthesia. saliva is useful for clinical assays as collection is simple, non-invasive. we are developing a standardized enzymelinked immunosorbent assay (elisa) to detect respiratory infection of p. aeruginosa in cf children who cannot expectorate. methods 18 children (7-18 years) with cf and recent p. aeruginosa lung infection history and 16 non cf children (1-6 years) with no previous p. aeruginosa infection history provided saliva as positive, negative controls respectively. saliva was obtained by spitting, or absorbed using cellulose swabs and later extracted. these cell-free supernatant samples were used in an elisa anti-p. aeruginosa iga using commercial antigen. all results were standardized to account for flow using total iga expression. results median value was increased 9 fold in the recent p. aeruginosa lung infection group (mann-whitney test, n = 34, p յ 0.001). there was no significance between mucoid and non mucoid samples, and detection was independent of cfu/ml. discussion early findings support that p. aeruginosa respiratory infection can be detected through specific analysis of salivary iga expression. larger population sampling (30 positive, 90 negative) will aid selection of cut-off values for specificity and sensitivity testing in the future to objectively determine the utility of this assay as a means of monitoring for p. aeruginosa and for determining effectiveness of treatment. medical thoracoscopy is utilized widely throughout europe and northern america by thoracic physicians for the management of pleural disease, including the undiagnosed pleural effusion, malignant effusions and less commonly pneumothorax (ptx). australia has limited experience in this modality. we report the success of medical thoracoscopy in both primary and secondary ptx requiring intervention. methods data were collected from 2001 to 2007 in patients treated with medical thoracoscopy for the treatment of ptx. results 11 patients, 7 male, 4 female. average age 48 (range 19-86). 1 first episode primary spontaneous (ps) ptx, 2 third episodes of ps, 5 first secondary spontaneous (ss), 1 second ssptx, 2 third ssptx. underlying pulmonary disease in secondary ptx included: 4 chronic obstructive pulmonary disease, 1 lymphangioleiomyomatosis, 1 mesothelioma, 1 metastatic angiosarcoma and 1 was secondary to a motor vehicle accident. 7 had a history of smoking, 5 were former smokers and 2 were current smokers, with a mean 24 pack year history (range 5-45). 7 ptx were large, 4 moderate. 5 patients had an intercostal catheter (icc) inserted prior to thoracoscopy, 1 had failed pleural aspirate. there was evidence of bronchopleural fistula in 7 patients prior to the procedure. there was a median of 9 days from ptx to thoracoscopy. light sedation was used for the procedure in 10 patients, 1 required a general anaesthesia with a double lumen endotracheal tube due to anxiety. single port entry, dry talc poudrage and a 16 gauge french icc was used for all procedures. icc was removed a mean of 2 days following thoracoscopy and patients discharged on day 4. pain was the most common complication, requiring narcotic analgesia. one patient died on day 7, secondary to metastatic angiosarcoma. there has been no recurrence of ptx in any patient. conclusion medical thoracoscopy, performed by thoracic physicians is an effective procedure for the treatment of pneumothorax requiring intervention, including selected patients with evidence of bronchopleural fistula. funding nil. conflict of interest nil. nomination for young investigator award no. background lung cancer incidence and mortality are high in tasmania. australia (aihw 2003) 85/100 000 72/100 000 tasmania (cancer registry 2003) 102/100 000 89/100 000 aims and objectives (a) to determine patient demographics in southern tasmania, (b) to determine compliance to identified measures of best practice and (c) assess referral rates, clinical utility and potential delay to positron emission tomography (pet) in a regional setting. methods a prospective database collected information on local clinical practice. cases presented at a multidisciplinary lung cancer meeting over a 12 month period (march 2006 -april 2007 were analysed. data were available for n = 121/161 (75%). results are shown as mean ϯ sd. results 113 primary lung cancer cases were identified. the mean age was 71 ϯ 11 years. 58% of patients were male and 95% were current or ex-smokers. 81% were non-small cell lung cancers (nsclc). tissue diagnosis 93% time from diagnosis to surgery (27 ϯ 15 days) 82% < 42 days macroscopically complete surgical resection (9/11) 82% pet for stage iiib before radical chemoradiotherapy 75% 62% of patients presenting with early or locally advanced disease underwent further staging with pet (n = 34/55). management was changed in 50% of cases (17/34). the average time from pet referral to scan was 11 ϯ 5 days. conclusion a disproportionate number of lung cancers occurred in women. although surgery was performed within recognized timeframes, 2 of 11 patients had incomplete resections. pet influenced management decisions and was performed in a timely fashion. hp chan 1,2 , v tran 1,2 , c lewis 1,3 , p thomas exhaled breath condensate (ebc) is a simple, safe and non-invasive method of sampling breath and has the potential to investigate lung cancer and the associated neoplastic process in the lungs. increased oxidative stress has been implicated in the pathogenesis of lung cancer, and is characterized by elevated hydrogen ions, and hydrogen peroxide (h2o2), which is formed from the conversion of superoxide anions by superoxide dismutase. airway ph has already been shown to be decreased in ebc of patients with other respiratory conditions, but not in lung cancer. therefore the concentration of h2o2 and hydrogen ions in the ebc of lung cancer subjects was compared with matched controls. methods six subjects with newly diagnosed lung cancer were recruited and matched with control subjects: non-smokers, ex-smokers and smokers. ebc was collected and h2o2 was then measured by an assay method based on oxidation of 3,3',5,5'-tetramethybenzidine by horseradish peroxidase and h2o2 while ph was measured using a ph meter. results there was a significant difference (p = 0.033, anova) in h2o2 concentration between the 4 groups with the lung cancer group having elevated mean h2o2 concentration of 23.68 mm (9.15 (sem) compared to the controls: non-smokers, 17.59 mm (6.53 (sem); ex-smokers, 14.35 mm (3.79 (sem); and smokers, 5.21mm (0.69 (sem). ph did not differ significantly (p = 0.659, kruskal-wallis test) between the groups. conclusion these preliminary data suggest that there is significant difference in h2o2 concentration between the groups. the demonstration of an elevated h2o2 level in those with lung cancer indicates an increase in oxidative stress which implies that this may be part of the pathogenesis or response to neoplasia. supported by none. conflict of interest none. pro-inflammatory th1 cytokines produced by t cells and monocytes play an important role in the immune response to malignant cells. however, tumours may escape immune surveillance by inhibiting th1 response and promoting chronic inflammation at the tumour site. methods to investigate the effect of soluble factors released by lung cancer cells on t cell and monocyte pro-and anti-inflammatory cytokines, culture supernatants from several lung cancer cell lines and a normal epithelial cell line (16hbe) were cultured with whole blood for 24 hours, then for a further 16 hrs with and without stimuli. intracellular cytokine / chemokine production was determined using multiparameter flow cytometry. results in stimulated cultures, there was a significant decrease in t cell th1 pro-inflammatory cytokines ifng, tnfa and il-2 and a decrease in monocyte il-1a, il-8, il-12, tnfa, mcp-1 and mcp-3 but an increase in antiinflammatory cytokine il-10 compared with 16hbe and control media. in non-stimulated blood cultures there was an increase in all monocyte inflammatory cytokines / chemokines in the presence of lung cancer supernatants. conclusions lung cancers secrete soluble factors that inhibit the antitumour pro-inflammatory th1 response by t cells and monocytes and upregulate monocyte anti-inflammatory cytokine il-10 following "antigenic challenge". lung cancer cells may also escape immune surveillance by secreting soluble factors that cause newly recruited monocytes to release inflammatory cytokines promoting chronic inflammation at the tumour site. cytotoxic t-cells (ctl's) are important barriers against tumour cells. ctl's induce apoptosis of target cells by mechanisms that include the release of pore-forming perforin and granule associated enzymes, such as granzyme b and granulysin. proteinase inhibitor-9 (pi-9) is the only known granzyme b inhibitor and its expression has been observed in some cancers. we hypothesized that pi-9 would be differentially expressed in lung cancer cells and may inhibit granzyme b-induced apoptosis in these cells. methods we investigated pi-9, granulysin and granzyme b expression in various lung cancer cell lines (1299 ( , 1466 ( , 2009 and normal epithelial cells obtained from bronchial brushing using flow cytometry. peripheral bloodderived t-cells were then incubated with lung cancer cell line supernatants and levels of pi-9, granzyme b and t-cell reactive oxygen species (ros) were assessed. results pi-9 expression was detected in all lung cancer cell lines, (1299 (54.2%), 1466 (90.2%), 2009 (85%), sbc-1 (81%)), at much higher levels than in normal bronchial epithelial cells (8.5%). granzyme b and granulysin levels were undetectable or low in cancer cells (0-9.2%). increased expression of pi-9 and reduced levels of granzyme b were observed in cd8+ t-cells in the presence of all cancer cell supernatants tested (p < 0.05). interestingly, t-cell ros levels were significantly increased in cd8+ t-cells after incubation with cancer cell supernatants (p < 0.05). conclusions high pi-9 expression in lung cancer cells combined with a reduction in t-cell granzyme b expression and enhanced intracellular t-cell ros levels may be a mechanism of immune evasion of lung cancer cells to granzyme b-induced cytotoxicity. immunotherapy for lung malignancies such as lung cancer and mesothelioma is most likely to be successful it it can be combined with conventional tumour debulking approaches such as chemotherapy and surgery. but they scientific basis of such combinations is yet to be determined. to study this we evaluated (1) the capacity of different lung chemotherapy drugs to alter tumour antigen cross-presentation and immunogencity, (2) duration of antigen presentation and responsiveness to immunotherapy after debulking surgery with/without lymphadenectomy, and (3) the pattern of tlr agonism which best synergized with chemotherapy and surgery. we used the ab1-ha murine model of lung malignancy in balb/c mice. results (1) the antimetabolite drugs gemcitabine and pemetrexed were most immunogenic compared to the cytotoxic antibiotics doxorubicin and mitomycin c and the alkylating agent cisplatin. gemcitabine delived large amounts of tumour antigen into the cross-presentation pathway. (2) tumour antigen cross-presentation persisted for only 10 days following resection. the optimal window for immunotherapy following cancer surgery is 1 week for effector ctl stimulation and 2-4 weeks for memory ctl stimulation. (3) the viral-like tlr agonists tlr 3, 7 and 9 were the most effective adjuvant tlr molecules, with tlr 7 agonists generating the strongest systemic anti-tumour responses. conclusion these results help explain previous lung immunotherapy failures and will inform new clinical trials. background mesothelioma is a highly aggressive tumour with an increasing world wide incidence. the serum biomarker mesothelin is elevated in some individuals prior to development of clinical symptoms of the disease and may be useful for screening. we therefore studied the sensitivity and specificity of urinary versus serum levels of mesothelin for mesothelioma patients and evaluated the influence if renal function on the biomarker level. materials and methods concurrent sera and urine samples collected from patients with and control populations. mesothelin concentrations were determined by double-determinant elisa using the mesomark tm assay (fdi, pa). their estimated glomerular filtration rate (egfr) was also calculated. results mesothelin levels correlated between serum and urine samples (pearson's correlation 0.791; p < 0.0001). mesothelin levels were significantly higher in patients with mesothelioma compared to those with asbestosis and/or pleural plaques in serum (4 ϯ 0.9 versus 0.9 ϯ 0.05 nm; p < 0.0001, respectively), in urine (1.9 ϯ 0.5 versus 0.3 ϯ 0.03; p < 0.0001) and in urine following normalization using creatine levels (0.2 ϯ 0.05 versus 0.04 ϯ 0.01). age and egfr were significantly associated with mesothelin levels. conclusion the sensitivity and specificity of mesothelin in urine and in serum were comparable. urine mesothelin may prove to be a useful alternative to serum mesothelin for mass screening of asbestos-exposed individuals. patients undergoing ct coronary angiogram (cta) are often former or current smokers with a high incidence of asymptomatic lung disease. overseas reports show a rate of lung abnormalities ranging from 6.7% to 19%. there are no studies from australia and local factors such as the higher incidence of atypical mycobacteria may influence the rate of benign findings. we are therefore performing a prospective observational study to identify the prevalence and characteristics of incidental lung findings in people undergoing routine cta. methods population: 100 patients undergoing routine cta after informed consent. intervention: radiologist evaluation of lung windows on diagnostic standard workstations. comparator: uncontrolled observational study of consecutive patients. outcomes: primary: prevalence and characteristics of abnormal findings, final diagnosis (clinical judgment, biopsy or long term followup). secondary: number of downstream investigations and costs. results 25 ctas have been studied to date. in 8/25 (32%), abnormalities were noted on lung windows. in 2/25 (8%), there were lung nodules, in 2/25 (8%) there were hilar lymph node abnormalities, in 1/25 (4%), there was hemidiaphragm elevation and in 3/25 (12%) there were pleural plaques (data collection ongoing with study closure expected in february 2008). conclusions preliminary data indicate a substantial number of incidental pulmonary findings from cta; full results will be presented. further analysis is required to determine the impact (benefits, costs and harms) that may result from the concurrent examination of lung windows at routine cta. aim increased levels of nitrogen oxides (nox) and inflammatory markers have been found in bronchoalveolar fluid of lung cancer (lc) patients, but have not been investigated in exhaled breath condensate (ebc).the aim of this study was to compare nox and total protein levels in ebc of lc patients with control subjects. methods ebc was collected during tidal breathing through a glass collection device cooled to 4°c. ebc nox concentrations were measured by a fluorescent modification of the greiss method. total protein in ebc was determined employing the bicinchoninic acid (bca) assay. ebc nox data were log transformed. all data were analysed using anova and expressed as mean ϯ sem. results a total of 88 control subjects and 54 patients with primary lc were recruited. nox and protein concentrations are shown in table 1 . there was no significant difference in ebc nox levels (p > 0.05), but in total protein there was a significant difference between lung cancer patients and all control groups (p = 0.04). conclusion significantly increased ebc total protein levels were found in patients with lung cancer. these data suggest that protein mediator secretion or vascular leak may be present in those with lung cancer. future studies will focus upon the identification of these proteins. methods in this two stage case-control study 446 lung cancer cases and 484 healthy smoker controls were recruited. 180 genetic markers (snps) implicated in lung cancer were screened in our test cohort of 439 smokers and ex-smokers. 30 snps whose genotypes (co-dominant or recessive model) were associated with either the healthy smokers (protective) or lung cancer (susceptibility) phenotype were identified. after genotyping this 30 snp panel in a second cohort of 491 subjects 19 snps were chosen and assigned a simple composite genetic score that was combined with scores for age, history of copd and family history of lung cancer, weighted according to our multivariate regression analysis (n = 930 total subjects). the lung cancer risk score was linearly related to the likelihood of lung cancer with odds ratios (referenced against the lowest score quintile) ranging from 1 to 29 in the highest quintile. on receiver operator curve analyses, the auc was 0.78 and the frequency distribution showed bimodal separation between healthy smokers and lung cancer cases. utility of the score was not affected by effects of age, smoking history or lung function. we suggest that genetic data may be combined with other risk variables to define smokers or ex-smokers at risk of lung cancer for targeted interventions such as smoking cessation and early detection of lung cancer. supported by health research council, nz. conflict of interest yes. tp 144 v aiyappan 1 , a graham 2 1 department of medicine, maroondah hospital, melbourne, australia, and 2 the new disease-modifying anti-rheumatic drug (dmard) leflunomide is being used increasingly to treat inflammatory arthritis. its association with interstitial lung disease needs to be considered before combining it with methotrexate. case report a 73-year-old male who was known to have rheumatoid arthritis and was on methotrexate was admitted with progressive dyspnoea and malaise. he had been recently started on leflunomide. investigations revealed interstitial lung disease and acute renal failure. he improved on conservative treatment (stoppage of disease modifying drugs (dmard), iv fluids and steroids). review of literature an epidemiological study by suissa et al has suggested that there is increased risk of ild associated with leflunomide in patients with a history of ild or methotrexate use but they attributed this to channelling bias. there has also been a report of leflunomide associated with iga glomerulonephritis.by this presentation we aim to increase the awareness of this entity. we also suggest that any patient who is started on combination dmard (i.e. methotrexate and leflunomide) should have a baseline chest x-ray and be monitored for development of interstitial lung disease. conclusion we are reporting the first ever case of interstitial lung disease and glomerulonephritis (in the same patient), due to usage of leflunomide. this entity needs to be thought about in any patient on combination dmards. background bone morphogenic protein receptor ii (bmpr-ii) mutations are associated with pulmonary artery hypertension. failure of the growth inhibitory effects of bmp may contribute to vascular obliteration and remodelling leading to pulmonary artery hypertension (pah) [1] . pah has been observed following venous thrombembolic disease (vte), including pulmonary embolism (pe) and deep venous thrombosis (dvt) [2] . local markers of the pulmonary vascular endothelium rather than traditional markers of thromobophilia are thought to be involved [3] . methods plasma was collected from age and gender matched participants within 24 hours of diagnosis of vte and prior to commencement of warfarin therapy. plasma samples were hybridized to individual human cytokine antibody arrays, to detect protein levels of bmp2, bmp4 and bmpr-ii. results bmp2 and bmp4 levels were higher in patients with dvt than pe. no difference in the bmp level was observed between patients with pe and controls. soluble bmpr-ii receptor was lower in patients with pe than in controls or patients with dvt. conclusion in patients with pulmonary artery stress during the time of a pe the bmpr-ii receptor is reduced, which may predispose patients to vascular remodelling and obliteration. the bmp 2 and 4 levels are reduced at the same time, suggesting a possible overriding regulatory mechanism. the physiological role of bmp's and bmp receptors in patients with vte warrants further investigation. historically, cyclophosphamide has had a variable role in interstitial lung disease (ild), the rationale for its use based on the benefit seen in vasculitis and scleroderma, its rapid effect and low toxicity profile. in patients with severe progressive ild a rapidly effective, well-tolerated agent is desirable. for this reason a treatment protocol for the use of intravenous (iv) cyclophosphamide was implemented at our hospital. aim to review the indications, duration, tolerability and effect of intravenous cyclophosphamide in ild patients following the introduction of a treatment protocol. methods records of 92 patients [dlco was 40 ϯ 15% and fvc 61 ϯ 20%] completing a course of iv cyclophosphamide during 2005-6 were reviewed (excluding patients with systemic sclerosis). data covering 18 months prior to and following treatment were collected. comparative analysis of paired pulmonary function data 6 months before and after treatment was performed. 61% had underlying autoimmune disease. results primary treatment indications included progressive disease(n = 67); severe disease (n = 16); suspected vasculopathy (n = 11); bridging therapy to transplantation (n = 10); and accelerated decline (n = 5). patients received 600 mg/m 2 [mean dose 1152 ϯ 165 mg, median number of pulses 6 (1-12)]. patients with paired pulmonary function data had a difference in median change in dlco% predicted from -15.6% (-95.4 to 29.9%) before treatment to +4.25% (-17.3 to 73.9%) following treatment (p < 0.0001). this remained significant with exclusion of vasculitis, or any autoimmune disease, and independent of prior immunosuppression. therapy was well tolerated (4 withdrew from treatment, 5 deaths within 1yr, none directly related to treatment). conclusion iv cyclophosphamide is well tolerated, and associated with functional stability or improvement in the majority of patients. it remains a viable treatment alternative for consideration. pulmonary hypertension is common in interstitial lung disease (ild) and associated with a poor prognosis. as the gold-standard test, right-heart catheterization (rhc) is invasive, and resource-limited, reliable non-invasive measures of ph are needed. methods all ild patients referred for rhc during 1997-2007 were included (n = 95; 54 male; age 56.5 ϯ 12 yrs). all patients had concurrent echocardiography (tte) and pulmonary function. the relationship of rhc mean pulmonary artery pressure (mpap) to tte variables, pulmonary function, exercise capacity, as measured by six minute walk testing (6mwt, n = 58) and brain natriuretic peptide (bnp, n = 36), was examined. case a 65 year old male, non-smoker for 25 years, retired professor of anatomy (had chronic exposure to embalming fluids, formaldehyde, phenol, antifungal and other solvents, for 20 years) presented with chronic cough and phlegm production. these symptoms were worse at night (waking him several times) and early morning. his pulmonary tests were stopped due to persistent cough. a chest x-ray revealed features of longstanding interstitial lung disease. the hrct revealed widespread subpleural interlobular thickening, worse at bases, in keeping with idiopathic pulmonary fibrosis (ipf). there was minimal fibrosis and honeycombing, but no groundglass opacification, large bullae, pleural calcification or pleural plaques. however, there was associated bronchiectasis at the lung bases considered to be due to traction. the ba lavage showed 50% macrophages, 7% neutrophils, 3% lymphocytes, and 40%, eosinophils and no infection. the patient declined to have a lung biopsy. as per his past x-rays, the duration of his ipf is a little over one year. he maintains that his symptoms started only after starting irbesartan (irb). introduction transbronchial lung biopsy (tbb) has a variable and unpredictable diagnostic yield in sarcoidosis. we hypothesized that the extent and pattern of parenchymal disease on ct would predict the likelihood of a positive tbb. methods data relating to ethnicity, symptoms, pulmonary function and site and results of tbb and bronchoalveolar lavage (bal) from 70 sarcoidosis patients were recorded. all had a ct scan within 6 weeks prior to the tbb procedure. cxr stage was determined from radiology report. ct scans were scored quantitatively for patterns of parenchymal disease (nodular, reticular, consolidation, ground glass and mosaic attenuation) on a lobar basis. results 50% patients had a positive tbb (total 67% of cohort had histological confirmation). symptoms, ethnicity, treatment, lung function and cxr stage were not predictors of a positive biopsy. positive biopsy was associated with higher bal lymphocyte count (p < 0.05) and female gender (p < 0.01). a reticular pattern (p < 0.05) and higher total lung score (excluding da) (p < 0.05) on ct scan predicted a positive biopsy. in those patients with tbb from right lower lobe (53/70) the total rll score on ct was predictive of positive biopsy (p < 0.05). on multivariate analysis gender, bal lymphocytosis and total lung score were independent predictors of a positive tbb (area under roc 0.82). pulmonary arterial hypertension has two histological variants; 'arterial-only pulmonary arterial hypertension' (artpah) and 'pulmonary veno-occlusive disease' (pvod). bosentan, a dual endothelin receptor antagonist, has been found to improve haemodynamics, functional capacity and survival in artpah. however, the response to bosentan in clinically diagnosed artpah is often variable. it was hypothesized that a lack of response to bosentan therapy in clinically diagnosed artpah can be explained by misdiagnosed pvod. aims included to: (1) perform morphometric and qualitative pulmonary vessel analysis on normal controls and cases clinically diagnosed with artpah who had failed bosentan therapy; (2) ascertain if pvod is present within the case group; (3) correlate clinical variables and vessel microanatomy to identify the pathologies driving pulmonary pressure elevation. this study reviewed 14 cases of clinically diagnosed artpah (idiopathic n = 12, associated with scleroderma n = 2), who had failed bosentan therapy and had available lung tissue. controls (n = 6) were obtained from explanted lungs for other causes and a prior transthoracic echocardiogram excluded pulmonary hypertension. vessel morphometry and qualitative analysis was performed with a novel technique of smooth muscle actin immunohistochemistry counterstained with verhoeff's elastin. baseline clinical data were retrieved. we found 86% of cases had pathology confirmed pvod. only 14% of cases had artpah, the original clinical diagnosis. in pvod, significant pathology was present in all vessel types. all vessels had significant smooth muscle hypertrophy. the obstructive, collagenous, pauci-cellular intimal fibrosis of the venules (p < 0.0001) and arterioles (p < 0.0001) was considerably different to the concentric laminar proliferation of smooth muscle observed in the muscular arteries (p < 0.0001) and arterioles (p = 0.001) in artpah. artpah also had muscular artery smooth muscle hypertrophy (p = 0.007). the median time to bosentan failure was shorter in pvod than artpah (290 vs. 657 days). in conclusion, pvod is an under-diagnosed cause of pulmonary hypertension, is commonly clinically misdiagnosed as artpah and may present with a poor bosentan therapy response. finally, pvod is a vaso-occlusive, not a veno-occlusive disease, and is an independent type of pulmonary hypertension, not a subtype of pulmonary arterial hypertension. cutaneous t cell lymphomas (ctcl) are a heterogenous group of lymphoproliferative disorders. they show various clinical manifestations and diverse morphological, histological and immunological characteristics of the malignant cells. they are caused by clonally derived, skin invasive t cells. peripheral t cell lymphomas (ptcl) are generally more aggressive and have one of the lowest overall and failure-free survival rates. because of the rarity of these disorders, diagnosis and treatment remain challenging. this case report describes a 69-year-old woman presenting with progressive dyspnoea and cough, together with a distressing generalized pruritic rash. she was initially treated as left ventricular failure with the rash ascribed to a drug reaction as suggested by initial skin biopsies. the diagnosis was made on a third skin biopsy and flow cytometry of lymphocytes obtained by broncho-alveolar lavage 6 months after presentation. despite an initial response to chemotherapy she succumbed to the disease 20 months after diagnosis. clinical pathways to guide the investigation of suspected pulmonary embolism (pe) have been increasingly adopted by emergency departments (ed) worldwide. compliance with these diagnostic algorithms is critical in ensuring good patient outcomes. this study evaluated the compliance to the clinical pathway used in our ed that combines risk assessment (wells scoring system) with d-dimer test, vq scan or ctpa. the main objectives of this study were to identify those factors which contributed to compliance and to assess patient outcomes. methods a prospective observational study of 239 consecutive patients who underwent investigation for pe in our ed. patient demographics, pathway parameters and patient outcomes at 3-month follow-up were collected. case we report the case of a 37 year old woman who presented to the emergency department with a three day history of dry cough and dyspnoea. the patient was in her third pregnancy at 30 weeks gestation. she had no fever, chest pain or coryzal symptoms. the patient had presented with a right sided spontaneous pneumothorax seven months prior to the current presentation. her past medical history included placental abruption, complicating her previous two pregnancies. her second pregnancy was complicated by placental abruption at 27 weeks and the foetus had not survived. her first pregnancy was complicated by placental abruption at 36 weeks with successful delivery of the foetus. at presentation, significant findings included tachycardia, hypoxemia, tachypnoea and reduced breath sounds over the right side of the chest. chest x-ray demonstrated a large right pneumothorax. a right intercostal catheter was inserted resulting in right lung re-expansion. the catheter was removed three days later. the patient returned to hospital twenty four hours after catheter removal with a recurrent right sided pneumothorax. the patient agreed to surgical intervention involving video-assisted thoracotomy and talc pleurodesis. the patient had no further complications with the pregnancy. she delivered a healthy baby at 38 weeks gestation. discussion spontaneous pneumothorax in pregnancy is rare and there is little evidence to provide guidelines for the management of recurrent pneumothorax in high risk pregnancy. our case illustrates a successful outcome for mother and foetus with surgical intervention at 32 weeks gestation. folfox is currently the standard adjuvant treatment for locally advanced (stage iii) colon cancer and increases disease free survival. its toxicity is well tolerated with common adverse effects being paraesthesia, bone marrow suppression and gastrointestinal disturbance. pulmonary toxicity has rarely been reported. three clinical cases of acute dyspnoea following folfox therapy (2005) (2006) (2007) for stage iii colon cancer are reported. all had an anterior resection followed by 11-12 cycles of folfox. each developed rapidly progressive dyspnoea requiring hospital admission within one week of their last cycle. one patient required invasive ventilation in icu. high resolution computed tomography (hrct) showed bilateral widespread honeycomb pattern with associated ground glass opacification consistent with pulmonary fibrosis. they had reduced lung volumes and gas transfer. transbronchial biopsy and bronchoalveolar lavage in one patient showed an acute eosinophilic pneumonitis. other causes of interstitial lung disease were carefully excluded. all three patients received high dose corticosteroids with one receiving additional cyclophosphamide. the first patient showed complete recovery following an eight week course of corticosteroids, with resolution of the hrct changes and improvement in lung function. the second had symptomatic improvement of dyspnoea, but a persistent moderate reduction in gas transfer. the final patient had persisting radiographic changes and a reduced gas transfer. he remained dependant on ambulatory oxygen 6 months after his initial presentation. these patients' interstitial lung disease appears due to folfox with oxaliplatin being the most likely causative agent. the use of oxaliplatin chemotherapy has increased markedly over the last 3 years and although rare, physicians should be aware of its potential for lung toxicity. lung function testing at baseline, during and towards the end of oxaliplatin treatment should be undertaken and may allow early detection and intervention in cases of pulmonary toxicity. the forced oscillation technique (fot) with broadband signals has been employed relatively rarely in the studies on respiratory mechanics. recent work from our laboratory [1] indicated that the cheek support and the neck angle have minor influence on the impedance spectra around the first antiresonance (far,1), which makes the use of the broadband fot especially attractive in young children. methods we studied 7 healthy children (c; female: 4) and 8 children with bronchopulmonary dysplasia (bpd; female: 3), using multiple-frequency fot between 8 and 256 hz superimposed on spontaneous breathing. results groups c and bpd did not differ in age ( lung function impairment is common in children with cardiac defects associated with increases in pulmonary blood flow/pressure. to investigate the development of bronchial hyperreactivity (bhr), an aorto-caval shunt was created in a model of precapillary pulmonary hypertension. surgical shunt repair was performed to assess the reversibility of bhr. methods 26 rats were divided into 3 groups: group c (n = 10) with sham surgery, group s (n = 8) where an aorto-caval shunt was created (follow-up 4 wks), group r (n = 8) with aorto-caval shunt but surgical correction of the shunt at 4 wks (follow-up 8 wks). in all animals, respiratory input impedance (zrs) was measured at baseline and following increasing doses of methacholine (mch 2, 4, 8, 12 mcg/kg). airway resistance (raw), inertance, tissue damping (g) and elastance were estimated from the zrs spectra by model fitting. measurements were repeated in all animals at 4 wks and at 8 wks for groups r and c. results there was a significant increase in raw and g in group s and rat 4 wks at baseline and following mch ( fig.) which was reversed after surgery. to characterize the factors contributing to lung function impairment following cardiopulmonary bypass (cpb), functional residual capacity (frc), lung clearance index (lci) and respiratory mechanics were measured in children with pulmonary hypoperfusion (tetralogy of fallot, tof n = 12) and hyperperfusion (ventricular septal defect, vsd n = 12) undergoing surgical repair of congenital heart disease. methods frc and lci were measured using a sf6 washout technique and respiratory mechanics using a low frequency oscillation technique in the perioperative period. results while chest opening led to a significant improvement of lung volumes and respiratory mechanics in all patients (p < 0.001), a reduction in pulmonary blood flow during cpb decreased lung volumes and airway resistance in parallel but significantly more in children with tof compared with those with vsd. re-establishing pulmonary blood flow during cpb improved respiratory function particularly in children with tof ( figure) . conclusions sternotomy had a great impact on lung function with parallel improvement in alveolar recruitment, ventilation inhomogeneity and airway resistance. in contrast, onset of cpb led to lung function impairment with a significant drop in frc especially in children with pre-existing hypoperfused lungs. this suggest that pulmonary blood flow enhances alveolar stability through a tethering effect on the alveolar walls. children with advanced lung disease being considered for lung transplantation are likely to spend disproportionately longer periods on transplant waiting lists before appropriately sized donor organs become available. these longer waiting times reflect the lower organ donation rates seen in children; rates that are significantly lower than those reported in the adult population. we describe two children with advanced lung disease who deteriorated whilst on the waiting list for lung transplantation, and in the absence of appropriately sized donor lungs, underwent lobar lung transplantation. methods we describe the clinical course of two children, aged 9 and 13 years old, with advanced lung disease secondary to post-mycoplasma obliterative bronchiolitis and cystic fibrosis-associated bronchiectasis, respectively. results both children received a "cutdown" bilateral lobar transplant from two oversized adult brain-dead organ donors. in both cases the transplant operation involved implantation of the right middle and upper lobes, and of the left upper lobe from the donor. conclusion given the low organ donation rates in children, and in the absence of appropriately sized donor lungs, novel strategies such as lobar transplantation must be considered, particularly when children continue to clinically deteriorate whilst on the lung transplant waiting list. data from the west australian adult outcomes of extreme preterm birth study suggest that adult survivors of bronchopulmonary dysplasia (bpd) may be left with functional and structural pulmonary abnormalities, most notably emphysema. animal data suggest that the antenatal administration of corticosteroids may adversely affect lung development. we therefore sought to determine if maternal variables, including administration of corticosteroid, could predict emphysema severity in adulthood. methods bpd subjects (birthweight < 1500 g and oxygen dependence at 36 weeks post-menstrual age) born prior to 1988 were identified and recruited prospectively via the statewide neonatal follow up program as previously described. pulmonary function tests and thin selective inspiratory and expiratory computerised (ct) images were acquired and scored for emphysema severity (voxel index (%)). the obstetric history was obtained from retrospective review of case notes. results 21 adults (12 females, aged 18-34) were studied, 2 declined ct. all subjects had abnormal ct findings. fifteen (79%) had areas of emphysema. emphysema score and fev1 were not influenced by the administration of antenatal corticosteroids, indication for delivery, maternal age or presence or absence of chorioamnionitis. conclusion maternal factors, including the administration of antenatal corticosteroids, do not predict the long term respiratory outcome of bpd. the factors determining the severity of emphysema in this group remain unknown. the prevalence of childhood asthma is high in the torres strait. children have generally more severe asthma and asthma knowledge is poor. however, there is no culturally appropriate asthma education program for these children. we are conducting a randomized controlled trial to examine the additional benefits of an education intervention by indigenous health care workers (hcw) on asthma outcomes. we describe the study's objectives, design and baseline measurements. methods children with wheeze were reviewed by two paediatric respiratory physicians using a standardized protocol; children with asthma were eligible. after obtaining informed consent children were randomly allocated to: (1) three additional asthma education sessions with a hcw; or (2) no additional education from a hcw. trained hcws carried out the education sessions using culturally appropriate tools. primary outcome was the number of unscheduled hospital/doctor visits due to asthma exacerbation. all children were re-assessed at 12 months. results we enrolled 113 children aged 1 to 17 years, 81% were torres strait islanders and 12% aboriginal and torres strait islanders. the clinical spectrum of asthma was: 51% infrequent episodic asthma, 22% frequent episodic asthma and 27% chronic asthma. eighteen percent of the children knew what a written asthma action plan was; 8.5% had one. carers' assessment of knowledge of medications showed that 52% could not name any asthma medication used by their child, 40% could not explain dosage, and 67% could not explain how beta2 agonists worked. conclusions asthma knowledge and possession of asthma action plans in this cohort is poor at baseline. there is substantial room for improvement and additional asthma education by hcws potentially has significant benefits. impulse oscillometry system (ios) measures respiratory function during normal breathing by transmitting mixed frequency rectangular pressure impulses down the airways and measuring reflected pressure. computer analysis calculates respiratory impedance and its components, airways resistance and reactance, at a range of frequencies from 0.1 hz to 150 hz. no previous australian normative data exists. the ios software generates predictive normal values for each of the parameters measured including total airway resistance (r5), the proximal airway resistance (r20) as well as peripheral capacitive reactance (x5). however, they are based on german data. methods cross-sectional study of 100 community dwelling adults, with 10 males and females per 10-year cohort. inclusion criteria: age range 25-74 years, apparently good respiratory health. exclusion criteria: smokers, asthmatics and others with acute or chronic respiratory disease. both ios and spirometry were conducted on all participants. results australian predictive normal equations have been generated and compared to the current published equations. the ios parameters have been correlated with the spirometric data. results have been analysed by gender, age, height and weight and compared with the predictive normal values for each parameter provided by the german manufacturer of the ios instrument. analysis includes calculation of mean range, and lower limit of normal. conclusions a preliminary set of australian predictive equations have now been produced for the ios. these have been compared with international equations. ios has potential application in a range of respiratory disease states and in population screening for occupational health (e.g. mining, & high dust load environments). supported by phc red. rationale although clinical practice guidelines for both asthma and copd recommend spirometry for diagnosis and monitoring, beneficial effects on the management of chronic respiratory diseases in general practice have not been established. we hypothesized that spirometry would improve health outcomes compared to usual care. methods we are conducting a single masked rct with 3 arms: group a receive 3 monthly spirometry and followup, group b receive spirometry before and after the trial and group c usual care. 45 general practices were recruited though divisions of general practice in melbourne. invitations were mailed by 31 of these practices to patients who had been prescribed inhaled medications during the previous 6 months. participants returned respiratory and generic quality of life questionnaires and an asthma score card. groups a and b were tested on a micromedical turbine spirometer following ats/ers guidelines. results 351 eligible patients (275 adults, 50 children aged 8-13 and 26 youths aged 14-17 years) entered the trial. 122 were randomized to group a, 134 to group b and 95 to group c. the mean (sd) age of adult participants was 54.3 (12.7), children 10.3 (1.7) and youths 15 (1.1) years. there were 130 males and 221 females. the adults were highly symptomatic in the previous 12 months: 82% reporting wheeze, 50% chest tightness on waking, 74% shortness of breath on exertion, 61% nocturnal cough, 46% morning cough and 75% sputum. symptoms of chronic bronchitis were reported by 39% of adults and a diagnosis of copd by 19%. asthma was reported by 84%, confirmed by a doctor in 96% and 55% had experienced an attack in the last 12 months. only 35% had a written asthma action plan. 37% of adults had ever visited a hospital ed and 28% had been admitted. conclusion it is possible to recruit asthma and copd patients from general practice and to randomize them to spirometry or usual care. whether spirometry is associated with fewer symptoms, changes in medication, uptake of action plans or improvement in lung function or quality of life requires further followup. supported by nhmrc. s shah 1 , jk roydhouse 1 , b toelle 2 , s sawyer 3 , c jenkins 2 for the pace australia management committee 1 university of sydney, 2 woolcock institute of medical research, sydney, nsw 2006, and 3 royal children's hospital, melbourne, vic 3052 it is widely held that recruitment of general practitioners for research can be challenging. in this paper, we discuss the recruitment experience from a current study evaluating the impact of an educational asthma intervention on patient outcomes. our aim is to describe the two different strategies utilized to date: (1) in-house through an academic department of gp and (2) outsourced to a private gp organization. methods initial interest was generated through faxes, presentations at gp divisional meetings and newsletter advertisements. gps who expressed interest were visited by project staff to discuss the study further. a major difference was recruiting one gp per practice in the first strategy versus multiple gps per practice in the second strategy. to assess the strategies, we examined participant characteristics, number of gps recruited and number retained. results participant characteristics: under both strategies, 30% of recruits had trained in asia and 54% were women. the first strategy recruited more gps who spoke at least two languages at home (85% vs 42%) and the second strategy recruited more recently graduated gps (58% vs 50%). recruitment: the first strategy recruited 35 gps over 6 months and the second recruited 34 gps over 3 months. retention: 19 gps (54%) from the first strategy stayed in, compared to 29 (85%) from the second. conclusions whilst absolute numbers of gps recruited were similar, retention was much higher under the second strategy. recruitment in primary care is difficult and requires a range of approaches which need to be re-evaluated and adapted as necessary during the course of the study. supported by the australian government department of health and ageing. bronchiectasis is a heterogeneous condition with a large number of causative factors and range of symptoms. the classification of this condition is often confusing and hard to remember. the aim of this study was to classify non-cf bronchiectasis into different clinical phenotypes. methods 178 consecutive patients with non-cf bronchiectasis confirmed on high resolution ct scanning had a detailed clinical, spirometric and laboratory assessment performed by a respiratory physician (pk/mf/pw) and were then followed up for an average of 9 ϯ 4 years (mean and sd) for a total of over 2000 reviews. results 160 of the 178 patients (90%) could be classified as belonging to 3 phenotypic groups; 1) bronchiectasis arising in childhood, 2) bronchiectasis occurring in smokers and 3) bronchiectasis occurring in the elderly. each group had different features which are listed in the there are few data on the long term outcomes of treatment for tuberculosis (tb) by directly observed therapy (dot) in low-incidence settings. the aim of this study was to assess the incidence of recurrent tb in nsw. methods data linkage was performed within the nsw department of health tb notifications database to identify cases that had more than one tb notification between 1994 and 2006. recurrent tuberculosis was defined to include all patients with two or more culture positive episodes at least 6 months apart, where patients had received at least six months treatment for the initial episode. in cases where data contained within the notification details was not sufficient to allow us to distinguish between true cases of recurrent disease, duplication notification for the same episode or persistent disease after incomplete treatment, additional information was obtained from the area tb coordinator. results there were 5723 tb notifications between 1994 and 2006 with 3731 being culture positive. 15 cases of recurrent culture positive disease after completed treatment for the first episode were identified (recurrence rate: 0.4%). conclusions in a population with a low tb incidence, treatment of active tuberculosis with dot results in a very low rate of disease recurrence over a long period of follow-up. support nhmrc ccre in respiratory and sleep medicine. introduction rhinoviruses (rvs) are the major cause of viral-induced exacerbation of asthma. to date, the molecular mechanisms of rv pathogenesis are not understood. recent findings suggest that rv pathology may involve host cell nucleocytoplasmic trafficking, inhibiting key cell functions such as transcription and translation. the study aims to investigate the mechanism of rv 3c protease nuclear trafficking. methods hela cells were infected with rv or transfected with plasmids and cellular localization of 3c analysed at various times thereafter using immunofluorescent confocal microscopy and western blotting with specific antibodies. results 3c protease was predominantly present in nuclei of rv infected cells up to 6 hours after infection, becoming increasingly cytoplasmic thereafter. the nuclear membrane of infected cells became progressively indistinct with time. using a specific inhibitor we also found that 3c utilizes the crm-1 nuclear export pathway. 3c was predominantly in the form of 3cd in both cytoplasm and nucleus of infected cells; mature 3c protease was also detected from 6 hours after infection. deletion analysis indicats that the nuclear localization domain and a nuclear export signal are most likely to be present within the n terminal 64 amino acids. the nuclear export signal is inhibited in the full length protein, via an unknown mechanism. conclusion our data suggest that 3c and 3cd proteins localize to the nucleus in infected cells where they may play a key role in rv pathogenesis by disrupting cellular transcription and the nuclear transport machinery. chronic necrotizing pulmonary aspergillosis (cnpa) is a relatively uncommon, sub-acute, locally destructive process due to aspergillus invasion of the lung. the incidence and prognosis of cnpa are poorly described. case report we present a case of cnpa in a patient on intermittent low dose steroid therapy and recurrent refractory exacerbations of chronic obstructive pulmonary disease (copd).the patient presented with worsening shortness of breath and productive cough requiring recurrent inpatient admissions. human influenza virus is found to bind preferentially to saa2,6gal receptors found in the upper respiratory tract, while avian viruses bind to saa2,3gal receptors expressed in lower airways. this is thought to affect the ability of transmission to humans. our aim was to study the ability of avian and human influenza strains to infect bronchial epithelial cells and relate this to levels of the sialic acid receptor expression. methods calu-3 cells were used as a proximal airway cell and a549 were used as distal airway cell. human primary bronchial epithelial cells (pbecs) were obtained from healthy, asthmatic, and copd volunteers by endobronchial brushing. epithelial cells were stained with sambucus nigra lectin that binds saa2,6gal receptor, and maackia amurensis lectin ii that binds to saa2,3gal. the cells was analysed by flow cytometry. human influenza a/h3n2/wellington strain and low pathogenic avian influenza a/h11n9/sandpiper were chosen and were used at an moi of 0.005 to infect cells. the supernatants were harvested at 48 hr post infection, of which was then analysed by plaque assay for virus replication. results the calu-3 showed greater expression of saa2,6gal linkage than saa2,3gal linkage, and a549 displayed slightly higher expression of both receptors compared to pbecs. despite this human and avian influenza virus replicated to similar titre at 15,000 pfu/ml in both cell lines, but showed low replication in pbecs. background treatment of community-acquired pneumonia remains based on 'best guess' empiric algorithms because of the poor utility of current pathogen tests. furthermore our ability to stratify patients into risk groups is crude at best, relying on scores such as the pneumonia severity index or the curb-65 have major limitations. we have been slowly improving real-time pcr assays for pneumococcus as a clinical tool in patients with pneumonia. methods building on previous research we assesed two targets in the autolysin (lyta) gene and the pneumolysin (ply) gene of s.pneumoniae using the lightcycler instrument and fluorescence resonance energy transfer (fret) probes. all common s. pneumoniae serotypes were detected while other bacteria and viruses were not. the lyta target had the best sensitivity with a detection range between 21 ng to 21 fg. both assays were then applied to whole blood samples from 400 adult patients with community-acquired pneumonia, all of whom had blood cultures prior to antibiotic administration and urinary antigen testing for s.pneumoniae. the lyta pcr had the best performance characteristics with a sensitivity more than twice that of blood cultures in the clinical samples. most pcr+ve/culture -ve patients had positive urinary antigen tests. there was clinical evidence that urinary antigen +ve/ pcr -ve patients were false +ves. most significantly there was a strong correlation between quantitative bacterial count and clinical outcome. conclusions real-time quantitative pcr for pneumococcus has significant potential as both a diagnostic and therapeutic tool in patients with pneumonia. the pitjantjatjara lands are situated in the north-western corner of south australia, occupying an area of over 120 000 square kilometres with a population of approximately 3000. the population lives in small communities or homelands, and there is a high level of mobility between this region and other aboriginal communities in south australia and the northern territory. nganampa health council provides all health care services to the region. specialized support for tb control comes from both the south australia tb service based at royal adelaide hospital as well as a centre for disease control in alice springs. the prevalence of tuberculosis (tb) in this predominantly indigenous community is thought to be significantly higher than the national rate. there are considerable challenges in detecting and managing tuberculosis, relating to the community's geographical remoteness, migration of populations and access to health services. the aims of this study are to quantify the prevalence of tuberculosis in the pitjantjatjara lands, and describe the significant barriers to tb diagnosis and treatment. methods a retrospective study of all diagnoses of tuberculosis within the pitjantjatjara lands in the period 1995-2006. outcomes include measures of tuberculosis diagnosis, the rates of completed tb treatment and rates of tuberculosis drug resistance. the study will draw conclusions about the reasons for high levels of tb prevalence in this community and identify barriers to effective tuberculosis treatment. conflict of interest no. patients admitted to hospital with a diagnosis of community-acquired pneumonia (cap) are usually treated with intravenous (iv) antibiotics irrespective of pneumonia severity. available guidelines vary in recommended timing and indications for switching to oral antibiotics. aim to examine the patterns of antibiotic choice and delivery method (iv, oral and time to switch) in patients admitted with cap. methods a retrospective chart review of admissions to the respiratory unit over a 12-month period with a diagnostic-related group (drg) coding of pneumonia. 41 charts were reviewed. data collected included patient demographics, clinical features at presentation (temperature, pulse rate, respiratory rate, bp, oxygenation), initial investigations, initial antibiotic regime, time to change (iv to oral), subsequent antibiotic regime and duration, time to defervescence, length of stay and outcome. pneumonia severity was calculated using the revised british thoracic society system (curb-65), score ն 2 = severe. results 3 patients were excluded due to incorrect coding. of the 38 patients, age was 50 ϯ 21 (mean ϯ sd) yrs and 25 (66%) were male. 28 patients (74%) were febrile at presentation and the median curb-65 score was 1 (range 0-4). 37 patients (97%) received iv antibiotics. the curb-65 score was 0 or 1 (non-severe) in 25 patients and 22 of these patients received a combination of iv ceftriaxone and a macrolide. time to defervescence was 2.9 ϯ 2.3 days. time from defervescence to switching to oral therapy was 3.4 ϯ 2.8 days. in non-febrile patients, time to switch was 4.7ϯ4.3 days. length of stay was 8.7ϯ13.0 days. conclusions the time between defervescence and switch to an oral regime was relatively long, possibly contributing to an increased length of stay. many patients received ceftriaxone even with a curb-65 severity rating of 0 or 1. implementing local guideline-based treatment protocols may reduce length of stay. ultrasonic flow sensors can determine flow, volume and molar mass (mm) of the gas flow simultaneously. during tidal breathing the expired molar mass curve can be used to compute co2 over expired volume and a capnography index (cpi) can be computed. the relationship between cpi and copd classification according to gold was investigated. methods prospective, controlled trial. consecutive patients who underwent routine lung function were enrolled to participate in a tidal breathing test using an ultrasonic flow sensor. each test consisted of three tidal breathing recordings of 60 sec. flow, volume and molar mass were measured at 200 hz and data were acquired using prototype wbreath data acquisition software. mean expirograms (mm over volume) were computed and the measurements were analyzed to determine the slope of exhaled phase ii (s2), the slope of phase iii (s3) and the relationship between s2 and s3 (cpi = s3/s2). gold stages were determined from the lung function results and the ers predicted values. results 53 volunteers participated in the study with a mean age of 62 (sd 14), 23 were male, mean bmi 26 (sd 5), 17 had never smoked. the mean pack/year smoking history was 38. there was a clear relationship between gold stage and cpi: gold stage 'normal' had a mean cpi of 5.5 (sd 3.7, n = 21), stage 'severe' had a mean cpi of 13.7(sd = 3.9, n = 7). conclusion computation of cpi based on tidal breathing analysis using an ultrasonic flow and mm sensor correlates well with gold stages. it may therefore be possible to use a simple tidal breathing test to determine the severity of airways disease. background osa is common in tetraplegia and appears within weeks of injury. although cpap treatment is efficacious in able-bodied subjects, case series suggest that cpap is poorly tolerated in tetraplegia. no prospective study has examined cpap efficacy or adherence in tetraplegia. aim to determine the feasibility of cpap use to treat osa following acute tetraplegia. methods all acute admissions who consented and fulfilled the inclusion and exclusion criteria underwent full, portable polysomnography. those found to have an apnoea hypopnoea index of >10 events per hour (osa) were offered cpap, delivered via an auto-titrating device. results to date, 25 patients have been admitted (11 excluded, 3 refused consent). no significant, adverse events have been observed. two patients did not have osa. of the nine with osa, four are mid-study, two had incomplete follow-up (1 returned to uk and 1 refused 3 month assessment), two adhered with cpap and one did not due to severe, pre-existing nasal obstruction. preliminary analyses suggest that those who adhered to cpap had a marked reduction (80% compared with 10-40%) in sleepiness and a greater reduction in the functional outcomes of sleepiness compared to either those without osa or who were unable to use cpap. patient accrual, recruitment and completion rates are consistent with our initial estimates. study recruitment will be completed by end-october 2007. conclusion initial data suggest that auto-titrating cpap is a feasible treatment for osa in acute tetraplegia. these data will be used to finalize planning for a multi-national, multi-centre randomized controlled of therapy. this research was supported by the transport accident commission. visual recognition of cyanosis is an important clinical activity. cyanosis recognition is affected by lighting colour and there is anecdotal evidence that people with significant colour vision deficiencies (cvds) have particular difficulty. studies to date have centred on the colour change with oxygenation of isolated blood but it is not clear how this extrapolates to cyanotic patients in vivo. methods ten patients known to be chronically hypoxaemic and showing signs of cyanosis were recruited from the chronic respiratory program. ten normal subjects were recruited as controls. the spectral reflectances of their lips, nail beds and palm creases were measured using a topcon sr-3 telespectroradiometer. the patients were measured at rest and after exercise to lower their saturation by 5-10%. the chromaticities were calculated and plotted. results both groups showed a spread of colours but they fell into two distinct ranges. the colour difference between the groups lies very close to the colour confusions made by congenital cvds. within the cyanosed group, the colour shift was not tightly related to decreasing oxygen saturation. this is most likely due to interpersonal factors such as pigmentation and vascular perfusion that affect colour and the difficulties in measuring the colour of heterogeneous anatomical features. conclusions these results quantify the anecdotal difficulties in detecting cyanosis and suggest that observers with cvd would have problems recognizing the condition. the photographs obtained from this study will be used to compare the ability of subjects with and without cvd to detect cyanosis. supported by the nsw ambulance service. baroreflex sensitivity is depressed in osa patients during sleep but effects during wakefulness are less clear. we have now examined relationships between awake brs and severity of sleep disordered breathing (sdb). methods immediately prior to overnight polysomnography, continuous (5 min) beat-to-beat arterial blood pressure was measured via finger plethysmography (portapres) and heart rate via ecg in 20, supine, normotensive, untreated osa patients (17 males; age: 49 ϯ 15 years (mean ϯ sd); bmi: 26 ϯ 11 kg/m 2 ). spontaneous baroreflex sensitivity (brs) was calculated using the sequence technique. sdb was characterized as apnoea hyponoea index (events/hour) and arousal index (ai). data were analysed via mathematical modelling and unpaired t test. results brs fell with increasing ahi. patients with ahi > 30 events/hour (n = 9) had a significantly lower brs (8.1 ϯ 1.5 ms/mmhg) than those with ahi < 30 events/hour (19.8 ϯ 8.7 ms/mmhg, p < 0.001). brs was negatively related to both ahi and ai via fitted exponential functions (r 2 = 0.45 and 0.70, respectively). it is hypothesized that the analysis of morphology of the ecg waveform in combination with the heart rate patterns could lead to the possibility of detection of the start and duration of apnoea/hypopnoea events and consequently estimation of the apnoea-hypopnoea index (ahi). to the authors' knowledge the published ecg based algorithms for detecting sleep disordered breathing are only capable of minute by minute analysis rather than detection of individual respiratory events. methods changes to ecg parameters were investigated during respiratory events with no distinction made between apnoea and hypopnoea events. 632 isolated respiratory events and 1264 controls of identical duration were obtained from 7 polysomnographic studies, using a randomized procedure. features such as the r wave amplitude, t wave amplitude, qrs area and the r-r interval were extracted from the 2 lead ecg. a number of physiological predictors based on these features were generated. a logistic regression model was used to investigate the association between the predictors and true events, using the statistical software, stata. results univariate and multivariate analyses were performed. three multivariate models were developed; heart parameters only, ecg waveform morphology parameters only and the combinations of the two. the area under the receiver operator characteristic curves (auc) for these models were compared. the best results were obtained with the combination of morphology and heart rate parameters (auc = 0.8858 (0.0078 (sd))) compared to the morphology (auc = 0.8169 (0.0121 (sd))) and heart rate (auc = 0.7195 (0.0103 (sd))) models. the multivariate analysis has shown encouraging results indicating that an algorithm using a combination of heart rate and ecg morphological parameters could potentially be constructed that would enable the determination of individual respiratory events and subsequently an ahi. supported by the arc. introduction sacin and scond are measures of ventilation heterogeneity in acinar and conducting airways, derived from analysis of mbnw. maintaining tidal volumes of 1 l at 9-11 breaths/minute (bpm) is impossible for some. our aim was to examine the effect of different tidal volumes on sacin and scond in normals and asthmatics. methods 10 normals (23-41 yrs) and 12 asthmatics (21-63 yrs) underwent mbnw at tidal volumes of 500 ml at 20-23 bpm, 1 l at 9-11 bpm, and 2 l at 5-7 bpm. scond and sacin, were determined from the normalized phase iii slopes of breaths between turnovers (cumulative ventilation/frc) 1.5 & 6. results the mean ϯ sd %predicted fev1 was 97.3 ϯ 17% in normals and 88 ϯ 11% in asthmatics. in normals, sacin at tv of 0.5, 1 and 2 l were 0.195 ϯ 0.105 l -1 , 0.095 ϯ 0.036 l -1 and 0.058 ϯ 0.031 l -1 , respectively (p = 0.0003, anova), while scond were 0.098 ϯ 0.047 l -1 , 0.042 ϯ 0.021 l -1 and 0.029 ϯ 0.014 l -1 (p = 0.0002), respectively. in asthmatics, sacin were 0.440 ϯ 0.195 l -1 , 0.181 ϯ 0.087 l -1 and 0.100 ϯ 0.047 l -1 , respectively (p < 0.01), while scond were 0.204 ϯ 0.111 l -1 , 0.068 ϯ 0.037 l -1 and 0.031 ϯ 0.013 l -1 , respectively (p < 0.0001). conclusion increasing tidal volume while maintaining the same minute ventilation during mbnw led to large decreases in scond and sacin in both asthmatics and normals. this may be due to reduced inter-regional differences in specific ventilation with greater tv. the log-log relationship between sacin and tv allows an adjustment to be made for variations in tidal volume. funding crc for asthma and airways and nhmrc project grant #547346. dj smith 1 , k bowden 2 , t lloyd 2 , j coucher 2 , l garske 1 1 respiratory medicine, and 2 radiology, princess alexandra hospital, brisbane, australia introduction we have shown diaphragmatic flattening and decreased diaphragmatic excursion qualitatively assessed on ultrasound is strongly predictive of dyspnea severity and lower lung inflation in patients with pleural effusion. we sought to quantitatively measure diaphragm length and movement and determine how closely these are related to dyspnea severity and lung inflation. methods patients with unilateral pleural effusions had ct imaging of their diaphragm during a measured inspiratory capacity manoeuvre. maximal sagittal length was measured at tlc, and frc. patients had a baseline dyspnea index (bdi: 0-12) and respiratory function measured. results 4 patients with unilateral effusion (all right side; 3 malignant mesothelioma, 1 inflammatory) had a mean (sd) bdi of 5.5 (2.89), and tlc of 74% (3.91) predicted. the right diaphragm on the side of the effusion tended to be shorter than the left at frc (p = 0.08), and had a trend to reduced shortening with inspiration (p = 0.08). conclusions the right diaphragm is known to be longer than the left in health. the strong trend to a shorter and less mobile right diaphragm associated with effusion suggests this is a potential mechanism for dyspnea. further recruitment will enable correlation between bdi, tlc and diaphragm length and mobility. 4) ) that was slightly worse than an able bodied, control population (17.9 (3.1)), but better than an able-bodied population with untreated osa (14.5 (3.6)). the mapi predicted that 14% of the sample were likely to have osa. these data will be complimented by full sleep studies to be performed at the participants' homes in late 2007, early 2008. conclusion our interim data suggest that the rate of subjective sleep complaints are not substantially different in the population with tetraplegia compared with the able-bodied. this research was supported by the victorian neurotrauma initiative. it has long been assumed that the ventilation heterogeneity associated with lung disease could in itself affect the measurement of carbon monoxide transfer factor. the aim of this study was to investigate the potential estimation errors of carbon monoxide diffusing capacity (tlco) measurement that are specifically due to conductive ventilation heterogeneity. we induced conductive airway ventilation heterogeneity in 35 never-smoker normal subjects by histamine provocation, and related the resulting changes in ventilation heterogeneity (derived from the multiple breath washout test) to corresponding changes in diffusing capacity, alveolar volume and inspired vital capacity (derived from the single breath tlco method). average conductive ventilation heterogeneity doubled (p < 0.001), while tlco decreased by 6% (p < 0.001), with no correlation between individual data (p > 0.1). when dividing diffusing capacity by alveolar volume, the resulting transfer coefficient was not significantly different pre versus post histamine (p = 0.074). these findings can be brought in agreement with recent modelling work, where specific ventilation heterogeneity resulting from different distributions of either inspired volume or end-expiratory lung volume have been shown to affect tlco estimation errors in opposite ways. the combination of these errors appears to largely cancel out in our experimental situation of induced ventilation heterogeneity comparable to that observed in lung disease. we conclude that conductive ventilation heterogeneity per se has a negligible effect on diffusing capacity measurement. an important determinant of airway function in humans is vagal-mediated cholinergic tone in airway smooth muscle (asm). this airway tone may be altered in disease states. the use of mouse models for the study of airway diseases, including asthma, pulmonary fibrosis and copd is well established. however, it is not known whether mice actually possess basal asm tone or, if it does exist, how this tone changes in disease models. this study was undertaken to determine whether mice have detectable asm tone in vivo. methods respiratory system impedance (zrs) was measured in female adult balb/c mice using a wave-tube modification of the forced oscillation technique. zrs was measured during slow (~35 s) inflation-deflation manoeuvres between the transrespiratory pressures of 0 and 20 cmh2o. baseline lung mechanics and thoracic lung volumes (tgv) were measured before and after each mouse was allocated to one of four treatment groups: 'saline' mice received an i.p injection of saline, 'atropine' mice received i.p. atropine sulphate, 'vagotomy' mice had their left and right cervical vagus nerves isolated by blunt dissection and cut, and 'sham' mice had the area of the vagus nerves exposed but the nerves were not cut. results there were no post-treatment changes in tgv, airway resistance, tissue damping, tissue elastance, inertance or tissue hysteresivity in any of the four groups. conclusions the lack of change in lung mechanics post-atropine or postvagotomy in balb/c mice suggests that, unlike humans and many other species, the airways of mice have no baseline asm tone. supported by nhmrc grant#11488. nomination none. conflict of interest none. both male gender and increased mandibular enclosure volume predict more severe sleep disordered breathing in obstructive sleep apnoea patients. we now examine gender/body size/mandibular enclosure volume relationships for normal subjects stepwise multiple linear regression analysis was used to model body size/enclosure volume interactions. results for the whole group, mv was 261.1 ϯ 6.0 ml (mean ϯ se) while rmv was 205.1 ϯ 4.9 ml. head circumference (positive) and forehead height (negative) were both independent predictors for mv and rmv (both p < 0.02), while hip circumference was an additional positive predictive factor for rmv (p < 0.04). after adjusting for these parameters, male mv and rmv were larger than for females conclusion these findings suggest that mandibular enclosure volumes are relatively larger in males, even after adjusting for body size/cranial dimension. differing body size/mandibular enclosure volume interactions may contribute to gender influences on the severity of sleep disordered breathing. supported by nhmrc of australia nomination john read prize for sleep and physiological research tp 027 audit of ctpa in a regional hospital y raje, s vincent, g simpson department of thoracic medicine, cairns base hospital, cairns, qld 4870 since the introduction of computerized tomographic pulmonary angiograms (ctpa) at our institution the number of requests for this investigation at our institution has grown at an alarming rate. the purpose of this study was to evaluate the clinical assessment of suspected pulmonary embolism (pe). methods 50 ctpa were reviewed. results 31 female, 19 male. mean age 50 yrs (range 21-87). 26 ctpa requests came from department of medicine, 21 from emergency department, 2 from surgical teams and 1 from oncology outpatients. 36 patients presented with chest pain (pleuritic in 20 cases), 25 had dyspnea, 7 presented with collapse. 4 patients had haemoptysis. hypoxaemia was recorded in 7. none were clinically shocked and only one had a recorded tachycardia. d-dimer requested in 10 patients and was elevated in 9. arterial blood gases performed in only 10 patients (20%). 47 patients had prior chest x-ray which was normal in 24 (48%). 8 patients had consolidation on chest x-ray, 2 pleural effusions, 2 atelectasis and 1 fractured ribs. recorded risk factors included 4 patients with previous dvt or pe, 4 patients with malignancy and 6 patients were immediately post-operative. only 6 ctpas (12%) demonstrated evidence of pe. of these 2 had recent dvt and 2 were post-operative. 1 had a history of bowel cancer. there was no formal record of pre-test clinical probability of pe (eg wells' score) for any of the 50 cases. retrospective calculation of the cases of pe, 4 had a wells' score of 4.5 and 1 of 4 with the remaining patient with wells' score of under 2. only 3 patients (one with clinically probable pe) had received fractionated heparin prior to the ctpa. conclusion (1) ctpas performed at our institution have a low yield (12%).(2) pre-investigation clinical assessment was poor and there was poor adherence to published guidelines, (3) this results in many unnecessary ctpa examinations generating increased work and expense for the medical imaging department and exposes many patients to unnecessary and potentially harmful radiation exposure. the evaluation and management of hereditary hemorrhagic telangiectasia involves a multidisciplinary approach according to international guidelines. the aim of this audit was to compare the assessment process in one centre with that of the international recommendations. methods retrospective comparison was made by medical chart review of all patients with a diagnosis of hht between the years 1994 to 2006. demographic along with clinical data with diagnostic investigations, complications, treatment and genetic evaluation, including family screening was collected. the proportion of patients evaluated and managed as per the international recommendations was determined. results the audit identified 26 patients with the diagnosis of hht, with the mean age 58 years. diagnostic criteria were met in 77% of the cohort. of the known clinical features, 54% had a family history, and 81% epistaxis. cutaneous telangiectasia was present in 85% and visceral involvement in 92%. pulmonary arterio-venous malformations (pavm) were seen in 16 patients, cerebral avm in 4, gastrointestinal telangiectasia was documented in 8. one patient had a spinal (cervical) avm, and another had pulmonary hypertension in association with this condition. only 8 patients underwent diagnostic or screening investigations in accordance with the international recommendations. furthermore, one patient was referred for a genetic evaluation. conclusions this clinical audit found that 31% of patients referred to this centre were evaluated in accordance with the international recommendations. genetic assessment was lacking. the study supports the need for a coordinated, multidisciplinary approach to the evaluation and management of hht in this centre. lm young 1 , n good 1 , d milne 2 , w fergusson 1 , i zeng 1 , j kolbe 1 , ml wilsher 1 background while airflow limitation is the most common physiological impairment in sarcoidosis, there are limited data on airway hyperresponsiveness (ahr). understanding the role of ahr in sarcoidosis, if any, may help to identify individuals who might benefit from inhaled therapies. aims (1) to determine the prevalence of ahr in sarcoidosis. (2) to determine the correlation between responses to direct (using histamine) and indirect (using hypertonic saline) bronchial challenge. (3) to determine the clinical, physiological and radiological predictors of ahr. methods subjects with a diagnosis of sarcoidosis based on typical clinical presentation and compatible hrct features and/or tissue biopsy and with a baseline fev1>35% predicted were recruited. subjects underwent standard hypertonic (15% fall in fev1) and histamine (20% fall in fev1) challenge (>1 day but <7 days apart), lung function testing and high resolution computed tomography (hrct) of the chest. results the 52 subjects (48 ϯ 11 years, 35% female, 92% european, 35% stage i, 25% stage ii, 40% stage iii, 0% stage iv) had well preserved lung function overall (fev1 = 2.8l ϯ 0.7.87% predicted). ahr was detected in 5/47 (11%) to hypertonic saline and 19/43 (44%) to histamine challenge. on univariate analysis, response to histamine challenge was predicted by conglomerate fibrosis (p = 0.002) and reticular pattern (p = 0.05) on hrct. the baseline % predicted fev1 was significantly associated with ahr on univariate (p = 0.004), and multivariate analysis (p = 0.01) when adjusted by hrct patterns. conclusions there is a high prevalence of ahr using histamine challenge in this study of sarcoidosis subjects. ahr most strongly associates with baseline % predicted fev1 but also conglomerate fibrosis and reticular pattern on hrct. these findings may reflect the consequence of airway remodelling following inflammation. further studies are warranted to confirm these findings. background upper airway shunt represents a significant source of measurement artefact in the use of the forced oscillation technique (fot), with increasing importance in young children. changes in respiratory system admittance, ars (or zrs -1 ), are theoretically independent of the upper airway shunt. this study examines the possible clinical benefit of ars in preschool children by assessing any increased ability to differentiate responses to bronchial challenges in the routine clinical setting. we hypothesized the use of ars would provide improved sensitivity to clinically relevant obstruction, bronchodilator responsiveness (bdr) and airway hyper-responsiveness (ahr) in young children with respiratory disease. method previous fot measurements were re-analysed and ars calculated to derive: (1) ars reference equations in healthy young children (n = 158); (2) bdr in ars, respiratory system resistance (rrs) and reactance (xrs) in healthy children (n = 78), children with cystic fibrosis (n = 39), neonatal chronic lung disease (n = 49), asthma (n = 56) and wheeze (n = 66); (3) ahr to inhaled adenosine-5′-monosphate (amp) in 19 children. fisher's exact tests were used to assess changes in diagnostic outcomes between ars and conventional fot outcomes (rrs and xrs). results ars was no more sensitive to bronchodilator induced changes than conventional fot outcomes. amp challenges resulted in equivalent responses measured by relative changes in rrs and ars while absolute changes in ars were the least sensitive variable. conclusion this study does not support a clinical advantage in using ars in measuring responses to either inhaled bronchodilator or amp. c hollier 1,2 , c menadue 1,2 , d flunt 1,2 , aj piper 1,2 1 department of respiratory and sleep medicine, royal prince alfred hospital, nsw 2050, and 2 woolcock institute of medical research, nsw 2050 serial measurement of arterial carbon dioxide (paco2), ph and bicarbonate (hco3 -) is essential in the management of patients with hypercapnic respiratory failure (hrf). this information is usually obtained from a sample of arterial blood (abg). the procedure can be painful and distressing for patients, and is sometimes technically difficult due to obesity or contractures. our aim was to determine the validity and feasibility of arterialized venous blood (av) sampling as an alternative to abgs in measuring paco2, ph and hco3levels in patients with chronic hrf. method eighteen patients completed the study. venous blood was arterialized by heating forearm skin to a temperature of 42-45°c with an electric heating pad. an av sample was taken from a cannula positioned in a vein of the heated forearm simultaneously with an abg. in addition, the reliability of av sampling within the recommended temperature range (42-45°c) was investigated in ten healthy volunteers placed on volume cycled ventilation in order to maintain constant ventilation. av samples were taken at 0.5°c temperature intervals from 42.5-45°c results the table below summarizes results for validation of av sampling: based on the evidence that cardiovascular dynamics are altered due to obstructive sleep apnea, this study aims to identify the onset and termination of each apnea event using power spectral density (psd) and morphological features of single lead ecg signal over 5 second period. methods ecgs from 4 patients overnight sleep studies were examined for location of the pre-scored apnea events. onset (n = 1995), maximum (n = 6751) and termination (n = 1996) of each apnea event and normal events (n = 11219) were annotated on 5 second windows. features extracted were psd, amplitudes of r and t wave of 5 second ecgs. receiver operating characteristics (roc) analysis was used to gauge the event recognition ability of all features. weight loss causes an improvement in the severity of osa, however substantial weight loss is very difficult for obese patients. the very low caloric diet (vlcd) has been shown to be successful in causing significant weight loss in obese patients. this is a pilot study on the use of a formal screening protocol to identify osa patients who are potentially eligible for the supervised vlcd program offered by the endocrinology department at auckland city hospital. method 344 consecutive patients who attended the sleep laboratory at ach between june to december 2006 were screened using the protocol. patients who are eligible to be considered for the vlcd program are identified as having a combination of obesity (bmi > 30), osa (ahi > 5 on sleep study) and being residents within the auckland district healthboard region. results 243/ 344 patients screened did not fulfil the inclusion criteria: 171 lived outside the adhb region; 71 had bmi < 30; 7 patients did not have osa (ahi < 5). 101 patients fulfilled the inclusion criteria. 54/101 patients (54%) were excluded due to medical or psychiatric contraindications to vlcd.47 patients (47%) who did not have contraindications to vlcd were contacted. 33 patients were contacted successfully. 14 patients were either unavailable to phone contacts on 3 separate days or were disconnected. 12/101 patients consented to being referred (12%). 21/101 patients declined referral (21%). conclusion this pilot study is the first study using a formal comprehensive screening protocol in the recruitment of obese osa patients into a medically supervised vlcd program. only a small proportion (12%) of patients proceeded to being referred to the vlcd program. key: cord-023239-06a03o14 authors: nan title: ii. topic sessions date: 2016-06-10 journal: pediatr pulmonol doi: 10.1002/ppul.23455 sha: doc_id: 23239 cord_uid: 06a03o14 nan although the majority of children with asthma achieve symptom control on low or moderate doses of maintenance inhaled steroids, there is a small proportion that remain uncontrolled despite high doses of prescribed maintenance therapy. these children are prescribed treatments equivalent to stage 4/5 of the british thoracic society (bts) guidelines for asthma management, and either need at least this amount of therapy to achieve control, or have persistent symptoms and frequent exacerbations despite maximal treatment. children with poor control despite maximal prescribed therapy have problematic severe asthma 1 . however, the reasons for poor control may be very varied and can broadly be divided into two sub-categories. the first, "difficult asthma" is the term used to describe patients whose asthma is difficult to control because of a failure to address the basics of asthma management, an incorrect diagnosis has been made, or there has been a failure to address associated comorbidities. underlying reversible and modifiable factors that can result in poor control include poor adherence, unfavourable environmental exposures such as tobacco smoke and aero-allergens to which the patient is sensitised, poor inhaler technique and psychosocial issues 2 . if modifiable factors are successfully identified and addressed, then control can be achieved in children with difficult asthma without the need for escalating therapy or additional invasive investigations. a multidisciplinary team (mdt) is critical to enable modifiable factors to be identified and addressed in children with difficult asthma. the team must include specialist respiratory nurses, a psychologist, pharmacist, physiotherapist and medical staff. significant resources are therefore required to manage paediatric difficult asthma optimally and only specialist centres should be tasked with the assessment of these patients. although this may have an impact on healthcare resources, long term benefits for lung health are significant. the second sub-category of children that have poor asthma control despite maximal therapy are those with true severe asthma. these patients remain with persistent symptoms, or can only be controlled on maximal doses of maintenance therapy, often including oral steroids, after underlying reversible or modifiable factors have been identified and addressed 3 . importantly, more than half of all children with problematic severe asthma have difficult asthma because of underlying modifiable or reversible factors preventing asthma control 4 . therefore, the overall approach to managing a child with problematic severe asthma includes an initial step to identify and treat difficult asthma, and if symptoms persist after this, true severe asthma can be confirmed, which requires additional investigation and management 5 . very clear criteria and definitions that allow distinctions between difficult and severe asthma have been specified for both adults and children aged six years and above by the european respiratory society and american thoracic society 3 . an important point to consider when faced with a child that has poor asthma control despite maximal doses of prescribed maintenance therapy is that once above a threshold of treatment (>800mcg/day or equivalent of budesonide), the child should be referred to a specialist for further management. the national review of asthma deaths in the uk identified 20% of asthma deaths occurred in patients who should have been referred to a specialist for management of problematic asthma 6 . the modifiable factors that result in a child having difficult asthma may be identified extremely efficiently if the mdt approach described is adopted. however, what remains equally important is the continuing assessment and follow-up of patients with difficult asthma in order to ensure: 1. maintenance therapy is reduced to the minimal amount needed to achieve control 2. symptoms do improve after all modifiable factors have been addressed, and there is no progression to true severe asthma à either after short term follow-up or in the longer term 3. the basics of inhaler technique / device / adherence / allergen exposure are all being maintained a retrospective analysis of follow-up of children with difficult asthma for up to six years revealed that those in whom underlying modifiable factors were identified and addressed had an improvement in lung function and reduction in exacerbations over time, while being able to reduce maintenance dose of inhaled steroids such that the majority fell below the threshold for problematic severe asthma 4 . however, there was a large drop out in the number of patients that could be traced for the full six years, highlighting the need for better prospective longitudinal data of outcomes for children with difficult asthma. these missing data are essential in light of recent cohort studies that have followed children with severe asthma to adulthood and shown the irreversible reduction in lung function and prevalence of copd 7 . asthma is one of the most common chronic diseases in children, with a high prevalence in many developed and developing countries. worldwide prevalence of asthma in children varies from 1.6-36.8% according to the international study of asthma and allergies in childhood (issac) study. (1) despite its high prevalence, information about the prevalence of severe asthma in children is unknown, particularly in countries in transition. some estimates come from different studies that have shown that the prevalence of severe asthma in a general population is approximately 0.5-5% among children with asthma, however its true prevalence in a low-income country is unknown. (2) (3) (4) according to issac phase iii, the centers with the highest prevalence of severe asthma symptoms were mostly from english language countries, latin america, africa, the indian subcontinent and the eastern mediterranean. (5) lack of control of the disease has been attributed to various factors such as low accessibility to basic medications, weak healthcare services, poor compliance with prescribed therapy, lack of asthma education, and social and cultural factors. in general, asthma in both children and adults represents a significant problem in public health given the reduced quality of life, school or work absenteeism and increased healthcare costs, especially in countries in transition. in addition, asthma severity and control in childhood are of particular importance as they have been shown to translate into asthma morbidity in adulthood. (6) practical guidelines addressing the management of severe asthma in children have pointed out various aspects important in the development of this condition: medication issues, the environment, asthma education, comorbidity, and psychological problems. worldwide, but particularly in countries in transition, both intrinsic (race, ethnicity, weight) and extrinsic (exposure to allergens, indoor or outdoor pollutants) factors may overlap in a single child to enhance or diminish asthma control and severity. different to many developing countries from other continents, asthma is highly prevalent in latin america. moreover, issac phase iii showed that asthma prevalence in this region is still on the rise. furthermore, evidence suggests that poorly controlled asthma in some areas of latin america leads to significant economic costs attributed to emergency and unscheduled visits, and high mortality rates from asthma. (7) similar to other regions, asthma control is not obtained in most patients, despite available management guidelines and evidence of ics as controllers. several surveys have shown that close to 2.4% of all patients met all the gina criteria for total asthma control, proposing under-recognition of uncontrolled asthma, underuse of appropriate controller treatment, inadequate patient education, and patient denial as possible explanations. (8) also, several risk factors such as poverty, environmental factors, diet, genetics, vitamin d deficiency and tobacco smoking have detrimental effects on asthma control. cross-sectional data from 616 children with asthma in costa rica suggested that low serum vitamin d detected in children with mild to moderate asthma is associated with asthma severity. (9) since the development of worldwide guidelines on the diagnosis and management of asthma, special attention on achieving and maintaining asthma control as the key goal in asthma treatment has been a priority. in clinical studies of children with asthma, satisfactory asthma control can be achieved and maintained in most patients by regular treatment with ics. nevertheless, large population-based surveys consistently show that poor asthma control is common in many children with asthma, despite ics treatment. (10) other several studies have shown a reduction in the number of hospitalizations caused by asthma in various countries in transition when effective preventive and controller measures are implemented, (11) mainly avoidance of risk factors, importance on the use of basic medications and patient education. patients should be educated about the cause of asthma, what triggers the condition, how it should be monitored and managed and, importantly, the outcomes that can be expected and when to recognize lack of asthma control. moreover, health professionals should also be educated regarding under-recognition and under-treatment of asthma, as patients or parents tend to deny the severity of symptoms. in a recent study performed in costa rica (12) , we aimed to examine trends in hospitalization and mortality due to asthma over a 15-year period (1997-2011) , in particular following a national asthma plan (nap). this nap consisted of education meetings at all major public health care centers, emphasizing early diagnosis, early treatment using ics as first-line therapy for asthma control, early use of reliever medication to treat exacerbations, appropriate referral to specialists for asthma care, and avoidance of common allergen sources (e.g. dust-mite and cockroaches) or tobacco smoke. concurrent with this program, general practitioners, pediatricians and internists were first allowed to prescribe ics for asthma (only pulmonologists or allergists could prescribe ics before 2003). as a result of the implementation of the nap, the total number of asthma hospitalizations in costa rica in both children and adults decreased by approximately 53% over this period. in children younger than 10 years, hospitalizations for asthma were reduced by 57% in boys and 54% in girls between 1997 and 2011. in addition, the number of deaths due to asthma decreased by 80% over the 12-year period, with a more marked reduction occurring after implementation of the nap. in parallel with the decrement in asthma hospitalization and mortality, the number of prescriptions for ics (beclomethasone) increased by 129%. in summary, asthma prevalence in deprived regions is high and shows increased severity. reasons for inadequate asthma control in poor populations include low accessibility to effective controller medications, weak infrastructure of health services for the management of chronic disease, poor adherence to therapy, lack of educational approaches, and social, cultural and language barriers. however, recent studies have shown several alternatives to control its burden and improve outcomes. there is urgent need for more research into severe asthma, in particular in children in countries in transition. it has now become a much used adage that asthma is not a single disease but rather multiple diseases which present with common symptoms [1, 2] . this paradigm has been fundamental in shaping the way we think about asthma and possible approaches to treatment and management strategies. if one is not treating a single disease when we talk about what is commonly known as the syndrome of asthma, then we need a more personalised medication strategy to treat these different syndromes. alongside this acknowledgment of moving medicine towards more personalised treatment and management strategies, statistics and machine learning have been instrumental in helping us to shape the face of medicine by fostering engagement between clinicians, basic scientists, statisticians and mathematical modellers in order to attain a more unbiased approach to classifying different subgroups of patients using probabilistic models. the proliferation of genetic, molecular, clinical and biological data has made it necessary to use a cross-disciplinary approach to understanding the underlying mechanisms which precipitate distinct profiles of asthma and allergic disease during childhood. statistical analysis to understand subtypes of childhood wheezing the seminal paper by martinez et al. [3] was the first to propose the existence of different subgroups of childhood wheezing. based on visual assessment of patterns of wheeze during childhood using data from the tuscan children's respiratory study, they identified four groups of wheezers: "no wheeze", "transient early wheeze", "late-onset wheeze" and "persistent wheeze". this classification has been used as a classical basis for subsequent definitions of distinct subgroups of wheeze and has provided the building block for statistical pattern recognition-based methods to identify heterogeneous groups of children based on probabilistic modelling of the longitudinal profiles of asthma and wheeze over time. one such statistical technique is latent class analysis. latent class analysis assumes that the longitudinal fluctuation observed in data is measured with uncertainty. some of this uncertainty is due to random error, but another element of this uncertainty may be due to the existence of a subgroup or latent class which explains some of the heterogeneity in clinical measures which is not directly observed. henderson et al. were the first to apply such models using a data-driven approach based on wheeze observations from the avon longitudinal study of parents and children [4] . using latent class analysis based on parental reporting of wheeze, this group identified two additional phenotypes to those identified by martinez et al.: "prolonged early" and "intermediateonset" wheeze. this classification has been replicated in other studies. [5] one of the caveats of basing these modelling strategies on parental reporting of wheeze is that parents may not be able to correctly ascertain a clinical diagnosis of wheeze [6] . in light of this, belgrave et al. extended these methods by jointly modelling data from both parental questionnaires and general practitioner records which provided complementary data to give a more accurate measure of wheeze [7] . this model identified two classes of persistent wheeze: a "persistent controlled wheeze" group and a "persistent troublesome wheeze" group who had poorer lung function and more reactive airways compared to the other wheeze groups, including the "persistent controlled wheeze" group. where machine learning begins and statistical modelling ends identifying consistently defined and optimal numbers of subgroups of wheeze across different cohorts is challenging. within the era of "big data" rather than focusing on traditional statistical methodology, the medical field is looking towards data science as a means to extract knowledge and meaning from the vast quantity of information provided by clinical data. to achieve this, both traditional statistical inference methods based on robust assumptions and machine learning models which are more amenable to data complexity, breadth and depth. although there is overlap between the functionality of machine learning and statistics, the flexibility of machine learning is driven towards learning from data and integrating new information in order to update models and create more accurate models with better model performance. the programmatic focus of machine learning which incorporates vast amounts of computational power provides an excellent framework where tools traditionally used for statistical modelling would be unable to accommodate large, multi-scale datasets. in the near future, the capability of machine learning to be able to learn from data interactively may facilitate computer-assisted reasoning in identifying subgroups of patients. identifying such subgroups may be crucial in proposing effective personalised treatment strategies. such an approach will also allow us to capitalise on the existent data. as data-transparency and data-sharing become more widespread in the global community, we will have a better understanding of the evolution of asthma and allergic diseases. research into identifying heterogeneous subgroups of asthma and allergic disease has reached crucial milestones. we have moved from a subjective approach to classifying subgroups of wheezers, whereby the clinician gives a clinical assessment or diagnosis of the most likely subgroup based on observed clinical history, and we are moving towards computer-assisted reasoning, whereby we can use new information to predict the most likely class assignment based on models derived from prospective data. such reasoning would also allow us to model the evolution of asthma and allergic diseases in the future. populations of microbes (such as bacteria and yeasts) inhabit the skin and all mucosal surfaces. healthy individuals host thousands of different types of bacteria and different body sites have their own distinctive communities, with estimates suggesting that 50%-90% of all the cells in the human body are microbes. the highest density and greatest diversity of bacteria is found within the gastrointestinal tract. research suggests that the relationship between the microbiome and humans is not only commensal (a non-harmful coexistence), but is a mutualistic, symbiotic relationship with benefits for both (1) . even though we live in such a "dirty" bacterial world, infections due to bacteria are relatively very rare in individuals with a competent immune system. the microorganisms that make up a microbiome perform a wide range of useful functions, such as fermenting unused energy substrates, educating the immune system, preventing growth of pathogens, regulating the development of organs such as the gut, producing vitamins for the host and producing hormones to influence host metabolism such as directing the host to store fats. in particular, specific microbe-host interactions are thought to be critical for inducing mucosal tolerance and immune regulatory cells such as tregs. why do we develop "tolerance" to the microbes living in us and on us? perhaps we should consider tolerance as an alternative defense strategy. the continuous effort involved in destroying the microbes that surround us would impair organ function and require vast amounts of energy, which is not compatible with life. for this reason, it makes much more sense to have robust tolerance mechanisms that work in tune with potent effector responses, to ensure optimal host fitness. an intriguing question is that posed by the concept of the hygiene hypothesis in that altered exposure to microbes may influence the induction of tolerogenic immune responses, thereby making individuals more susceptible to react aggressively to nondangerous encounters with antigens such as allergens. the balance between immune tolerance and inflammation is regulated through the crosstalk between epithelial and immune cells with the microbiome involving many signaling pathways and molecules. direct contact with bacterial-associated structures can activate receptors (e.g. tlrs) on host cells, which induce signaling cascades resulting in both innate and adaptive polarized immune responses. the microbiome is also metabolically active and microbial metabolites have been shown to exert significant effects on host immune signaling networks (e.g. scfas and biogenic amines). the biogenic amine histamine can promote either pro-or anti-inflammatory effects depending on which of its four receptors are activated (2) . some, but not all, commensal bacteria express histidine decarboxylase (the enzyme needed to convert histidine to histamine). lactobacillus saerimneri 30a produces high levels of biologically active histamine and feeding this strain to mice resulted in a deterioration in health, particularly in histamine receptor 2 knock-out mice (3). significant efforts are underway to determine the positive and negative health effects associated with production of histamine by the microbiota (4). abnormalities in microbiome composition and/or metabolic activity have been shown in a wide range of disease states including type-2 diabetes, obesity, inflammatory bowel disease, colorectal cancer and allergies. efforts to use microbiome-associated therapeutics (e.g. probiotics) have clearly shown beneficial effects in animal models, with inconsistent findings in humans probably due to differences in the bacterial strains used. one probiotic bacterium that has shown consistent immunoregulatory effects in murine models and humans is b. longum subsp. longum 35624. murine models have demonstrated that oral consumption of this strain results in the induction of treg cells and these treg cells dampen nfkb activation, preventing excessive inflammation induced by salmonella infection (5, 6) . similarly, in humans, oral consumption induces treg cells, which is associated with increased secretion of il-10 by peripheral blood cells (7) . interestingly, this strain reduces systemic pro-inflammatory biomarkers in patients with psoriasis, ibs patients with chronic fatigue syndrome and patients with ulcerative colitis (8) . the mechanism involved includes the recognition of this bacterium via tlr-2/6 and dc-sign by myeloid dendritic cells and tlr-9 by plasmacytoid dendritic cells, resulting in changes in dendritic cell cytokine secretion and the production of metabolites such as retinoic acid (9) . however, these effects and mechanisms are not seen even with closely related bacterial strains, suggesting that the careful selection of microbes is essential for the future clinical development of immunotherapeutic microbes for allergy and asthma. overall, it can be concluded that the vast majority of microbes, which interact continuously with the host, are not bad. certain specific microbes can positively influence the host, while there is a minority that can have negative effects on the host. gwas findings are based upon association p-values below 5 ã 10 à8 , socalled "genome-wide significance", as well as replication in independent populations. this generally requires very large sample sizes and in order to obtain these, a 'team science' approach has been used where several studies have combined their data in meta-gwas. the largest gwas on asthma to date combined data from 23 different studies involving more than 26,000 individuals from the gabriel consortium and identified 6 genome-wide significant asthma loci.(1) similar meta-gwas have been conducted, for example by the eagle consortium, revealing a number of susceptibility loci for asthma-related traits, including feno,(2) eczema,(3) and allergic sensitization.(4) it could be expected that the large heterogeneity in disease phenotypes introduced by combining many different studies in meta-gwas would preclude valid discoveries. nevertheless, gwas on asthma and the related traits have resulted in identification of relatively few, but robust, loci with more consistency between studies compared to previous candidate gene studies. one example of this is the first large-scale gwas on allergic sensitization.(4) by meta-analysis of data from 16 different studies, it included a discovery phase of approximately 5,800 cases and 10,000 controls and a similar-sized replication phase. allergic sensitization was assessed objectively and defined by elevated levels of allergen-specific ige and/or a positive skin prick test. this study identified 10 loci associated with allergic sensitization at the genome-wide significant level and with robust replication. simultaneously, another large gwas was performed on allergic symptoms including approximately 54,000 individuals. (5) in spite of the large phenotype differences between the two studies, there was a high agreement in results with all of the 10 genome-wide significant loci from the sensitization study also showing strong association in the study on allergic symptoms, and previous gwas findings were confirmed. there has been some disappointment with the results from gwas. the identified loci only explain a minor part of the heritability, and the susceptibility variants identified in gwas are mainly common variants with relatively small effect sizes (often with odds ratios around 1.1 per risk allele) with no clinical relevance on the individual level. (1, 4) on the other hand, gwas have identified novel and robust susceptibility loci, with the potential to provide important understanding of disease mechanisms. also, comparison of results from gwas on different diseases and traits have increased the understanding of the mechanistic relationship between these, for example the relationship between allergic sensitization and asthma,(4) between allergen-specific ige and total ige levels, (4) and between atopy and autoimmunity. (3) (4) (5) larger, consortium-based studies on asthma and the related phenotypes are ongoing and are expected to identify many novel susceptibility loci. novel loci discovered from these larger studies are likely to have even smaller effect sizes than the ones previously found but, from the perspective of understanding disease pathology, each novel locus may potentially pinpoint a novel mechanism and a potential treatment target. furthermore, the era of genome-wide nucleotide sequencing applied on gene expression-and epigenome-profiling has brought new possibilities of combining gwas data with data from large public 'omics repositories. these data will increase the usefulness of gwas data by providing understanding of functional effects related to susceptibility loci, and future gwas on asthma and related diseases will be a part of integrated approaches to discover how different molecular layers modulate the genetic effect on disease, and will thereby be a central component in the attempt to tailor and improve medical treatment. asthma is a highly heterogeneous disease probably consisting of several subtypes of disease associated with different functional mechanisms. genetic loci may be involved in specific disease mechanisms and thereby help understanding this heterogeneity. for example, the strongest asthma locus identified in gwas, the 17q12-21 locus, seems strongly associated with an asthma phenotype characterized by onset in early childhood (1) and recurrent, severe exacerbations (6) and was stronger associated with asthma than allergic rhinitis. (5) in contrast, another locus at chromosome 11q13 has been associated with multiple allergy-related phenotypes, including allergic sensitization,(4) allergic symptoms,(5) eczema,(3) and asthma, suggesting a different, allergy-related, disease mechanism. the heterogeneous nature of asthma suggests that an alternative to increasing sample size in genetic studies is to focus on more specific phenotypes. such phenotypes are likely closer associated to specific mechanisms and the genetic substrate and might therefore increase study power. this was demonstrated by a gwas focusing on a specific asthma phenotype characterized by onset in early childhood and recurrent, severe exacerbations. (6) in spite of the relatively small sample size, this study resulted in association results of the same magnitude as previous much larger gwas (1) and with much larger effect sizes, particularly for the children with the highest number of exacerbations. one novel asthma gene, cdhr3, was identified, and it was confirmed, in a collaborative effort involving several birth cohort studies, that the cdhr3 locus was strongly associated with asthma exacerbations in the first years of life, both in individuals of european and non-european ancestry. these results highlight the potential of future genetic studies focusing on more homogenous phenotypes. one important future step is the translation of genetic associations to disease mechanisms. a major limitation of gwas is that they often merely identify a susceptibility locus without any clear relationship to a specific gene or biological function. two examples of this are the 17q12-21 and 11q13 loci mentioned above, where the underlying mechanisms are still poorly understood several years after their discovery, even though these loci are strong and probably central to the pathogenesis of asthma and allergy. one example of a gwas discovery where the functional mechanism might have been identified is cdhr3. in the discovery study (6) , it was suggested that the association to asthma was caused by a specific functional variant affecting surface expression of cdhr3. a later study reported that cdhr3 functions as a rhinovirus c receptor and showed that the functional variant associated with asthma exacerbations increases rhinovirus c binding and replication. (7) this potentially explains the underlying mechanism of this locus and identifies a target for future asthma and virology research. another major future challenge is to understand how genetic susceptibility interacts with environmental factors. gene-environment interactions are not accounted for in normal gwas and that might be one reason for the large heritability not explained by gwas findings. one important environmental risk factor for childhood asthma and other wheezing disorders is viral infections, and focusing on this environmental factor might be a tool to understanding mechanisms of asthma genes. (8) as an example, children with 17q12-21 risk variants seem more susceptible to rhinovirus infections, (9) and the finding that cdhr3 seems to be a rhinovirus c receptor (7) indicates that children carrying cdhr3 risk variants will have a specific susceptibility to rhinovirus c infections, a hypothesis that is currently being tested. only a few genome-wide gene-environment interaction studies have been performed, and the results of these have generally been disappointing without convincing findings. there are many inherent challenges in such studies. first, they might require even larger sample sizes than normal gwas, and exact information on environmental exposures is difficult to obtain in such large-scale studies. furthermore, the effect of a specific environmental exposure can be difficult to disentangle from that of other related environmental factors. an alternative approach is to perform cell or animal models where specific exposures can be controlled.(8) a recent study investigated the potentially protective effect of endotoxin and farm dust exposure in a mouse model of house dust mite-sensitized asthma.(10) it was found that a20 was an important mediator of the protective effects of endotoxin exposure, and this was validated in human bronchial epithelial cells. furthermore, a potential modifying effect of a20 was supported by 'look up' of snps located near the human tnfaip3 gene using data from an earlier genome-wide interaction study. this potential gene-environment interaction needs to be replicated, but this study exemplifies how mechanistic studies targeting specific environmental exposures and the use of experimental models can facilitate identification of genes involved in gene-environment interactions. in conclusion, improved understanding of the genetic architecture of asthma and other childhood wheezing disorders will require a combination of gwas focusing on more homogeneous subtypes of disease, geneenvironment interaction studies in birth cohorts and in cell models, and integration with other types of omics data. this challenge can only be overcome by a 'team science' approach bringing together many studies to provide sufficient statistical power and bringing together researchers from many disciplines to translate clinical associations to mechanistic understanding. such studies present great challenges but also the opportunity to understand asthma pathogenesis and heterogeneity, and ultimately to improve prevention and treatment of disease. recently, who definitions have changed to classify children with lower chest indrawing as having pneumonia rather than severe pneumonia and recommending treatment with oral antibiotics as ambulatory cases. [1] however, a recent meta-analysis reported that no single clinical feature is sufficient to accurately diagnose radiological pneumonia and that the who recommended diagnostic signs alone lack sufficient sensitivity or specificity, particularly for identifying children who need antibiotics. [2] radiological diagnosis of pneumonia has relied largely on changes on chest x-ray, principally consolidation or interstitial infiltrates. [3] however, chest x-rays are subject to variable interpretation, expose a child to ionizing radiation and require infrastructure and skill to do. recently, chest ultrasound has been suggested as a feasible imaging modality for diagnosis of childhood pneumonia. ultrasound has several advantages including that it can be used as a point-of-care test, can be taught to non-radiologists, is quick to perform and does not involve exposure to radiation. initial studies suggest that it has high sensitivity and specificity for pneumonia compared to chest x-rays. [4, 5] diagnosis of the etiology of pneumonia remains challenging as bacteremia is rare, distinguishing colonizing from pathogenic organisms may not be possible on respiratory specimens and co-infections are common. improvements in specimen collection and improved molecular techniques for detection of organisms have enabled more accurate detection of organisms, however ascribing etiology may be difficult unless the organism is invariably pathogenic. advances in specimen collection include the use of induced sputum in infants and young children, which provides a better specimen for detection of specific pathogens such as b. pertussis or m. tuberculosis. [6] urine antigen detection has not proven to be useful for pneumococcal pneumonia or for pulmonary tuberculosis in children. [7, 8] for induced sputum, testing of sequential, repeat specimens provides a higher yield for pathogens such as m. tuberculosis. [9] careful attention to specimen collection methods and use of different specimens may maximize the yield especially in the context of new sensitive molecular detection techniques. [10] with the availability of improved tools for etiological diagnosis, and with better vaccine coverage for conjugate vaccines, including pneumococcal conjugate vaccine, viral pathogens especially rsv and other bacteria, such as s. aureus or pertussis, are emerging as prominent causes of childhood pneumonia. [11] [12] [13] in areas of high tb prevalence, m. tuberculosis has been reported to be associated with acute pneumonia in children, with culture confirmed disease occurring in approximately 8% of cases. [14] however, better tools for detection of potential pathogens have also provided data on the complexity of etiology, with several potentially pathogenic organisms frequently identified in a single pneumonia episode. further delineation of the interactions between different organisms and pneumonia pathogenesis is needed. asthma affects as many as 334 million people of all ages in all parts of the world and is the commonest long-term respiratory condition affecting children in developed countries, the prevalence and morbidity varying by ethnic group 1 . accurate diagnosis and effective management of respiratory diseases such as asthma requires objective measures of lung function, but reliable use of such measures is only possible if appropriate normative ranges are available to distinguish the effects of disease and treatment from those of growth and development. evidence for ethnic differences in lung function ethnic differences in lung function have been well documented 2 . in the past, attempts to interpret observed ethnic differences in lung function were often confounded by selection bias related to use of small population samples that were not necessarily representative or generalizable, use of different methods, equipment and quality control (qc) criteria, failure to adjust for other important determinants of lung function, including socio-economic circumstances and/or inappropriate statistical analyses. in recent years, many of these problems have been addressed by applying standard methodology, inclusion criteria and qc to large, ethnically homogenous groups. current research shows that after adjusting for age, sex and standing height, forced expired volume in 1 sec (fev 1 : a measure of airway calibre) and forced vital capacity (fvc: a measure of lung size) are both reduced by approximately 14% in individuals of african ancestry (black) across the entire life span when compared with those of european ancestry (white) [3] [4] [5] [6] . similar though smaller reductions have been observed among south asian (from indian subcontinent) [7] [8] [9] and south-east asian (e.g. china, thailand, malaysia, etc) 6 subjects. since these "ethnic" reductions in fev 1 and fvc are generally proportional, the fev 1 /fvc ratio, which is the most commonly used outcome to assess airways obstruction, is usually independent of ethnic background [5] [6] [7] , suggesting that there are no structural or functional ethnic differences in lung design. thus the observed ethnic differences in lung function appear to be primarily limited to lung size rather than airway or dynamic respiratory characteristics. however, the same adjustment factor cannot be used for all lung volume outcomes. for example, there is evidence that the lower fvc found among black children can be attributed at least in part to a relatively high residual volume, suggesting that factors such as anatomic differences in diaphragmatic position or respiratory muscle strength might contribute to some of the observed differences 5 . furthermore, lung function indices that are internally adjusted for the size of the individual's resting lung volume, such as the lung clearance index (lci: a measure of gas mixing efficiency) 10, 11 or specific airways resistance (sraw: a measure of airway calibre adjusted for lung volume) 11 , do not appear to be influenced by ethnic background. nevertheless, since larger sample sizes will be required to confirm these findings, data interpretation of lci and sraw from non-white subjects should currently be undertaken with caution. recently, the global lung function initiative (gli) collated results from >74,000 healthy non-smokers aged 3-95 years to create the first allage, multi-ethnic reference equations for spirometry with appropriate age dependent lower limits of normal 6 . prediction equations were derived using the lms method, which allows simultaneous modelling of the mean (mu), the coefficient of variation (sigma) and skewness (lambda) of the distribution, and reference equations were derived for caucasians (white); african-americans (black), north-and south-east asians. these equations enable assessments to be evaluated over the entire age range using a single reference data set, thereby avoiding the errors that can occur when switching between equations, particularly during the transition between paediatric and adult care 12 . defining ethnicity ethnicity is extremely difficult to define. self-assigned ethnicity may differ from observer-assigned ethnicity and in certain countries it is against the law to record ethnic origin for any purpose. furthermore, in recent censuses in both the uk (2011) and us (2010), mixed-race populations have been shown to be the fastest-growing ethnic group. thus, classifying ethnicity may become an increasingly complex task! could differences in body proportions explain the ethnic differences in lung function? standing height is a major determinant of lung volumes, reflecting the fact that lung size is adapted to our metabolic needs. however this is not ideal since the size of the lungs is more closely related to thoracic size than leg length and differences in body proportions may underpin much of the observed ethnic variation in lung function. the size and lung function in children (slic) study was designed to improve normative reference ranges for lung function by taking differences in body physique into account to facilitate early diagnosis and treatment of lung disease in all children, irrespective of ethnic background 7 . however, of the numerous additional anthropometric measurements undertaken to quantify body physique, only sitting height and chest width significantly contributed to the prediction of spirometric lung function. chest dimensions and lean mass also significantly predicted fev 1 and fvc within each ethnic group, but did not affect differences between groups. the persistence of ethnic differences after adjustment for sitting height, chest dimensions, body composition and socio-economic factors may reflect the fact that some factors affecting chest size such as diaphragmatic position or muscle strength cannot be assessed by anthropometry, and emphasises the importance of taking ethnicity into account when interpreting spirometry data 7 . while some studies have shown an association between socio-economic conditions (sec) 13, 14 and lung function and suggested that this is a key factor in explaining ethnic differences in lung function 15 , there is increasing evidence that the contribution of sec to variability of lung function is very small except under the most adverse of conditions 7, 14, 16 . a recent study in india 8 , using identical equipment and techniques as those used in the slic study found that while average fev 1 and fvc in urban indian children were similar to those in indian children residing in the uk, they were significantly higher than in semiurban and rural indian children (by $6% and 11% respectively). these results probably reflect the marked differences in the degree of social deprivation between the uk and india 7,8 and suggest that there may be a threshold effect of poverty on lung function. adjusting for sitting height has been shown to reduce the contribution of sec to ethnic variability 7, 14 . the use of inappropriate reference equations and misinterpretation can lead to serious errors with respect to both under-and over-diagnosis. in the past, attempts to correct for ethnic differences, if made at all, tended to apply the same fixed adjustment factor across all ages 2 , all ethnic groups, both sexes and all spirometric outcome measures, an approach now shown to be oversimplistic 14, 17 . in addition to errors relating to ethnic differences in lung function, misdiagnosis may also occur when fixed cut-offs, such as 80% predicted fev 1 or 0.7 fev 1 /fvc are used; particularly in young children and elderly adults. while %predicted has historically been used to interpret lung function results, z-scores are more appropriate as they take into account the between-subject variability of measurements for any given outcome at any given age, as well as the predicted value 17 . similarly, use of <0.7 as a fixed threshold for abnormal fev 1 /fvc can lead to gross under-diagnosis of airway obstruction in the young and over-estimation in the elderly 17 . with exception of extreme deprivation, ethnic differences in lung function cannot be explained by socio-economic factors. after adjusting for confounders, genetic factors do contribute to ethnic differences in body physique and lung function. given the marked ethnic differences in lung function, the magnitude of which are similar across the entire life span, it is essential that lung function results in children are interpreted using ethnic specific equations whether in clinical practice or epidemiological research. although gli-2012 do not and never will cover all ethnic groups, appropriate use of age, height and sex adjusted values of fev 1 /fvc ratio derived from these equations (which is consistent across all ethnic groups) will facilitate better identification of airway obstruction in children irrespective of ethnic background. failure to adjust lung function for ethnic differences will result in overestimation of both the severity of airway obstruction and the severity and prevalence of restrictive lung disease. it is now recognised that asthma is a complex, heterogeneous disease. therefore, we need to move away from offering a single approach to management for all children and consider the identification of individual phenotypes for each child to enable optimal treatment and control. the specific facets of the disease that need to be considered and defined in each child include: i. an accurate description of symptom pattern (exacerbations alone, or persistent symptoms with and without exacerbations), ii. the nature of airway inflammation (eosinophilic, neutrophilic or non-inflamed), iii. the type and degree of structural airway changes (remodelling). although asthma control can be achieved in most children with low-moderate doses of inhaled steroids, we remain unclear about the choice of optimal maintenance therapy for each child. how should a decision between regular inhaled steroids, or leukotriene receptor antagonists be made? when additional therapies are required to achieve control, a scientific rationale for add-on therapies also is unavailable. the majority of decisions about therapies are made using a "trial of treatment" approach 1 . if one approach is not successful, then another is adopted without a clear thought process dictating choice of treatments. it is apparent that we need to change our current one size fits all approach to the management of asthma in children. although perhaps less important for children with mild or moderate disease, this becomes extremely important when we consider those with more severe disease. personalised medicine for severe asthma although atopy, airway hyperresponsiveness, eosinophilic inflammation and remodelling are the cardinal pathophysiological features of paediatric asthma, we now know that each of these features can be present to very different degrees in the individual child 2-4 . pathology has been most studied in children with severe disease, and although features such as eosinophilic inflammation and increased airway smooth muscle represent the patients as a group, there is huge overlap between children with and without asthma, and a huge spread of severity of these features within the group of children with severe asthma 2 . this within-group variability means assessments need to be made in the individual before deciding on the most appropriate add-on therapy. a proposed approach to identifying the "individual phenotype" in children with severe asthma is to split response to steroids into different domains (bossley c et al. j allergy clin immunol 2016, in press). not all children with asthma have abnormal lung function, not all have inflammation or remodelling, the response to a trial of systemic steroids can therefore be split into the following: i. lung function response, ii. inflammation response (exhaled nitric oxide and sputum eosinophils) and iii. symptom response. we have analysed this approach in 54 patients with severe therapy resistant asthma and shown a similar proportion of children (approx. 40%) responded to systemic corticosteroids in each domain, but there were no reliable predictors of a response pattern. furthermore, only 13% were complete responders (response in all domains), 15% were nonresponders (no response in any domain) and the majority (72%) were partial responders (response in >1 domain). these data highlight that childhood severe asthma is heterogeneous and a complete response in symptoms, inflammatory and physiological parameters is rare (bossley c et al. j allergy clin immunol 2016, in press). individual response patterns to systemic steroids need to be applied in the future to guide the choice of addon therapies in each child as a step towards achieving personalised medicine. subsequently, this multi-domain approach was applied clinically to identify characteristics of responders to the add-on therapy omalizumab. it became apparent that only those with a positive response in the inflammation domain (a significant reduction in exhaled nitric oxide after a trail of systemic steroids) had a beneficial response from omalizumab 5 . as increasing numbers of add-on therapies become available for use, specifically in the context of severe asthma, we need to better define pathophysiological phenotypes in individual patients and we need to understand the mechanisms mediating disease in children. in addition, we now need to incorporate individual genotypes into our definition of phentoypes to more accurately define treatment responses 6 , as has been successfully done for response to montelukast in preschool wheeze 7 . not only will this individualised approach allow us to discover novel molecular targets that will be effective specifically in the paediatric population, but it will also enable us to objectively choose the best therapy tailored to the individual child. europe consistently report that 20-40% of children with a recognized asthma diagnosis require acute medical care yearly. this is a reflection of the inadequacy of the available treatment options for prevention and treatment of exacerbations, suggesting that asthma with severe exacerbations may represent a distinct subtype of disease and demonstrating a need for improved understanding of its pathogenesis. asthma heritability is estimated at 50-80%. a number of genes have been verified in genome-wide association studies (gwas), but still the genetic background of asthma remains poorly understood. larger gwas may reveal new susceptibility loci with smaller effects, but due to the large heterogeneity of asthma (1), an alternative strategy may be to increase phenotype specificity. a specific phenotype is likely to be closer related to a specific pathogenetic mechanism and may therefore markedly increase the power of genetic studies. this was the background for a gwas focusing on a particular asthma phenotype defined by repeated, severe exacerbations in early childhood. (2) a sufficient number of cases were obtained by identification of children with recurrent acute hospitalizations for asthma between 2 and 6 years of age in the danish national patient register, and extraction of dna from dried blood spots from the danish newborn screening biobank. the case phenotype was rare with only 1/1000 of children born in denmark between 1982 and 1995 fulfilling the inclusion criteria. the final study comprised 1,173 children with repeated hospitalization and 2,511 healthy controls. five loci were identified with genome-wide significant association (pvalue < 5 ã 10-8): gsdmb, il33, rad50, il1rl1 and cdhr3. even though the sample size of this gwas was less than one fifth of the largest published gwas on asthma from the gabriel consortium,(3), it identified a similar number of genome-wide significant loci with similar statistical significance. the effect estimates were remarkably high with odds ratios between 1.4 and 2.3 per risk allele, compared to the odds ratios around 1.1-1.2 usually found in gwas on complex traits. further increasing phenotype specificity by stratified analysis in the 358 children with the highest number of exacerbations resulted in a further increase in effect estimates, with odds ratios between 1.6 and 2.7 per risk allele, and strong statistical significance. these strong results demonstrate the value of focusing on a more specific phenotype in asthma genetics. furthermore, it indicates that studies on this severe and early-onset phenotype is a "cost effective" approach whereby methodologies requiring large resources and/or strong statistical power can be applied in a limited number of individuals and still provide powerful results. the top-locus in this study, at chromosome 17q12-21 near gsdmb/ ormdl3, has consistently been associated with childhood onset asthma. (3) (4) (5) the effect size in the present study was remarkable with an or of 2.3 (p-value ¼ 1.3 ã 10 à48 ) and increasing to 2.7 for the children with highest number of exacerbations. this suggests an important role for this locus in severe exacerbations in early childhood in line with a previous report from the copsac 2000 birth cohort study.(5) cdhr3 had not previously been associated with asthma or any other disease. the association with asthma was replicated in the publically available gabriel results (3) protein structure modeling showed that the risk-associated variant is located at the interface between two domains where it could be involved in disulfide rearrangement and interfere with inter-domain stabilization, overall protein stability or conformation, in agreement with the observation in experimental studies of altered cell surface expression. (2) the biological function of cdhr3 is unknown but it seems to be a highly plausible asthma gene. it belongs to the cadherin gene family of transmembrane proteins involved in several cellular processes including epithelial polarity, cell-cell interaction, and differentiation (6) and is highly expressed in the lungs. also, other members of the cadherin family have been associated with asthma and related traits, including e-cadherin. (7) recently, it was reported that cdhr3 functions as a receptor for rhinovirus c. (8) cdhr3 was differentially expressed in epithelial cells susceptible to rhinovirus c infection compared to unsusceptible cells, and its expression on epithelial cells enabled rhinovirus c binding and replication. importantly, introduction of the risk variant at rs6967330 by transfection resulted in 10-fold increased rv-c binding and progeny yield compared to the non-risk variant. these data provide strong evidence that cdhr3 is a rhinovirus c receptor and that the association signal in the cdhr3 gene might result from increased susceptibility to rv-c infections. this finding is in line with the exacerbationrelated phenotype from the discovery gwas, since rhinovirus c has been reported to be the most common viral trigger of severe asthma exacerbations in children and associated with more severe disease and higher rates of hospital readmissions compared to other respiratory viral infections.(9,10) if correct, this would indicate that children with the cdhr3 risk variants are specifically susceptible to rhinovirus c infections compared to illnesses triggered by other viruses, a hypothesis that is currently being tested. in conclusion, the strong results found in this gwas on childhood asthma with severe exacerbations demonstrate the value of specific phenotyping in the search for asthma genes. focusing on this extreme subtype of disease might reveal mechanisms that would not be revealed in studies of milder disease, but might also increase the understanding of general asthma mechanisms. identification of cdhr3 as a risk gene might be one of the first examples where the underlying mechanism of an asthma gwas finding is understood. future studies of this gene may improve understanding and treatment of asthma exacerbations in childhood. the timing of bacterial colonization early in life is thought to be important for appropriate immune education and the transmission from mother to the fetus during pregnancy and birth is being better described. cultures of meconium have shown diverse groups of gram-positive and gram-negative bacteria, possibly not all derived post-delivery. the development of the gut microbiome is a dynamic process and early colonization with bacteroides and bifidobacterium species might play a crucial role in the development of immune regulation (1) . factors that can influence early life colonization include antibiotic treatment, method of delivery, maternal and infant diet and biodiversity in the home, surrounding environment and in family members. the gut microbiome increases in diversity during the first years of life. germ-free mice, which are not exposed to live bacteria, display exaggerated th2 and ige responses, associated with diminished polarization of treg cells. monocolonization of the mice with specific microbes, but not all microbes, suppresses the ige response and promotes treg differentiation (2) . however, certain immunological changes, such as increased inkt numbers in the mucosa, cannot be reversed following colonization of mice later in life (3). interestingly, more severe allergic responses and anaphylaxis were observed in mice who received a microbiome transplant from allergic animals, suggesting that certain microbial species can actually promote allergic responses (4). the immune system at birth is dominated by th2 cells. however, the human fetus has a functional immune system at a relative early status of development comprising cd4þ and cd8þ t cells but also foxp3þ treg cells. one concept gaining support is that the developing fetus may become educated by whole bacteria or their genetic material that is provided via maternal serum. dna from bifidobacteria and lactobacilli, two genera typically used as probiotics, are found in human placenta. in contrast, in utero exposure to potentially pathogenic bacteria such as ureaplasma species leads to immune dysregulation commonly ending in fatal complications. maternal consumption of probiotic-containing food components may reduce the risk for childhood allergic diseases and mouse models demonstrate a reduced risk of inflammatory bowel diseases. epigenetic mechanisms may be critical since application of acinetobacter lwoffii to pregnant mice reduced the airway hypersensitivity response of the offspring. the promoter region of ifn-g in cd4þ t cells of the offspring had high levels of histone-4 acetylation, associated with enhanced transcription, while the il-4 promoter region had lower levels of histone-4 acetylation (5). moreover, exposure of pregnant mothers to the farm environment, which have high levels of acinetobacter lwoffii, was associated with dna demethylation of the foxp3 locus and methylation of the th2-associated genes rad50 and il-13. since gut microbiota composition during the first months of life seems to be important for development of appropriate immune regulatory networks and thereby influence later life disease risk, intervention with probiotics, prebiotics or synbiotics might be most effective at this age or even during pregnancy. probiotics can be defined as live micro-organisms which, when administered in adequate amounts, confer a health benefit on the host. notably, the definition of a probiotic does not differentiate between the wide range of potential health benefits and it is clear that not all probiotics will influence the immune system in the same way. findings observed with one probiotic strain cannot be extrapolated to other probiotic strains. current evidence does not indicate that the probiotics clinically tested to date reduce the risk of children developing allergy but there are significant differences between studies such as the use of different probiotic strains, different age groups and different endpoints (6) . despite very poor quality of evidence, it has been suggested that there may be benefits in specific high risk groups, such as pregnant women at high risk of having an allergic child, in women who breastfeed infants at high risk of allergy and in infants at high risk of developing allergy. in general, probiotic-supplemented formula was found to be well tolerated and safe for infants. in conclusion, a better description of the bacterial strains and metabolites, which influence immune function, is required in order to allow for the improved design and selection of future probiotic strains for prevention and treatment of allergic disorders (7). people with cystic fibrosis (cf) are living longer lives than ever in the past. the median predicted survival in developed countries is now above 40 years of age and adults with cf are outnumbering pediatric patients in several regions. various reasons may explain such improvement in life expectancy, including the establishment of cf-dedicated and multidisciplinary centers; greater attention to nutritional issues and use of pancreatic enzymes replacement therapy; airway clearance techniques tailored to individual needs and attitudes; infection control measures; use of antibiotics both chronically by inhalation and aggressively to treat pulmonary exacerbations; mucolytic and airway hydration therapies; and liver and lung transplantation (1, 2). on account of the overwhelming evidence that organ impairment begins very early, even in asymptomatic cf infants, there is now general consensus that at least some of these strategies of care should be implemented as soon as possible in order to prevent or delay irreversible structural lung damage. indeed, this has possibly been the main argument in favor of cf nbs (3). the strength of such argument has been tested by several studies and considering different approaches. randomized studies à only two randomized trials on newborn screening for cf have been completed (5, 6, 7). these evaluations need many years of follow-up and, given the high degree of evidence in favor of cf newborn screening presently available, further implementation of similar studies seems improbable and possibly non ethical. observational studies à although most of these studies confirm clinical benefits from early diagnosis of cf, their results are hampered by several biases inherent to the methodological approach. the constant improvement in treatment and the consequent longer survival has an influence on the comparison of screened individuals and unscreened historical controls. on the other hand, examining the clinical evolution of screened infants and unscreened controls from different geographical areas but born in the same years may be affected by different care practices. finally, ascertainment biases may also have an impact on the assessment of outcomes, as patients presenting clinically are likely to have more severe cf than those identified through screening or unscreened patients with very critical disease may have died before being diagnosed. health economics studies à these studies use surrogate end-points, such as the quantity of treatment needed to remain healthy, and are based on the assumption that the optimal management offered to cf patients makes it harder to detect evidence of better clinical outcome in those diagnosed by screening. late-diagnosed patients may show clinical pictures similar to those diagnosed early, but at the expense of a considerably heavier burden of care (8) . most of these studies have focused on respiratory and nutritional outcomes and on hta assessments. their overall results clearly point in the direction of a positive effect on height and weight, of longer survival and of health service savings in populations screened at birth for cf. positive effects may also be obtained in several other domains, namely: -the prevention of salt loss syndrome thanks to early beginning of salt supplementation the opportunity of surveying from birth the natural history of cf -a better understanding of the early stages of cf. the possibility of testing presymptomatic therapeutic strategies, both conventional and patient targeted. cystic fibrosis (cf) is associated with the presence of two cf-causing mutations, one in each parental cftr gene, resulting in the absence or abnormality of the cftr protein and defect in electrolyte transport across epithelial membranes, the most well known being sweat chloride >60 mmol/l. even in 2016, cf remains by essence a clinical diagnosis. the wide range and severity of symptoms/ organs involved between and within individuals makes it a clinical decision as to whether or not a person should be managed as a cf patient. this is especially the case in a small number of ambiguous or atypical cases. in 1998, a first diagnosis consensus listed criteria for cf diagnosis: (i) one or more of the phenotypic features of the disease or (ii) cf in a sibling or (iii) a positive immunoreactive trypsin (irt), in association with at least one other feature, including a positive sweat test result on two occasions, a cf-causing mutation in each cftr gene or an abnormal nasal potential difference (npd) (1). this consensus statement of the us cystic fibrosis foundation was later modified in europe based on the concept of cftr dysfunction included in the diagnosis algorithm (2) . most atypical cf patients are diagnosed based on sweat tests and/or genetic analysis. these "mild cf" individuals usually present later in their lives with pancreatic sufficiency and milder respiratory disease. they frequently carry wide clinical spectrum mutations. the difficulty occurs when patients present with clinical symptoms suggestive of cf and a sweat chloride value in the intermediate range (30-59 mmol/l). among these subjects, those with abnormalities in npd measurement or 2 identified cftr mutations have, on average, more severe lung disease than the remaining subjects, although their disease symptoms are milder than those in subjects with a sweat chloride concentration above 60 mmol/l. therefore, from a physician's and also from a patient's perspective, these individuals must be differentiated from subjects with the classical life-shortening form of cf. the remaining cases, termed "possible" or "borderline", are difficult to classify because there is poor agreement between sweat test results and prognosis on the one hand and the frequent presence of at least one cftr mutation of uncertain clinical relevance on the other. the term "cftr-related disorders" (cftr-rds) designates these varied conditions, which include multi-system disease and monosymptomatic disorders associated with cftr dysfunction but which do not fulfill the diagnostic criteria for cf (3). this encompasses 3 main clinical entities with cftr dysfunction: cbavd (congenital bilateral absence of the vas deferens), acute recurrent or chronic pancreatitis and disseminated bronchiectasis. diagnosis of cbavd is based on impalpable vas deferens on scrotal examination. even if in a proportion of men scrotal palpable vas deferens are present, surgical exploration reveals a fibrous cord or a non-permeable duct. cbavd males have either a severe and a mild/variable (88%) or two mild/ variable (12%) cftr mutations (4) . approximately 34% of men with cbavd have a cftr mutation in one gene and the splicing variant ivs8-5t on the other allele, often in association with a longer polymorphic dinucleotide repeat, a combination that does not result in cf, but reduces levels of functional cftr protein in wolffian tissues, which constitutively produce less full-length cftr mrnas than other tissues (5) . about 30% of patients with idiopathic chronic pancreatitis or recurrent acute pancreatitis are found to carry cftr mutations. no specific cftr mutations have been reported, but rare class 4 or class 5 mutations are often found (6) . an increased incidence of cftr gene mutations has been found in bronchiectasis. according to the studies, at least 1 cftr mutation is found in 10-50%, and 2 mutations in 5-20% of cases. mutations found are mostly uncommon and likely to result in residual cftr function (7) . no specific cftr mutation is associated directly with bronchiectasis. (2) . these patients must be monitored carefully for development of any complications and appropriate therapy implementation. it should be pointed out, however, that labeling patients with mild or unclear manifestations with a cf diagnosis may have negative implications such as psychological, reproductive, social, employment, and insurance issues. therefore the explanation of the diagnostic challenge, including also prognosis, must be fully and honestly explained to the patient and or his family. department of pediatrics, cf and pcd center, hadassah hebrew-university medical center, mount scopus, jerusalem, <eitank@hadassah.org.il> effective mucociliary clearance (mcc) in the respiratory system requires proper mucus production and functioning airway surface fluid layer as well as competent and coordinated ciliary beating. the vital role of these systems is best demonstrated in patients with genetic defects such as primary ciliary dyskinesia (pcd) and cystic fibrosis (cf), both of which are characterized by impaired mcc leading to acute and chronic sino-pulmonary infections. pcd is caused by defects in genes that encode the structure or regulate the movement or function of the respiratory cilia. cf is caused by mutations in the cftr gene causing abnormality in the airway surface fluid layer, with production of thickened and viscous mucus leading to impaired mcc. in both diseases, recurrent and chronic respiratory infections and persistent inflammation cause progressive lung damage. most patients with cf suffer from pancreatic insufficiency (cf-pi); however, approximately 15% have sufficient pancreatic enzyme production to maintain normal fat absorption (cf-ps). patients with pcd are similar to patients with cf-ps in that they have normal pancreatic function, and are usually without the nutritional deficiencies that are typically associated with more severe pulmonary disease in cf. in addition, pcd and cf-ps are often diagnosed at a later age and have better survival compared to cf-pi (1,2). therefore when comparing cf and pcd, one should differentiate between patients with cf-pi and cf-ps. santamaria et al. compared chest hrct scan scores for patients with pcd and a group of age-and gender-matched cf patients and showed that patients with pcd had significantly less structural damage than cf patients (3) . a recent study comparing between pcd and cf-ps and cf-pi revealed that patients with pcd had disease severity in terms of pulmonary function and structural abnormality similar to patients with cf-ps, which was significantly less severe when compared to patients with cf-pi (4). furthermore, when comparing structural abnormalities by hrct, there was a significant disparity in the distribution of the structural changes in the lungs between the three groups of patients: in pcd, the upper lung zones were relatively preserved and most changes were localized to the middle and lower lobes, whereas in cf-pi, the upper lobes were remarkably involved. in cf-ps, there was no characteristic distribution of the structural damage (4) . other studies showed that in pcd, contrary to cf groups, there was no correlation between fev 1 and ct score and between fev 1 and age (3) (4) (5) (6) (7) (8) , which provides further support to the understanding that, in pcd, lung function is not a strong indicator of severity of lung disease and therefore, follow-up by low radiation chest hrct scans should be considered. it is important to note that, in general, patients with pcd receive less intensive therapy (9) . they are not always followed regularly in specialized centers, and many are not adherent to routine treatments. the most common bacterial infection in pcd patients is h. influenzae, which is significantly less common in older cf patients (4, 10) . in cf, chronic infection with p. aeruginosa is associated with a more severe lung disease (11) . however, among patients with pcd, there was no correlation between p. aeruginosa infection and pulmonary function or hrct severity score, suggesting a different role for this microorganism in the pathogenesis of pulmonary disease in pcd (4). bush et al. compared the mucous properties in both diseases and demonstrated that inflammation, measured by il-8 concentration, was greater in pcd sputa, and that there were no significant differences in biophysical or transport properties of sputum between the two groups; however, survival in patients with pcd was generally better (12). ratjen et al. (13) assessed the inflammatory response in the airways of cf and pcd patients during pulmonary exacerbation. in stable pcd patients, no significant differences were found in sputum inflammatory markers between individuals colonized with different bacterial pathogens. however, higher bacterial density for s. aureus and h. influenzae was found in patients with cf versus pcd, and the absolute neutrophil counts were higher in pcd patients. while sputum elastase activity was similar in pcd and cf at the time of exacerbation, it decreased with antibiotic therapy in pcd but not cf patients. thus, pcd patients differ from those with cf in their responses to treatment of pulmonary exacerbations, with higher neutrophil elastase activity persisting in the cf airways at the end of treatment. joenesen et al. (14) measured the difference in breath profiles of patients with pcd and cf, with and without distinct chronic lung infections, using an electronic nose. no significant difference was found between the breath profiles of pcd patients with a chronic pa infection and pcd patients without a chronic infection. however, there was a significant difference between the breath profiles of cf patients with a chronic pa infection and cf patients without a chronic pa infection, suggesting a different response to infection between pcd and cf. in conclusion, although pcd and cf are both characterized by impaired mcc and respiratory infections, patients with pcd have a different lung disease expression compared to patients with cf-ps and with cf-pi, as assessed by fev 1 , hrct, nutritional status and bacterial infection on sputum cultures. in pcd, normal fev 1 can be maintained over time in spite of severe structural damage. this suggests a greater involvement of the large airways in pcd and the small airways in cf. furthermore, p. aeruginosa infection is less common in pcd than in cf. bronchopulmonary dysplasia (bpd) is the most important complication following mechanical ventilation in preterm infants and no definite therapy can eliminate this complication. although the mechanism is not completely clear, pulmonary inflammation is believed to play a central role in the pathogenesis. glucocorticoid is one of the most effective therapies to treat or prevent bpd. however, systemic glucocorticoid therapy is not generally recommended because of long-term adverse events (1,2). our previous pilot study in neonates and studies in animals indicated that surfactant can be used as a vehicle to deliver a topical glucocorticoid, budesonide, to the lung periphery and effectively suppress lung inflammation and lung injury (3.4.5). the mechanism for the effective delivery of budesonide using surfactant as vehicle is based on a physical phenomenon, the "marangoni effect": in the interface between high and low surface tension, a convection force is generated and this force can be used as a vehicle to facilitate the delivery of medication (6) . this is an important delivery method because inhaled glucocorticoid is technically difficult and the effect has been shown to be limited (7, 8 there was no significant difference between the groups during the study in serum electrolytes, glucose, bun and in blood pressure, and in physical growth. there was no significant difference between the groups in neuromotor function, and in mdi, pdi and in neurodevelopmental impairment (ndi) score when examined at 2-3 years of corrected age. we concluded that in very low birth weight infants with severe respiratory distress syndrome, intra-tracheal administration of surfactant/budesonide compared with surfactant alone significantly decreased the incidence of bpd or death without apparent short term or long term adverse effect. further large-sample, double-blind trials are warranted. measuring lung function in "non-collaborating" children has always been one of most difficult tasks for pediatric pulmonologists. this is because young children are not able to perform the voluntary forced expiratory maneuvers generally used in adults and schoolchildren. in infants and children up to 2 years, this problem has been generally overcome by the use of sedation, although this contributes to make lung function measurements less suitable for routine clinical use in this age group. preschool children (2-5 years) are too old to be sedated and yet too young to properly perform the forced expiratory maneuvers required for spirometry. for this age group, several techniques that just require tidal breathing have been implemented during the past decades. the american thoracic society/european respiratory society (ats/ers) working group on lung function in young children has published technical recommendations for most infant (1,2) and preschool techniques (3) and their clinical applications have also been recently summarized (4) . this lecture will focus on the most used pulmonary function tests (pfts) in infants and preschool children. chloral hydrate (80-100 mg/kg, maximum 1 g) is commonly used to sedate infants and young children up to 2 years for performing lung function testing. however, chloral hydrate is no longer available in the u.s.a. and the use of other sedatives might lead to different results (4). the most commonly used pfts in infants are the raised volume rapid thoracoabdominal compression and infant plethysmography. other pfts that are performed during tidal breathing (e.g.: tidal breathing measurements, multiple breath washout, forced oscillation technique) are more suitable to be used without sedation, especially in younger infants. the raised volume rapid thoracoabdominal compression (rvrtc) allows for the measurement of forced expiratory flow and volume in sedated infants (2) . repeated inflations using a pressure of 30 cmh 2 o are applied through a facemask and an inflatable jacket is then activated to rapidly compress the infant's chest and abdomen to obtain forced vital capacity (fvc), forced expiratory volume in 0.5 seconds (fev 0.5 ) and forced expiratory flow (fef) at defined proportions of fvc. to ensure that flow limitation has been reached, the inflation pressure of the jacket is increased at each maneuver until no further increase in flow is noticed. recently published reference equations using a current commercially available device (5) will improve the interpretation of the results. rvrtc has been successfully used in children with all kinds of respiratory diseases, including children with cystic fibrosis (cf), children born prematurely, and those with recurrent wheezing (4), showing its capability to distinguish disease populations from healthy control subjects and to detect lung function changes in clinical intervention trials. however, its long-term clinical utility still remains to be established. moreover, the need for sedation along with the time and resource intensity required are other important limitations for its use in routine clinical practice (4) . infant plethysmography is used to measure functional residual capacity (frcpleth) in sedated infants (1) . specific airway resistance (sraw) can also be measured, provided that a proper electronic thermal compensation is applied to the system to account for thermal artifacts. this technique is based on the same principle (boyle's law) as plethysmography for older subjects and uses an infant whole body plethysmograph where the infant lies supine breathing through a facemask sealed with silicon putty (1). infant plethysmography has been successfully applied to children with lung disease, especially cf and bronchopulmonary dysplasia (bpd) (4). however, as for rvrtc, its long-term clinical utility remains to be ascertained and its role in routine clinical practice is hence very limited. preschool children (2-5 years) are too old to be sedated, but also too young to properly perform the forced expiratory maneuvers required for spirometry. for this age group, several techniques that just require tidal breathing have been implemented during the past decades, allowing for lung function to be measured in awake children (3) . also, modified acceptability criteria for spirometry have been proposed for the use in preschool children (3) . it is important to highlight that the feasibility of any lung function technique in preschool children strongly depends on the capability of the operator of keeping the child quiet and focused (3). spirometry has been proposed for preschool children using modified acceptability criteria (3). since the forced expiratory volume in 1 second (fev 1 ) often cannot be obtained in preschoolers due to their different lung physiology, the use of fev in 0.5 (fev 0.5 ) or 0.75 seconds (fev 0.75 ) is recommended in this age group. also, fvc should not be reported if flow stops at more than 10% of peak flow (early termination), but fev may still be reported. less stringent repeatability criteria have also been proposed in preschool children: at least two acceptable maneuvers should be obtained with the two fvc and fev within 100 ml or 10%, but in case of a single acceptable maneuver, this should be recorded nevertheless (3) . spirometry is reported to be feasible in 55-85% of 4-5 year old children, but its feasibility tends to be much lower in younger children (4) . global multiethnic reference equations including preschool children have recently be published (6) . spirometry has been reported to discriminate healthy controls from preschool children with cf and with recurrent wheezing, although substantial overlap between groups may occur and bronchodilator response appears to be more sensitive than baseline values (4). however, a careful and rigorous approach to the use of spirometry must be taken in preschool children and several gaps in our knowledge still limit the application of this technique to clinical practice in this age group (4). the interrupter technique is based on the principle that a sudden flow interruption at the mouth during tidal breathing would make alveolar pressure rapidly equilibrate with mouth pressure, thus allowing an estimation of alveolar pressure by measuring mouth pressure. the interrupter resistance (r int ) is then calculated dividing the change in mouth pressure by the flow measured immediately before the interruption ("classical" technique) or immediately after the interruption ("opening" technique). measuring r int has been proved to be particularly suitable for preschool children, its feasibility being generally higher than 80% in this age group (4). proper reference values have been published (7) and cut-off values for the bronchodilator response have also been reported. r int is able to detect changes in the airway caliber and has been successfully used in preschool children with recurrent wheezing (4). however, its utility in clinical care remains to be established, especially by longitudinal studies (4) . the forced oscillation technique (fot) is used to measure the impedance of the respiratory system (z rs ) during tidal breathing by applying, through a mouthpiece and a filter, low-frequency pressure oscillations generated by a loudspeaker (usually 4-48 hz) (3) . changes in flow and pressure measured at the mouth are used to calculate z rs and its two components, resistance (r rs , reflecting frictional losses) and reactance (x rs , reflecting elastic properties at low frequencies and inertial forces at higher frequencies). forcing signals based on sinusoidal waves or impulses have been used, both as single-frequency or composite signals. frequencies between 5 and 10 hz are considered to reflect the mechanical properties of the total airways. fot has a good feasibility in preschool children (>80%) and several reference equations have been published (8) . fot has been used in many studies on children with recurrent wheezing, showing a good capability in discriminating health from disease, especially when bronchodilator response is used (4). however, for this technique as well, longitudinal studies on its clinical utility in young children are still needed (4). the multiple breath washout (mbw) is based on the washout of an inert gas (typically n 2 washout using 100% o 2 ) to measure ventilation inhomogeneity and frc during tidal breathing (3). non-resident inert gases have also been used. the lung clearance index (lci, the number of lung volumes expressed as frcs required to washout the inert gas) is the most commonly used mbw index. the general standard operating procedure for this technique has been recently reported (9) . lci has a good feasibility in preschool children (nearly 80%). lci has been successfully used in preschool children with cf (4), proving to be more sensitive than spirometry and plethysmography in detecting abnormal lung function. however, longitudinal studies on the clinical utility of mbw in preschool children are lacking (4) and more data are needed before lci or other mbw indices can be recommended in the routine clinical management of patients with cf (10). specific airway resistance (sraw) can be measured at tidal breathing in preschool children using a whole body plethysmograph. since sraw is the product of airway resistance by the thoracic gas volume, it can be calculated without the need to breathe against a closed valve (11), provided that a proper electronic thermal compensation is applied to obviate the need for the panting maneuver. the measurement of sraw has a good feasibility in young children and reference values are also available (11) . however, the lack of consensus on measurement methods and outcome measures makes it difficult to compare results among centers and methodological techniques are urgently needed for this technique. an accurate assessment of pulmonary function is now possible in infants and preschool children using a number of techniques. although these techniques have proven to be powerful research tools, further studies are needed to ascertain their utility in the clinical care of infants and young children with lung disease. . past studies have shown that persistent echocardiographic evidence of ph beyond the first few months of life is associated with up to 40% mortality in infants with bpd. the association of ph with poor survival in bpd has continued into the recent era of the "new bpd," especially in infants with severe disease who require prolonged support with mechanical ventilation. thus, developing insights into the pathogenesis and pathobiology of ph and related pulmonary vascular disease (pvd) in bpd continue as an important challenge and may help to improve early and late cardiopulmonary outcomes after preterm birth. mechanisms that coordinate normal vascular growth and alveolarization during development or cause abnormal lung growth in bpd are poorly understood. disruption of key signals between airway epithelium and endothelial cells can alter vascular and alveolar growth, resulting in decreased arterial and airspace structure. for example, hyperoxic lung injury in newborn animals decreases expression of the critical proangiogenic and endothelial cell survival factor, vascular endothelial growth factor (vegf). early impairment of vegf production inhibits vascular growth and impairs endothelial function, which leads to ph. in addition, disruption of angiogenesis due to adverse antenatal factors, such as chorioamnionitis, preeclampsia or maternal smoking, and postnatal events after premature birth, can cause vascular injury that not only lead to ph but can also impair distal lung growth. ongoing laboratory studies suggest that the developing endothelial cell plays a key role in the regulation and coordination of epithelial growth and distal airspace structure through the production of critical "angiocrines," such as nitric oxide (no), hepatocyte growth factor, vitamin a, insulin growth factor-1 and others. thus, since angiogenesis is necessary for normal alveolarization, it has been suggested that protecting the developing pulmonary vasculature from early injury may not only lower pvr and improve gas exchange, but may enhance distal lung growth and improve long term outcomes. abnormalities of the pulmonary circulation in severe bpd include altered tone and reactivity, structure and growth, which can cause right heart failure, impaired gas exchange, pulmonary edema, decreased exercise capacity and other clinical problems. physiologic abnormalities of the pulmonary circulation in bpd include elevated pulmonary vascular resistance (pvr) and abnormal vasoreactivity, as evidenced by the marked vasoconstrictor response to acute hypoxia and by impaired gas exchange due to abnormal distribution of lung blood flow. abnormal pulmonary vascular structure also contributes to high pvr due to increased smooth muscle cell hyperplasia and altered vascular compliance caused by increased production of an abnormal extracellular matrix. growth of the distal lung circulation is abnormal in infants with severe bpd, and decreased arterial growth (angiogenesis) reduces vascular surface area that further impairs gas exchange and increases the risk for the development of ph and impaired exercise capacity in older children. prominent bronchial or other systemic-to-pulmonary collateral vessels were noted in early morphometric studies of infants with bpd, and can be readily identified in many infants during cardiac catheterization. although these collateral vessels are generally small, large collaterals may contribute to significant shunting of blood flow to the lung, causing edema and need for higher fio 2 . in addition, recent autopsy studies suggest the presence of striking intrapulmonary anastomotic, or "shunt," vessels that link the distal pulmonary and bronchial vessels, and may contribute to poor oxygenation. past clinical studies have further shown that metabolic function of the pulmonary vasculature is impaired in bpd, as reflected by the lack of pulmonary clearance of circulating norepinephrine during passage through the lung, which may contribute to left ventricular dysfunction and systemic hypertension. clinical studies have recently shown that early echocardiographic findings of pvd after preterm birth are strongly associated with the development and severity of bpd and ph at 36 weeks corrected age. interestingly, these findings were not only associated with a worse respiratory course during the initial hospitalization, but also late respiratory outcomes, including respiratory exacerbations, hospitalizations and the need for asthma medications. ongoing studies are exploring the impact of ph-specific drug therapies, such as sildenafil and other agents, on ph and related complications. thus, pvd in preterm infants with bpd is characterized by altered lung vascular development, growth, structure, and function, which precede the onset of measureable ph. pvd due to disruption of normal pulmonary vascular development in association with preterm birth is an important determinant of the pathobiology of bpd and contributes significantly to morbidity and mortality. exposure to adverse stimuli during the antenatal and/ or early postnatal periods impairs normal pulmonary vascular development and creates an imbalance between risk and resiliency factors. recent studies have revealed the magnitude of ph in preterm infants, but many aspects of pvd remain understudied, and ongoing investigations continue to explore risk factors, mechanisms of disease, and long-term outcomes. prospective studies are needed to definitively establish standardized clinical criteria for pvd and ph in bpd, and to determine the best methods for early diagnosis, risk stratification and disease monitoring. larger collaborative studies and improved clinical infrastructure to conduct these important investigations will provide answers to these critical questions. recent evidence suggests that cftr does not act as a pure ion channel but as a platform for multiple cellular signaling pathways. importantly, the protein interactomes of wt-and f508del-cftr are rather different, and there is growing consensus that indirect measures that avoid the enhanced degradation of f508del-cftr may restore its function. recently, we discovered that cftr orchestrates a proteostatic network that influences multiple cellular functions by acting as a hub protein. this hub-dysfunction model proposes that the proteostasis network is widely deranged, both in transgenic cf mice and in primary nasal epithelial cells freshly collected from cf patients bearing f508del-cftr either in homozygous or compound heterozygous form, at two levels. firstly, autophagy, the major mechanism determining cytoplasmic protein turnover, is blocked due to tissue transglutaminase (tg2)-mediated depletion of the essential autophagy-related protein beclin 1 (becn1), leading to secondary accumulation of the autophagic substrate sqstm1/p62. secondly, peptide fragments released from proteolytically-cleaved f508del-cftr provoke an over-activation of a pleiotropic protein kinase (protein kinase ck2), which in turn contributes to f508del-cftr degradation. combined inhibition of tg2 by cysteamine, which is fda-approved for the treatment of cystinosis, and over-active ck2 by the over-the-counter greentea flavonoid epigallocatechin-gallate (egcg) respectively rescue and stabilize a functional f508del-cftr protein at the pm, both in mice and in primary nasal cells from cf patients bearing f508del-cftr or other class ii-cftr mutations. pre-clinical evidence on transgenic mice has provided the mechanistic proof-of-concept for using this combination of proteostasis regulators as an alternative cftr-repairing therapy. moreover the combination treatment reduces lung inflammation and this beneficial effect persists up to 2 weeks following cysteamine withdrawal provided that egcg was administered during washout. this prompted an open-label phase-2 trial to assess the individual response to the synergistic combination of cysteamine and egcg in cf patients bearing different cftr mutations. the combination treatment was well tolerated and decreased sweat chloride from baseline while increasing the abundance and function of cftr protein and restored autophagy in nasal cells. notably, the treatment decreased cxcl8 and tnf-a in the sputum and improved respiratory function. these positive effects were particularly strong in patients carrying f508del-cftr (or other class ii) mutations in homozygosity or heterozygosity, whereas patients with class i cftr mutation failed to respond to therapy. altogether, these results suggest that the combination treatment acts "on target", according to the hypothesis underpinning our drug design. discordance in therapeutic response rate complicates mutation-specific approaches, thus entailing the need of patient-centered (personalized) approaches to assess drug efficacy. testing the putative individual responsiveness to treatment by appropriate biomarkers before in vivo therapy should support the decision to treat. we show that restoring cftr function in vitro in nasal cells in response to cysteamine plus egcg, is highly predictive of whether the combination treatment will restore cftr function in vivo. hence, this in-vitro assay may constitute a tool to guide the clinical development of cf treatments, allowing to select patients for new therapeutic options. general frame for care infants with cf must receive care in an accredited cf care center. they must be reviewed in clinic frequently after diagnosis, for example once a month during the first 6 months of age, every 2 months until 1 year of age, and every 3 months thereafter (3). after initial diagnosis, the cf center should contact the primary care professionals for regular ambulatory follow-up to implement therapeutic strategy. parents of infants with cf should be offered access to genetic advice and counseling. the standard childhood immunization schedule must be applied in accordance with national guidelines. anti-influenza vaccination is recommended for the infant from the 6 th month of life and for all household members and healthcare providers. according to french guidelines, vaccination against chicken pox could be recommended. growth targets should reflect genetic potential, sibling height and local population demographics (1) . french guidelines recommend to catch-up birth weight percentile at 6 months (3). at 2 years, weight-for-height should be at the 50 th percentile and height at the target height percentile (target height: average of the height of the 2 parents plus 6.5 cm for boys and minus 6.5 cm for girls) (3). energy intake evaluation should be performed by a dietician on a regular basis and adapted to achieve the objectives of weight-for-height growth. energy intake could be as much as 150% of the daily recommended calorie intake for the same age in the general population (4). breast feeding is encouraged, all the more that recent data acknowledge its protective effect against pseudomonas aeruginosa infection (4, 5). formula with hydrolyzed cow's milk protein is recommended in infants with risks of malabsorption, or severe undernourishment. sodium chloride supplementation is systematic, particularly in the case of breast feeding and should be adapted to natriuresis (6) . it should be increased during periods of hot weather and all other causes of high salt loss (diarrhea, fever, ileostomy, etc.). at initial diagnosis, infants must have pancreatic function assessed by stool fecal elastase. if elastase is normal, repeat assessment is recommended. pancreatic enzyme replacement therapy should be started at diagnosis in case of clinical symptoms of exocrine pancreatic insufficiency even before obtaining the results of the elastase assay. the starting dose could be 2.000 iu lipase per 100 ml of milk. in case of persistence of symptoms of pancreatic insufficiency despite a maximum dose of 10.000 ui/kg/day of lipase, it may be necessary to evaluate the patient's compliance and the methods of conservation and administration of the pancreatic extracts. in case of poor weight-for-height growth despite an adapted substitutive pancreatic opotherapy, an evaluation is necessary including a dietetic review, a search for sodium insufficiency and other etiologies of malabsorption. in case of persistence of symptoms of exocrine pancreatic insufficiency despite a maximum dose of 10.000 ui/kg/day of lipase and in the absence of other etiologies, the administration of gastric secretion inhibitors may be envisaged. bacterial cultures of bronchial flora should be performed at each session of physiotherapy or, in case of abnormal clinical status, ideally on bronchial secretions expectorated or obtained by sputum induction (7). a chest x-ray should be performed at baseline and annual assessment, and, in case of clinical abnormality. high resolution computed tomography should complete the assessment in case of clinical or radiological abnormality and/or at initial assessment according to local practice to detect early bronchiectasis (8) . systematic respiratory physiotherapy is recommended from the time of diagnosis. the frequency of sessions of physiotherapy depends on the clinical status of the infant. regular therapy might be recommended even in the asymptomatic infant (3). any evidence of respiratory infection justifies performing a respiratory culture and adapted antibiotic treatment of the isolated pathogens. infection by staphylococcus aureus sensitive to meticillin should be treated by adapted antibiotherapy. in case of isolation of s. aureus resistant to meticillin, a treatment aiming eradication is recommended. evidence of p. aeruginosa justifies systematic antibiotic treatment, even in the asymptomatic infant. although there is still no consensus, treatment might begin with an inhaled antibiotic, eventually associated with oral ciprofloxacin. in case of persistence of p. aeruginosa after initial therapy, or if the infant presents with severe clinical signs, intravenous antibiotics should be considered (1, 2, 3) . for other pathogens, there is less clear agreement and treatment should be guided by local policies. in the absence of clinical improvement despite an adapted antibiotherapy, bronchial sampling by bronchoalveolar lavage should be considered and non-infectious causes should be searched for, including gastroesophageal reflux, asthma and an ent cause. respiratory syncytial virus (rsv) may have adverse effects on respiratory status in patients with cf (9) . there is insufficient evidence to support systematic recommendation of palivizumab in the cf infant even if some small studies suggest that there could be benefit from the use of rsv prophylaxis in infants with cf (10). us and french guidelines state that palivizumab could be discussed, namely for the infant of less than 6 months of age during an epidemic period (2,3). finally, dornase alfa, 7% hypertonic saline might be used in symptomatic infants (2) . with increasing numbers of infants with cf being diagnosed by newborn screening across most of europe and in north america, we will have the opportunity for large cohort follow-up and randomized controlled trials. this will help to establish still lacking best available evidence to harmonize therapeutic strategy in infants newly diagnosed with the final aim of improving clinical status at later ages. department of pediatrics, cf and pcd center, hadassah hebrew-university medical center, mount scopus, jerusalem, israel <eitank@hadassah.org.il> bronchiectasis is the distraction of the normal anatomy of conducting airways that results in impaired mucociliary clearance leading to chronic cough, sputum production, and recurrent infections and inflammation that cause further damage to the bronchial and bronchiolar walls leading to a vicious cycle of airway injury. the prevalence of non-cf bronchiectasis (ncfb) in children differs between developed and poor countries. in the developed world, the most common cause of bronchiectasis in children is cystic fibrosis (cf), followed by primary ciliary dyskinesia and immune deficiencies. however, up to half of cases remain without a known etiology. in developing countries, a systematic review of 989 children (1) demonstrated that an etiology was identified in 63% of children, with a previous severe pneumonia of bacterial or viral etiology and b-cell defects as the most common identified disorders. bronchiectasis should be suspected in patients who present with chronic productive cough of mucopurulent sputum. physical findings in bronchiectasis patients are nonspecific but may include crackles and wheezes on lung examination and clubbing of the digits. pulmonary function testing results generally show airflow obstruction. the diagnosis of bronchiectasis is confirmed by hrct scan which is now the gold standard for diagnosis. these include bronchial dilatation (an internal bronchial diameter greater than the diameter of the accompanying bronchial artery [i.e., the "signet ring" formation]) and a lack of bronchial tapering on sequential slices (2) . patients in whom bronchiectasis has been diagnosed should be evaluated for potential underlying causes. they need to undergo chest ct scan to define the extent of their disease. patients with focal disease require bronchoscopy to evaluate for a localized airway obstruction as the cause of the bronchiectasis. patients with diffuse bronchiectasis should be assessed for underlying systemic abnormalities including congenital disorders, chronic aspiration, impaired mucociliary clearance and systemic or local innate immune dysfunction. all patients with bronchiectasis should have a regular routine microbiological examination of their sputum for routine bacterial and ntm organisms. pulmonary exacerbations of ncfb are known to be associated with poor outcomes, and infections are common causes. gram-negative bacteria are isolated more frequently in patients with ncfb, with h. influenzae and p. aeruginosa representing the majority of identified species. however, up to 40% of sputum samples fail to grow any pathogenic bacteria (3). patients with sputum samples dominated by p. aeruginosa (pa) had a higher frequency of exacerbation and poorer lung function compared to patients whose samples were dominated by other organisms (4). nontuberculous mycobacteria (ntm) are opportunistic pathogens that afflict patients with preexisting lung disease; in particular those with ncfb, shown in a meta-analysis by chu et al. to be prevalent in nearly 10% of the patients (5). respiratory viruses were found in nearly 50% of exacerbations. the goals of bronchiectasis treatment are to reduce the number of exacerbations and to improve quality of life. if an underlying systemic etiology such as immune deficiency is identified, it should be addressed. pharmacologic agents and the mechanical mobilization of secretions have been evaluated to a limited degree in patients with non-cf bronchiectasis. short-acting or long-acting bronchodilator adrenergic and anticholinergic agents are commonly prescribed, but there have been no randomized controlled trials to support their use. pulmozyme had adverse effects when studied in patients with non-cf bronchiectasis. inhaled mannitol showed improved time to first exacerbation and quality of life. nebulized hypertonic saline solution (7%) have shown promise in the treatment of patients with both cf and non-cf bronchiectasis, but long-term prospective trials are needed. the role of the use of maintenance antibiotic therapy is uncertain in patients with non-cf bronchiectasis. rotating oral antibiotic strategies have been commonly used. for exacerbations, antibiotic therapy should be tailored to their sputum microbiology results. severe exacerbations, particularly in patients who are infected with organisms that are resistant to therapy with oral quinolones, require iv antibiotic therapy. azithromycin has been shown to attenuate muc5ac and muc2 gene expression, thereby suppressing the synthesis of mucin on human airway epithelial cells. clinically, this was demonstrated in a study that found that mean 24-hour sputum volume and qol were significantly lower in patients with bronchiectasis after 12 weeks of azithromycin compared with control subjects (6) . a recent randomized, double-blind, placebo-controlled trial in adults assigning patients to receive 500 mg azithromycin or placebo three times a week for 6 months, showed that azithromycin significantly reduced the exacerbation rate with no significant effect on fev1 (7) . based on the above and other studies, it is recommended that all patients with ncfb be treated with azithromycin. long-term inhaled antibiotics are used for patients with uncontrolled ncfb, but until more recently, data on their efficacy have been lacking. the use of mechanical aids, including chest physical therapy with postural drainage, active cycle of breathing, oscillatory positive expiratory pressure devices, and high frequency assisted airway clearance, also constitute potential adjunct therapies for patients with bronchiectasis. though these modalities are considered to be standard therapy for patients with cf bronchiectasis, their utility is less well proven in patients with non-cf bronchiectasis. it was shown that comprehensive medical care in children with ncfb was associated with a decrease in exacerbation rates (8) . these findings further exemplify the importance not only of identifying ncfb in pediatric patients, but also of ensuring that they receive close surveillance. treatment burden with lack of immediate apparent outcomes cause patients to avoid daily therapy and seek therapy only for exacerbations. resectional surgery and lung transplantation are rarely required. surgical treatment has classically been an option for patients who have localized bronchiectasis with persistent symptoms despite maximal therapy, or recurrent infections with resistant pathogens (9). the prognosis for patients with bronchiectasis is variable given the heterogeneous nature of the disease. because there are so few randomized controlled trials of therapies for non-cf bronchiectasis, patients must be evaluated and treated on an individual basis in a tailored, patient-focused approach in a specialized center to optimally evaluate and treat individuals with bronchiectasis. in humans, the dominant innervation to the airways is provided by the parasympathetic vagus nerve, whose activation induces the release of acetylcholine [1] . acetylcholine, the primary parasympathetic neurotransmitter in the airways, interacts predominantly with nicotinic receptors and the five muscarinic receptor subtypes. in addition to its well-known functions, i.e. bronchoconstriction and mucus secretion regulation, there is evidence that acetylcholine might also modulate inflammatory cell chemotaxis and activation and participate in signaling events that lead to airway wall remodeling [2] . these findings can have significant implications for anticholinergic therapy of diseases characterized by airway inflammation, bronchial obstruction and mucus hypersecretion, since a variety of data indicate that the function of muscarinic receptors is altered in these patients. nicotinic acetylcholine receptors (nachrs) are ligand-gated ion channels, formed by five homologous or identical subunits, arranged to form a central ion channel [3, 4] . depending on the subunit composition, nachrs show different kinetics and pharmacological properties. in lung tissues, the "muscle" nachrs are localized at the neuromuscular junctions of the smooth muscle cells, whilst the "neuronal" nachrs are expressed by autonomic ganglia, but also by almost every cell type, including bronchial and alveolar epithelial cells, endothelial cells, pulmonary neuroendocrine cells, submucosal glands, airway and vascular smooth muscles, fibroblasts and alveolar macrophages [4] . although nachrs are classically linked to the depolarization of the plasma membrane required for neurotransmission, non-neuronal nachrs in the lung act most frequently as calcium channels and have been linked to regulatory proteins controlling cell proliferation [2] [3] [4] . the functional role of nachrs is particularly complex and depends on subunit composition, dose response, and duration of ligand stimulation. although nachr activation often leads to a positive feedback loop that induces receptor expression, chronic stimulation of nachrs can produce channel desensitization and decreased activity. the majority of studies of nachr function in the lung are related to the effects of nicotine, i.e. to tobacco-induced mutagenesis and lung carcinogenesis, whilst little is known on the physiological functions in regulating lung growth and repair, airway epithelial cell proliferation and differentiation and electrolyte transport [3] . muscarinic receptors belong to the large family of g protein-coupled receptors, characterized by seven transmembrane domains. out of the five subtypes identified, only m1, m2 and m3 receptors have been detected in the airway and lung tissues of most mammals, including humans. almost all airway and lung cell types express muscarinic receptors. m1 receptors are present mainly in the peripheral lung tissue and in the alveolar walls: they are expressed by airway epithelial cells, where they modulate electrolyte and water secretion, by goblet cells, where they regulate mucus production, and by the ganglia, where they facilitate parasympathetic neurotransmission. m2 and m3 receptors represent the major populations in the large airways. m2 receptors are expressed by neurons, where they function as autoreceptors inhibiting the release of acetylcholine from both preganglionic nerves and from parasympathetic nerve terminals. in airway smooth muscles, they modulate different ion channels involved in cell contraction, effects that require concomitant m3 receptor-mediated release of calcium from intracellular stores. in fibroblasts and smooth muscles, m2 receptors stimulate cell proliferation and modulate cellular responses associated with airway remodeling [2, 4] . m3 receptors are the dominant receptor subtype in the regulation of airway smooth muscle contraction and of mucus secretion from submucosal glands and goblet cells [3] . m3 receptors can also favor airway smooth muscle proliferation, increasing the responses to epidermal growth factor and platelet-derived growth factor [3] . acetylcholine, in addition to the parasympathetic nerve, is also synthesized and released by a large number of non-neuronal cells, including neuroendocrine, ciliated, basal and secretory epithelial cells where it can act as an autocrine or paracrine signaling molecule. secretory and ciliated cells release acetylcholine into the luminal periciliary fluid, whereas endocrine and basal cells secrete acetylcholine basally [3] . current knowledge suggests that the local auto/paracrine production of acetylcholine by epithelial cells may play a role in regulating various aspects on the innate mucosal defense mechanisms, including mucociliary clearance. acetylcholine is known to increase ciliary beat frequency in the airways and to modulate the release of inflammatory mediators by these cells through m3 receptors and to affect inflammatory cells involved in the pathogenesis of obstructive airway diseases [3] . expression of muscarinic receptors has also been shown by most inflammatory cells, including macrophages (m1-m3) , t-and b-lymphocytes (m1-m5), mast cells (m1), neutrophils (m1-m3) and eosinophils (m1). in these cells, muscarinic receptors appear to be involved in cell proliferation and release of pro-inflammatory mediators [2, 3] . arteries, veins and bronchopulmonary anastomoses also express muscarinic receptors (m3) and dilate in response to acetylcholine released by vagal nerve stimulation. the postganglionic nerve fibers do not form defined synapses to their target cells but a terminal meshwork called 'autonomic plexus' with numerous varicosities, called sites of transmitter release, in variable and only rarely close contact to cells, such as airway smooth muscle [4] . release of acetylcholine from the parasympathetic nerve terminals in the airways appears to be under complex prejunctional regulatory mechanisms. the available data indicate that acetylcholine release can be enhanced by a variety of pro-inflammatory mediators (histamine, bradykinin, neuropeptides) and by b 2 -adrenergic agents, whist it is under the inhibitory control of muscarinic autoreceptors and downregulated by eicosanoids, such as pge 2 , opioids, nitric oxide and a 2 -adrenergic agents [5] . the activity of m3 receptors in smooth muscle appears to be spared or even increased in asthmatics, possibly because of a greater affinity of the acetylcholine binding site. there is also no evidence that muscarinic receptors are overexpressed or upregulated in airway smooth muscle in disorders characterized by bronchial obstruction or hyperresponsiveness although an acquired loss or impairment of neuronal m2 receptor function may be involved in their pathogenesis [15] . these functional changes occur after exposure to allergens, infectious agents (viruses) or pollutants (ozone) and result in increased acetylcholine release from parasympathetic nerves [6] . m2 autoreceptors dysfunction in allergic asthma is caused by the eosinophil basic protein released by activated eosinophils that, upon binding to m2 autoreceptor sialic acids, acts as an allosteric antagonist [3] . with the same mechanism, an early recruitment and activation of eosinophils is thought to cause the airway hyperreactivity that follows environmental ozone exposure [3] . in contrast, viral respiratory infections are purported to induce bronchial hyperresponsiveness through different mechanisms, including: a) the inhibition of m2 receptor synthesis, mediated by the release of interferon-g by activated cd8þ t-lymphocytes; b) the production of neuraminidase, that determines functional impairment of m2 receptor activity by cleaving their sialic acid; c) m2 receptor dysfunction, caused by the activation of the substance p (nk1) receptor overexpressed by influenza, parainfluenza and respiratory syncytial virus [3] . interestingly, increased substance p production has been reported in patients with asthma and gastroesophageal reflux, a disorder that recognizes vagus-mediated oesophageal-tracheobronchial reflexes in its pathogenesis. experiments performed in humans have corroborated the relevance of pathogenesis of m2 autoreceptors in generating airflow limitation showing that m2 receptor selective agonists inhibit cholinergic-induced bronchoconstriction in normal individuals but not in asthmatic patients [3] . defects in m2 autoreceptor activity may also explain bronchoconstriction induced by b-blockers in asthma. these drugs can increase cholinergic tone downregulating the action of endogenous catecholamines on b 2 -adrenoceptors present on cholinergic nerves [3] . thus, in extreme synthesis, the three muscarinic receptor subtypes expressed in the airways have different, somehow conflicting functions: m1 and m3 receptors facilitate cholinergic-induced events, including bronchoconstriction and mucus glands secretory activities, whilst m2 receptors have a feedback inhibitory function, regulating the release of acetylcholine from cholinergic nerve endings. this information is of great importance to understand the activity of the three anti-cholinergic agents that can be used to treat patients with reversible airway obstruction. two of these, ipratropium and oxitropium bromide, are short-acting and non-selective muscarinic antagonists. because of the lack in selectivity, they also block m2 receptors, increasing acetylcholine release, and therefore reducing the degree of their "useful" action on m1 and m3 receptors [3] . in contrast, the more recent longacting anticholinergic drug tiotropium bromide is characterized by a kinetic selectivity for m1 and m3 receptors over m2 receptors: it dissociates rapidly from m2 receptors and very slowly from m1 and m3 receptors [3, 7] . to date, the anti-cholinergic agents most commonly used to treat respiratory disorder in childhood is the "non-selective" ipratropium bromide which, alone or associated with inhaled b 2 -adrenoceptors agonists, has been demonstrated to significantly improve pulmonary function and clinical outcomes in acute asthma, in preschool wheezing, although no long-term assessments have been included [3, 8] . interestingly, preliminary data show that inhaled tiotropium bromide, once daily, is well tolerated and also improves lung function in pediatric patients with cystic fibrosis [9] and in asthmatic adolescents, symptomatic despite inhaled corticosteroids [10] . evidence from experimental models also suggest that tiotropium bromide may also modulate the acetylcholine-induced inflammatory and remodeling changes induced in the airways by a variety of stimuli, leading to hopes of having favorable clinical responses in other respiratory disorders. a relevant role in the pathogenesis of obstructive airway disorders is thought to be played by an increased acetylcholine release, at least in part due to m2 receptor dysfunction. the most commonly prescribed short-acting anticholinergic drug, ipratropium bromide, is not selective for muscarinic receptor subtypes. despite some efficacy in the most common pediatric airway diseases such as asthma and pre-school wheeze and cystic fibrosis, ipratropium bromide is not commonly prescribed as a standalone medication. the more recently introduced anticholinergic drug, tiotropium bromide, has advanced pharmacologic properties such as long duration of action and a functional selectivity for m1 and m3 receptors over m2 receptors, and has shown a good efficacy and safety profile in adult respiratory disorders, such as asthma, cystic fibrosis and chronic obstructive pulmonary disease. ongoing studies are now under way to define its therapeutic role for pediatric airway diseases. inhalation of smoke from datura strammonium, a member of the deadly nightshade family, was recommended for the treatment of asthma in 17th century ayuverdic literature. general gent, himself an asthmatic, on return from india in the early 19th century, was reported to have brought this therapy to england. strammonium and belladonna cigarettes were widely used to treat respiratory disease until the middle of the 20 th century. however there were frequent side effects, including tachycardia, hallucinations, and even addiction. with the introduction of synthetic atropine derivatives with fewer side effects, there has been a renewed interest in anticholinergic therapy for asthma. bronchial smooth muscle tone is predominantly set by cholinergic activation. patients with asthma have increased bronchial smooth muscle tone and mucus hypersecretion, likely as a result of cholinergic activity. anticholinergic medications can relax smooth muscle in children with acute asthma, these drugs also appear to have anti-inflammatory properties, and may reduce goblet cell hyperplasia driven by neutrophil elastase à a feature of severe asthma known to be resistant to steroid therapy. the short-acting anticholinergic agents, ipratropium bromide and oxitropium bromide, have been used in asthma for many years, primarily for acute asthma in the emergency department. paradoxically, although the addition of an anticholinergic medication to a beta agonist can decrease acute asthma severity and hospital admission, studies suggest that continuing the anticholinergic while the patient is in hospital does not hasten recovery or decrease length of hospital stay. however these studies have been small and potentially underpowered. until the past decade, these results have dampened enthusiasm for studying anticholinergic medications as maintenance asthma therapy. this has changed with long-acting anticholinergic (lama) bronchodilators under investigation or are available for treating lung disease: these include tiotropium, aclidinium, glycopyrronium, glycopyrrolate and umeclidinium. the once-daily lama, tiotropium bromide, is demonstrated to improve lung function and decrease the risk of exacerbation in adolescents and adults with moderate to severe asthma, despite the use of inhaled corticosteroids (ics) and long-acting b 2 -agonists (labas). in september 2015, the fda in the united states approved tiotropium for the long-term, maintenance treatment of asthma in patients 12 years of age and older. tiotropium by respimat soft-mist inhaler is now included in the global initiative for asthma report (gina) 2015 global strategy for asthma management and prevention. in phase 3 studies, tiotropium improved asthma symptoms in 68% of enrolled subjects and decreased exacerbations by 21% whilst having a safety profile similar to that of placebo. studies also show that tiotropium was effective in improving pulmonary function (fev1) and decreasing asthma attacks in children age 6-11 with poor asthma control despite use of a medium dose of ics with or without a leukotriene modifier. there was no difference in effectiveness when comparing the fda-approved dose or 2.5 mcg (2 â 1.25 mcg) once daily tiotropium to a higher dose of 5 mcg. initial studies in children younger than 6 years do not appear to show benefit. with increasing knowledge about the diverse actions of the cholinergic system in asthma and the role of muscarinic receptors in the airway, we are gaining an increased appreciation of how anticholinergic medication can play an important role in treating children and adults with chronic and poorly-controlled asthma. the 2008 ers task force opted to not use the term asthma to describe preschool wheezing illness since there was insufficient evidence showing that the pathophysiology of preschool wheezing illness is similar to that of asthma in older ages. the task force referred to pre school wheezing and described episodic (viral wheeze) for children who wheeze intermittently and are well between episodes versus multiple-trigger wheeze for children who wheeze both during and outside discrete episodes.(2) we will therefore in our current discussion refer to this young age morbidity as an entity that should be discussed separately from asthma, acknowledging that much has yet to be learned on the nature of this entity. amongst the many mechanism of virus-induced airway hyperreactivity; a common phenomenon in pediatric practice related to this young age group, studies have shown that cholinergic overactivity such as through the modulation of substance p may mediate virus-induced airway hyperreactivity. virus-specific cd8þ t lymphocytes may induce cholinergic activation through m2 receptor dysfunction.(3) hence anticholinergic medications may have a role in viral-induced wheeze with compounds that display selectivity for m1 and m3 muscarinic receptors over m2 receptors having advantages over nonselective compounds. a number of small studies addressed the role of anticholinergics in acute bronchiolitis but failed to show a role for this acute intervention. a study on 69 infants who were randomly assigned to receive nebulized salbutamol, ipratropium bromide or placebo resulted in faster improved clinical scores and oxygen saturation levels in the bronchodilator groups than in the placebo, but no effect to change the natural course of the disease. (4) in studies on this topic from 1981, inhaled ipratropium bromide administered to wheezy children (3 -32 months of age) improved lung function when measured by total body plethysmography and forced oscillation technique. (5) the authors were unable to differentiate between responders and nonresponders by clinical or by physiological parameters, but submitted that the differential distribution of obstruction between small and large airways may underlie response or lack thereof; and that subjects with a predominance of large airways obstruction were the responders to inhaled ipratropium. a logical if unproven additional speculation was that anticholinergics decrease airway secretions and with it reduce large airway resistance. a cochrane review examining the effect of adding ipratropium bromide to b 2 -agonists in wheezy infants (6) suggested that the combined therapy improved symptom scores after 24 hours compared to the use of jb 2 -agonist alone. the ers task force cited above(2) offered evidence-based recommendations on the definition, assessment and treatment of wheezing disorders in preschool children. addition of ipratropium bromide to short acting b 2 -agonists was suggested for patients with severe wheeze. in the 2014 review of the task force recommendations no reference was made to the use of anticholinergic medications. (7) tracheobronchomalacia it is widely believed amongst pediatric pulmonologists that administration of b 2 -agonists in infants with airway structural instability, predominantly tracheobronchomalacia is detrimental, while the use of anticholinergics for bronchodilatation is safe. this notion derives from a study of only 3 infants with intrathoracic tracheomalacia, using infant pulmonary function testing and demonstrating that flows improved significantly after administration of metacholine but worsened after administration of albuterol.(8) these results suggest that in patients with abnormally collapsible tracheas or large bronchi, stimulation of the smooth muscle can improve airway stability, thereby increasing forced expiratory flows, while relaxation of airway smooth muscle by bronchodilators can exacerbate obstruction. the sole support for this observation comes from a review of a series of patients with tracheobronchomalacia from chile, in whom beta-agonist medications were discontinued while the anticholinergics were not. (9) the effect of anticholinergic medication has not been assessed directly in any study, and thus whether this class of medications may have a different effect compared to beta 2 -agonists in such pathology has not been established. further studies on the effect of the various bronchodilators for such pathologies using newer technologies to assess airway resistance (e.g., forced oscillation) should be undertaken. while more invasive and challenging, a technique of direct quantitative assessment of tracheal collapsibility in infants with tracheomalacia has been described, and may be the most adequate technique to answer this important clinical question. (10) tiotropium bromide in pediatric use -asthma and the asthma-copd overlap syndrome ipratropium bromide has a limited role in childhood asthma, largely due to lack of selectivity. the more recently introduced long-acting muscarinic antagonists/anticholinergic (lama), tiotropium bromide, presents advanced pharmacologic properties such as selectivity for m3 muscarinic receptors over m2 receptors and long duration of action. a high safety profile and increasing evidence of efficacy have rendered it a mainstay medication for copd with an emerging role in adult asthma. few studies have emerged on its role in the treatment of childhood asthma and defining its therapeutic niche for pediatric airway diseases. in a recent 1-year randomized controlled trial, tiotropium add-on therapy in adolescents with moderate asthma, (11) significantly improved lung function and was safe and well tolerated when added to at least ics maintenance therapy. a study of 71 pediatric patients with asthma and chronic cough from an asthma center (12) concluded that tiotropium can be beneficial in 3 distinct patient populations: add-on therapy to asthmatics on maximal maintenance medication, an alternative to highdose inhaled steroids in patients who are experiencing significant side effects, and patients with bronchorrhea as their predominant symptom manifested by a chronic productive cough, the latter population is most likely explained by its drying effect on airway secretions. a recent editorial (13) states "approximately 1 in 12 people worldwide are affected by asthma or chronic obstructive pulmonary disease (copd); once regarded as two distinct disease entities, these two conditions are now recognized as heterogeneous and often overlapping conditions. the term "asthma-copd overlap syndrome" (acos) has been applied to the condition in which a person has clinical features of both asthma and copd". in recent years multiple reports describing this interface between asthma and copd have been published recognizing that the demarcation line between these two entities is difficult to define. while the precise definition in various populations is still being worked out, and it is obvious that the majority of such patients are adults, there is early recognition that some pediatric populations, who are viewed as asthmatic, yet have no airway reversibility, may constitute an early presentation of the overlap syndrome. the mainstay therapies for copd are long-acting inhaled bronchodilators, including longacting b2-agonists (labas) and lamas, with its characteristic member being tiotropium bromide. in patients with copd they are recognized as being equally effective because they reduce air trapping by relaxing airway smooth muscle as a result of reducing the effects of intrinsic cholinergic tone. it is therefore intriguing to speculate that once a better definition of the overlap syndrome emerges in pediatrics, an important role for tiotropium is likely to emerge particularly as a potential steroid sparing medication. peter d sly, ao mbbs, md, dsc, fracp, fers, f thor soc, fapsr, fahms p.sly@uq.edu.au the measurement of lung function is of major importance in clinical practice or respiratory medicine and in respiratory research. much has been learned about the risk factors underlying respiratory disease by measuring lung function in patients and comparing it with that in healthy controls. however, for managing an individual patient or assessing risk of disease onset or progression, it is necessary to know whether an individual's lung function is "normal" or "abnormal". over the years, a number of sets of normative equations have been produced by individual research groups in different parts of the world. these have been incorporated into commercially-available spirometers and used in populations other than those in which the data were collected. this situation was far from ideal, especially as some of the normative equations were many decades old. what is the gli? data were obtained from 73 centers in 33 countries (n ¼ 160,330) ; however not all could be used due to lack of data on ethnicity (which is illegal in france!), small numbers, missing data, lack of quality control and other factors. data were also pooled by region with data from europe, israel, while fev 1 and fvc varied between ethnic groups, they did so proportionally, meaning that fev 1 /fvc was independent of ethnicity. the lower limit of normality for fev 1 and fvc showed age dependence that differed between males and females, reaching 80% by mid-childhood and falling progressively below 80% from approximately 40 years of age. the rate of fall in the lower limit of normal for fev 1 and fvc was identical for women but fvc declined more slowly in males. a ratio of fev 1 / fvc >0.7 is taken to indicate pathological airflow limitation; however, the proportion of the healthy non-smoking population with fev 1 /fvc >0.7 rises steadily to 20-25% at 80 years of age. how well do the gli reference equations predict lung function in people in individual countries? given that the gli reference equations were compiled by pooling data from a variety of sources, one might expect that the equations would provide good estimates of lung function for populations that were well represented in the pooled data whereas they may not for populations either not included or underrepresented in the pooled data. indeed this appears to be the case, with the gli equations adequately representing lung function in australasian caucasians 2 , but not performing as well for adults in brazil 3 , north africa 4 , madagasca 5 , and children in poland 6 and peri-urban and rural india 7 . further study is required to ascertain how widely the gli reference equations can and should be applied. what constitutes "normal" data? an important consideration when creating reference equations is what characterizes a "normal" population and who should be excluded? the dataset used to construct the gli reference equations excluded ever smokers, but is this reasonable? if 20-30% of an adult population smoke, should they be excluded from equations designed to the lung function of that population? maternal smoking during pregnancy results in long-term reduction in lung function 8 but is not generally taken into consideration when defining a healthy population. "healthy" children are often defined as those with no prior asthma or hospitalization for respiratory problems, born full term with birth weight ! 2.5 kg and asymptomatic at the time of testing 9 . however, lum et al. 9 recently demonstrated that with the exception of clear-cut factors such as current and chronic respiratory disease, including children born prematurely or with low birth weight, prior asthma and mildly symptomatic made little difference to the reference equations but increased the generalizability to the target population. this debate continues! the implications of switching to the gli equations will depend on how well the gli equations represent lung function of the local population. in poland, a switch from the 1998 polish reference values to the 2012 gli would see an increase in diagnosis of obstructive lung disease from 17.5% to 20.3% and an increase in diagnosis of restrictive lung disease from 3.8% to 7.6%. whether this represents an over-diagnosis with gli or an under-diagnosis with the old equations is a matter of clinical judgment. the impact on parents and children with cystic fibrosis is likely to be substantial as families tend to focus on lung function, especially fev 1 expressed as a percent of predicted as evidence of the state of the child's lung disease. a change in number for a technical reason must be balanced against the likelihood of creating anxiety in the clinic population. respiratory symptoms are very frequent in infants and young children. special emphasis has been put on symptoms signaling bronchial obstruction and bronchial hyperresponsiveness as these may be associated with early onset of asthma. since the early 1980 0 s, several research groups have been focusing on early events in the development of asthma, especially seeking potential risk factors for predicting persistent symptoms. structural changes in the bronchial mucosa and lung function impairment in children with early obstructive symptoms have also been studied. it was documented that eosinophilic inflammation and remodeling (particularly epithelial basement membrane thickening and increased airway smooth muscle mass) are consistently present in patients with persistent asthma. interestingly, some markers of inflammation and even those of initial remodeling have already been described in children before the clinical diagnosis of asthma could be confirmed 1 . this finding supports the hypothesis of remodeling not being a late consequence of a long lasting eosinophilic inflammation but that it may run in parallel with the development of asthma, if not even precede or initiate inflammation in the bronchial mucosa. this hypothesis was later supported by further research based on bronchial biopsies in infants. eosinophilic inflammation and some markers of remodeling have been documented in the bronchial mucosa of symptomatic children as early as in the second year of life 2 . in a recent study, we were able to show that basement membrane thickening could be found even in young children at risk of developing asthma even without a history of recurrent wheeze 3 . however, the significance of these findings in terms of long term prognosis still remains less documented. it is known that airway hyperresponsiveness in infancy is associated with persistent symptoms later in childhood 4 . also, reduced airway patency at birth was shown to be linked to an increased risk of developing asthma and severe bronchial hyperresponsiveness by the age of 10 years 5 . long-term follow up of children investigated in infancy and reassessed in later childhood have so far showed that reduced baseline lung function in symptomatic infants was significantly associated with subsequent respiratory morbidity as well as with the need of anti-asthma medication at the age of 3 years. in addition, the usage of inhaled corticosteroids at the age of 3 years also seems to be in positive correlation with basement membrane thickening and increased number of mast cells in bronchial mucosa in bioptic samples taken earlier in infancy 6 . this study has thus suggested that early morphological changes in the airway wall might indeed play a role in determining subsequent respiratory morbidity. on the other hand, at the next follow-up of these children at the age of eight years, the positive correlation between current respiratory symptoms and markers of inflammation and remodeling described in infancy was no longer found 7 . this finding is consistent with the results of the follow-up of our group of children where we did not find a significant correlation between lung function (both fev 1 and fvc) measured in preschool age and basement membrane thickness measured earlier in infancy and toddler's age both in the risk group and control group of children (unpublished data). more recently, airway smooth muscle mass has come into the center of interest of many researchers in respiratory medicine. smooth muscle hyperplasia and hypertrophy in the bronchial wall of patients with asthma are considered to be a consistent feature of bronchial remodeling. it is notably a possible dysfunction of newly formed smooth muscle bundles that deserves attention and more studies in this area are urgently required. the first works in children have shown that the increase in the airway smooth muscle mass in the bronchial wall might be associated with school age asthma 8 . lately, another study has described a negative correlation between the airway responsiveness at the age of 8 years and airway smooth muscle mass in infancy 7 . however, this area of airway remodeling still remains poorly understood, especially with regard to its role in childhood asthma. based on currently available data, reduced lung function at birth or in early childhood is apparently associated with the persistence of symptoms and the decrease in lung function in later life. however, it still has not been reliably confirmed whether this low lung function has any correlation with early signs of airway remodeling. more long-term follow-up studies are needed in pediatric patients comprising both tissue biopsies taken in early age followed by longitudinal long-term lung function monitoring. nasal and sinus disease is universal in cystic fibrosis (cf). because nasal and sinus disease usually coexist, we will refer to this as "sinonasal disease". since the mucosa of the sinuses and upper respiratory tract and the mucosa of the lower respiratory tract are similar, disease may be similar in both locations and sinonasal disease could influence the severity of pulmonary disease. this view of the "universal airway" has been demonstrated in patients with pulmonary conditions, such as asthma and copd. in these diseases, an improvement in sinus health is reflected by an improvement in the lower airway disease. this has not been well studied in cf but the implications of this relationship combined with increasing life span makes an understanding of sinonasal disease important to the care of these patients. mutations in the cystic fibrosis transmembrane conductance regulator (cftr) gene in cf carriers appear to be independently associated with a higher prevalence of sinonasal disease; 36% of carriers reported chronic rhinosinusitis compared to the 13-14% in the general population. the bacterial flora of the sinuses changes with patient age, can include anaerobes and fungi, and often mirrors the organisms present in the lower respiratory tract. a link between sinus infection and lower respiratory tract infection may contribute to morbidity following lung transplantation and immunosuppression. somewhat surprisingly, the prevalence of otitis media in cf appears to be no greater than in an age-matched general population. endoscopy and computerized tomography have broadened our understanding of how cf affects the sinuses. endoscopic sinus exams are almost always abnormal and give a better indication of the presence of nasal polyposis than physical examination of the nose alone. nasal polyps become more common with age and may represent a proliferative airway repair mechanism. sinus ct has demonstrated several anomalies characteristic of sinonasal disease in cf such as bulging or displacement of the lateral nasal wall, demineralization of the uncinate process, and hypoplasia or aplasia of the paranasal sinuses. serious complications of sinonasal disease in cf are rare and include mucoceles and periorbital abscesses. these usually require surgery. there are few randomized, controlled trials evaluating medical or surgical treatments of cf sinus disease. sinus surgery may provide some benefit, though there are no established selection criteria for appropriate candidates. the trend today in neonatal intensive care units (nicus) is to be as gentle and less invasive as possible in the care of neonates. this attitude takes place in every field of neonatology, and will discuss its implementation specifically in the respiratory care administered to premature infants with respiratory distress syndrome (rds). 1, 2 prenatal corticosteroid therapy is recommended in all pregnancies with threatened preterm labor below 34 weeks' gestation. recently, it was shown that such therapy could also be beneficial in late preterm infants as it significantly reduced the rate of a neonatal composite of respiratory treatments in the first 72 hours or stillbirth or neonatal death within 72 hours after delivery. 3 at delivery, the term stabilization and not resuscitation is preferred for the vast majority of very preterm infants. only a minority of babies should require delivery room intubation. neopuff can be helpful in the delivery room and the transport to the nicu, and enables the administration of continuous positive airway pressure (cpap) and intermittent positive pressure ventilation under controlled conditions. recent large trials that reflect current practice (including greater utilization of maternal steroids and routine post delivery stabilization on ncpap) demonstrated less risk of bronchopulmonary dysplasia (bpd) or death when using early stabilization on ncpap with selective surfactant administration to infants requiring intubation. the comprehensive strategy to prevent bpd in the nicu is based on ventilatory and non-ventilatory measures. 4 the ventilatory route allows an individualized endotracheal intubation approach. recent studies concluded that early nasal cpap (ncpap) is a safe alternative to immediate intubation even in extremely low birth weight (elbw) infants. 1, 2, 4 endotracheal intubation and ventilation can result in significant damage to premature lungs and are independently associated with cerebral palsy. furthermore, despite new modes of ventilation and surfactant, bpd remains a significant morbidity and its incidence was correlated with the use and length of endotracheal mechanical ventilation. bpd in itself is associated with adverse neurodevelopmental outcome. thus, we need to avoid endotracheal ventilation, if possible. when the infant requires nasal respiratory support (nrs), we should aim for adequate oxygenation (spo 2 of 90-95%), 1 permissive hypercapnia (paco 2 of 45-55 mm hg, ph >7.22) and gentle ventilation, similarly as in endotracheal ventilation. 1, 4 ncpap is recommended as the early primary treatment of active respiratory distress syndrome (rds) (to avoid intubation or as part of the insure [intubation surfactant extubation] approach), or later, post extubation at rds resolution, in order to allow shortening of the duration of endotracheal ventilation and to treat apnea of prematurity. 1, 2 recent studies 1, 4 report comparable rates of bpd in elbw infants treated initially with ncpap as compared to endotracheal ventilation with surfactant administration. can we enhance ncpap and get better outcome for nrs by using nasal intermittent positive pressure ventilation (nippv)? nippv was defined as a method of augmenting ncpap by delivering ventilator breaths via nasal prongs. the rationale behind the use of nippv is the administration of "sigh" to the infant, thus opening microatelectasis and recruiting more ventilation units. it was shown that synchronized nippv (snippv) compared with ncpap may improve the patency of the upper airway, could activate the respiratory drive, improves thoraco-abdominal synchrony, stabilizes the chest wall, improves lung mechanics and decreases the work of breathing in premature infants. when nippv was compared to ncpap for the different indications of nrs, it was shown to enhance the potential of nrs. 4 a recent meta-analysis demonstrated a relative risk reduction for intubation in the first 72 hours in the nippv group compared with ncpap (rr 0.60, 95% ci 0.43, 0.83). 5 the nippv trial 6 was a large international multicenter randomized trial powered to study the important outcome of bpd, recruiting 1,009 extremely low birth weight babies, and it showed no difference between babies randomized to nippv compared with cpap. snippv vs. ncpap for later use, post extubation at rds resolution, as a "bridge" to spontaneous unsupported breathing, was shown to be more effective than ncpap. a pooled meta-analysis showed that snippv was more effective than ncpap in preventing failure of extubation [rr 0.21 (0.10, 0.45)] and the number needed to treat was only 3 infants to prevent one extubation failure. 7 snippv vs. ncpap, post extubation, also tended to decrease the rate of bpd. snippv may also be more effective than ncpap for apnea of prematurity. 4 a meta-analysis regarding apnea of prematurity suggests that snippv is more efficacious with apnea that is frequent or severe. however, the studies performed addressed short-term outcomes and as such could not properly address the incidence of requirement for reintubation. thus, more studies are needed before recommending snippv as standard of care for apnea of prematurity. while non-invasive ventilation is probably safe, its success depends on gestational age. the data indicate that surfactant may still have a significant role in the treatment of rds, especially in elbw infants. recent studies reported on an intubation rate of $50% in their ncpap group in elbw infants. 1, 2, 4 this leads us to the insure approach. this approach may allow the infant to benefit from both surfactant and nrs. a cochrane review 8 concluded that the insure approach with ncpap compared with later selective surfactant administration, continued mechanical ventilation, and extubation from low respiratory support was associated with less need for mechanical ventilation, lower incidence of bpd and fewer air leak syndromes. another option for surfactant application to the trachea without endotracheal intubation was described by using a thin catheter in spontaneously breathing preterm infants receiving ncpap. this technique was reported to reduce the need for mechanical ventilation. 9 there are ongoing trials with inhaled surfactant. to summarize, ncpap is still the most common mode of non invasive respiratory support worldwide. 1, 2 the available evidence supports the preference of early or later use of nippv/snippv compared to ncpap because of minimizing the use and the length of endotracheal ventilation. 4 there are data to suggest that this approach may also reduce the rate of bpd, however this has yet to be shown. 4 the results of a large international rct comparing both primary and post-extubation use of nippv with ncpap, with a composite primary outcome of death or bpd at 36 weeks' corrected age, indicate no additional benefit, or risk, conferred by nippv in comparison to ncpap. 6 whether nippv/snippv is more beneficial than ncpap within the insure approach needs to be shown. recently, heated, humidified high-flow nasal cannula (hhhfnc) is frequently used as a mode of nrs. high flows result in washout of anatomical and physiological dead space and contribute to improved fractions of alveolar gases with respect to carbon dioxide as well as oxygen and decrease the work of breathing and the energy cost of gas conditioning. hhhfnc probably creates positive end expiratory pressure (peep) that may contribute to its beneficial effect. however, the peep that is not monitored had raised concerns regarding the safety of hhhfnc in terms of air leak. recent prospective studies support the notion that hhhfnc is as effective as ncpap for early stages of rds, post extubation 10 and for apnea of prematurity. yet, more studies, especially in the initial treatment of rds and in elbw infants, are needed before adopting hhhfnc as an alternative mode of nrs in these conditions. new modes of nrs such as neurally adjusted ventilator assist (nava), and nasal high frequency ventilation, need to be further studied before concluding on benefits for the short and long term outcomes in premature infants. non-ventilatory measures in the treatment of rds, such as caffeine, nutrition, fluid and pda management and postnatal steroids in certain conditions should be included in the care of premature infants with rds in order to minimize the rate of bpd. 1, 4 the noninvasive ventilator strategy needs to be confirmed by large prospective randomized controlled trials (with long-term follow up) in order to assure it is applicable to most elbw infants. furthermore, the strategy needs to be tailored to individualized infants according to the infant's maturation; antenatal steroid treatment and severity of rds; general condition; and to certain practical nicu conditions such as experience, personnel and timing during the day. for many years, it has been generally accepted that the pathophysiology of rsv bronchiolitis is driven by the inflammatory response evoked by horizontal (i.e., interpersonal) transmission of the virus in the first few months after birth (1). however, a recently published study has brought to the forefront a striking new idea: rsv may be transmitted vertically from the respiratory tract of the mother to the lungs of the fetus (2) . until now, we believed that when a pregnant woman got a cold, the developing fetus was protected by the placenta from rsv and other respiratory viruses. in this study, pregnant rats were inoculated with a recombinant rsv strain that could be tracked through expression of a red fluorescent protein (rrrsv). the same virus was subsequently found in 30 percent of fetuses exposed in utero, as well as in the lungs of 40 percent of newborn rats and 25 percent of rats born to inoculated mothers when tested in adulthood. these data provide proof of concept for the transplacental transmission of rsv from mother to offspring and the persistence of vertically transmitted virus in lungs after birth. notably, the intrauterine rsv infection changed expression and function of critical neurotrophic pathways that control the development of cholinergic nerves in the budding airways and lung tissues (3). these changes in cholinergic innervation of the fetal respiratory tract resulted in the development of postnatal airway hyperreactivity upon reinfection with the same virus (2) . the airway smooth muscle tone was normal in the absence of stimulation and its contraction was normal in the absence of either maternal or neonatal infection. but in pups reinfected with rsv after prenatal exposure to the virus, markedly potentiated contractile responses were measured after either electrical nerve stimulation or methacholine inhalation, suggesting the involvement of both pre-and postjunctional mechanisms. these findings are consistent and provide a plausible mechanism to the epidemiologic evidence that early-life rsv infection -or possibly reinfection -predisposes a subpopulation of children to recurrent wheezing and asthma that typically spans through the first decade of life even in the absence of atopic phenotype (4). to our knowledge this is the first report of vertical transmission of rsv, or for that matter any common respiratory virus. a number of infectious agents, including herpesviruses and retroviruses, have been shown to cross the placenta and establish persistent infection in offspring. the new evidence extends this possibility to other infections, such as rsv, once regarded as temporary and localized and that instead may be longer lasting and more pervasive than we thought. also, as shown for other viral pathogens, if rsv seeds the fetus before full t-cell maturation, this could lead to induction of prenatal tolerance and justify the limited synthesis of interferon and other inflammatory cytokines that have been noted when newborns develop severe infections (5) . vertical rsv and asthma -the general concept that we have been working under for decades is that nothing bad happens in the lungs until the baby is born -even with serious conditions such as cystic fibrosis -and that the lungs are "clean" of pathogens at birth. but if human studies replicate the findings from animal models outlined above, our understanding of the pathogenesis of rsv infections would be completely changed. it would turn back the clock of respiratory developmental diseases by months and mean that we would need to start thinking about lung development and pathology during pregnancy rather than at birth. this could create a paradigm shift by extending our focus on prevention from the first few years after birth to also include the last few months before birth. this new paradigm is in line with the emerging evidence that many (or most) chronic inflammatory, degenerative, and even neoplastic diseases plaguing adults have their origins from often-subtle events occurring during fetal life. the "foetal programing hypothesis" was originally formulated by dr. david barker more than two decades ago to explain the extensively reproduced and confirmed epidemiologic evidence that low birth weight predisposes to cardiovascular disease in late adulthood (6) . dr. barker died aged 75 in september 2013, leaving the legacy of this initially controversial, but now widely accepted, idea that common chronic illnesses such as cancer, cardiovascular disease and diabetes result not always from bad genes and an unhealthy adult lifestyle, but from poor intrauterine and early postnatal health. in one of his last public speeches, he argued: "the next generation does not have to suffer from heart disease or osteoporosis. these diseases are not mandated by the human genome. they barely existed 100 years ago. they are unnecessary diseases. we could prevent them had we the will to do so." we believe the same concepts can be extended to chronic obstructive airway diseases like asthma and copd. asthma is the final product of complex interactions between genetic and environmental variables. prenatal events like the intrauterine exposure to viruses with specific tropism for the developing respiratory epithelium (7) or imbalanced maternal diet (8) will cause a shift in the trajectory of structural and functional airway development towards a hyperreactive phenotype. the same intrauterine exposures can affect gene expression via epigenetic modifications like dna methylation, histone acetylation, and by altering the relative expression of regulatory micro-rnas (9) . the resulting neonatal phenotype will predispose the child to aberrant responses to common respiratory infections and airborne irritants, thereby increasing the risk of obstructive lung disease later in life. postnatal events, such as exposure to indoor and outdoor pollutants and allergens, can further shift the equilibrium of the adult phenotype by exacerbating airway inflammation and hyperreactivity (10) . the continuous range of possible developmental trajectories and multiple sequential events acting during development will define the severity and duration of disease. the incidence, severity and mortality from childhood pneumonia has declined substantially in the last decade due to improved socioeconomic conditions, better access to care, wider implementation of effective management and preventative strategies and development and availability of improved vaccines, particularly the pneumococcal (pcv) and h influenzae type b (hib) conjugate vaccines. [1] however, pneumonia remains the leading cause of childhood mortality globally outside the neonatal period and a major cause of morbidity and hospitalization despite good immunization coverage. [2, 3] further, early childhood pneumonia has increasingly been associated with the development of chronic noncommunicable respiratory diseases into childhood and adulthood, such as asthma or chronic obstructive airways disease (copd). [4, 5] with improved global coverage of the newer conjugate vaccines, it is likely that viral causes of pneumonia may be responsible for an increasing proportion of pneumonia cases. [6] however, defining the etiology of pneumonia may be challenging as it can be difficult to distinguish colonizing from pathogenic organisms in respiratory specimens, blood culture rarely is positive and pneumonia, especially severe disease, may frequently be due to multiple co-pathogens. the development of better methods for specimen collection and of molecular diagnostics have provided more sensitive techniques to define potential etiologic agents but further compound the difficulty of ascribing pathogenicity. [7, 8] despite these limitations, studies in the post-pcv era have reported an increasing predominance of viruses in childhood pneumonia cases, with a virus identified in 70-90% of cases. [9, 10] in children vaccinated with 13valent pcv (pcv13), rsv has been reported to be the predominant pathogen in case control analyses from both high income countries and lowmiddle country settings. however, there is frequent co-occurrence of other potential pathogens with rsv, including bacteria and other viruses. [9] children under 6 months of age are at highest risk of rsv disease. [11] to adequately interpret data on viruses in the context of childhood pneumonia, the prevalence of these in healthy control children must be considered. using case control designs, viruses identified in association with pneumonia have been rsv, influenza virus and human metapneumovirus (hmpv); adenovirus, parainfluenza virus and coronavirus have been variably associated with pneumonia while the prevalence of rhinovirus has consistently been similar in cases and controls. [9, 10, 12, 13] the use of quantitative measurements of viral load has not shown to be useful in distinguishing cases from controls except for rsv and for hmpv, but the presence of these alone is sufficient to ascribe etiology. these studies indicate that rsv is a major cause of pneumonia in the era of conjugate vaccines for bacterial pathogens, particularly in young infants. however they also highlight the limitations of current diagnostic strategies, particularly the poor sensitivity of current tests for bacterial etiology and the potential for incorrectly assigning etiology based on molecular diagnostics. they also provide further data on the complexity of ascribing pneumonia etiology, showing interactions between multiple potential pathogens. despite these limitations, the emerging data indicate that a key strategy for reducing the burden of childhood pneumonia lies in prevention of rsv disease in young children. identifying the etiology of pneumonia is key for initiating appropriate management strategies particularly use of antibiotics and to guide development of new vaccines. the reduction in bacterial pneumonia through conjugate vaccines underscores the need to reconsider the empiric treatment of pneumonia in settings where there are strong immunization programs. case management with antibiotics for pneumonia or severe pneumonia in the world health organization integrated management of childhood illness (imci) program has been a highly effective strategy for reducing mortality prior to widespread conjugate vaccine availability [14] , but defining the residual burden and identifying clinical or laboratory features that distinguish bacterial from viral pathogens will be important before any change in pneumonia strategy can be recommended globally. late preterm (lp) newborns (born at 34-0/7 to 36-6/7 weeks gestational age) comprise the fastest growing subset of neonates, accounting for approximately 74% of all preterm births and about 8-9% of total births in the us [1] . "late preterm" infants are born near term, but are "immature". the late premature birth interrupts normal in utero fetal development during the last 6 weeks of gestation that are probably a "critical period" of growth and development of the fetal lungs [2] . three factors play a role in the respiratory vulnerability of lp infants [2] : 1. prematurity with its developmental and consequently physiologic components; 2. heightened rate of respiratory morbidity in the neonatal period; 3. short-term pulmonary outcome respiratory complications are the prime morbidities of lp infants [2] . a large retrospective study [3] found that the odds of respiratory morbidity (respiratory distress syndrome [rds] , transient tachypnea of the newborn [ttn], pneumonia, respiratory failure, surfactant administration, and mechanical ventilation) decreased significantly with each advancing week of gestation up to 38 weeks compared with 39 to 40 weeks. despite a relatively low absolute risk for rds or ttn at 34 weeks compared with more premature infants, this rate poses an increased risk for lp infants when compared with term infants [2] . acknowledgement of these morbidities led to studies aiming to decrease this burden. a recent large randomized controlled study [4] showed that administration of betamethasone to women at risk for late preterm delivery significantly reduced the rate of a neonatal composite of respiratory treatments in the first 72 hours (the use of continuous positive airway pressure or high-flow nasal cannula for at least 2 hoursr, supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least 4 hours, extracorporeal membrane oxygenation, or mechanical ventilation) or stillbirth or neonatal death within 72 hours after delivery. of note, neonatal hypoglycemia was more common in the betamethasone group than in the placebo group. late prematurity may affect the respiratory system in the long term [2] . several studies reported an association of preterm birth (30-36 weeks' ga) without clinical lung disease with altered lung development and function [2] . friedrich et al. [5] in a longitudinal study found that despite normal lung volume, healthy preterm infants had persistently reduced airflow through the age of 16 months and concluded that preterm birth in itself was associated with altered lung development. a single study [6] showed a potential improvement, especially for large airway function, with advancing age. a recent large prospective cohort study showed that the number of hospitalizations caused by respiratory problems during the first year of life was doubled in moderately/late preterm (32-36 weeks' ga) compared with term infants [7] . at preschool age, moderately preterm infants revealed more nocturnal cough or wheeze during or without a cold and increased use of inhaled steroids. at the age of 5 years, rates of respiratory symptoms between moderate and early preterm born (<32 weeks' ga) children were similar; both were higher than in term born children. whether lp birth is associated with airway disease such as asthma in early childhood remains controversial [2] . different findings in published studies could result from the different methods of asthma diagnosis, age groups at diagnosis, and from the difficulties in diagnosing asthma in early childhood. a recent study [8] found that late preterm birth history is not independently associated with childhood asthma until 7 years of age. lp infants are more vulnerable to viral respiratory infections, particularly rsv, which are more severe in these infants vs. term infants. the pernicious combination of rsv bronchiolitis affecting an a priori compromised lung/ airways of lp infants may have a lasting effect on respiratory function and consequent long-term morbidity [2] . long-term persistence of an early decrease in pulmonary function tests (pft) was demonstrated by a longitudinal follow-up into early adulthood for an unselected random population in the tucson children's respiratory study [9] . these observations suggest that the notion of a "critical developmental period" for the respiratory system does exist. deficits in lung function during early life, especially if associated with lower respiratory illnesses (especially rsv), increase the risk for chronic obstructive pulmonary disease later in adult life [10] . summary lp infants are born during a "critical developmental time period" for the lungs. this may result in short and long-term pulmonary consequences. in addition, to screen the population at high-risk for disease. therefore, the effectiveness of early case finding should be a priority, but it depends on several factors such as health care system, contact tracing, and laboratory diagnosis. the diagnosis of tb in children is a common clinical challenge, and relies on a careful assessment of history of exposure, clinical examination, and relevant investigations. the most recommended approach to the diagnosis of tb in both children and adults is based on the who guidelines recommendations from 2010 and 2014 (table 1) . (2, 3) important factors to consider in all children with suspected tb is the endemic setting as well as the age and immune status of the child. in countries with a low incidence of tb, a positive contact with a case in combination with suggestive symptoms makes diagnosis more straightforward. in high tb endemic areas, a history of tb contact remains important, but is much less sensitive, given that transmission often occurs through unknown source cases. (5) laboratory tests for the diagnosis of infections can be grouped into two groups: detection of microbes (or components) and detection of components of the immune response to the microbe. the sensitivity of the first group will depend on the quality of the specimen and the concentration of microorganisms. this group includes microscopy, culture, elisa, and nucleic acid detection (pcr). the second group measures the activity of the immune system against microbe-specific antigens in the possibly infected host. this category includes antibody detection and activated t cells. the gold standard for the diagnosis of tb is bacillary detection by smear or culture. in adults, microscopy can detect up to 60% à 70% of culture-positive samples. in children, this does not work as well due to limited access to appropriate body specimens, and also because children usually have paucibacillary disease, since cavitating disease is rare in children. studies have shown that under best circumstances, acid-fast bacilli sputum smear is positive in only about 10-15% of children with tb while culture gives a better yield of 30-40%. until recently, the diagnosis of ltbi has been based exclusively on the tst, which has relatively poor sensitivity and specificity. despite these limitations, it remains the standard of care for diagnosis of ltbi worldwide, particularly in low-income countries. interferon gamma release assays (igras) measure the in vitro response to specific m. tuberculosis antigens. although they offer several advantages over tst such as better specificity, single visit, little inter-observer variability, and no booting effect; they have not been found better than tst, and are not able to predict the risk of infected individuals developing active tb disease. given their increased cost, replacing tst by igras as a public health intervention in resourceconstrained setting is not recommended. novel approaches to confirmation of tb have been developed. these include methods based on rapid culture techniques and genotypic techniques that improve detection of m. tuberculosis. an example is the xpert mtb/rif assay, which is a fully automated realtime dna based test that can detect both tb and rifampicin resistance in less than two hours. (3, 6, 7) as expected, it should be used rather than conventional microscopy and culture in children suspected of having mdr-tb. the clinical diagnosis of primary tb in children remains challenging because of non-specific signs and symptoms and difficulty with acquiring diagnostic specimens. because of this, the diagnosis of primary tb in practice, relies on a combination of clinical features and chest x-ray (cxr) findings. the detection of lymphadenopathy in the hilar and para-tracheal regions on the frontal cxr, supported by identification of subcarinal lymphadenopathy on the lateral cxr, represent a useful surrogate marker of tb at relatively low cost. however, sensitivity and specificity for identifying lymphadenopathy on cxr in children is relatively poor with significant inter-observer variation in the interpretation of radiographs, complicated further by poor quality of radiographs. affecting both accuracy and observer agreement is the lack of standardized imaging criteria and lymph nodes sizecriteria for a positive diagnosis of primary tb. attempts are therefore being made to establish 'objective' chest radiograph signs backed up by a standard set of images as a guide. ultrasound is an especially attractive imaging alternative to cxr as it does not involve radiation or require sedation and because it is relatively cheap and mobile. ultrasound of the mediastinum has been used to detect mediastinal lymphadenopathy and can also be used to detect extrapulmonary tb through abdominal imaging, at the same sitting. it is particularly useful in rural settings where no other imaging is available. the ability to store digital ultrasound images and cine-loops also enables teleradiology support by expert interpretation and opinion, from a distance. computed tomography (ct) and magnetic resonance imaging (mri) are obvious diagnostic imaging considerations that will improve diagnostic accuracy of primary tb, but the radiation dose in ct, the need for anesthesia in mri, the limited availability and high cost are real barriers to their clinical utility. mri is preferred to ct because it does not involve ionizing radiation. however, the disadvantages of mri for lung imaging (poor signal generated from the air in the lungs and movement artefacts from breathing), the cost and the requirement for the child to keep still for a prolonged period (requiring anesthesia) have slowed its use in thoracic infections. yet, whole body mri, including thoracic imaging is mainstream for detecting lymphadenopathy in childhood lymphoma. the preferred imaging technique varies with the suspected pathology and available equipment. dynamic imaging techniques such as inspiratory/ expiratory cxr, fluoroscopy, and inspiratory/expiratory or cine ct permit the lungs and airways to be imaged at different phases of the respiratory cycle. inspiratory/expiratory cxr and inspiratory/expiratory chest ct have long been the preferred initial imaging methods for detecting foreign body aspiration or bronchiolitis obliterans, respectively, on the basis of air trapping rather than direct visualization of the airway obstruction. fluoroscopy has historically been the preferred noninvasive method for diagnosing tracheobronchomalacia due to its ease of performance, even in uncooperative patients, and its high specificity, but it is limited by its subjective interpretation, low sensitivity, poor depiction of the paratracheal structures, and inability to simultaneously display the anteroposterior and lateral walls of the airway and quantify luminal cross-sectional area 1 . in infants and children too young to comply with breath-hold instructions, inspiratory/expiratory phases can be simulated by imaging during right/left lateral decubitus or prone/supine positioning. controlled-ventilation ct under sedation or anesthesia also permits inspiratory/expiratory imaging of the lungs and airways in uncooperative patients. dynamic cine ct technique allows the airways to be imaged sequentially during successive phases of the respiratory cycle, but coverage was initially limited to short (4 cm or less) segments of the airway, resulting in sampling misregistration and preventing synchronous evaluation of the true extent and severity of airway collapse during the same phase of the respiratory cycle 1 . made possible by recent technologic advances including more rapid gantry rotation and wider detector arrays (up to 16 cm craniocaudal coverage), dynamic volumetric cine ct now allows all or nearly all of the lungs and central airways to be imaged rapidly and sequentially throughout the respiratory cycle without the need for sedation or intubation. this technique is capable of providing multiplanar, 3d and 4d information about the airways during normal tidal breathing or forced expiratory maneuvers, as well as depicting the relationship of the airways to the adjacent vasculature if intravenous contrast is administered 2 . with dynamic volumetric cine ct, intrinsic and extrinsic causes of airway narrowing can be distinguished and fixed airway stenosis can be differentiated from expiratory central airway collapse due to tracheobronchomalacia (softening of tracheobronchial cartilage) or excessive dynamic airway collapse (inward bulging of the posterior membrane) 3 . tracheobronchomalacia is primary (congenital) in approximately 1/2100 children and often resolves in isolated mild to moderate cases by 2 years of age as the cartilage geometry and composition matures and posterior membrane tone develops. tracheobronchomalacia is often accompanied by gastroesophageal reflux disease and is associated with other foregut anomalies, especially esophageal atresia and tracheoesophageal fistula. tracheobronchomalacia can be secondary to extrinsic compression, chronic airway inflammation, intubation, or positive pressure ventilation and is identified in about onefourth of children with chronic respiratory symptoms or signs such as wheezing, barking cough, recurrent respiratory tract infection, apnea, cyanotic spells, or difficulty weaning from respiratory support 4 . tracheobronchomalacia was originally defined as >50% reduction in airway cross-sectional diameter during coughing, but false positives are very common with this definition, especially for the bronchi in which physiologic expiratory airway narrowing is more pronounced than for the trachea. the shape and cross-sectional area of the airway lumen can be precisely determined by ct, but there is no current consensus on the optimal threshold degree of expiratory airway collapse for a diagnosis of tracheobronchomalacia among children of varying ages with or without coexisting lung disease during either tidal breathing or forced expiration. expiratory collapse of normal airways can occur in the setting of obstructive lung disease such as asthma or bronchopulmonary dysplasia due to increased pleural pressure and increased peripheral airways resistance that reduces airway transmural pressure 4 . dynamic volumetric cine ct provides objective information to classify expiratory central airway collapse according to the femos (functional status, extent, morphology, origin, severity) system 5 , but it should be noted that the degree of luminal narrowing is only one factor in airflow limitation. evidence of airway compression or expiratory collapse on imaging does not necessarily indicate a condition requiring therapeutic intervention, and correlation with the clinical symptoms, signs, risk factors, and pulmonary function tests is necessary to determine the functional significance 1, 4 . in addition to the noninvasive nature, the advantages of dynamic volumetric cine ct over bronchoscopy include the ability to directly evaluate for vascular structures or soft tissue masses that impinge on the airway, depict the airways distal to a narrowing impassable by bronchoscope, and assess the lung parenchyma for conditions such as air trapping that may be associated with dynamic central airway collapse 2 . a disadvantage of ct is the exposure to ionizing radiation. for perspective, dynamic airway ct incurs a radiation dose similar or less to than that from a year of natural background radiation exposure 6 . dynamic cine magnetic resonance imaging (mri) avoids exposure to ionizing radiation and is capable of imaging the central airways and vasculature 7 , but is limited by a longer scan time, more frequent need for sedation/anesthesia and less detailed depiction of the lung parenchyma compared to ct. additional studies in children are needed to determine how the anatomic and functional information provided by dynamic ct is best applied to the diagnosis, treatment planning, and post-therapeutic monitoring of pediatric airway disorders. the main driving force to develop sophisticated mri sequences for pediatric chest imaging is that mri is a radiation-free technique. this is especially important for children who are more sensitive to ionizing radiation than adults [8] . this justifies the use of chest mri for short-and long-term follow-up of chronic lung diseases such as cystic fibrosis (cf), so as to reduce the lifelong cumulative radiation dose [1] . chest mri is challenging because of the magnetic heterogeneous environment in the chest region [2] . lung parenchyma is a low proton density structure and hence has a reduced signal-to-noise ratio [3] . in addition, the numerous airtissue interfaces within a voxel induce strong localized microscopic magnetic field gradients, which produce extensive mri signal dephasing leading to extremely short t2 star (t2 ã ) and geometric distortions. these effects become stronger at higher magnetic field strengths (i.e. 3 t), which are increasingly used in clinical settings for enhanced signal-to-noise ratio [1] . however, signalto-noise ratio in cases of lung pathology, such as pneumonia, edema, tumors and atelectasis, is increased by higher fluid content and amount of tissue. these conditions result in higher proton density and improved visualization [4] . moreover, mri has the advantage of integrating anatomical and functional information in a single examination, a possibility not as readily available with other imaging modalities. mri can provide functional information regarding lung perfusion using gadolinium contrast [5] , lung mechanics using dynamic acquisitions [6] , and ventilation using inhaled hyperpolarized gases [7] , oxygen enhancement or dynamic motion-based methods [8] . moreover, dwi is able to give new insight in the management of pneumonia, especially in cf patients [9] . chest mri has reached the point where it can be used in routine clinical practice. although mri cannot yet be compared to ct for anatomical detail, new sequences allow acquisition of lung images with high diagnostic quality in less than 15 s, which makes mri feasible in a clinical setting. mri can be considered an alternative to ct for the diagnosis of lung diseases and for monitoring response to treatment in pediatric lung disease. moreover, in some diseases that require long-term follow-up, such as cystic fibrosis, mri can play an important role in reducing lifelong radiation exposure related to repeated ct scans. furthermore, mri has the ability to offer functional information: information regarding lung mechanics, perfusion and ventilation can provide new insight in different pediatric lung diseases. this functional information can not only improve our understanding with regard to the pathophysiology of pediatric lung diseases, it can also open new diagnostic and therapeutic options. obstructive sleep apnea syndrome (osas) is characterized by prolonged partial airway obstruction and/or intermittent complete obstruction (obstructive apnea) during sleep, affecting about 2% to 3% of children [1] . osas is a complex syndrome with multiple etiologic factors: the main causative factor is adenotonsillar hypertrophy while other conditions, such as craniofacial dysmorphism, obesity, hypotonic neuromuscular diseases, despite inducing reduction of the caliber of the upper airways, are commonly mistreated [2] . adenotonsillectomy has been considered for many years the only treatment in children with osas although its efficacy remains uncertain, depending on the severity and on the presence of other co-morbidities, [3] . since a residual osa is reported in a large proportion of children after adenotonsillectomy [3] , and children with osa display a complex phenotype (mild or major craniofacial anomalies, and/or comorbid obesity, and/or adenotonsillar enlargement), a multi-therapeutic approach to pediatric osas and a defined timing of therapy are required [3, 4] . a narrow upper airway accompanied by maxillary constriction and mandibular retrusion is commonly reported in children with osas [5] . the skeletal conformation showing hyperdivergent skeletal growth pattern associated with posterior displacement of the tongue base, increases the upper airway narrowing and craniomandibular, intermaxillary, goniac and mandibular angles leading to a high-arched (ogival) palate [6] . rapid maxillary expansion (rme) is the most common dento-facial orthopedic procedure used in young patients to treat maxillary transverse deficiencies, starting up to 4 years of age. recently, it has been demonstrated to be efficacious to treat osas in children with a narrow palate and malocclusion: a significant reduction in the apnea-hypopnea index and in diurnal symptoms after six months of therapy with rme [7] , and positive long-term effects in children with osa and malocclusions treated with rme have been reported [8] . similar results were obtained after one year of treatment with rme in 16 preschool and school-aged non obese children with osas and dental malocclusions with a significant drop in clinical symptoms as well as apnea-hypopnea index [8] . this study also demonstrated that starting treatment early when the bone is still extremely plastic and its growth rate is maximum increases the percentage of success of rme treatment. a two-year follow up after the end of the rme application was performed in the same population of children confirming a stable decrease in apnea-hypopnea index, an increase of mean overnight oxygen saturation and a persistent improvement in clinical symptoms [9] . finally, a recent randomized study showed preliminary results regarding the effect of rme applied before adenotonsillectomy compared to the effect of rme applied after surgery, in children with osa. no significant differences between the two different approaches were described [10] . in conclusion, orthodontic treatment is a valid treatment for osa, improving clinical symptoms, respiratory parameters measured during psg with long lasting effect. the widening of the maxilla, the corrections of dental malocclusions and the correct relationships between maxillary and mandibular arches with respect to the anterior cranial base, are the main craniofacial changes induced by rme that may explain the efficacy of orthodontic therapy. orthodontic therapy should be encouraged in pediatric osas, and an early approach may permanently modify nasal breathing and respiration, thereby preventing obstruction of the upper airway. towards the turn of the century, david gozal's group published a series of papers that raised important questions. in a sample of 297 1 st grade pupils whose school performance was in the lowest decile of their class ranking, they found that 18% had sleep-associated intermittent hypoxia and/or hypercapnia; school performance improved in those whose parents had opted for adenotonsillectomy (1) . they then showed that 13% of 14-15 year olds with poor school performance had parent-reported snoring at age 4-5, compared to only 5% among those with good school performance (2). finally, a group of first graders with snoring, but no obstructive sleep apnea, i.e. an obstructive apnea index <1, performed worse on measures related to attention, social problems and visuospatial function than non-snorers, suggesting that simple snoring may not be as benign as hitherto widely believed (3) . against this background, we set out to perform the hannover study on sleep apnea in childhood (hassac), a community-based cross-sectional study on several aspects of sleep-disordered breathing (sdb) in 1144 primary school children incorporating a two-phase sequential screening procedure: participants were screened for symptoms and signs of sdb using an sdbquestionnaire and home pulse oximetry (hpo), those with outlying results on either screening method subsequently underwent an abbreviated home polysomnography (hpsg) for a final diagnosis of obstructive sleep apnea syndrome (osas). overall, participants were representative of the underlying population of third-graders in the study region. we found that 10.1% of this cohort were habitual snorers, while the population prevalence for osas was 2.8% (4, 5) . we then wanted to know how these symptoms affected behavior and academic achievements. for this, we used parental questionnaires and collected teachers' ratings, and defined poor school performance as grade 4 or worse in the last school report form, or requirement for special assistance, with this classification roughly corresponding to the lowest quintile of a class. we found that children with habitual snoring, compared to those who never snored, had 3-10 times the odds for daytime symptoms such as hyperactivity, difficulty concentrating, falling asleep while watching tv or at school or having peer problems, and 2-3 times the odds for poor school performance in mathematics, science and spelling (4, 6) . there was a clear dose-effect gradient, i.e. the proportion of children with poor school performance increased with increasing frequency of parent-reported snoring. considering its high prevalence, and assuming a causal link to disturbed behavior, habitual snoring appeared to be a substantial public health problem in primary school children. given this association, we wanted to know how this is mediated, i.e. whether this is mainly through detrimental effects of intermittent hypoxemia or more likely due to recurrent arousal. contrary to our hypothesis, the increased odds for poor school performance or daytime symptoms associated with habitual snoring stayed the same once children exhibiting intermittent desaturation in their overnight pulse oximetry recording had been excluded, suggesting that even so-called benign snoring, i.e. snoring without hypoxemia, may in fact not be benign. if not via intermittent desaturation, could the relationship with poor school performance be mediated via frequent arousals elicited by recurrent obstructive apnea? to address this question, we took advantage of the fact that children with an abnormal questionnaire score in our hassac study also underwent hpsg. thus, we re-analyzed our data on the relationship of snoring with daytime symptoms and poor school performance after excluding all children with a mixed-obstructive apnea/hypopnea index (maohi) !0.5, but again, the risk for poor school performance was not reduced among snorers after excluding those with recurrent apneas. given that simple snoring has such a strong association with daytime symptoms à are these reversible? in our hassac study, we could collect 1year follow-up data in 82 snorers and 80 controls. among these, 42 snorers (51%) had stopped snoring. while their scores for emotional problems, hyperactivity and problems with peers improved, their school performance did not (6) . this is in line with other data suggesting that reduced scores in executive functioning and iq seen in children prior to adenotonsillectomy may not improve following this operation (7) . similarly, in the avon longitudinal study on parents and children (alspac), even those whose sdb symptoms peaked at age 30 months and abated thereafter still had almost twice the odds for hyperactivity and 60% higher odds for behavioral problems at age 7 years (8). taken together, there is now a growing body of evidence that frequent snoring in children may not be as benign as previously thought, but may instead be associated with impaired behavior and poor academic achievements. these problems may even persist after snoring ceases, which à if these statistical associations were confirmed as causal à would argue for their early recognition and treatment. here, it is encouraging to see that in another longitudinal study on snoring and daytime symptoms, the proportion of children who did not snore at age 2 and 3 years was 42% in those who were breastfed for less than 1 month, but 83% in those who were breastfed for 12 months or longer (9) , suggesting that breastfeeding may reduce the risk of snoring during early childhood. in addition, given the limited availability of sleep labs, we urgently need better and easier-toperform screening methods to identify those who may need treatment for their snoring, e.g. in whom poor school performance can be predicted from a screening test (10) . also, interventions such as nasal steroids, montelukast or orthodontic treatment may deserve further study. diagnosis of osas using home respiratory polygraphy (hrp). alonso-alvarez et al. 3 prospectively assessed the diagnostic reliability of hrp in children aged 2 to 14 years with a clinical suspicion of osas. they found a sensitivity of 91% and a specificity of 94% and concluded that hrp emerges as a potentially useful and reliable approach for the diagnosis of moderate/ severe osas in children. drug-induced sedation endoscopy (dise) aims to reproduce upper airway obstruction during sleep and is gaining increasing popularity, with the hope of guiding efficient surgery and cure osdb children. in a meta-analysis, galluzi et al. 4 concluded that dise may benefit a minority of children with osas, and should only be used in children with unremarkable clinical evaluation or upon persistent osas after at. obstructive sleep-disordered breathing and obesity pathogenesis of osas in obese adolescents. literature on the pathogenesis of osas in adolescents is very limited. schwab et al. 5 prospectively compared upper airway magnetic resonance imaging in 137 adolescents aged 12 to 16 years. results indicated that lymphoid tissue, rather than other soft tissue components (tongue, lateral pharyngeal walls, parapharyngeal fat pads), are the primary upper airway anatomical risk factors for osas. while the pathogenesis of osas is clearly multifactorial (e.g., decreased upper airway reflexes in osas obese adolescents) and often require additional treatment, the results are clinically important since they suggest that at should still be considered as the first-line treatment in adolescents with osas. osdb and metabolic syndrome. in a systematic assessment of the literature on the interactions between sleep, osdb, obesity and disruptions of metabolic homeostasis in children and adolescents, hakim et al. concluded that obesity and osdb appear to contribute to the initiation and progression of each other, and that both are linked to the metabolic phenotype 6 . one intriguing mechanism postulates that osdb/ disrupted sleep as well as other factors favoring obesity, such as high-fat/ fructose diet, disrupt the gut microbiome and lead to increased systemic levels of lipopolysaccharides, in turn promoting inflammation and metabolic dysfunction. treatment of sleep-disordered breathing in children watchful waiting. chervin et al. 7 followed 192 children aged 5 to 9 years with mild/moderate osas after seven months of watchful waiting only. they found resolution of osas in 42% of the children. independent predictors of resolution were lower ahi and normal waist circumference. the authors concluded that, in practice, a baseline low ahi and normal waist circumference, or low pediatric sleep questionnaire and snoring score, may help identify an opportunity to avoid at. myofunctional therapy (mt). camacho et al. 8 performed a meta-analysis of the use of mt as a treatment for osas in adults and children. although the total number of patients (especially children, n ¼ 25) was low, the effects were highly significant. overall, mt decreased ahi by 50-60% in pediatric and adult patients. in children, a positive effect was reported when used as the only treatment in mild osas as well as to consolidate osas cure after at þ rapid maxillary expansion. the authors concluded that mt could be an adjunct to other osas treatments in patients of all ages. evolution of obstructive sleep-disordered breathing in children evolution in preschool children with osdb. walter et al. 9 investigated the long-term evolution of osdb in preschool-aged children with normal weight. half of the preschoolers with osdb were treated, most often by adenoidectomy and/or tonsillectomy. overall, osdb resolved in half of the children, either spontaneously (35%) or with treatment (57%). however, 40% still had osas, similarly to observations in school-aged children. intriguingly, complete resolution of osdb at three years post-treatment was more likely in preschoolers with moderate/severe osas compared to those with mild osas or primary snoring. long-term evolution of osas. spilsbury et al. 10 reported results on both remission and incidence of osas in 490 participants who underwent psg at 8-11 and 16-19 years of age. the authors first observed that osas in middle childhood usually remitted by adolescence. secondly, while habitual snoring and obesity predicted osas at each time point, distinct additional risk factors for osas were found in middle childhood vs. adolescence. hence, prematurity, a disadvantaged neighborhood or african-american origin also predicted osas in middle childhood, while risk factors in adolescents included male sex and previous at. finally, obesity, but not habitual snoring, in middle childhood predicted adolescent osas. these results confirm that prevention and 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bronchopulmonary dysplasia: nhlbi workshop on the primary prevention of chronic lung diseases guidelines on the early management of infants diagnosed with cystic fibrosis following newborn screening cystic fibrosis foundation evidence à based guidelines for management of infants with cystic fibrosis recommandations nationales pour la prise en charge du nourrisson d epist e atteint de mucoviscidose. consensus de la f ed eration des centres de ressources et de comp etences de la mucoviscidose growth and pulmonary outcomes during the first 2 years of life of breastfed and formula-fed infants diagnosed with cystic fibrosis through the wisconsin routine screening program do infants with cystic fibrosis need a protein hydrolysate formula? a prospective, randomized, comparative study evaluation of salt supplementation in cystic fibrosis infants induced sputum compared to bronchoalveolar lavage in young, non-expectorating cystic fibrosis children risk factors for bronchiectasis in children with cystic fibrosis palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis palivizumab immunoprophylaxis effectiveness in children with cystic fibrosis the etiologies of non-cfbronchiectasis in childhood: a systematic review of 989 subjects ct of airways disease and bronchiectasis an investigation into causative factors in patients with bronchiectasis rapid identification of bacterial species associated with bronchiectasis via metagenomic approach a novel microbiota stratification system predicts future exacerbations in bronchiectasis prevalence of nontuberculous mycobacteria in patients with bronchiectasis: a meta-analysis efficacy of azithromycin in the treatment of bronchiectasis azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis (em-brace): a randomised, double-blind, placebo-controlled trial respiratory exacerbations in indigenous children from two countries with noncystic fibrosis chronic suppurative lung disease/bronchiectasis localised pulmonary resection for bronchiectasis in hypogammaglobulinaemic patients autonomic regulation of the airways regulation of airway inflammation and remodeling by muscarinic receptors: perspectives on anticholinergic therapy in asthma and copd treatment of disorders characterized by reversible airway obstruction in childhood: are anticholinergic agents the answer? the airway cholinergic system: physiology and pharmacology tiotropium bromide (ba 679 br), a novel long-acting muscarinic antagonist for the treatment of obstructive airways disease pulmonary neuronal m2 muscarinic receptor function in asthma and animal models of hyperreactivity anticholinergics in the treatment of children and adults with acute asthma: a systematic review with metaanalysis the development of anticholinergics in the management of copd tiotropium in asthmatic adolescents symptomatic despite inhaled corticosteroids: a randomised dose-ranging study treatment of disorders characterized by reversible airway obstruction in childhood: are anti-cholinergic agents the answer? definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach mechanisms of virus induced exacerbations of asthma efficacy of salbutamol and ipratropium bromide in the management of acute bronchiolitis--a clinical trial bronchodilator effect of inhaled ipratropium bromide in wheezy toddlers anticholinergic drugs for wheeze in children under the age of two years classification and pharmacological treatment of preschool wheezing: changes since 2008 effect of altering smooth muscle tone on maximal expiratory flows in patients with tracheomalacia tracheobronchomalacia in pediatric patients: clinical experience quantitative assessment of tracheal collapsibility in infants with tracheomalacia tiotropium add-on therapy in adolescents with moderate asthma: a 1-year randomized controlled trial tiotropium use in pediatric patients with asthma or chronic cough: a case series the asthma-copd overlap syndrome multi-ethnic reference values for spirometry for the 3-95 year age range: the global lung function 2012 equations the global lung initiative 2012 reference values reflect contemporary australasian spirometry comparison between reference values for fvc, fev 1 , and fev 1 /fvc ratio in white adults in brazil and those suggested by the global lung function initiative 2012 the recent multi-ethnic global lung initiative 2012 (gli 2012 ) reference values don't reflect contemporary adult's north african spirometry spirometry reference values for malagasy adults aged 18-73 years the influence of the reference values on the interpretation of lung function in children: comparison of the global lung initiative 2012 and polish 1998 reference values disparities in pulmonary function in healthy children across the indian urban-rural continuum persistent effects of maternal smoking during pregnancy on lung function and asthma in adolescents how "healthy" should children be when selecting reference samples for spirometry? markers of eosinophilic inflammation and tissue re-modelling in children before clinically diagnosed bronchial asthma airway remodeling and inflammation in symptomatic infants with reversible airflow obstruction structural changes in the bronchial mucosa of young children at risk of developing asthma childhood asthma and increased airway responsiveness: a relationship that begins in infancy reduced lung function at birth and the risk of asthma at 10 years of age lung function, airway remodelling and inflammation in symptomatic infants: outcome at 3 years lung function, airway remodeling, and inflammation in infants: outcome at 8 years increased airway smooth muscle in preschool wheezers who have asthma at school age european association of perinatal medicine. european consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants-2013 update surfactant and noninvasive ventilation nichd maternal-fetal medicine units network. antenatal betamethasone for women at risk for late preterm delivery a comprehensive approach to the prevention of bronchopulmonary dysplasia nasal intermittent positive-pressure ventilation vs. nasal continuous positive airway pressure for preterm infants with respiratory distress syndrome: a systematic review and meta-analysis a trial comparing noninvasive ventilation strategies in preterm infants nasal continuous positive airway pressure versus nasal intermittent positive ventilation for preterm neonates: a systematic review and meta-analysis early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (amv): an open-label, randomised, controlled trial high-flow nasal cannulae in very preterm infants after extubation respiratory syncytial virus infection and bronchiolitis vertical transmission of respiratory syncytial virus modulates pre-and postnatal innervation and reactivity of rat airways the role of neurotrophins in inflammation and allergy rsv and asthma: speed-dating or long-term relationship? vertical transmission of respiratory syncytial virus to fetuses in utero conveys elevated nerve growth factor expression and airway hyperreactivity upon repetitive post-natal rsv re-challenge infections fetal nutrition and cardiovascular disease in adult life alternative mechanisms for respiratory syncytial virus (rsv) infection and persistence: could rsv be transmitted through the placenta and persist into developing fetal lungs? maternal high-fat diet in pregnancy results in metabolic and respiratory abnormalities in offspring microrna-221 modulates rsv replication in human bronchial epithelial cells by targeting ngf expression less air pollution leads to rapid reduction of airway inflammation and improved airway function in asthmatic children child pneumonia at a time of epidemiological transition incidence and severity of childhood pneumonia in the first year of life in a south african birth cohort: the drakenstein child health study global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis early life origins of chronic obstructive pulmonary disease wheezing rhinovirus illnesses in early life predict asthma development in high-risk children childhood pneumonia: the role of viruses specimen collection for the diagnosis of pediatric pneumonia laboratory methods for determining pneumonia etiology in children community-acquired pneumonia among u. s. children respiratory viruses associated with communityacquired pneumonia in children: matched case-control study global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: a systematic review and meta-analysis aetiological role of common respiratory viruses in acute lower respiratory infections in children under five years: a systematic review and meta-analysis a preliminary study of pneumonia etiology among hospitalized children in kenya the effect of case management on childhood pneumonia mortality in developing countries highly prevalent clinical issues infant mortality statistics from the 2006 period linked birth/infant death data set late preterm infants: near term but still in a critical developmental time period consortium on safe labor. respiratory morbidity in late preterm births nichd maternal-fetal medicine units network. antenatal betamethasone for women at risk for late preterm delivery growth rate of lung function in healthy preterm infants effect of late preterm birth on longitudinal lung spirometry in school age children and adolescents moderately preterm children have more respiratory problems during their first 5 years of life than children born full term risk of asthma in late preterm infants: a propensity score approach poor airway function in early infancy and lung function by age 22 years: a non-selective longitudinal cohort study overview of issues in the longitudinal analysis of respiratory data assistant professor, department of pediatrics, school of medicine, university of costa rica. <quiquesoto@gmail.com> bibliography 1. global tuberculosis report 2013. geneva. world health organization. 2013. 2. world health organization who world health organization who. guidance for national tuberculosis programmes on the management of tuberculosis in children a refined symptom-based approach to diagnose pulmonary tuberculosis in children proportion of tuberculosis transmission that takes place in households in a high-incidence area assessment of the xpert mtb/rif assay for diagnosis of tuberculosis with gastric lavage aspirates in children in sub-saharan africa: a prospective descriptive study evaluation of the xpert mtb/rif assay at a tertiary care referral hospital in a setting where tuberculosis and hiv infection are highly endemic treatment of paediatric tb: revised who guidelines immune-based diagnostics for tb in children: what is the evidence? paediatric respiratory reviews interferon-gamma assays in the immunodiagnosis of tuberculosis: a systematic review systematic review: t-cell-based assays for the diagnosis of latent tuberculosis infection: an update tracheobronchomalacia in children: review of diagnosis and definition dynamic volume cta of the airway and vasculature in children: technical report tracheobronchomalacia and excessive dynamic airway collapse paediatric tracheomalacia description of a multidimensional classification system for patients with expiratory central airway collapse comparison of standard-dose and reduced-dose expiratory mdct techniques for assessment of tracheomalacia in children real-time, cine magnetic resonance imaging for evaluation of the pediatric airway general hospital ca' foncello, treviso (italy) à <gmorana61@gmail.com> 2 department of radiology, sophia children's hospital mri of the lung (2/3). why ... when ... how? mr imaging of pulmonary parenchyma impact of lung volume on mr signal intensity changes of the lung parenchyma /3): methods contrast-enhanced 3d mri of lung perfusion in children with cystic fibrosis-initial results spirometer-controlled cine magnetic resonance imaging used to diagnose tracheobronchomalacia in paediatric patients imaging of lung function using hyperpolarized helium-3 magnetic resonance imag-ing: review of current and emerging translational methods and ap-plications epidemiology of pediatric obstructive sleep apnea upper airway collapsibility in children with obstructive sleep apnea syndrome adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study pediatric obstructive sleep apnea: complications, management, and long-term outcomes craniofacial morphology in preschool children with sleep-related breathing disorder and hypertrophy of tonsils craniofacial modifications in children with habitual snoring and obstructive sleep apnoea: a case-control study randomized controlled study of an oral jaw-positioning appliance for the treatment of obstructive sleep apnea in children with malocclusion rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12 months follow-up efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study germany <christian-f.poets@med.uni-tuebingen.de> references 1. gozal d. sleep-disordered breathing and school performance in children snoring during early childhood and academic performance at ages thriteen to fourteen years neurobehavioral implications of habitual snoring in children snoring, intermittent hypoxia and academic performance in primary school children population prevalence of obstructive sleep apnoea in a community of german third graders. the european respiratory journal: official journal of the european society for habitual snoring, intermittent hypoxia, and impaired behavior in primary school children adenotonsillectomy and neurocognitive deficits in children with sleep disordered breathing sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years persistent snoring in preschool children: predictors and behavioral and developmental correlates predicting poor school performance in children suspected for sleep-disordered breathing utility of symptoms to predict treatment outcomes in obstructive sleep apnea syndrome pediatric osas: oximetry can provide answers when polysomnography is not available reliability of home respiratory polygraphy for the diagnosis of sleep apnea in children drug induced sleep endoscopy in the decision-making process of children with obstructive sleep apnea understanding the anatomic basis for obstructive sleep apnea syndrome in adolescents obesity and altered sleep: a pathway to metabolic derangements in children? childhood adenotonsillectomy trial. prognosis for spontaneous resolution of osa in children myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis long-term improvements in sleep and respiratory parameters in preschool children following treatment of sleep disordered breathing remission and incidence of obstructive sleep apnea from middle childhood to late adolescence polysomnographic findings after adenotonsillectomy for obstructive sleep apnea in obese and non-obese children: a systemic review and meta-analysis this last year has seen a number of significant advances in the field of pediatric sleep-disordered breathing. the following is a personal selection of a few publications. overnight polysomnography (psg) is considered necessary to diagnose children suspected of sleep-disordered breathing (sdb). in practice, however, most children do not have access to overnight psg, due to the lack of sleep laboratories worldwide. the quest for a simpler means to diagnose sdb, or at least to prioritize children for referral to a sleep laboratory, remains a high priority. questionnaire. in a prospective study in children aged 5 to 9 years with obstructive sleep apnea syndrome (osas), rosen et al. 1 found that, conversely to psg, the pediatric sleep questionnaire results reflect osasrelated impairment in behavior, quality of life and sleepiness as well as predict their improvement post-adenotonsillectomy (at). the authors concluded that while psg is needed to diagnose osas, results from a careful clinical assessment provide important adjunctive information on comorbidities and their improvement after surgery. overnight oximetry in osdb children. kaditis et al. 2 performed a systematic analysis of the literature on the use of nocturnal oximetry in children with obstructive sdb (osdb ¼ from primary snoring to osas). their conclusion confirmed that overnight oximetry (spo 2 ) is useful for diagnosing osdb and for predicting post-at complications in a child with a history suggestive of osdb. overall, a desaturation index (!4%) higher than 2 episodes/hour can predict both mild and moderate-to-severe osdb, while criteria based on clusters of desaturation such as the mcgill oximetry score can predict moderate-to-severe osdb. key: cord-022527-a0x6lws3 authors: nan title: eosinophils in human disease date: 2012-10-12 journal: eosinophils in health and disease doi: 10.1016/b978-0-12-394385-9.00013-4 sha: doc_id: 22527 cord_uid: a0x6lws3 nan in healthy individuals, eosinophils represent a minor leukocyte subpopulation, accounting for less than 5% of total circulating white blood cells. tissue compartments with abundant resident populations of eosinophils include bone marrow, primary, and secondary lymphoid tissues, the uterus, and most of the gastrointestinal tract (with the exception of the esophagus under homeostatic conditions). these tissues share features of substantial cellular turnover and regenerative capacity. to a large extent, eosinophils serve as effector cells, capable of inducing significant tissue damage as a result of their release of preformed cytotoxic mediators, including the granule proteins, major basic protein, and eosinophilic cationic protein. these mediators lead to the production of reactive oxygen species and generate an array of lipid mediators. the role of eosinophils was previously considered to be defensive in the setting of parasitic infections or offensive in the development of an allergic response to an environmental allergen. this binary expression of the role or function of eosinophils, especially in the context of human disease, has recently undergone considerable evolution. eosinophilia and eosinophil products are now centrally positioned in ongoing immune responses through production of pivotal cytokines and chemokines, expression of features of antigen-presenting cells, ligation of toll-like receptors, and the elicitation of thelper (t h 2) immune responses. in these activities, eosinophils have been shown on the one hand to enhance local inflammatory responses, while on the other to dampen such responses. with this extensive array of activities, it is not surprising that a role for eosinophils has been demonstrated in normal tissue homeostasis and in many disease states. this chapter details the unique positions eosinophils play in a wide range of disease states, in both pathological and protective roles. in chapter 13.2, per venge begins by addressing the proteome of human eosinophils and the differences in molecular forms of many of the proteins in healthy and allergic subjects. identification of the spectrum of proteins produced and the genetic polymorphisms of the major secretory molecules is fundamental to our understanding of the role of eosinophils in health and disease and provides the potential for targeted regulation of specific functions. eosinophilia is a hallmark of allergic disorders characterized by the activation of selective hematopoietic processes during the onset and maintenance of allergic inflammation. the appearance of eosinophils in the circulation and in tissue involves processes in the bone marrow that lead to accumulation, differentiation, and proliferation of eosinophil lineage-committed hematopoietic progenitors at tissue sites. in chapter 13.6, gavreau and denburg summarize mechanisms that lead to the accumulation of eosinophils and their progenitors in the airways of allergic asthmatics. the role of eosinophils in asthma is further developed by thomas and busse. recognizing the controversial relationship between airway eosinophilia and asthma severity, they focus on the dynamic contribution of eosinophils to asthma. what emerges are two major roles, one in which the eosinophil serves as an effector cell in airway remodeling, the other as a biomarker for asthma exacerbations. the link between eosinophils and asthma is strengthened with the recognition that viruses are a primary cause of asthma exacerbations. in chapter 13.7, bivins-smith and jacoby explore the association of eosinophils with virus-induced asthma, especially eosinophil contact with airway nerves, which become activated and release mediators that cause dysfunction. in releasing excess acetylcholine, the altered airway nerves modulate airway smooth muscle responses and induce the development of bronchoconstrictive responses. moving from the airways to the skin, in chapter 13.3 simon and simon discuss eosinophil infiltration of the skin in a wide variety of disorders, both allergic and nonallergic. however, it remains somewhat unclear what mechanisms are responsible for eosinophil recruitment and activation in the skin, especially as conditions and pathogenic roles vary from disorder to disorder. a similar scenario is observed in the various primary eosinophilic gastrointestinal disorders. in chapter 13.8, davis and rothenberg identify common and uncommon features of these disorders and the surprising and somewhat frightening increases in prevalence of these conditions, especially eosinophilic esophagitis. beyond the association of eosinophilic infiltration of the airways, skin, or gastrointestinal tract, the entity hypereosinophilic syndrome has emerged, in which there is introduction almost 40 years ago, the eosinophil granule major basic protein (mbp) was purified by gleich and colleagues from guinea pig cells 1,2 and the eosinophil cationic protein (ecp/ rnase3) purified from human leukemia cells by our group. 3, 4 these achievements were the starting points for the study of the proteome of the human eosinophil, with the subsequent purification of mbp from human eosinophils 5 and the identification and purification of the two other major eosinophil granule proteins, eosinophil protein x/eosinophilderived neurotoxin (epx/edn) 6, 7 and eosinophil peroxidase (epo). 8, 9 remarkably, these four highly basic proteins make up about 90% of the proteins contained in the secretory granules of the human eosinophil. the eosinophil is regarded to be a secretory cell and it was consequently assumed that the biological activities of the human eosinophil are governed to a large extent by the activities of these proteins. thus, in attempts to understand the role of the human eosinophil in health and disease, a detailed study of the proteins and their genetics in relation to human disease therefore seemed logical. in this context, it should be emphasized that the granule content of human eosinophils is unique and shared only with other primates, since the duplicated gene products ecp and epx/edn are rapidly evolving and highly divergent orthologues are present in nonprimate mammalian species. 10 such findings indicate that the interpretation of activities of eosinophils of other species should be extrapolated to humans with care. in this subchapter, i will describe some of the key activities of the four major granule proteins and the experience of assaying these proteins in various biological materials in human disease. i will also describe recent attempts to map the protein content further using modern proteomics techniques. at the end of the subchapter, i will summarize the genetic findings of the proteins and the associations of single nucleotide polymorphisms (snps) of the genes encoding these proteins with disease. more details of the biological activities of the four proteins are found throughout this volume. the four major granule proteins of human eosinophils will be considered in turn (table 13. 2.1). ecp is a single chain, highly basic protein [isoelectric point (pi) ranging from 10.5 to 11] with apparent molecular masses ranging from 15.7 kda to 22 kda. the heterogeneity is largely due to glycosylation of the protein. 11, 12 the gene encoding ecp comprises two exons and one intron and is located on the q arm of chromosome 14 (14q). exon 2 is the coding dna sequence for ecp. ecp is located in the secretory granules of human eosinophils and is unique to humans and primates. minute amounts of ecp may be produced by monocytes and neutrophils under certain conditions. 13e15 however, most of the ecp located in neutrophils probably derives from the active uptake of ecp from the environment. 16 ecp belongs to the large family of rnases and is also named rnase3. in addition to being an rnase, ecp is a true multifunctional protein with both cytotoxic and noncytotoxic activities. the cytotoxic activities are determined by post-translational glycosylations and the majority, if not all, of ecp stored in the granules is richly glycosylated and noncytotoxic. 12, 17, 18 upon release from the eosinophil, the molecule is deglycosylated and acquires cytotoxic capabilities. 19 several snps have been found in the dna sequence of ecp; however, only two are in the coding part of exon 2. 20, 21 the most commonly found snp is located at position 434, in which guanine (g) is replaced by cytosine (c). in scandinavian populations 434g is most commonly found, whereas in african populations 434c is the most common. 22 thus, in scandinavia about 60% of the population carry the 434gg genotype and about 8% the 434cc genotype, whereas the reverse is the case in a ugandan population. the 434g>c snp results in an amino acid shift from arginine at position 96 to threonine and a fundamental change in biological activity, since the cytotoxic activity is lost. 18 whether the loss in cytotoxic activity is due to the amino acid shift per se affecting the cytotoxic site of the molecule or due to the fact that the replacement of arginine with threonine potentially creates a new glycosylation site that might disguise another cytotoxic site is at present not entirely clear. attempts to identify the bactericidal active sites were made by engineering recombinant protein and peptides. 23 these experiments suggest a location for the activity at the n-terminal portion of ecp. the presence in the ecp molecule of several active sites, possibly with different targets, seems likely. the snp 277c>t in the coding region of the ecp gene is much less common and gives rise to a replacement of arginine at position 47 with cysteine. the possible functional consequences of this amino acid shift are unknown, but it is predicted to have a great impact on the molecular structure. other biological activities of ecp, such as the rnase activity and the ability of ecp to activate fibroblasts, are not affected by the amino acid shift from arginine to threonine, which shows that these capabilities of ecp are dissociated from each other. 17 other snps in the ecp gene are associated with protein expression. thus, the 562g>c snp in the 3 0 utr region was found to closely correlate with the cellular content of ecp. 24 the affected sequence is a binding site for the transcription factor, retinoic acid receptor (rxr), which in turn acts as a cofactor to the transcription factor, sp1. sp1 was shown to affect ecp synthesis by binding to the promoter region of the gene. also, the intronic snp c.-38a>c has been shown to relate to the ecp content of eosinophils. thus, several parts of the ecp gene seem to affect ecp production. in a japanese population, a promoter polymorphism -393c>t is common, but is not found at all in the scandinavian population. 25 this mutation is closely related to serum levels of ecp, thus suggesting an impact on ecp production. the activities of ecp are counteracted by heparin, but also by a protease-modified a 2 -macroglobulin. 11 eosinophil protein x/eosinophil-derived neurotoxin epx/edn is a single chain protein of 18.6 kda that shares 70% homology with ecp, since the formation of the two proteins is the result of a gene duplication 30e40 million years ago. 26, 27 the ancestral gene was an rnase and this property has been conserved by the gene product epx/edn, but almost completely lost in the gene product ecp, which has instead acquired cytotoxic properties. the protein was independently described, purified, and named (epx) by our group 7 and the group of gleich (named edn) 28 and both names are used in the literature. for the sake of clarity the name eosinophil derived neurotoxin (edn) will be used throughout this volume, since this is the more commonly used name and also because the gene of eosinophil peroxidase (epo) recently has been renamed epx. the edn gene is located close to the ecp gene at chromosome 14. chromosome 14 is also the location of the genes of the rnase a superfamily to which ecp and edn belong; hence, the alternative name of rnase2. edn is also a highly basic protein (pi of about 9), although less so than ecp. edn is produced in small amounts by macrophages and neutrophils, but also by liver cells. edn is stored in the eosinophil within the secretory granules together with ecp, but is also stored in a separate compartment of easily mobilized secretory vesicles. 29 the biological activities of edn are related to its rnase activity and involve antiviral properties. however, recent studies indicate several other activities of great interest. thus, edn has been added to the growing list of alarmins, 30 which are proteins that attract and enhance the activities of antigen-presenting cells, such as dendritic cells. activation of cells through toll-like receptor 2 (tlr2) further links the activity of edn to components of innate immunity. the neurotoxic activity, which is the basis for the name edn, suggests cytotoxic properties for edn, although the cytotoxic activity of the molecule against any other cell is modest and mostly absent. in our previous studies, we could show some alterations in purkinje cells in the cerebellum of rabbits following injection of edn, thus resembling the gordon phenomenon. 31 however, the injection of 100 times lower amounts of ecp had much more detrimental consequences, with the disappearance of purkinje cells and the rapid development of ataxia and other neurological disturbances. the neurotoxic activities of the eosinophil proteins and the development of the gordon phenomenon may therefore be the combined actions of the potent rnase edn and the cytotoxic ecp. four snps were identified in the edn gene in a scandinavian population, none of which gives rise to an amino acid shift. one snp, 405g>c, is located in the intron and is closely related to the cellular content of edn. this locus is the binding site for several different transcription factors that may be involved in the expression of edn. epo is a two chain heme-binding protein with one heavy chain of about 52 kda and one light chain of about 14 kda. 9 the gene is located on chromosome 17q31 and consists of 12 exons and 11 introns. the amino acid sequence shows an almost 70% homology with that of myeloperoxidase and also considerable homology with other members of the peroxidase family of proteins. 32 epo is a highly basic protein with a pi of >11. it is located in the matrix of the secretory granules and is probably specific to eosinophil granulocytes, since no other locations have been identified in mature cells. epo is difficult to extract from mixed blood leukocytes, since it has a high affinity for neutrophil membrane structures. 33 the biological activities of epo are partly related to its peroxidase activity and partly to other properties of the molecule. the peroxidase catalyzes halidation reactions leading to the formation of long-acting hypohalides, such as hypobromous acid, oxidation of thiocyanate, and nitration of tyrosine. 34, 35 such radicals may act on cellular membranes and take part in defense reactions against a variety of microbes. numerous mutations and polymorphisms have been found in the epo gene, five of which result in amino acid shifts. the possible consequence to functional activities of these amino acid shifts is unknown. eosinophil mbp was named from findings in guinea pig eosinophils, since it appeared to make up the majority of the proteins contained in the secretory granules. 1,36e40 in human eosinophils the content of mbp is in the range of the other three major proteins, i.e., 5e10 mg/10 6 eosinophils. the mass of mbp is 13.8 kda and its pi is 11.4. the mbp gene is located on chromosome 11q12 and consists of six exons and five introns. mbp is apparently produced as a much larger preproprotein, and an acidic portion of prombp is cleaved off upon storage in the eosinophil granules. this acidic portion of prombp may serve to protect cellular structures from its cytotoxic activities during synthesis and packaging. the larger prombp, however, has been identified in immature bone marrow cells. prombp has also been found in placental cells in complex with the metalloproteinase pappalysin-1, or pregnancy associated protein a (papp-a), and shown to inhibit the activities of papp-a. the mbp molecule makes up the typical crystals seen in the specific granules of human eosinophils. an mbp homologue was identified, characterized, and named mbp2. 40 this protein was purified from human eosinophils and has a molecular mass of about 13.5 kda and a much lower isoelectric point of 8.7. the gene encoding hmbp2 is located in close proximity to the gene of mbp1 at chromosome 11q12 and has five exons. mbp1 is expressed in several cell types other than human eosinophils, such as basophils and placental cells, whereas hmbp2 seems to be located only in eosinophils. the biological activities of mbp are predominantly related to its cytotoxic capabilities, but numerous noncytotoxic activities have also been identified, many of which will be described throughout this volume. in the mbp genes, several mutations and polymorphisms have been identified, five of which may result in an amino acid shift. consequences to the activities of mbp resulting from these amino acid shifts have not been described. proteins in addition to the major proteins described above. these include large numbers of adhesion molecules, chemokines, cytokines, and others. in an attempt to gain further insight into the biology of human eosinophils, modern proteomics techniques may be applied to map the major protein content of normal and diseased eosinophils. in this regard, several different approaches may be applied. one is the description of as many proteins as possible and another is the selected description of proteins based on criteria such as extraction procedures or detection methods, e.g., based on the identification of phosphorylated proteins only. one study incubated eosinophils with sonicates of mast cells and the cytokines granulocyte-macrophage colony-stimulating factor (gm-csf) and tumor necrosis factor (tnf-a) and used [ 35 s]methionine to monitor protein synthesis. 41 extracts of eosinophils were run on two-dimensional (2-d) gels and the number of protein spots increased dramatically following these stimuli compared to control cells. in addition, the position of the spots differed depending on the stimuli used, which suggests that eosinophils respond differently to these stimuli. unfortunately, no attempts were made to identify the proteins in these spots. another study showed differences in 51 spots between healthy subjects and those affected by atopic dermatitis. 42 one such difference was downregulation of the grb7 adaptor protein in cells from patients, which may relate to eosinophilia of the patients and antiapoptotic features of these cells. overall, 1121 spots were identified in healthy subjects and 1310 spots in the eosinophils of atopic dermatitis patients, which emphasizes that circulating eosinophils of such patients are exposed to various stimuli that induce protein synthesis. one upregulated spot of particular interest in atopic dermatitis relates to increased expression of the low-affinity receptor for immunoglobulin e (ige). a different approach involved the study of phosphoproteins in an acute myelogenous leukemia (aml) eosinophil cell line after exposure to dexamethasone or il-5. 43 fourteen phosphoproteins showed significant changes, i.e., were either phosphorylated or dephosphorylated, after il-5 and 12 after dexamethasone. phosphorylation of the translation initiation factor elf-3 subunit was increased by il-5 and was also found to be increased in patients with atopic dermatitis. interestingly, phospho-apolipoprotein e (p-apoe) was induced in eosinophils by dexamethasone but was decreased by il-5 treatment. p-apoe levels could therefore be used as an indicator of proliferation or apoptosis of eosinophils. a 2-d gel of a survey of proteins in whole eosinophil extracts and extracts of membrane fractions of eosinophils of healthy subjects and of eosinophils obtained from allergic subjects during a pollen season is shown (fig. 13. 2.1). altogether more than 336 spots were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (maldi-tof ms), representing 98 different proteins. 44 among the proteins identified were the four major granule proteins described above and a number of other proteins hitherto not associated with human eosinophils. as expected, the proteins represent, to a large part, cytoskeletonrelated proteins such as actin, but more than 11% of all proteins are of granular origin ( fig. 13.2 .2). the study also showed large differences in the expected pis of several proteins. thus, the cytoskeleton-related proteins cofilin-1, profilin-1, adenylyl cyclase-associated protein 1 (cap 1), and coronin-1a were all found to be significantly acidified, whereas edn and mbp2 were much more basic than expected. the actual biological significance of alterations to cytoskeleton-related proteins is uncertain, but may relate to the well-documented migrating capacity of eosinophils. in eosinophils obtained from allergic subjects exposed to pollen, several intriguing changes were observed (table 13. 2.2). one such was a change of more than three units in the pi of two protein spots identified as the heavy chain of epo due to heavy chain glycosylations. we speculate that such heavy glycosylation may interfere with the enzymatic activity of epo. in support of such speculations are our previous findings that the peroxidase-dependent luminol-enhanced chemiluminescence reaction of blood eosinophils purified from allergic subjects during the pollen season is significantly reduced. 45 altogether 12 spots were significantly changed in eosinophils from pollen-exposed allergic subjects, five of which were identified by maldi-tof ms. the other three identified spots were heat shock cognate protein 70 (hsc70) and the a and b subunits of cap 1. as indicated above, cap 1 subunits are involved in cell motility. the upregulation of these proteins, therefore, indicates that eosinophils from allergic subjects have an increased potential to respond to chemoattractants, a capacity that is well documented, since eosinophils harvested from the blood of allergic subjects show increased migration toward several chemoattractants. 46 the upregulation of hsc70 has a number of biological implications of interest, such as changes in protein folding, intracellular protein transportation, and antigen presentation. the latter may lend further support to the eosinophil being actively involved in antigen presentation. 47 the eosinophil marker that has become most widely used in the everyday clinical routine of the allergist is ecp, although several reports have shown that the measurement of edn, epo, or mbp may also be useful. the measurement of any of these eosinophil proteins may indicate the activity and turnover of the eosinophil granulocyte. currently, ecp is measured in serum/plasma, but measurements in nasal lavage fluid, sputum, and possibly saliva are interesting alternatives, since ecp in these biological fluids more accurately reflects the local process. the advantages and disadvantages of measuring ecp in various biological fluids will be discussed below, and the current evidence that ecp may be a useful complement to the diagnostic armamentarium for monitoring and characterizing disease activity in the allergic patient. the emerging evidence of the clinical usefulness of urine measurement of edn as alternative to serum ecp measurement to reflect eosinophil turnover and activity will also be considered. instrument for characterizing and monitoring inflammatory processes in the airways. 11, 48 this has been particularly shown in patients with asthma, chronic obstructive respiratory disease, and cystic fibrosis. in most cases, sputum has to be induced by hypertonic saline and cells in the sputum need to be separated from the supernatant in order to analyze mediators released from inflammatory cells. the relatively time consuming and complicated procedures required to achieve this are probably the main obstacles for a more widespread use of sputum measurement as a clinical tool. an alternative and much simpler procedure is the measurement of specific markers of various cells in whole sputum extracts. the numbers of eosinophil granulocytes in sputum have been estimated using ecp and several publications show that the numbers of eosinophils measured in this way correlate well with disease activity in asthma and are reduced as a consequence of corticosteroid treatment. an interesting alternative to sputum is saliva, since we showed recently that asthmatics have significantly raised levels of ecp in saliva that are reduced by corticosteroid treatment. 49 still, however, we do not know what the ecp levels in saliva actually reflect, as they may be indicative of either systemic or local eosinophil activity. in addition, the measurements of specific cell markers in nasal lavage fluids or ear secretions have been widely used, and the usefulness of such measurements in the understanding of cellular involvement has been clearly indicated. 50 however, their clinical application is still not established. ecp may be measured in both serum and plasma. 11 if plasma is chosen, the blood should be anticoagulated with ethylenediaminetetraacetic acid (edta) or citrate in order to prevent spontaneous extracellular release of ecp and subsequent interaction with heparin. the levels of ecp in serum are consistently higher than in plasma, due to the fact that eosinophils in the test tube continue their extracellular release of ecp ex vivo. this is an active process that is both time and temperature dependent, which means that higher extracellular levels are achieved with increasing time and ambient temperature, and vice versa. 51 thus, if ecp is measured in serum, strict standardization of the blood sampling procedure and handling of the blood sample are necessary in order to avoid unacceptable variations in ecp levels. our recommendation is that blood should be taken in tubes with a gel separator and that coagulation is allowed for 1 h at room temperature (22 c) before centrifugation and separation of serum. both plastic and glass tubes may used. however, differences in the material and the inclusion of coagulation activators in the tubes may affect measurements. this means that normal ranges of ecp have to be determined in each laboratory that does not follow the recommendations of the manufacturer. the levels of ecp in edtaeplasma probably correctly reflect the circulating levels of ecp at the time of blood sampling. these levels are the consequences of production and elimination of ecp, i.e., local or systemic release of ecp to the circulation as well as variations in the turnover rate of ecp. normally, turnover is quite rapid, with a half-life (t â½ ) of about 45 min. for several reasons, we can assume that the turnover is more rapid in subjects with ongoing inflammation. this means that an increased release of ecp to the circulation in certain diseases does not always lead to the anticipated increase in plasma levels, since the increased release may be partly or fully counteracted by an increased elimination rate. the dynamics of such counteracting principles may be the main explanation of the fact that in most cases clinical information obtained by edtaeplasma measurements of ecp is less clear and less useful than the information obtained by serum measurements. in addition to the circulating levels, serum levels of ecp also reflect the secretory activity of the eosinophil population in the blood and, since the levels in serum are often 5e10 times those in plasma, we may draw the conclusion that it is above all the secretory activity of the eosinophils that determines ecp levels. the propensity of blood eosinophils to release ecp is increased in subjects exposed to allergen. 52 my own interpretation of serum ecp levels is that they reflect the propensity of the eosinophil population to release ecp in the local process, e.g., in the lung of asthmatics. the higher this propensity is, the more damage is inflicted on the patient. in order to eliminate the influence of eosinophil counts on the serum levels of ecp and thereby obtain a purer reflection of eosinophil activity, serum levels may be divided by the eosinophil count, thus forming an ecp/eosinophil ratio. in some studies, such a ratio was found to be more closely related to disease severity in asthma. more than a thousand papers have been published dealing with the relation between ecp levels and allergic or other inflammatory diseases. 11, 48, 53, 54 the majority of these publications indicate that ecp provides novel information about the process and that the information may be used in treatment stratification and monitoring of the disease, since ecp levels are closely related to exacerbation propensity and severity in diseases such as asthma and atopic dermatitis. recent data also indicate that serum levels of ecp and epo predict the further development of allergic disease. 55 thus, serum levels of the two proteins were significantly elevated in a group of patients with allergic rhinitis who developed asthma-like symptoms 6 years later. the prediction was not seen for blood eosinophil counts or nasal lavage findings. several publications, though, have questioned and sometimes rejected ecp as a clinically useful marker. one reason for this may be the simplified view that asthma is one disease and that the disease is caused by one cell, the eosinophil, and that one marker such as ecp will solve all clinical problems. this is obviously not true, since we know today that the involvement of eosinophils in the asthmatic process is very variable between individuals. another cause of variations in the results is probably the lack of awareness of the importance of correct sample handling. still another possibility may be related to the recent discovery of several genetic variants of ecp and the fact that these variants are related to the expression of allergic symptoms and serum levels of ecp. the levels of ecp in blood or any other biological fluid are not disease specific, but provide us with information about the extent to which eosinophils are involved in the particular disease process. in a search for noninvasive means to monitor eosinophil involvement in inflammatory diseases, urine measurement of edn has emerged as a promising candidate, particularly in children. 56e58 in order to minimize the influence of differences in water dilution of the urine, edn levels have to be adjusted to creatinine concentrations unless 24-hour samplings are carried out. it is also useful to bear in mind that all eosinophil markers, including the excretion of edn, show circadian rhythms with the highest levels occurring at night. 59 thus, for the sake of standardization of blood or urine measurements of eosinophil markers, sampling should always be carried out at the same time of the day. several studies have shown that edn in urine is elevated in asthma and atopic dermatitis, is related to disease activity, and reduced by anti-inflammatory treatment, i.e., corticosteroid treatment. elevated levels of edn in urine in wheezy children also seem to predict the development of asthma. as mentioned above, two major granule proteins of human eosinophils are unique to humans and primates. thus, knowledge of the role of these proteins in human disease cannot be extrapolated from mouse gene knockout experiments. the alternative is therefore to search for human counterparts to such knockouts, i.e., snps or mutations that have an impact on the biological activities of these proteins either with regard to their functional alterations or altered production. as shown above, only one snp is known to lead to a functional alteration in any of these proteins: the ecp434g>c gene polymorphism, in which the replacement of g with c in the dna sequence results in the production of a noncytotoxic protein with the amino acid threonine at position 97 instead of arginine. 18 in the first study examining the possible association of the ecp434g>c snp with human disease, we found strong associations with the development of allergic symptoms, both in a group of 209 medical students and in a group of 79 subjects with allergic or nonallergic asthma. 21 in the group of medical students, the diagnosis of allergy was based on a self-assessment questionnaire and in the asthma group the distinction was based on a clinical diagnosis. we found that the genotype ecp gg, giving rise to the production of the cytotoxic species, was more common in those experiencing allergic symptoms than in nonallergic subjects or those with nonallergic asthma. however, most notable was the absence of any allergic manifestations in the two cohorts carrying the ecp cc genotype. the ecp cc genotype therefore seemed to exclude the development of allergic symptoms and provided strong support for a key role for eosinophils in allergy. in a larger community-based study on 574 randomly selected subjects in estonia and sweden [the european community respiratory health survey (ecrhs)], symptoms and signs of allergy were based on a structured interview. 60 the results of this study were much less clear, although the ecp434g>c genotypes (ecp434gg, ecp434gc, and ecp434cc) showed significant associations with various expressions of allergic symptoms. however, it also became clear that ethnicity, gender, and smoking habits are important confounders. one intriguing finding of the ecrhs study was the associations of the ecp434g>c genotypes with lung function with reduced lung functions found in both women and men carrying the ecp434g>c g-allele compared to those carrying the c-allele. if confirmed, these findings suggest a detrimental effect of the cytotoxic ecp on lung tissues. in a norwegianedutch study, no associations between allergy and the ecp434g>c genotype were found. 61 in contrast, this study showed an association with nonallergic asthma, which was also the case in our ecrhs study. an association with allergic rhinitis of the ecp434g>c genotype was also negated in a korean study. 62 the association between asthma/allergy and the ecp434g>c genotype is at present confusing and the seeming differences in findings not easily explained. ethnicity and gender differences may have an impact, but the definition of the phenotypes studied is probably more important. it is important to clarify these relationships, since the cytotoxic activities of ecp could be targets for therapeutic interventions if such associations are confirmed and established. ecp has the capacity to kill schistosoma mansoni larvae. knowing that the cytotoxic capacity is lost by an amino acid shift from arginine to threonine at position 97, we conducted a study on subjects living in uganda in an endemic area of s. mansoni infections. 22 the ecp434g>c genotype distribution in this population was dominated by subjects carrying the ecp434 cc genotype, i.e., the opposite of the distribution found in non-african populations. thus, the majority of people living in these endemic areas have a genotype that gives rise to the production of a noncytotoxic ecp and possibly a poorer defense against s. mansoni infection. we examined parasite egg excretion in feces, to reflect the level of defense against the infection, and indeed found higher numbers in subjects carrying the c-allele, thus suggesting the involvement of ecp in this defense reaction. we also found that subjects carrying the g-allele are much more prone to develop liver fibrosis, one of the serious consequences of the infection that affects about 10% of those infected by s. mansoni. thus, it seems that the capacity to produce the cytotoxic ecp has some effect on defense against s. mansoni, but that the host's reaction to the infection is the major threat to the infected subject. in this regard, cytotoxic ecp may play a key role. as mentioned above, the ecp562g>c genotype is closely related to the cellular content of ecp, with the lowest levels found in those carrying the ecp cc genotype. 24 we found few, if any, associations between this genotype and the expression of allergic symptoms or asthma, but close relations to gender, with a higher prevalence of the g-allele in women, and relations to smoking habits. 60 similar findings were seen for the 434g>c genotypes and may relate to the fact that these two genotypes are in strong disequilibrium. in the korean study, the ecp562 g>c callele was found to be more prevalent in allergic rhinitis. 62 in the norwegianedutch study, no apparent relations to allergy, asthma, and ecp levels were found, whether evaluated alone or as part of a haplotype. 61 the intronic snp ecp c.-38a>c is located in a part of the gene that may be involved in regulating ecp production. the norwegianedutch study showed a higher proportion of elevated serum levels of ecp and ige, as well as higher proportions of subjects with asthma and bronchial hyperreactivity, in those carrying the adenine (a)-allele. 61 most of these associations, though, were only seen in the dutch population. in a japanese study, no association between the intronic snp and serum ecp levels were found. 25 in our ecrhs study, we found an intriguing association between the ecp c.-38a>c genotypes and atopy. 60 among males, but not among women, atopy was associated with the ecp c.-38(a>c) genotypes, with a significantly higher frequency of the cc genotype. in a logistic regression analysis, the ecp c.-38cc genotype was independently associated with an increased risk of atopy with an odds ratio of 1.9 and confidence interval (ci) of 1.2e3.1 when adjusted for gender, ethnicity, and smoking habits. the ecp -393c>t snp is located in the promoter region of the ecp gene. this snp has only been described in the japanese population. 25 interestingly, the -393c>t genotypes are related to serum levels of ecp, with undetectable levels in subjects carrying the tt genotype. eosinophil protein x/eosinophil-derived neurotoxin, eosinophil peroxidase, and major basic protein genotypes and clinical findings one study examined a large number of edn and ecp snps in a south indian population with microfilaria infection and tropical pulmonary eosinophilia. 63 no associations between either of these conditions and the snps examined were seen. however, the south indian population seemed to have unique snps and haplotypes of the edn and ecp genotypes compared to asian and scandinavian populations. in two japanese reports, snps in the coding parts of the epo gene were found to be associated with cedar pollinosis. 64, 65 in particular, an snp in exon 7, resulting in the amino acid shift from proline to leucine and which might affect the activity of the protein, showed a strong association. in the second study, an association with a silent snp in exon 6 was shown in addition to the exon 7 snp. in a recent czech study on allergic rhinitis, the exon 6 snp was also found to be associated, whereas the exon 7 snp was not present in this population. 66 these reports suggest the involvement of epo in the allergic process, although whether it involves the peroxidase activity of epo or reflects other mechanisms is unknown. one report from germany studied patients with atopic dermatitis and possible associations between nine different snps located in the four major eosinophil granule protein genes. 67 however, no associations with atopic dermatitis were found for any of the snps studied, despite the fact that eosinophils are regarded to be important effector cells in this tissue eosinophilia with or without associated blood eosinophilia is observed in a number of skin disorders, including allergic diseases, autoimmune diseases, bacterial or viral infections, hematologic diseases, parasitic infestations, as well as in association with tumors. 1, 2 the presence or absence of eosinophils in skin specimens is often used for differential diagnoses by dermatopathologists. for instance, eosinophils in the upper dermis might be a clue for the diagnosis of early lesions of bullous pemphigoid (bp), even in the absence of blisters. in addition, the detection of eosinophils might indicate the differential diagnosis of drug reactions, which often cannot be distinguished from other inflammatory skin diseases. in hematoxylin and eosin (h&e) stained skin specimens, eosinophils are seen as round shaped cells stuffed with coarse eosinophil granules ( fig. 13.3.1a) . disrupted oval-shaped eosinophils may also be found, e.g., in subacute and chronic eczematous lesions ( fig. 13 .3.1a, b). 3 depending on the disease, eosinophils are located among other inflammatory cells in the perivascular areas (e.g., in eczema), between collagen bundles in the dermis (e.g., in eosinophilic cellulitis), or in the epidermis (e.g., in pemphigus foliaceus; fig. 13 .3.1bed). moreover, in eosinophilic pustular folliculitis, eosinophils enter the hair follicle. 4 extracellular granular proteins can be detected in varying amounts either as separate deposits or as a thin coating on collagen bundles. the latter are called flame figures and are typically seen in eosinophilic cellulitis. recently, deposition of eosinophil granule proteins in association with extracellular dna traps was reported in several allergic, autoimmune, and infectious skin diseases. 5 immunofluorescence staining using antibodies directed against eosinophil cationic protein (ecp) or major basic protein (mbp) allows a more sensitive detection of eosinophils and extracellular granular protein depositions than h&e staining. 6 under physiological conditions, eosinophils are usually not detectable in the skin. therefore, primary causes (intrinsic) or stimuli (extrinsic) are required for initiating the increased production, recruitment, and/or survival of eosinophils under pathological conditions. 1 myeloproliferative forms of hypereosinophilic syndromes (hes) represent intrinsic eosinophilic disorders, 7 in which mutations of multipotent or pluripotent hematopoietic stem cells occur, with subsequent increased eosinophil proliferation, often affect the skin (table 13. 3.1). cutaneous manifestations vary from multiple erythematous papules, plaques, and nodules, to generalized erythematous maculopapular eruptions, often associated with pruritus. 8, 9 clonal eosinophilia can occur as a consequence of gene rearrangements that result in increased tyrosine kinase activity. 10 as a consequence, patients with hypereosinophilia due to fusion of the platelet-derived growth factor receptor a (pdgfra) and fip1 like 1 (fip1l1) genes respond to imatinib therapy. 11 extrinsic eosinophilic disorders due to cytokine release by either t cells or tumor cells are more common than intrinsic hes forms due to genetic abnormalities within hematopoietic stem cells (table 13. 3.1). cytokines involved in the development of skin eosinophilia are interleukin-3 (il-3), il-5, and granulocyte/macrophage colony-stimulating factor (gm-csf). the expression of il-5 in association with eosinophilic skin disorders has been reported for atopic dermatitis (ad), bp, cutaneous t cell lymphoma, episodic angioedema with eosinophilia, eosinophilic cellulitis, eosinophilic fasciitis, eosinophilic folliculitis, exanthematous drug reactions, hypereosinophilic syndrome with skin involvement, and urticaria. 2 il-3 expression has been detected in blister fluids of bp and blood leukocytes of hes patients. 12e14 in langerhans cell histiocytosis, as well as in ad, atopy patch test reactions, and cutaneous late phase reactions, the expression of both gm-csf and il-3 has been shown. 2 the chemokine eotaxin/c-c motif chemokine 11 (ccl11) is important for tissue recruitment and activation of eosinophils. eotaxin expression has been observed in ad, autoimmune-blistering diseases like dermatitis herpetiformis and bp, drug reactions, eosinophilic folliculitis, and parasitic dermatoses, and also in lymphomas, e.g., cutaneous t-cell lymphoma and hodgkin disease. 2 the primary function of eosinophils was originally thought to be related to the protection against helminth parasites. 15 recently, a novel mechanism of eosinophil function in innate immunity has been reported. by releasing mitochondrial dna and granule proteins, eosinophils form extracellular structures that can bind and kill bacteria invading the gastrointestinal tract. 16 such extracellular dna structures generated by eosinophils have recently also been reported in inflammatory skin diseases. 5 furthermore, eosinophils are presumed to cause tissue damage. 15, 17 in addition, eosinophils play an important role in repair and remodeling processes, as well as in immunomodulation. 18, 19 the role of eosinophils under pathological conditions has mostly been studied in parasitic infections and bronchial asthma. in contrast, the role of eosinophils has not been explored in substantial depth in skin diseases. with regard to skin diseases, it can be assumed that eosinophils directly contribute to or amplify pruritus (itch) in the skin, by releasing neurotrophins (nerve growth factor and brain-derived neurotrophic factor) or indirectly by acting on mast cells. 20 pruritus is associated with most eosinophilic skin diseases, in particular with ad, bp, cutaneous t-cell lymphoma, and parasitic infections. in the following sections, we summarize the current knowledge on the activation and function of eosinophils in selected eosinophilic skin disorders. tissue eosinophilia is a typical feature of eczema, in particular of ad. the numbers of eosinophils in the skin are usually modest (2.8 cells/mm 2 ; range 0e90.3) and correlate with disease severity, as well as with the degree of spongiosis in acute exacerbations and marked epidermal hyperplasia in chronic stages. 21 besides eosinophils, eosinophil-derived products, such as ecp, eosinophilderived neurotoxin (edn), and mbp, are present in increased amounts in the blood and the skin of ad patients. 22 immunostaining with antibodies to ecp and mbp, as well as electron-microscopic evaluation revealed eosinophil granule proteins inside eosinophils, but also in the extracellular spaces, and the near absence of intact eosinophils, suggesting eosinophil degranulation and degeneration. 3, 23 in ad, eosinophil production, differentiation, recruitment, survival, and activation are under tight control of cytokines, particularly gm-csf, il-3, and il-5, and chemokines, including eotaxin and rantes (c-c motif chemokine 5; ccl5), as well as adhesion molecules, complement factors and leukotrienes. 22 however, the pathogenic role(s) of eosinophils in ad have not yet been defined. the release of granule proteins suggests a role in host defense and/or tissue damage. furthermore, eosinophils release a broad spectrum of mediators such as cytokines [gm-csf, il-1, il-3, il-4, il-5, il-8, il-10, il-13 , and transforming growth factor (tnf)] and leukotrienes (in particular, the cysteinyl leukotrienes ltc 4 , ltd 4 , and lte 4 ) and thus they can regulate immune responses or initiate tissue repair processes. 18 improvement of ad upon both systemic and topical therapy is usually associated with a decrease in eosinophils and other inflammatory cells in the skin. 22 however, the administration of an anti-il-5 antibody showed only moderate effects on clinical symptoms, although blood eosinophils were almost completely depleted. 24 currently, it remains unclear whether anti-il-5 antibody treatment reduces eosinophil tissue infiltration in lesional ad skin. although the development of pruritic wheals in urticaria is attributed to the release of histamine by mast cells and basophils, other cell types, including eosinophils, neutrophils, and macrophages, and t cells, are also present in 25 extracellular deposits of mbp have been observed as granular deposits and coating tissue fibers in the dermis, as well as in small blood vessel walls. 26 ecp may stimulate histamine release by mast cells and basophils. 27 by generating eicosanoid mediators and secreting neuropeptides, such as substance p, eosinophils may contribute to vasodilation. 25 vascular endothelial growth factor, which is elevated in the plasma of chronic urticaria patients and correlates with disease severity, has been reported to be predominantly expressed by eosinophils. 28 recently, an involvement of the coagulation cascade in the pathogenesis of chronic urticaria has been suggested. eosinophils that were shown to express tissue factor in urticarial lesions may activate the tissue factor pathway of coagulation, resulting in the generation of thrombin, which stimulates mast cells for histamine release. 29 eosinophilic cellulitis is characterized by an intense infiltration of eosinophils, extracellular granule deposition, and flame figures in the dermis. 30 recently, high numbers of eosinophils generating extracellular dna traps in association with ecp have also been observed in this eosinophilic disorder. 5 patients present with recurrent episodes of acute pruritic dermatitis and occasionally with blisters, painful edematous swellings, or persistent urticarial eruptions. 30 the cause is unknown, but some patients develop eosinophilic cellulitis in association with hematological disorders, infections, or anti-tnf-a therapy. corticosteroids are usually helpful in this disease. in 37% of patients with hes, the skin is affected. 31 skin manifestations of hes include blisters, eosinophilic cellulitis, erythematous macules, lichenoid eruptions or urticarial lesions, necrosis, papules or nodules, pruritus, purpura, and ulcerations. cutaneous symptoms are usually present in a subgroup of patients with hes, in which il-5-producing t cells exhibiting an abnormal immunophenotype have been identified. 13 anti-il-5 antibody therapy has been shown to improve skin symptoms in hes patients. 6 eosinophilic pustular folliculitis (epf) presents with recurring clusters of sterile follicular papules and pustules, predominantly on the face and trunk. 4 epf may affect immunocompetent subjects (ofuji disease), but is most commonly seen together with immunosuppression. epf has been reported in association with infections, in particular acquired immunodeficiency syndrome (aids), autoimmune diseases, and medications, as well as autologous peripheral blood stem cell and allogeneic bone marrow transplantation. 4 the histology shows a dense follicular and perifollicular infiltrate of eosinophils and scattered lymphocytes, and sometimes follicle destruction. a pathogenic role for eosinophils in response to fungi (malassezia), demodex mites, and bacteria has been suggested. 4 the histopathology of bp reveals eosinophil infiltration in and below blisters and along the basement membrane, 32 as well as in nonblistering, urticarial, or eczematous lesions of bp. 33 patients with active bp exhibit increased eotaxin and il-5 levels, as well as eosinophil numbers in the blood compared with patients in clinical remission and healthy controls, 34e36 associated with significant eosinophil infiltration in the skin, as well as disease intensity. 37, 38 whether bp180 and/or bp230 autoantibodies of immunoglobulin g (igg) or ige types can activate eosinophils with or without preceding priming has not been investigated so far. eosinophils exhibit cd16, the fc-g receptor, and degranulate upon stimulation with igg immune complexes. 39 furthermore, il-5-primed eosinophils from these patients release granule proteins upon stimulation with complement c5a. 40 it has been hypothesized that in the presence of complement, eosinophils release enzymes and reactive oxygen onto the basement membrane, causing tissue destruction and blister formation in bp. 41 eosinophil granule protein depositions have been observed in both blistering and evolving lesions. 42 recently, extracellular dna traps generated by eosinophils were also described in bp. 5 mmp9 has been reported to be expressed by eosinophils in lesional skin, as well as in blister fluids of bp. 43 moreover, mmp9 cleaves the extracellular, collagenous domain of bp180 autoantigen in vitro. 43 eosinophilic spongiosis can be observed in early pemphigus including pemphigus foliaceus. 44 the presence of eosinophils may be due to il-5 as part of the mixed thelper 1/2 (t h 1)/t h 2 cytokine profile that has been found in pemphigus vulgaris. 45 complement-fixing antibodies were shown to induce eosinophil infiltration in pemphigus. 46 charcoteleyden crystals have been observed in pemphigus vegetans. 47 eosinophils can be seen in the papillary dermis in dermatitis herpetiformis, although neutrophils and leukocytoclasis are more characteristic in this disorder. 32 furthermore, both neutrophils and eosinophils are the predominant infiltrating cells in linear iga bullous dermatosis. 48 epidermolysis bullosa acquisita following gm-csf therapy has been related to eosinophil infiltration and deposition of eosinophil peroxidase (epo) and mbp at the dermaleepidermal junction. 49 in drug reactions, the presence of eosinophils in the skin is quite a striking finding, despite various clinical and histopathological presentations [e.g., acute generalized exanthematous pustulosis (agep), erythema multiforme, maculopapular rashes, and pseudolymphomatous and granulomatous drug reactions]. 50 drug reaction with eosinophilia and systemic symptoms (dress) is a drug reaction with both blood and tissue eosinophilia and systemic symptoms. it presents with an acute, severe skin eruptions that may develop from a maculopapular rash into erythroderma, as well as with blood eosinophilia, fever, hepatitis, lymphadenopathy, and other organ involvement. 51 eosinophils accompanied by other inflammatory cells are found in the skin and lymph nodes. severe hepatitis, in which eosinophilic infiltration or granulomas as well as hepatocyte necrosis and cholestasis are striking features, may result in liver failure, accounting for the high mortality rate of 10%. 51 the treatment is based on high-dose corticosteroids. drugs known to cause dress are anticonvulsants, anticancer drugs, antidiabetics, antimicrobial agents, nonsteroidal anti-inflammatory drugs, and sulfa drugs. 1 in langerhans cell histiocytosis (lch), among the infiltrate of langerhans cells (lc), scattered or clusters of eosinophils can be found in the papillary and deeper dermis, respectively. 52 since activated lc generate a broad spectrum of proinflammatory cytokines, e.g., chemokines and gm-csf, they are able to recruit and activate eosinophils directly or via stimulation of other cell types. a predominant t h 2 type cytokine production by cutaneous t-cell lymphoma (ctcl) results in eosinophilia, extracellular granule protein depositions, as well as increased il-5 levels in the skin and/or peripheral blood. 53 in angiolymphoid hyperplasia with eosinophilia, clonal t cell populations have been identified. 54 currently, it is not known whether the eosinophils inhibit or modulate proliferation of the malignant cells. eosinophilia is a common histological finding in a number of diseases characterized by marked tissue fibrosis, such as cutaneous forms of systemic sclerosis, drug induced scleroderma-like illness (e.g., bleomycin), eosinophiliae myalgia syndrome, eosinophilic fasciitis, localized scleroderma, and toxic oil syndrome. 55 elevated eosinophil granule protein levels have been detected in the serum of patients with diffuse cutaneous forms of systemic sclerosis, suggesting eosinophil activation and degranulation. 56 as they produce fibrogenic cytokines, e.g., transforming growth factor b (tgf-b), eosinophils are thought to contribute to skin fibrosis. 55 together, these examples show that most observations on eosinophils in skin diseases are rather descriptive. the exact mechanisms whereby eosinophils are recruited and activated, as well as their pathogenic role(s), are not yet fully understood. depending on the skin disease, a role in host defense, immunoregulation and/or remodeling, and fibrosis can be assumed. further research is therefore required in order to understand the function of eosinophils in skin diseases and to develop new therapeutic strategies. 10 asthma is characterized by variable airflow obstruction, bronchial hyperresponsiveness, and chronic airway inflammation, all of which are likely to be intertwined and interdependent. the immune processes involved in the development of these characteristics in asthma are complex, redundant, and interactive, making it difficult to specifically define which factor, or factors, are the principal contributors to these processes and the eventual pathophysiology of asthma. as has also become apparent, asthma is represented by multiple phenotypes in which the clinical profiles and patterns of inflammation have distinct, though overlapping, characteristics. to appreciate the mechanisms of disease in asthma and the role of eosinophils, it is helpful to explore the contribution of individual cells to the pathophysiology of asthma. as early as the turn of the 20th century, the eosinophil was identified as a prominent cell associated with asthma. 1,2 for example, postmortem examinations of the lungs of patients who died from status asthmaticus showed, in many cases, sheets of eosinophils infiltrating the airways. these telling findings led to the long-held belief that eosinophils are an inherent characteristic and possibly an essential component of asthma, particularly in severe exacerbation of disease. as the role of airway inflammation became more fully defined, the assumption that eosinophils are a primary, if not the principal, contributor to asthma was integrated into concepts of asthma, at least until the last decade. 3 this positioning into asthma was further supported by animal models, which strengthened the hypothesis that eosinophils are a principal contributor to inflammation, airflow obstruction, and airway hyperresponsiveness (ahr). 4 from animal models, it was possible to separate individual components that contribute to inflammation, and the cytokine, interleukin-5 (il-5), was found to be responsible not only for terminal differentiation of eosinophils, but by ablating il-5 with a specific monoclonal antibody, many of asthma-like airway responses to inhaled antigen were inhibited. based upon these findings, eosinophils and il-5 became a major pathway in allergic inflammation and a target to regulate and more mechanistically control asthma. these theories would subsequently be tested with the administration of anti-il-5 to patients with asthma. as expected, there was a significant reduction in circulating and sputum eosinophils but, surprisingly, little to no impact on features of asthmadairflow obstruction or ahrdand only a 50% reduction in bronchial mucosa eosinophils. based upon these data, the role of the eosinophil in and contribution to asthma appeared less apparent. what has evolved since these dramatic shifts from an early appreciation of the eosinophil to asthma has been a more accurate and informed picture of this cell's involvement and contribution to asthma, which is the objective of our subchapter. to most fully appreciate current views of eosinophils in asthma, we feel that it is helpful to trace the key observations that have attempted to define this cell's role in asthma. retracing these discoveries has led to a more well-defined elucidation of the eosinophil's role in asthma. clinical evidence to suggest that eosinophils are key players in asthma first emerged from examinations of peripheral blood samples, largely because of the ease and safety of such studies. peripheral eosinophilia had been recognized as a feature of asthma for decades, with clinical correlations arising between airflow obstruction and the magnitude of peripheral blood eosinophilia. 5 in 1975, a pivotal study by horn et al. 6 found that the total peripheral blood eosinophil count in a cohort of asthmatic patients was greater in those individuals with a more severe disease. this was an important early observation and provided a clue to what the eosinophil may contribute to asthma as an association arose between the degree of airflow obstruction and peripheral blood eosinophil counts. these and subsequent observations suggested that circulating eosinophils may be a key clinical feature of asthma and, because of these associations, contribute to airflow obstruction and hence disease severity. in a subsequent study of 43 patients with chronic asthma, bousquet et al. 7 assessed clinical symptoms of patients in relationship to peripheral blood eosinophil counts. these investigators found a positive correlation between the eosinophil count and disease severity. to extend the value of peripheral blood eosinophils to features of asthma, taylor et al. 8 was also able to find correlations between peripheral blood eosinophilia and another key characteristic of asthma, bronchial hyperresponsiveness. collectively, these studies were helpful in gaining an understanding of the role of eosinophils in asthma as they showed that the level of circulating eosinophils may serve as a biomarker not only for the presence of disease but also to indicate the degree of severity. how did the eosinophil's biology further link this cell type to asthma? the eosinophil was named for the ability of eosin to stain its basic granules and thus impart the cell's well-recognized red color. 5 these eosin-staining granules, however, were found to be more than a marker for this cell type. eosinophil-derived granule products have been found to have multiple actions, some of which can produce pathological and physiological features associated with asthma, including injury to respiratory epithelium (desquamation) and ahr. the eosinophil granules consist of four major cytotoxic cationic proteins: major basic protein (mbp), eosinophil peroxidase (epo), eosinophil-derived neurotoxin (edn) or nonsecretory ribonuclease, and eosinophil cationic protein (ecp). 9 mbp accounts for 55% of the eosinophil granule content, is toxic to parasites, and has similar cytotoxic effects on the respiratory epithelial cells of both animals and humans (table 13 .4.1). 10, 11 in vitro studies have shown that the application of mbp to respiratory tissue, at concentrations consistent with values found in sputum and bronchoalveolar lavage (bal) fluid of asthmatic patients (50e100 mg/ml), leads to almost complete erosion of tracheal epithelium and parallels the observed desquamation of respiratory epithelium in the bronchial mucosa of subjects with asthma. these effects of mbp suggest a potential mechanism by which eosinophils may contribute to airway injury, initiate repair (i.e., remodeling), and subsequently induce hyperresponsiveness. 12 to extend these observations, flavahan et al. incubated guinea pig tracheal rings with mbp and found bronchial smooth muscle tension to acetylcholine was significantly enhanced compared to tissues not exposed to eosinophils. 13 in a dog model, the intraepithelial administration of mbp also increased the bronchoconstriction response. 14 ecp also causes cytotoxic effects on respiratory tract cells. by adding small amounts of ecp to the respiratory tract, dahl et al. 15 found damage and denudation of bronchial and tracheal epithelial cells, which paralleled observations in asthma. elevated ecp values are found in bal fluid of asthmatic subjects during the late-phase response (lpr) to an allergen challenge, as well as in lavage fluid of patients with chronic, persistent asthma. 16 in guinea pig models, the application of increasing concentrations of epo to tracheal mucosa caused epithelial cell exfoliation, ciliostasis, and bleb formation. 17 serum edn levels are elevated in asthma and return to normal levels following treatment with prednisolone and the achievement of disease control. 18 finally, when compared to normal subjects, edn concentrations in urine are greater in asthmatic children. 19 eosinophils also produce other inflammatory products such as cysteinyl leukotrienes, platelet activating factor (paf), reactive oxygen species (ros), and substance p. in in vitro studies designed to assess eosinophil biology, paf stimulated the release of granule products and led to superoxide anion generation. 20 paf was also chemotactic for the eosinophil, as reflected by the induction of an eosinophilic infiltrate of the airway after local or systemic delivery of paf in guinea pigs. 21, 22 these early findings in animals suggested that the release of paf by eosinophils could potentially create a self-perpetuating cycle to further the development of eosinophilic inflammation and hence airway injury. paf also has direct proinflammatory properties. when administered to humans, paf causes rapid bronchoconstriction, which can last up to 2 h. 23 similar to changes that follow an airway allergen challenge, paf causes a prolonged increase in bronchial responsiveness. 24 although a role for paf in human asthma has not been established, the biology of this eosinophil product is associated with airway changes reflective of asthma and also implies an important role for eosinophils in this process. eosinophils also generate the cysteinyl leukotrienes, ltc 4 and ltd 4 , which can cause both an increase in vascular permeability and bronchoconstriction. 25 ltc 4 is secreted by eosinophils and is increased in asthmatic children. 26 activated eosinophils can also release substance p, a neuropeptide, to increase vascular permeability and promote plasma extravasation. 27 eosinophils, like other phagocytes, generate ros, which are produced in greater concentrations in asthma. 28 in asthma, ros can cause mucus secretion, which leads to increased vascular permeability and airway obstruction. when damaged by ros, respiratory epithelium produces fewer bronchodilatory substances, such as prostaglandin e2 (pge2) and nitric oxide, with the net result of increased airflow obstruction 29 ( fig. 13 .4.1). although t cell-derived cytokines may be the major source of factors that influence eosinophil development and function, eosinophils themselves can also produce several cytokines to perpetuate their own inflammatory biology and that associated with asthma. transforming growth factor b (tgf-b) is a profibrotic cytokine produced by eosinophils and found in increased concentrations in asthma. 30 tgf-b stimulation of fibroblasts leads to a thickening of the reticular lamina of the airways, and thus provides a conceptual link between eosinophilic inflammation and structural remodeling of the airway in asthma. 30 eosinophils also produce several other mediators/cytokines, such as il-13, matrix metalloproteinase-9 (mmp-9), tissue inhibitor of metalloproteinases 1 (timp-1; or metalloproteinase inhibitor 1), and vascular endothelial growth factor (vegf), which have also been implicated in matrix remodeling in asthma. 31 il-1, il-2, il-3, il-4, il-5, il-6, il-8, il-10, and il-16 are all produced by eosinophils in varying concentrations. il-1, initially observed in mice and later found in hypereosinophilic patients, is associated with hla-dr expression and is thought to contribute to the eosinophil's function as an antigen-presenting cell. 32 il-3 and granulocyte macrophage colony stimulating factor (gm-csf), are also produced by eosinophils, and can function in an autocrine fashion to prolong the cell's survival. 33 il-4, which upregulates vascular cell adhesion molecule (vcam) receptors on endothelial cells and is a cofactor in immunoglobulin e (ige) isotype switching, is produced gm-csf, granulocyte-macrophage colony-stimulating factor; il, interleukin; paf, platelet-activating factor. by eosinophils from patients with atopic asthma. 34 il-5, which regulates terminal differentiation and survival of eosinophils, is found in eosinophils obtained from bal fluid of asthmatic patients. 35 il-5 release also follows eosinophil stimulation by iga, igg, or ige immune complexes. 36 the presence of eosinophils in sputum has been a characteristic finding of asthma since the early 19th century. 2 bousquet et al. increased sputum and peripheral blood eosinophils in asthma patients. 7 sputum eosinophilia is also a feature of nonasthmatic eosinophilic bronchitis, a relatively nonspecific term. in contrast, sputum eosinophilia is not a feature of chronic obstructive pulmonary disease (copd). in addition, previous studies have suggested a relationship between bal fluid eosinophilia and the level of bronchial responsiveness. 37 the concentrations of ecp and mbp in bal fluid were also found to directly relate to the percentage of eosinophils, implying that eosinophils in asthmatic airways are activated and have undergone degranulation. 38 to extend these observations, uchida et al. 4 evaluated the effect of mbp on airway responsiveness in an animal model. within 1 h of direct instillation of mbp onto the trachea of rats, significant increases in airway responsiveness to methacholine occurred. finally, 22 subjects with asthma were identified, half of whom were treated with inhaled corticosteroids (ics) and the other half given only bronchodilators, to be used as needed. 39 ics use led to a fall in serum and bal ecp levels but, interestingly, the eosinophil count was unchanged in both the corticosteroid or bronchodilator treated groups. collectively, eosinophil-derived products can have a significant influence on the function and pathohistology of the airway and mirror many features of asthma. in the 1950s, a further relationship of asthma to eosinophils was supported by the finding of a marked infiltration of eosinophils in the lung tissue of patients who died suddenly of status asthmaticus. 40 in cases of death from acute, severe asthma, eosinophilic infiltrates were found in the lung parenchyma, bronchial lumen, and entire thickness of the bronchial wall. 41 bronchial biopsies obtained by bronchoscopy from patients with mild disease also showed eosinophils as a prominent cellular infiltrate. 42 in addition to the presence of eosinophils and their granule products in airways of asthmatic patients, the airway histology showed epithelial desquamation, impaired ciliary function, basement membrane thickening and mucous plugs. 9, 43 expanding upon these findings, ohashi et al. 44 found the eosinophilic infiltration of mucosal tissue was associated with opening of tight junctions of bronchial epithelial cells. these histological analyses showed eosinophil infiltration of the airways was associated with epithelial damage and possibly linked to subsequent airway hyper-responsiveness. 44 when subjects with allergic asthma inhale allergens to which they are sensitized, there is an immediate, or early, response, characterized by an acute fall in forced expiratory volume in one second (fev 1 ). approximately 40% of subjects will go on to develop an lpr, which occurs 4e8 h after allergen exposure. in lpr, eosinophils are the prominent airway cellular infiltrate both in animal models and human subjects. to define the kinetics of eosinophil recruitment and eotaxin/c-c motif chemokine 11 (ccl11) generation, humbles et al. 45 found the chemokine eotaxin was increased 2e3 h postallergen challenge in sensitized guinea pigs. by 12e24 h postallergen challenge, there was a significant increase in eosinophil numbers in the bal fluid, but no further rise in eotaxin. these findings in the guinea pig suggest that eosinophil recruitment to the airway following an inhalation of allergen is, in part, regulated by eotaxins. findings of an early recruitment of eosinophils and the later development of a late-phase airflow obstruction to allergen suggested that these events reflect processes in asthma that could provide insight into how eosinophils may contribute to asthma. histopathological findings of the airway in lpr are also similar to events found in patients with chronic asthma and persistent airway obstruction. in guinea pigs sensitized to ovalbumin, 17 h after an inhalation challenge with ovalbumin the cellular composition in bal fluid is predominantly neutrophils. 46, 47 by 72 h post antigen exposure, 50% of bal cells are eosinophils. in addition, the subsequent eosinophilic infiltration of the peribronchial smooth muscle and epithelium persists for up to 7 days. eosinophils in the bal of immunized guinea pigs with an lpr were found to be activated, suggesting that these cells are primed during recruitment to the airway. 48 similarly in humans, de monchy et al. 16 found significant eosinophilia only in patients who developed lpr to inhaled antigen. moreover, the eosinophils in the bal fluid had undergone degranulation, as evidenced by an elevated ecp:albumin ratio. there was also evidence that peripheral blood eosinophils and ecp concentrations are increased prior to antigen challenge in those subjects who eventually develop an lpr. subsequently, cockcroft et al. 49 evaluated the lpr in a population of asthma patients who had been given a single dose of inhaled beclomethasone dipropionate, inhaled salbutamol or inhaled cromoglycate in a randomized, double-blind, placebo-controlled crossover trial. while beclomethasone had no effect on the allergeninduced early pulmonary obstructive response, there was a significant inhibition of the lpr at 7 h and 30 h later. collectively, these data suggest that allergen provocation of allergic inflammation is likely to be regulated by eosinophils and can be controlled by corticosteroids, which block both the late-phase rise in recruited eosinophils and the subsequent reduction in lung function. thus, a logical conclusion from work at this time was that a direct association between eosinophil recruitment and altered lung function existed in asthma, a finding substantiated by kidney et al. 50 in 2000, gauvreau et al. 51 extended these observations when she evaluated the development of the lpr and recruitment of eosinophils in asthma patients who were initially treated with inhaled budesonide for 1 week and then underwent an inhaled allergen challenge. budesonide administration reduced the intensity of the lpr and also inhibited eosinophil recruitment to the airway, reflected by sputum eosinophils and the parallel increase in peripheral blood eosinophils 24 h after challenge. from these data, it was assumed that allergic activation of the airway and the subsequent development of the lpr were caused by eosinophils recruited to the lung. to extend observations from whole-lung allergen challenges, a number of groups developed the technique of using a bronchoscope to deliver antigen into single segments of the airway. to perform these studies, a bronchoscope is introduced into the lung and then wedged into an isolated airway segment, where a dose of allergen is introduced and a lavage performed immediately; the cells and lavage fluid obtained at this time represent events associated with the acute or early response. bronchoscopy is repeated 24e48 h later, the challenged segment of the airway identified, and lavage performed: the airway events analyzed at this time model the lpr. this approach, while not allowing for measures of pulmonary function, provides a direct measure of cells, mediators, and retrieval of cells for ex vivo study to compare early-and late-phase allergic reactions. when antigen is introduced to airway segments in allergic patients, there is a strong eosinophilic response 24e48 h postchallenge. 52 the analysis of bal is characterized by large concentrations of granule proteins, ecp, edn, epo, and mbp, as well as ltc 4 , suggesting that the recruited eosinophils are activated when they appear in the airway. additionally, when eosinophils are retrieved from bal fluid, they are phenotypically distinct from circulating cells and have greater superoxide anion release, collagen adherence and cell surface adherence receptors compared to peripheral blood eosinophils. these findings suggested that lpr-associated eosinophils, which are recruited to the lung during the late phase and are terminally differentiated, have a greater capacity to generate inflammation. bal levels of il-5 were also increased and correlated with the eosinophils, suggesting a key role for this cytokine in these processes. from these studies, a more expanded picture of the allergic inflammatory response was made, along with the identification of key mediators and evidence for an enhancement of the eosinophil's inflammatory potential. calhoun et al. 53 used segmental antigen challenges in subjects with allergic rhinitis who had been inoculated with rhinovirus to further evaluate the interactions between viral upper respiratory infections and allergic reactions, and gain insight into mechanisms of asthma exacerbations. during an acute rhinovirus infection, bal fluid obtained 48 h after antigen challenge contained increased numbers of eosinophils. in some subjects, the increase in eosinophils persisted for up to 1 month following the acute viral infection and initial antigen challenge. this augmented antigen-induced eosinophil recruitment was thought to be a possible mechanism for an intensified inflammatory airway response during viral infections and to account for greater asthma symptoms at that time. alternatively, virus-induced epithelial damage, with a subsequent increase in mucosal permeability, was hypothesized to increase allergen contact with immune cells, thus creating a greater inflammatory response. 54 the presence of eosinophils is regulated by apoptosis and modulated by cytokines, growth factors, and lipid mediators, which are released during allergic inflammation but suppressed by glucocorticoids. 55 consequently, the persistence of airway eosinophilia in some patients with asthma was attributed to cells that had developed resistance to corticosteroids. 56 the reduction in airway eosinophils with corticosteroids and improved asthma control further supported a central role for eosinophils in asthma. 3 under both circumstances, either a reduction or persistence of eosinophils, and their correlation with symptoms of asthma, supported a direct link of eosinophils to the pathobiology of asthma. in 1991, evans et al. 57 measured eosinophil numbers in 10 asthmatic subjects 14 days following the initiation of inhaled budesonide treatment. airway responsiveness to methacholine was improved and was associated with a fall in peripheral eosinophils. these findings also suggested that eosinophil production, maturation, and differentiation may take place in the lung, as well as the bone marrow. as corticosteroid treatment reduced serum, sputum, and tissue eosinophils, and these reductions were associated with improved asthma symptoms, the eosinophil's place as a primary contributor to asthma appeared further substantiated. however, not all patients with asthma have eosinophilia, nor are all asthma patients responsive to corticosteroids. these observations, in the face of data already discussed, raised questions as to how essential the eosinophil is to all of the clinical features of asthma. while many studies of asthma confirm the presence of elevated eosinophils, circulating and bal fluid eosinophilia are not always present in asthma. 40, 58 theories as to these differences included the possibility that eosinophils may be present only during an exacerbation and their absence may result from the actions of medication, particularly ics. 59, 60 these observations also led to an emerging theory that at least two asthma phenotypes exist, based on the presence or absence of tissue eosinophils. 48 persistent eosinophilic inflammation, despite treatment, was found to be more common in adult onset asthma and less common in classic allergic asthma in patients receiving ics. 61 while up to 40% of cases of severe asthma appear to start later in life, the presence of eosinophils in patients with late-onset asthma is also more variable. interestingly and importantly, patients with asthma and existing eosinophilia had greater airway remodeling and more exacerbations, despite treatment. 62 to begin to dissect and clarify these relationships, woodruff et al. 63 used a number of innovative approaches for study. firstly, to determine the molecular basis for asthma heterogeneity and the involvement of eosinophils, the effect of an underlying t-helper type 2 (t h 2)-mediated profile of inflammation was evaluated in a cohort of 42 patients with mild to moderate asthma and 28 healthy control subjects. the recruited subjects were stratified based on high or low expression of il-13-inducible genes in samples of their airway epithelium. using the response of their epithelium to stimulation with il-13, investigators were able to classify the reaction as th-2-high vs. th-2-low. the t h 2-high asthma group was indistinguishable from the t h 2-low asthma group in relationship to demographics, lung function, and response to bronchodilators. however, the t h 2-high group had significantly greater ahr, total ige levels, and bal and peripheral blood eosinophils. the presence of airway remodeling was also evaluated in this study population, and both the reticular basement membrane thickness and epithelial mucin stores were increased in subjects with a t h 2-high profile. following this classification, subjects were randomized and treated with either inhaled fluticasone or placebo to determine if there was a difference in clinical response to ics based upon their t h 2 profiles. in the t h 2-high group, ics improved the fev 1 , whereas no change occurred in the low t h 2 group. this study further supported the concept of heterogeneity in the pathogenesis and pathophysiology of asthma that can be characterized by the presence of t h 2-driven inflammation with eosinophilia and responsiveness to corticosteroids as markers of this profile. these findings also indicated that other phenotypes of asthma exist but their features were poorly understood. t h 2 cell-derived il-5 has been identified as the major cytokine involved in terminal differentiation of eosinophils, figure 13.4.2 interleukin-5. interleukin-5 (il-5) is a signaling molecule that stimulates eosinophil proliferation, maturation, and activation. an antigen-stimulated immune response in tissues leads to the secretion of il-5 by cells such as eosinophils, mast cells, and t-helper type 2 (t h 2) cells. il-5 then acts on the bone marrow to mobilize existing eosinophils and induce further eosinophil production. these maturing eosinophils become responsive to eotaxin/ c-c motif chemokine 11 (ccl11), produced by the endothelium, allowing for their exit from the bone marrow to tissue. ccr3, c-c chemokine receptor type 3; il-5r, interleukin-5 receptor. activation of mature eosinophils, and prolongation of eosinophil cell survival ( fig. 13.4 .2). 64 il-5 enhances eosinophil degranulation, chemotaxis, antibody-dependent cytotoxicity, and adhesion to endothelium. 65 van der veen et al. 66 identified 22 patients with mild to moderate, dust mite-sensitive allergic asthma and found a significant correlation between the magnitude of the lpr, the allergenspecific proliferative response of peripheral t lymphocytes, and an increase in il-5 in vivo following inhaled antigen. extending beyond observational studies of an elevation of il-5 in relationship to lpr, inhaled il-5 was found to cause, or significantly contribute to, ahr. 67 shi et al. 68 also demonstrated that inhaled il-5 in asthma acted as an eosinophil chemoattractant and activator of the recruited eosinophils to the airway. in a subsequent, blinded, placebocontrolled crossover study of eight patients with allergic bronchial asthma, shi et al. 68 found a significantly enhanced methacholine pc 20 (the dose of the inhaled antagonist that provokes a 20% drop in fev 1 ) responsiveness 24 h and 48 h after an inhalation of il-5, as well as a significant increase in sputum eosinophils and ecp. using a mouse model with il-5 knocked out, inhaled allergen did not lead to eosinophilia or an increase in ahr. 69 il-5 was also decreased during treatment with corticosteroids that improved asthma control. 70 from these and other data, il-5 emerged as the dominant cytokine regulating the eosinophil's involvement in allergic airway disease. the anti-il-5 monoclonal antibody is an igg antibody that binds with high affinity to free il-5, thus preventing its binding to the il-5 receptor on the surface of eosinophils and their progenitors. van oosterhouet et al. 71 used ovalbumin to challenge sensitized guinea pigs and induce airway eosinophilia, neutrophilia, and tracheal hyperreactivity. when the sensitized guinea pigs were treated with anti-il-5 and then challenged with ovalbumin, airway eosinophilia, not neutrophil recruitment, was suppressed as well as the allergen challenge-induced increase in ahr. when sensitized guinea pigs were treated with the anti-il-5 monoclonal antibody by akutsu et al., 72 there was a decrease in ahr, tracheal wall eosinophil infiltration, and the lpr. animal studies in which anti-il-5 decreased airway eosinophilia, ahr to allergen, and lpr provided further support for the hypothesis that eosinophils are central to many important aspects of the pathogenesis of asthma, and suggested that if eosinophil migration to the airway could be inhibited, signs and symptoms of asthma could be controlled or prevented. in 2000, leckie et al. 73 conducted a randomized, doubleblind, placebo-controlled trial in which a single infusion of either of two doses of anti-il-5 humanized monoclonal antibody or placebo was administered to 24 men with mild allergic asthma. the study goal was to evaluate the effect of anti-il-5 on the lpr to inhaled antigen, on the premise that this treatment would ablate eosinophil recruitment and hence the airway responses to allergen, including the development of the lpr and an associated increase in ahr. the investigators found anti-il-5 to decrease blood and sputum eosinophils following inhaled allergen challenge. surprisingly, anti-il-5 treatment had no effect on either the lpr or postallergen increase in airway responsiveness to histamine. thus, in striking contrast to animal studies, there was no significant effect of anti-il-5 on the development of an lpr, despite the absence of eosinophils in the blood or the airways following antigen exposure. this study, though conducted in a small numbers of patients, prompted a total reevaluation of the eosinophil's role in asthma, including whether it had one at all. extending this study, flood-page et al. 74 evaluated anti-il-5 monoclonal antibody treatment in asthma patients by examining its multidose effect on blood and sputum, as well as bone marrow and airway tissue eosinophils. in a randomized, double-blind, placebo-controlled study, 24 patients with mild asthma received three intravenous doses of mepolizumab (i.e., il-5 monoclonal antibody) or placebo for 20 weeks. within 4 weeks of the first anti-il-5 dose, there was a significant decrease in peripheral blood eosinophils. at weeks 4 and 10 of the study, there was nearly a 100% reduction of eosinophils in blood and sputum samples following anti-il-5 treatment. in contrast, eosinophils were reduced by only 52% in bone marrow aspirates. similarly, bronchial mucosa eosinophils were reduced by 55% from baseline. despite this reduction of intact eosinophils, staining of the bronchial biopsy for intracellular mbp was unchanged by mepolizumab. despite these reductions in eosinophils, there was no change in ahr, exacerbations, fev 1 values, peak flow measurements, or symptoms between the anti-il-5 and placebo-treated groups. while a reduction in blood and bal fluid/sputum eosinophils occurred with anti-il-5, there was only a 50% reduction in bone marrow and bronchial eosinophils. 74 this finding confirmed that, despite anti-il-5 therapy, residual airway eosinophils persisted and the total amount of mbp present in airway tissues was unchanged. from these observations, it was also hypothesized that the residual eosinophil population in the airway continued to exist and release, or retain, granule proteins, despite anti-il-5 treatment. furthermore, it was proposed that these persistent effects may be responsible for the lack of improved asthma control, fev 1 , and ahr. these findings with anti-il-5 contrasted sharply with effects noted with oral corticosteroids, which caused an 80% decrease of bronchial mucosal eosinophilia and led to significant clinical improvements of asthma symptoms. 75 given the possibility that, despite anti-il-5 treatment, residual airway eosinophils may be sufficient to continue to exert their influence on clinical outcomes, including lung function and symptoms, the eosinophil should not have been excluded as a target for asthma therapy, although the outcome may not be symptoms or airflow obstruction. 74 in 2008, rothenberg et al. 76 reported the results of a randomized, double-blind, placebo-controlled trial of anti-il-5 in 85 prednisone-dependent (20e60 mg/d) patients with hypereosinophilic syndrome. in addition to a significant lowering of peripheral blood eosinophilia, 84% of the mepolizumab-treated subjects were able to reduce their oral prednisone dose to 10 mg/d compared to only 43% in the placebo group. in addition, mepolizumab significantly reduced the likelihood of an exacerbation of their hypereosinophilic disease. while the effect of therapy on hypereosinophilic syndrome patients may not be extrapolated to asthma, this study did show that mepolizumab has the ability to decrease eosinophils, the prednisone requirement to maintain disease control, and exacerbations from the hypereosinophilic syndrome. expanding on this theme, green et al. 3 examined a strategy designed to determine the effects of treatment directed toward reducing sputum eosinophil counts rather than administering a dose of ics based on symptoms alone, i.e., a guidelines approach. seventy-four patients with moderate to severe asthma were identified and randomly assigned to either a management strategy based upon british thoracic society guidelines or one using a dose of ics that reduced sputum eosinophils to <3%. the sputum management strategy group had an average eosinophil count that was 63% lower than that of the guidelinemanaged group during the study. as an apparent consequence of this reduction in eosinophils, patients in the sputum management group had significantly fewer asthma exacerbations and were admitted less frequently to the hospital for asthma ( fig. 13.4 .3). however, total asthma quality of life scores, mean peak flow measurements, postbronchodilator fev 1 , and the use of rescue bronchodilators were not different in the two management groups. 3 while this study did not show a relationship between sputum eosinophils and variable airflow obstruction and other parameters, such as daily symptoms, it did support the notion that eosinophils play a central role in asthma by either serving as a marker for exacerbation risks or being possibly linked to an increased susceptibility for exacerbations. it can be argued that previous studies of anti-il-5 had examined patients with only mild asthma and with outcome measures that were not specifically related to ongoing eosinophilic inflammation. to extend upon this hypothesis, haldar et al. 77 and nair et al. 78 published results of studies designed to evaluate mepolizumab treatment in patients with severe asthma, persistent eosinophilia in sputum, and frequent exacerbations. in an approach similar to that of green et al., 3 haldar et al. 77 evaluated the effect of a reduction in sputum eosinophils with anti-il-5. in this randomized, double-blind, placebo-controlled trial, 61 patients were enrolled with asthma and sputum eosinophilia that was refractory to treatment and a history of recurrent exacerbations. patients were given anti-il-5 monoclonal antibody or placebo monthly for 1 year. the mepolizumab group had 57 exacerbations requiring prednisone (a mean of 2.0 exacerbations per year per subject) compared to 109 exacerbations (3.4 exacerbations per subject per year) in the placebo group ( fig. 13.4.4) . the mepolizumab treatment group also had a greater improvement in scores of the asthma quality of life questionnaire, with a mean improvement of 0.55 compared to 0.19 in the placebo group. 77 similar to findings of flood-page et al., 31, 74 the anti-il-5 treatment group had significantly lower eosinophil counts in bal, blood, and bronchial wash, but less of a decrease in bronchial mucosa eosinophils. as noted in previous studies, 74 there were no significant changes from baseline in ahr, bronchodilator use, or fev 1 in the mepolizumab group. interestingly, when prednisolone was given after the mepolizumab treatment, there was an improvement in exhaled nitric oxide or lung function, suggesting these symptoms and pathways may be dissociated from eosinophilic inflammation, and are possibly mediated through other mechanisms. reticular basement membrane thickening in asthma is associated with the presence of bronchial mucosal eosinophils. using allergen-sensitized mice, humbles et al. 79 found eosinophil-deficient mice were protected from the development of peribronchiolar collagen deposition and increased airway smooth muscle mass following allergen challenge. however, increases in ahr and mucus secretion occurred in the eosinophilic deficient mice, just like wildtype mice. the authors concluded that eosinophils contribute substantially to airway remodeling, but are not obligatory for allergen-induced lung dysfunction. 79 as noted earlier by flood-page et al., 74 residual bronchial wall eosinophils persists despite treatment with anti-il-5, even when blood and sputum eosinophils are nearly eliminated. in addition, anti-il-5 has little effect on the mbp found in the airways, airflow obstruction, and ahr. these observations raise the possibility that bronchial mucosal eosinophils are a privileged cell or are in a privileged location when lodged in tissues, and their levels are not responsive to previously used methods of eosinophil depletion. furthermore, these findings suggest that another important contribution of eosinophils to the pathophysiology of asthma is airway remodeling, which is supported by other studies. in a 2-year study, sont et al. 80 evaluated an asthma treatment strategy aimed at reducing ahr compared to treatment that followed international guidelines and was based primarily on symptom and lung function assessments. in this randomized, prospective, parallel trial of 75 adults with mild to moderate asthma, 41 patients were placed in the reference strategy group, with a treatment based on current guidelines, while 34 patients were placed in the ahr group with a treatment strategy based on guidelines as well as a reduction in ahr. in addition to measuring bronchodilator use, fev 1 , peak expiratory flow (pef) and symptoms, ahr was also quantified following methacholine challenges. patients in the ahr strategy group received higher doses of ics to reduce ahr. this use of higher doses of ics and reduction in ahr was associated with a lower incidence of exacerbations and a greater improvement in lung function. of the 75 patients in the study, 80 55 also underwent bronchial biopsies before and after their individual treatment approaches. in ahr strategy group subjects, who received an additional 400 mg/d of ics, there was a significantly greater decrease in subepithelial reticular layer airway thickness and bronchial mucosa eosinophils compared to the reference group ( fig. 13.4 .5). the study also showed that the decrease in mucosal eosinophils related to an accompanying improvement in ahr. when the investigators evaluated the relationship between improvements in ahr and changes in the histology of the airway biopsies, they found a correlation with the reduction in tissue eosinophils ( fig. 13 .4.6). these findings further support for a role of eosinophils in airway remodeling. the haldar et al. 77 study also evaluated the effects of anti-il-5 on features of airway remodeling. airway wall thickness and airway wall area were evaluated by chest x-ray computed tomography (ct). changes in these assessments of airway structure were made following a year of treatment in both the mepolizumab and placebo groups. the investigators found a significant reduction in airway wall thickness and total wall area (ta and wa) in the mepolizumab-treated group ( fig. 13.4.7) . flood-page et al. 31 also hypothesized that a reduction in bronchial wall eosinophils with anti-il-5 would reduce markers of airway remodeling. twenty-four mild atopic asthma patients received three monthly infusions of mepolizumab and had bronchial biopsies taken before and after each infusion. in an attempt to determine if bronchial mucosa eosinophilic inflammation was associated with an increased deposition of extracellular matrix (ecm) proteins, researchers found a positive correlation between the thickness, density and expression of the ecm protein tenascin, and bronchial mucosal eosinophil numbers. as noted previously, mepolizumab caused a significant, though incomplete elimination of bronchial mucosal eosinophils. associated with these changes in eosinophils was a decrease in the thickness and density of tenascin, as well as density of the ecm proteins lumican and procollagen iii, in the reticular basement membrane. in addition, there was a decrease in expression of both tenascin and lumican. bal fluid in the mepolizumab-treated group also had a significant decrease in tgf-b. not only did this study confirm that the expression of ecm proteins is greater in asthma, it also showed that a reduction in eosinophil numbers is associated with a decrease in ecm protein deposition in the airway. figure 13.4.6 relationship between changes in eg2 ã¾ eosinophils and changes in methacholine pc 20 (the dose of the inhaled antagonist that provokes a 20% drop in fev 1 , the forced expiratory volume in one second) during 2 years of treatment according to the reference and airway hyperresponsiveness (ahr) strategies. the greater the decrease in number of eg2 ã¾ eosinophils, the greater the improvement in ahr to inhaled methacholine. eg2, antibody marker for activated esinophils. (reproduced with permission from sont jk, et al. 80 ) figure 13.4.5 individual changes in reticular layer thickness beneath the epithelium in bronchial biopsy specimens before and after treatment for 2 years according to the reference and ahr strategies. bars indicate mean values at the visits for both strategies. there is a significant decrease in reticular layer thickness within the ahr strategy group, which is significantly greater than in the reference strategy group. (reproduced with permission from sont jk, et al. 80 ) thus, the above studies provide convincing evidence for a relationship between the presence of eosinophils and features of airway remodeling. firstly, an increased ics dose leads to a decrease in bronchial mucosal eosinophils and airway thickness, as well as a reduction in bronchial hyperresponsiveness. 80 anti-il-5 studies built on such observations by showing that a decrease in bronchial mucosal eosinophils is associated with a reduction in airway thickness, as assessed by ct scans of the chest. 77 finally, evidence for a decrease in tgfb and ecm proteins following the use of anti-il-5 provides further support of the link between bronchial mucosa eosinophilic inflammation and airway remodeling in asthma. 31 since the discovery of the eosinophil in the late 1800s, this cell has been considered to be a characteristic feature and possibly an essential and etiological component of the pathophysiology of asthma. these assumptions were supported by demonstrating tissue eosinophilia in postmortem analyses of the lungs of patients who died in status asthmaticus, as well as by finding parallel relationships between blood eosinophilia and asthma severity. the belief in the central role of eosinophil in asthma was further strengthened by animal models that convincingly found anti-il-5 strategies to reduce ahr, blood and lung eosinophils, and the lpr to inhaled antigen. these studies identified eosinophils as a central contributor to asthma. surprisingly, when anti-il-5 was evaluated in patients with asthma, airway and peripheral eosinophils dramatically diminished, but there were no significant improvements in daily symptoms of asthma or airflow obstruction. what has emerged in the wake of anti-il-5 studies is perhaps a more informed opinion on two major roles for eosinophils in asthma: as effector cells of airway remodeling and exacerbations. 16 the role of the eosinophils as key players in the pathophysiology of asthma has been debated, despite evidence that the cells are present and activated in the airway lumen and tissue 1 of patients with current asthma; are increased in number when asthma is uncontrolled 2 or severe 3 and decreased when asthma is controlled 4 ; and treatment strategies that aim to control airway eosinophilia are significantly more effective and less expensive in improving asthma control 5,6 and decreasing asthma exacerbations compared to guideline-based clinical strategies. cynicism was fueled by observations that in murine models of allergic sensitization, airway hyperresponsiveness could be induced without eosinophils. 7 skepticism grew stronger when therapy using monoclonal antibodies against interleukin-5 (il-5), which has no known clinically relevant biologic activity other than targeting eosinophils, failed to demonstrate improvement in asthma outcomes despite decreasing airway and blood eosinophil numbers. 8 the molecule did not reduce allergen-induced airway constriction or hyperresponsiveness, airflow limitation, exacerbations, or symptoms. the likely explanations for this apparent paradox are inappropriate methodology, inadequate sample size, 9 or an inadequate reduction in bronchial mucosal eosinophil numbers. 10 this subchapter will describe the clinical studies that demonstrated an improvement in asthma control using treatment strategies that aimed to normalize sputum eosinophil count using corticosteroids; to evaluate critically the clinical trials that failed to demonstrate an improvement in asthma using monoclonal antibodies directed against il-5; and to present evidence from a prospective audit of clinical outcomes of patients managed by normalizing sputum cell counts. airway eosinophilia can be reliably and relatively noninvasively assessed in sputum. 11 in clinical practice, approximately 30% of patients with asthma attending a tertiary clinic have eosinophilic bronchitis. 12 more severe asthma and more severe airflow limitation are associated with more intense sputum eosinophilia. 13 two studies in adults and one study in children have evaluated the outcomes of titrating anti-inflammatory treatment with the intention of normalizing eosinophils in sputum. the first single center, 1-year trial that examined the effect of treating asthma to reduce eosinophils to 2% resulted in a significant reduction of severe exacerbations compared with a control group treated without sputum eosinophil counts. 5 the large number of exacerbations and their severity was probably a result of the policy at the time to reduce corticosteroid use further if control was maintained for 2 months. the second trial 6 was a multicenter trial conducted over 2 years, and differed in that the minimum dose of corticosteroid to maintain sputum eosinophils at 3% was determined first and then maintained for the duration of the study. exacerbations were few and mild compared with the first study and were reduced by about 50% compared with the group treated with the same bestguideline approach to treatment without sputum cell counts. the active treatment reduced eosinophilic exacerbations but had no effect on neutrophilic exacerbations, which were regarded to be probably of viral cause. the benefits in both studies were achieved without any increase in corticosteroid dose over that required by the control group. in contrast, a similar study in children showed a nonstatistically significant effect on reducing exacerbations using a sputum strategy that aimed to keep eosinophil levels to below 2.5%. 14 the modest benefit was most likely due to the inadequate control of eosinophils in the treatment arm that was probably related to the inadequate dose of inhaled corticosteroids allowed in the study. the effectiveness of using sputum eosinophils as a marker to decrease exacerbations in adults and children with moderate to severe asthma was recently confirmed in a systematic review and meta-analysis. 15 a critical review of the recently published clinical trial literature reveals that the reduction in exacerbation reported in all the most recent large clinical trials for either asthma or chronic obstructive pulmonary disease (copd) for any new medication compared to placebo is significantly less than those reported for strategies employing the judicious use of currently available medications guided by cell counts in sputum (table 13 .5.1). in addition to a significant reduction of exacerbations at a reduced cost, 16 the adverse consequences of new therapies and suboptimal treatment may also be avoided. the beneficial effects of corticosteroids are not limited to decreasing eosinophil numbers in the airways. 17 they can also reduce the numbers of other cells, such as lymphocytes and mast cells, and decrease some markers of remodeling. thus, it is not possible to conclude definitively the pathobiological role of eosinophils in asthma from those studies. definitive proof would be obtained by reducing eosinophil numbers in the airway using treatments that directly target the eosinophils. recently, the availability of monoclonal antibodies directed against il-5 has provided us with the opportunity to examine this question. in two recently published randomized controlled trials (rcts) on the effect of mepolizumab 18, 19 and a clinical trial on the effect of reslizumab, 20 these drugs reduced sputum eosinophils numbers to almost zero. this reduction was associated with a reduction of exacerbations compared with the placebo group in the first mepolizumab study 18 and a prednisonesparing effect and improvement in clinical outcomes in a small sample number in the second. 19 in the larger reslizumab clinical trial, 20 the reduction in sputum eosinophils was associated with an improvement in the forced expiratory volume in one second (fev 1 ) and in asthma controls over a 5-month period in patients with moderate to severe asthma. the results of these three studies contrasted with the negative results of five other trials, in which the effect of the antieosinophil drug was not examined in patients with asthma and current sputum eosinophilia. in two of the five studies that measured sputum eosinophils and in the three rcts, the greater the certainty that an increase in eosinophils was persistent, the greater the success of the treatment (table 13 .5.2). clinical outcomes are significantly improved when patients who require daily prednisone are monitored using sputum cell counts. sixty-three patients with asthma (36 men; mean age, 52 years; mean bmi, 29.1) were followed for a median period of 7 years (range, 0.25e26 year). 21 thirty-seven patients had associated chronic airflow limitation (postbronchodilator fev 1 /vital capacity <70%). twenty had never smoked. forty-two percent were nonatopic. significant comorbidities included gastroesophageal reflux disease (70%), nasal polyps and sinusitis (65%), and sensitivity to nonsteroidal anti-inflammatory drugs (28%). ethmoid and sphenoid sinusitis were the most important predictors of persistent airway eosinophilia. 22 at the time of their initial assessment, the majority of the patients were not on daily prednisone (median daily dose, 0 mg; sputum eosinophils: mean, 18.8%; median, 5.3%; minimum, 0%; maximum, 84%). monitoring with the aim of keeping sputum eosinophils at <2% resulted in higher doses of corticosteroids (median daily dose of prednisone was 10 mg and for inhaled corticosteroids was 1000 mg of fluticasone equivalent), and this was associated with predictable significant adverse effects. over the period of follow-up, despite decreasing the eosinophilic exacerbations to 0.2 years/patient, there were 22 noneosinophilic neutrophilic exacerbations. overall, there was no significant loss of lung function over the period of follow-up (mean decrease in fev 1 , 35 ml/year). corticosteroids are very effective in reducing eosinophil numbers and activation in the airways of most patients with asthma. therefore novel treatment strategies such as anti-il5 should probably be reserved for patients who require high doses of inhaled or regular ingested corticosteroids to control their airway eosinophilia and asthma. although a larger number of antisense molecules, monoclonal antibodies, and small molecules are currently being evaluated to target a number of relevant cytokines or chemoattractants involved in eosinophil recruitment into the airway, such as eotaxin/ c-c motif chemokine 11 (ccl11), il-4, and il-13, 23 none of them have yet been demonstrated to be effective in suppressing an airway eosinophilia that persists despite being treated with prednisone. these are currently being investigated. eosinophils, a prominent feature of asthma, are found in increased numbers in the circulation and airways in relation to the severity of asthma. 1,2 inhaled allergen challenge in asthmatic subjects results in the appearance and accumulation of mature and immature eosinophils in the bone marrow, blood, 3 and airways. 4e6 the kinetics of eosinophilia are compartment-specific ( fig. 13 .6.1), 4, 7, 8 and the number of eosinophils correlates with the severity of the late asthmatic reaction. 9 this will be covered in detail elsewhere in this book. eosinophils are terminally differentiated myeloid leukocytes that migrate to tissues as effector cells in a number of inflammatory processes, including allergic diseases and helminth infections. 10 the migration and accumulation of eosinophils is highly regulated via signaling of cytokines and chemokines through cell-surface receptors, and by induction of adhesion molecule expression. 11 since allergic asthma is primarily a t-helper type 2 (t h 2)-mediated disease, it is not surprising that cytokines driving eosinophilia are t h 2 cell products: specifically, granulocyte-macrophage colony-stimulating factor (gm-csf), interleukin-3 (il-3), and interleukin-5 (il-5), which signal through specific high-affinity cell-surface receptors linked to a common b-chaindall of which can act as eosinophil growth factors that promote formation of eosinophil/basophil (eo/b) colony-forming units (cfu) in functional assays. 12 the common b-chain is especially important for eo/b proliferation, production of cytokines from eosinophils, and eosinophil migration to effector sites. 13 of the three eo/b differentiation-inducing cytokines, il-5 is necessary for mobilization of eosinophil progenitors from the bone marrow and their terminal differentiation. 14 other t h 2 cytokines, such as il-4 and il-13, are known to regulate transmigration of eosinophils from the vascular bed into the tissue compartments by augmenting expression of adhesion molecules on the endothelium 15 and inducing expression of potent eosinophil chemokines, such as eotaxin/c-c motif chemokine 11 (ccl11) and rantes/ccl5 in the airways. 16, 17 il-9 has also been shown to play a supportive role in both mast cell and eo/b differentiation. 18, 19 once in the inflamed tissue, eosinophils contribute to the manifestation of symptoms through release of granule proteins and proinflammatory mediators. 10 hemopoietic progenitors, which are found in the circulation under steady-state and disease conditions, exist in the bone marrow at various stages of lineage commitment; in the latter compartment, these progenitors can be allowed or selected to differentiate in specific directions in response to various ambient stimuli, such as hemopoietic cytokines engaging specific cell-surface receptors. this hemopoietic activity occurs in the bone marrow proper under the influence of stromal cells and microvascular endothelial cells, and in tissues, also in response to epithelial cells. each of these resident cell populations can respond to inflammatory stimuli by increasing transcription and translation of hemopoietic growth factors and/or cytokines. the bone marrow environment itself, as well as primed tissues, can each support and accelerate production of eosinophils for either release into the circulation or amplification of tissue eosinophilic inflammation, respectively. 20, 21 the process of tissue amplification of eosinophilic inflammation through progenitor differentiation at the site has been termed in situ hemopoiesis (figure 13.6.2). 22,23 hemopoietic progenitors express the cell stage-specific antigen, cd34, which is present at the highest levels on early hemopoietic myeloid progenitors and is progressively lost on terminally differentiating cells. 24 these cd34 ã¾ hemopoietic progenitors contribute to the ongoing recruitment of eosinophils and basophils to sites of allergen challenge in allergic diseases, including asthma. 25 indeed, the number of cd34 ã¾ cells, as well as both mature and immature eosinophil cell numbers, are higher in blood and bone marrow of atopic subjects compared with nonatopic controls; 26,27 mild asthmatic subjects have fewer circulating cd34 ã¾ cells than severe asthmatic subjects, 28 after airway allergen inhalation challenge in atopic asthmatic subjects, cd34 ã¾ cells from bone marrow synthesize mrna and protein for membrane-bound il-5 receptor subunit a (il-5ra), 29 permitting them to further respond to the eosinophilopoietic cytokine, il-5. progenitor cells from the bone marrow of atopic subjects show increased responsiveness to il-5, 26 probably due to increased levels of bone marrow cd34 ã¾ il-5ra ã¾ cells, a unique feature of atopic disease. 30 the phenotype of bone marrow cd34 ã¾ cells from mild asthmatic subjects has been carefully examined by flow cytometry, demonstrating a higher proportion of cd34 ã¾ il-5ra ã¾ after allergen challenge in those subjects who developed airway eosinophilia and increased methacholine airway responsiveness. 29, 31 taken together with in vitro experiments demonstrating il-5-induced expression of il-5ra on human progenitor cells, 32,33 these data demonstrate eosinophil lineage skewing of cd34 ã¾ cells in response to an allergic stimulus. thus, increased production of eo/b lineage-committed progenitors within the bone marrow, the subsequent development of blood and tissue eosinophilia, 29 and the maintenance of an allergic inflammatory response 26, 34 have been linked. reports of antigeninduced increases in cd34 ã¾ il-5ra ã¾ cell numbers in murine bone marrow coincident with enhancement of il-5-dependent eosinophilopoiesis provide further evidence that eosinophil production occurs as a result of expansion of the relevant eosinophil progenitor population rather than exclusively from demargination or release of sequestered mature eosinophils into the circulation. 35e39 the rapid increase in expression of il-5ra on cd34 ã¾ cells from the bone marrow of atopic asthmatics 28, 40 clearly demonstrates that progenitor cells in these subjects are primed to respond to il-5; indeed, cd34 ã¾ il-5ra ã¾ cell numbers circulate at higher numbers in subjects with asthma compared to controls, and correlate with asthma severity. 28 although controversial, chemokines such as eotaxin may also play a role not only in the migration 41 but also in the differentiation of progenitor cells. since cd34 ã¾ progenitor cells are found to express c-c chemokine receptor 3 (ccr3), 42 which is upregulated in a t h 2 environment, it is possible that signaling through this receptor also causes progenitor cells to differentiate into eosinophils independently of gm-csf, il-3, and il-5. 43 colony assays are functional measures for the quantification of hemopoietic differentiation potential. eo/b cfu are clusters of immature, nascent eosinophils and basophils derived from single progenitors 44e46 present in nonadherent mononuclear or purified cd34 ã¾ cell populations seeded into a semisolid medium in the presence of hemopoietic growth factors. there are significantly greater numbers of eo/b cfu in the peripheral blood of subjects with various allergic airway disorders, including asthma, nasal polyposis, and rhinitis. 47, 48 greater numbers of cd34 ã¾ cells are detected in blood and bone marrow of atopic than nonatopic subjects, correlating positively with higher numbers of eo/b cfu grown from the blood and marrow of these subjects. 26 the higher levels of cd34 ã¾ cells and il-5-responsive eo/b cfu in atopic subjects indicate a role for eo/b progenitors in allergic diseases, such as asthma. 26 the growth of eo/b cfu is also influenced by exposure to specific antigen, which initiates a cascade of events with a stimulatory effect on the bone marrow to produce and release newly formed inflammatory cells. importantly, allergic individuals can exhibit fluctuations in the numbers of circulating progenitors and tissue eosinophils during an allergen pollen season. 49, 50 an initial increase in circulating eo/b cfu at the beginning of seasonal allergen exposure is followed by a significant decline at the peak of the season, coincident with nasal symptoms and inflammation, probably reflecting the migration and differentiation in situ of progenitor cells from the blood to the inflamed tissue. 49e51 this increase in eo/b cfu has also been demonstrated in allergic asthma exacerbation. 52, 53 supporting the latter in vivo observation, higher numbers of bone marrow 31 and circulating 54 eo/b cfu can be measured 24 h after allergen inhalation. studies conducted in animal models of allergic asthma that carefully investigate the trafficking of cells from bone marrow confirm that allergen-induced airway inflammation is associated with increased numbers of newly formed cells in the blood and airways. 34, 55 in mouse models of allergic rhinitis and/or asthma, changes in bone marrow eosinophilopoiesis, accompanied by appropriate peaks of hemopoietic cytokines and chemokines, such as eotaxin, gm-csf and il-5, and changes in cell surface receptors for these factors, were shown to occur as early as 2 h after allergen challenge, 38,39,56e58 indicating that progenitor cell fluctuations and hemopoietic processes contributing to eosinophilic airways inflammation can occur quite rapidly in response to allergen challenge. studies to assess changes in cytokines levels within the bone marrow of sensitized mice or atopic asthmatics following allergen exposure have detected increases in levels of il-5 consistent with the kinetics of eosinophil lineage commitment. 37e39,56,57,59 using colony-forming assays, bone marrow progenitor cells from asthmatic subjects developing late-phase responses and airway eosinophilia postallergen challenge were shown to be more responsive to il-5 than cells from subjects without these allergen-induced responses. 29 a subsequent investigation demonstrated that allergen inhalation by allergic asthmatic subjects induces a time-dependent change in the levels of growth factors and cytokines in the bone marrow: subjects with elevated levels of airway and circulating eosinophils postchallenge had increased numbers of il-5-responsive progenitors at 12 h and 24 h postallergen ( fig. 13 .6.1), coincident with increased il-5 protein levels in the bone marrow. 4 as such, allergeninduced activation of an eosinophilopoietic process highlights the relationship between increased bone marrow il-5 levels and the regulation of eosinophil production from bone marrow progenitor cells. given the observed delayed interferon g (inf-g) increase in the marrow of these subjects, 4 it could be postulated that activated t cells migrate from the airways to the bone marrow and release cytokines such as il-5 and il-9 that may locally orchestrate activation of hemopoietic events during an allergic inflammatory response. 60e63 to this end, investigations of the cell-associated cytokine production within the bone marrow have shown that cd34 ã¾ cells 64, 65 and t cells 61e63,65 produce il-5 during the course of the allergic inflammatory response. nascent eosinophils and basophils picked from eo/b cfu have also been shown to constitute autocrine sources of gm-csf and il-5, 54,61e63,66,67 which could further amplify the process of differentiation and proliferation. more recently, it has been shown that cd34 ã¾ cells from blood and bone marrow release more il-5 following stimulation with calcium ionophore and phorbol-12-myristate-13-acetate than do the equivalent number of cd3 ã¾ t-lymphocytes. 68 traditionally, the focal point of the differentiation and maturation process involving hemopoietic progenitors has been the bone marrow, under the regulation of its proper microenvironment. however, there is now an abundance of evidence demonstrating that eosinophil progenitors can traffic as fully or partly undifferentiated cells to allergic inflammatory tissues in the upper and lower airways, where they can and do differentiate into mature eosinophils under the control of local stimuli. indeed, eo/b cd34 ã¾ cells are found in tissues such as the bronchial mucosa, 69 nasal polyps, 70 and even in atopic dermatitis lesions. 71 despite the importance of systemic and local il-5 production for the differentiation of cd34 ã¾ cells in the bone marrow, it is apparent that eo/b can differentiate similarly at sites of tissue inflammation. this has been demonstrated functionally in several studies. firstly, inflamed tissue from subjects with allergic rhinitis and nasal polyposis has been shown to produce hemopoietic cytokines that promote the differentiation and maturation of eo/b cfu. 23,72e78 next, mononuclear cells extracted from nasal polyp tissue have the potential to produce eo/b cfu in response to growth factors such as il-5. 23, 70, 72 this supports the concept of in situ hemopoiesis, in which locally elaborated growth factors can drive the differentiation and maturation of hemopoietic progenitors into mature eosinophils ( fig. 13.6.2) . finally, phenotypic evaluations have identified cd34 ã¾ cells in various airway compartments, including the mucosa of the upper and lower airways of subjects with allergic rhinitis and asthma, respectively. 60, 69, 70 the already elevated levels of cd34 ã¾ cells in induced sputum samples collected from mild asthmatic subjects are further increased after allergen inhalation challenges compared to healthy controls. 3 with respect specifically to in situ eosinophilopoiesis, increased numbers of cells double positive for cd34 and il5ra mrna are found in nasal biopsies 60 and lung biopsies of allergic asthmatic subjects compared to normal controls, 60, 69 suggesting that il-5-responsive cd34 ã¾ cells committed to the eo/b lineage are present within the inflamed tissue. furthermore, cd34 ã¾ cells appearing in sputum of allergic asthmatic subjects stain positive for il-5 and il-13 intracellularly, suggesting that they themselves may act as proinflammatory effector cells in the microenvironment of the inflamed tissue. 64 autocrine production of growth factors in eo/b cfu grown from the blood of allergic asthmatic subjects has likewise been documented, which suggests that cytokine expression by differentiating progenitors may provide an additional stimulus to enhance differentiation in situ. 54, 66 a similar autocrine upregulation of both eosinophilopoietic factors and their receptors has recently been demonstrated for tlr-ligated cd34 ã¾ cells in cord blood. 79, 80 in situ il-5-dependent differentiation of eosinophil progenitors can be triggered in the nasal mucosa of allergic rhinitic donors: ex vivo nasal mucosa cultures stimulated with allergen were shown to contain reduced numbers of cd34 ã¾ il5ra mrna ã¾ cells and increased numbers of major basic protein (mbp) immunoreactive cells, thus shifting cells locally from an immature to a mature phenotype. 60 in a mouse model of allergen-induced airway inflammation, newly produced cd34 ã¾ ccr3 ã¾ cells, isolated from lung and stimulated with eotaxin-2/ccl24 or il-5, differentiated into significant numbers of cfu; cell cycle analysis showed significant increases in the number of cd34 ã¾ ccr3 ã¾ proliferating cells in allergenexposed animals. 81 these data support the notion of local eo/b differentiation within tissues, suggesting that the ccr3/eotaxin pathway is also involved in the regulation of this allergen-driven in situ hemopoiesis, at least in mice. recently, it has been shown that human airway smooth muscle of allergic asthmatics can also stimulate increased eo/b differentiation in vitro, 82 adding to the complexity of systemic and local hemopoietic processes in the generation of eosinophilic tissue inflammation. the evidence described above for in situ hemopoiesis 43 is also in keeping with a recent observation that il-33/thymic stromal lymphopoietin (tslp) is sufficient to induce the differentiation of cd34 ã¾ progenitors into eosinophils, in addition to activating t h 2 and mast cells. 64 a major recent discovery is that tslp promotes t h 2 pathways (via il-25 and il-33) that induce the development of a c-kit int sca-1 ã¾ multipotent progenitor (mmp; also known as 'nuocytes') 83 population in gut-associated lymphoid tissue; 84, 85 this provides further support for in situ hemopoiesis, and promotes the idea that tslp provides a critical link between adaptive and innate immunity in the process of hemopoietic cd34 ã¾ cell differentiation within tissues ( fig. 13 .6.2). as mentioned above, recent data showing that cd34 ã¾ il-5 ã¾ and cd34 ã¾ il-13 ã¾ double-positive cells can be detected in sputum of asthmatic patients, with increases after allergen challenge, 64 are consistent with the concept of allergen activation, via tslp, of multipotent as well as lineage-committed progenitors, some of which can thus potentially function as inflammatory effector cells without further differentiation. preliminary data show that recombinant tslp, with or without il-33 as a coligand, can also upregulate il-5ra on cd34 ã¾ cells, rendering them more responsive to the effects of il-5, with concomitant functional eo/b cfu differentiation. 86 moreover, stimulation of cd34-enriched human cord blood cells with the toll-like receptor (tlr) agonists, lipopolysaccharide (lps) or cpg-oligodeoxynucleotides (cpg odn), induces increased expression of tlr-2, tlr-4, and tlr-9 on cd34 ã¾ cells, as well as increases in gm-csfra, il-3ra, and il-5ra. 79, 80 these observations demonstrate additional mechanisms through which innate immunity can regulate the responsiveness of eo/b progenitors. cd34 ã¾ cells stimulated with a combination of tlr agonists and hemopoietic cytokines have been shown to give rise to more eo/b cfu responsive to il-3 and il-5 than through hemopoietic cytokine stimulation alone. 79, 80 collectively, these data point to tslpetlretlr ligand interactions that can result in autocrine upregulation of t h 2 cytokines (e.g., il-5, il-13) in cd34 ã¾ cells, 61, 64, 65 and further support the idea that tslp provides a critical link between adaptive and innate immunity in the process of hemopoietic cd34 ã¾ cell differentiation within tissues (fig. 13.6 .2). il-5 is central for upregulation of myeloid progenitors in the bone marrow after airway allergen challenge, 38, 87 and for trafficking from the marrow to the airways in several animal models of either upper or lower airways inflammation. 56, 88, 89 airway, blood, and nasal eosinophilia are completely inhibited by either neutralizing the biologic effects of il-5 90 or through deletion of the gene encoding il-5. 62 although the asthmatic lung can release abundant amounts of il-5, studies in animal models have led to debate regarding the distribution and sources of il-5 required to drive airway eosinophilia. studies in mice have shown that circulating, rather than local, il-5 in the lung is critical for the development of allergic airways eosinophilia. 91 this was investigated through systemic il-5 gene transfer to il-5-knockout mice, which effectively supported ovalbumin (ova)-induced eosinophilia in the blood, bone marrow, and lung. this contrasts with il-5 gene transfer into the airways, which did not induce eosinophilia following ova challenge. 91 thus, systemic il-5 seems to be necessary for the development of eosinophilia in the mouse. however, this is more controversial in humans. further studies have demonstrated that inhalation of il-5 by allergic asthmatic subjects leads to the development of peripheral blood and sputum eosinophilia, 92 and inhaled il-5 induces airway eosinophilia accompanied by increased airway hyperresponsiveness (ahr). 93 in contrast, three subsequent studies reported no effect of il-5 inhalation on eosinophil levels in blood, airways, or ahr in allergic asthmatics. 94e96 by inhalation, il-5 was found to significantly decrease cd34 ã¾ il5ra mrna ã¾ cells within the bronchial mucosa and decrease the percentage of cd34 ã¾ ccr3 ã¾ cells in the bone marrow of atopic asthmatics. 96 it has been hypothesized that lung-derived il-5 provides a signal to a population of cells within the bronchial mucosa that traffic to the bone marrow, where they locally induce the efflux of cd34 ã¾ ccr3 ã¾ cells. 65, 96 elegant experiments involving perfusion of the femoral bone marrow of guinea pigs confirmed that whereas il-5 induces chemokinesis of bone marrow eosinophils, mobilization of mature eosinophils by il-5 occurs synergistically with, and requires, the presence of eotaxin. 41 eotaxin is a potent and eosinophil-specific chemoattractant. 97e99 eotaxin-1 is thought to be more important than eotaxin-2 for inducing mobilization of eosinophils and their progenitors from the bone marrow into the blood circulation. 41,100 a reduction of eosinophil numbers was observed in the lungs of mice treated with eotaxin-1 blocking antibodies 101, 102 and in strain-specific eotaxin-1 knockout mice. 103, 104 eotaxin-1 is released from lung structural cells, 105 and is released at increased levels following allergen challenge. 106 human endothelial progenitor cells also express eotaxin-1, 107 and have been shown to be rapidly mobilized to the lung after allergen challenge in sensitized mice 107 and atopic asthmatic subjects, 108 where they also can contribute to the development of lung eosinophilia through the expression and secretion of eotaxin-1. more recently, both eotaxin-1 and eotaxin-2 have been shown to induce migration of murine bone marrow and blood cd34 ã¾ ccr3 ã¾ cells using an in vitro transmigration assay. 81 these data suggest that the ccr3/eotaxin pathway is involved in the regulation of allergen-driven accumulation/mobilization of eosinophil lineage-committed progenitor cells in the lung. the receptor for eotaxin, ccr3, is upregulated on cd34 ã¾ cells after allergen challenge, thereby facilitating eotaxin-mediated progenitor cell mobilization from the bone marrow to the peripheral circulation. 42, 109 other migration signals studies in sensitized mice have indicated that t cells are the major gatekeepers regulating eotaxin and il-5 levels, and thus eosinophilia. reductions in airway, bone marrow, and peripheral blood eosinophil levels in cd4 ã�/ã� and cd8 ã�/ã� mice suggest that these t cell populations are critical regulators of allergen-induced eosinophilia. furthermore, reduced serum il-5 and bronchoalveolar lavage eotaxin-2 levels in cd4 ã�/ã� mice suggest that cd4 ã¾ t cells are obligatory for the development of allergen-induced airway eosinophilia. 110 in addition to eotaxin and il-5, many other mediators have been shown to induce responses in both mature eosinophils and eo/b progenitors. cysteinyl leukotrienes, which are released in the airways following perturbation by allergen, are chemoattractants for mature eosinophils, 111 but have also been shown to aid differentiation 112 and induce chemotaxis and in vitro transendothelial migration of eo/b progenitors. 113 preliminary work has shown that both il-4 and il-13 can prime hemopoietic progenitor cells in a transmigration assay, 114 and studies are under way to investigate whether progenitors are also responsive to the eosinophil chemoattractants prostaglandin d2 receptor 2 (crth2; reviewed in 115 ) and peroxisome proliferatoractivated receptor g (pparg). 116, 117 in the allergen challenge model, there is attenuation of cxcr4 (sdf-1a receptor) expression on bone marrow cd34 ã¾ cells from mild asthmatic subjects, as well as a reduction in sdf-1a levels in the bone marrow. this demonstrates a mechanism whereby retention of progenitors in the bone marrow regulates their egress into the blood. 109 the discoveries that il-5 is a specific eosinophil growth factor in humans and that eotaxins can selectively induce eosinophil recruitment, as described above, were instrumental for the development of drugs targeting the eosinophil. this is reviewed in detail elsewhere. 118 anti-il-5 treatment in mild atopic asthmatic subjects has been shown to induce a reduction of airway eosinophils, arrest bone marrow eosinophil maturation, and decrease eosinophil progenitors in the bronchial mucosa. 119, 120 though initial clinical trials of il-5 blockade in patients with asthma were unsuccessful in demonstrating clinical efficacy, 119,121e124 a number of issues may have contributed to the failure of these studies, including lack of depletion of tissue eosinophils and their granule products; patient selection; and methodological problems. 125 subsequent studies, conducted in a subgroup of asthmatic patients selected on the basis of having persistent eosinophilic asthma, have demonstrated that blocking il-5 with the humanized il-5 antibody, mepolizumab, has a steroidsparing effect, reduces exacerbations, and improves quality of life for asthma patients. 126, 127 the anti-il-5 approach is troubled by the inability to completely abolish eosinophilia, consistent with murine observations (reviewed in matthaei et al. 89 ), since it is hypothesized that if eosinophilia were solely controlled by il-5 then a more complete suppression of eosinophils would ensue from therapeutic anti-il-5 interventions. a propos this possibility, however, medi-563 is a humanized anti-il-5ra monoclonal antibody that binds il-5ra with high affinity and mediates cell lysis via antibody-directed cell-mediated cytotoxicity. as such, medi-563 kills all cells bearing il-5ra, including eosinophil progenitors, and has been shown to eliminate eosinophils from the circulation of subjects with mild asthma. 128,129 this antibody is currently under investigation in other clinical models of asthma. that eosinophils can remain in the lung tissue of asthmatic subjects despite il-5 blockade suggests that additional signals promote eosinophil survival. indeed in il-5-deficient mice, responses to gm-csf and il-3 are normal, despite absence of eosinophilia in the nasal mucosa and the bone marrow, significantly lower numbers of il-5-responsive eo/b cfu and maturing cfu eosinophils, and reduced expression of il-5ra on bone marrowderived cd34 ã¾ cd45 ã¾ progenitor cells. 56 these results indicate that redundant cytokine mechanisms can compensate for il-5 deficiency and highlight the multifactorial nature of allergic inflammation, indicating that combined, as opposed to single-line, therapies may be more effective in the treatment of diseases such as asthma. one such therapy is currently being tested in clinical trials of allergic asthma. tpi-asm8 is a combination of two antisense oligonucleotides, one blocking translation of the il-3/il-5/gm-csf receptor common b chain, and the other blocking translation of ccr3. as such, tpi-asm8 prevents expression of receptors for gm-csf, il-3, il-5, eotaxin-1, and eotaxin-2, and will thus hypothetically inhibit many of the signals shown to be crucial for eosinophilopoiesis, as well as eosinophil migration, activation and survival. following allergen challenge in mild atopic asthmatic subjects, inhaled tpi-asm8 inhibited accumulation of mature eosinophils and cd34 ã¾ il-5ra ã¾ cells in the sputum, in addition to inhibiting the late asthmatic response. 130,131 despite advances made in the development of eosinophilspecific therapies, corticosteroids remain the gold standard for the treatment of allergic inflammatory diseases like asthma. 132e134 local delivery using inhalers is intended for topical treatment of the affected tissue; however, the antiinflammatory actions of corticosteroids have been shown to extend beyond the environment of the airways, probably due to a small amount of systemic availability. these systemic effects are beneficial for regulating hemopoietic mechanisms that originate in the bone marrow. stepwise withdrawal of inhaled corticosteroids results in a rapid and substantial increase in eo/b progenitors assayed in peripheral blood, which returns to baseline when treatment is reinstated. 135 only 1 week of treatment with inhaled corticosteroid is sufficient to significantly attenuate allergen-induced levels of circulating eo/b cfu 66 and reduce baseline numbers of bone marrow eo/b cfu 34 in mild allergic asthmatic subjects, further demonstrating the efficacy of corticosteroids on progenitors in peripheral blood. however, the inhaled steroid has no effect on the allergen-induced increase in the number of bone marrow cd34 ã¾ cells, the increase in il-5ra expression on these cells, or the number of eo/b cfu. these findings suggest that topical corticosteroids may exert indirect suppressive effects on the differentiation of eosinophil progenitors. eosinophil progenitors are now emerging as effector cells that can migrate to inflamed tissue where they rapidly proliferate in response to allergic stimuli. understanding communication between eosinophil progenitors and the innate immune system will require further exploration. asthma is a chronic pulmonary disease characterized by airway remodeling, airway inflammation, and bronchoconstriction. patients with asthma cycle between periods of exacerbations, which result in significant morbidity, and recovery. virus infections are the leading cause of asthma exacerbations in children and adults, yet specific treatment and prevention strategies for virus-induced asthma are limited. the tissue damage caused during virus-induced asthma is divided into two categories: damage caused by the virus itself and damage from the host immune response. eosinophils play a significant role in both virus clearance and immunity-mediated tissue damage. as many as 80% of childhood cases and 55% of adult cases of asthma attacks have an identifiable underlying virus infection. 1,2 diagnosis of virus infection in acute asthma is often presumptive and based on patient history and physical examination, but other diagnostic laboratory techniques include serology, virus culture, and reversetranscription polymerase chain reaction. respiratory rna viruses are the main types of virus that induce asthma attacks, with rhinovirus (the common cold virus) accounting for approximately two-thirds of viruses identified. 3 coronavirus, influenza, parainfluenza, and respiratory syncytial virus (rsv) comprise the remainder of respiratory rna viruses that induce asthma attacks. 1 the immune response to viral infections is t-helper type 1 (t h 1)-driven and involves the production of proinflammatory cytokines such as interleukin-12 (il-12) and interferon g (ifn-g). studies show that t h 1 responses in patients with asthma are impaired, which results in decreased t h 1 cytokine production during viral infection. 4 asthma also skews the immune system away from a t h 1 response toward a t h 2 immune environment through increased production of t h 2 cytokines, such as il-4, il-5, and il-13. il-5 is the central cytokine involved in eosinophil proliferation, maturation, and survival. when the immune environment of a virus-infected patient with asthma shifts from t h 1 to a t h 2 response, these patients experience more severe symptoms of infection and delayed pathogen clearance, which likely contribute to increased asthma exacerbations and hospital admissions. 4, 5 the association of eosinophils with virus-induced asthma is well documented. eosinophil products are present in the sputum of patients with virus-induced asthma, 6 and histology studies show that in patients who have died from severe asthma, eosinophils are clustered around airway nerves (fig. 13.7.1) . 7 in the following sections, we will present the mechanisms of eosinophil pathophysiology in virus-induced asthma, focusing on virus-induced airway inflammation, viral activation of eosinophils, virus-induced eosinophil-mediated neural changes, and t celleeosinophil interactions during virus infection. we then discuss the beneficial role of eosinophils in virus-induced asthma and potential targets for prevention and treatment of the disease. respiratory virus infection induces airway inflammation in all individuals, but the inflammatory response is different in patients with asthma from in nonasthmatic individuals. experimental rhinovirus infection of human subjects increases eosinophil numbers in the bronchial epithelium in both nonasthmatic and asthmatic volunteers. eosinophils remained in airway tissues of virus-infected patients with asthma 6 weeks longer than in infected, nonasthmatic controls. these data suggest that virus-induced eosinophil influx into the airways occurs in individuals both with and without asthma and that the eosinophil response to viral infection is accentuated in patients with asthma. 8 the airway epithelium is the primary site of respiratory virus infection. virus-infected epithelial cells release a wide array of proinflammatory cytokines that recruit inflammatory cells into the airways. among these proinflammatory cytokines are eotaxin/c-c motif chemokine 11 (ccl11), granulocyte-macrophage colony-stimulating factor (gm-csf), mip-1a/ccl3, and rantes/ccl5, which are chemoattractants and activators of eosinophils. 9e16 virus infection increased eosinophil inflammation in the airways of antigen-sensitized and antigen-challenged mice compared to sensitized-challenged, mock-infected animals. in addition, virus infection of epithelial macrophages induced the release of eotaxin, and the blockade of eotaxin bioactivity with a neutralizing antibody inhibited airway eosinophilia in sensitized-challenged, virus-infected but not sensitized-challenged, mock-infected mice. these data suggest that virus infection recruits eosinophils to the lungs of sensitized-challenged animals and that this is dependent on eotaxin. 17 virus infections of allergic individuals may lead to the development of eosinophilic inflammation as well as features of asthma. calhoun et al. showed that patients with allergic rhinitis who were experimentally infected with rhinovirus had increased eosinophil influx into the airways following allergen challenge. these patients also had increased histamine release and edema from fluid leakage, which are consistent with asthma. these data suggest that virus infection may induce asthma in individuals with preexisting allergic respiratory diseases. the t h 2 immune environment that allergic rhinitis elicits closely resembles the cytokine profiles of asthma, so a subsequent viral infection may tip airway physiology toward an asthma phenotype. 18 eosinophils are activated during viral infection. studies of patients with rsv bronchiolitis showed the presence of eosinophil cationic protein (ecp) and eosinophil-derived neurotoxin (edn) in their lower airway secretions. 19, 20 other studies have shown that cell surface expression of cd11b, a marker of cellular activation, is upregulated in eosinophils of rsv-infected patients compared to uninfected volunteers. 21 these data suggest that eosinophils are activated and degranulate following viral infection. toll-like receptors (tlrs) are pattern recognition receptors that recognize pathogen-associated molecular patterns (pamps). many groups have shown that tlrs are present and functional in eosinophils. tlrs mediate both the innate and adaptive immune responses, and some believe they are involved in controlling sensitization. studies suggest that polymorphisms in tlr2, tlr4, tlr9, and tlr10 are associated with an increased risk of developing asthma. 22e25 human eosinophils express tlr1, tlr4, tlr7, tlr9, and tlr10 mrna. tlr7 recognizes single-stranded rna (ssrna) found in respiratory rna viruses. nagase et al. showed that r848 (a synthetic ligand for tlr7 and tlr8) increases cd11b expression on human eosinophils, induces superoxide generation, and promotes cell survival. 26 phipps et al. showed that mouse eosinophils express tlr7 on their cell surface and tlr3, tlr4, and tlr7 in endosomes. furthermore, ssrna treatment of mouse eosinophils increases eosinophil peroxidase (epo) release, increases cd11b expression, and induces degranulation. 27 eosinophil tlr responses to stimulation may differ between atopic and nonatopic individuals. mansson et al. showed that eosinophils treated with il-5 and then stimulated with polyi:c (a tlr3 agonist) had increased il-8 release compared to il-5 treatment alone. 28 in addition, il-5 pretreatment potentiates r837 (a tlr7-specific synthetic ligand)-induced il-8 release. moreover, eosinophils collected from atopic patients and stimulated with r837 release increased il-8 compared to r837-stimulated eosinophils from nonallergic volunteers. 29 these data suggest that atopy affects eosinophil tlr responses and that aberrant virus-induced eosinophil activation in patients with asthma may exacerbate their airway disease. eosinophils can be infected and activated by respiratory viruses. eosinophils can be activated directly by virus binding to receptors on either the cell surface or in endosomes, depending on the virus's mechanism of entry. rsv mediates entry into target cells by binding tlr4. although it has not been demonstrated that rsv binds tlr4 on eosinophils, in vitro culture of rsv with human eosinophils prolongs cell survival. 30 transmission electron microscopy studies showed that rsv is internalized by human eosinophils and identified virions in phagocytic vacuoles near the cell surface. in addition, infected eosinophils underwent piecemeal degranulation, suggesting that these cells were activated upon infection. 31 in some cases, virus-induced eosinophil activation requires priming prior to infection and, in other cases, viruses prime eosinophils to respond to treatment with additional stimuli. handzel et al. showed that rhinovirus binds intracellular adhesion molecule-1 (icam-1) on human eosinophils primed with gm-csf and that gm-csf treatment upregulates icam-1 on eosinophils. 32 additional studies showed that rsv increased superoxide generation and cd11b in eosinophils that were first treated with platelet activating factor. 33 rsv infection of eosinophils potentiates phorbol-12-myristate-13-acetate (pma)-induced superoxide generation and leukotriene c 4 release. 34 these data suggest that virus-induced eosinophil activation in asthma may lead to an exaggerated host immune response, resulting in airway inflammation and constriction. during virus-induced asthma, eosinophils cause dysfunction of parasympathetic nerve signaling. airway parasympathetic nerves provide the dominant control over airway smooth muscle. 35 these neurons release acetylcholine (ach), which binds m3 muscarinic receptors (m 3 rs) on smooth muscle to cause bronchoconstriction. 36 ach release is normally limited via negative feedback inhibition of ach on neuronal m2 muscarinic receptors (m 2 rs). 37 when neuronal m 2 rs are dysfunctional, ach release by neurons is not inhibited, and increased levels of ach binding to m 3 rs on airway smooth muscle cause airway hyperresponsiveness (ahr). in antigen-sensitized, antigen-challenged guinea pigs, eosinophils mediate ahr. 38 parasympathetic nerves recruit eosinophils to the nerves via eotaxin signaling. 39 cholinergic nerves express icam-1 and vascular cell adhesion protein (vcam), which bind to eosinophils. 40 eosinophils bind to nerves and release major basic protein (mbp), which blocks m 2 rs on nerves. this causes loss of m 2 r function, resulting in increased ach release and bronchoconstriction. 41, 42 viral infection of nonsensitized guinea pigs causes the loss of m 2 r function and ahr, but this loss is not eosinophil-mediated (not prevented by antibody to il5 or antibody to mbp). 43 in nonsensitized guinea pigs, the virus-induced loss of m2r function appears to be on the level of reduced m2r gene expression. this appears to be the result of production of tnf-a, which decreases m 2 r mrna stability. 44 in contrast, in sensitized guinea pigs, virusinduced loss of m 2 r function and ahr is mediated by eosinophils. adamko et al. showed that depletion of eosinophils with an anti-il-5 antibody prevents virus-induced ahr in sensitized guinea pigs, but not in nonsensitized, virus-infected animals. additional studies showed that blockade of mbp bioactivity inhibits virus-induced ahr and m 2 r dysfunction in sensitized guinea pigs. collectively, these data suggest that in the context of asthma, eosinophils are recruited to airway nerves, virus infection activates the eosinophils to release mbp, and mbp antagonizes m 2 rs, resulting in bronchoconstriction (fig. 13.7.2 ). 45 in addition to eosinophilenerve interactions, eosinophils communicate with t cells in virus-induced asthma. as mentioned above, eosinophils mediate virus-induced ahr and m 2 r dysfunction in sensitized guinea pigs but not in nonsensitized animals. 45 adamko et al. demonstrated that depletion of cd8 ã¾ t cells prevents virus-induced ahr and m 2 r dysfunction in sensitized but not in nonsensitized guinea pigs. sensitization increases the number of eosinophils in the airways, and virus infection of both nonsensitized and sensitized guinea pigs reduces the total number of eosinophils in the airways and eosinophils associated with nerves, suggesting that virus infection induces eosinophil degranulation. cd8 ã¾ t cell depletion inhibits virus-induced eosinophil cytolysis, suggesting that cd8 ã¾ t cells promote virus-induced eosinophil degranulation. 46 these data suggest that cd8 ã¾ t cells interact with eosinophils in the airways of virus-infected, sensitized animals to promote ahr and m 2 r dysfunction. schwarze et al. showed that cd8 ã¾ t cells are also necessary for ahr and lung eosinophilia during rsv infection of mice. 47 in vitro studies have shown that eosinophils directly interact with t cells to induce eosinophil degranulation and promote antiviral, t cell-mediated immunity. when human eosinophils are incubated with parainfluenza virus in the presence of t cells and antigen-presenting cells (apcs; macrophages or dendritic cells), they release epo. uvinactivated virus also induces epo release from eosinophils, suggesting that this process occurs in the absence of viral replication. additional studies showed that rsv is also able to induce epo release from eosinophils in the presence of t cells and apcs. 48 handzel et al. showed that eosinophils present rhinovirus antigens to cd4 ã¾ t cells, inducing their clonal expansion and the release of ifn-g. 32 these data suggest that eosinophils directly interact with cd4 ã¾ and cd8 ã¾ t cells, and that their interactions result in eosinophil degranulation, which may augment symptoms of asthma as well as initiate antiviral adaptive immunity. despite the detrimental role eosinophils play in the pathophysiology of asthma, the antiviral effect of eosinophils may also be beneficial in the context of virus infection and asthma. the antibacterial and antiparasitic effects of eosinophils are well documented, yet their antiviral properties have been studied only recently. while eosinophils have historically been acknowledged for their pathophysiological role in asthma, recent studies suggest that these cells also play a beneficial antiviral role in virus-induced asthma. adamko et al. showed that guinea pigs sensitized to ovalbumin had reduced parainfluenza titers in their lungs 4 days following infection compared to nonsensitized, virus-infected animals. furthermore, depletion of eosinophils with an anti-il-5 antibody increased viral levels in sensitized virus-infected animals to above those observed in nonsensitized infected animals. 45 these data suggest that eosinophils serve an antiviral role in the context of virus infection and allergy. additional studies have investigated the mechanisms by which eosinophils promote virus clearance in vivo. phipps et al. showed that il-5 transgenic mice, which have increased levels of eosinophils, have improved rsv clearance compared to wild-type rsv-infected mice. myd88 is the adaptor molecule for many tlr7 signaling pathways, and studies show that adoptive transfer of wildtype eosinophils, but not eosinophils deficient in myd88, into the lungs of infected wild-type mice improves virus clearance and inhibits ahr. blockade of nitric oxide synthase 2 (nos-2; inducible nitric oxide synthase) activity inhibits rsv clearance in vivo. these data suggest that eosinophils contribute to rsv clearance in both a myd88-dependent and nos-dependent manner. furthermore, these data suggest that eosinophils may aid the prevention of rsv-induced ahr. 27 as mentioned above, eosinophils can be activated by viruses to degranulate. upon degranulation, eosinophils release granule proteins and reactive oxygen species, which can cause damage to pathogen moieties. several groups have shown that eosinophils increase superoxide generation in response to virus exposure. 33, 34 klebanoff et al. showed that human eosinophils stimulated with pma are virucidal against human immunodeficiency virus (hiv) type 1 in vitro and that purified epo, when incubated with hydrogen peroxide and a halide (its substrate), is also virucidal against hiv. 49 50 others have demonstrated an antiviral effect of edn against hiv in vitro. 51, 52 collectively, these data suggest that eosinophils inactivate rna viruses by a number of different mechanisms involving granule proteins and reactive oxygen species. figure 13.7.2 viral infection activates airway eosinophils in a cd8 d t cell-dependent process. activated eosinophils release major basic protein, which binds to inhibitory m2 muscarinic receptors on parasympathetic nerves. blocking these receptors increases acetylcholine (ach) release, causing bronchoconstriction. m3, m3 muscarinic receptor. while some studies have shown that eosinophils destroy virus, other groups have shown that eosinophils are productively infected by viruses. as mentioned previously, eosinophils can bind and internalize viruses. kimpen et al. showed that rsv can bind to the eosinophil membrane and observed virus in the phagocytic vacuoles of eosinophils. 31, 34 dyer et al. showed that rsv and mouse pneumovirus productively infect human and mouse eosinophils, respectively, resulting in the release of infectious virions and proinflammatory cytokines in vitro. 53 in contrast, our laboratory has presented evidence suggesting that parainfluenza virus abortively infects human eosinophils. parainfluenza virus can enter eosinophils and replicate the viral rna genome, but infectious virus particles are not released. 54 a productive infection of eosinophils could potentially serve to induce cytokine release and attract other immune cells, while an abortive infection would remove extracellular virus from the local environment and/or promote the presentation of virus antigens to t cells. collectively these data suggest that interactions between eosinophils and different types of viruses are varied and complex. standard treatments for patients suffering from virusinduced asthma exacerbations consist of b-agonists in combination with anticholinergics and steroids. b-agonists relax smooth muscle by stimulating adenylate cyclase activity and closing calcium channels, while anticholinergics block the effects of the neurotransmitter ach on airway smooth muscle constriction. viruses and interferon downregulate inhibitory m 2 rs on parasympathetic nerves, thereby increasing ach release, and steroids can reverse these effects. 55 steroids can also reduce eosinophil influx into the lungs, icam-1 expression on nerves, and neuronal m 2 r dysfunction. 56, 57 while eosinophil in sensitized animals can prevent virus-induced hyperreactivity, 45 the effects of eosinophil depletion in human virus-induced asthma attacks are less clear. while eosinophil depletion with anti-il5 has limited effects on the response to antigen challenge in human subjects 58 and a clinical study of anti-il5 had unimpressive effects in unselected asthmatics, when asthmatics with sputum eosinophilia were treated with anti-il5, steroids were withdrawn without exacerbation in the majority of cases. 59 whether eosinophil depletion can prevent virusinduced asthma exacerbation awaits further studies. another potential treatment for virus-induced asthma is the correction of deregulated cytokine production. as mentioned previously, the immune environment of patients with asthma is skewed toward a t h 2 phenotype, with decreased interferon production. 4 treatments that promote a t h 1 phenotype, the immune response typically observed in viral infection, may prove clinically valuable. the most direct method of treatment or prevention of virus-induced asthma is targeting the viral infection itself. however, such treatments are at present limited. treatment and prevention of rhinovirus, the cause of twothirds of virus-induced asthma exacerbations, presents a significant challenge because over 100 serotypes of the virus exist. the varying antigenicity among serotypes further hinders vaccine design. as mentioned previously, rhinovirus uses icam-1 binding for entry into cells, thus the blockade of cellular infection by blocking virus binding to target cells presents one promising mechanism for drug design. while ribavirin, which is believed to interfere with viral rna synthesis, has activity against a range of viruses, including rhinovirus and rsv, its clinical efficacy is limited and it is not widely used in the treatment of rhinovirus. rsv vaccine development has been problematic, with paradoxical worsening of the clinical response being an issue. palivizumab is a monoclonal antibody that prevents rsv infection by interfering with the rsv fusion protein and, thus, viral entry into cells. in addition, studies show that type iv phosphodiesterase inhibitors inhibit rsvinduced ahr and eosinophilia in the lungs. 60 effective vaccines for influenza are recommended for patients with airway disease, including asthma. although it is difficult to prove that influenza-induced asthma attacks are reduced by vaccination, this may be due to the relatively small number of asthma attacks caused by influenza. treatment for influenza viral infections consists of neuraminidase inhibitors. again, the role of neuraminidase inhibitors in preventing asthma attacks is difficult to demonstrate. currently no treatments or vaccines exist for parainfluenza virus and coronavirus. improved immunological understanding of these viruses and of virus interactions with the host, and eosinophils specifically, will aid in the advancement of future vaccines and treatments. respiratory virus infections are the primary cause of asthma exacerbations in children and adults. in asthma, eosinophils are recruited to the airways as a part of the t h 2 immune response, where they contribute to asthma pathophysiology. however, eosinophils may play a dual role in virus-induced asthma; on the one hand recognizing viruses, releasing virucidal mediators, and presenting antigens, and on the other hand becoming activated and increasing airway reactivity. current treatments for virus-induced asthma are not specific to virus infection and instead focus on smooth muscle relaxation and reduction of airway inflammation. further investigation of the interactions between eosinophils and viruses is warranted and will likely lead to more targeted treatments and prevention. primary eosinophilic gastrointestinal disorders (egid) are diseases with eosinophilia in the absence of known causes (e.g., drug reactions, malignancy, and parasitic infections). these disorders include eosinophilic colitis, eosinophilic enteritis, eosinophilic esophagitis (eoe), eosinophilic gastritis, and eosinophilic gastroenteritis, a term used when more than one gastrointestinal (gi) segment is involved. 1, 2 the symptoms of egid include abdominal pain, diarrhea, dysphagia and food impaction, failure to thrive, gastric dysmotility, irritability, and vomiting. both genetic and environmental factors have a role in egid. approximately 10% of patients with egid have a first-degree relative that also has egid. it appears that allergy may play a role. in fact, approximately 75% of egid patients have atopy, allergen-free diets have been shown to be therapeutic, and tissue specimens show mast cell degranulation. animal studies of egid also provide evidence of allergic etiology. 2 although food-specific immunoglobulin e (ige) is common in egid patients, food-induced anaphylactic responses occur in only a minority of patients. thus, egid appears to fall between pure ige-mediated food allergy and cellularmediated hypersensitivity disorders ( fig. 13.8.1 ). in fact, a recent study shows a higher incidence of eoe in patients with celiac disease, supporting a cell-mediated hypersensitivity or t-helper type 1 (t h 1)-mediated mechanism, 3 although another recent study demonstrates a lack of celiac disease-associated alleles in eoe. 4 the chief differential diagnoses include gastroesophageal reflux disease (gerd), inflammatory bowel disease (ibd), and specific infections including parasites and helicobacter pylori. 5, 6 the prevalence of egid has not been rigorously calculated, but they appear to be widespread and not uncommon. 1 for example, eoe has been reported in australia, 7 brazil, 8 england, italy, japan, 9 spain, and switzerland. 10 in one study approximately 10% of pediatric patients with gerd-like symptoms who were unresponsive to acid blockade had eoe. 11 another study reported that 6% of children with chronic esophagitis have eoe. 1 prevalence estimates vary from 1:70,000 adults in australia to 1:2000 children in cincinnati, usa. the increased prevalence of the disease is primarily due to increased recognition, as the disease accounted for approximately 30% of refractory chronic esophagitis in the 1980s and 1990s; however, a bona fide increase in disease incidence is also occurring. 12 it appears that egid may be even more prevalent than pediatric ibd. the blood eosinophil level in eoe patients is typically not dramatically elevated, although it averages twice the normal value. 13 the relative normal value of blood eosinophilia compared with esophageal eosinophilia highlights the tissue-specific pathogenesis of the disease. however, some egid patients have peripheral eosinophilia high enough to meet criteria for hypereosinophilic syndrome (hes), defined by sustained peripheral blood eosinophilia (>1500 cells/mm 3 ) and end-organ involvement in the absence of known causes of eosinophilia. 14,15 while hes often involves the gi tract, the other organs typically affected in hes (heart and skin) are rarely involved in egid. in most tissues, eosinophils are present in minute amounts. organs with substantial eosinophils include gi tract, lymph nodes, spleen, and thymus. interestingly, in a large study of healthy patients, on autopsy eosinophil degranulation was only seen in the gi tract. eosinophils are normally present in the lamina propria of the colon, small intestine, and stomach, but are not normally present in the epithelium or peyer patches, although they infiltrate these regions in egid. 2 eosinophil homing to the gi tract appears to occur independent of gut flora, as evidenced by prenatal, adult, and germ-free mice having eosinophils in similar locations and concentrations. additionally, mice deficient in innate signaling responses (i.e., myd88 deficient) have normal numbers of gi eosinophils. together these data indicate that eosinophils respond to signals distinct from those of most other intestinal inflammatory cells that typically require gut flora-induced signaling. in fact, eotaxin/c-c motif chemokine 11 (ccl11) is the unique signal that induces localization of eosinophils to the gi tract. in vitro, the granule components of eosinophils are toxic to many tissues, including intestinal epithelium. the eosinophil cationic proteins major basic protein (mbp), eosinophil peroxidase (epo), and eosinophil cationic protein (ecp) are cytotoxic to epithelium at concentrations similar to those found in biological fluids from patients with eosinophilia. ecp can render cell membranes porous. mbp increases smooth muscle reactivity via vagal muscarinic m2 receptors and can trigger mast cell and basophil degranulation. in patients with eosinophilic gastroenteritis, mbp and ecp are deposited extracellularly in the small bowel, and ultrastructural changes in eosinophil secondary granules (indicating degranulation and mediator release) are found in duodenal biopsies. furthermore, charcoteleyden crystals are commonly found in feces, and disease severity correlates with mucosal eosinophil numbers. eosinophils can secrete a number of different cytokines, suggesting that they may modulate multiple aspects of the immune response, as well as epithelial growth, fibrosis, and tissue remodeling. in addition, tissue eosinophils have distinct cytokine expression patterns under inflammatory versus noninflammatory conditions. for example, esophageal eosinophils from eoe patients express high levels of t h 2 cytokines and transforming growth factor b (tgf-b). 16 other molecules secreted by eosinophils include halide acids, hydrogen peroxide, and leukotrienes, which increase vascular permeability and mucus secretion and stimulate smooth muscle contraction. in ibd, eosinophils form only a small percentage of the infiltrating leukocytes, but their level has been proposed to be a negative prognostic indicator. observations of eosinophilia in ibd suggest that eosinophils mediate axonal necrosis. recently, it has been shown that eotaxin is upregulated in intestinal macrophages and epithelial cells in pediatric ulcerative colitis and thus may be a future target for therapy. 17 common symptoms of egid patients include abdominal pain, diarrhea, dysphagia, failure to thrive, gastric dysmotility, hypoproteinemia, irritability, microcytic anemia, and vomiting. patients with these refractory problems, especially individuals with a strong history of allergic diseases, peripheral blood eosinophilia, and/or a family history of egid, should be evaluated for egid. evaluation for egid starts with a comprehensive history and physical examination. symptoms vary depending on the intestinal segment involved (e.g., abdominal pain and dysphagia are most common in eosinophilic gastroenteritis and eoe, respectively). in most egid patients, peripheral eosinophilia is not present. total ige levels may help classify patients with atopy or those with occult parasite infection. in atopic egid patients, food allergy is common and can be verified by skin prick and skin patch testing. 18 there are no pathognomonic symptoms or blood tests for diagnosing egid. therefore, the diagnosis of egid is based on endoscopic biopsy procurement and appropriate clinical information. the diagnosis of egid is dependent on histological evaluation of biopsy samples, contingent upon the quantity, location, and characteristics of the eosinophilic inflammation. egid patients often have a variety of endoscopic findings, 10 but it is not uncommon for the lumen to look normal endoscopically; thus, a microscopic evaluation of biopsy samples is required. egid often has patchy involvement, requiring analysis of biopsies from multiple intestinal segments. while the normal esophagus is devoid of eosinophils, the rest of the gi tract contains readily detectable eosinophils. with the lack of diagnostic criteria, diagnosis of egid depends on clinical and histopathological expertise. diagnosis of egid depends on several factors including the following: (1) eosinophil quantification, (2) the histological location of eosinophils, (3) associated histopathological abnormalities, and (4) the absence of pathological features suggestive of other primary disorders. recently, gene expression profiles (transcriptomes) have been proposed to be helpful for the diagnosis of eoe; elevated levels of esophageal eotaxin-3/ccl26 in a single biopsy specimen has approximately 90% sensitivity. 19 other disease processes, such as drug hypersensitivity, collagen vascular disease, malignancy, or infection, should be ruled out (table 13 .8.1). evaluation for intestinal parasites via stool samples, colonoscopy aspirates, or antibody titers should be performed, especially if patients have high-risk exposure (e.g., drinking well water, living on a farm, or travel to endemic area). in one study of eosinophilic enteritis, the dog hookworm ancylostoma caninum was identified as the cause in 15% of cases. 20 infection with strongyloides stercoralis should be excluded before treating for egid, as immunosuppressants can be life threatening with this infection. 21 the esophagus is normally devoid of eosinophils. 1, 2 disorders associated with esophageal eosinophil infiltration include allergic vasculitis, bullous pemphigoid, carcinomatosis, drug injury, eoe, eosinophilic gastroenteritis, esophageal leiomyomatosis, gerd, hes, ibd, myeloproliferative disorders, parasitic and fungal infections, periarteritis, pemphigus vegetans, recurrent vomiting, and scleroderma. 6, 22 eosinophil-associated esophageal disorders are classified as primary or secondary (i.e., due to another known disease process) (table 13 .8.1). the primary subtype includes the atopic, nonatopic, and familial variants, and the secondary subtype is subdivided into those with and without systemic eosinophilia. eoe is familial in about 10% of patients. the etiology of eoe is poorly understood, but food allergy has been implicated. most eoe patients have specific ige to foods and aeroallergens, but only a few have experienced anaphylaxis. 1 esophageal eosinophilia may also be linked to allergic airway disease. several independent studies have linked eoe to allergic etiology. for example, repeated delivery of allergens or interleukin-13 (il-13) to murine lungs (via direct delivery or transgenic overexpression) induces experimental eoe; patients with allergic rhinitis have increased esophageal eosinophils; 23 intranasal delivery of indoor insect allergen induces eoe in mice; 24 patients with eoe commonly report seasonal variations in symptoms; and there is a seasonal variation in eoe diagnosis. 25, 26 in addition to eosinophils, t cell and mast cell numbers are increased in esophageal biopsies, suggesting a chronic t h 2-associated inflammation (fig. 13.8.2) . 27 mast cells have been shown to be elevated in the esophagus and to degranulate in eoe, and they appear to be stimulated by the kit ligand. carboxypeptidase a3 and tryptase appear to be good surrogate markers for mast cell involvement. 28 is overproduced in the esophagus of eoe patients. in addition, in experimental systems, such as il-13 lung transgenic systems, il-13 induces eosinophilic esophagitis and tissue remodeling with features both dependent and independent of eosinophils. 29 consistent with t h 2 activation, il-5 overexpression induces eoe, and il-5 neutralization completely blocks allergen-or il-13-induced eoe in mice. 30 however, anti-il-5 therapy in humans has not yet been shown to be effective at ameliorating clinical aspects of the disease, although esophageal eosinophilia improves. 31, 32 interestingly, a cytokine with more of a t h 1 skew, il-15, appears to mediate cd4 ã¾ t cells and to be involved in the pathogenesis of eoe. 33 in a recent genome-wide microarray expression profile analysis of esophageal tissue 19 from patients with eoe and normal controls, an eoe transcriptome was found to contain changed expression of approximately 1% of the entire human genome. interestingly, eotaxin-3 was the most prominently overexpressed gene in eoe patients, and levels correlated with disease severity. furthermore, a single nucleotide polymorphism (snp) in eotaxin-3 was overrepresented in eoe patients. conversely, mice lacking the eotaxin receptor (c-c chemokine receptor type 3; ccr3) were protected from developing experimental eoe. notably, eotaxin-3 is induced by il-13. two recent studies have implicated genetic susceptibility for eoe with genetic variants of the tslp gene; tslp encodes thymic stromal lymphopoietin, an epithelial gene product that targets dendritic cells and promotes their t h 2polarizing ability. these studies included a genome-wide analysis study of common variants, as well as a largescale candidate snp approach. notably, sex-associated tslp receptor polymorphisms on xp22.3/yp11.3 may explain male predisposition to eoe. 34 symptoms of eoe include dysphagia, epigastric or chest pain, gi obstructive problems, and vomiting. 35 patients are predominantly male 35 and have robust esophageal eosinophilia, 2 extensive epithelial hyperplasia, and are commonly atopic compared to gerd patients. in adults with eoe, dysphagia and food impaction are common complaints. 36 one study presented a symptom scoring tool that can help identify patients with eoe and correlates with tissue inflammation. 37 however, another study demonstrated dissociation between symptom scores and histology in treated eoe patients. 38 at present, it is important to develop validated disease instruments so that these important parameters can be tracked, especially in clinical trials. eoe is associated with esophageal dysmotility/ dysphagia, which may be related to motor dysfunction of the esophagus rather than to physical narrowing. 39 esophageal ultrasound shows dysfunctional muscularis mucosa in eoe. 40 radiographic and endoscopic studies demonstrate furrowing, mucosal rings, polyps, strictures, ulcerations, and whitish papules. 41 it appears that a small diameter on barium esophagography can help diagnosis of eoe, 42 although many patients have normal barium assessments and need further evaluation by endoscopy. 43 recently, it has been demonstrated that esophageal distensibility, defined as cross-sectional area following intraluminal pressure, is significantly reduced in eoe patients. 44 the number and location of eosinophils helps distinguish eoe from gerd. greater than 15 eosinophils per high-power field (hpf) and a lack of response to protonpump inhibitors suggest eoe. proximal and distal esophageal eosinophilia suggests eoe, whereas eosinophilia confined to the distal esophagus suggests gerd. 1 histopathological changes in eoe include esophageal mucosa thickening with basal layer hyperplasia and papillary lengthening. tissue eosinophil counts may underestimate eosinophil involvement, particularly with marked degranulation. eosinophil-derived neurotoxin (edn) staining of biopsy specimens may be useful for diagnosis and management. 45 clinical assessment of eoe includes analysis of food and aeroallergen sensitization and exclusion of gerd as well as other causes of eosinophils in the esophagus. however, eoe and gerd are not mutually exclusive and may coexist in the same patient ( the inflammatory response in eoe. food antigens trigger t-helper type 2 (t h 2) cells to release interleukin-5 (il-5) and il-13, which stimulate eosinophils and esophageal epithelial cells, respectively. il-13 induces epithelial cells to produce eotaxin-3/c-c motif chemokine 26 (ccl26) and downregulate filaggrin. reduced production of filaggrin might inhibit esophageal barrier function, which could perpetuate the inflammation by maintaining local food antigen uptake. il-5 and eotaxin-3 activate eosinophils to release major basic protein (mbp) and eosinophil-derived neurotoxin (edn), which activate mast cells and dendritic cells, respectively. eosinophils and mast cells also produce tgf-b, which activates fibroblasts and muscle cells and contributes to dysmotility, fibrosis, and hyperplasia. 24,62 ecp, eosinophil cationic protein; epo, eosinophil peroxidase; tgf-b, transforming growth factor b. specific food antigen and aeroallergen avoidance, identified by skin testing or history, is indicated for patients with atopic eoe. if feasible, an elemental diet is recommended, as it improves symptoms and reduces the number of eosinophils in the esophageal biopsies of patients with eoe (allergic or nonallergic subtypes). elemental diet therapy frequently requires placement of a gastrostomy tube to achieve adequate caloric intake. glucocorticoids are also effective. systemic steroids are used for acute exacerbations, and topical steroids provide day-to-day control. 47 for topical steroid delivery, the patient is instructed to swallow the dose to promote deposition on the esophageal mucosa. topical fluticasone lowers the level of eosinophils, cd3 ã¾ cells, and cd8 ã¾ cells in the proximal and distal esophagus 48 and improves symptoms. 36 side effects of inhaled glucocorticoids are less likely with swallowed fluticasone, as this drug undergoes extensive first-pass metabolism in the liver. however, local esophageal candidiasis may occur. 48 in addition to inhaled steroids, an oral suspension of budesonide can be used. 49 viscous budesonide improves symptoms and endoscopic/histological appearance and also appears to reach the distal esophagus. 50 a recent study shows fk506 binding protein 5 (fkbp5) transcript levels increase with glucocorticoid exposure, thus helping to distinguish responders from nonresponders and treated from untreated. this also provides the best evidence that swallowed steroids induce local effects in the esophagus. 51 although food antigen avoidance and glucocorticoids are the mainstay of treatment, additional therapies may be beneficial. in eoe patients for whom impaction has become an issue, esophageal dilation appears to be safe and effective. 52, 53 even if gerd is not present, neutralizing gastric acidity (with proton-pump inhibitors) may improve symptoms and esophageal pathology. on the horizon, an anti-il-13 antibody is a promising future therapy. in an animal model of il-13-induced esophageal eosinophilia, an anti-il-13 antibody was effective, and clinical studies are now under way. 54 additionally, anti-il-5 antibodies prevent experimental eoe in mice 55, 56 and appear to decrease eosinophilia of the human esophagus in earlystage clinical trials. 57 human clinical trials are currently under way. although the natural history of eoe is not fully known, it is not uncommon for children with eoe to have a parent with a history of chronic esophageal strictures. esophageal biopsies in some of these parents have revealed eoe. the following symptoms occur in order of increasing age: feeding problems, vomiting, abdominal pain, dysphagia, and food impaction. 13 thus, if left untreated, eoe is likely to progress to esophageal scarring and dysfunction. recent data show that pediatric eoe patients, diagnosed by retrospective biopsy analysis, are at increased risk of developing persistent disease characterized by dysphagia, food impaction, a need for esophageal dilation, and food allergy. 12, 58 despite this, the development of barrett esophagus in eoe has not been studied. however, it appears that eoe requires chronic treatment. having eoe increases the risk of developing other forms of egid. thus, routine surveillance guided by symptoms of the entire gi tract by endoscopy is recommended. at baseline, the stomach and intestine have readily detectable eosinophils. therefore, diagnosis of enteritis, eosinophilic gastritis, and gastroenteritis is more complex than diagnosis of eoe. these diseases are characterized by selective infiltration of eosinophils in the stomach and/or small intestine with variable involvement of the esophagus and/or large intestine. eosinophilic enteritis, gastritis, and gastroenteritis can be divided into primary or secondary. the primary disorders have also been called idiopathic or allergic gastroenteropathy. primary eosinophilic gastroenteritis is subdivided on the basis of the level of histological involvement into mucosal, muscularis, and serosal forms. endoscopic biopsy can be normal in the latter two subtypes. importantly, many other disorders feature eosinophil infiltration in the stomach, including allergic vasculitis, drug hypersensitivity, drug injury, hes, ibd, myeloproliferative disorders, parasitic and bacterial infections (e.g., h. pylori), periarteritis, and scleroderma. because total ige is elevated and food-specific iges are detectable in most egid patients, an allergic mechanism is suspected. however, even though most patients have positive skin tests to a variety of food antigens, they do not have typical anaphylactic reactions, suggesting a delayed form of food hypersensitivity syndrome. in support of an allergic mechanism, mast cells are increased in egid. 59 also, eosinophilic gastroenteritis can be induced by feeding enteric-coated allergen beads to sensitized mice. 60 these mice develop eosinophil-associated gi dysfunction, including delayed food transit, gastromegaly, and weight loss. 61 in addition, duodenal lamina propria t cells in egid preferentially secrete t h 2 cytokines (especially il-13) when stimulated with milk proteins. furthermore, elevated secretion of il-4 and il-5 by peripheral blood t cells has been observed in eosinophilic gastroenteritis. iga deficiency can also be associated with eosinophilic gastroenteritis and may be related to the increased rate of atopy or to occult gi infection in these patients. in general, these disorders present with symptoms related to the degree and area of the gi tract affected. the mucosal form of eosinophilic gastroenteritis (the most common variant) is characterized by abdominal pain, bloody stools, diarrhea, failure to thrive, iron-deficiency anemia, malabsorption, protein-losing enteropathy, and vomiting. in the muscularis form, thickening of the bowel wall may result in gi obstructive symptoms. the serosal form is characterized by exudative ascites. there are no standards for the diagnosis of eosinophilic gastritis or gastroenteritis, but the presence of increased eosinophils in biopsy specimens, infiltration of eosinophils within intestinal crypts and gastric glands, lack of involvement of other organs, and exclusion of secondary causes of eosinophilia support a diagnosis of eosinophilic gastroenteritis. patients with eosinophilic gastritis may have micronodules (and/or polyposis), and these lesions often contain aggregates of lymphocytes and eosinophils. food allergy and peripheral eosinophilia may be present but are not required for diagnosis. eliminating foods implicated by skin prick or radioallergosorbent (rast) testing has variable results, whereas complete resolution is generally achieved with amino acidbased elemental diets. once remission has been achieved by dietary modification, specific food groups are reintroduced (at approximately 3-week intervals for each food group), and endoscopy is reperformed to identify sustained remission or disease flares. systemic or topical steroids are the main therapy when diet restriction has failed or is not feasible. for systemic steroid therapy, a course of 2e6 weeks of therapy with relatively low doses seems to work better than a 7-day course of glucocorticoid bursts. various topical glucocorticoid preparations are designed to deliver drugs to specific segments of the gi tract [e.g., budesonide tablets (entocort ec) targeted to the ileum and proximal colon]. as with asthma, topical steroids have a better riskebenefit ratio than systemic steroids. in cases refractory to or dependent on glucocorticoid therapy, parenteral nutrition or antimetabolite therapy (azathioprine or 6-mercaptopurine) may help. drugs such as cromoglycate, ketotifen, mycophenolate mofetil (an inosine monophosphate dehydrogenase inhibitor), suplatast tosilate, and various alternative therapies are not generally very useful, although successful long-term remission of eosinophilic gastroenteritis has been reported following montelukast treatment. use of proton-pump inhibitors can improve symptoms and the degree of esophageal and gastric pathology, even if gerd is not present. the natural history of eosinophilic gastritis, enteritis, and gastroenteritis is not well documented; however, they are often chronic, relapsing/remitting diseases. when the disease presents in infancy and specific food sensitization can be identified, remission is likely by late childhood. in food antigen-induced disease, abnormal levels of circulating ige and eosinophils often serve as markers for tissue involvement/relapse. as noted earlier, due to concern for hes, routine surveillance of the cardiopulmonary system is recommended. colonic eosinophilia occurs in a variety of disorders, including allergic colitis of infancy, drug reactions, eosinophilic gastroenteritis, infections (e.g., helminths), ibd, and vasculitis (e.g., churgestrauss syndrome). allergic colitis in infancy (or dietary protein-induced proctocolitis of infancy syndrome) is the most common cause of bloody stools in the first year of life. similar to other egid, these disorders are classified into primary and secondary. in contrast to other egid, eosinophilic colitis is usually not ige associated. some studies point to a t cell-mediated process, though the exact mechanism is unclear. allergic colitis of infancy may be an early expression of proteininduced enteropathy. cow's milk and soy proteins are the foods most frequently associated, but other food proteins can also induce this disorder. interestingly, this condition may more commonly occur in infants who are exclusively breastfed and can occur in infants fed with protein hydrolysate formulas. an association between allergic colitis and the later development of ibd has been reported but remains controversial. similar to eosinophilic gastroenteritis, the symptoms of eosinophilic colitis vary depending on the degree and location of tissue involvement. although diarrhea is a classic symptom, symptoms that can occur independent of diarrhea commonly include abdominal pain, anorexia, and weight loss. in infants, bloody diarrhea precedes diagnosis by several weeks, and anemia due to blood loss is not uncommon. most infants affected do not have constitutional symptoms and are otherwise healthy. there is a bimodal age distribution, with the infantile form presenting with a mean age at diagnosis of approximately 60 days, and the second group presenting during adolescence and early adulthood. there is no single gold standard diagnostic test, but peripheral blood eosinophilia or eosinophils in the stool are suggestive of eosinophilic colitis. on endoscopic examination, patchy erythema, loss of vascularity and lymphonodular hyperplasia are seen; findings are mostly localized to the rectum but can affect the entire colon. histological examination often reveals preservation of mucosal architecture, with focal aggregates of eosinophils in the crypt epithelium, lamina propria, and muscularis mucosa and occasionally, multinucleated giant cells in the submucosa. treatment of eosinophilic colitis varies according to the disease subtype. clinical symptoms of eosinophilic colitis of infancy resolve within 72 hours of withdrawal of the offending protein. treatment of eosinophilic colitis in older patients, for which ige-associated triggers are rarely identified, usually requires medical management. antiinflammatory drugs, including aminosalicylates and systemic or topical steroids, are commonly used and appear to be efficacious, but clinical trials have not been conducted. several forms of rectally delivered glucocorticoids treat the distal colon, though eosinophilic colitis typically also involves the proximal colon. in cases refractory or dependent on systemic glucocorticoid therapy, parenteral nutrition or antimetabolite therapy (azathioprine or 6-mercaptopurine) are alternatives. eosinophilic colitis presenting in the first year of life has a very good prognosis with the vast majority of patients able to tolerate the culprit food(s) by 1e3 years of age. the prognosis for eosinophilic colitis developing in adolescence or adulthood is less favorable. as with eosinophilic gastroenteritis, the natural history has not been studied, and this disease is considered to be a chronic relapsing/remitting disorder. because eosinophilic colitis can often be a manifestation of other disease processes, ruling out autoimmune disease and other secondary causes of eosinophilia is recommended. the term hes describes patients with systemic symptoms due to marked eosinophilia. diagnostic criteria for hes include persistent eosinophilia of at least 1500 cells/mm 2 for a sustained duration; lack of known causes of eosinophilia; and symptoms and signs of organ system involvement. patients with egid and blood eosinophil counts greater than 1500/mm 2 meet these diagnostic criteria but generally do not have the high risk of life-threatening complications associated with classic hes (i.e., cardiomyopathy or central nervous system involvement). as is true in any patient with prolonged and marked eosinophilia, hes patients are prone to develop eosinophilic endomyocardial disease with embolization. thus, routine echocardiograms are warranted in patients with egid and peripheral blood eosinophilia. additionally, the diagnosis of hes should be considered in patients with egid who develop extra-gi manifestations. additional testing may include bone marrow analysis (searching for myelodysplasia), serum tryptase and vitamin b12 levels (both moderately elevated in classic hes), and genetic analysis for the fip1-like 1/platelet-derived growth factor receptor-a (fip1l1epdgfra) fusion event. a major advance in our understanding of hes has come about through treatment of hes with imatinib mesylate, a tyrosine kinase inhibitor. in many hes patients, treatment with imatinib mesylate dramatically reduces peripheral blood and bone marrow eosinophils, suggesting that certain hes patients express a kinase that is sensitive to imatinib mesylate. a fusion gene, the result of an 800-kb deletion in chromosome 4, yields a novel activated kinase (fip1l1epdgfr). fip1l1epdgfr is inhibited by imatinib in vitro, explaining the sensitivity of hes patients to imatinib. those responsive to imatinib are typically 20e50-year-old males who present with marked peripheral eosinophilia (i.e., classic hes). these patients have been shown to meet minor criteria for systemic mastocytosis, having elevated levels of serum mast cell tryptase and high numbers of dysplastic mast cells in the bone marrow. egid are now being recognized more frequently. they have strong genetic and allergic components and share clinical and immunopathogenic features with asthma. egid are associated with a variety of nonspecific common gi symptoms and laboratory findings, making their diagnosis dependent on microscopic examination biopsies and ruling out of other eosinophil-associated disease. eosinophils have potent proinflammatory effects mediated by their cytotoxic granule constituents and various lipid mediators and cytokines. in t h 2-associated gi inflammatory conditions, eosinophilia in the lamina propria is dependent on il-5 and eotaxin. esophageal eosinophilia can be induced experimentally by pulmonary deposition of aeroallergens or the t h 2 cytokine, il-13. many new therapeutic approaches are now being developed for egid, including eotaxin-3 receptor/ccr3 antagonists, eotaxin-3 blockers, humanized anti-il-5, and il-4/il-13 inhibitors. however, although much progress has been made concerning gi eosinophils and egid, there is still a paucity of knowledge compared with other cell types and gi diseases that may be even less common (e.g., ibd). a better understanding of the pathogenesis and treatment of egid will emerge by combining comprehensive clinical and research approaches involving experts in the fields of allergy, gastroenterology, nutrition, and pathology. although case reports describing eosinophilic infiltration of tissues accompanied by pronounced peripheral eosinophilia have existed since the 1950s, the concept of a hypereosinophilic syndrome (hes) was not introduced until 1975 in a landmark paper by chusid and colleagues. 1 the original description of hes was based largely on clinical findings highlighting the heterogeneous presentations of hes and proposed the following diagnostic criteria: 1 blood eosinophilia >1500/mm 3 for at least 6 months (or death before 6 months with signs and symptoms of eosinophilic disease); 2 lack of evidence for allergic, infectious, parasitic, or other known causes of eosinophilia; and 3 presumptive signs of organ involvement. since that time, the evolution of diagnostic testing has led to the identification of several hes variants with defined etiologies. furthermore, the availability of novel targeted therapies precludes waiting 6 months for a diagnosis. as a result, several new conflicting classification schemes have been proposed. the 2008 world health organization (who) classification specifically distinguishes between hes and eosinophilic disorders with proven clonal populations of myeloid or lymphoid origin. 2 although correct from a diagnostic standpoint, there are many issues that are not addressed, namely the clinical overlap between patients with a detectable clonal population and those with similar disease in whom the mutation is not detectable with current techniques, and the heterogeneity of patients with nonclonal hes. in contrast, an hes classification scheme proposed at a 2005 nih-sponsored workshop, 3 and subsequently refined by the same authors, groups clinically similar disorders with known and unknown etiologies into hes variants. although useful from the standpoint of treatment approaches, this approach creates confusion with respect to diagnostic labels, since a patient with proven clonal eosinophilia is classified as having both hes and chronic eosinophilic leukemia (cel). 3 despite these limitations, for the purposes of this subchapter, hes will be defined as (1) blood eosinophilia of >1500/mm 3 on at least two separate occasions or evidence of prominent tissue eosinophilia associated with symptoms and marked tissue eosinophilia, and (2) exclusion of secondary causes of eosinophilia, such as drug hypersensitivity, hypoadrenalism, and parasitic infection. 4 the approach to classification, diagnosis, pathophysiology, and treatment of the various forms of hes and other rare manifestations of eosinophilic disease will be discussed. hypereosinophilic syndromes are rare diseases, and correct estimates of incidence and prevalence are unavailable. by extrapolation from the surveillance, epidemiology and end results (seer) database of cancer statistics in the united states, the incident rate of hes has been estimated to be between 0.018 and 0.036 per 100,000 person-years in the period from 2001 to 2005. the calculated prevalence was estimated at 0.36e6.3 per 100,000. 5 these estimates are approximations and rely on coding of eosinophilia by individual physicians. in addition, the lack of specific codes for hes variants precludes a more specific characterization of incidence. unified comprehensive patient databases would be useful in this regard. hes characteristically develops between the ages of 20 and 50 years; however, young children and the elderly can also be affected. a male predominance has been described, although this is due primarily to overrepresentation of males with the fip1-like 1/platelet-derived growth factor receptor-a (fip1l1/ pdgfra) mutation in most series. 6 hypereosinophilia may be attributable to secondary causes requiring specific treatment. therefore, a careful history and physical examination are of paramount importance for making the correct diagnosis (fig. 13.9.1) . the history should include the degree and duration of eosinophilia, with documentation if available. specific symptoms related to individual organ systems should be elicited, as patients can present with a multitude of findings ranging from the most common complaints of skin involvement to more rare presentations of connective tissue or ocular involvement. pertinent medication, occupational, and travel histories should also be obtained to exclude drug allergy, hypersensitivity reactions, and helminth infections, respectively. a family history of eosinophilia should also be investigated. the initial physical exam should be complete, with a focus on examination for organ involvement commonly seen in eosinophilic syndromes. notably, careful examination of the skin, abdomen (to assess organomegaly), cardiovascular system (to assess evidence of heart failure and valvular disease), lungs, neurological system (to exclude neuropathy) should be performed. finally, laboratory and diagnostic testing for eosinophilia should be directed by the history and prior physical findings, but should include basic testing to assess endorgan involvement (fig. 13.9.1 ). initial laboratory evaluation should include, at a minimum, a complete blood count (cbc) with a differential, chemistry panel to assess creatine kinase, creatinine, electrolytes, erythrocyte sedimentation rate (esr), liver enzymes, quantitative immunoglobulin e (ige), levels serum b12, and serum tryptase. assessment of cardiac status should include echocardiogram, electrocardiogram (ekg), and measurement of serum troponin. spirometry with assessment of lung volumes and diffusion capacity should be performed to assess occult pulmonary involvement. often the initial evaluation will determine the need for further testing. for example, a patient with asthma and sinusitis should be screened for churg-strauss syndrome (css) with serum anti-neutrophil cytoplasmic antibody (anca). electrolyte abnormalities with eosinophilia might necessitate a workup for hypoadrenalism. findings of anemia, neutropenia, or thrombocytopenia would initiate a search for hematological disorders, including cel. a pertinent drug history should prompt discontinuation of potentially offending agents to see if the eosinophilia resolves. exceedingly uncommon in secondary eosinophilia, an elevated serum b12 or tryptase level should prompt evaluation for cel and systemic mastocytosis (sm). if no secondary or reactive cause is identified, one can reasonably proceed to further evaluation for hes and other rare eosinophilic disorders. additional screening tests at this point should include computed tomography (ct) of the abdomen, chest, and pelvis, and bone marrow examination to assess cellularity, dysplastic changes of either eosinophils or mast cells, eosinophil precursors, mast cell numbers, and myelofibrosis. cytogenetic analysis of dividing cells should be performed, as well as specific testing by real-time polymerase chain reaction (rt-pcr) or fluorescence in situ hybridization (fish) for the most common genetic abnormalities associated with eosinophilia, including pdgfr-associated cels. d816v kit analysis should also be performed to exclude sm in patients with elevated serum tryptase and/or suggestive findings on bone marrow biopsy. t-cell clonality should be assessed by rt-pcr for t-cell receptor rearrangement and/ or flow cytometry. phenotypic assessment should also be performed to identify aberrant populations of t cells that may or may not be clonal and should include cd3, cd4, cd8, and if possible cd5 and cd7. aberrant t-cell populations often exhibit elevated intracellular interleukin-4 (il-4), il-5, and il-13 levels; 7 however, intracellular cytokine analysis is not routinely available except at specialized academic centers. various biomarkers have been clinically correlated with particular variants of hes, including serum b12 and tryptase elevation in myeloproliferative forms of hes and elevated serum ige and thymus and activation-regulated chemokine (tarc)/c-c motif chemokine 17 (ccl17) levels in lymphocytic variant hes and are discussed further in the next section. it is important to recognize that the diagnosis of hes is an iterative process and may be revisited if new clinical findings develop and as new biomarkers and diagnostic tests become available. as stated in the introduction, the current classification of hes variants is in evolution as specific etiologies become better defined. despite the molecular uncertainties and current unknowns, it remains useful to subdivide patients into hes variants based on clinical characteristics and a combination of molecular and biologic data (fig. 13.9.2) , since this has important implications regarding prognosis, monitoring, and treatment. unfortunately, the vast majority (60e70%) of patients with hes remain classified as idiopathic. in the following section, we discuss hes variants in lymphocytic variant hes (l-hes) is defined by the expansion of an aberrant and/or clonal t-lymphocyte population with increased production of eosinophilopoietic cytokines in a patient who meets criteria for hes. historically, the evidence for t-cell-mediated pathogenesis came to light when peripheral t-cell clones generated from a patient with hes were cultured with bone marrow progenitors, leading to outgrowth of eosinophilic colonies in culture. 8 further studies demonstrated that il-5 was overproduced; however, other cytokines such as il-2, interferon g (ifn-g), and additional t-helper type 2 (t h 2) cytokines, il-4 and il-13, may also be increased in individual clones. 9 l-hes affects males and females in equal proportions. patients frequently have elevated serum ige levels and skin involvement, ranging from urticaria and eczematous rashes to subcutaneous involvement with angioedema. rare patients present with cyclic eosinophilia and angioedema in the setting of an abnormal lymphocyte population (gleich's syndrome). lymphadenopathy and splenomegaly are uncommon except in the case of occult lymphoma, and bone marrow examination is generally normocellular with increased eosinophils. in contrast to the myeloproliferative variant, life-threatening end-organ involvement, including endomyocardial fibrosis, neurologic complications, and hypercoagulability are extremely rare in l-hes. furthermore, l-hes is usually glucocorticoid-responsive, although moderate to high doses may be necessary to control symptoms. blood counts reflect elevated eosinophil levels; there may be lymphocytosis, but this is uncommon. there is often a polyclonal expansion of igg or igm, and markers of inflammation, such as esr and c-reactive protein (crp), and t-cell activation, such as ccl17, may be elevated. thrombocytosis may also be present. the majority of aberrant t-cell populations in l-hes are detectable by flow cytometry using standard panels. although cd3 ã� cd4 ã¾ is the most common phenotype, cd3 ã¾ cd4 ã� cd8 ã� and cd4 ã¾ cd7 dim/ã� have also been described in some patients. 10 it is important to include appropriate markers to distinguish these cell populations from monocytes, especially if cd4 expression is decreased, 9 and to exclude tcell lymphomas that may present with eosinophilia, including cutaneous t-cell lymphoma 11 and angioimmunoblastic t-cell lymphoma. clonal populations of il-5producing cells with a normal surface phenotype have also been described in l-hes. consequently, t-cell receptor (tcr) rearrangement analysis and/or assessment of clonality by flow cytometry using tcr-vb staining should be performed. demonstration of increased t h 2 cytokine production by the aberrant and/or clonal t-cell population by intracellular flow cytometry is also diagnostic, but is impractical at most centers. 12 the decision to treat l-hes patients depends on the nature and extent of disease. patients with clinical manifestations attributable to the eosinophilia should be treated initially with corticosteroids (20e60 mg prednisone/d depending on the severity of the signs and symptoms), reducing slowly to the lowest dose that suppresses symptoms and eosinophilia. steroid-sparing agents should be considered for patients with elevated eosinophil counts and symptoms requiring moderate to high dose (>10e15 mg prednisone equivalent daily) corticosteroids. aims of therapy should be to reduce disease manifestations and prevent organ dysfunction. a number of steroid-sparing agents targeting t cells have been tried with variable success. 6 among currently available agents, ifn-a (at a dose range of 1e3 mu daily) has shown the greatest efficacy. due to in vitro data demonstrating decreased apoptosis of the clonal population in the presence of ifn-a, concomitant low dose corticosteroid therapy is recommended in patients with l-hes. 13 more recently, anti-il-5 therapy with mepolizumab (available only for compassionate use through glaxosmithkline) has been shown to be safe and effective as a steroid-sparing agent in this subgroup of patients. 14 it is important to monitor patients with a clonal t-cell population for progression to t-cell lymphoma throughout the course of their disease. this may be preceded by lymphadenopathy, expansion of the clone, and/or the development of cytogenetic abnormalities. yearly bone marrow examination with karyotyping has been recommended, 9 although the impact of this approach on prognosis is unknown. the most common cause of marked eosinophilia with myeloproliferative features is an interstitial deletion in chromosome 4q12 between fip1l1 and the tyrosine kinase, pdgfra, that results in the fusion gene product fip1l1/pdgfra. 15 other pdgfra fusion partners have been identified, but are less common. colony forming assays using an fip1l1/pdgfra reporter showed that expression of the fusion gene in human hematopoietic progenitors induces differentiation of erythrocytes and neutrophils in addition to eosinophils, 16 and multiple lineages, including b-and t-lymphocytes, monocytes, mast cells, and neutrophils, can express the fusion gene in affected patients. 17 current data suggest, however, that the detrimental clinical effects are mediated primarily by eosinophils. in fact, the clinical presentation of fip1l/ pdgfra-positive cel is indistinguishable from that of a subset of idiopathic hes patients with myeloproliferative features. a number of other myeloproliferative disorders (mpds) can present with marked blood and bone marrow eosinophilia and have been defined at the molecular level. these include pdgfrb-associated chronic myelomonocytic leukemia (cmml), janus kinase 2 (jak2)-associated mpds, 5q-syndrome and d816v kitassociated sm. although sm shares bone marrow features with fip1l1/pdgfra-positive cel, the clinical presentation is often quite different from hes 18 and the eosinophils are not usually implicated in disease pathogenesis. myeloproliferative variant hes (mhes) is the most aggressive form of hes, with fatality rates of up to 50% at 3 years prior to the availability of imatinib therapy. patients are predominantly male with a near 100% male predominance in pdgfra-associated disease. mhes typically presents between the ages of 25 and 50 years, although children and the elderly can be affected. the clinical presentation ranges from fatigue and malaise to endomyocardial fibrosis and stroke. splenomegaly is common and characteristic laboratory findings include anemia and thrombocytopenia, occasional neutrophilia, and elevation of serum b12 and tryptase levels. bone marrow examination reveals a hypercellular marrow with increased and dysplastic eosinophils and eosinophil precursors, fibrosis, and, in most cases, a concomitant increase in atypical mast cells. eosinophilia is unresponsive to corticosteroids in most patients with mhes. although the existence of a myeloproliferative (leukemic) variant of hes had long been recognized, the availability of molecular testing has revolutionized diagnosis of this syndrome. the fip1l1/pdgfra fusion gene can be detected either by rt-pcr or fish in peripheral blood. additional testing, including cytogenetics, fish, and/or quantitative pcr, should be performed, as indicated, to identify other mpds associated with peripheral eosinophilia. the discovery that the tyrosine kinase inhibitor, imatinib, can decrease eosinophilia and improve symptoms in patients with hes facilitated the discovery of the fip1l1/ pdgfra fusion gene 15 and has dramatically improved prognosis in mhes. some patients with fip1l1epdg-fra-negative mhes also respond to imatinib. therefore, a trial of imatinib in such patients is reasonable if they fail low dose corticosteroids, particularly in the setting of myeloproliferative features. most fip1l1/pdgfrapositive patients achieve clinical and molecular remission within 1e2 weeks of beginning imatinib therapy and can be maintained on low-dose therapy (100 mg daily) for many years without disease progression. although fip1l1/pdgfra-negative patients may require longer to respond, a trial of imatinib 400 mg daily for 4 weeks is sufficient to assess response. side effects of therapy are comparable to that seen in the treatment of chronic myeloid leukemia (cml), but rarely lead to discontinuation of therapy, and the development of resistance appears to be extremely rare. unfortunately, imatinib is not curative in mhes. 19 since the clinical symptoms may be rapidly progressive, any new diagnosis of hes with myeloproliferative features should be evaluated without delay so that treatment can be initiated rapidly. ekg, troponin, and echocardiogram should be performed prior to initiating therapy. if cardiac dysfunction is present or serum troponin is elevated, corticosteroids should be initiated concurrent with imatinib therapy, due to reports of necrotizing myocarditis after initiation of therapy in patients with preexisting cardiac involvement. initial monitoring on imatinib therapy should include weekly complete blood counts, liver function tests, and serum troponin levels. bone marrow examination should be repeated at 4e8 weeks, even in the setting of hematologic response, to exclude occult leukemia or lymphoma that may have been masked by the marked eosinophilia. long-term monitoring should include echocardiograms every 3e6 months to assess progression of disease, as well as to monitor for possible treatment-related cardiomyopathy. for patients with fip1l1/pdgfra-positive mhes who fail or are intolerant to imatinib therapy, a trial of one of the newer tyrosine kinase inhibitors with activity against the most common resistance mutations is indicated. for fip1l1/pdgfra-negative mhes patients who fail imatinib, a step-wise approach of commonly used medications for reduction of eosinophils should be employed, balancing toxicities of the drugs and the individual patient's comorbidities. drugs that have been used successfully include hydroxyurea, ifn-a, anti-il-5 therapy, and vincristine. 20 patients with rapidly progressive or aggressive disease unresponsive to standard therapies should be considered for nonmyeloablative allogeneic bone marrow transplant, a strategy that has proven curative in a number of cases. 21 by definition, the mechanism of pathogenesis in idiopathic hes is unknown. similar to other forms of hes, pathogenesis is due to tissue infiltration by eosinophils, with deposition of granule proteins and release of inflammatory mediators. patients with idiopathic hes may have relatively few or no symptoms (benign eosinophilia) or a wide variety of manifestations attributable to eosinophilic infiltration of target organs. the most commonly affected organs are the gastrointestinal tract, lungs, and skin ( fig. 13.9 .3). 6 nonspecific symptoms, including arthralgias, fatigue, malaise, and myalgias, are also common. cardiac manifestations, including eosinophilic myocarditis and endomyocardial fibrosis, and neurological involvement each occur in 15e20% of patients with idiopathic hes and are major causes of morbidity and mortality in this patient group. two areas of confusion with regards to secondary forms of eosinophilia may delay treatment for true hes. the first involves appropriate testing to rule out parasitic disease. prompt referral to an infectious disease specialist can target helminth infection testing based on the patient's travel history and likelihood of exposure. whether to empirically treat for strongyloides according to centers for disease control and prevention (cdc) guidelines is an area of controversy. recommendations of the cdc are that all patients who are 'at risk of disseminated strongyloidiasis should be treated.' the drug of choice for treatment of uncomplicated strongyloidiasis is ivermectin. the second area of confusion is that of medications causing hypersensitivity syndromes such as drug reaction with eosinophilia and systemic symptoms (dress). many drugs can cause eosinophilia starting from days to years after initiation. simplification of drug regimens can vastly improve the ability to make the diagnosis of hes. once the diagnosis of hes is made, the decision to treat is tailored to the likely etiology. since patients with idiopathic hes are heterogeneous in their presentation, virtually all treatment must be individualized based on the presence of signs and symptoms and the likelihood of disease progression with end-organ involvement. although the discovery of imatinib has dramatically altered prognosis in myeloproliferative hes, and in particular for patients with fip1l1/pdgfrapositive cel, patients with idiopathic hes are much less likely to respond. corticosteroids remain first-line therapy for the majority of patients with hes, including l-hes, although many patients require moderate to high doses or develop significant steroid-related toxicity. patients who fail to respond to corticosteroids or have significant side effects from prolonged high dose therapy should be considered for second-line therapy. a short (4e6 week) trial of imatinib, the only united states food and drug administration (fda)-approved drug for the treatment of hes, may be warranted in steroid-resistant patients. hydroxyurea is the most commonly used of the cytotoxic medications and has been used alone or in combination with ifn-a at doses ranging from 500 mg to 3 g daily. it can be associated with cytopenias or other adverse effects at high doses, thus limiting its use as a solitary agent. furthermore, hydroxyurea may be associated with an increased risk of secondary malignancy with prolonged use. of the immunomodulatory medications, ifn-a is most frequently used and at doses of 1e3 mu daily is effective in up to 30% of patients. 6 prolonged remission of clinical symptoms and eosinophilia has rarely been reported after prolonged ifna use or when inf-a is used in combination with cytotoxic medications. 22 other cytotoxic and immunomodulatory agents have been used with varied success and include cytosine arabinoside (ara-c), 23 vincristine, 20 alemtuzumab, 24, 25 intravenous immunoglobulin, 26 cyclosporine, 27 cyclophosphamide, 28 azathioprine, and methotrexate. however, bone marrow transplantation remains the only curative therapy. 21 familial hypereosinophilia is an autosomal dominant disorder discovered in one kindred family. eosinophilia is present at birth in affected individuals and remains remarkably stable over time. although the index case and his sister presented with eosinophilic end-organ involvement (endomyocardial fibrosis and peripheral neuropathy) that progressed despite therapy, most affected family members have followed a benign course despite eosinophil counts ranging from 2000e5000/mm 3 over many years without treatment. 29 there have been isolated reports of additional families with eosinophilia, but no clear genetic inheritance pattern has been found. common environmental exposures, including helminth infection, must be excluded prior to attributing the eosinophilia to a familial origin. the genetic defect in familial hypereosinophilic syndrome is not known. the gene has been mapped to an area on chromosome 5q harboring the cytokine gene cluster; 30 however, sequencing of a number of candidate genes in this region, including gm-csf, il-3, and il-5, has failed to identify polymorphisms that could account for the affected phenotype. additional sequencing is currently under way. eosinophils from affected family members appear to be less activated than those from patients with hes, coincident with the general lack of eosinophil-mediated pathology. 29 no further family members have developed organ involvement, thus precluding further studies of disease pathogenesis in this disorder. single organ eosinophilic tissue infiltration has been described for nearly all organ systems, although isolated involvement of the skin, lung or gastrointestinal tract is most common. the mechanism whereby certain tissues are targeted preferentially over others is not well understood. some organ-restricted disorders, such as eosinophilic esophagitis, have distinct clinical presentations and rarely progress to multiorgan involvement even in the presence of marked peripheral eosinophilia. other disorders, such as chronic eosinophilic pneumonia (cep), may overlap considerably in presentation with, or be the initial manifestation of, systemic hes. treatment varies depending on the specific clinical manifestations, but local or systemic corticosteroids are often effective. it is beyond the scope of this subchapter to discuss all organ-restricted eosinophilic syndromes, several of which are covered in other subchapters. consequently, only a few examples are provided to illustrate the diversity of syndromes seen. eosinophilia restricted to the lung, with or without peripheral eosinophilia, is associated with a wide variety of allergic, infectious, inflammatory, and neoplastic disorders, including asthma, allergic bronchopulmonary aspergillosis, drug hypersensitivity reactions, fungal pneumonia, helminth infection, and sarcoidosis. pulmonary eosinophilia can also be the first indicator of systemic eosinophilic diseases, including css. when no trigger is identified and disease remains restricted to the lung, pulmonary eosinophilia can be classified into two distinct syndromes: acute eosinophilic pneumonia (aep) and cep. aep typically occurs in healthy men between the ages of 20 and 40 years without a history of asthma. symptoms include the abrupt onset of dyspnea, fever, malaise, night sweats, nonproductive cough, and pleuritic chest pain, and respiratory failure requiring mechanical ventilation is common. physical examination may reveal bibasilar rales or rhonchi. radiological findings include diffuse alveolar infiltrates or reticular opacities in the early stages and bronchoscopy reveals increased absolute eosinophil counts as well as an increased percentage of eosinophils (>25%) relative to the total inflammatory cell content. 31 whether an environmental exposure plays a role in the pathophysiology remains controversial. patients typically respond well to high-dose corticosteroid therapy despite respiratory failure at presentation, and long-term sequelae are extremely uncommon. cep presents as a subacute illness, often mistaken for asthma in the early stages. it progresses to involve similar symptoms of cough and dyspnea, and is occasionally associated with constitutional symptoms of fever, sweats, and weight loss. physical exam findings are similar to aep, with wheeze and or crackles being present in most cases. radiological findings typically show peripheral infiltrates. bronchoalveolar lavage fluid (balf) shows an eosinophil predominance. while patients may respond initially to corticosteroids, many relapse and may require long-term corticosteroid treatment. peripheral eosinophilia of >1000/mm 3 is common, but not universal. 32 eosinophilia of the liver may occur in primary liver diseases, such as primary biliary cirrhosis or autoimmune hepatitis, in the setting of hepatobiliary involvement by helminth infections, including clonorchiasis and schistosomiasis, or secondary to a wide variety of prescription and nonprescription drugs. primary eosinophilic hepatitis with or without peripheral eosinophilia is, however, relatively rare. early studies using immunohistochemistry implicated eosinophils in the pathogenesis of progression to chronic hepatitis by demonstrating major basic protein and activated, degranulated eosinophils in close proximity to affected hepatocytes. 33 hepatic cholangiopathy, fibrosis and liver failure have been reported, although most patients in the literature have been responsive to corticosteroids or hydroxyurea. eosinophilic cystitis is a rare disorder, primarily seen in children, that presents with dysuria, gross hematuria, or suprapubic pain. urinalysis may reveal microscopic hematuria or pyuria. cystoscopy often reveals bladder wall erythema, edema, or nodules, and the diagnosis is made histologically from biopsies of the bladder. 34 infrequently, necrosis or fibrosis can be present with delayed diagnosis. it is important to exclude bladder cancer, since eosinophilic cystitis may be present in the setting of bladder cancer. treatment with antihistamines, nonsteroidal antiinflammatory medications, fulguration and steroids were reported to be successful in one series. 35 overlap syndromes with hypereosinophilic syndrome a number of systemic disorders have overlapping clinical presentations with hes. of these, the two most common are sm and css. sm is a myeloproliferative disorder, most commonly associated with a d816v mutation in kit. patients typically present with symptoms related to mast cell tissue infiltration and mediator release, including anaphylaxis, diarrhea, flushing, and urticaria. diagnosis is based on the presence of major and minor criteria according to the who classification. 2 d816v-positive sm with eosinophilia (sm-eo) is clinically distinct from fip1l1-pdgfra-positive cel and can be distinguished using molecular and clinical findings. 18 css is a distinct multisystem disorder that is characterized by the presence of eosinophilic vasculitis in the setting of asthma, pulmonary infiltrates, sinusitis with polyps, and marked peripheral eosinophilia. anca may be present and appears to be associated with a more severe course, often with renal involvement. definitive diagnosis can be made by tissue biopsy demonstrating granulomata and necrotizing eosinophilic vasculitis. significant overlap in clinical presentation with idiopathic hes can cause diagnostic confusion, particularly since corticosteroids must often be initiated to prevent serious end-organ damage before appropriate biopsies can be obtained. 36 marked eosinophilia can be seen in association with immunodysregulation of varied etiologies, including primary immunodeficiencies, secondary immunodeficiencies [e.g., human immunodeficiency virus (hiv) infection], and autoimmune disorders (table 13 .9.1). in general, the peripheral eosinophilia seen in these disorders is not associated with characteristic end-organ manifestations. exceptions include omenn syndrome and dock8 deficiency, which may present with eosinophilic tissue infiltration involving the skin or other organs. 37, 38 in some disorders, including autoimmune lymphoproliferative syndrome (alps) and hiv, peripheral eosinophilia reflects more profound immunodysregulation and in some cases may portend a worse prognosis. 39, 40 novel therapies for hypereosinophilic syndrome improved understanding of the pathogenesis of eosinophilic disorders, including eosinophilic asthma, has led to the development of a number of novel agents, including agents targeting il-5 and its receptor, although none are currently fda approved. these are discussed in chapter 15. additional agents, including alemtuzumab, a monoclonal antibody that targets cd52 on aberrant t cells, and tyrosine kinase inhibitors with activity against imatinibresistant fip1l1/pdgfra-positive mutations, have also been used with success in small numbers of patients with l-hes and cel, respectively. 24 the complexity of diagnosing and treating hes arises from the difficulty in excluding secondary forms of eosinophilia and knowing when to treat and with what medications. an understanding of underlying pathogenesis has improved genotypeephenotype classification of some eosinophilic disorders and reinforced the perception of hes as a heterogeneous group of rare disorders with differing pathogenesis, prognosis, and treatment options. advancing knowledge of molecular pathogenesis and new genetic discoveries will provide the foundation for development of novel targeted therapies, as well as a promising outlook for the care of patients with hes. advanced epithelial tumors typically undergo necrosis with subsequent release of damage-associated molecular pattern molecules (damps). 1 tumor cells are dependent on the host-created microenvironment, including endothelial cells, inflammatory cells, and stromal cells. this makes it difficult to cultivate more than a minority of tumor cells in vitro but, as is increasingly being understood, provides unique opportunities for cancer therapy. thus, when evaluating a tumor, it is important to assess three elements within the microenvironment: 1. factors released by tumor cells and their surrounding cells, consisting of epithelial and endothelial cells, fibroblasts, specialized local mesenchymal cells, and infiltrating leukocytes; 2. the quantity and quality of tumor-associated cells, specifically leukocytes; 3. their state of activation. the mammalian immune system reciprocally interacts within dynamic networks of tissue-associated nonimmune cells, enabling metabolic homeostasis, orderly scheduled cellular maturation and replacement, the timely eradication of effete cells, the repair of damage, and protection against pathogens. the simultaneous tolerance to self-antigens and reciprocal reactivity to new or occult antigens often occurs in settings of tissue damage and wound healing. when tissue homeostasis is perturbed, mast cells, granulocytes, and macrophages are recruited and rapidly release mediators such as cytokines, chemokines, matrix remodeling proteases and reactive oxygen species (ros), and bioactive mediators such as histamine. these in turn induce mobilization and infiltration of additional leukocytes into damaged tissue (causing inflammation). subsequently, the process of wound healing begins, characterized by phagocytosis of cellular debris and apoptotic cells, immune suppression, reepithelialization, and synthesis of extracellular matrix (ecm). thus, inflammation is resolved, thereby restoring tissue homeostasis. tumor cells, paradoxically growing in the setting of substantial necrosis and (chronic) inflammation, harness the collaborative capabilities (see below) of immune cells and local nonmutated but injured tissues to promote cell survival and proliferation, partly by releasing factors such as transforming growth factor b (tgf-b) and interleukin-10 (il-10), leading to restoration of barrier function in epithelial tissues. the host therefore enables tumor cells to escape from eradication and to release tissue-healing factors, thereby providing neovascularization and subsequent nutritional supply to tumor cells. wound healing and tumor stroma formation share many important properties. nevertheless, wound healing is itself a self-limiting process, whereas tumors addicted to death 1 release damps, thereby sustaining tissue proliferation, angiogenesis and continuous leukocyte recruitment. prolonged (chronic) inflammation is often associated with carcinogenesis. ros generated largely intracellularly or at the cell membrane by nadph oxidases can also promote mutagenic changes in cells when aerobic denaturation of extracellular damps is ineffective. 2 tumor necrosis factor a (tnf-a) 3 and matrix metalloproteinases promote recruitment of inflammatory cells and tissue remodeling, but also facilitate tumor metastasis. a state of metabolic symbiosis 4e8 between the tumor and the surrounding stroma, or within central hypoxic tumor cells and those at the growing rim of the tumor, allows regional variations in oxidative phosphorylation and autophagy that depend on nutrient supply and availability of molecular oxygen. compartments with abundant resident populations of eosinophils include tissues with substantial cellular turnover and regenerative capacity, such as the bone marrow, primary and secondary lymphoid tissues (e.g., lymph nodes, spleen, and thymus), 9 the uterus, 10 and almost the entire gastrointestinal tract (with the exception of the esophagus, except under abnormal states). 9, 11 this link with cell turnover and tissue repair may also explain the presence of eosinophils at sites of wound repair 12 and the commonality of an eosinophil infiltrate among solid tumors. 13 eosinophil localization to the lamina propria of the gastrointestinal tract is critically regulated by eotaxin/ c-c motif chemokine 11 (ccl11), a chemokine constitutively expressed throughout the gastrointestinal tract. 14 nevertheless, eotaxin expression within the gastrointestinal tract (e.g., the esophagus) is by itself insufficient to induce eosinophil accumulation, because the esophagus is normally devoid of these granulocytes. this suggests the potential involvement of other eosinophil chemoattractants and activating factors that contribute to tissue-specific accumulation and degranulation. in particular, the correlation of eosinophil recruitment/activation with tissue damage and cell death associated with these inflammatory responses suggests that damps may represent previously overlooked signaling molecules that elicit eosinophil agonist activities (fig. 13.10.1) . consistently, high mobility group box 1 (hmgb1; a prototypic damp molecule) serves as a chemoattractant and survival factor for eosinophilic granulocytes. 15 eosinophilic granulocytes are found within necrotic tissues and the pseudocapsule surrounding tumors. 16 these immune cells contain, and can release, several cationic proteins that, in addition to their toxic tissue damaging character, are also potentially important for tissue remodeling and clearing cellular debris. 17 eosinophils are thought to be, in part, responsible for the cell death and tissue damage commonly observed in disease states that are associated with increased eosinophil numbers and tissuespecific eosinophil recruitment. 18 since the mid-1980s, eosinophils have been known to mediate their effects via at least three independent mechanisms in addition to the release of cytotoxic granule proteins, which enable them to modulate the intensity of inflammation, as well as to elicit cell death leading to the loss of tissue integrity: in addition, they initiate an acute inflammatory response to recruit, activate, and polarize b cells, cytotoxic lymphocytes, dendritic cells (dcs), and monocytes. chronic exposure to active damps promotes angiogenesis and immunosuppression by recruiting and activating endothelial cells, fibroblasts, and leukocytes such as t-regulatory (t reg ) cells, and myeloid-derived suppressor (mds) cells, which are important for promoting wound healing. atp, adenosine 5 0 -triphosphate; hmgb1, high mobility group box 1; hsp, heat shock protein; s100, protein s100 t h 2, t-helper type 2. a growing body of literature suggests that both immunoregulation and tissue repair/remodeling may represent important nonoverlapping eosinophil effector functions. 17 a quantitative assessment of eosinophil recruitment/accumulation in solid tumors showed that the tissue eosinophilia is apparently mediated by one or more factors released directly from necrotic tissues within the tumor. studies linking eosinophil recruitment and activations with cell death and necrosis abound. 15, 16, 29 thus, damps released from damaged/dying epithelial cells may represent a previously underappreciated signaling event capable of mediating both eosinophil recruitment and the execution of effector functions leading to (and/or promoting) tissue repair and remodeling. in addition to their capacity to synthesize and release a variety of immunoregulatory molecules, 30 some studies have suggested that eosinophils may function as antigen presenting cells (apcs) 31 or enhance dc maturation. 19 eosinophils may also affect local t cell responses by modulating the balance of t-helper type 1 (t h 1) and t h 2 immune responses [e.g., through eosinophil-derived indoleamine 2,3-dioxygenase (ido) production of kynurenine 32 ]. importantly, ido appears to be essential for the induction of tolerance by tissue recruited t cells. thus, similar to other eosinophil-mediated immunosupressive activities (e.g., the potential induction of t-regulatory cells through tgfb production), 33 eosinophil-derived ido may also play a crucial role in immunosuppression and potentially facilitate tissue repair and, as a by-product, tumor growth. the eosinophil plays a somewhat passive role in the tumor. eosinophils are frequently observed following immunotherapy with il-2, 34 il-4, 35,36 gm-csf, 37 repeated vaccination, 38 and antibodies to ctla-4, but the significance of their appearance remains largely unknown. in particular, the antitumor effects of successful cytokine therapy of cancer with il-2 has been associated with the identification of degranulating eosinophils within the tumor, 34 suggesting that eosinophil effector functions (e.g., direct or antibodydependent tumor cell lysis or the immunoregulatory capacity of eosinophils modulating the local tumor microenvironment) may play a role in the anticancer activities mediated by systemic il-2 administration. 34, 39 however, despite the promise of these potential eosinophilmediated antitumor activities, the presence of eosinophils is not an important prognostic indicator in high-dose il-2treated patients. mouse studies suggesting a link between eosinophils and the therapeutic value of antitumor responses associated with il-4 administration 40 have led to clinical trials to evaluate these responses in cancer patients. in a phase i clinical trial of il-4 administered to cancer patients, sosman and colleagues 35 showed that il-4 therapy induced systemic eosinophil degranulation associated with increased serum and urine major basic protein (mbp) levels. moreover, the increase in serum mbp was il-4 dose dependent. unfortunately, the link of antitumor activities with eosinophil numbers in these patients is only correlative and similar to observations made in patients following il-2 administration. no definitive conclusions can be made as to whether and how eosinophils modulate tumor growth. efforts to demonstrate experimentally a role for eosinophils in tumor immunity have also been fraught with complicating factors yielding qualified interpretations. most notably, considerable excitement was generated by data from the elegant studies of tepper and colleagues 36, 40, 41 that demonstrated in athymic nude mice that malignant cell lines transfected for constitutive expression of interleukin 4 (il-4) elicited a tumor associated macrophage and eosinophil infiltrate that led to the attenuation of tumor growth. this provoked a series of tumor xenograft studies that attempted to define the cellular and molecular mechanisms of the apparent il-4-mediated antitumor effect. although these studies have shown that spontaneous tumors showed evidence of tumor regression, associated with tumor-infiltrating eosinophils, none of these studies has resolved the role(s) of eosinophils in tumor rejection reactions. recently, colon tumor eradication by eosinophils in murine models suggested a more conventional cytolytic response. 42 in this study, coculture of eosinophils with colorectal tumor cells led to the release of eosinophil cationic protein and eosinophil-derived neurotoxin, as well as tnf-a secretion. interestingly, this may be related to the ability of eosinophils to both lyse and promote clearance of stressed or damaged cells. 43 eosinophils accumulate at unique sites in response to cell turnover, thus regulating tissue homeostasis, and are regulators of local immunity and/or remodeling/repair according to the liar hypothesis, suggesting a more nuanced and interesting role for these cells in damaged tissues and tumors. 44 within several tumor types, including gastrointestinal tumors, tumor-associated tissue eosinophilia (tate) is associated with a significantly better prognosis. 30 the converse is true in other tumor types, such as differentiated oral squamous cell carcinoma 30 or hodgkin lymphoma, 45, 46 where eosinophils may be involved in promoting cancer cell growth. the mechanism by which eosinophils, in particular, are recruited into tumor tissues is largely unknown. we could characterize damps, including the nuclear protein hmgb1, as candidate factors eliciting eosinophil chemotaxis into tumor tissue. 47 thus, eosinophil activities are likely to have multiple roles, dictated by specific circumstances, which were originally adapted to maintain tissue homeostasis. eosinophils are not only able to destroy tissue but are also attracted and activated by stressed and damaged cells, as we and others have demonstrated. 16, 47 it is likely that stressed cells attract and activate eosinophils by expressing molecules such as nkg2d ligand 4 (letal), major histocompatibility complex class i chain related a (mica), and micb, 11 as well as other nkg2d ligands or ul16-binding proteins (ulbps). these stress-associated molecules all serve as ligands for nkg2d, first described on natural killer (nk) cells 45 and subsequently on eotaxin-activated eosinophils 48 and t cells. 49 thus, tumorassociated eosinophils appear to have at least two dominant nonoverlapping activities: 1. destructive effector functions that may limit tumor growth and induce recruitment and activation of other leukocytes; 2. immunoregulatory and remodeling activities that suppress immune response and release cytokines, thus promoting wound healing. consistent with the hypothesis that damps initiate innate immune cell activation when encountering microbes or parasites, 50 eosinophils are often first responders to tissue damage and likely mediate some aspects of tissue remodeling and repair. the presence of damps such as hmgb1 in the necrotic areas of tumors may, in part, elicit both eosinophil tissue recruitment and localized execution of effector functions such as degranulation. the available data, however, suggest that while all threatened epithelial cells, including cancer cells, release damps, not all eosinophil tissue infiltration is associated with tumor eradication. 51, 53 this conclusion again suggests that the relationship of eosinophils with the modulation of tumor onset/growth is complex and that expression of damps, the emergent role of autophagy, and redox chemistry 54e68 is likely to be only one of several inflammatory mechanisms capable of eliciting eosinophil effector functions. interestingly, of all tested biologic activities, eosinophils respond most sensitively to the presence of damps, including hmgb1, with generation of peroxide leading to oxidative degradation and thus inactivation of damps. 15 these damps with or without oxidation, play differential roles in the recruitment of mesenchymal stem cells as well as t regulatory cells which may confound and limit the antitumor response. 69e72 in summary, while the role of eosinophils in tumor onset and growth is unresolved, recent studies suggest that eosinophils are a common and robust tumor infiltrate and that much interesting biology remains to be explored. specifically, do eosinophil activities limit tumor growth through destructive effector functions or do eosinophilderived immunoregulation and tissue repair/remodeling promote tumor growth and metastasis? how does the critical role of redox 49 inform eosinophil function in relation to damps? the resolution of these questions could inform the initiation of eosinophil-based modalities and, in turn, novel therapeutic approaches to treat cancer patients. eosinophils have been associated with numerous diseases affecting multiple organ systems and, as this volume attests, their activities have been implicated as a cause of tissue pathology in a wide range of these conditions. eosinophils are strongly implicated in the pathogenesis of allergic diseases, including allergic rhinitis, asthma, atopic dermatitis, food allergy, and others. although chronic rhinosinusitis (crs) is not strictly an allergic disease, it is often associated with allergy and the appearance of intense eosinophilia in tissues from the upper airways and sinuses of patients suffering from this condition has been known for the better part of a century. the purpose of this subchapter is to review the evidence showing an association between the eosinophil and crs; the mechanisms of recruitment of eosinophils into sinonasal tissue in crs patients; the roles that eosinophils play in the pathogenesis of this disease; and the potential for treatment modalities based on targeting the eosinophil. crs is a disease of the upper airways and paranasal sinuses that affects 5e10% of the general population. it is typically characterized by one or more of the following symptoms: copious secretion of mucus, facial pressure and headache, fatigue, loss of smell, and nasal obstruction. the physical exam may be unremarkable, although in some cases nasal endoscopy may reveal the presence of purulent drainage and/or nasal polyps. historically, crs has been subdivided according to many of its pathophysiological features, including appearance of fungal mucins, comorbidity with asthma, formation of polyps, hyperplasia of connective tissue, and sensitivity to aspirin. more recently, partly for the sake of simplifying the study of this condition, it has generally been divided into crs with nasal polyps (crswnp) and crs without nasal polyps (crssnp), a terminology that we will use here. the vast majority of crs cases are idiopathic with an unpredictable clinical course; however, a minority have a more characteristic clinical picture. specifically, crs with fungal mucins together with fungal atopy is often viewed as a distinct condition known as afs (allergic fungal sinusitis). patients with aspirin allergy, asthma, and nasal polyps have a syndrome known as samter's triad, characterized by a severe form of recurrent polyposis. lastly, crs occurs in nearly all patients with cystic fibrosis, commonly with nasal polyposis, and this is frequently categorized as a discrete entity as well. in the united states, there are in excess of 300,000 surgeries performed annually to relieve the suffering of patients with crs, and the discarded tissue from these procedures has provided access to tissue for those interested in studying the pathogenesis of the disease. the formation of nasal polyps occurs in roughly 15e20% of patients with crs and the inflammatory process within the polyp is particular intense and may differ from inflammation that occurs in crssnp. the level of eosinophilia is greater in crswnp and this form of the disease has been the most extensively studied. consequently, we primarily focus the discussion in this review on the role of the eosinophil in crs with nasal polyps. the appearance of eosinophils in pathological conditions in the airways was noticed shortly after paul ehrlich developed the acidic dyes that continue to be used to detect these cells today. 1 crs is one of the most intensely eosinophilic diseases, rivaling hypereosinophilic syndromes, eosinophilic esophagitis and eosinophilic gastroenteritis, in terms of tissue density of eosinophils (fig. 13.11 .1). 2,3 bachert and his colleagues have shown that average eosinophil numbers are elevated in both crssnp and crswnp, but they are higher in crswnp and highest within nasal polyps themselves. 4 in our own studies, eosinophilia is the highest in patients with samter's triad (see belowdunpublished observations). although some controversy exists as to whether there are relative differences in the eosinophilia of nasal polyps in populations of african, caucasian, and chinese descent, bachert has reported low levels of eosinophilia in chinese patients with crs. 5e7 such studies are often complicated by the fact that the degree of eosinophilia in sinonasal tissue of patients with crs can be dramatically altered by therapies that patients receive prior to surgery, especially oral glucocorticoids, which can diminish the eosinophil number by an order of magnitude (see below). it has been suggested that some intranasal chinese herbal remedies may also alter eosinophil numbers. 6 along with elevated levels of eosinophils, nasal polyps also demonstrate elevated levels of b cells, dendritic cells, neutrophils, macrophages, mast cells, and t cells, and thus represent a tissue undergoing a robust immune and inflammatory response. although mast cells are not the subject of this volume, it must be acknowledged that they are likely to play an important role in the pathogenesis of crs, especially in the tissue swelling and formation of nasal polyps that occur. 8, 9 detection of eosinophils and eosinophilia in crs has employed assays for eosinophil granule proteins, such as eosinophil cationic protein (ecp), as well as specific antibodies against eosinophil granule proteins, notably eg2, which is considered to specifically stain activated eosinophils. 10, 11 studies using these approaches have confirmed the presence of eosinophilia in crs and provided evidence for activation of the tissueresident eosinophils. 12e14 persson and colleagues have emphasized the importance of cytolytic eosinophil degranulation and release of clusters of free granules. evidence has been provided to demonstrate that eosinophils in sinonasal tissue of crs patients undergo both piecemeal degranulation and cytolytic degranulation. 15, 16 recently, a method has been developed to purify eosinophils from human tissues, including nasal polyps, that should allow further studies into the activation state of eosinophils and gene expression in crs. 17 crs is often comorbid with asthma, and one of the most severe forms of the disease, nasal polyps with asthma and aspirin sensitivity (referred to often as samter's triad), manifests both severe polyposis and severe, often glucocorticoid-resistant, asthma. 18 crs with nasal polyps is also comorbid with churg-strauss syndrome, a systemic vasculitic disorder in which eosinophils feature prominently. 19 several groups have compared the level of eosinophils in sinonasal tissue with asthma severity, levels of eosinophils in bronchial lavage, or sputum samples from the lower airways. in one study, levels of eosinophils in lavage from the middle meatus correlated with fev 1 (forced expiratory volume in one second) in asthmatics with crs. 20 in another study, the presence of eosinophils in sinonasal tissue was higher in crs patients undergoing sinus surgery who had comorbid asthma than in those who did not have asthma. 21 mehta et al. found that the extent of crs disease as measured by sinus computed tomography (ct) scores correlated with eosinophils in blood and sputum, suggesting that systemic elevation and activation of eosinophils may be a feature of crs. 22 patients with crswnp were found to have increased asthma prevalence, as well as increased exhaled nitric oxide. 23 the etiology of crs has yet to be definitively ascribed to infection with any single pathogen or class of pathogens. it is clear that patients with crs experience frequent acute, presumably infectious, exacerbations of disease, and crs patients are generally treated frequently with antibiotics, suggesting that treating physicians suspect the presence of bacteria. along these lines, it has been suggested that patients with crs may have a defect in the innate immune barrier, making them more susceptible to infection or colonization with microorganisms in general. 24, 25 another line of investigation implicates fungi, or at least allergy to fungi, in crs, based on the presence of activation of lymphocytes to express cytokines in response to fungal extracts. 26, 27 while atopy to aeroallergens is frequently seen in patients with crs, nearly half of crs patients are nonatopic according to standard tests, and based on this present state of knowledge, crs should not be viewed as a classical allergic disease. 28 yet another line of investigation suggests that staphylococcus aureus and the toxins it produces are important inciting factors in crs. 29e32 according to the superantigen hypothesis of crs, staphylococcus-derived superantigens drive a t-helper type 2 (t h 2)-skewed inflammatory response that is responsible for the eosinophilia observed in crs (the mechanism of eosinophilia in crs is discussed below). superantigens activate large numbers of t cells by cross-linking class ii mhc on antigen-presenting cells with specific vb regions on the t-cell receptor, leading to profound release of cytokines, in some cases skewed toward t h 2. 33 reports on the extent of staphylococcal colonization in crs have been variable but most have demonstrated normal or supranormal frequencies. bachert et al. and desrosiers et al. have reported that 50e90% of crs patients with nasal polyps have colonization with staphylococcus. 34, 35 staphylococcal superantigens can also act as allergens, and several reports have detected staphylococcal superantigens in the airways of crs patients and/or demonstrated the presence of functional immunoglobulin e (ige) antibodies directed against the staphylococcal superantigens. 36e39 a recent study by bachert et al. has implicated the presence of interleukin-5 (il-5) and ige directed to staphylococcal enterotoxins in crs comorbid with asthma. 40 a longitudinal study demonstrated that high numbers of eosinophils in the nasal mucosa or in mucus collected from crs patients are strong risk factors for recurrence of disease and the need for subsequent surgery in a 5-year follow-up study. 41 in summary, eosinophil numbers are increased in sinonasal tissue of patients with crs and increased the most in those with nasal polyps, those with asthma, and especially those with all three conditions. the correlation of eosinophils with disease severity implicates them as either a biomarker of the pathogenic process or a mediating cell responsible for disease. the molecular mechanisms by which eosinophils are recruited to tissues have been reviewed and are the topic of another subchapter in this volume. we restrict our comments therefore to the available evidence on recruitment of eosinophils in crs. in general, several important processes occur. one is the priming and survival-promoting effects of cytokines on eosinophils, especially including granulocyte-macrophage colony-stimulating factor (gm-csf) and il-5, both of which also play a role in the generation of eosinophils. another is the local expression of eosinophil-attracting chemokines by epithelium and other tissue cells. the expression of adhesion molecules by endothelium, especially vascular cell adhesion protein 1 (vcam-1), is equally important in the rolling, arrest and transmigration of these cells into the affected tissue. an extensive literature that shows the elevation of these factors in sinonasal tissue of patients with crs will be summarized next. the primary receptor driving chemokine-mediated recruitment of eosinophils is c-c chemokine receptor 3 (ccr3), which has a number of ligands, notably rantes (or c-c motif chemokine 5; ccl5), eotaxin (ccl11), eotaxin-2 (ccl24), eotaxin-3 (ccl26), and mcp-4 (ccl13), with less activity for mcp-1, mcp-2, and mcp-3. 42, 43 mice lacking ccr3 have severe, but not totally diminished, eosinophil infiltration in allergic inflammation, and ccr3 antagonists are under investigation in clinical trials. beck et al. found elevated levels of rantes mrna and tissue staining in nasal polyp tissue but not in normal turbinate tissue. 44 rantes expression is primarily found in epithelial cells, an observation leading to speculation that localization of eosinophils to the epithelium and lamina propria may be related to epithelial chemokine expression. 45e47 similar findings have subsequently been made with other ccr3 ligands, including eotaxins 1e3 and mcp-4. 48e51 a careful study by jahnsen et al. found that levels of mrna for eotaxin-1, eotaxin-2, and mcp-4 are elevated in nasal polyp tissue and that levels of eotaxin-2 and mcp-4 in turbinates from crswnp patients are higher than in normal turbinates. 49 taken together, it is clear that both surrounding tissue (i.e., turbinate) and affected tissue (nasal polyps, which commonly emerge from the ethmoid sinuses and other deeper tissues) in patients with crs have elevated levels of ccr3 ligands that are likely to play a role in eosinophil recruitment to both of these regions in crs. regulation of chemokine expression by epithelium is complex, but both nf-kb and signal transducer and activator of transcription 6 (stat6) play important roles in the response, and t h 2 cytokines including il-4 and il-13 are important inducers. 52, 53 other stimuli may also be important in activating ccr3 ligand expression in crs, and chitin has recently been shown to induce eotaxin-3 in human sinonasal epithelial cells in vitro. 54 eosinophils not only respond to ccr3 agonists but also release eotaxin, eotaxin-2, eotaxin-3, and rantes. 51, 55 the release of ccr3 agonists from eosinophils may be involved in the local eosinophil accumulation in nasal polyps. recently, our group has found that mpif-1 (ccl23) is elevated in eosinophilic nasal polyps and that eg2 ã¾ eosinophils are major mpif-1-producing cells in nasal polyps. 55a mpif-1 is a ligand for ccr1 and is known to recruit monocytes, macrophages, and dendritic cells. 56, 57 these findings indicate that activation of eosinophils may further enhance local inflammation via secondary recruitment of additional cells in nasal polyps. exposure of eosinophils to gm-csf or il-5 leads to several notable phenotypic changes that are likely to be relevant to their accumulation in crs, including increased expression and function of adhesion molecules, increased transendothelial migration, and increased survival. the earliest studies on crs were by denburg and colleagues, and showed elevated levels of gm-csf in eosinophils in nasal polyp tissue, 58, 59 and that gm-csf is prominently expressed by epithelial cells, in agreement with earlier in vitro studies showing that epithelial cells are a rich source of this cytokine. 60 several studies have shown that conditioned medium from nasal polyps stimulated with antigen or from cultured nasal polyp epithelial cells can prolong eosinophil survival or activate eosinophils in vitro and that the activity can be significantly blocked by anti-gm-csf antibodies. 61e64 additional studies have shown that il-5 is also an important eosinophil priming and survival factor in nasal polyp tissue. 13,65e67 this finding is supported by success in recent clinical trials by bachert et al. using anti-il-5 antibodies (see below). the relative importance of il-5 and gm-csf as priming cytokines in sinonasal tissue is unknown. liu and busse found that lung-migrating eosinophils have reduced expression of the il-5 receptor in asthmatics and postulated that the main effects of il-5 (and therefore probably anti-il-5) may be in the bone marrow and circulation. 68 whether the same is true in the upper airways and sinuses in patients with crs requires further investigation. in vitro, vcam-1 is known to be an important and relatively selective endothelial adhesion molecule that mediates eosinophil rolling, firm adhesion, and transendothelial migration. several groups have demonstrated increased endothelial expression of vcam-1 in nasal polyps and shown that vcam-1 levels correlate with the presence of eosinophils, leading to the hypothesis that recruitment of eosinophils in crs is partially mediated by vcam-1. 46,69e73 using the stamperewoodruff assay, symon, wardlaw, and collaborators have demonstrated that eosinophils bind to nasal polyp tissue in vitro via interactions with p-selectin and on this basis suggested a role for p-selectin as well. 74 in general, the t cell cytokine milieu that most drives eosinophilic inflammation is a t h 2 pattern, including the vcam-1 activators il-4 and il-13 as well as the eosinophil priming cytokine il-5. although most crs is probably t h 2 driven, it has been suggested that in some cases of crs, including nonallergic crs, other t-cell cytokines may be involved. 75 the discussion above firmly establishes that eosinophils are present in high numbers in the sinonasal tissue of patients with crs, especially the polypoid form, and that these tissue eosinophils are activated. together, these two lines of investigation provide circumstantial evidence that eosinophils may play a role in alterations to nasal physiology, tissue structure, and clinical phenotype. this section discusses some features of crs that may be mediated by activated eosinophils. in most cases, these discussions should be viewed as hypothetical or speculative, as there is no validated animal model of crs and in most cases it is not possible to definitively assess mechanisms in human subjects (other than some recent studies with antibodies against il-5 or ige, discussed in the next section). in our view, it is clear that crssnp and crswnp are distinct disease entities that are primarily related by their frequent resistance to treatment, need for surgery (probably greater in crswnp), and eosinophilia (probably greater in crswnp). however, they are distinct in many of the clinical and inflammatory processes that we and others have been investigating at the molecular level. 86e89 as to the roles of eosinophils in pathogenesis, by far the most data are available for polypoid crs, and we will restrict our comments here to crswnp, even though they may in many cases apply to crssnp. although eosinophils are elevated in crs and express the activation marker eg2 (see above), eg2 has not proven to be a reliable marker of degranulation; eosinophils in nasal polyps are undoubtedly activated, as studies of eosinophil morphology by erjefã¤lt and persson have demonstrated extensive piecemeal degranulation and cytolytic degranulation in eosinophils in nasal polyp tissue. 16, 90 the most obvious and prominent feature of crswnp is the formation of the polyp itself, although details of the mechanism of this metamorphosis of sinonasal tissue are not well understood. perhaps the best studies have been those by bachert et al., who studied early-phase and established nasal polyps. 91 they found formation of a subepithelial eosinophilic cap at the upper surface of the tissue outgrowth and implicated fibronectin and deposition of albumin and extracellular matrix proteins in the early and late phase, respectively. the presence of il-5 and eotaxin-2 correlated with the process, thus leading them to propose an important role for eosinophils. 91 based on the deposition of albumin, we can presume that vascular leakage is occurring in crs, although the stimuli for the leak are not well understood. studies by steinke, borish, and others have shown that the 5-lipoxygenase (5-lo) pathway is activated in crs, especially in aspirin-sensitive disease, and that eosinophils express 5-lo and ltc4 synthase within the polyp tissue. 92, 93 increased eicosanoid metabolism has been reported in crs and correlates with ecp and il-5. 82 although eosinophil cyclooxygenase and lipoxygenase metabolites might be important in vascular leakage driving polyp formation, in general the clinical experience with inhibitors of both of these pathways has been disappointing and they are unlikely to be the primary mediators driving vascular leak in a forming polyp. the relative importance of mast cell and eosinophil mediators in polyp formation is unknown. di lorenzo et al. measured ecp, histamine, and tryptase in nasal lavage and found only tryptase and ecp to correlate with symptom scores. 94 since mast cells are highly elevated in nasal polyps and are capable of releasing numerous mediators of vascular leakage, their potential role in polyp formation must be seriously considered. considerable evidence has accumulated to demonstrate elevations of both ige and iga in nasal polyp tissue, and it is not unreasonable to speculate that these antibodies play a role in activating mast cells and eosinophils, respectively, in crswnp. with respect to eosinophils, activation by ige, if it occurs at all, most likely occurs indirectly as a result of the action of mediators released from basophils, mast cells, and other cells that clearly express a functional ige receptor (e.g., inflammatory macrophage-like cells). kita and colleagues have shown that igg and iga, but not ige, can prolong eosinophil survival, and induce cytokine expression and effector function. 95, 96 however, convincing data demonstrate that eosinophils are activated to degranulate by cross-linking receptors for iga. 97, 98 more uncertain is the nature of the antigen systems that might drive iga-mediated degranulation in nasal polyp eosinophils. as discussed above, only half of patients with crswnp are atopic, and it is difficult to implicate typical aeroallergens as anything more than exacerbating factors. recent studies by tan and colleagues have demonstrated the presence of autoantibodies of both igg and iga isotypes in patients with recalcitrant crs requiring revision surgery. 99 suh et al. found correlations between both total igg and total ige with the number of eg2 ã¾ cells, but not iga or secretory iga. 100 clearly, further work is required to establish the importance of immunoglobulins in eosinophil activation in crs. in both asthma and crs there is evidence for epithelial damage mediated by eosinophils. gleich and colleagues demonstrated that the presence of eosinophils and extracellular levels of the toxic eosinophil granule protein major basic protein (mbp) correspond to regions of epithelial injury in patients with crs. 101 this occurs in asthma as well, and there is ample evidence for a similar pathological process occurring in the two diseases. chanez, bousquet, and colleagues and gaga et al. demonstrated a strong correlation between eosinophils in the nose and lung in asthmatics. 101e103 bresciani et al. found that 70% of asthmatics have crs, as determined using clinical and ct scores, and observed a correlation of clinical scores to blood eosinophils in those with mild and moderate asthma. 104 eosinophil-derived granule mediators are well established to be toxic to epithelium, to activate mast cells and basophils, and to drive inflammation. an ultrastructural investigation of epithelial damage in asthmatic and nonasthmatic nasal polyps revealed reduced length of desmosomes in allergic crswnp and in asthmatics. 105 several studies suggest that the epithelium in both asthma and crs presents a poor barrier. 24, 25, 106 whether damage from eosinophils occurs as a result of the cationic granular proteins, the respiratory burst and peroxidase activation, protein nitration, or another mechanism is worthy of further investigation. 107, 108 recent studies indicate reduced spink5 in epithelial tissue from crs patients. 109 spink5 is a protease inhibitor that can regulate barrier function in the skin via preventing activation of par2 and subsequent induction of thymic stromal lymphopoietin (tslp). 110 briot et al. found that high levels of tslp in the skin drive a highly eosinophil and mast cell rich inflammation even in the absence of t cells. 110 kamekura et al. presented evidence that tslp itself can induce claudins and occludins and enhance tight junction function in nasal epithelial cells in vitro, suggesting that its influences may be complex. tslp is elevated in crs, and whether tslp regulates barrier function in crs and/or contributes to eosinophilia needs further clarification. 111e113 studies in the lower airways indicate that eosinophilic inflammation is often associated with fibrotic changes, including the laying down of extracellular matrix proteins or repair proteins (e.g., lumican, procollagen, and tenascindsee chapter 12). 114, 115 some nasal polyps are characterized by the deposition of collagen and other matrix proteins, and it is possible that eosinophils may play a role in this process. studies by ohno et al. have demonstrated that transforming growth factors a and b1 (tgf-a and tgf-b1), as well as platelet-derived growth factor receptor (pdgf), are expressed by eosinophils in nasal polyps and suggest that eosinophil-derived growth factors may alter the structure of the affected nasal mucosa. 116, 117 eosinophil production of tgf in nasal polyps was confirmed by elovic et al. 118 ultrastructural studies in nasal polyposis using anti-il-5 antibodies, such as the ones used by flood-page, kay et al. in asthma, will be required to assess the role of eosinophils in remodeling of the sinonasal tissue in crs. 114 at present, there are no specific approved therapies for the treatment of crs. in general, a significant number of patients that present with the diagnosis have failed treatment with antibiotics and/or intranasal glucocorticoids. since nasal polyps commonly grow out of the sinuses, it is a challenge for intranasal glucocorticoid sprays to penetrate to the area of relevant inflammation. treatment with oral steroids is often effective, especially in crswnp, and is frequently used to treat crswnp, although most patients and physicians prefer to avoid chronic treatment with oral glucocorticoids. glucocorticoids continue to be the most effective antiinflammatory drugs available for a wide variety of autoimmune and allergic chronic inflammatory illnesses. their mechanisms are pleiotropic and represent actions exerted upon numerous cell types known to participate in crs, including epithelial, t h 1, and t h 2 cells. other important cells, such as endothelial cells, mast cells, neutrophils, and t h 17 cells, are relatively unresponsive to glucocorticoid treatment and are unlikely to be important targets in crs. 119 among the steroid responsive cells are eosinophils, and the actions of glucocorticoids on eosinophils have been reviewed. 120, 121 in 2007, patiar and reece performed a cochrane review of the literature and identified only one randomized-controlled study comparing oral steroids with no intervention or placebo. 122, 123 as found in earlier uncontrolled trials, oral treatment with prednisone or a similar systemic steroid shrank polyps, reduced symptoms, and improved olfaction in this study. alobid et al. also found that continued treatment with intranasal steroid maintained the benefits of the 2-week treatment with oral steroids for nearly 1 year. 123 subsequently, hissaria et al. performed a controlled trial testing a short course of prednisolone in crswnp, and found improved symptom scores and a reduction in polyp size, as determined both subjectively and objectively by mri. 124 recently, van zele, bachert, and collaborators performed a double-blind placebo-controlled multicenter trial of oral methylprednisolone in crswnp. 125 in addition to shrinking polyps, improving olfaction and reducing symptoms, the oral steroids improved congestion, nasal peak flow rates, postnasal drip, and rhinorrhea. importantly, in this study methylprednisolone reduced ecp, ige, and il-5 in nasal secretions and decreased blood eosinophils, ecp, and soluble il-5ra in the serum. 125 in vitro studies have identified numerous effects of glucocorticoids on eosinophils (for a summary, see 119 ) . glucocorticoids diminish eosinophil survival in vitro by promoting apoptosis and this effect is blocked by survivalpromoting cytokines such as gm-csf or il-5. glucocorticoids also diminish production of these specific cytokines by many cell types, including epithelial cells and t lymphocytes. steroids have a similar suppressive effect in vitro on the expression of cytokines that activate endothelial adhesion molecule expression [e.g., il-1, il-4, il-13, and tumor necrosis factor (tnf)] and of chemokines known to cause eosinophil migration (e.g., ccr3 agonists). thus, theoretically, glucocorticoids should diminish eosinophil recruitment to the sinuses and nasal cavity and hasten the disappearance of the eosinophils once they arrive in the sinonasal cavity. numerous in vivo studies have addressed these theoretical effects of glucocorticoids by administering intranasal or oral glucocorticoids to patients with crs prior to surgery or biopsy. a general feature of these studies is that glucocorticoids uniformly reduce the number of eosinophils found in nasal polyps. kanai et al. also found treatment with budesonide to reduce the proportion of activated (eg2 ã¾ ) eosinophils, along with reducing levels of total eosinophils, t cells, the icam-1 adhesion molecule, and hla-dr, a marker of adaptive immune activation. 126 similar findings were made by hamilos and coworkers, who additionally found reduced p-selectin (but not il-1b, tnf, or vcam-1) in polyps from patients treated with intranasal fluticasone propionate. 127 they also found reduced numbers of cells expressing t h 2 cytokines (il-4 and il-13). delbrouck et al. reported that budesonide decreases levels of both icam-1 and vcam-1, and to a lesser extent p-selectin. 128 as mentioned above, denburg, dolovich, and collaborators identified gm-csf as an important eosinophil-priming and survival-promoting cytokine in the nose of patients with allergic rhinitis and crs. nonaka et al. from this group found that budesonide reduces survival of peripheral blood eosinophils in vitro but not eosinophils extracted from nasal polyps, suggesting that the polyp eosinophils are primed and rendered glucocorticoid resistant as a result of the gm-csf exposure within the polyp. 129 it is unclear whether gm-csf or il-5 is the most important eosinophil survival cytokine in crswnp, and this is not a question that can be easily addressed, since both of these cytokines have effects on eosinophils outside of the sinonasal cavity. nonetheless, bolard et al. found a correlation between levels of il-5 and eosinophils in the nasal secretions of patients with nasal polyps and that intranasal steroids reduce both of these parameters. 130 whether glucocorticoid treatment directly induces apoptosis in tissue eosinophils or indirectly induces eosinophil death as a result of suppressing survival-promoting cytokines is still an open question. as to the expression of chemokines that attract eosinophils, jahnsen et al. found that nasal polyp tissue expresses highly elevated levels of eotaxin, eotaxin-2, mcp-4 and rantes, and that after treatment with oral glucocorticoid these factors are all profoundly reduced along with a reduction in eosinophil numbers in the tissue. 49 importantly, in association with the reduction of eosinophils and of the cytokines that induce their accumulation, treatment of crs with intranasal glucocorticoids also leads to a reduction in damage to the epithelium that is thought to be mediated by eosinophils and is accompanied by the restoration of epithelium integrity. 131 perhaps the most valuable data implicating eosinophils in the pathogenesis of crswnp is from the group of gevaert, bachert, and collaborators. 132e134 these researchers noted increased levels of il-5 and soluble il-5ra in patients with nasal polyposis and found that treatment of crswnp patients with an antibody against il-5 led to a reduction in nasal polyp size, particularly in patients with elevated il-5. the same patients had a corresponding reduction in the level of eosinophilia, as measured by total eosinophils in the blood and levels of ecp in both the serum and in nasal secretions. 132e134 studies using anti-il-5 antibodies to reduce eosinophilic inflammation are still ongoing and this approach continues to show promise for the treatment of crs. as kinase inhibitors that block the development of eosinophils are developed, it is possible that some will emerge that have some specificity for the eosinophilic lineage of cells and will thus have utility in a variety of diseases including crs. treatment of mice with antibodies against fas caused widespread apoptosis of eosinophils but lacked specificity and thus killed many other important cell types. 135 treatments based on siglec-8 activation may induce apoptosis more selectively in eosinophils, and in the related allergic cells mast cells and basophils, and thereby provide some benefit without undue safety concerns 136 (see also chapter 15.4 ). in addition, recent studies from our group demonstrate that b cells and immunoglobulins, especially iga which is a potent eosinophil activator, are highly elevated in crs. 137, 138 therapies targeting b cells, such as antibodies against b cell activating factor belonging to the tnf family (baff) or b cells (e.g., anticd20), may prove to diminish the activation of eosinophils in crs if iga and secretory iga are important in activating eosinophils in crs. 128 the ability of organisms to repair themselves is an indispensable requirement for their survival. most members of the animal kingdom inevitably encounter external or internal environmental pressures that can threaten their existence. examples of these are, respectively, injury inflicted by a traumatic event, such as a stab wound, and parasites that inappropriately reside in various tissues. a complex series of reactions to these survival challenges has evolved among vertebrates to correct tissue damage traumatically imposed by a foreign object (i.e., a knife) or to completely remove an injurious agent (i.e., an infection). these shared mechanisms of self-preservation are collectively referred to as healing. in many individuals, healing events in the coronary vasculature occur and can be characterized by both types of reactions, including correction of vessel damage inflicted by circulating substances (i.e., coronary artery disease) and subsequent introduction of a foreign agent (i.e., a stent), as well as to mount an immune response (i.e., hypersensitivity) aimed at eliminating such a foreign body. the most common type of healing occurrence in blood vessels is, paradoxically, also responsible for the most common type of coronary artery disease. indeed, atherosclerosis is likely the result of a response to injury that occurs predominantly in medium-sized muscular vessels, including the left anterior descending, left circumflex, and right coronary arteries. 1 the injury is thought to be primarily inflicted on endothelial cells (ecs), which, from their position as a lining of the vessel lumen, normally provide a nonthrombogenic, nonadhesive surface despite their direct contact with flowing blood. agents suspected of damaging ecs include elevated blood cholesterol levels and oxidized low-density lipoprotein. the outcome of vessel healing is often manifest as an eccentrically oriented lesion consisting of, in its most mature form, lipid-laden macrophages and smooth muscle cells (or so-called foam cells), and lymphocytes enclosed by a fibrous cap comprised of collagen, elastin, and proteoglycans. 1 consequently, these lesions, or plaques, in their stable form can compromise critical oxygen supply to the energetic myocardium by significantly impeding blood flow and, in their unstable or vulnerable forms, can cause myocardial infarction and death by providing sites for platelet adherence and activation of clotting factors to promote formation of a fully occlusive thrombus. although lifestyle changes and medications, including cholesterol synthesis inhibitors (or statins), effectively reduce the risk factors for developing atherosclerosis, 2 its place as a predominant cause of morbidity and mortality in industrialized nations has not wavered. indeed, its recurrent detection is afforded by sophisticated angiographic evidence through catheterization of vessels suspected of harboring lesions. once detected, a patient's physician has several choices for revascularizing occluded coronary vessels. since the late 1970s, a variety of minimally invasive, catheter-based procedures have evolved to displace occlusive atherosclerotic plaques in coronary vessels. andreas gruentzig and colleagues performed the first such procedure in 1977 by using a catheter to guide a balloon to the site of atherosclerosis. 3 once positioned, the balloon was expanded to crush the plaque against the vessel wall. this procedure, referred to as percutaneous transluminal coronary angioplasty (ptca), or simply angioplasty, was at least acutely successful for providing a less-invasive treatment, compared to traditionally used coronary artery bypass grafting (cabg), to restore adequate blood flow to the myocardium. approximately 6 months following the procedure, however, approximately 35% of patients experienced a renarrowing (restenosis) of the blood vessel at the original atheromatous site. 4 since then, two major modifications to ptca have been made in an effort to reduce the incidence of restenosis, including balloon-mediated deployment of bare metal stents (bms) and drug and polymer addition to such stents to form a device collectively referred to as a drug-eluting stent (des). the former amendment to ptca originated with the recognition that restenosis was at least partially attributable to elastic recoil of the vessel as an immediate reaction to balloon-induced vessel expansion, while the addition of drug came with an appreciation for the significant contributions of vascular smooth muscle cell (vsmc) proliferation 5 and migration 6 to restenosis following bms insertion into coronary arteries. the cell proliferative component is similar to that which promotes benign tumor formation and, therefore, was as a good candidate for being disrupted by antiproliferative agents such as those on first-generation des that emerged from johnson and johnson in 2003 (cypher des; cordis, miami lakes, fl) 7 and boston scientific corporation in 2004 (taxus express2, maple grove, mn), 8 and which included sirolimus and paclitaxel, respectively. vascular responses to stent implantation in coronary arteries occur in sequence to culminate in what is collectively referred to as healing. in the traditional sense, vascular wound healing is orchestrated by platelet-and clotting factor-mediated hemostasis, cytokine-/chemokineand leukocyte-mediated inflammation, and vsmc-and fibroblast-mediated tissue remodeling. 9 although healing naturally connotes a process that is favorable, it can be characterized by an exaggeration of the processes outlined above, leading to unfavorable consequences, such as reocclusion, or restenosis of the vessel and/or thrombosis. restenosis can occur in conjunction with stent use. 10 moreover, thrombosis rates associated with des implantation are higher than those related to bms deployment after 1 year, 11 possibly owing to insufficient ec coverage of the stent itself and of the local vascular area in which a des resides. 12 the fate of the vessel wall localized to the area of stent implantation is determined, for the most part, by a balance between the interactions of cells and the soluble factors that they secrete. these events, in turn, may be dictated by the circumstances of des deployment itself, such as the extent of mechanical injury imposed by stent insertion. 13 additionally, des composition may play a significant role in determining the prognosis of des use as a therapy to alleviate occlusive coronary vascular disease. along with their differential abilities to prevent restenosis and association with thrombosis, des and bms platforms may be distinguished by inflammatory cell infiltrates, based on the extent of eosinophil presence that follows deployment of each. clinically used variations of des currently feature controlled drug release from polymers that coat the metal stent skeleton. twenty-eight days following their deployment, overlapping taxus and cypher des each had more eosinophils associated with them compared to their respective overlapping bms controls in rabbit iliac artery. 14 these des are composed of different drugs and nonerodible polymers, but the same metals (316l stainless steel), suggesting that drugs and/or polymers may ultimately attract eosinophils to stent insertion sites. john and colleagues found that a critical amount of polymer may selectively incite eosinophil recruitment in rabbit iliac artery. cypher was associated with significantly more luminal eosinophils than a polymer-free sirolimuseluting stent, a polymer-free sirolimuseestradiol-eluting stent, or a bms, but only when each stent platform was overlapped upon itself (i.e., one stent on top of another of the same kind) in the vessel. 15 eosinophil recruitment following des implantation in rabbits appears not to be specific to this species, since eosinophil accumulation was observed around cypher stent struts, followed by less infiltration near both taxus and bm stents, in porcine coronary arteries. 16 table 13 .12.1 provides a summary of studies citing the occurrence of eosinophil infiltration in response to a variety of catheter-based revascularization interventions, including purely balloon-mediated, or plain old balloon angioplasty (poba), and bms or des implantation. such reactions to foreign-body stent substances suggest an eosinophil-mediated hypersensitivity, 17 which has been implicated in thrombosis and restenosis following stent insertion into blood vessels, as described below. several instances of thrombosis occurring after bms or des implantation and their correlation with histological evidence of eosinophil infiltration have been recorded. zavolloni and colleagues 18 reported that inflammatory infiltrate observed in thrombectomy material retrieved from right coronary artery previously implanted (10 years) with a bms for myocardial infarction contained a prevalence of eosinophils. data such as these contrast with previous reports that associated stent thrombosis and eosinophil recruitment particularly with des rather than bms. virmani and colleagues provided histological evidence of thrombus formation in left circumflex coronary artery of a 58-year-old male who had received overlapping cypher stents in that vessel 18 months earlier. 19 aneurysm formation and inflammatory prominence consisting of eosinophils, giant cells, lymphocytes, macrophages, and plasma cells within the vessel area localized to stent placements were evident. the authors referred to these phenomena as a 'hypersensitivity vasculitis,' which has since been described by other investigators following des implantation in conjunction with repeated thromboses associated with implantation of cypher stents into the left circumflex 20 and also in autopsy specimens. 21 the latter study is especially informative, given that it compared eosinophil presence among thrombotic events according to classification, and in the context of acute myocardial infarction or not, and time-frame, including early ( 30 days) after bms or des [cypher, taxus, and endeavor (medtronic, inc. minneapolis, mn); drug is zotarolimus] deployment, late (31e365 days) after bms deployment, and very late (>1 year) after des deployment. here, eosinophil accumulation and the fraction of leukocytes accounted for by eosinophils around cypher stents was substantially greater than that measured in association with taxus or endeavor stents. furthermore, eosinophils were most evident in thrombi that occurred very late following des (predominantly of cypher) deployment. interestingly, vessel remodeling was exclusively related to very late stent thrombosis that occurred after des, with its extent varying according to the number of eosinophils found in thrombi. the authors speculated that vessel remodeling likely caused stent malapposition and subsequent thrombosis. taken together, these studies indicate eosinophilic reactions to bms or des deployment and suggest a role for eosinophils in stent thrombosis. at least two questions may be drawn from these conclusions: 1. what factors related to coronary stents and/or their deployment attract eosinophils to stented vessel segments? 2. how might eosinophils contribute to stent-related thrombosis? eosinophilic inflammation occurs following both poba and stent insertion. however, eosinophilic recruitment is more robust following stent placement, 22e24 suggesting that balloon-mediated vessel expansion, which is common to both poba and stent placement, is not completely responsible for enhanced eosinophilic recruitment associated with stent placement. indeed, stent components and prophylactic dual antiplatelet (medicinal) therapies (dapt) that are prescribed for use after stent implantation, including the platelet adenosine diphosphate (adp) receptor antagonist, clopidogrel (plavix; bristol-myers squibb, new york, ny, and sanofieaventis, paris, france) and acetylsalicylic acid (aspirin), an inhibitor of prostaglandin g/h synthase 1 (inhibits thromboxane production), can elicit hypersensitivity reactions. 25 the well-recognized role of eosinophils in allergic reactions 17 and their suggested role in a localized hypersensitivity reaction to stent placement 19 are in agreement with positive correlations between allergic sensitivity to metal stent components, including nickel 20,26 and molybdenum, 26 and eosinophil recruitment to stented vessel segments. 20, 26 however, restenosis incidence may 27 or may not 28 positively correlate with allergic reactions to nickel and molybdenum. in addition, drug-eluting stent-related hypersensitivity reactions appear not to guarantee subsequent thrombosis, as revealed by a study 29 showing that a minority (approximately 1.5%) of total des-specific hypersensitivity reactions (based on 262 hypersensitivity cases reported) were accompanied by thrombosis. these hypersensitive, thrombotic cases, however, were characterized by eosinophilic inflammation and incomplete stent coverage, or so-called delayed healing, 100% of the time. overall, the majority of des-specific hypersensitivity cases were associated with cypher implantation (approximately 80%) and likely attributable to the poly n-butyl-methacrylate and polyethylene-vinyl acetate cypher copolymer allergens, 25 but not to sirolimus, since the latter can reduce eosinophil infiltration. 30 consistent with this, finn and colleagues reported that 5/105 cases of late stent thrombosis were associated with hypersensitivity reactions, with four occurring after cypher and one after taxus implantation. 12 in these episodes, too, eosinophilic inflammation was always present. taken together, these studies suggest that the risk of hypersensitivity to stent components is likely to be small among patients that have or will receive des, with the onset of thrombosis occurring in such hypersensitivity cases also to be small. however, histological evidence shows that the incidence of such rare cases is consistently associated with eosinophil accumulation at stent sites and seems to be especially common with cypher implantation. 12, 29 at least one study found the combination of hypersensitivity and delayed healing (i.e., endothelialization) of stent struts to be a risk factor for developing late-stent thrombosis. 31 identification of patients prone to each of these circumstances is not performed and may, in fact, be unpredictable considering that hypersensitivity reactions to stents appear not to be unequivocally associated with thrombosis 29 and, further, the incidence of eosinophil involvement in such reactions, which correlates with hypersensitivity-related thrombosis, 12,29 is also unclear. thus, without objective, basic study-and clinical trial-based reasoning for differential postprocedural prescription to des recipients, it is essential that all patients that receive des comply with using dapt medicines for their full recommended terms. currently, the exact duration of dapt therapy following stent deployment is questionable, but would appear to be optimized by an awareness of when stent struts are completely healed (or endothelialized) such that the risk of platelet adhesion and activation is dramatically diminished. unfortunately, the time required for adequate, antithrombotic endothelialization of stent struts and the local vascular wall likely varies among patients, because endothelialization rates among des patients afflicted with complicating clinical backgrounds, such as diabetes, 32 may vary, especially compared to des patients without complicating ancillary medical conditions. the concern, then, pertaining to eosinophil involvement in thrombus formation associated with stent deployment is that dapt may be suspended before stent struts, whether covered by polymer or not, are masked enough by healing processes so as not to be a potentially chronic stimulus for eosinophil recruitment and activation. indeed, the nonspecific nature of antiproliferative drugs currently included on clinically used des inhibit not only vsmc proliferation and migration, two major contributors to restenosis, 5,6 but also attenuate the same properties of ecs. 33, 34 therefore, the risk of eosinophil-related thrombosis following des deployment may be assessed by (1) whether the stent is bms or des and (2) evidence of allergies to stent components that may predispose the patient to a hypersensitivity reaction that involves eosinophils. fortunately, research efforts have provided suggestive evidence concerning the mechanism of eosinophil recruitment to stented vessel segments and the mechanism through which eosinophils contribute to thrombus formation. these pieces of information may be used to direct future therapies intended to mitigate the purported role of eosinophils in promoting thrombosis following stent deployment. descriptions of two hypersensitivity reactions (i and iv) have been suggested to provide hypothetical explanations for eosinophilic involvement in inflammatory responses to stent insertion. as suggested by virmani and coworkers, eosinophil recruitment to segments stented with cypher and their association with thrombosis 19 in this context may be due to a type iv hypersensitivity reaction, in which t-helper lymphocyte liberation of t-helper type 2 (t h 2) cytokines and interleukins 4 and 13 attract eosinophils. 35 another hypothesis 25 includes a two-phase cascade of cell-and soluble factor-mediated reactions being initially orchestrated by ige-activated mast cells and the mediators that these cells elaborate (approximately 1e24 h post-stent deployment) to promote secondary infiltration of basophils, eosinophils, macrophages, neutrophils, and t lymphocytes (approximately 12e24 h post-stent deployment) that can remain chronically situated around stent struts. thus, occurrence of the first phase of hypersensitivity would coincide with onset of acute stent thrombosis, while the latter time frame would fit the onset of both late and very late stent thromboses. evidence of a role for eosinophils in thrombogenesis includes observations made in hypereosinophilic patients. 36 furthermore, endothelial cells are likely targets for the highly basic-charged major basic and eosinophil cationic proteins (mbp and ecp) of eosinophils, considering that ecs express a negatively charged glycocalyx on their luminal surface. once bound to ecs, these proteins may inflict damage or even kill these cells, as suggested by their cytotoxic capabilities. 17 alternatively, direct activation of platelets by mbp and/or eosinophil peroxidase (epo), 37 or disruption of thrombomodulin function by mbp, 38 may explain the contribution made by eosinophils to stent thrombosis. eosinophil presence in the context of stent-related thrombosis cases that may be secondarily related to tissue remodeling and consequent stent malapposition 21 raises the possibility that eosinophils directly or indirectly possess tissue-remodeling properties. both may be true, since eosinophils express matrix metalloproteinase-9 (mmp-9), 39 which is a collagenase capable of degrading type iv collagen, a major component of subendothelial layer basement membranes. furthermore, eosinophils secrete interleukin-8, 17 a chemokine that has been shown to induce release of mmp-2 (a collagenase) and mmp-9 from ecs. 40 eosinophils also express vascular endothelial growth factor (vegf) 41 and heparanase. 42 these factors are likely to partially mediate the ability of eosinophils to promote angiogenesis, 43 by inducing ec growth (vegf) and degradation of perlecan (heparanase), a heparan sulfate proteoglycan component of basement membranes. the relevance of this is that angiogenesis can occur in the context of the granulation stage of vascular healing following stent insertion. the cumulative occurrence of any thrombi that may form as a result of angiogenic events may culminate as a thrombus of significant size, with the ability to dramatically or completely block blood flow in the main stented vessel. table 13 .12.2 summarizes investigations that have linked stent-related thrombosis with eosinophilic inflammation. kawano and coworkers reported that a patient who received a bms to relieve total occlusion of the left coronary artery experienced repeated episodes of restenosis after stent implantation. 26 examination of the restenotic lesion revealed granulation tissue with eosinophil infiltration. the patient displayed positive reactions to allergic patch tests for nickel and molybdenum, both of which are components of the 316l stainless steel bms that the patient received. thus, through their direct association with granulation tissue formation, eosinophils may contribute to both thrombotic and restenotic mechanisms that pertain to stent deployment. details concerning the former are outlined above, while the latter may be due to activation of platelets by eosinophilic proteins 37 and subsequent platelet degranulation to release promitogenic factors, such as plateletderived growth factor and fibroblast growth factor, capable of stimulating vsmc migration and proliferation. restenosis of revascularization attempts by bms or des implantation are associated with eosinophil infiltration. this was documented nearly 20 years ago, when the transition from poba to poba with bms deployment was being tested for clinical use. karas and colleagues compared histological patterns of restenosis between poba and insertion of a bm tantalum stent into swine coronary arteries. 22 inflammation accompanied by greater vsmc proliferation was observed in association with in-stent restenosis. the inflammatory infiltrate consisted of eosinophils, macrophage-like histiocytes, and t lymphocytes surrounding stent struts. consistent with this, a more recent report found vsmc proliferation to be primarily responsible for restenosis following stenting, but not following poba, in swine. 23 macrophages were selectively found in stented lesions and were accompanied by neutrophils and eosinophils. in another investigation, t lymphocytes were found in restenotic lesions of both poba and bms; however, significantly more vsmcs and eosinophils were associated with in-stent restenosis. 24 these studies suggest a positive correlation between inflammation characterized by eosinophil presence and vsmc proliferation and, similar to observations made relating eosinophils to stent thrombosis, a hypersensitivity reaction to a stent component that ultimately attracts eosinophils to the stented vessel segment. such a relationship between the vsmc proliferative component of restenosis and eosinophil infiltration is significant, given the importance of vsmc growth in restenosis 5 and the fact that des are loaded specifically with antiproliferative compounds primarily intended to block vsmc mitogenesis. interestingly, other studies have shown the selective association of eosinophils, among other circulating cells including inflammatory and bone marrowderived progenitor cells, with in-stent restenosis. gabbasov and colleagues found that the number of osteonectinpositive progenitor cells, but not granulocytes, in blood were higher in patients afflicted with ischemic heart disease (ihd; n â¼ 38) than in healthy individuals (n â¼ 17). 44 in contrast, only elevations in eosinophils were detected in ihd patients that subsequently received cypher des and experienced restenosis (n â¼ 15). blood eosinophil levels were not increased in patients that did not undergo restenosis (n â¼ 23). together, histological and blood analyses have established a link between eosinophil presence and restenosis that is particularly associated with stent deployment, compared to poba. these study observations suggest that eosinophils are equipped to contribute to the mechanism of restenosis. however, the question remains: are eosinophilic contents biomarkers of restenosis and thrombosis or do they actively contribute to these processes? niccoli and colleagues 45 showed that serum ecp levels prior to cypher or taxus implantation predicted whether patients would experience a major adverse cardiac event (mace), including cardiac death, recurrent myocardial infarction, or target lesion revascularization (tlr), which was defined as being necessary if >50% stenosis occurred within 5 mm upstream or downstream of the stent. the majority (60%) of mace onset occurred 180 days after stent insertion, while 27% of such cases happened more than 1 year following deployment. clopidogrel was prescribed for 9 months and aspirin for a lifetime after stent insertion. some patients had allergies, none of which were confirmed to stent components, such as metals or polymers. furthermore, ecp levels were nearly equivalent between allergic and nonallergic patients that did not experience mace. what factor(s) could preelevate ecp levels in individuals who had not yet been exposed to potential allergens contained in des? elevated ecp levels may be explained by prior observations indicating that eosinophil count positively correlated with ihd development 46 and that eotaxin/c-c motif chemokine 11 (ccl11) levels may play a role in atherosclerosis. 47 taken together, these studies suggest that ecp may play a causative role in mace, particularly tlr, which represented the majority of mace cases in this study, since it was elevated before stent implantation. related to this issue, experimental evidence implicates eosinophilic contents as having the potential to promote prorestenotic events during the healing process post-stent deployment. for example, as discussed earlier, activation of platelets by both mbp and epo 37 may liberate growth factors from platelets that are capable of inducing migration and proliferation of vsmcs. by secreting eotaxin and transforming growth factor b (tbf-b), 17 eosinophils may directly stimulate vsmc migration 48 and extracellular matrix production by fibroblasts and vsmcs, 49 respectively. each of these manifestations of eosinophilic secretory products would contribute to restenotic lesion development. masu and colleagues described that a heat-labile, unidentified constituent of <10 kda in eosinophilic lysates can promote proliferation of airway smooth muscle cells (smcs), 50 suggesting the ability of eosinophils to also stimulate vascular smc growth. table 13. 12.3 provides a summary of studies that have reported an association between eosinophilic inflammation and restenosis. further studies involving genetic deficiency or mrna silencing may delineate which specific eosinophil component is responsible for this and other prorestenotic activities. in summary, healing in coronary vessels can be a deleterious phenomenon in two instances, including forming atherosclerotic lesions following ec injury and forming thrombi and restenotic lesions following stent implantation. ironically, treatments to alleviate atherosclerotic burden have evolved to include use of a minimally invasive therapeutic mode, namely deployment of bms and des, that potentially incites yet further, exaggerated, healing responses that can manifest as clinical concerns. this subchapter explains that healing events associated with stent deployment may be two-fold, including standard hemostatic, inflammatory, and tissue-remodeling phenomena that are likely common to all occurrences of stent implantation and, in a minority of individuals, superimposition of such standard healing responses by hypersensitivity reactions to the stent itself. to date, data suggest that both bm and polymer components of des are candidates to stimulate involvement of factors and cells that mediate such hypersensitivity reactions, including eosinophils. basic science studies have revealed the possibility that eosinophils contribute to thrombosis and restenosis associated with stent implantation, by virtue of the potentially prothrombotic effects of their granule proteins, such as ecp, epo, and mbp, on platelets and thrombomodulin, and on smc growth. as the incidence of hypersensitivity reactions as sequelae to stent implantation becomes more evident, routine prophylactic measures may be warranted, in addition to postprocedural dapt prescription, in candidate stent recipients, to include prescreening individuals for allergies to stent components. of course, the integrity of such tests is encumbered by the caveat that positive allergic patch tests may not predict the occurrence of stent-related thrombotic or restenotic events. 28 alternatively, the use of next-generation bioabsorbable stents, which have relatively limited residency times in vessels compared to nonbioabsorbable stents such as cypher and taxus, would theoretically eliminate the stimulus for eosinophilic responses relatively quickly and serve as a reasonable and useful way to reduce complications due to hypersensitivity in vulnerable patients. clearly, observations made of eosinophils in the vicinity of stent struts in association with thrombosis and restenosis are highly suggestive of a role for these cells in such adverse events. further work, perhaps involving eosinophil-deficient animals or cultured eosinophils deficient in granule proteins, is needed to more precisely define the role of eosinophils and the extent of medical attention deemed necessary to mitigate their presumed involvement in stentassociated thrombosis and in restenosis. 44 eosinophils are a minor leukocyte subset in healthy subjects, representing less than 5% of circulating white blood cells, and present in discrete locations, specifically the bone marrow, digestive tract, mammary glands, thymus, and uterus. 1,2 eosinophils belong to the myeloid lineage, and their differentiation and proliferation in the marrow is controlled successively by specific transcription factors [including gata binding protein 1 (gata1) and transcription factor pu.1] and growth factors [granulocytemacrophage colony-stimulating factor (gm-csf), interleukin-3 (il-3), and il-5]. among the latter, only il-5 is specific for the eosinophil lineage in humans, as eosinophil precursors express the ligand-binding il-5ra on their surface. increased production of il-5 in vivo by cd4 ã¾ t cells 3 or transformed cells (e.g., carcinomas 4 or reed sternberg cells 5 ) results in increased eosinophilopoiesis and peripheral eosinophilia in blood and/or tissues. various factors contribute to preferential eosinophil transendothelial migration and homing in tissues, 1 including adhesion molecules (vascular cell adhesion protein 1; vcam-1), cytokines (il-5), chemokines [specifically, eotaxins 1, 2 and 3, as well as rantes (c-c motif chemokine 5) and monocyte chemoattractant protein (mcp)], and arachidonic acid metabolites [leukotriene b 4 (ltb 4 ), cysteinyl-leukotrienes, and prostaglandin d2 (pgd2)], in addition to the more general signals generated under conditions of cell stress and death. eosinophils were long considered as exclusively effector cells, able to induce significant tissue damage and dysfunction by releasing preformed, highly cytotoxic mediators, including the granule proteins, major basic protein and eosinophil cationic protein, producing reactive oxygen species, and generating arachidonic acid metabolites such as platelet activating factor (paf) and ltc4 (reviewed in 1). these effector functions were considered potentially beneficial in the setting of parasitic infections, and harmful in the setting of allergic responses to environmental antigens. recent studies have shattered this paradigm. it is now well established that eosinophils are active participants in ongoing immune responses through the production of cytokines and chemokines, and through previously unrecognized functions of their granule proteins [e.g., the ability of eosinophil-derived neurotoxin, a natural toll-like receptor 2 (tlr2) ligand, to induce dendritic cell maturation and to promote antigen-specific t-helper type 2 (t h 2)-biased immune responses 6 ] , and that they possess many characteristics of antigen-presenting cells, enabling them to elicit antigen-specific cd4 ã¾ t cell responses. indeed, eosinophils express major histocompatibility molecule (mhc) class ii and co-stimulatory molecules (cd40, cd80, and cd86), and were shown to be able to process antigen (ovalbumin; ova) and present it to naive cd4 ã¾ t cells in lymph nodes, in a murine model of allergic pulmonary inflammation. 7 further upstream in allergic pulmonary inflammation, eosinophils have been shown to be required for the recruitment of antigen-specific effector cd4 ã¾ t cells to the lungs and the development of typical histopathological changes after allergen challenge in mice. 8 their ability to induce production of the t h 2 chemokines thymus and activation-regulated chemokine (tarc) and macrophage-derived chemokine (mdc) in the lung is critical in this process. in parallel with these proimmune functions, eosinophils also have the potential to modulate local inflammatory responses, for example dampening t h 1-dominated inflammation through release of il-4 and il-6. 9 production of galectin-10 (also known as charcoteleyden crystal protein), il-10, indoleamine 2,3-dioxygenase, and transforming growth factor b (tgf-b) may confer eosinophils with a regulatory role on effector t-cell responses. 10e12 eosinophils also contribute to processes of remodeling and repair. although eosinophils produce several potentially relevant factors, including fibroblast growth factor 2 (fgf-2), matrix metalloproteinase-9 (mmp-9), and vascular endothelial growth factor (vegf), mechanistic studies establishing a causal role in remodeling are lacking; in contrast, several studies strongly suggest that eosinophilderived tgf-b contributes to airway remodeling in allergic asthma. 13, 14 a series of observations on eosinophil behavior in health and disease unaccounted for by our current understanding of eosinophil biology, together with the paucity of experimental data supporting a causal relationship between eosinophil cytotoxicity and tissue damage and/or disease, have generated the local immunity and/or remodeling/ repair (liar) hypothesis, which has recently been presented for scientific scrutiny. 15 the authors propose a central role for eosinophils in modulating liar, with recruitment of these cells to sites of cell death and turnover where stem cell activities are operative, in order to maintain tissue homeostasis. the accumulation and functions of eosinophils are dependent on various factors in the local microenvironment, including the presence of other specific immune effector cells, and of soluble growth factors liable to sustain eosinophil survival and activation. at physiological sites of high cell turnover, such as the endometrial lining and the gut, it is assumed that eosinophils dampen immune responses that could be triggered by such active metabolic activity. similarly, eosinophils may inhibit the immune response elicited by tissue-infiltrating helminth parasites, favoring cohabitation between host and pathogen. in contrast, the local production of eosinophil growth-promoting and activating cytokines by other immune cells in allergic inflammation may favor positive feedback loops that sustain and amplify the immune response. 7, 16, 17 finally, in addition to the increasing complexity of eosinophil contributions to adaptive immunity, a role for eosinophils in innate immunity was recently suggested by a study showing that eosinophils express variable levels of cd3 and g/d t-cell receptors, which are involved in antimycobacterial and antitumor immune responses. 18 the inflammation that develops in solid organ transplants in the setting of an alloimmune response (i.e., transplant rejection) may contain, and in some instances be dominated by, eosinophilic infiltrates. 19 whether eosinophils are directly involved in the damage to foreign tissue and thus actively contribute to rejection through release of their cytotoxic mediators, or are engaged in liar activities, is currently unknown. the local release of small molecule mediators, such as damage-associated molecular pattern molecules, by dying cells within the transplant may contribute to very early eosinophil recruitment. 15 eosinophils could theoretically contribute to initiation of the allogeneic response by cross-presentation of foreign mhc antigens; they may also favor local recruitment of allospecific effector t cells, as is seen in allergic inflammation. in mouse models of acute graft rejection in the setting of deficient cd8 ã¾ t-cell effector functions, namely mhc class ii-incompatible skin grafts 20 and fully histoincompatible cardiac transplants in cd8-deficient recipients, 21 marked eosinophilic infiltrates emerge that are dependent on il-5 produced by antidonor cd4 t cells. however, il-5 neutralization or silencing, and associated eosinophil depletion, fails to prevent rejection in these stringent alloreactive models, indicating at most a partial contribution of eosinophils to rejection. 19 this is not surprising, since allograft rejections are mediated by multiple redundant pathways. 22 nevertheless, turning off t-cell cytotoxicity revealed a role for il-5 and eosinophils in a model of acute and chronic rejection of mhc class ii-incompatible skin grafts. 19, 20, 23 in the chronic rejection model, the t h 1 component of alloreactivity and t-cell cytotoxicity were dampened by repeated injections of anti-cd3 antibody. similarly, treatment with anti-cd154 and a depleting cd8 monoclonal antibody ab resulted in eosinophilic infiltration in a model of transplant arteriosclerosis. 24, 25 in other experiments, the adoptive transfer of alloreactive noncytotoxic t h 2 clones into t cell-deficient mice induced the rejection of skin or cardiac allografts characterized by a dense eosinophil infiltrate. 26, 27 finally, il-4 or il-5 neutralization, as well as eosinophil depletion through repeated injections of anti-ccr3 (c-c chemokine receptor type 3) antibody, prevented the rejection of weakly immunogenic skin grafts bearing a single minor antigen disparity in mhc class i-deficient recipients. 28 the role of eosinophils in renal transplantation has aroused little attention. although publications described the presence of eosinophils during renal allograft rejection in the early 1980s, 29 the first systematic reviews on the subject only appeared in the mid-1980s. 30, 31 this may be due to technical reasons. indeed, conventional staining techniques, like hematoxylineeosin (h&e), underestimate the presence of tissue eosinophils and do not usually detect their degranulation. 32 motivated by a case report of marked hypereosinophilia and eosinophilic infiltration in a rejected renal allograft, in 1986 weir and coworkers decided to investigate retrospectively a cohort of 132 renal transplant recipients (124 biopsies) with 187 episodes of acute rejection. 30 they concluded that increased eosinophils in the blood or renal biopsy represented an adverse prognostic factor for renal outcome. this was followed by a prospective study by kormendi and coworkers analyzing cellular infiltrates using fine-needle aspiration in a cohort of 83 renal allograft recipients during the first month posttransplantation. 31 tissue eosinophilia exceeding 4% was considered a useful cutoff with a predictive accuracy for serious or irreversible rejections of 71% (sensitivity: 78%; specificity: 91%, with a prevalence of acute rejections of 32.5%). in contrast, blood eosinophil counts were found to be less reliable. in another study, ten and coworkers showed eosinophils in the kidney interstitium and in tubular casts. 33 of note, eosinophil degranulation was evaluated by the extracellular localization of the eosinophil granule major basic protein (mbp) as revealed by immunofluorescence. in this small cohort of 16 patients, eosinophils and extracellular mbp were more frequently observed in acute rejection (94% and 87%, respectively) than in cyclosporine toxicity (6 patients; 17% and 17%), whereas both features were absent in controls (normal kidney donors). similarly, urinary levels of mbp were also elevated in acute rejections and acute interstitial nephritis while they remained normal in cyclosporine nephrotoxicity. in another study, eosinophils and extracellular eosinophil cationic protein (ecp) were prominent features of acute vascular rejection rather than interstitial rejection, and eosinophil density increased in areas bordering necrotic tissue and in arteries with necrotic lesions. 34 a correlation between eosinophil infiltrates and rejection severity was also observed by meleg and coworkers, who reviewed 29 allograft nephrectomies. 35 they concluded that a significant interstitial graft eosinophil infiltrate called sige was statistically associated with vascular rejections but not iatrogenic interstitial nephritis. this was already reported by hongwei and coworkers, who also found a correlation between the density of the eosinophil infiltrate and the rate of graft loss by rejection. 36 all together, these observations reinforce the possibility of a nonincidental, causative association between eosinophils and acute allograft rejection (table 13 .13.1). eosinophils are also linked to chronic allograft rejection characterized by interstitial fibrosis, obliterative arteriopathy, and tubular atrophy. indeed, nolan and coworkers reported the presence of eosinophils in 93% of renal allografts undergoing chronic rejection. 32 they were located in the intimal and adventitial space of the thickened arteries, as well as in the interstitium. interestingly, in vitro experiments revealed that eosinophil by-products (see above) enhanced fibroblast and vascular smooth muscle cell proliferation in murine and human experiments, perhaps reflecting a pathogenic mechanism involved in obliterative arteriopathy. although these data strongly suggest a pathogenic role for eosinophils and by-products in kidney allografts, their presence may be related to other functions, as evoked in the liar hypothesis. although eosinophils are described in chronic and acute lung allograft rejection, their role in these processes remains unclear. 37e39 acute lung rejection classically occurs during the first year after transplantation and its diagnosis is essentially based on transbronchial biopsies (tbb). the current international guidelines, published in 2010 by the international heart and lung transplantation society (ishlt), 40 establish acute lung rejection as the presence of, firstly, perivascular and interstitial mononuclear cell infiltrates (grade a) and, second, small-airway inflammation, namely lymphocytic bronchiolitis (grade b). grading is scaled depending on the composition, extension, and intensity of the infiltrate. eosinophils are not a feature of grade a1 (minimal rejection), but are found in grade a2 (mild vascular rejection) and, importantly, are considered to be a common finding in severe vascular rejection (grade a3). regarding airway inflammation, eosinophils are considered to be occasional in low-grade (b1r) and common in high-grade (b2r) inflammation. chronic lung allograft rejection, synonymous with bronchiolitis obliterans syndrome (bos), occurs in up to 50% of recipients. bos is characterized by a persistent decrease in expiratory flow and is potentially life threatening, requiring retransplantation. although eosinophils are not taken into consideration in the ishlt working formulation for this condition, a recent prospective cohort study reported that recurrent tissue eosinophilia (with higher concentrations of il-6 and il-8) is significantly associated with an increased risk of developing bos. 37 increased eosinophilia in lung transplant recipients should be interpreted with caution for two reasons. 39 firstly, there are numerous nonrejection-related causes of graft eosinophilia. among these, infectious diseases are dominant, including fungi (e.g., aspergillus and coccidioidomycosis), bacteria (e.g., tuberculosis), helminths (e.g., toxocara canis and ascaris lumbricoides), and even viruses (e.g., cocksackies). high-dose steroid treatment could be detrimental under these conditions. drug reactions are also a common cause of pulmonary eosinophilia (e.g., antibiotics, diuretics, or methotrexate). the second reason is that blood eosinophilia does not always reflect bronchoalveolar lavage fluid or lung tissue eosinophilia. lung biopsies are therefore crucial for assessing the role of eosinophils after lung transplantation. there are many similarities regarding eosinophilia in liver transplantation compared with other transplanted organs already discussed. il-5 and eosinophils were rapidly identified during liver allograft rejection. 41e45 there was a consensus for considering eosinophils and il-5 as mediators of a nonclassical pathway of rejection (i.e., non-t h 1-mediated rejection). 46;47 indeed, liver allografts with evidence of rejection showed concomitant intragraft il-5 mrna and activated eosinophils releasing mbp. 46 in pediatric recipients, elevated biliary and serum il-5 correlate with rejection. 47 along the same lines, another study reported that blood eosinophilia and serum ecp are early indicators of acute liver allograft rejection and precede alterations of conventional liver function tests by several days. 48 however, the use of increased serum ecp as a rejection marker is limited by its association with infections. 48 these pioneering findings were confirmed and refined by more recent studies that identified graft and blood eosinophilia as an independent highly specific marker of acute liver allograft rejection. 41, 42, 45, 49, 50 in addition, an elevated blood eosinophil count may predict the severity of rejection, just as in the case of lung and kidney transplantation. 49 however, the use of this potential marker of rejection is limited in patients with hepatitis c infection, and those treated with corticosteroids, as both these circumstances decrease eosinophil levels. 49 inflammation plays a pivotal role in the complex pathogenesis of acute and chronic graft-versus-host disease (gvhd). conventionally, acute gvhd (agvhd) is described as a t h 1 disease associated with the release of interferon g (ifn-g) , il-2, il-12, and tnf-a. 51e53 the gastrointestinal tract, liver, and skin are the most common targets of gvhd, and diarrhea, jaundice, and skin rash are its most common manifestations. chronic gvhd has features resembling autoimmune and other immunological disorders, such as bronchiolitis obliterans (see above), chronic immunodeficiency, sjã¶gren syndrome, and systemic sclerosis. although the pathophysiology has not been fully elucidated, chronic gvhd appears to be mediated by the overproduction of t h 2-type cytokines, namely il-4 and il-5. 53, 54 the role of eosinophils in acute and chronic gvhd is a matter for speculation. thirty years ago, shulman and coworkers showed for the first time that eosinophilia after allogeneic hematopoietic stem cell transplantation (hsct) was often present at the time of diagnosis of chronic gvhd. 55 afterwards, it was shown that eosinophilia could precede, sometimes by several months, the onset of chronic gvhd symptoms, and seemed to have a strong predictive value for the subsequent development of this condition. 56, 57 should this be confirmed by additional prospective trials, this observation may have significant clinical impact. more recently, eosinophilia was also observed among patients who developed agvhd and, similar to chronic gvhd, was seen before the beginning of symptoms in some cases. 58, 59 the pathophysiology behind eosinophilia in the setting of gvhd remains unclear. t h 2 cytokine production may be involved, as suggested by the finding that serum il-5 concentrations are elevated in patients with symptoms of agvhd. 60, 61 however, no correlation with blood eosinophilia has been observed. 62 studies focusing on the prognostic importance of eosinophilia have produced conflicting data. in chronic gvhd, some retrospective data suggest a better outcome for hsct recipients with eosinophilia, while others found no correlation, suggesting that eosinophilia may just be a bystander of cgvhd rather than a prognostic biomarker. 57, 61, 63 among young patients with malignant diseases treated by hsct, those with eosinophilia showed increased event-free survival and a lower relapse rate than those without eosinophilia, suggesting that eosinophils could be involved in the graft versus leukemia effect. 61 in agvhd, observational studies showed that patients with eosinophilia after allogeneic hsct have a milder disease than patients without eosinophilia. 58 one could hypothesize that improved prognosis of agvhd when eosinophils are present is related to the fact based on the histological examination of muscle biopsy sections. infiltration of skeletal muscle tissue by eosinophils is an unusual event, observed especially during parasite infections (including taenia solium, trichinella spiralis, and sarcocystosis) 1 or more rarely bacterial infections (borreliosis). several immune disorders, such as sarcoidosis or rheumatoid arthritis, may also be accompanied by eosinophilic infiltration of the skeletal muscle tissue. these forms must be identified as they may benefit from specific therapeutic management. additionally, some toxic causes have been implicated in the formation of eosinophilic infiltrates in muscle tissue. those include, in particular, the ingestion of certain plant oils (which caused spanish toxic oil syndrome in 1981) 2 and the eosinophiliamyalgia syndrome, caused by the ingestion of l-tryptophan and presenting with a histological aspect resembling eosinophilic fasciitis, but associated with multisystemic manifestations. 3e4 the exclusion of the aforementioned different etiologies determines the diagnosis of idiopathic eosinophilic myositis. depending on the localization of the eosinophilic infiltrate, idiopathic eosinophilic myositis can be classified into three subgroups (reviewed in 5e6 ): focal eosinophilic myositis, eosinophilic polymyositis, and eosinophilic perimyositis. focal eosinophilic myositis includes eosinophilic infiltration of muscle tissue with invasion of muscle fibers, and is associated with necrotic fibers. 5 clinically, myopathy preferentially affects the lower limbs, without involvement of skin or fascia. eosinophilia is usually observed, and is associated with elevated serum creatine phosphokinase (cpk) levels. spontaneous or corticosteroid-induced recovery may be observed, but with frequent relapses. at the histological level, eosinophilic polymyositis combines diffuse eosinophilic infiltration of the muscle tissue and at perivenular locations, associated with necrotic fibers. 5, 7 unlike focal eosinophilic myositis, infiltration is instead located at the perimysium, without muscle fiber invasion. clinical presentation associates myositis with severe systemic symptoms, including possible cardiac and skin involvement. myopathy is preferentially proximal and high serum cpk levels are observed, reflecting extensive muscle damage. corticosteroid treatment can allow recovery, but with possible relapses if not continued long term. in eosinophilic perimyositis, infiltrates predominate at the superficial fascia and perimysium. 5, 8 there is usually no damage to muscle fibers and, in particular, no necrosis. clinically, a prodromal phase (abdominal pain, arthralgia, and fever) precedes muscle damage, which involves preferential impairment of lower limbs with localized induration. eosinophilia is rare, and serum cpk levels are usually normal. the evolution can be spontaneously favorable. shulman's syndrome, 9 or eosinophilic fasciitis, is a distinct entity characterized by eosinophilic infiltration of the deep fascia, without systemic manifestations, and about half the cases are responsive to corticosteroid treatment. 10 the identification of capn3 mutations as the first genetic cause involved in eosinophilic myositis indicates that mutations in other genes may also be causal, or act as modifiers, of this pathophysiology. in this regard, a case of dystrophinopathy in which a muscle biopsy shows the appearance of eosinophilic myositis has been described, 26 and baumeister and coworkers recently reported a case of idiopathic eosinophilic myositis caused by a homozygous mutation in the g-sarcoglycan gene, 27 which is implicated in another form of lgmd. interestingly, these reports suggest that early, but transient, eosinophilic infiltration may be a feature of a wider range of muscular dystrophies. the role of eosinophils in the natural history of diverse muscular dystrophies should therefore be further investigated, and it is possible that eosinophils may represent a novel therapeutic target. eosinophilic disorders organ-specific eosinophilic disorders of the skin, lung, and 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eosinophil, mast cell, and basophil siglec-8 expression the expression of the receptor for advanced glycation endproducts (rage) is permissive for early pancreatic neoplasia cellmediated autophagy promotes cancer cell survival tumor-cell death, autophagy, and immunity p53/hmgb1 complexes regulate autophagy and apoptosis inhibiting autophagy during interleukin 2 immunotherapy promotes long term tumor regression metabolic regulation by hmgb1-mediated autophagy and mitophagy high-mobility group box 1 is essential for mitochondrial quality control hmgb1 as an autophagy sensor in oxidative stress high mobility group box 1 (hmgb1) activates an autophagic response to oxidative stress principles and current strategies for targeting autophagy for cancer treatment rage regulates autophagy and apoptosis following oxidative injury the beclin 1 network regulates autophagy and apoptosis apoptosis promotes early tumorigenesis the receptor for advanced glycation end-products (rage) protects pancreatic tumor cells against oxidative injury high-mobility group box 1, oxidative stress, and disease human tumor-induced and naturally occurring treg cells differentially affect nk cells activated by either il-2 or target cells human mesenchymal stem cells respond to native but not oxidized damage associated molecular pattern molecules from necrotic (tumor) material hmgb1 is overexpressed in tumor cells and promotes activity of regulatory t cells in patients with head and neck cancer hmgb1 conveys immunosuppressive characteristics on regulatory and conventional t cells chapter the eosinophil in health and disease nasal polyposis; value of blood eosinophils in surgical indications and in sinusal surgical therapy polyposis of nasal sinuses; pathogenetic study with therapeutic conclusions differentiation of chronic sinus diseases by measurement of inflammatory mediators pattern of inflammation and impact of staphylococcus aureus enterotoxins in nasal polyps from southern china histological 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study nasal polyps: their relationship to allergy, particularly to bronchial asthma nasal polyposis in churg-strauss syndrome correlation between the cytology of the nasal middle meatus and bal in chronic rhinosinusitis histopathologic characteristics of chronic sinusitis with bronchial asthma blood and sputum eosinophil levels in asthma and their relationship to sinus computed tomographic findings determinants of exhaled nitric oxide in chronic rhinosinusitis perspectives on the etiology of chronic rhinosinusitis: an immune barrier hypothesis alterations in epithelial barrier function and host defense responses in chronic rhinosinusitis the role of ubiquitous airborne fungi in chronic rhinosinusitis chronic rhinosinusitis: an enhanced immune response to ubiquitous airborne fungi relationships between severity of chronic rhinosinusitis and nasal polyposis, asthma, and atopy staphylococcus aureus superantigens and airway disease superantigens and nasal polyps a superantigen hypothesis for the pathogenesis of chronic hyperplastic sinusitis with massive nasal polyposis superantigen hypothesis for the early development of chronic hyperplastic sinusitis with massive nasal polyposis superantigens: mechanism of t-cell stimulation and role in immune responses staphylococcus aureus colonization and ige antibody formation to enterotoxins is increased in nasal polyposis molecular characterization of the polymicrobial flora in chronic rhinosinusitis aspirin sensitivity and ige antibodies to staphylococcus aureus enterotoxins in nasal polyposis: studies on the relationship increased ige-antibodies to staphylococcus aureus enterotoxins in patients with copd superantigens and chronic rhinosinusitis: detection of staphylococcal exotoxins in nasal polyps specific immunoglobulin e for staphylococcal enterotoxins in nasal polyps from patients with aspirin-intolerant asthma presence of il-5 protein and ige antibodies to staphylococcal enterotoxins in nasal polyps is associated with comorbid asthma chronic rhinosinusitis: risk factors for the recurrence of chronic rhinosinusitis based on 5-year follow-up after endoscopic sinus surgery cloning and functional expression of cc ckr5, a human monocyte cc chemokine receptor selective for mip-1a, mip-1b, and rantes cloning, expression, and characterization of the human eosinophil eotaxin receptor detection of the chemokine rantes and endothelial adhesion molecules in nasal polyps characterization of the eosinophil chemokine rantes in nasal polyps detection of the chemokine rantes and endothelial adhesion molecules in nasal polyps the role of rantes in nasal polyposis increased eotaxin-mrna expression in non-atopic and atopic nasal polyps: comparison to rantes and mcp-3 expression glucocorticosteroids inhibit mrna expression for eotaxin, eotaxin-2, and mcp-4 in airway inflammation with eosinophilia localization and quantitation of eotaxin mrna in human nasal polyps eotaxin-1, -2, and -3 immunoreactivity and protein 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intravascular ultrasound findings with histopathological analysis of thrombus aspirates in patients with very late drug-eluting stent thrombosis coronary intimal proliferation after balloon injury and stenting in swine: and animal model of restenosis mechanisms of restenosis after coronary intervention. difference between plain old balloon angioplasty and stenting eosinophilic infiltration in restenotic tissue following coronary stent implantation drugeluting stent thrombosis. the kounis hypersensitivity-associated acute coronary syndrome revisited granulation tissue with eosinophil infiltration in the restenotic lesion after coronary stent implantationda case report nickel and molybdenum contact allergies in patients with coronary in-stent restenosis evaluation of metal allergies in patients with coronary stents hypersensitivity cases associated with drug-eluting coronary stents. a review of available cases from the research on adverse drug events and reports (radar) project rapamycin inhibits airway leukocyte infiltration and hyperreactivity in guinea pigs pathology of drug-eluting stents in humans. delayed healing and late thrombotic risk the effects of high glucose on human endothelial cell growth and gene expression are not mediated by transforming growth factor-beta drug-eluting stents: sirolimus and paclitaxel differentially affect cultured cells and injured arteries comparative characterization of cellular and molecular antirestenotic profiles of paclitaxel and sirolimus requirement for il-13 independently of il-4 in experimental asthma cardiovascular manifestations of hypereosinophilic syndromes activation of platelets by eosinophil granule proteins major basic protein binding to thrombomodulin potentially contributes to the thrombosis in patients with eosinophilia eosinophils as a source of matrix metalloproteinase-9 in asthmatic airway inflammation il-8 directly enhanced endothelial cell survival, proliferation, and matrix metalloproteinases production and regulated angiogenesis expression of vascular endothelial growth factor by human eosinophils: upregulation by granulocyte macrophage colony-stimulating factor and interleukin-5 eosinophil major basic protein: first identified natural heparanase-inhibiting protein human peripheral blood eosinophils induce angiogenesis biology of the eosinophil the eosinophil human th1 and th2 subsets: doubt no more non-small-cell lung cancer associated with excessive eosinophilia and secretion of interleukin-5 as a paraneoplastic syndrome detection of interleukin-5 messenger rna in reed-sternberg cells of hodgkin's disease with eosinophilia eosinophil-derived neurotoxin acts as an alarmin to activate the tlr2-myd88 signal pathway in dendritic cells and enhances th2 immune responses airway eosinophils: allergic inflammation recruited professional antigen-presenting cells allergic pulmonary inflammation in mice is dependent on eosinophil-induced recruitment of effector t cells human eosinophils constitutively express multiple th1, th2, and immunoregulatory cytokines that are secreted rapidly and differentially eosinophils: singularly destructive effector cells or purveyors of immunoregulation? cutting edge: human eosinophils regulate t cell subset selection through indoleamine 2,3-dioxygenase human cd4ã¾cd25ã¾ regulatory t cells: proteome analysis identifies galectin-10 as a novel marker essential for their anergy and suppressive function a role for eosinophils in airway remodelling in asthma intravenous anti-il-5 monoclonal antibody reduces eosinophils and tenascin deposition in allergen-challenged human atopic skin eosinophils in health and disease: the liar hypothesis eosinophils promote allergic disease of the lung by regulating cd4(ã¾) th2 lymphocyte function schistosoma mansoni egg-induced early il-4 production is dependent upon il-5 and eosinophils a functional gammadeltatcr/cd3 complex distinct from gammadeltat cells is expressed by human eosinophils a role for eosinophils in transplant rejection il-5 mediates eosinophilic rejection of mhc class ii-disparate skin allografts in mice il-5 and eosinophils mediate the rejection of fully histoincompatible vascularized cardiac allografts: regulatory role of alloreactive cd8(ã¾) t lymphocytes and ifn-gamma multiple pathways to allograft rejection critical roles for il-4, il-5, and eosinophils in chronic skin allograft rejection intragraft interleukin-4 mrna expression after short-term cd154 blockade may trigger delayed development of transplant arteriosclerosis in the absence of cd8ã¾ t cells critical role for il-4 in the development of transplant arteriosclerosis in the absence of cd40-cd154 costimulation type 2 immune deviation has differential effects on alloreactive cd4ã¾ and cd8ã¾ t cells heterogeneity of t cell clones specific for a single indirect alloantigenic epitope (i-ab/h-2kd54e68) that mediate transplant rejection il-4 deficiency prevents eosinophilic rejection and uncovers a role for neutrophils in the rejection of mhc class ii disparate skin grafts eosinophilia associated with acute allograft kidney rejection the prognostic value of the eosinophil in acute renal allograft rejection the importance of eosinophil cells in kidney allograft rejection role of the eosinophil in chronic vascular rejection of renal allografts eosinophil granule major basic protein in acute renal allograft rejection activated eosinophil infiltration and deposits of eosinophil cationic protein in renal allograft rejection abundance of interstitial eosinophils in renal allografts is associated with vascular rejection eosinophils in acute renal allograft rejection eosinophilic granulocytes and interleukin-6 level in bronchoalveolar lavage fluid are associated with the development of obliterative bronchiolitis after lung transplantation eosinophilic infiltrates in a pulmonary allograft: a case and review of the literature graft eosinophilia in lung transplantation revision of the 1996 working formulation for the standardization of nomenclature in the diagnosis of lung rejection grading of cellular rejection after orthotopic liver transplantation the eosinophil as an effector cell of the immune response during hepatic allograft rejection morphometric inflammatory cell analysis of human liver allograft biopsies eosinophil cationic protein's role in human hepatic allograft rejection blood and graft eosinophilia as predictors of rejection in human liver transplantation evidence for a nonclassical pathway of graft rejection involving interleukin 5 and eosinophils elevated biliary interleukin 5 as an indicator of liver allograft rejection monitoring eosinophil activation and liver function after liver transplantation applications and limitations of blood eosinophilia for the diagnosis of acute cellular rejection in liver transplantation peripheral eosinophil count both before and after liver transplantation predicts acute cellular rejection new perspectives on the biology of acute gvhd pathophysiologic mechanisms of acute graft-vs.-host disease th2 cytokines (il-4, il-10 and il-13) and il-12 mrna expression by concanavalin a-stimulated peripheral blood mononuclear cells during chronic graft-versus-host disease biology of chronic graft-versus-host disease: implications for a future therapeutic approach chronic graft-versus-host syndrome in man. a long-term clinicopathologic study of 20 seattle patients eosinophilia after allogeneic bone marrow transplantation using the busulfan and cyclophosphamide preparative regimen peripheral blood eosinophilia has a favorable prognostic impact on transplant outcomes after allogeneic peripheral blood stem cell transplantation eosinophilia predicts better overall survival after acute graft-versus-host-disease hypereosinophilia as a presenting sign of acute graft-versushost disease after allogeneic bone marrow transplantation serum cytokine concentrations and acute graft-versus-host disease after allogeneic peripheral blood stem cell transplantation: concurrent measurement of ten cytokines and their respective ratios using cytometric bead array significance of eosinophilia after stem cell transplantation as a possible prognostic marker for favorable outcome kinetics of serum cytokines after allogeneic bone marrow transplantation: interleukin-5 as a potential marker of acute graftversus-host disease blood eosinophilia as a marker of favorable outcome after allogeneic stem cell transplantation donor cd4-enriched cells of th2 cytokine phenotype regulate graftversus-host disease without impairing allogeneic engraftment in sublethally irradiated mice pretreatment of donor mice with granulocyte colony-stimulating factor polarizes donor t lymphocytes toward type-2 cytokine production and reduces severity of experimental graft-versus-host disease ex vivo rapamycin generates donor th2 cells that potently inhibit graft-versus-host disease and graft-versus-tumor effects via an il-4-dependent mechanism combined th2 cytokine deficiency in donor t cells aggravates experimental acute graft-vs-host disease production of il-10 by alloreactive sibling donor cells and its influence on the development of acute gvhd a possible association between the presence of interleukin-4-secreting cells and a reduction in the risk of acute graft-versus-host disease th1 and th2 mediate acute graft-versus-host disease, each with distinct endorgan targets reciprocal differentiation and tissue-specific pathogenesis of th1, th2, and th17 cells in graft-versus-host disease eosinophilia indicates the evolution to acute graft-versus-host disease activated eosinophils in upper gastrointestinal tract of patients with graft-versus-host disease immunophenotypic profile of peripheral blood eosinophils in acute graft-vs.-host disease acute flare-up of conjunctival graft-versus-host disease with eosinophil infiltration in a patient with chronic graft-versus-host disease sparing effect by montelukast treatment for chronic graft versus host disease: a pilot study eosinophils and severe forms of graft-versus-host disease mast cells are essential intermediaries in regulatory t-cell tolerance defining a link with asthma in mice congenitally deficient in eosinophils deletion of a high-affinity gata-binding site in the gata-1 promoter leads to selective loss of the eosinophil lineage in vivo musculoskeletal syndromes in parasitic diseases clinical epidemiology of toxic-oil syndrome. manifestations of a new illness association of the eosinophilia-myalgia syndrome with the ingestion of tryptophan eosinophilia-myalgia syndrome associated with ingestion of l-tryptophan: muscle biopsy findings in 4 patients idiopathic eosinophilic myositis eosinophilic myopathic syndromes relapsing eosinophilic perimyositis diffuse fasciitis with eosinophilia: a new syndrome eosinophilic fasciitis. a pathologic study of twenty cases capn3 mutations in patients with idiopathic eosinophilic myositis the calpain system sequence comparison among musclespecific calpain, p94, and calpain subunits calpain 3: a key regulator of the sarcomere? insertion sequence 1 of muscle-specific calpain, p94, acts as an internal propeptide suppressed disassembly of autolyzing p94/capn3 by n2a connectin/titin in a genetic reporter system calpain 3 is activated through autolysis within the active site and lyses sarcomeric and sarcolemmal components mutations in the proteolytic enzyme calpain 3 cause limb-girdle muscular dystrophy type 2a adults with eosinophilic myositis and calpain-3 mutations eosinophilic myositis in calpainopathy: could immunosuppression of the eosinophilic myositis alter the early natural course of the dystrophic disease? calpainopathy and eosinophilic myositis eosinophilic major basic protein and interleukin-5 in eosinophilic myositis characterization of a new p94-like calpain form in human lymphocytes eosinophilia of dystrophin-deficient muscle is promoted by perforin-mediated cytotoxicity by t cell effectors human muscle protein degradation in vitro by eosinophil cationic protein (ecp) becker muscular dystrophy presenting as eosinophilic inflammatory myopathy in an infant eosinophilic myositis as presenting symptom in g-sarcoglycanopathy our research is supported by the stanley thomas johnson foundation and swiss national science foundation, bern, switzerland. inflammometry. this chapter is dedicated to the fond memory of professor freddy hargreave who tirelessly argued for the implementation of measurement of bronchitis by sputum examination in clinical practice. the authors would like to thank drs guy delespesse and zoulfia allakhverdi, laboratory on allergy, chum research center, notre dame hospital, montreal, canada, for providing input from their research into tslp effects on progenitor cells (fig. 13.6.2) . thanks also to lynne larocque for her expert assistance with the preparation of the manuscript. funding for this research was provided by the canadian institutes of health research (cihr), and the allergy, genes and environment network of centres of excellence (allergen nce inc.). that this reflects t h 2, rather than t h 1 (classically considered as the effectors of agvhd cell activation). in agreement, murine studies have shown that several cytokines that are known to favor t h 2 polarization of donor t cells, such as gm-csf, il-4, or rapamycin, can reduce agvhd. 64e67 in humans, it has been shown that an increased number of il-4-and il-10-producing cells are associated with reduced severity or absence of agvhd, 68,69 also suggesting a possible protective role for t h 2 cytokines in agvhd. nevertheless, reports indicate that t h 2 subsets may actually cause agvhd by targeting other organs than those targeted by t h 1 subsets. 70, 71 this argues against a rigid paradigm according to which agvhd is a t h 1 process and chronic gvhd a t h 2 process. in support of this hypothesis, prospective data have shown that bone marrow eosinophilia after hsct may be a predictive marker of severe agvhd. 72 similarly, the presence of eosinophils in duodenal biopsy specimens taken during acute flares correlates with intestinal gvhd severity. 73 there is also evidence that eosinophils show signs of activation in both blood and target organs of patients during agvhd flares. 74, 75 the bad reputation of eosinophils in gvhd generated by these observations has led some investigators to test the efficacy of montelukast (an orally active leukotriene antagonist that inhibits eosinophils) as a supplement to standard therapy for patients with chronic gvhd, with promising preliminary results. 76 for the time being, the role of eosinophils in target organ damage still needs to be assessed in the setting of well-conducted experimental studies. 77 in conclusion, compelling evidence links activated eosinophils with allograft rejection and graft-versus-host disease. in contrast to mast cells, they are not (yet) linked to transplantation tolerance. 78 their presence seems to be correlated with the gravity of tissue damage, which may reflect effector functions contributing to rejection, or eosinophil accumulation in response to tissue damage, in agreement with the liar hypothesis. to date, the roles played by il-5 and eosinophils in the redundant pathways of allograft rejection and the potential graft healing processes remain cryptic. the recent availability of genetically engineered mice lacking eosinophils (phil and ddblgata) provides a unique opportunity to clarify their contribution to these processes. 79, 80 chapter 13.14 eosinophils and calpain-3 mutation: a genetic cause implicated in idiopathic eosinophilic myositis eosinophilic myositis is a rare histopathological entity characterized by infiltration of skeletal muscle tissue by eosinophils, possibly in association with peripheral blood and/or bone marrow hypereosinophilia. these characteristics distinguish eosinophilic myositis from other idiopathic inflammatory myopathies, such as polymyositis and dermatomyositis. the diagnosis of eosinophilic myositis is at the current state of knowledge, eosinophilic myopathies constitute a heterogeneous group of rare diseases without a causal factor being identified in most cases.in 2006, our group reported an unexpected clinical observation: a 4-year-old boy was diagnosed with idiopathic eosinophilic myositis and muscle biopsy analysis revealed a calpain-3 protein defect. 11 calpain-3 is a muscle-specific protein, belonging to the family of calpains, nonlysosomal calcium-dependent cysteine proteases. 12 the most well studied of the calpains are the ubiquitous heterodimeric calpains (m-calpain and mcalpain). the human calpain-3 gene is located on chromosome 15q15.1eq21.1. the predominant product of this gene is encoded by 24 exons corresponding to a 3316 bp mrna expressed mainly in adult skeletal muscles. 13 the translation of the main calpain-3 gene (capn3) product leads to the formation of a 94 kda protein comprising 821 amino acids and consisting of a short n-terminal region (domain i), a papain-type proteolytic domain (domains iia and iib), a c2-like domain (domain iii), and a calcium-binding domain composed of five ef-hand motifs (domain iv). in addition, calpain-3 possesses three unique sequences not found in other calpains: the ns (n-terminal sequence), and the is1 and is2 (inserted sequences 1 and 2) sequences. 14 is1 is a polypeptide of about 50 amino acids encoded by an alternative exon 6. it is composed of an a-helix flanked by loops that close the catalytic cleft, thus blocking access to substrates and inhibitors. 15 it also contains autolytic sites involved in the initiation of calpain-3 proteolysis by opening the catalytic cleft. 16 immunolocalization studies carried out in human and mouse demonstrated that calpain-3 located in the n2a, m-line, and z-line regions of the sarcomere. in addition to these localizations, calpain-3 has also been found at costameres and near the triad of the t-tubule. 17 calpain-3 functions to promote proteolysis of several substrates located in the costameres, sarcolemma, and sarcomere and seems to be most important in fully differentiated fibers (for review see 14 ) . in adult fibers, calpain-3 participates in sarcomere adaptation by cleaving cytoskeletal proteins during muscular adjustment, in accordance with the distribution of known substrates. 17 mutations in the capn3 gene cause the most prevalent form of autosomal recessive limb-girdle muscular dystrophy (lgmd), type 2a (lgmd2a), 18 also referred to as calpainopathy. based on the calpain-3 protein defect identified in the boy with idiopathic eosinophilic myositis mentioned above, the capn3 gene was analyzed, revealing mutations and thus a genetic cause associated with eosinophilic infiltration in this case. nonspecific inflammatory features may be associated with a variety of muscle dystrophies, possibly leading to misdiagnosis of polymyositis in some cases (e.g., congenital muscle dystrophy, fascioscapulohumeral muscular dystrophy, and dysferlinopathies). however, eosinophilic infiltration had not been previously characterized as a component of inflammatory features in muscular dystrophies.we subsequently identified five additional children diagnosed with idiopathic eosinophilic myositis (exemplified in one patient in fig. 13 .14.1) and identified capn3 disease-causing mutations in all cases, either in a homozygous or compound heterozygous state. following our publication of these pediatric cases, two adult cases of idiopathic eosinophilic myositis and capn3 mutations were reported by amato. 19 in 2009, oflazer and colleagues reported another pediatric case of idiopathic eosinophilic myositis associated with capn3 mutations, 20 in which a positive effect of immunosuppressive therapy was observed. since our initial report, we have characterized five additional unrelated patients with idiopathic eosinophilic myositis and capn3 mutations (one adult and four children, unpublished data). importantly, except for the initially identified boy presenting with a calpain-3 defect, inclusion criteria for capn3 mutation screening of the other cases were based only on the particular histopathological presentation, without any identified etiological factors.noteworthy, capn3 mutations identified in patients with idiopathic eosinophilic myositis do not appear to constitute any particular mutational spectrum as compared to typical lgmd2a. our findings demonstrate that at least a subset of idiopathic eosinophilic myositis has a genetic origin, caused by mutations in the capn3 gene and with an autosomal recessive mode of inheritance. on the other hand, as eosinophilic infiltration is not known to be a typical feature of lgmd2a, it is possible that eosinophilia may be a transient feature in the natural course of this disease.the explanation for eosinophilic infiltration correlating with defective calpain-3 needs to be further evaluated. t lymphocytes may be a key component in this process 21 as:1. together with macrophages, they are the main components of inflammatory lesions in the vicinity of damaged muscle fibers. 2. they play a central role in the chemoattraction of eosinophils by secreting interleukin-5, which induces local eosinophil accumulation 22 and they express calpain-3. 23 regarding the latter, no relevant function for calpain-3 in t lymphocytes has been identified to date. the presence of eosinophils has been previously reported to be a component of muscular dystrophy in mdx mice, promoted by perforindependent cytotoxicity of effector t cells. 24 in addition, eosinophils play a specific role in muscle fiber degradation, due to degradation of myofibrillar and membrane-associated proteins by eosinophil cationic protein. 25 key: cord-022653-qa1uph35 authors: nan title: poster discussion session pds date: 2017-08-30 journal: allergy doi: 10.1111/all.13251 sha: doc_id: 22653 cord_uid: qa1uph35 nan objectives: since bradykinin is a short-lived, low-abundance mediator in the systemic circulation, the discovery of additional biochemical biomarkers correlating hae disease activity with contact system dysregulation may be useful for further elucidation of hae pathophysiology and pharmacodynamic therapeutic modulation of the contact system. results: activated pkal cleaves single chain high molecular weight kininogen to generate bradykinin and cleaved 2chain hmwk. cleaved 2-chain hmwk was measured in human plasma using both a semi-quantitative western blot assay with fluorescent detection (licor) and a novel elisa with a capture antibody that specifically binds 2-chain hmwk. the western blot assay was previously used to monitor pharmacodynamic activity in hae patients treated with lanadelumab, a fully human antibody inhibitor of pkal that is in clinical development for hae attack prophylaxis. lanadelumab inhibited 2-chain hmwk generation following contact system activation in vitro, confirming that 2-chain hmwk is a product of pkal activity. plasma 2-chain hmwk levels from hae patients during or between attacks were compared to that from healthy volunteers using both the western blot assay and elisa. roc curve analyses with both methods suggest that 2-chain hmwk is a trait-specific biomarker capable of differentiating hae patients from healthy volunteers. the elisa was able to differentiate samples from hae patients collected during an attack from those collected between attacks with moderate sensitivity and specificity (c-statis-tic=0.8176). a comparison of 2-chain hmwk levels in citrated plasma versus plasma that contains protease inhibitors (scat169 plasma) provides estimates of endogenous versus ex vivo activation. the measurement of 2-chain hmwk using the specific assays described may find use in further dissecting the role of the contact system in disease pathology, to identify additional indications for modulators of this pathway, and to investigate therapeutics targeting the contact system. 0206 | g protein coupled receptor kinase 2 (grk2) regulates endothelial permeability induced by bradykinin 0208 | pharmacokinetics (pk) and pharmacodynamics (pd) of c1 esterase inhibitor of chronic urticaria challenges most commonly identified were the following: time of onset of disease; frequency/duration of and provoking factors for wheals; diurnal variation; occurrence in relation to weekends, holidays, and foreign travel; shape, size, and distribution of wheals; associated angioedema; associated subjective symptoms of lesions; family and personal history regarding urticaria, atopy; previous or current allergies, infections, internal diseases, or other possible causes; psychosomatic and psychiatric diseases; surgical implantations and events during surgery; gastric/ intestinal problems; induction by physical agents or exercise; use of drugs; food allergies; relationship to the menstrual cycle; smoking habits; type of work, hobbies; stress; quality of life and emotional impact; previous therapy and response to therapy, and previous diagnostic procedures/results. we included all of these aspects in our guide and as a result we developed a chronic urticaria check list. conclusions: our guide of clinical history for chronic urticaria (gur) contributes to have an easy tool in order to achieve a better diagnosis and evaluation of chronic urticaria. 0213 | clinical and diagnostic features in acquired cold urticaria patients in a coruña sanitary area, spain physicians and dermatologists/allergists; c/sa patients were more likely to visit dermatologists/allergists (51% vs. 47%) and less likely to visit general physicians (32% vs. 57%) than european patients. emergency room visits due to cu were more common in c/sa (40%, mean [sd] number=23.2 [124.3] ) than europe (29%, mean [sd] number=3.7 [11.4] ). conversely, hospital admissions due to cu were more likely to occur in europe (22%) than c/sa (8%), but the average (sd) number of admissions among those hospitalised was greater in c/sa (3.3 [4.7] vs. 2.0 [3.1]). variations were seen in subregion comparisons. mean (sd) overall wpai scores were 7.0 (18.9), 25. 1 (26.8), 27.3 (28.5), and 33.3 (30.8) for absenteeism, presenteeism, work productivity loss, and activity impairment, respectively; patients in c/sa reported a higher rate of impairment (range, 13%-36%) on all domains compared with patients in europe. conclusions: cu is associated with substantial hru and work and activity impairment in both europe and c/sa. general physicians should be considered key members of the treatment team in the care of patients with cu in these regions. objectives: cu patients (n=15) received monthly subcutaneous injections of omalizumab for up to six months. urticaria-related symptoms were assessed by both the urticaria control test (uct) and the chronic urticaria quality of life score (cu-q 2 ol). peripheral blood was drawn prior to each injection for determining the concentration-dependent reactivity of patients' basophils to specific anti-fceri and unspecific fmlp stimulation by basophil activation test. furthermore, the impact of anti-ige treatment on ige-bearing cell populations was characterized by flow cytometry analyzing the surface expression of both fceri (e.g. on monocytes, dendritic cells, basophils) and the low-affinity receptor for ige, fcerii (e.g. on b cells, eosinophils). results: anti-ige treatment of cu patients significantly improved clinical symptoms of cu already after the first injection as evaluated by cu-q 2 ol and uct, the latter of which correlated with an increase of basophil numbers and a decrease of basophil surface bound ige. of note, cell-bound ige on fcerii-expressing cells was not altered. furthermore, while clinical amelioration also was accompanied by reduced fceri expression on basophils, the basophil responsiveness to anti-fceri stimulation increased in 73% (11/15) of treated patients. in contrast, ige-independent activation of basophils by fmlp was unchanged. conclusions: clinical improvement of cu patients treated with omalizumab is associated with characteristic immune alterations in basophils, like rapid, cell-specific reduction of surface bound ige and fceri-expression as well as normalization of basophil responsiveness to fceri-stimulation. while our findings might help to better understand the mode of action of anti-ige therapy in cu, they also can shed new light on the pathomechanisms underlying cu. 0216 | omalizumab in patients with severe active chronic spontaneous urticaria (csu) heavily treated with corticosteroids and cyclosporine introduction: increased levels of blood d-dimers (d-d), the byproducts of fibrin degradation, is linked to the severity of chronic spontaneous urticaria (csu) and to poor response to antihistamines h1 (ah1). omalizumab (oma) is a human monoclonal anti-immunoglobulin-e antibody registered as an add-on treatment of csu in adults and adolescent (≥ 12 years old) and with insufficient response to ah1. the sunrise study assessed the efficacy of omalizumab on csu symptoms and the correlation between d-d levels and response over time to treatment with oma to explore its potential predictive value. objectives: sunrise was a french prospective non comparative phase 4 study. included patients had to have been diagnosed with csu for at least 6 months, be resistant to ah1 treatment, and have a uct score (assessed by patient over the 4 last weeks, values from 0 (maximal disease)to 16 (full control)) <8, indicative of a poorly controlled disease. the widely used uas score (assessed by patients over 1 week which captures intensity of pruritus and number of hives, values ranging from 0 (no disease) to 42 (severe disease)) was further used to evaluate the proportion of patients achieving a well controlled disease(uas≤6). all patients received 300 mg oma by sub-cutaneous injections at day 0, weeks (w) 4 and 8. blood levels of d-d were assessed (turbidimetric immunoassay) at d0, w4 and w8. response to treatment was evaluated at w12 by means of the uas7. results: median level of d-d assessed at d0 in 112 patients was increased at baseline (618 ng/ml, extremes 108-5170) and normalized as early as w4 reaching 286 ng/ml (108-481) at w8. correlation between d-d concentration and uas7 score at w12 was weakly positive (spearman coefficient 0.108). among the 10 patients with a very high baseline de d-d level (>3000 ng/ml) 8 were responder (uas7≤6) at w12. conclusions: baseline d-d levels were increased in more than half of patients of this study in line with relevant literature. a fast normalization was observed with oma as early as w4 of treatment. d-d levels at w8 were weakly correlated with uas7. subgroup analyses may help to better understand the link between d-d and clinical response, as these preliminary results do not yet allow the predictive use as a biomarker. the sunrise study explored for the first time in a prospective way the impact of oma on dd and found weak correlations were measured between dd level and response to oma. further studies will be needed to evaluate its predictive value for response. (crp, esr, il-6, il-10, il-33, ccl2/mcp-1), and the disease severity in patients with chronic spontaneous urticaria introduction: pru p 3 is the primary sensitizer of some fruits and responsible for severe reactions in the mediterranean area. sublingual immunotherapy (slit) using peach extract enriched in pru p 3 (prup3-enriched-slit) brings a new perspective to treat patients with reactions to peach considering that currently the treatment of the allergy to peach is based on avoidable ingestion of fruit. we performed a pilot study to examine the immune modulation by slit in patients with peach allergy over a 1-year treatment period. objectives: we aimed to evaluate the effect of the slit during one year in patients with peach allergy. we analysed the capacity pru p 3enriched-slit to modulate immune response, from a th2 to th1 response with increases of treg cells. we studied three groups of subjects: peach allergic patients who received prup3-enriched-slit for 1 year, peach allergic patients non treated, and healthy controls who tolerated peach. monocyte-derived dendritic cells (dcs) maturation, peripheral blood mononuclear cell phenotype and lymphocyte proliferation after prup3 stimulation were assessed by flow cytometry from samples obtained before, and 1, 6 and 12 months during slit. results: we found statistically significant differences in dcs activation and maturation between allergic patients and controls at the basal state. when we analyzed the effect of prup3-enriched-slit over time, we found a significant reduction of activation and maturation markers (ccr7, cd40, cd80, cd83 and cd86) at the first month of treatment that was maintained after 1 year. concerning lymphocytes, we observed a significant decrease of effector cells immune cells. recent studies showed that fructo-oligosaccharides (fos) increase the efficacy of oral immunotherapy (oit) in a mouse model for cow's milk allergy, however, the mechanism is unknown. objectives: investigating the effect of oit+fos on the effector response and the process of tolerance induction. methods: female c3h/heouj mice (5-6 weeks old, n=8/group) were sensitized to the cow's milk protein whey (20 mg in pbs, intragastrically (i.g.)) with cholera toxin (15 lg) once a week for 5 weeks (d0-d28). the mice received a diet with 1% fos or a control diet from d35-d70. oit (10 mg in pbs or pbs) was provided 5 days a week for 3 weeks (d41-d59). intradermal (i.d.) and i.g. challenges were performed to measure the acute allergic response. serum, bone marrow, caecum content, small intestines and mesenteric lymph nodes (mln) were collected at d50, d63 and d70. spleen-derived t cell fractions (whole spleen, cd4+cd25-and cd4+cd25+, using macs) were transferred to na€ ıve recipient mice at d70. the recipients were sensitized and challenged as described for the donor mice. conclusions: this study shows that oit+fos results in an early induction of functional tregs and a reduction of mast cell degranulation upon challenge. the latter may be caused by inhibition of mast cell activation by galectin-9 and/or butyric acid. moreover, the effect of fos on bone marrow suggests possible epigenetic changes reducing development of mast cells. further research is needed to investigate if this approach may be of potential value to treat food allergies. 0348 | safety and feasibility of slow low-dose oral immunotherapy sugiura s; kitamura k; tajima n; takasato y; kato t; tajima i; ono m; tagami k; sakai k; nakagawa t; ito k aichi children's health and medical center, obu, japan introduction: slow low-dose oral immunotherapy (sloit) is an ongoing clinical trial conducted in our institute (umin registry number 000017416). this is a type of oral immunotherapy with a low dose antigen increased very slowly. objectives: to evaluate the safety and feasibility of the protocol. results: sloit enrolled the patients who were diagnosed as severe egg, milk or wheat allergies, with a threshold dose of 5 g (or ml) or less in the oral food challenge (ofc, 20-minutes boiled egg white, whole milk, udon noodle). subjects were divided into two groups, intervention (sloit) group or elimination (control) group, based on their preference. sloit group began to ingest 1/2 to 1/10 amount of the final dose of the ofc based on the severity of provoked symptoms. intake was continued everyday with an increasing dose less than 1.5 times/ month, expecting a 10 times increase from the starting dose after 12 months. feasibility was evaluated based on the proportion of patients who complied the protocol. safety was evaluated based on the frequency of immediate allergic reactions observed in the programmed intakes. fifty-nine patients were enrolled from april to december 2015, and 36 of them (egg: 23, milk: 4, wheat: 9) preferred the sloit group. among them, 11 patients (30.6%) dropped out from the study protocol because of provoked allergic symptoms (n=2) or the other personal reasons (n=9). among a total of 7090 ingestions by 25 patients who continued the protocol over 10 months, mild symptoms were observed 25 times (0.35%), to which rescue medicine such as oral antihistamines was used in 9 cases (0.13%). no one needed an emergency visit or an adrenalin auto-injector. low threshold dose at the initial ofc (1.0 g or less, n=16) was associated with higher proportion of provoked allergic symptoms in the protocol (low threshold: 0.50%, non-low threshold: 0.12%, p=.019). the level of specific ige titer was not associated with the safety. conclusions: sloit protocol has sufficient safety and feasibility, but low threshold patients should be monitored closely. the efficacy of this protocol is being evaluated by an ofc after 12-15 months of the treatment, and the overall data will be presented after march 2018. objectives: the aim of this phase i, randomized, non-controlled, multicenter, opened, with parallel groups clinical trial, is to evaluate the safety and tolerability of subcutaneous immunotherapy (scit), in a polymerized mixture (100/100) depot presentation. patients with rhino-conjunctivitis polysensitized to olea europaea/ phleum pratense received a schedule consisting of two weeks of initiation with three weekly injections; or a program comprising two administrations in the same day separated by 30 minutes. both treatments continued with a maintenance period of three months with a monthly administration. the primary outcomes are the number, percentage, and severity of adverse reactions. secondary endpoint included subrogate efficacy parameters evaluation: changes in immunoglobulin titers (specific ige, igg and igg4) and changes in cutaneous reactivity at different concentrations. 2 systemic reactions were registered, representing 4.3% of the included patients: one grade 0, described as general discomfort plus dizziness and one grade i, such as rhinoconjunctivitis. there were no local reactions. all were classified as of mild intensity and took place with the cluster schedule. symptomatic treatment was not required. conclusions: both schedules with polymerized mixture of phleum pratense/olea europaea, (100/100), presented a good safety and tolerability. a statistically significant decrease in cutaneous reactivity to olive and grass allergens was observed after immunotherapy. 0351a | design of the pivotal phase iii study to assess the efficacy and safety of subcutaneous hdm allergoid immunotherapy in patients with hdm induced allergic rhinitis/ rhinoconjunctivitis introduction: in order to comply with ema guidelines on development of allergen immunotherapy products, a clinical development program was started to obtain full marketing authorization for a allergoid subcutaneous immunotherapy (scit) product for the treatment of house dust mite (hdm) allergy. previously, the safety and tolerability of increasing doses of this allergoid scit product was evaluated in patients with hdm-induced allergic rhinitis/rhinoconjunctivitis (arc) [eudract 2008-006261-81] . no safety or tolerability issues were identified for doses up to 40 000 aueq. subsequently, a dose-finding study to identify the optimal, i.e. effective and safe dose in hdm arc with or without concomitant asthma was performed [eudract 2011-000393-61; pfaar, allergy 2016] . this study demonstrated a dose response relationship with doses of 10 000 aueq (0.5 ml of 20 000 aueq/ml) up to 50 000 aueq (0.5 ml of 100 000 aueq/ml) showing significant improvements compared to placebo. the current pivotal phase iii study [eudract 2016-000051-27] aims to confirm safety and efficacy of this hdm allergoid scit product at a dose level of 50 000 aueq/ml (0.5 ml) compared to placebo after one year of treatment in patients with hdm-induced arc. objectives: the current study is a multi-center (80 clinical study centers in 7 european countries) randomized, double-blind, placebocontrolled, parallel-group study in 730 adult patients, with moderate to severe hdm induced arc with or without mild to moderate persistent asthma. the primary outcome of the study is the difference in mean combined symptom and medication score (nasal symptoms only) (csms (n)) between 50 000 aueq/ml allergoid scit and placebo treatment, assessed during the last 8 weeks of the approximately 1 year treatment period. results: 211 patients from 14 centers, (mean age 32.9 years) have been included and analyzed. the 49.8% are men, 65.9% presented associated asthma. a large majority of patients have received subcutaneous sit (98.6%), and 58.8% of them containing a single allergenic source. 55.8% in polymerized formulation and 40.9% in depot. accelerated schedule has been the most prescribed (56.9%), followed by clustered one (32.2%). from the 81 patients who have completed the study, 45.7% of them improved from persistent to intermittent rhinoconjunctivitis (p<.01) and 49.4% from moderate/severe to mild intensity (aria) (p<.01). moreover, 21% of asthmatic patients at baseline, did not have any bronchial symptoms after 1-year treatment. the improvement in quality of life was possible to be analyzed in 53 patients. mean values in rqlq questionnaire (total score) decreased from 3.1 to 1.5 points (51.6% of score reduction) in final visit, reflecting a statistically significant improvement (p<.01). mean value of treatment satisfaction was 7.3 (sd=1.7) and 7.2 (sd=1.9) for physician and patients respectively. for safety assessment, out of 199 analyzed patients, only 8 systemic reactions were reported in 8 patients (4.02%). seven of them were classified as grade i, and one as grade ii according to eaaci grading system. strasbourg is a 147 m 3 chamber, located into the university hospital of strasbourg at less than to 5 minutes to the intensive care unit. one of the characteristics of this unit is that the maximum parameters are controlled: temperature, relative humidity, ventilation rate, particles number and particles size, concentration of airborne of der p 1 and airborne voc. mite allergens extract were nebulized through a nebulizer. airborne der p1 concentrations were sampled using 5 glass fiber filters and measured with an elisa assay. particles number and particles size were monitored continuously during nebulization, using 10 particles counters distributed inside the exposure room. the cleaning process was also controlled and validated. objectives: to validate the technical parameters of the environmental exposure chamber (eec) of strasbourg with mite allergens. results: the reproducibility was excellent for the indoor temperature, relative humidity and airflow (5 cv interassay <20%). three concentrations of der p1 were measured: 63, 76, 105 ng/m 3 (n=45). for all 3 concentrations, the cv intra-assay of airborne der p1 was 22ae1.3%, the interassay was less than 30%. for the particle size 0.5-5 and 5-10 lm, the cv interassay was 8 and 13%, respectively (n=19). the cv of the mmad was 2.2% (n=10). no measurable airborne der p1 was detected in the toilets and the medical supervision room (n=6) neither in the exposure room 10 minutes after the end of the allergen exposure (n=9). no airborne voc was measured in the chamber and the other rooms of the clinical unit (n=10). there was no significant change in particles size and number when 2 to 6 persons entered the room (n=4). introduction: pathogenesis of systemic sclerosis (ssc) includes vasculopathy with endothelial dysfunction which is considered to be one of the earliest changes in the pathogenesis of ssc. several biological molecules, including e-selectin (e-sel), inter-cellular adhesion molecule 1 (icam-1), endothelin 1 (et-1), von willebrand factor (vwf) and interleukin 6 (il-6) have been associated with endothelial activation. objectives: we aimed to determine if these vascular biomarkers are associated with distinct capillaroscopic ssc patterns and/or more severe disease in ssc patients. results: correlations between serum levels of all 5 vascular biomarkers were good to moderate and statistically significant, with r indices varying between 0.660 and 0.332, the only exception being et-1 which did not correlate with e-sel. good correlations (r 0.465 to 0.727) were also found between all 5 biomarkers and crp. patients with severe vasculopathy, as reflected by the nfc "late" pattern, had higher levels of il-6 (median 12.06 vs 3.08 pg/ml, p=.001), et-1 (median 2.06 vs 1.59 pg/ml, p=.029), vwf (median 3284 vs 2730 iu/ml, p=.013) and e-sel (median 52.6 vs 42.3 ng/ml, p>.05), compared to patients with nfc "early" or "active" patterns. there was a significant, negative correlation between lung transfer for carbon monoxide (dlco) and e-sel, icam-1 (both p<.001) and vwf (p=.013). et-1 was higher in patients with more severe disease (dcssc, patients positive for anti-topoisomerase antibodies and patients with a history of digital ulcers-all p<.05). conclusions: serum endothelial activation biomarkers are elevated in patients with more severe ssc-associated vasculopathy and correlate with serum crp. together with nfc data they may be used for assessing vasculopathy severity in ssc. objectives: here we present the imagination findings of eye involvement in a family whose 11 members have mws. method: clinical data was collected during the course of ongoing patient care. results: we evaluated the clinical features of 11 patients who were referred to our center. the median age of the patients was 25 years (range: 9-65 years). the ratio of females /males was 1.2 (6/5). all patients had arthritis with exacerbation on exposure to cold and ocular involvement, mostly in the form of conjunctivitis and far less other forms. the median age of onset of ocular involvement was 8 years (2-45 y). chronic eye damage were detected in three patients. corneal involvement and clouding was detected in four patient. two conclusions: in this study, it has been shown that eye findings related to mws can vary from conjunctivitis to severe uveitis. we want to emphasize that ocular involvement in mws should be carefully assessed, since it can lead to visual impairment. 0485 | antiretroviral activity of the conjugates 3'-azido-3'deoxythymidine and derivatives of 1,3-diacylglycerides case report: aids epidemics remain the critical problem due to both their emergent and long development. treatment of aids with azt reduces p24 antigenemia, increases cd4 + lymphocyte counts, reduces the frequency and severity of opportunistic infections and prolongs life. however, zidovudine and other dideoxynucleotides do not decrease the ability to isolate hiv from pbmc, and in addition, these drugs are very toxic. this phenomenon is caused by insufficient inhibition of hiv due to low levels of nucleoside kinases in ccr5-positive cells, including in macrophages, which are a major reservoir of hiv. potential advantages of these liponucleotide prodrugs include: greater in vivo efficacy and lower toxicity due to a greater delivery to monocytes/macrophages, ability to bypass the initial anabolic phosphorylation due to the presence of the phosphorous center in the structure, and the prospect of improved pharmacokinetics and prolonged intracellular persistence. the aim of this work is the study of cytotoxicity and anti-hiv activity of glycerolipids derivatives of azt. evaluation of the cytotoxicity of azt and test compounds was per0488 | bone mineralisation defect in patients with hax-1 deficiency 4 and osteopenia (z score <à1) in 3 patients. bone mineralisation defect was found in all female patients while only one male had osteopenia (table 1) . conclusions: in this study, a significant decrease (87.5%) of bone mineralization was observed in patients with hax-1 deficiency. female patients were found more prone to bone mineralisation defect. to conclude on this subject, more studies are needed with large number of patients having not only hax-1 deficiency but also ela-2 mutations. gene mutation age ( introduction: bronchopulmonary diseases are kept as one of the actual problems of the pediatricians. nevertheless fulfilment of several scientific works on study of these diseases, presently we meet the complication of the respiratory diseases, recurrency, changing to the chronical type. objectives: the main purpose of our work to study the cytokine status and substance p, mutual connection they in frequently ill chilresults: in fic with respiratory diseases in the acute period of the disease increase of levels proinflammatory cytokines il-1beta, il-6, il-8, tnf-alpha and substance p,decrease of levels il-2 and ifngamma was marked. clinical remission in these children is not accompanied by normalization of cytokine status and substance p. the high level of proinflammatory cytokines and substance p testifies to proceeding of inflammatory process that is possible connected with persistence of the infections agent. acute decrease in level of cytokines il-2 and ifn-gamma in these children,most likely, is caused by the presence of a immunodeficiency of cellular type. conclusions: in this connection it is necessary to carry out an adequate therapy of fic with arvi. introduction: atopic diseases are known to be characterized by a t helper (th) 2-skewed immunity. th2-skewed immunity at birth, th2-associated cc chemokine ligand (ccl)-22, appears to be associated with high total ige levels but not of allergic outcomes later in life. the prevalence of asthma increases with a rapid upward trend after age 2; however, there are few studies addressing the changes of ccl22 chemokine levels during infancy related to the development of atopic diseases in early childhood. objectives: we investigated 182 children followed up regularly at the clinic for 5 years in a birth cohort study. the levels of th2 related chemokine ccl22 were quantified in cord blood and age 1.5 by multiplex luminex kits. specific immunoglobulin e antibodies against food (egg white, milk, and wheat) and inhalant allergens (d. pteronyssinus, d. farina, and c. herbarum) were measured at 6 months as well as 1.5, 3, 4 and 5 years of age. results: a total of 125 pairs of ccl22 chemokine levels from birth to age 1.5 were recruited in this study. k-means clustering was performed using r software and package mfuzz and this resulted in 3 groups of ccl22 chemokine levels that declined from around 2000 to 500 pg/ml (cluster a, n=51), from around 1200 to 400 pg/ml (cluster b, n=46) , and raised from around 400 to 600 pg/ml (cluster c, n=28) . in children with raised ccl22 chemokine levels appeared to be associated with a higher prevalence of house dust mite sensitization at age 1.5. furthermore, raised ccl22 levels during infancy were significantly associated with higher risk of asthma at age 3 (p=.026). conclusions: raised ccl22 chemokine levels during infancy appear not only to be associated with an increase in the prevalence of house dust mite sensitization but also the risk of asthma in early childhood. 0520 | serum periostin is "not" a biomarker for pediatric asthma suzuki n 1 ; hirayama j 1 ; nagao m 1 ; kameda k 1 ; kuwabara y 1 ; kainuma k 1 ; ono j 2 ; ohta s 3 ; izuhara k 3 ; fujisawa t 1 1 mie national hospital, tsu, japan; 2 shino-test corporation, kanagawa, japan; 3 saga medical school, saga, japan introduction: periostin is a matricellular protein induced by type 2 helper t-cell cytokines, expressed by airway structural cells and is thought to contribute to airway remodeling and progressive lung function decline in severe asthma in adults. we sought a possible clinical utility of serum periostin in children with asthma. objectives: we recruited volunteer children and adolescents (age range, 3 to 17 years) who were otherwise healthy except for allergic diseases including bronchial asthma. allergic diseases were classified with isaac questionnaire and serum levels of periostin were measured with elisa. abstracts | 167 results: a total of 661 volunteers were enrolled. among them 161 had no allergic diseases (na), 215 had only allergic rhinitis (ar) and the rest of 285 had bronchial asthma (ba) and/or atopic dermatitis (ad) . serum levels of periostin in na younger than 15 were significantly higher than the older counterpart and the levels in children <15 years old were similar across each age. data distribution of serum periostin in ar were very similar with that in na and we defined na and ar groups as reference population. reference values, geometric mean (+2 geometric sd range), for serum periostin were 101 (179) and 82 (151) ng/ml in children/adolescents <15 and ≥15, respectively. there were no gender differences in serum periostin in the reference population. we then compared the serum levels of periostin in ad and/or ba with the reference group and found that serum periostin in ad and ad+ba, not ba, in <15 years old were significantly higher than the reference group. in addition, severity of asthma had no association with serum periostin levels in age group of <15. on the other hand, the levels in ba aged ≥15 were slightly higher than non-ba (statistically significant). conclusions: serum periostin is physiologically high in children and adolescents, possibly in growing age, and the levels are elevated in those with ad, not ba. serum periostin is "not" a useful biomarker for pediatric asthma. 0521 | clinical, biochemical and radiological factors for response to aspirin desensitization in patients with aspirin exacerbated respiratory disease-pilot study introduction: aspirin desensitization is regarded as an effective and well-tolerated therapy for patients with aspirin exacerbated respiratory disease (aerd). despite many studies investigating the pathophysiology of aerd, the underlying mechanism responsible for the beneficial effects of aspirin therapy has not yet been clarified. the aim of the study was to evaluate the influence of aspirin desensitization on clinical, biochemical and radiological changes in aerd individuals. objectives: this is a prospective study of twenty-one aerd patients subjected to one-year aspirin desensitization. all participants were hospitalized three times over the period of one year. at baseline and during each follow-up visit (2 nd and 12 th month) blood, urine, induced sputum (is) and nasal lavage (nl) were collected from all participants. the acquired material was processed in order to evaluate 1) is and nl cell count 2) concentrations of is and nl eicosanoids 3) leukotriene e4 (lte4) in urine and 4) periostin in blood. additionally, participants underwent a ct scan of the paranasal sinuses at baseline and after 12 months of aspirin therapy. the lund-mackay score values were compared. for statistical analysis, summary statistics and repeated measures anova with post-hoc test were applied. results: twenty participants completed a one-year aspirin therapy. there was a statistically significant decrease in the number (p=.007) and percentage (p=.02) of eosinophils in is between baseline and after aspirin desensitisation. significant increase of urine lte4 in the course of aspirin therapy was observed (p=.02). the levels of prostaglandins and leukotrienes in is and nl as well as blood periostin level and the differential cell count in nl did not change during aspirin desensitization. in ct scan images the regression of the lesions in paranasal sinuses was observed in 32%, the worsening in 42% and in 26% of patients no changes were noted. in is count of eosinophils in aspirin-sensitive individuals, which may potentially be used in disease monitoring and tailoring asthma therapy. aspirin desensitization did not lead to significant changes in local eicosanoid levels in is and nl. blood periostin level is not a good marker for patient's response to aspirin desensitization. introduction: one of the main severe asthma phenotype is the "severe eosinophilic" or "eosinophilic refractory" asthma, for which novel biologic agents are emerging as therapeutical options. in this context, blood eosinophils count are one of the most reliable biomarker. objectives: the aim of our study is to evaluate the performance of a point-of-care peripheral blood counter in a clinical setting of severe asthmatics. seventy-six patients with severe asthma were evaluated, for blood cells count, by both a point-of-care and a standard analyser. results: the inter-and intra-assay variation was acceptable for leukocytes, neutrophils, lymphocytes and eosinophils. this was not the case of monocytes and basophils. a significant correlation between blood eosinophils assessed by the two devices was found (r 2 = 0.854, p<.0001); similar correlations were found also for white blood cells, neutrophils and lymphocytes. the point-of-care device showed ability to predict blood eosinophils cutoffs used to select patients for biologic treatments for severe eosinophilic asthma, and the elen index, a composite score useful to predict sputum eosinophilia. introduction: over 10 years ago there was revealed periostin should play an important role in pathogenesis of allergic inflammation including asthma and processes of tissue remodeling and fibrosis. its expression has been observed in the thickened basement membrane as well as in serum of asthmatic patients. thus, measuring of periostin serum levels may shed some light on these elusive asthma features. periostin has already demonstrated a convenient value in clinical studies as a companion diagnostics for lebrikizumab, tralokinumab or omalizumab treatment. however, to date, the changes of periostin serum levels following asthma therapy except for inhaled corticosteroids remain unclear. objectives: to emphasize this issue we have collected clinical and laboratory data including serum periostin of 48 asthma patients (19 males/29 females) in a cross-sectional study. all patients were treated either by conventional therapy comprising inhaled corticosteroids (n=38) or by inhaled corticosteroids with additional biological therapy (omalizumab) (n=10). asthma phenotype, control, complications, comorbidities and other available biomarkers have been assessed and statistically analysed. results: we have observed a weak but statistically significant correlation between serum periostin and total ige levels (p=.039) and absolute eosinophil count (p=.045). association between periostin and total ige had nonlinear character (p=.007), and was expressed particularly in non-severe asthma patients without omalizumab treatment (p=.018). despite mutual correlation between serum periostin a total ige levels, both biomarkers showed different reaction on asthma treatment. multivariate analysis demonstrated, that only periostin levels, in contrast to all other assessed biomarkers, were significantly decreased in severe asthma patients treated by omalizumab (p=.013). this relationship was independent of asthma control (assessed by asthma control test -act), exacerbation rate, hrct or spirometry measurement results or comorbidities, except chronic rhinosinusitis with nasal polyps (crswnp) (p<.001). conclusions: we demonstrate, serum periostin levels are dependent on therapy, thus it may contribute not only to asthma phenotype stratification, prediction of treatment responsiveness, complications such as remodeling but probably more precise monitoring of therapy effect too. 0527 | usefulness of serum pteridines as a biomarker for childhood asthma kasuga s 1 ; hamazaki t 1 ; fujitani h 1 ; fujikawa s 1 ; niihira s 2 ; shintaku h 1 1 department of pediatrics, osaka city university graduate school of medicine, osaka, japan; 2 the national institute of special education, tokyo, japan introduction: reliable and stable biomarker of airway inflammation is essential to determine intensity of asthma treatment. exhaled nitric oxide (feno) has been introduced to assess useful marker of airway inflammation but it fluctuates depending on steroid inhalation. nitric oxide is produced by nitric oxide synthase which requires tetrahydrobiopterin (one of pteridines) as a cofactor. objectives: to assess pteridines as a biomarker of childhood asthma control. results: asthmatic children were recruited for periodical asthma checkup program in japan to assess asthma control status by using objective questionnaire, respiratory function tests, airway resistance, feno, and serum pteridine levels. serum pteridine levels were measured by high performance liquid chromatography. total 131 japanese children (4-17 years) were participated in this program. 36 children who have no asthma attack over three years were divided as remission group to evaluate the long-term asthma control. the other 95 children were divided as asthma group. furthermore, we divided asthma group for three groups by childhood asthma control test (c-act) scores to evaluate the short-term asthma control. and we had 61 age matched children as control group. pteridine levels tended to decrease in patients who showed higher feno in asthma group. asthmatic children showed lower pteridine levels than other groups. there are significant differences between control group and remission groups and asthma groups (p<.001, tukey's honestly significant difference test). but there are no significant differences between the three groups in asthma group (well-controlled group, partly-controlled groups and uncontrolled groups) which were divided by c-act scores. the low concentration of serum pteridines in children with stable asthma may indicate poor long-term control of asthma. but that not indicate poor short-term control of asthma. since pteridine biosynthesis pathways were suppressed by th2 mediated immune response, these results suggest that th2 mediated immune response was dominating the th1 response in asthmatic children. therefore, serum pteridines could be a novel biomarker of stable asthmatic children. introduction: asthma is a syndrome with chronic airway inflammation. the goal in the treatment of asthma is to control the inflammation. however, there has been a scarcity of useful noninvasive tests for monitoring the airway inflammation in clinical setting. metabolites of the eicosanoids pathways in induced sputum of the patients with asthma could be valuable biomarkers that can reflect the airway inflammation. objectives: to investigate eicosanoid metabolites and to find out their phenotypic differences, induced sputum supernatants from 37 patients with refractory asthma, 40 patients with controlled asthma, and 6 normal control subjects were analyzed by using liquid chromatography tandem mass spectrometry. in addition, we evaluated the relationship between asthma exacerbation and eicosanoid metabolites. results: among 43 metabolites which were measured, 26 metabolites were detected in the induced sputum. we found that normal control subjects had higher concentrations of prostaglandin (pg) d2 (normal subjects vs controlled asthma vs refractory asthma, median conclusions: eicosanoid profiles in induced sputum supernatant were different between patients with refractory asthma, those with controlled asthma, and normal control subjects. our findings suggest that they could be biomarkers to differentiate refractory asthma from controllable asthma or non-asthma. this work was supported by the research program funded by the korea centers for disease control and prevention (2016-er7402-00) . 0529 | serum periostin in asthma is related to disease severity, eosinophilia and il-33 introduction: introduction: asthma is a chronic inflammatory disease where more than 100 powerful inflammatory mediators are associated with airway hyperresponsiveness, mucus hypersecretion, activation of fibroblasts and hyperplasia and hypertrophy of smooth muscles of the airways and if they do not use preventive antiasthma treatment can cause irreversible airway remodeling. objectives: the aim of this study was to determine the effect of adding montelukast to combined therapy icss/labas in patients with uncontrolled asthma by analyzing of serum level of il-13, il-5, eosinophils and symptom score. methods: in study we included 29 patients, they were treated with icss/labas (500/50 mcg-twice daily) plus montelukast (10 mgdaily). in each of them were measured serum levels of il-13 and il-5 by the elisa method, value of eosinophils were obtained with visual examination of peripheral blood smear, and assessing symptom scores with 5-point likert scale of breathlessness at the beginning and after 6 months of therapy. objectives: this study has been focussed on a detailed comparison of two samplers-cyclone and chemvol-and on the parameters that could influence their efficiency. results: airborne concentrations of two key olive and grass allergens, ole e 1 and phl p 5, respectively, were monitored over two years with different weather patterns, 2012 and 2014, in c ordoba, located in south-western spain. allergenic particles were quantified by elisa assay and results were compared with pollen concentrations monitored using a hirst-type volumetric spore trap over the same study periods. the influence of weather-related parameters on local airborne pollen and allergen concentrations was also analysed. inter-year differences were observed with regard to pollen season timing and intensity. for both olive and grass, the pollen season was longer and the pollen index (pi) higher in 2014; that year the peak value was higher and it was recorded earlier. although a positive correlation was detected between results obtained using the two samplers during the pollen season, results for the cumulative annual allergen index varied considerably. the two samplers revealed a positive correlation between pollen concentrations and both minimum temperature during the warmer year (2012) and maximum temperature during the cooler year (2014); a negative significant correlation was observed in both cases with rainfall and relative humidity. conclusions: in summary, although differences were observed between the two samplers studied, both samplers may be suitable for allergen detection. objectives: the scientific council of rnsa was asked to update the allergy potency (ap) of plant species that can be established in urban areas. to update the allergy potency of plant species, the rnsa used scientific work on the subject, and also the opinions of allergists and botanists. the pollen grains of anemophilous species are transported by wind; they produce very large quantities of pollen grains so that the fertilization of female flowers has a greater chance of being effective. the majority of allergenic species are anemophilous. results: the pollen allergy potency of a plant species is the ability of its pollen to cause an allergy to a significant part of the population. the allergenic potential can be: low or negligible: no problem to plant them in urban garden moderate: only a few species can be planted in the same garden high: this species cannot be planted in urban places. the table presented on the poster will permit to know the level of allergy potency of more than 30 species. conclusions: species or genus with a strong ap should be labeled as "not to be planted in habitation or residence area ", those with moderate ap should be labeled as "not to be planted in big quantities in habitation or residence area". other species with low or negligible ap may not be affected by public information. gadermaier g 1 ; metz-favre c 2 ; stemeseder t 1 ; de blay f 2 ; pauli g 2 1 universit e de salzbourg, salzbourg, austria; 2 chru strasbourg-allergologie, strasbourg, france introduction: the purpose is to study the profile of cutaneous and molecular sensitization of patients sensitized to plantain pollen living in the north-east of france. objectives: the sera of 28 patients with seasonal pollinosis and cutaneous polysensitization including a positive test to plantain, are investigated through immunoblot (ib), elisa and immunocap. the plantain immunoblot is inhibited with plantain, grass, ash and birch pollen extracts as well as with pla l 1. the specific iges against pla l 1, phl p 1-5 and profilin are measured. results: pla l 1, the major plantain allergen is detected by ib in 10 cases out of 28, either in glycosylated or non-glycosylated form. an allergen of 35 kda is detected in 21 out of 28 cases, always and exclusively inhibited by the grass extract. the intensity of the spot is proportional to the anti-phl p 1 / phl p 5 ige levels, and corresponds to an allergen which is cross-reacting with grass. other cross-reacting allergens with grasses are detected at 30 kda (14/28), and at 50-54 kda (5/28). at the molecular weights of 15 to 17 kda, we detected in addition to pla l 1, cross-reacting allergens with grass, ash and birch pollen which predominantly corresponded to profilin which was confirmed by specific ige measurements in 20 cases. conclusions: among the patients included in this study, only 28% had genuine sensitization to plantago, which never corresponded to a monosensitization in our cohort. most often cutaneous sensitizations to plantain pollen were based on ige cross-reactivity with grass pollen allergens mainly through a 35 kda allergen and/or profilin. the strong environmental grass pollen pressure, compared to the low plantain pollen exposure, seems to be at the origin of this profile of molecular sensitization. these results reinforce the superiority of molecular diagnosis in patients with pollinosis, who are polysensitized. 0536 | sensitisation to peach tree pollen in a highly exposed population results: the 14% of subjects were sensitized to pp, which was the most prevalent after olive tree, grass and cypress pollens, respectively. sensitization to peach fruit was 8%. pru p 3 spt was tested in 30/78 pp positive cases, being 46% positive (14/30). specific ige to pru p 3 was detected in 4/10 pp sensitized individuals. immunoblot showed specific ige to different components in the pp extract, being the most frequent band recognised a 20-25 kda protein. conclusions: pp is a prevalent inhalant allergen in highly exposure areas. in our population pru p 3 was not identified as the major allergen. other pp molecular components need to be identified and their clinical relevance should be further investigated. introduction: allergic respiratory diseases increase after an exposure to airborne pollen, as asthma and allergic rhinitis, are deeply increasing and nowadays, they represent one of the major public health problems. olive pollen is one of the main causes of allergic disease in the mediterranean area, especially in northwest and west of the turkey. olive pollen has been characterized 20 proteins with allergic activity and ole e 1 is the major allergen of olea pollen. objectives: the aim of this study was to estimate the correlation between daily airborne olive pollen and ole e 1 in the atmosphere. aeroallergen load of ole e 1 detected by cascade impactor (chemvol) using prewashed polyurethane foam and pollen counts recorded by hirst trap. chemvol sampler collects particles at 800 l/minutes and it contains 2 impaction stages pm>10 micron and 10>pm>2.5 lm. this sampler is being tested in the frame of the project hialine. results: generally, similar behaviour of pollen count and total allergenic load of ole e1 was observed during the main pollen season. nevertheless, in some occasions, before and later of main period, airborne ole e 1 activity was recorded and some differences between pollen grain/m3 and allergen concentration/m3 were detected. pollen from different days released 11-fold different amounts of ole e1 per pollen. average allergen release from pollen was much higher in 2011 (1.11 pg ole e 1/pollen, r 2 =.44) than in 2012 (0.65 pg ole e 1/pollen, r 2 =.3148). indeed, yearly olive pollen counts in 2011 were 3.8 times higher than in 2012, but ole e1 concentrations were 2.2 times higher. these results have shown that ole e 1 is mostly associated with olive pollen grains but aeroallergen load was not always directly proportional to airborne pollen counts. this suggests that ole e 1 quantification is a better marker for olive allergen exposure. in conclusion, aeroallergen monitoring may contribute to a better understanding of the ole e 1 exposure from airborne pollen. objectives: to describe the clinical profile of the patients sensitized to alt at 6 and to assess the sensitivity of the prick test with the alternaria extract in comparison to the patients sensitized to both allergens alt a 6 and alt a 1. out of the 726 patients, 94 (12.9%) were sensitized to alternaria with specific ige of ≥0.3 isu to alt at 1 or alt a 6. twenty patients (11 females and 9 males, age 6-57 years old) who were sensitized to alt a 6 were selected. we analyzed the clinical profile, total ige values, other co sensitizations as well as the clinical relevance of alternaria sensitization in these patients. : of the 94 patients sensitized to alternaria, 20 (21.3%) were sensitized to alt a 6, of which 9 (9.6%) were monosensitized to alt at 6. the mean age was lower in monosensitized (ẋ 16.2 vs 25.2). among the 9 patients monosensitized to alt a 6, 4 (44%) had prick test negative with the alternaria extract. eight out of 9 patients were polysensitized to more than three different aeroallergens and were asthmatics (6 persistent). the median total ige was higher in monosensitized (859 ku/l vs 479 ku/l). of these 8 patients, alternaria sensitization has clinical relevance in 5 (62%), of which 3 have positive prick test to alternaria. all the patients (12/ 12) sensitized to both allergens have positive prick test to alternaria. ten of them were polysensitized, 8 were asthmatic (3 persistent) and 5 sensitized patients showed clinical relevance. introduction: the role of vitamin d as a potential immune-modulator has been recently elucidated. dendritic cell, a key regulator driving towards th2 immune response in allergic diseases is known to be affected by vitamin d. however, the role of vitamin d in the pathogenesis of allergic rhinitis is unclear and its anti-allergic effect has not been established yet, especially in the mouse model. objectives: the aims of this study are to evaluate 1) the anti-allergic effect of topically applied vitamin d in the allergic rhinitis mouse model, and 2) the effect of vitamin d on dendritic cell activation. results: balb/c mice were intraperitoneally sensitized with ovalbumin (ova) and alum, and they were intranasally challenged with ova. intranasal 1, 25-dihydroxyvitamin d3 was given to treatment group and solvent was given intranasally to sham treatment group. allergic symptom scores, eosinophil infiltration, cytokine mrna levels (il-4, il-5, il-10, il-13, ifn-c) in the nasal mucosa, serum total and ova-specific ige, igg1, and igg2a were analyzed and compared with negative and positive controls. cervical lymph nodes were harvested for flow cytometry analysis. in the treatment group, allergic symptom scores, eosinophil infiltration, and the mrna levels of il-4 and il-13 were significantly reduced compared to positive control. il-5 mrna level, serum total ige, and ova-specific ige and igg1 levels showed a tendency to decrease in the treatment group, but did not reach to a significant level. il-10 did not show a significant difference between groups. cd11c + , mhcii hi , cd86 + activated dendritic cells were significantly reduced in the treatment group. cd4 + , cd25 + , foxp3 + treg cells tended to increase in the treatment group, however it was not significant. the intranasal instillation of 1, 25-dihydroxyvitamin d3 has an anti-allergic effect in the allergic rhinitis mouse model. we believe that the anti-allergic effect of vitamin d is mediated by the inhibition of dendritic cell activation, and therefore decreased objectives: we wanted to assess whether treatment with cyclosporine and tacrolimus allows children with vkc to improve the level of vitamin d due to the higher summer sun exposure for good control of the ocular symptoms. objectives: our objective was to assess the expression of smad2 and smad5 proteins in patients with asthma in correlation with clinical parameters and the expression's changes in response to allergen and methacholine challenge test. the study included 151 patients with asthma and 77 healthy volunteers. spirometry, skin prick tests (spt), allergen and methacholine provocation tests were performed in compliance with standards. personalized clinic surveys including act tm were collected. venous blood was collected before and after provocation. the expression levels of il-5 and il-15 and smads were evaluated by qrt-pcr using isoform-specific primers. results: we showed correlation between the mrna expression of smad2 and the asthma control according to act tm (p<.001). the expression of smad2 is higher in the group of uncontrolled (2 -δct =0.52, p<.001) and in the group of partially controlled patients (2 -δct =0.50, p<.05) in comparison to the group of patients with controlled asthma (2 -δct =0.40). we proved that expression of mrna of smad5 correlates significantly with expression of il-5 and il-15 in patients with asthma (il-5 r=0.34; il-15 r=0.36) and in the control group (il-5 r=0.36; il-15 r=0.27) (p<.05). expression of smad5 elevates more after methacholine provocation test (median 2 -δct =0.69) rather than after allergen provocation test (median 2 -δct =0.51; p=.04). we showed also that skin prick test results correlate positively with smad5 level after the provocation (p<.001). conclusions: the loss of asthma control is connected with expression of smad2, which is part of tgf-ßrii related pathway. il-5 and il-15 correlates with smad5 expression, which can indicate the participation of these cytokines in the regulation of this pathway. the expression of smad5 elevates after methacholine and allergen provocation as well as it correlates positively with skin prick test results, which can be useful clinically. to sum up, tgf-ß-tgfßrii-smad proteins are an important mediators of inflammation in asthma. 0545 | deletion of nfatc1 in t lymphocytes affects th2 and th17 cell differentiation as well as il-9-mediated mast cell activation in allergic asthma objectives: analysing the role of nfatc1 in the allergic trait of human asthma. additionally, we investigated the influence of nfatc1 on t cell differentiation and immunoglobulin class switch and explored its impact on mast cell differentiation in experimental asthma. with the children 0 s hospital in erlangen, we studied nfatc1 mrna expression in freshly isolated pbmcs from pre-school children with and without asthma. in asthmatic children, we found increased nfatc1 mrna expression, especially in those with a positive skin test. these results were confirmed in the asthma bio-repository for integrative genomic exploration (asthma bridge) study, where the isoform a and d of nfatc1 were found significantly increased in asthmatic adults with a positive skin test. moreover, il-9 was also found increased in the supernatants of pbmcs of asthmatic children with a positive skin test. furthermore, mice with a deficiency of nfatc1 in cd4 + t cells display significantly lower levels of il-9. additionally, these mice show reduced numbers of lung th2 and th17 cells. moreover, basic leucine zipper atf like (batf), which is known as an important transcription factor for t cell differentiation as well as immunoglobulin class switch, was found decreased in these mice. consequently, ova-specific ige and total igg1 levels were found significantly decreased after allergen exposure and in the absence of nfatc1. furthermore, nfatc1 deletion also resulted in decreased mast cell numbers. we then analyzed the effect of il-9 on mast cell differentiation and histamine release. we observed that bone marrow differentiated mast cells incubated with ova and il-9 had an induced histamine release. conclusions: thus, nfatc1 deficiency in t cells results in defective ige production affecting ige-orchestrated mast cell activation mediated through il-9. therefore, nfatc1 emerges as a novel target for anti-allergy intervention. 0546 | efficiency of the use of nitric oxide donors for the treatment of bronchial asthma bazarova s; djambekova g center of therapy, tashkent, uzbekistan introduction: to study the influence of nitric oxide donor-l-arginine-on indicators of endothelial system in patients with bronchial asthma. objectives: 58 patients aged 27-55 years (41 ae 4.12 years) with moderate persistent bronchial asthma were examined. ratio of men to women was 30/28. two age-and sex-matched groups were randomly selected. main group (32 patients) received nitric oxide donor -l-arginine in addition to standard background therapy (gina, 2012) . the medication (100 ml of 4.2% solution, tivortin, "yuria-farm", ukraine) was administered intravenously once daily for 10 days. the control group (26 patients) only received the background therapy. the efficiency was assessed with the use of conventional methods of study (clinical laboratory methods, instrumental methods: spirography, peak flow monitoring, bronchomotor tests). concentration of nitric oxide stable metabolites in exhaled breath condensate (ebc) and in blood was studied. their ratio was also assessed. results: baseline data in patients of both groups demonstrated the increase of level of nitric oxide stable metabolites in blood (0.78 ae 0.02 mmol/l) and in ebc (0.43 ae 0.01 mmol/l). after the treatment the positive clinical efficiency of inclusion of l-arginine was much higher than that in the control group (p<.05). in the main group, reduction of requirement for beta2-agonists, decrease of frequency of night-time symptoms, decrease of frequency of lowest pef rate in the morning and improvement of respiratory function were observed on average on the 3rd/4th day compared to the control group were such improvements were evident on the 7th/8th day. in the main group the concentration of nitric oxide stable metabolites significantly increased in blood (0.59 ae 0.02 mmol /l, p<.05) and in ebc (0.21 ae 0.03 mmol/l, p<.05). in the control group the concentration of nitric oxide stable metabolites changed in blood (0.69 ae 0.06 mmol/l) and in ebc (0.32 ae 0.05 mmol/l), but not significantly. introduction: abpa is currently believed to be an exaggerated form of aspergillus sensitization, and is probably the first step in its development. objectives: the aim of this study was to investigate the clinical and immunologic characteristics of fungal-sensitive asthma (fa), nonfungal-sensitive asthma(nfa) and abpa. conclusions: there were different clinical and immunological features among nfa, fa and abpa. the abpa had worse function as well as higher percentage of bronchiectasis, and higher dose of oral corticosteroid. besides, the sensitivity to aspergillus was more severe in abpa. the level of sige-a.f was associated with the damage of lung function. 0548 | self-reported allergic rhinitis and/or allergic conjunctivitis associate with il13 rs20541 genotypes in finnish adult asthma patients introduction: the increased prevalence of asthma and allergic diseases is a major public health problem worldwide. atopy, family history, inhaled irritants, and upper airway inflammation are known risk factors of asthma. a population-based sample of finnish adult asthma patients (n=1156) and matched controls (n=1792) filled a questionnaire. asthma was diagnosed based on a typical history of asthma symptoms and lung function tests. skin prick tests (spt) with 17 aeroallergens and blood tests including analysis of interleukin 13 (il13) rs20541 (g/a) genotypes were performed for a subsample (n=193). objectives: our aim was to observe in adult asthmatics with and without allergic co-morbidities e.g. subject-reported allergic rhinitis and/or allergic conjunctivitis (ar/ac) association with il13 rs20541 genotypes and other factors. results: the proportion of asthmatics reporting ar was 61.9% and ac was 40.7%. after adjustments, the presence of il13 rs20541aallele (or=3.06 ci=1.42-6.58, p=.004) or multi-sensitization (adjusted or=4.59, ci=1.48-14.26, p=.008) associated with ar/ac-asthma. nasal polyps and aspirin-exacerbated respiratory disease associated also with ar/ac-asthma. conclusions: adult ar/ac-asthma could putatively be a phenotype, characterized by the presence of atopic and/or eosinophilic factors and a high prevalence of the il13 rs20541a-allele. studies on the mechanisms behind this and in other populations are needed. 0549 | immunoregulatory role of nfatinteracting protein (nip) 45 in adaptive and innate immune responses in allergic asthma introduction: nfat-interacting protein (nip) 45 is a th2 associated transcription factor. after t cell receptor stimulation, the arginine methylation domain of nip45 supports the interaction with nfat, thereby enhancing the production of the th2 cytokine il-4. moreover, nip45 deficient mice have been shown to be deficient in il-4 and ifn-gamma production indicating that nip45 controls both th1 and th2 cytokine production and might therefore play a protective role in allergic asthma . objectives: we wanted to analyze the importance of nip45 in allergic asthma in pre-school children as well as adults. furthermore, we investigated the role of nip45 in a murine model of allergic asthma to find out more about its contribution to adaptive as well as innate immune responses in the disease. results: in the european study predicta, in collaboration with the children 0 s hospital in erlangen, we analyzed nip45 mrna expression by using quantitative real time pcr in rna extracted from pbmcs isolated from pre-school children with and without asthma. in the pbmcs of the asthmatic children, nip45 mrna expression was found significantly increased compared to healthy control children. furthermore, nip45 mrna expression was also found induced in cd4 + t cells in adult asthmatics from the asthma bio-repository for integrative genomic exploration (asthma bridge) study. we further analyzed the importance of nip45 in a murine model of allergic asthma. after allergen sensitization and challenge nip45 (-/-) mice showed decreased airway hyperresponsiveness, inflammation and mucus production, three of the main patho-physiological features of asthma. additionally, we discovered that nip45 (-/-) mice released decreased th2 type cytokines and also expressed less st2, which is the receptor for il-33, after allergen challenge. furthermore, a defect in innate lymphoid cell type 2 (ilc2) differentiation was observed in the absence of nip45 in allergic asthma and in bone marrow differentiated ilc2s indicating a crucial role for nip45 in mediating asthma via ilc2s. conclusions: in summary, we found that the lack of nip45 influences not only immune responses of the adaptive immune system but also influences components of innate immunity resulting in a abstracts | 181 protective phenotype to allergic diseases such as asthma. objectives: in the study were included 40 ap and 10 healthy controls (hc). fraction of exhaled no (feno), standard lung function parameters, complete blood count and absolute count of cells, serum ige, crp, il-6, il-17a and periostin were measured. results: four clusters were identified by cluster analysis: cluster 1 (c1)(n=14)-late-onset, non-atopic, eosinophilic asthma with impaired lung function, cluster 2 (c2)(n=13)-late-onset, atopic asthma, cluster 3 (c3)(n=6)-late-onset, aspirin sensitivity, eosinophilic asthma and cluster 4 (c4)(n=7)-early-onset, atopic asthma. we have found higher levels of il-6 in all clusters ap as compared to hc (c1: p=.001, c2: p=.017, c3: p=.012 and c4: p=.003). tendency for higher levels of serum il-6 in c1 compared with c2 or c4 (p=.089 or p=.062, respectively) was observed. periostin levels were significantly higher in c1 (p<.001), c2 (p<.001) and c4 (p<.01) as compared to hc. there were no differences in periostin levels between all clusters (anova, p=.389). il-17a levels were significantly higher only in c4 as compared to hc or to c1 and c2 (p<.05, for each comparison). we have found correlation between il-6 and crp (r=.640; p=.014) in c1, il-17a and periostin in c1(r=.631; p=.016) and in c2 (r=.641; p=.018). interestingly, we have observed negative correlation between the duration of asthma and il-17a (r=à.886; p=.019), but positive between the duration of asthma and crp (r=.886, p=.019) in c3. our results have shown higher levels of il-6 in all clusters as compared to hc that are associated with marker for systemic inflammation. periostin levels were significantly elevated in c1, c2 and c4 as compared to hc with no differences between the clusters. a positive correlation between periostin and il-17a in c1 and c2 was observed, that rising the question about their interrelationship in the pathogenesis of late-onset asthma. serum il-17a was significantly higher in c4 in comparison with hc or c1 and c2 suggesting that th17 mediated immunity may be involved in early-onset, atopic asthma. these data support the concept of heterogeneity of the bronchial asthma. 0551 | eosinophil activation with autophagy and extracellular dna traps is involved in severe asthma results: il-5+lps treatment significantly increased autophagy and eet levels from pbes of the study subjects (p<.05 for all), which were in a positive correlation (r=.802, p<.001). compared to nsa patients, both untreated and il-5+lps-treated pbes from sa patients had significantly higher autophagy levels (p=.007 and .002, respectively), while only il-5+lps-treated pbes from sa patients had higher eet level (p=.036). eet level from untreated pbes was correlated with serum eosinophil cationic protein level (r=0.608, p=0.036) and fev1% predicted value (r=à.620, p=.056). co-culture of aec with pbes slightly increased il-8 production, which was significantly enhanced by il-5+lps treatment (p<.001). the il-8 production in co-culture system was reduced by pretreatments with dexamethasone (1 mm, p=.001), antibodies against major basic protein (200 ng/ml), il-5 receptor (1 mm) and il-4 receptor (1 mm, p=.05 for all), but increased by cotreatment with micrococcal nuclease (10 iu/ml, p=.001). conclusions: pbes from sa patients are highly susceptible to be activated to produce high levels of autophagy and eet, which could enhance and maintain airway inflammation. we suggest that steroid and anti-il-5/il-4 receptor antibodies may be beneficial to control airway inflammation in severe eosinophilic asthma via inhibition of eet production, while dna digesting reagents may increase airway inflammation. introduction: it has been demonstrated that exposure to stress induce hyporeactivity of the hpa system by modifying the secretion of cortisol and also that psychosocial stressors such as poor social status are associated with an increased risk of childhood asthma, decreased serum cortisol and high ige response. thus, from this concept it could be postulated that a blunted hpa axis response may increase the risk for allergic inflammatory reaction. objectives: aim of this study was to evaluate the association of serum cortisol in pediatric allergic bronchial asthma and its influence on the ige immune response in a poor children community with psychosocial chronic stress. results: this was a pilot analytical case control study(50 ipa positive subjects and 50 healthy control paired by age and gender, both from poor areas of barranquilla objectives: in order to characterize bp14 an immunoproteomics analysis was conducted, i.e. electrophoretic separation of cypress pollen extracted proteins, ige western blotting using cypress pollen allergic patient's sera and mass spectrometry (lc/ms/ms) for identification of ige-binding proteins. results: ms analysis using chymotrypsin identified in bp14 a peptide also found in the family of protein snakin/gibberellin-regulated protein (grp). the snakin-1, an anti-microbial peptide of potato, produced as a 63 amino-acid recombinant protein (homologous to the c-terminal part of grp), is recognized by ige from cypress pollen allergic patients with ige to bp14. this ige reactivity is abolished after reduction of disulfide bridges and is inhibited by a cypress pollen extract. ige reactivity to bp14 is however barely inhibited by the recombinant potato snakin-1. conclusions: bp14 exhibits a molecular mass closer to grp than to snakin and the absence or very low inhibition of the ige reactivity to bp14 with snakin may be explained by peptidic ige epitopes on the n-terminal part of bp14. the potato snakin-1 share 83% sequence identity with peamaclein, the peach allergen pru p 7, also shown in citrus. these results might explain the peach/cypress and citrus/cypress syndromes described and point out bp14 as the cross reactive allergen. the proteins of snakin/grp family present in many fruits and vegetables might include allergens involved in pollen/food associated syndromes. introduction: exposure to high levels of grass pollen may lead to a high degree of allergic inflammation, sensitization to minor allergens, such as profilin, and development of severe profilin mediated food reactions, similar to those described due to sublingual immunotherapy (slit). objectives: our objective here was to identify genetic biomarkers in order to generate a model that can improve the classification and treatment of patients with a higher probability of developing severe adverse reactions. results: 6 healthy subjects (group 1, control) and 17 patients with mild (group 2) or severe (group 3) profilin mediated food reactions were studied. rna extraction was performed on ficoll-isolated pbmcs using the rneasy ® mini kit (qiagen) and its integrity was analyzed with experion rna stdsens analysis kit (bio-rad). the gene expression profile of all the samples was analyzed using the gene-chip ® wt plus reagent kit (affymetrix) and two specific software: affymetrix ® expression console ™ and affymetrix ® transcriptome analysis console (tac). finally, the microarray data was validated by quantitative real-time pcr (qpcr). the hierarchical clustering of the samples shows the separation of the patients into three clusters coincident with the three established clinical groups (control, mild and severe). genetic profile of patients with mild reactions is similar to healthy patients while severe subjects were significantly different from the other two groups. genes regulated in the severe group were related to histone modification pathways, human complement system, cell adhesion and tgf-b and its receptor. these changes may be associated with the different degree of inflammation between patients in each experimental group. in the course of our study we found out that severe patients had different rna expression patterns compared to mild and non-allergic patients. this lead to the identification of genetic biomarkers useful for the generation of a model able to predict severe reactions and/or adverse reaction during immunotherapy, thus improving the diagnosis and treatment of this type of allergic results: his-tagged recombinant allergens, namely parvalbumin, aldolase, enolase and tropomyosin from c. idella and l. crocea, as well as cod parvalbumin, were synthesized in e. coli and purified using immobilized metal-chelate chromatography. 14 children with history of immediate-type fish allergy were included in this study and their serological ige reactivity to the fish allergen components were measured by elisa. 11 children were positive to at least one allergen component, with nine of them being positive to parvalbumin. despite the high similarity between l. crocea, c. idella and cod parvalbumins (70.6-81.6%), three children only reacted to l. crocea and c. idella parvalbumin but not to cod parvalbumin, while the other six children were positive to all three parvalbumins. competitive inhibition elisa revealed that c. idella parvalbumin inhibited >85% of the binding of specific ige to both l. crocea and cod parvalbumin, while reciprocally only inhibition of 60% and 50% could be achieved respectively. two children were reactive to aldolase and enolase but not parvalbumin. one of them had positive sige to both enolase and aldolase from l. crocea, while the other reacted to aldolase from both species. these two children exhibited relatively mild subjective allergy symptoms (itchy skin and throat). notably, three children were non-reactive to all components tested, and two of them were outgrowing fish allergy clinically. introduction: anti-a-gal antibodies are naturally produced in response to the gastrointestinal flora. in red meat allergy, patients develop ige antibodies towards the a-gal epitope, which itself are structurally closely related to the blood group b antigen. objectives: this study aimed to explore the relationship between a-galand b-antigen-specific antibodies in red meat allergic patients compared to healthy individuals with blood group b or a/o. sera from 39 red meat allergic patients and 84 healthy blood donors of whom 52 belonged to blood group b and 32 to blood group a or o were included. ige reactivity against a-gal and the b-antigen were determined using immunocap. allergen-specific igg, igg1, igg2, igg3, igg4 and ige were assessed by indirect elisa assay. statistical analysis was performed using spearman rank correlation and unpaired t-tests. results: all red meat allergic patients, 12 of the healthy a/o and 3 of the healthy b donors were ige positive to a-gal. however, the ige levels to a-gal were significantly higher in the allergic group compared to the healthy a/o and b individuals. the majority of the meat allergic patients, but none of the healthy individuals had ige antibodies against the b-antigen. a moderate correlation between a-gal and b-antigen specific ige was noted (r 2 =.48). the red meat allergic patients had significantly higher igg levels against a-gal with igg1 and igg4 antibodies as the predominant difference compared to the healthy individuals. the 12 healthy a/o ige positive individuals had significantly higher igg1, igg3 and igg4 compared to the ige negative individuals. the igg response to the b-antigen followed the same pattern as to a-gal. there was a low correlation between the igg levels against a-gal and the b-antigen in both meat allergic patients and healthy a/o individuals (r 2 =.30 and .33). introduction: fx5, a food mixture of milk, egg white, fish, peanut, wheat and soybean, is largely used for food allergy detection. besides the fact that it is questionable if this is the better approach to identify a food allergy, the information that the test provides may represent a pitfall because a positive or negative result does not mean food allergy presence or absence, respectively. objectives: the goal of our study was to access the reason for fx5 request in a pediatric hospital and to analyze its suitability. methods: the fx5 requests, performed in a pediatric population of d. estefânia hospital over a five months' period, were analyzed, concerning demographic data, reason for request and attitude taken due to the result. this test was requested due to respiratory symptoms in 37 patients, gastrointestinal symptoms in 23 patients, cutaneous symptoms in 20 patients and nonspecific complaints in 48 patients. all of these symptoms were not directly related with food intake. a positive result was obtained in 25 patients; of those, only 15 were referenced to our immunoallergology department. in all of them a detailed clinical history was obtained and diagnostic tests (skin prick tests and specific ige) were performed in the ones considered suitable. food allergy was diagnosed in only one patient. conclusions: in the vast majority of patients, fx5 was asked for nonspecific complaints and often without a clinical history suggestive of food allergy. moreover, a positive fx5 test does not mean clinical reactivity or food allergy. on the other hand, the clinical history allows us to identify a suspect trigger in most of the children with food allergy. in such cases, it is preferable to request the specific ige towards the allergen, which gives a more precise and accurate result, instead of the fx5. as our results showed, in the majority of the cases, the fx5 request was often made without complying with a reasonable criterion, implying unnecessary costs. the high number of requests verified may be explained because it is an easily accessible analysis but this attitude should be discouraged. tuppo l 1 ; alessandri c 2 ; pasquariello s 3 ; petriccione m 3 ; giangrieco i 1 ; tamburrini m 1 ; rafaiani c 2 ; ciancamerla m 2 ; mari a 2 ; ciardiello ma 1 1 istituto di bioscienze e biorisorse -ibbr-cnr, naples, italy; 2 caam -centri associati di allergologia molecolare, rome, italy; 3 cra, research unit on fruit trees, caserta, italy introduction: pomegranate, punica granatum l., is one of the oldest cultivated fruit trees. the fruit contains the arils, which are seeds covered by a red pulp, that is a juice sac. the arils are surrounded by the white and fleshy mesocarp. pomegranate can trigger allergic reactions, but the allergenic pattern of this fruit is still poorly characterized and only one allergen, the ltp pun g 1, was reported. objectives: the aim of this study was the investigation of the allergen pattern in pomegranate tissues and cultivars. reported symptoms were food impaction (68%), dysphagia (65%), heartburn (33%) and vomiting (30%). the first 2 symptoms were more frequent in adolescents and adults (96%). children's main complaint was vomiting (73%) and 4 cases presented failure to thrive. most patients had associated allergic diseases (88%), 23% had previous food allergy and 74% were sensitized to aeroallergens. endoscopic evaluation revealed esophageal stricture in 5 patients. at least half of diagnostic esophageal biopsies had >20 eosinophils per highpower field and 33% showed microabscesses. food sensitization was found in 61% of the patients, mainly to cow's milk (46%), nuts and peanut (33%), cereals (30%) and egg (21%). considering therapeutic approach, 88% were treated with swallowed fluticasone and dietary elimination was recommended in 54%. oral corticosteroids were prescribed in 8 patients. at present time 42 patients had done endoscopic reevaluation, 30 (71%) showed histologic resolution. five patients had clinical and histologic relapse during follow-up. conclusions: eoe has a balanced distribution but a distinctly clinical presentation accordingly to age group: children may present unspecific symptoms like vomiting, whereas adolescents and adults complain of food impaction and dysphagia. other atopic diseases and food sensitization is very common. introduction: air pollution, particularly ambient air particulate matter (pm), is considered as one of the most important environmental risks for human health. pm could potentially disrupt immune regulatory mechanisms and predispose exposed individuals to asthma. in contrast, children exposed to traditional farm environment seem to have a natural resistance to asthma. this phenomenon links with exposure to stable dust and subsequent immune regulatory mechanisms initiated in the airways. the underlying exposure agents and definitive pathways determining the risk of asthma are still to be identified. objectives: our aim was to investigate the effect of urban air pm (high risk environment) and farm dust (protective environment) on immune responses in finnish children. briefly, peripheral blood mononuclear cells (pbmcs) of 4-year-old children (n=18) were stimulated with farm dust extract (40 lg/ml, stable in northern savonia, finland) and pm samples (75 lg/ml, pm 2.5-1 , pm 1-0.2 or pm <0.2 , nanjing, china) for 18 hours. expression of immunogenic cd80 and tolerogenic ilt4 in circulating myeloid dendritic cells (mdcs) and plasmacytoid dcs (pdcs) and monocytes were analyzed by flow cytometry. pm samples were analyzed for polycyclic aromatic hydrocarbons (pahs), inorganic ions and elements. farm dust sample will be analyzed for microbial content. results: pm stimulation decreased the percentage of cd80+ monocytes and dcs among children's pbmcs, whereas farm dust stimulation increased the percentage of cells positive for this marker. the percentage of tolerogenic ilt4+ was decreased in all cell types after stimulation with pm. farm dust also decreased the percentage of ilt4+ monocytes, but not dcs. specific metals and pahs in pm associated with the studied immunological parameters. conclusions: samples from high risk and protective environments have differing capacities to influence immunogenic and tolerogenic properties in children's immune cells. the importance of these findings in relation to the risk of asthma in exposed populations will be studied further. introduction: alterations in cell surface glycosylation pattern is a common feature of tumor cells that might be related to immune evasion and malignancy. objectives: to study the capacity of the carbohydrate a10 (ca10) located in the surface of murine ehrlich tumor (et) cells and also in certain human adenocarcinomas to condition the phenotype and function of human dendritic cells (dcs) and the capacity to polarize t cell responses. results: nf-jb/ap-1 are not activated in thp1 cells by ca10, however, this carbohydrate partially impairs the activation of these transcription factors induced by the tlr2 ligand pam3csk. ca10 induces the expression of the tolerogenic marker pdl1 in human monocyte-derived dcs (hmodcs) as well as the production of il-6 and il-10, analyzed by flow cytometry and elisa assays respectively. ca10-activated hmodcs generate functional il-10-producing cd4 + cd25 high cd127 -foxp3 + regulatory t (treg) cells that were able to inhibit the proliferation of cd4 + t cells from pbmcs in a dose-dependent manner. supporting the role of ca10 in the induction of treg cells, our in vivo data showed that the ca10 is present in the sera of tumor bearing mice and the percentage of foxp3 + treg cells is increased in the regional (inguinal) lymph nodes from tumor bearers. our results showed that ca10-activated hmodcs induce the generation of foxp3 + treg cells both in vitro and in vivo, which might well condition the immune response against the tumor and promote the tumor escape. 0567 | assessment of changes in expression of immune system biomarkers to assist the differential diagnosis of acute bacterial infections introduction: biomarkers for acute infections include c-reactive protein, mmp-9, sicam-1, procalcitonin, and neutrophil band counts for bacterial infection. a rapid means of assessment of acute bacterial infections via biomarker assessment was sought. objectives: the expression of toll-like receptors (cd282 and cd284), complement receptors (cd35 and cd88), integrins (cd11b and cd11c), fc-receptors (cd32 and cd64) and l-selectin (cd62l) on the surface of blood neutrophils and monocytes stimulated with inactivated e. coli, l. acidophilus, e. coli derived bacterial ghosts, e. coli lps and l. acidophilus cell walls was assayed using flow cytometry. both the percent of expression and mean fluorescence intensity (mfi) were analyzed for each molecule. results: all the bacterial components used exerted similar activation capabilities even in low concentrations. while the expression of cd11b, cd11c, cd32, cd35 and cd88 was enhanced by both neutrophils and monocytes under activation, the expression of cd64 significantly increased only in neutrophils. the expression of tlr2 and tlr4 was slightly increased by neutrophils and monocytes. the expression of cd62l by monocytes and neutrophils (the percent of activated cells as well as the mfi) was decreased during activation. there was a negative correlation between cd62l expression and integrins (cd11b and cd11b). the activation index was calculated for each molecule as a ratio of expression of molecule by activated cells vs cells used as a negative control (resting). the highest values for the activation index was seen with cd11b, cd11c, cd32, cd35, cd62l and cd88 mfi by neutrophils and monocytes, and the percent of cd64 expression by neutrophils. conclusions: e. coli and bacterial ghosts significantly increased the expression of cd11b, cd11c, cd32, cd35, cd62l and cd88 by neutrophils and monocytes even in very low concentrations, suggesting use as potential biomarkers in the differential diagnosis of the etiology of acute infections. objectives: the aim of this study was to evaluate changes in peripheral blood monocyte expression of cd16, cd163, cd206, cd209, hla-dr, and cd47 in kidney allograft recipients. in total, 88 patients who underwent renal transplantation from a deceased donor were enrolled in the study. the phenotype was evaluated by a multicolor flow cytometry in defined time points and in the case of complications requiring fine needle aspiration biopsy procedure. the results confirmed our pilot data, proportions of peripheral cd14+cd16+ monocytes were downregulated during the first week after the kidney transplantation while the percentage of cd14+cd163+ monocytes dramatically increased early after the kidney transplantation and remained high for at least four months in most patients. the expression of cd206 (marker of m2 macrophages) was limited only to a small population of monocytes (less than 5% in most patients) but the receiver operating characteristic (roc) curve analysis showed its potential importance by significant correlation with acute rejection with a sensitivity of 70% and specificity of 80.33% (area under the roc curve 0.7787, p-value: 0.004973). no correlation between two different m2 markers cd163 and cd206 has been found. the expression of cd209 (dc-sign) was low and did not show any changes in time or association with acute rejection. hla-dr (mhc ii) and cd47 (integrin associated protein) were constitutively expressed without any significant changes in patients with acute rejection of the allograft. we assume from our data that kidney allograft transplantation is associated with early reciprocal modulation of monocyte subpopulations (cd14+cd16+ and cd14+cd163+). a decreased proportion of cd206 positive blood monocytes seems to be associated with an increased risk of acute rejection of kidney allograft. introduction: thioredoxin (trx), a 12-kda oxidoreductase enzyme, is well known to be a redox-active protein that regulates reactive oxidative metabolism. in addition to its anti-oxidative activ0570 | progranulin-dependent regulation of th2 airway inflammation by house dust mite allergen introduction: progranulin is a growth factor that consists of 593 amino acids including 71/2 repeats of cysteine-rich motifs, and produced by variety kinds of cell. progranulin is involved in the regulation and maintenance of inflammatory response, and its role is wellstudied in neuronal and metabolic diseases such as neurodegeneration and type 2 diabetes. however, the role of progranulin during the development of airway inflammation induced by inhaled allergen is still obscure. objectives: in this study, we evaluated the role of progranulin in the development of th2 airway inflammation induced by house dust mite allergen. results: to find the main source of progranulin, we stimulated each cell line with various doses of house dust mite allergens. the production of each cytokine, including progranulin, was estimated in culture supernatant by elisa. to investigate the role of progranulin in airway inflammation, we intranasally administrated house dust mite allergens to 6-week-old female progranulin knock-out mice (macrophage-specific) or littermate mice. lung inflammation and immunological parameters were evaluated at 15 h after first sensitization with allergen or 24 h after final allergen challenge. the production of progranulin was significantly elevated by house dust mite allergen stimulation in innate immune cells, especially in alveolar macrophages over other cells. in the house dust mite allergeninduced airway inflammation model, we found that the level of progranulin increased earlier than other pro-inflammatory cytokines. in addition, in macrophage-specific progranulin knock-out mice, airway inflammation was down-regulated in the earlier phase after exposure to house dust mite allergen. moreover, we stimulated mice with house dust mite allergen for a longer period to observe the changes in the adaptive immune response of th2 airway inflammation, which was found to be decreased in conditional knock-out mice. conclusions: these findings indicate that th2 airway inflammation induced by house dust mite allergen is dependent on progranulin. objectives: the aim of the present study was therefore to investigate the immunomodulatory effect of epinephrine on m2a macrophages and its consequence on cross talk to mast cells in a human model of allergic inflammation. results: primary monocytes from healthy pbmcs were first differentiated into m2a macrophages using m-csf in the presence of il-4 and il-13 cytokines. after overnight incubation with epinephrine, supernatants were collected and analyzed by elisa for il-10, tnf, il-6, ccl1, il-12 and ifn-c, whereas cell surface markers including cd206, cd163 and cd86 were evaluated using flow cytometry. subsequently, both m2a and epinephrine-treated m2a supernatants were transferred onto cord blood-derived mast cells (cbmcs) for further overnight incubation, after which ige-mediated degranulation was assessed by the ß-hexosaminidase release assay. after overnight epinephrine treatment, m2a macrophages showed an increase in il-10, ccl1, tnf and il-6 production, but no ifn-c and il-12 expression was observed. epinephrine treatment also downregulated surface markers cd206 and cd163 and upregulated cd86. when supernatants from epinephrine-treated m2a macrophages were added to cbmc cultures, ige-mediated degranulation was impaired compared to cbmcs treated with supernatants of unstimulated m2a macrophages. conclusions: taken together, epinephrine promoted a phenotypic shift of m2a polarized human macrophages toward an m2b-like regulatory phenotype that was able to reduce the ige-mediated degranulation of cbmcs. we conclude that prolonged acute stress exposure in allergic patients may attenuate symptoms of acute allergy by directing macrophages towards an immunosuppressive phenotype, which can further dampen mast cell degranulation. objectives: a murine local lymph node assay was used to investigate the effect of oa on the immune response to the known skin sensitizer hexyl cinnamic aldehyde (hca, 25% w/v). the ear lobes tape stripped prior to immunization. test solutions (25 ll) were applied on the dorsal side of each ear on three consecutive days. female balb/c mice (8 groups a 6 mice), were exposed to the vehicle acetone:olive oil (4:1) alone, or in combination with hca, with or without oa in the concentrations 5, 10 and 20%, or oa alone (5, 10 and 20%). on day 5, the animals were weighed and exsanguinated by cardiac puncture. the auricular lymph nodes were harvested for single cell preparation, stimulation with cona and cytokine release of il-2 and il-17. the earlobes were excised and fixed for immunohistochemistry. results: no group differences were found for bodyweights or bodyweight change, number of lymph node cells or il-17 secretion. il-2 showed a tendency of dose-related increase, but a significant difference were only found between hca and hca+10% oa (p=.034) in one out of the two experiments. in he stained sections, the epidermal thickness was significantly increased in groups given hca + 10 and 20% oa (p≤0.001). sections immunostained with anti-ly6g showed significant increase in neutrophil influx for the same groups as above (p≤0.001). oa alone showed no effects or effects significantly lower than hca + oa. objectives: we hypothesized that plasma s1p levels in cf patients might be associated with cftr mutations and could influence disease presentation. results: plasma was collected with a defined standard operation procedure to impede unspecific s1p release from blood cells from 20 double lung transplanted adult cf patients as well as 20 sex-and age-matched, non-allergic healthy controls all being fasted overnight. total plasma s1p was measured by mass spectrometry and unbound plasma s1p by elisa. levels were correlated with cftr mutation status, routine laboratory parameters and clinical symptoms. we observed higher total and unbound plasma s1p levels in healthy controls compared to cf patients with the latter value reaching statistical significance (p=.044) after exclusion of two statistical outliers. unbound plasma s1p levels were significantly higher in df508 homozygous cf patients compared to patients with df508 heterozygosity (p=.029). 2 patients with other mutations were excluded. levels of unbound s1p were positively correlated with hemoglobin and negatively correlated with triglyceride levels. additionally, we observed a positive correlation of total plasma s1p levels in cf patients with hba1c. gastrointestinal symptoms were more common in df508 heterozygous (6/8) compared to df508 homozygous cf patients (4/10). fecal calprotectin levels were found to be significantly higher in df508 homozygous compared to heterozygous cf patients (p=.047). differences in unbound s1p levels were not correlated with immunosuppressive treatment after transplantation. conclusions: to the best of our knowledge this is the first clinical study directly correlating plasma s1p levels with cf genotypes and clinical presentation in cf patients. we emphasize to evaluate s1p as a potential novel disease biomarker as well as a therapeutic target for cf in future studies. supported by the austria science fund grant kli 284 (to eu). ochoa-grull on j 1 ; tejera-alhambra m 2 ; guevara k 1 ; guzm an-fulgencio m 2 ; benavente cm 3 ; mart ınez r 3 ; p erez c 3 ; peña a 3 ; rodr ıguez de la peña a 1 ; llano hern andez k 1 ; rodr ıguez-fr ıas e 1 ; s anchez-ram on s 1 objectives: we show preliminary data of one study aimed to evaluate the use of this strategy in the prevention of rrti in infants and preschool children. results: patients: 121 children (70 male and 51 female, age range 6-35 months) were included in a randomized double blind and placebo-controlled study (eudract 2012-002450-24) . all of them showed negative in vivo and in vitro allergy tests. active treatment consisted in a suspension of a mixture of selected strains, grown and inactivated in optimal conditions, of s. aureus (15%), s. epidermidis (15%), s. pneumoniae (60%), k. pneumoniae (4%), m. catarrhalis (3%) and h. influenzae (3%) in physiologic saline solution with 50% glycerol at a concentration of 300 formazin turbidity units (ftu)/ml (equivalent to 10 9 bacteria/ml). placebo did not contain any bacteria. patient were treated for a period of 6 months, receiving 2 daily sublingual puffs of active or placebo and with a follow-up of other 6 months (total period of evaluation was 1 year). symptom (cough, dyspnea, wheeze, mucus, fever, discomfort) and medication (inhaled corticosteroids, beta adrenergics, montelukast, antibiotics) scores were evaluated since the first day of treatment to the end of the study (1 year) . any adverse event was recorded to assess safety. for the comparison between both groups, t test was used. patients who received active treatment experienced an improvement of 39% over placebo in overall symptoms and 38% in medications scores (p<.01). in the combination of symptoms and medication scores the improvement was 38% (p<.0001). no adverse events related to treatment were recorded. conclusions: immunostimulation with these selected strains of bacteria is safe and can be successfully used in infants and preschool children in order to prevent rrti. introduction: to reduce the duration and the risk of the allergen specific immunotherapy using commonly used allergen extracts, new highly immunogenic and non reactogenic vaccines are needed. objectives: the goal of the present study was to employ the ap205 spytag/catcher system to develop a virus-like particle (vlp) vaccine based on the major house dust mite (hdm) allergen der p 2 and to evaluate its reactogenicity in vitro. spycatcher-ap205 vlps and recombinant der p 2, fused at the c-terminus to the 13 amino acid spytag binding-partner, were expressed in e. coli. purified spytagged der p 2 was mixed with spycatcher-vlps, which resulted in covalent conjugation of der p 2 to the surface of spycatcher-vlps. excess unbound der p 2 was removed by dialysis. dynamic lightscattering (dls) was used to analyse the size and aggregation state of vlp-der p 2. the ige reactivity of vlp-der p 2 was assayed by direct elisa and by rat basophil degranulation assays. conclusions: our results demonstrate that coupling of spy-tagged der p 2 to ap205 spycatcher-vlps dramatically reduces the reactogenicity of the allergen, suggesting that vaccination with ap205 vlp-der p 2 may be a safe and effective treatment for hdm allergy. objectives: the qm1s hybrid protein is a qm1 variant where cysteine amino acids have been replaced by serine. the expression of qm1s hybrid protein was performed in e. coli bl21(de3) after iptg induction. the purification of qm1s protein was performed from inclusion bodies by a three-step chromatography process. the stability of qm1s was analyzed by sds-page and total protein assay. qm1s ige-binding capacity was compared with natural der p 1 and der p 2 by elisa-inhibition and allergenicity was studied by mediator release from rbl cells. immunogenicity was evaluated in mice by analysis of the specific igg response to der p 1 and der p 2. results: qm1s was expressed in complex media as inclusion bodies that were solubilized in urea. soluble protein was purified by anionic ion exchange, hydrophobic interaction, and size exclusion chromatography in the presence of a detergent. qm1s purification process was shorter and more efficient than that of qm1. the purity obtained was >95%. elisa inhibition assay showed that qm1s hybrid protein was almost unable to inhibit ige-binding to the hdm extract, less than 10% in all the range of concentrations tested (0.1-10 000 ng/ml) and representing a 40-fold reduction as compared to qm1. qm1s showed a great reduction of the b-hexosaminidase release in rbl cells, compared to der p 1 and der p 2. qm1s was able to induce der p 1-and der p 2-specific lgg antibodies responses comparable with those induced by the mixture of wildtype allergens. mouse igg antibodies induced by the hybrid proteins qm1s and qm1 showed similar ige-blocking antibodies properties to mixture of der p 1 and der p 2. the stability of qm1s was studied in solution at 25°c, 4°c, and -20°c and lyophilized at 4°c, being the frozen and lyophilized forms the best conservation conditions. the qm1s hybrid exhibited less ige-binding activity than qm1 and the natural der p 1 and der p 2 while retained the immunogenicity. these properties together with the improved manufacturability made qm1s a good candidate for sit to hdm allergy. objectives: slit tablets of cockroach, slit tablets of parthenium, slit tablets containing both allergens together (mix) and slit bilayer tablets containing one layer with parthenium allergen and other layer with cockroach allergen, compress to single tablet were prepared. punches and dies of 11 mm were used for compression. slit drops containing cockroach, slit drops of parthenium and slit drops containing both allergens together, were prepared and filled in 10 ml amber colored dropper vials. results: tablet formulations were evaluated for thickness (3.5-3.6 mm), weight variation (357-402 mg), hardness (2.0-2.5 kg/cm 2 ), disintegration time (not more than 2 min.), and biologically active content (90%-110% of the stated label claim). in-vitro dissolution test was performed as per usp using distilled water as the medium and the release was shown between 70 to 80% in 5 minutes. the liquid formulations were analyzed for ph (7.0 -7.5), the biological content (90% -110% of the label claim), specific gravity ( introduction: virtually all patients suffering from the common birch pollen allergy exhibit ige against the bet v 1 relevant allergen. as such, an elisa method for the quantification of bet v 1 was selected and validated as part of the bsp090 project, aiming to establish reference methods for the european pharmacopoeia. herein, we report the mapping of the epitopes recognized on recombinant bet v 1 allergen by the two specific murine monoclonal antibodies (mabs) used for the accurate and precise quantification of bet v 1 within birch pollen extracts. objectives: in order to investigate the ability of mabs 5b4 and 6h4 to recognize various bet v 1 isoallergens, we first carried out immunochromatography combined with electrophoresis. epitope mapping was performed by hydrogen/deuterium exchange (hdx) coupled with mass spectrometry (ms) analysis, using a gmp-grade purified rbet v 1 molecule. results: immunochromatography unveiled that both mab 5b4 and mab 6h4 capture most of bet v 1 isoallergens present within birch pollen natural extracts. those two mabs cross-react with the aln g 1 allergen from alder pollen but do not react with the cas s 1 chestnut pollen allergen. hdx-ms experiments combined with site-directed mutagenesis evidenced that mabs 5b4 and 6h4 target two distinct epitopes. the hdx-defined 5b4 epitope is discontinuous and contains a dominating sequential element (i.e., loop ile56-lys68). the hdx-defined 6h4 epitope is also discontinuous and mainly composed of regions ile44-lys55 and arg70-phe79. conclusions: overall, this study provides a precise molecular characterization of epitopes within bet v 1 recognized by mabs 5b4 and 6h4, confirming that these two antibodies target distinct non-overlapping epitopes and recognize the vast majority of currently introduction: short or common ragweed (ambrosia artemisiifolia), belonging to the aster plant family, sheds enormous amounts of highly allergenic pollen late in the summer. due to its high allergenic potential ambrosia artemisiifolia is becoming a health threat in north america and europe. hal allergy is developing a subcutaneous immunotherapy for patients suffering from ragweed pollen allergy. a standardized ragweed pollen extract, chemically modified and adsorbed to aluminium hydroxide (al(oh) 3 ), is being investigated for its potential use in immunotherapy. objectives: ragweed extract (re) was modified by glutaraldehyde followed by adsorption to al(oh 3 ). in vitro, a mediator release assay (mra) using hurbl (humanized rat basophil leukemia) cells was performed. hurbl cells were pre-sensitized using individual sera of ragweed-allergic patients and challenged with serial dilutions of re and modified re starting at 10 lg/ml followed by eight 1/10 dilutions (0-10.000 ng/ml). antigen-specific release of ß-hexosaminidase was measured and calculated in relation to 100% release values. in vivo, the immunogenic potency of modified re was evaluated by measuring the induction of re-specific igg in mice. female balb/c mice (n=10 per group) were subcutaneously (s.c.) injected with 20.000 aueq/ml re or modified re adsorbed to al(oh) 3 (0.8 mg/ml) per mouse on days 0, 7, 14 and 21. control mice (n=6) were injected with matrix only. specific igg titres were determined in serum obtained at days -1, 13 and 28. results: the potency of modified re in mra was drastically reduced in all patients, with a mean reduction of 1000 fold or more. chemical modification resulted in a later onset of activation as well as a lowering of the maximum release of ß-hexosaminidase. in vivo, both re and modified re show comparable levels of re-specific igg antibodies in mice at day 28 of the immunogenicity model. shown that chemical modification impairs the capacity of re to activate basophils while retaining its capability to be immunogenic. therefore, chemical modification of re may be a promising approach for the development of a safe and effective immunotherapy for ragweed allergy. objectives: the children who had taken subcutaneous conventional venom immunotherapy in our pediatric allergy outpatient clinic between 2002 and 2015 were evaluated with respect to the side effects. in addition, each child was called to ask if the patient was exposed to bee sting and the result of a sting during immunotherapy. introduction: the major unmet needs for allergen immunotherapy (ait) are improved efficacy with good tolerability, and high adherence. to achieve these, allergoids, peptides and recombinant proteins are potentially the answer but their low rate of systemic aes make selection of the optimal dose difficult. to select the dose for an ultra-short course subcutaneous birch ait, the company has adopted the use of a conjunctival provocation test (cpt), a wide range of doses and the multiple comparison procedure -modelling (mcp-mod) statistical analysis to test for a dose response and to determine the shape of the dose response curve. objectives: a range of dose regimens of 5100 su, 15300, 20100 and 27300 su were compared with placebo with respect to reduction of total symptom score elicited by cpt after treatment. patients were administered 6 weekly injections outside the pollen season. cpt was performed at screening, at baseline and 4 weeks after completion of treatment. the study was undertaken in 28 sites in germany and austria with 370 patients. the primary efficacy analysis was performed on a modified full analysis set (fas). the mcp-mod methodology was used to test for a dose-response using the placebo and above doses to describe the shape of the dose response curve. three candidate models were pre-specified: a maximum possible effect for the agonist (emax) model, a logistic model, and a linear in log-dose model. a statistically significant dose-response (p<.01) was shown for the range of cumulative doses, which approached a plateau with the 27300 su dose. the median effective dose (ed-50) was 2600 su. only minor differences were observed between the six active treatment groups in prevalence of treatment-emergent adverse events (between 70.9% and 83.9% of patients with overlapping 95% two-sided confidence intervals), majority of which were local reactions, short-lived and mild. teaes classified as systemic reactions were seen in 2.0% (20100 su group) and in up to 15.1% (5000 su group) of patients in the active treatment groups, and in 11.3% of patients in the placebo group. no treatment related saes were observed. adherence was >90% in all treatment arms. the ed-50 was 2600 su, demonstrating that the currently marketed dose (5100 su) is effective. the highest 27300 su dose will be further investigated in a pivotal phase iii trial having achieved an increase in efficacy by 50% without differences in the onset of aes between the treatment arms. introduction: in order for allergen immunotherapy (ait) to induce long-term immunological and clinical effects prolonged administration is required. therefore adherence to treatment is crucial for its efficacy. there is currently limited data available on ait adherence beyond clinical trials i.e. in real-life clinical practice. objectives: this eaaci immunotherapy interest group endorsed survey aimed to prospectively evaluate adherence to sublingual and subcutaneous immunotherapy in adults with allergic respiratory diseases and hymenoptera venom allergy in real life practice across different european countries. in addition, the reasons for lack of adherence and discontinuation of treatment were explored. this was a prospective, multi-centre, observational survey which took place in eight countries: czech republic, georgia, germany, greece, italy, poland, portugal and spain. data collection involved an online survey that followed participants four-monthly for a period of 36 months from the start date of ait. results: a total of 1336 participants were included in the analysis. introduction: allergic rhinitis is a multiple gene-regulated disease involved in many immune cells such as mast cells and eosinophils, and various inflammatory mediators, and mirna probably plays a critical regulatory role in its pathogenesis. therefore, studies on the functions of critical mirna and its regulatory mechanisms in activated mast cells will lay an important theoretical foundation for our understanding of ar pathogenesis and the development of therapeutic strategies. objectives: to investigate the effect of mir-125a-3p on mast cell activation in an ar mouse model. the number of sneezes and the frequency of nasal rubbing in ar+mir-125a-3p group were significantly reduced compared to those for ar+mir-nc group (p<.05). histological examination showed that inflammation in the nasal mucosa from ar+mir-125a-3p group was slighter than that in ar+mir-nc group. the number of mast cells in ar+mir-125a-3p group was increased compared to ar+mir-nc group (p<.05). the levels of histamine and il-13 in nasal lavage fluid supernatants, histamine in plasmas and il-13 in sera were significantly decreased in ar+mir-125a-3p group compared to ar+mir-nc group (p<.05). conclusions: upregulation of mir-125a-3p can reduce allergic inflammation in the nasal mucosa of ar and alleviate ar symptoms through inhibiting mast cell activation in vivo. mir-125a-3p probably becomes a new target for gene therapy of ar. 0222 | correlation between chronic cough and chronic rhinosinusitis in adults: nationwide, population-based, and cross-sectional study the second hospital of shandong university, ji nan, china; 2 national university of singapore, singapore, singapore introduction: nasal polyp implies a refractory clinical course in case of chronic rhinosinusitis (crs). although hypoxia is believed to be associated with nasal polyposis, little is known about the mechanism underlying polypogenesis. objectives: the aim of this study was to assess mrna and protein introduction: nasal polyp is a multi-factorial disease commonly associated with inactive ciliary beating frequency (cbf), a condition partly attributed to the mis-localization of dnah5, a component of the outer dynein arm in ciliary axoneme. so far however, there have yet to be a systematic histopathological investigation directly linking dnah5 localization pattern in nasal polyps. therefore, we sought to examine the localization of dnah5 in cilia structure of both nasal polyps and inferior turbinates from healthy individuals, and assess whether there are any localization changes that can account for the extensive inactive cbf observed in nasal polyps. objectives: the focus of this work is to compare the localization of dnah5 from the nasal polyps biopsies (n=80) and normal inferior turbinates (n=19) by immunofluorescence. the characterization of each sample was obtained from an average of 10 fields at 4009 magnification. results: from the samples, we observed three distinct localization patterns of dnah5 in the nasal cilia. the three patterns were as follows: 1) the localization of dnah5 in normal cilia is present throughout the entire axoneme (pattern a); 2) the localization of dnah5 is within the axoneme except at their proximal regions (pattern b); 3) the localization of dnah5 is restricted exclusively at the ciliary base and not present in the entire axoneme (pattern c). approximately 96% of the samples exhibited more than one distinct localization patterns for dnah5 within the observed fields. the percentage of pattern a, pattern b and pattern c were observed in 36.5%, 24.7%, and 38.8% fields for samples from nasal polyps. correspondingly, 75.1%, 19.3%, and 5.6% were observed for samples from healthy controls. the results indicated that the predominance of "pattern c" in nasal polyps countered by "pattern a" in inferior turbinates from healthy individuals. conclusions: our study indicated that there is a significant increase in the mis-localization of dnah5 among the cilia in nasal polyps as compared to controls. this mis-localization may account for the inactive cbf, a hallmark characteristic, observed in nasal polyps. zhao l 1 ; zhi l 2 ; jin p 1 ; zi x 1 ; tu y 1 ; li a 1 ; li t 1 ; shi l 1 (3.64, 2.28-5.01, p<.05) and +gc np patients (10.39, 6.00-14.77, p<.05 the results showed that the number of th17 + cells were correlated with eosinophil cells and macrophage (r=.3210, p<.05, r=.3269, p <.05), but no correlation was found between th17 + cells and neutrophil cells. the significantly correlation were found between ilobjectives: this study aimed to reveal if some features of the sinus wall and content (as homogeneity and density of the sinus content, or the continuity, thickness and density of the sinus wall), differ between the afrs and other forms of crs. we tried also to establish early diagnostic parameters for recognition of fungal rhinosinusitis on ct. results: the study included 36 adult patients (mean age: 45.58ae14.29 years, m:f ratio=2.1:1) with clinically diagnosed crs. out of all maxillary sinuses (n=72) from study patients, 62 (86.11%) were opacified, and only these sinuses were included in further analyses. we found out that: (1) positive fungal finding had 33% (12/36) crs patients and 86% (31/36) of these patients had severe forms of crs, (2) patients with positive fungal finding had more often positive specific ige ab than those without fungi in sinuses (43.9% vs. 21.3%, p=.027), (3) foci of non-homogeneity, mean and maximum densities and wall density were more common found in maxillary sinuses with present fungi than those without fungi (p=.037, p=.05, p=.05; respectively) and (4) patients with crs lasting more than 10 years had more often foci of non-homogeneity and presence of hyperattenuation centres, than patients with shorter length of crs. results: neutrophil-related gene mpo and eosinophil recruitment genes ccl13 and ccl18 showed higher expression level in acp than in controls, which were in line with the significantly elevated neutrophils and eosinophils infiltration in acp compared to control. increased cd8 + t cells, macrophages and cd4 + t cells infiltration in acp were also observed. the expression level of t-reg transcription factor foxp3 was significantly higher in patients with acp than in controls, but the expression of th1/th2/th17 transcription factor tbet, gata3 and rorc were significantly decreased in acp vs controls. we further investigated the relationships between these t-cellassociated genes in acp. the expression of foxp3 was positively correlated with t-bet, gata3, il17r and il12a, while no significant correlation with rorc was evident. il6 was observed positively correlated with t-bet, gata3, foxp3, and il17r. il10 had significant correlation with t-bet and il12a. objectives: the aim of this study was to find the olfactory change pattern of crs after ess in short-term and the differences between crswnps and crssnps, secondary aim were to identify the relationship among olfactory dysfunction, ct scores and quality of life(qol). in this study, 48 crs patients who underwent ess were evaluated preoperative by t&t recognition threshold tests, snot-20 score and lund-mackay ct score. patient outcomes were re-evaluated at clinical follow-up 1 month, 3 months and 6 months postoperative. analysis of variance was performed and correlation was calculated, with results analysed separately for crswnp and crssnp subgroups. 1. subgroups of crs differed in the degree of olfactory dysfunction reported before and after the ess. a significant difference in the changes of olfactory dysfunction between the two groups was found at 6 month postoperative. 2. the mean t&t and snot-20 scores showed significant improvement within 6 months after ess in both crswnp and crssnp subgroups, however, no significantly recovery of olfactory dysfunction was observed at 3 months compared to 1 month postoperative. there is a plateau of olfactory recovery at 3 months postoperative. 3. in crswnps, the mean t&t scores preoperative were correlated with lund-mackay ct score significantly(r=.649, p<.001; r=.625, p<.001). however, no relations were found in crssnps and the changes of olfactory dysfunction at the 6 months postoperative with lund-mackay ct score. 4. olfactory scores, before and after the ess, and their changes did not correlate with sont-20 scores. conclusions: olfactory dysfunction was more severe in crswnps. olfaction and qol of crs patients were significantly improved after ess in both groups, but there was a plateau of olfactory recovery at 3 months postoperative. ct scan may predict olfactory disorder, but the olfactory scores were not related with the qol. objectives: in this study, we investigated the effect of hgf, tgf-b1, and pge 2 as effective components for allergic rhinitis treatment using in vitro and in vivo mouse model studies. results: pge 2 decreased infiltration of eosinophil in nasal mucosa. tgf-b1 decreased the infiltration of eosinophil in nasal tissue and increased the number of treg in spleen. however, there was no antiallergic effect of hgf in this experiment condition. in case of the combination treatment group (tgf-b1+pge 2 +hgf), eosinophil infiltrations and the expression of eotaxin-2 were reduced in the nasal tissue, and treg was increased in the spleen. in all treatment group, serum ige and systemic cytokine levels were not decreased due to intranasal administration rather than systemic administration. in vitro study showed that phosphorylation of map kinases such as erk, jnk, and p38 and translocation of p65 were inhibited after treatment of hgf, tgf-b1 and pge 2 , suggesting their anti-allergic mechanism. conclusions: we found that tgf-b1, and pge 2 decreased allergic inflammation and these effects might be derived from changes in the frequency of treg and the activation of map kinase and p65 in the t cell receptor signaling pathway. furthermore, we hypothesized that tgf-b1, and pge 2 would be effective components for allergic rhinitis therapy. introduction: interleukin (il)-10 is implicated in suppression of allergic inflammation. the role of il-10 in the early-phase reaction in type 1 hypersensitivity has been unclear, however. we investigated the contribution of il-10 in a mouse model of the ige-mediated early-phase reaction in allergic conjunctivitis. objectives: ige-mediated allergic conjunctivitis was induced in c57bl/6-kit(+/+) wild-type mice, kit(+/+) il-10-deficient mice, and kit(w-sh/w-sh) mast cell-deficient mice by means of passive conjunctival anaphylaxis. the mice were thus subjected to subconjunctival injection with anti-dinitrophenol ige (dnp-ige) followed after 24 h by intravenous injection with dnp antigen. kit(w-sh/w-sh) mice that had received a subconjunctival graft of cultured bone marrowderived mast cells from kit(+/+) wild-type mice or kit(+/+) il-10deficient mice were similarly treated. vascular permeability of the conjunctiva was examined 30 min after antigen injection by colorimetric evaluation of the extravasation of evans blue dye. results: passive transfer of dnp-ige followed by intravenous antigen injection increased vascular permeability in the conjunctiva of kit(+/+) wild-type mice but not in that of kit(w-sh/w-sh) mice, suggesting that this effect was dependent on mast cells. vascular permeability was increased to a significantly greater extent in kit(+/+) il-10-deficient mice than in kit(+/+) wild-type mice. reconstitution of kit(w-sh/w-sh) mice with kit(+/+) wild-type or kit(+/+) il-10deficient mast cells restored the dnp-ige-and dnp-induced increase in vascular permeability to similar extents. our results suggest that il-10 produced by cells other that mast cells suppresses the mast cell-mediated early-phase reaction in ocular allergy. objectives: our aim was to evaluate the effectiveness and the safety of ccl treatment for keratoconus in children with vkc. forty-two boys (mean age 13.5ae3.3 years) and 17 girls (mean age 11.8ae4 years) with vkc were included in the study. tarsal, limbal and mixed vkc were detected in 55.9%, 8.5% and 35.6% of the subjects, respectively. evaporative dry eye was detected in 23 children out of 43 (53.5%), schirmer test results were <10 mm/ 5 minutes in 20.5% and <5 mm (severe dry eye) in 4 out of 44 children (9.1%) and 39% of the subjects (n=23) had confirmed keratoconus/forme fruste keratoconus with corneal topography (sirius, cso, italy). allergic symptoms were controlled with topical steroids, cyclosporine, dual action antihistaminic/mast cell stabilizers and lubricant agents before the procedure. ccl surgery was performed under topical anesthesia. the children were followed-up at least 1 year and preoperative and postoperative corneal topographic parameters were compared using paired sample t test. results: the visual acuity was between 0.4 and 0.6 (moderate visual loss) in 16.9% of the subjects and less than 0.3 (severe visual loss) in 6.8% of the children. ccl procedure was performed to 19 eyes of 15 children. at the end of one year, the disease was stable in all children with no differences in k1 and k2 corneal parameters before and after cxl (p>.05). there was a statistically significant improvement in maximum keratometry value after the procedure (before 56.57ae4d, after 55.37ae3.5d, p=.005). in one subject, a corneal infiltrate was detected 3 days after ccl, which was treated successfully with topical moxifloxacin. otherwise, no complications were observed in the postoperative period. conclusions: as keratoconus is common in vkc, these children should be referred to ophthalmologists for an eye examination and corneal topography. ccl seems to be a safe and effective option to halt the progression of keratoconus, which might be very aggressive in children with vkc. results: surprisingly, we found among them 11 cases of celiac disease, 7 cases of thyroid dysfunction (thyroiditis), 3 cases of crohn's disease and 1 case of ulcerative colitis, 1 case of anterior uveitis and 1 case of pemphigus respectively. we realized that an average percentage of 7% of the total of vkc cases are affected by an "autoimmune" systemic disease. limbal form of vkc was prevalent and more than 70% of children showed it. we can suppose that a racial and genetic predisposition to systemic diseases can coexist with vkc or that there is a group of vkc affected subjects in which the immune disorder is predominant on the allergic disease. introduction: nasal polyposis (np) is a heterogeneous inflammatory disease of nasal mucosa affecting 1-4% of the population with a high rate of recidivism. polyps arise from nasal sinuses to nasal cavity and are often associated with a strong local eosinophilia. the pathophysiology of np remains controversial, as it seems to be a phenotypic manifestation of multiple possible immunologic processes, such as respiratory allergy, despite a lack of correlated systemic response. here we propose a multiparametric assessment of np patients, in order to shed light on the underlying mechanisms of the disease in allergic and non-allergic patients and aiming to find new predictive biomarkers. objectives: our main aim was to unravel the link between systemic and local allergic inflammation and polyp development, as well as the nasal epithelium condition in polyps and surrounding healthy tissue. methods: four groups of patients were included in the study: healthy donors with or without allergy and np patients with or without allergy. in this regard, several different approaches were followed: a metabolomics serum study, a polyp and nonpolypous nasal epithelium histology and transcriptomic study. results: as for the histological study, luna staining revealed differences in eosinophilia between allergic and non-allergic patients, especially when patients were polysensitized, including perennial allergens; and between nonpolypus tissue and polyps being higher in polyps. pas staining showed differences in epithelium integrity and submucous and goblet cell (pas positive) distribution. immunohistochemistry for cd4+ and cd11c+ reveal a significant inflammatory infiltration in polyps. this inflammatory response was also asses by abstracts | 209 gene expression quantitation. no differences were seen in the metabolic profile in patient sera between groups. for the first time, nasal epithelium from polyps and neighboring tissue were studied. histology techniques and image analysis revealed differences in eosinophil concentration in both mucosa and submucosa areas, as well as different features in epithelium and submucous tissue structure. some of these findings were confirmed by gene expression quantitation. conclusions: our data show an increased eosinophilia and inflammatory infiltration in polyp tissue suggesting a role for allergic inflammation in the progression of np. additionally, we provide clues for the role of inflammation in the damage on nasal mucosa and the following progression of the disease. 0235 | is specific immunotherapy effective in subjects suffering from vkc? a tertiary referral center ten years experience. objectives: our work shows the results of sit additional to usual treatments, in children suffering from vkc and followed in our tertiary referral center (lavagna hospital, genova, italy). we retrospectively analyzed the clinical data of 37 subjects (25 males and 12 females); their mean age at the beginning of treatment was 8 ae 1.2 years. the patients were treated both with scit (sub-cutaneous immune-therapy-56.7%) and slit (sub-lingual immune-therapy -43.3%) depending on patient's wishes. they had to be mono-sensitized to one of the usually more frequent allergens (dust-mites, grass pollen, and pellitory) which was detected by means of recombinant rast, prick test and conjunctival provocation test (cpt); these tests were performed after a complete ophthalmological and allergological history and examination. children selected for sit needed to be positive to all performed allergy tests. systemic involvement included 25 cases of asthma, 5 cases of atopic dermatitis and 1 case of rhinitis; the remaining 6 cases were asymptomatic. local involvement included only vkc cases, the 62% of which were of the limbal type and only 14 subjects were suffering from the tarsal papillary type. mean follow-up was 7.2 years. all the patients included into the study completed their treatment and followed the therapeutic protocol. after one year of sit, no variation in clinical course and treatment was recorded. after the third year of sit, an average improvement in symptoms and signs score (43%) and an average decreased need for allergy systemic medications (63%.) (i.e. antihistamines and corticosteroids) was registered. also topical therapy (including steroid and cyclosporine eye-drops) was discontinued in 43% of children, in this group, short courses of steroid drops were necessary in less than 30% of children (as rescue treatment in the acute phases of the disease). these positive results after sit treatment were stable for the following 5 years. few (only local sub-cutaneous) side effects were recorded and the treatment was generally well-tolerated. conclusions: our experience shows positive results with sit in vkc which can have sensitive-to sit-treatment subtypes. results: 39 deaths occurred in children (21 boys, 54%). median age at death was 11 years (iqr 2-15). pamr of any cause was 0.08 (95%ci, 0.05-0.10) per 10 6 children per year, with a decreasing rate over time (annual change: -2.5%; 95%ci, -5.6 to 0.9). triggers were iatrogenic causes (n=18, 46%), insect venom (n=3, 8%) and food (n=2, 5%). unspecified causes were frequently reported (n=16, 41%). there was no difference in overall pamr between boys and girls (p=.74). there was no age group related differences in fatalities: preschool children (<7 years) (n=14, 36%), school children (7-12 years) (n=12, 31%), adolescent and toddlers (>12 years) (n=13, 39%). the number of fatal cases was similar comparing the southern (n=16, 41%) and the northern regions of france (n=23, 59%) (p=.15). the first episode of anaphylaxis for each patient was captured to calculate incidence. we estimated incidence rate ratios using poisson regression models. results: between 2001 and 2015 there were 523 anaphylaxis episodes in 481 patients younger than 18 years in hong kong. the incidence of admission for anaphylaxis increased markedly from 2.46 to 6.63 per 100 000 person-years during the study period (p<.001). the incidence of food-related anaphylaxis increased significantly from 0.21 to 1.88 (p<.001). increases in anaphylaxis and food-related anaphylaxis were seen in all age groups, with the largest increase in those aged 0 to 4 years. at the beginning of the study period (2001), medication was a more common trigger for anaphylaxis than food (1.61 vs 0.21 per 100 000 person-years). by 2015, food had become the predominant trigger (1.88 vs 0.54 per 100 000 personyears for medication). the incidence of medication-related anaphylaxis decreased significantly (p<.05). the incidence rate of anaphylaxis was significantly higher in boys than girls in the 5-14 and 15-18 year age groups, while there was no significant gender difference in the 0-4 year age group. the most common food triggers of anaphylaxis were peanuts, seafood, eggs, milk products, tree nuts & seeds (in descending order). conclusions: even though the incidence of anaphylaxis among children in hong kong is lower compared with other western countries, it has recently increased significantly, with food-related anaphylaxis predominant. 0238 | prevalence of anaphylaxis and prescription rates of epinephrine self-injector in korea based on national health insurance data results: the prevalence of anaphylaxis over the 5 years were 0.02%. the annual prevalence of anaphylaxis increased over the 5 years. anaphylaxis was more prevalent in male than female (56% vs. 44%) and in population aged 50-59 years old. for the regional prevalence of anaphylaxis in korea, gangwon province showed the highest prevalence of anaphylaxis (41.5 per 100 000 individuals) and relatively low prescription rates (5.8%) of epinephrine self-injector for the patients with anaphylaxis. on the contrary, seoul showed relatively low prevalence of anaphylaxis (14.3 per 100 000 individuals) and the highest prescription rates (26.6%) of epinephrine self-injector for patients with anaphylaxis conclusions: the prevalence of anaphylaxis has increased annually in korea. the prevalence of anaphylaxis and prescription rates of epinephrine self-injector showed regional difference in korea. objectives: the aim of the study was to analyze the prevalence of allergic symptoms and anaphylaxis in mastocytosis patients analyzed in the registry of the ecnm. results: methods: a total of 1513 patient with mastocytosis were enrolled. in these patients, the prevalence of allergy, anaphylaxis, triggers of allergic reaction, and disease subtypes were analyzed. results: symptoms of allergy were observed in 28% of all patients. the most affected group were patients with bone marrow mastocytosis (bmm: 64.52%) and indolent systemic mastocytosis (ism: 32.78%). insect venom allergy (iva) was reported in 14.14% of all subjects. in ism/bmm patients iva affected 22.30% of the cases, while in other patient groups, only 4.3% of the cases were affected (p<.00001). most patients (64%) had wasp allergy, 18% had bee allergy, 2% polistes allergy, and 6.8% allergy to more than one venom. in 9.2% the culprit insect was not identified. food allergy was reported in 3.56%, drug intolerance/allergy in 4.7%, inhalant allergy in 4.43%, and physical triggers in 0.8% of patients. in mastocytosis patients iva is the most prevalent cause of anaphylactic reactions exceeding the prevalence of iva in the general population by far. iva affects mainly bmm and ism patients (22.3% of cases). but 267 (66.1%) subjects didn't know whether adrenaline was administered. only 6 within 44 patients who had adrenaline autoinjectors used their autoinjectors during an anaphylaxis attack. most common symptoms were skin (n=363, 89.9%) and respiratory symptoms (n=327, 80.9%). syncope, hypotension or hypoxemia were present in 273 cases(63.9%), at least three organ dysfunctions in 258 (63.9%) cases; 56 patients (13.9%) had to be hospitalized (f:36, m:20).nearly a third (26.2%) of the patients had stage 1-2 anaphylaxis and 298 patients(73.8%) had stage 3-4 reactions. in 184 cases (45.6%), basal tryptase levels were examined and the average value was correlated with the severity. concomitant drugs being used by the patients were antihypertensives (20.5%),oral antidiabetics (6.2%); angiotensin converting enzyme inhibitors or angiotensin receptor blockers(11.1%), beta blockers(8.4%), diuretics(4.7%) and nsaid's (7.2%). conclusions: male sex was noted as a risk factor for severe reactions and recurrent anaphylaxis. anaphylaxis requiring hospitalization was more frequent in the patients using oral antidiabetics or diuretics. baseline tryptase levels were higher in patients with neurological and gastrointestinal symptoms. cardiovascular symptoms were found to be higher if a cofactor was present. skin symptoms were seen more frequently and higher rate of hospitalization occurred in anaphylaxis in the presence of infections or nsaid use. this study is important to elucidate the factors affecting anaphylaxis severity. 0241 | serum levels of 9a,11ß-pgf2 in combination with apolipoprotein a1 or cysleukotrienes are reliable biomarkers of anaphylaxis objectives: we analyzed mast cell mediators in sera derived from patients with acute anaphylactic symptoms (n=18) versus patients with acute cardiovascular or febrile reactions (n=12) and patients with a history of anaphylaxis but without displaying any symptoms when sera were taken (n=27). in addition, we identified proteins with substantial changes during anaphylaxis. matched serum samples were used to compare basal mediator levels with corresponding levels during acute anaphylaxis in the same patient (n=9). roc curve analysis was performed to determine the sensitivity/specificity of each mediator. results: serum levels of histamine and tryptase were not increased upon anaphylaxis and showed no relation to anaphylaxis severity. however, serum 9a,11ß-pgf 2 , a metabolite of pgd 2 , was significantly increased in acute anaphylactic patients (~8-fold) and abstracts | 213 correlated well with anaphylaxis severity. 9a,11ß-pgf 2 distinguished anaphylaxis from cardiovascular or febrile reactions and showed the highest diagnostic power observed by roc curve analysis. cys-leukotrienes (cys-lts=ltc 4 , ltd 4 , lte 4 ) were increased upon anaphylaxis while apolipoprotein (apo) a1 was significantly decreased. the highest diagnostic power was observed with the combination of 9a,11ß-pgf 2 and apoa1. conclusions: in conclusion, histamine might only be used to detect anaphylaxis when assessed shortly after onset of an anaphylactic response because of its short half-life, whereas tryptase is a useful biomarker if the baseline level of the same patient is known. 9a,11ß-pgf 2 seems to be the most reliable marker as demonstrated by the distinct increase upon anaphylaxis and could be supported by apoa1 or cys-lts. further investigations are needed to prove the suitability of these markers. objectives: objective of this study was to estimate the long-term bv of tryptase using certain chronic disease models and to compare it with those in food and drug allergy. results: serial determinations of tryptase concentrations (n≥5 data points per patient) obtained from patients diagnosed with mastocytosis (n=10) or chronic urticaria (n=1) during a period of sometimes several years were measured by the immunocap assay and evaluated using sigmaplot software. polynomial curve fitting was performed and data points outside the 95% confidence interval of the curve were appointed as outliers and excluded. because the data points were not normally distributed due to long-term fluctuations in homeostatic set-point, a non-linear fitting was applied and used to compute the standard error of the estimate. these standard errors of the fit divided by the estimates themselves were used to calculate the total coefficient of variation within a subject (cv t ). the analytical cv (cv a ) was calculated based on quality control samples (3 levels, n=149 data points) in a conventional way, while the within-subject bv (cv i ) was defined as cv l =(cv t 2 à cv a 2 ) ½ . eleven patients with a chronic disease were selected, of which 1 patient was treated as a potential outlier and 2 patients had to be excluded because of cv t <cv a . the between-subject bv (cv g ) was without the outlier 3.68ae1.92% (n=85 data points during a period 5.6ae2.3 years) and with the outlier 5.75ae6.46% (n=92 data points during a period of 5.3ae2.4 years). as a food and drug allergy control group 2 additional patients were selected with an uncomprehended food (n=1) or drug allergy (n=1). this cv g was calculated under the same conditions and proved to be 9.61ae1.64% (n=16 data points during a period of 4.1ae1.2 years). the long-term between-subject biological variation of tryptase concentrations of patients in chronic disease models was smaller than that of patients with an uncomprehended food or drug allergy. chronic disease models may be of interest to determine the long-term "physiological" biological variation of tryptase. vilà-nadal g; rodr ıguez-sanz a; s anchez-villanueva r; fiandor-roman a; dom ınguez-ortega j; bell on-heredia t introduction: hypersensitivity reactions during hemodialysis sessions have been reported. our aim was to study the mechanisms of the allergic or "pseudoallergic" reactions to synthetic polysulfone (ps) dialysis membranes in "ps-allergic" patients who tolerated cellulose triacetate (cta) membranes. objectives: ten patients with adverse reactions to ps and 8 control non-allergic patients in hemodialysis were studied. 50 ml of blood were collected and an ex-vivo hd were performed on experimental external circuits with low or high priming volumes and pediatric membranes (fx-paed helixone 0.2 m 2 and sureflux). serum tryptase levels, basophil degranulation (hla-dr à cd123 + cd63 + leukocytes), and t cell activation (cd69 expression on cd4 + and cd8 + subpopulations) were analysed in pre-and post-dialysis samples. objectives: the aim was to investigate the influence of asa and alcohol on egg allergy. donor sera from 4 egg allergic patients (i-iv) with s-ige to ovalbumin at (i) 0.1, (ii) 8.87, (iii) 19.5, and (iv) 170 ku/l were injected intracutaneously to the forearm of 11 healthy/nonallergic volunteers. they were then orally challenged separately with: 1) egg white 2) egg white + asa and 3) egg white + alcohol. 'time to wheal' and 'wheal size' were compared between the three experiments. results: two sera (i-ii) with the lowest s-ige to ovalbumin did not react sufficiently and where excluded from further analysis. the 2 remaining sera (iii-iv) significantly decreased 'time to wheal' with both asa (p=.001) and alcohol (p=.019) added as co-factor compared to baseline. increase in 'wheal size' was only found with co-factors added for the less reactive serum (iii) and not for the serum with the highest s-ige (iv). introduction: eaaci have published numerous guidance documents providing evidence-based recommendations for the recognition, risk factor assessment and management of anaphylaxis. these guidelines clearly advocate intra-muscular adrenaline firstline for the treatment of anaphylaxis, and list absolute indications when an adrenaline auto-injector (aai) must always be prescribed; eg for those who have previously experienced an anaphylactic event, those who have a mast cell disorder and for those with co-existing unstable or moderate/severe asthma and a food allergy. furthermore, eaaci recommends that an aai should be prescribed to those at risk of anaphylaxis (termed relative indications), and that 2 aais should be prescribed and carried by patients at all times. despite widespread dissemination of these guidelines, anaphylaxis hospitalizations continue to rise in many european countries. objectives: in this environment eaaci developed the anaphylaxis survey (axis) as part of its allergy awareness initiative to gain insight into guideline awareness. this survey was sent by email to 8720 eaaci members. 873 members from 89 countries responded. data were anonymous and analysed descriptively. results: 81.4% (n=711) reported familiarly with the eaaci anaphylaxis management guidelines, and of these 96.8% (n=688) reported following them. 97.0% (n=847) responded that they would use adrenaline firstline for the treatment of anaphylaxis (although 9.6% (n=84) would still administer it subcutaneously). however, when confronted with a list of indications, only 41.8% (n=365) of eaaci members would prescribe an aai for all absolute indications. furthermore, although 90.1% (n=787) of respondents considered they would prescribe an aai for those at risk, when provided with a list of relative indications, 0% would prescribe an aai for all of them. there was also a lack of consensus about when an aai should actually be used, with 23.8% of respondents (n=208) considering aai use when individuals experienced breathing difficulties and felt that they were going to collapse. conclusions: these results reflect the latest findings that aais are under-prescribed in daily practice. there appears to be a mismatch between perception of guideline compliance and aai prescription behaviour. continued training, further simplification and wider dissemination of guideline messages are required. objectives: the aim of this study was to analyse the clinical practice of emergency physicians concerning the management of anaphylaxis in alsace and lorraine, a region of 3.5 million inhabitants, in france via an electronic survey. results: the response rate was 18.3% (44). fifty percent of physicians were female. 84.1% (37) (1). in case of grade 2 reactions, intramuscular adrenaline injection was performed by 11.2% (5) of physicians as first-line treatment, intravenous adrenaline injection by 8.4% (4), antihistamines (oral route or iv) by 16% (7) and corticosteroids (oral route or iv) by 17.8% (8). in case of grade 3 reactions, intramuscular adrenaline injection was performed by 13.6% (6) of physicians as first-line treatment, intravenous adrenaline injection by 64.3% (28), iv antihistamines by 6.8% (3) and corticosteroids (oral route or iv) by 16% (7). following an acute anaphylaxis episode, only 2.3% (1) of physicians systematically recommended an allergy assessment, 11.2% (5) sometimes, and 86.4% (38) never. conclusions: this study highlights the discrepancies between current guidelines for the management of anaphylaxis in emergency departments and common clinical practice. our results emphasised the need for specific programs to improve clinical management of anaphylaxis in ed. conclusions: a significant number of individuals among those surveyed reported a severe allergic reaction requiring an eai, yet less than a quarter used an eai. the study also identifies most common challenges faced by at-risk individuals including eai availability, cost, and concerns over short expiry dates. objectives: to evaluate the implementation of a stock epinephrine (stock epi) program in a mall setting. stock epinephrine devices are not prescribed for a particular person and can be used in anaphylactic emergencies. methods: a mixed methods approach was used to evaluate the implementation of the stock epinephrine program regarding its acceptability and adoption by diners, food service, mall administration and security personnel; and the appropriateness, costs (included costs for personnel, epinephrine auto-injector devices, and training materials), fidelity, reach, and sustainability (measured by the national health service (nhs) sustainability model, united kingdom) of the program in this setting (hamilton, ontario, canada). the study revealed that individuals with food allergy and food service establishments were in favour of a stock epi program. a total of 1580 individuals with food allergy completed our national online survey. approximately 42% dine out once or twice per month, and one-third had experienced an allergic reaction. we also completed in-person surveys with 120 diners at the mall food court. of these, 24% had a food allergy and 35% reported carrying their epinephrine auto-injector when dining out. the mean nhs sustainability score was 87 among survey participants, well above the mean considered a sustainable program (>55). total cost of the stock epi program over a one-year period varied by ontarian stakeholders: $2155 for the mall, $987 for fast-food restaurants, and $715 for sitdown restaurants. conclusions: this is the first study to evaluate the implementation of a stock epi program. the stock epi program was well received abstracts | 217 and sustainable. implementing a stock epi program provides enhanced access to emergency medication, however it does not replace the responsibility of individuals with food allergy to self-manage. objectives: to identify the optimal needle length for epinephrine prefilled syringe. results: three hundred seventy-two children aged 1 month to 18 years were enrolled. skin to muscle depth (stmd) and skin to bone depth (stbd), which can represent the minimum and maximum needle length respectively, were measured using an ultrasonography at the mid-anterolateral thigh. number of children who had stbd less than needle length (too long needle) and stmd greater than needle length (too short needle) were calculated. one hundred thirty-seven children weight <15 kg, 80 children weight >15-30 kg, and 155 children weight >30 kg were enrolled: 196 (52.7%) children were male. one inch needle was too long in 38 (27.7%) children weight <15 kg, 1 (1.3%) children weight >15-30 kg. it was too short in 8 (5.2%) children weight >30 kg. age≥3 months, weight≥6 kg, height≥59 cm, bmi≥13 kg/m 2 and thigh circumfer-ence≥23 cm, provided the sensitivity of 97-99% in predicting the appropriateness for using 1 inch needle for children weight <15 kg. in children weight >30 kg, thigh circumference≥48.75 cm provided the sensitivity of 86% and specificity of 75% for predicting the inappropriateness for using 1 inch needle. objectives: we present a patient with a probable mdh syndrome to unusual drugs, including ah and cct. results: we report a case of a 23-years-old female, with history of moderate-persistent asthma and chronic urticaria, who experienced angioedema and exacerbation of urticaria hours after the administration of multiple ah (desloratadine, loratadine, cetirizine), systemic cct (hydrocortisone, methylprednisolone, deflazacort) and nonsteroidal anti-inflammatories (nsaids) (paracetamol, ibuprofen, flurbiprofen). patch tests (pt) with excipients (bial arestegui ® ) and drug provocation test (dpt) with placebo were negative. skin prick tests (spt) and intradermal tests (id) with hydroxyzine, hydrocortisone, methylprednisolone and prednisolone were positive to hydroxyzine (5mg/ml) and pt with corticosteroids (bial arestegui ® ) and hydroxyzine were negative. dpts with desloratadine and an alternative ah, dimetindene, were positive with facial angioedema and generalized urticaria within 5 hours. lymphocytic transformation test (ltt) was positive to desloratadine, ebastine and clemastine. dpt with dexamethasone was negative, however, when administered as treatment, a reproducible reaction occurred. since dpt with montelukast was also positive, omalizumab 300mg was initiated to control angioedema and chronic urticaria. after 1 year of treatment, dpt with nimesulide was negative. omalizumab dose was reduced to half after the patient found out she was pregnant. there were no further episodes after anti-ige therapy introduction and pregnancy went uneventfully. conclusions: mdh syndrome is rare, more so when the drugs reported are ah and cct. hr to ah was confirmed, but diagnostic workup remains incomplete, postponed due to the patient's pregnancy. this case is as challenging in terms of diagnosis as it is in terms of therapeutic, so much so that omalizumab was initiated as an off label therapy, maintained during pregnancy based on the premise that risk was lower than benefit. objectives: in this study, we aimed to present our patients who were admitted with oral iron hypersensitivity. conclusions: according to our clinical experience, we think that oral iron salts with different conjugates are safe and acceptable option in patients with suspected oral iron hypersensitivity. introduction: antineoplastic agents are consider nowadays an essential treatment for many kinds of cancer. the increased use of these drugs in recent years is in parallel with a high rise of hypersensitivity reactions to them. these reactions range from mild to severe and as other allergic reactions, are not predictable. a nursing protocol in the desensitization schedules with these drugs is essential in allergy daily hospitals. objectives: the aim of this study are to describe a nursing protocol during desensitization schedules with antineoplastic agents carried out in our allergy unit in order to detect symptoms suggestive an allergic reaction during drug administration and to assess a correct intervention in case of reaction. conclusions: an appropriate nursing protocol in desensitization schedules with antineoplastic agents is essential in order to achieve the correct administration of the treatment in safety conditions. 0255 | long term clinical effects of aspirin desensitization in patients with nerd: comparison of maintenance doses of 300 mg vs 600 mg aspirin çelik ge 1 ; karakaya g 2 ; erkekol f € o 3 ; dursun ba 4 ; gelincik a 5 ; celebioglu e 6 ; y€ ucel t 7 ; yorulmaz i 8 ; dursun e 9 ; tezcaner ç 8 ; s€ ozener zç 10 ; b€ uy€ uk€ ozt€ urk s 11 ; kalyoncu f 12 ; aydin ö 1 introduction: aspirin desensitization (ad) treatment has been shown to be effective in relieving the respiratory symptoms as well in reducing recurrency of nasal polyps in patients with nsaids exacerbated respiratory diseases (nerd). however, a conflict occurs about effective maintenance doses of aspirin on clinical parameters. objectives: in this study, our aim was to compare the effects of two different maintenance doses of aspirin on clinical outcomes for 3 years of ad. this was a multicenter study which involved 4 tertiary centers. patients who completed at least one year of ad treatment were included to analysis. study outcomes were number of nasal surgery, sinus infections, asthma morbidity (number of severe asthma attacks, hospitalization) as well as medication uses for both clinical conditions. the study included 114 subjects, 33 of whom were under 300 mg aspirin daily as maintenance treatment whereas remaining 81 on 600 mg aspirin for a mean of 48.2ae32 months of ad duration. regardless of maintenance doses, number of nasal polyp surgery gradually decreased at 1 (0.04ae0.03/year) and 3 years (0.02ae0.01/year) compared to that of before ad (0.41ae0.06/year) (p<.0001) in all subjects and were comparable in 300 and 600 mg. considering asthma outcomes, decrease in asthma attacks were observed only in 600 mg aspirin group (p<.01) at 1 and 3 years whereas hospitalization due to asthma and systemic corticosteroid use decreased in both groups at 1 and 3 years. conclusions: ad has a reducing effect on nasal polyp recurrence for at least 3 years in patients with nerd. this effect was similar for both 300 and 600 mg maintenance doses of aspirin. considering both treatment arms provided decreased hospitalization due to asthma and systemic corticosteroid use, we think that at 3 years evaluation both 300 and 600 mg/day aspirin has comparable effects on asthma as well. however, reducing effect of ad on asthma attacks was only existed in patients taking 600 mg. aspirin. objectives: pregnant women with syphilis and history of immediate hypersensitivity reaction (hsr) to penicillin were enrolled. according to the risk stratification, which was based on the initial hsr, serum specific ige and skin tests, patients were re-exposed to penicillin either through desensitization or provocation. patients with a clinical history suggestive of penicillin-anaphylaxis and/or positive serum specific ige to penicillin and/or positive immediate skin test were considered at high risk and were desensitized. the remaining patients underwent penicillin provocation test. results: we evaluated 21 pregnant women with latent syphilis and history of penicillin allergy. clinical history was suggestive of immediate hsr in 13 out of these 21 (62%) patients, who were desensitized. all of them had negative serum specific ige to penicillin. intradermal tests were positive in 4/13 (30%). three out of those four were desensitized with an oral protocol and reacted during the procedure. one patient had a severe breakthrough reaction with uterine contraction and did not finish the procedure. the only patient with positive intradermal test that didn't react during the rdd underwent an intravenous protocol. the remaining 9/13 (70%) patients had negative skin tests and an uneventfully rdd. there was a statistically significant association between positive intradermal tests and breakthrough reactions during the rdd (p=.02). the other 8/21 (38%) patients with inconclusive history and negative skin test were submitted to penicillin provocation, which were negative in all of them. conclusions: risk stratification based on the initial clinical reaction and skin testing to guide penicillin re-introduction was safe and effective, as well as rdd. skin testing identified allergic patients to penicillin with increased risk of reactions during rdd. 0257 | utility of basophil activation test for monitoring the acquisition of clinical tolerance after subcutaneous desensitization to brentuximab-vedotin in two patients many hypersensitivity reactions (hsrs) produced by biologic agents have been seen and their true incidence is unknown. desensitization is a method to counter hsrs from monoclonal antibodies in patients with no other adequate alternative options. objectives: we describe a successful rapid desensitization to bv in two patients with scleronodular type hl, refractory to several lines of chemotherapy and asct. this clinical tolerance to bv is easily observed through the basophil activation test (bat) as a decrease in activated basophils after desensitization was done as a treatment of hsrs. because there was no therapeutic alternative in the two patients, we planned to pursue bv administration using a rapid desensitization 12-step protocol. a total dose of 125 mg of bv was given through increasing rate and concentration. the patients completed their infusion without difficulty. after desensitization to bv, bat was done in both patients. the percentage of activated stimulated basophils with bv descended in both patients. both values are similar to their corresponding negative controls. conclusions: the bat continues to be a useful in vitro tool for the study of drug allergic disease. also, the bat in flow cytometry is able to monitor an acquired tolerance induced by a desensitization treatment in hsrs to bv. however, studies involving a larger number of patients will be required to assess the safety and efficacy of this approach to bat as a method to validate rapid desensitization in patients with hsr to bv. objectives: we retrospectively reviewed 166 desensitizations in patients with a history of ihsrs to chemotherapy agents performed in our center from january 2014 to december 2016. the protocol consists of increases in infusion rate every 10 to 15 minutes, in a 10 to 12 steps depending on the drug. in all cases the protocol was performed without premedication (only using regular medication according to instructions for every drug). results: a total of 61 patients with a history of (ihsrs) received 166 desensitization protocol without premedication to chemotherapy agents. the most common involved drug was carboplatin in 24 (39.3%) patients (of these 66% presented positive skin test (st)), followed by paclitaxel in 15 (24.9%) patients (of these 46.6% presented a positive st) and oxaliplatin in 9 (14.75%) patients (of these 11.11% o the st were positive). other chemotherapy agents involved were cetuximab, rituximab, irinotecan, epirrubicin, etoposide, cisplatin and cyclophosphamide. all patients were able to successfully complete the desensitization protocol without premedication and none of them need to withdraw the drug. conclusions: this protocol for rapid desensitization to chemotherapy without premedication is safe and effective. in addition, minimizes secondary effects of the premedication in these patients that are polymedicated. 0259 | rapid desensitization for the management of hypersensitivity reaction to biologicals-infliximab and adalimumab in inflammatory bowel disease patients objectives: to identify barriers to best practice with regards to drug allergy history taking and documentation, and to elaborate the potential strategies to overcome them. results: a total 164 prescribers responded to the survey: doctors in training 47.6% consultants 44.5% non-medical prescribers 7.9% most respondents 56.1% (95%ci 47.9-64.3%) were not aware of the availability of penicillin allergy testing in our trust. among those that were aware of it, 63.9% (95%ci 51.9-76%) had not referred any penicillin-allergic patient to immunology during the past year. barriers to accurate allergy history collection: 55.2% (95%ci 47-63.4%) concurred that often it is not possible to draw a firm conclusion based on history alone. 59.4% (95%ci 51.4-67.5%) agreed with the statement saying that, regardless of the details of the allergy history, it is always better to "play it safe" and not to use alternative beta-lactams in patients labelled as being penicillin-allergic (figure will be attached in the poster). among the interventions proposed; practical educational sessions, an interactive questionnaire to guide allergy history taking and classification and a modified antibiotic policy to guide prescribing based on the allergy classification, were all rated as useful (average score >7 on a scale from 1-not useful at all-to 10-very useful). 0262 | the regulatory role of germinal center maturation during the early b cell response to inhalant allergens investigated in the piama cohort using the medall allergen microarray introduction: in contrast to common belief, igg to airborne allergens is higher in allergic subjects, even before immunotherapy. one of the confusing aspects of the allergic immune response is that not only the igg response, but also the ige response can follow more than a single trajectory (with or without gc maturation). for ige we assume that the direct isotype-switching pathway (igm to ige) is the most relevant for the initial, mature-gc independent phase of sensitization to low-dose airborne allergens (such a pollen, mite). in later phases and for higher exposure situations as well as for other immunization routes, indirect switching is assumed to be the more relevant pathway. methods: ige, igg1 and igg4 antibodies were measured using the medall allergen microarray in 105 children from the piama cohort at age 1 and 4. these results were analyzed in relation to the ige levels at age 4 and 12. objectives: to find support for the hypothesis that the ige/igg ratio reflects not only exposure, but also details on immunological processes during sensitization, such as germinal center maturation. results: sigg1 and sigg4 levels to the major inhalant allergens were low at age 1 and remained in general low at age 4. however, children who at that time were positive for ige an allergen had a significant increased sigg1 to the allergen in question. sigg4 also appeared, but this response was low. the sigg level at age 4 in sigenegative children was not consistently predictive for sige at age 12. conclusions: the initial igg1 response to inhalant allergens is synchronized with the ige response. this result fits with the hypothesis abstracts | 225 that in the initial phase of sensitization to inhalant allergens the allergen initiates a weak and incomplete germinal center response that allows parallel ige-and igg1 production. one of the consequences of the multiplicity of b cell developmental pathways is that the igg/ige ratio is potentially diagnostic: if a subject has sigg levels in the microgram range, and thus a high sigg/sige ratio, this indicates involvement of mature gcs and the indirect class-switching pathway for some or all of the sige in this subject. 0263 | synthetic allergoid consisted of plga nanoparticles covered with synthetic peptides from bet v1 objectives: the aim of this study was to test a hypothesis that the ahr signaling is critical in controlling sl homeostasis through the regulation of key sphingolipid enzymes involved in the s1p synthesis. results: we found that an ahr ligand and a tryptophan photoproduct, 6-formylindolo (3, 2-b) carbazole (ficz; 1 nm), induced a increase in s1p level in a ros and ca 2+ -dependent manner, leading to the degranulation as well as il-13 secretion in mast cells, when compared to those seen in vehicle-treated cells. this was concomitant with an increased level of sphk1 phosphorylation and with a reduction in the enzymatic activity of s1p lyase, which could be reversed by the addition of an anti-oxidant, nac. moreover, s1pl was found to be directly oxidized by ros in vitro and in vivo. conclusions: our findings suggested that ahr-mediated ros and ca 2+ signals are critical for controlling sl homeostasis through regulating sphk1 and s1pl metabolic pathways, providing a new regulatory pathway in mast cells. methods: peptide cytokine mimetics were selected by phage display technology. flow cytometry, elisa, elispot, t cell proliferation, reporter gene, mediator release, intravital microscopy and peritonitis assays were conducted to evaluate the capacity of the mimetic peptides to modulate the immune response. results: the synthetic tgf-b1-like peptide was able to down-regulate the production of tnf-a, il-4, ifn-c and il-8, up-regulate il-10, decrease basophil degranulation and induce t reg cell differentiation. furthermore, this peptide was able to decrease leukocyte rolling and neutrophil migration during an inflammatory condition in vivo. the synthetic il-10-like peptide was able to decrease basophil degranulation and to inhibit the proliferation of allergen-specific t cell lines established from the peripheral blood of birch pollen-allergic patients. conclusions: the peptide cytokine mimetics tested herein, were able to modulate the immune response in the tested conditions. they, thus, represent promising novel candidates for therapeutic approaches. nonetheless, most studies focus on changes occurring early in life and there are rare data on differences in responses between allergic and non allergic subjects. objectives: we aimed to evaluate i) the maturation trajectory of the tlr3 antiviral pathway ii) if this trajectory varies between atopics and non atopics. peripheral blood mononuclear cells (pbmcs) were isolated from otherwise healthy atopic and non atopic subjects. atopy was assessed by medical history and skin prick testing to 8 common aeroallergens and egg white. selected cytokines involved in the antiviral response were measured by luminex multiplexing technology in 24 hour culture supernatants of poly:ic-stimulated pbmcs. data were analyzed by estimating the non-parametric correlation between age and cytokine expression in atopics and non atopics and comparison of regression curves for each cytokine between the 2 groups was performed. results: the analysis comprised data from 39 atopic and 39 non atopic patients (mean age 10.8 years, age range 0-45 and mean 10.3 years, range 0-43.3, respectively). significant age-related increases in the production of ifn-a2, ifn-c, il-1b, il-17a, tnf-a, and mip-1b were found only in non atopics and of il-9 and il-10 in both groups. significant differences in the trajectories (slopes) of cytokine responses over time between atopics and non atopics were observed for ifn-a2, ifn-c, il-10, il-1b, tnf-a and mip-1b, with suboptimal production in atopics. conclusions: age-related increases in cytokines implicated in innate antiviral responses were observed mostly for non atopics. atopy was associated with suboptimal trl-3 induced cytokine responses. differences in the developmental pattern of those cytokines between atopics and non atopics may account for the reported increased susceptibility of atopics to infections. 0271 | a systems-immunology approach identifies a set of micrornas in shaping the th2 phenotype in allergic airway inflammation introduction: mouse allergy is a common disease in inner city households, affecting up to 18% of children who are exposed as determined by house dust analysis. it is associated with allergic rhinitis, atopic dermatitis and asthma and it has been reported that exposure and sensitization to mouse allergens is a strong predictor for asthmatic disease. despite a strong link between mouse exposure and asthmatic disease, the allergic immune response to mouse has been significantly understudied. to date, only one major allergen in mouse, mus m 1, has been identified and very little is known about the targets of the allergic immune response against mouse. objectives: using a proteomic/transcriptomic approach, we sought to identify t cell targets in 24 mouse allergic and asthmatic patients. results: mouse urine and epithelial extracts were analyzed by 2d-ige/igg immunoblots using pooled sera from mouse-sensitized donors. mass spectrometry of selected protein spots identified 30 novel antibody reactive proteins. predicted mhc binding peptides from these novel proteins and mouse homologs to mammalian allergens were screened for t cell reactivity in pbmcs from mouse allergic patients. overlapping peptides from the major mouse allergen mus m 1 and its major urinary protein isoforms were screened in parallel. our screen for t cell responses in pbmc from mouse allergic donors demonstrated that major urinary proteins account for >75% of the total t cell response but they are not the only target of mouse-specific t cell responses. reactivity to mouse peptides homologous to other mammalian allergens, specifically guinea pig, was also detected. conclusions: in summary, our data demonstrates that the cellular and serological targets of the allergic response overlap, with mus m 1 being the major target for both t cells and antibodies. to the best of our knowledge, this is one of the first comprehensive studies of t cell epitope targets in mouse allergy, which provides important insights into cellular and serological targets. this data may form the basis for the development of a mouse-specific immunotherapeutic approach. introduction: food allergy has a complex etiology with many potential underlying factors proposed to contribute to and modify its development and progression. the use of a databases to collect and analyse all relevant data related to incidents of food allergy is essential to fully understand causal factors and improve treatment. objectives: we developed a database using sql, hibernate and java server pages (jsp) that was designed to allow allergy professionals to easily add and modify patient data, including medical history, reaction details and in vitro/in vivo test results. we then filled this database with clinical data relating to reactions to plant-based foods for patients who visited the allergy service of the regional university hospital of malaga between 2012-2016. these data were then analysed in various ways. cluster analysis of skin test results was used to search for relationships between different allergens based on similarities between patient sensitisation profiles; descriptive statistics and graphical analysis were performed to search for relationships between food type, age of first reaction, number of reactions and reaction severity. results: cluster analysis placed the different skin test allergens in distinct groups, which generally correlated with the type of allergen. for example, nuts, rosacea plant-food, mites, trees and weeds formed distinct clusters. analysis of patient history data showed that the first reaction occurred most frequently between ages 10-20, with a right skewed distribution. a relationship was also found between age at first reaction and reaction severity, being urticaria and angioedema more common when the initial reaction occurs at a younger age, and anaphylaxis when the initial reaction occurs later in life. oas remained relatively prevalent at all ranges (around a quarter of all reactions in all age groups). we found fruits to be the most frequent triggers, followed by nuts; within fruits peach and banana were the most frequent. conclusions: this preliminary study show the importance and utility of recording patient allergy information in a well-structured and easily managed database. future work is currently underway to collect a new set of patients from the same geographical area and to analyse similar data from a different area in order to identify what results are replicable within our population and which results are generalizable to other areas. introduction: cow's milk allergy is very common in children and its correct diagnosis is important to prevent possible dangerous allergic reactions. the aim of the present work was to evaluate the prevalence of allergic sensitization to both cow's milk and to its main proteins. with medcalc 9 ® . normality distribution of data was evaluated through the kolmogorov-smirnov test. patients were divided into three age groups (0-2 years, 3-6 years-7-16 years). chi-squared test was performed to verify a statistical difference between sensitization to whole milk and to its main proteins and patients' age. introduction: the order fagales represents an important cause of tree pollen allergy, which is ubiquitous in the northern hemisphere. a high degree of allergenic cross-reactivity has been observed among allergens from these plants, mainly represented by pathogenesis-related protein class 10 (pr-10) pr-10s, including inhalant and food allergens. conclusions: testing ige reactivity to a panel of pr-10s unveils important associations between sensitization profiles and clinical presentation, and allows the identification of novel cluster patterns potentially useful to predict disease severity in patients with pr-10 allergy. results: 11 patients were included, seven boys and four girls, with a median age at diagnosis of six months. the most common offending foods were cow's milk protein (cmp, n=5) and rice (n=2). other foods were fish, egg, chicken, wheat, carrot and potato. average time of symptom onset was 2.5 hours. the most frequent symptoms were vomiting (n=10) and diarrhea (n=4). six patients had a history of hospital admission related to this problem. seven patients had concomitant atopic diseases, being the most frequent allergic comobility atopic eczema (n=5). skin prick tests and/or specific ige to culprit foods were negative at diagnosis, except for one patient with low specific ige to cmp. another patient become sensitized to cmp during follow-up. open food challenges were performed in 10 patients starting from six months of age. resolution was achieved in 6 patients, at a medium age of 36 months. results: a total of 2901 cases of immediate-type fa among 2056 children were reported, with 92.5% involving patients younger than 7 years of age. the major 7 causative foods were hen's egg (27.4%), cow's milk (26.6%), walnut (7.2%), wheat (6.2%), peanut (5.5%), soybean (2.4%), and shrimp (2.2%). the most common causative food in each age group was cow's milk (0-2 years), walnut (3-6 years), walnut and hen's egg (7-12 years), and buckwheat (13-18 years), respectively. the symptom onset time was less than 30 minutes in 65%. food-induced anaphylaxis was reported in 732 (25.2%) out of 2901 cases, and the major 7 causes were cow's milk (26.9%), hen's egg (20.1%), walnut (12.0%), wheat (9.6%), peanut (7.0%), buckwheat (4.0%), and shrimp (2.5%). the proportion of anaphylaxis was highest in buckwheat (60.4%), followed by walnut and pine nut (42.1% each). korean children were hen's egg, cow's milk, walnut, wheat, and peanut, with distinctive distributions according to different age groups. anaphylaxis was reported in 25.2% among immediate-type fa. results: a total of 263 children with a median (inter-quartile) age of 6.13 years (4.27-8.43) were enrolled to the study; (male 66.5%). their ages at diagnosis were 0.50 years (0.40-0.67); follow-up times were 5.63 years (3.57-7.69) and milk specific ige levels at diagnosis were 7.6 ku/l (1.9-27.2). in 30.8% of the children there was only cma; the other children were polyallergic to different foods having most frequently egg white allergy. concomitant diseases were 56.7% atopic dermatitis, 35.4% were asthma, 12.2% were allergic rhinitis. during the follow-up milk tolerance was developed in 43.1%, 65.2% and 68.1% at the ages of 3, 5 and 6 years respectively. the specific ige level at the beginning of the disease was found to be a risk factor for the persistence of the disease (p<.001). conclusions: cma is frequently present with other food allergies. nearly half of the patients develop tolerance to cm up to the age of 3 years; whereas 2/3 becomes tolerant when they are at the age of 5 years. most frequent concomitant diseases are atopic dermatitis and asthma. objectives: two survey tools were used; a questionnaire based on similar surveys done overseas, and the validated food allergy quality of life questionnaire (faqlq). this was distributed throughout paediatric allergy clinics at two metropolitan centres. children and adolescents aged 10-19 completed the questionnaire independently, whilst parents assisted with children aged 5-9 years. results: 102 surveys have been collected at the time of writing of which 64 were answered by parents for young children. overall, 44/ 97 (45%) reported bullying, with a higher portion in older children and adolescents (22/37; 59%). of this group, 10/20 (50%) reported being bullied or teased because of their food allergies. from parental reports, 11/19 (57%) stated that their child had experienced bullying or teasing because of food allergies. for those not bullied, parents mentioned that this may be due to their child having friends at school, being too young for bullying or because other children at school had a good understanding of the severity of allergies and were educated by teachers. the most common location for bullying was "in the playground or sportsground" (36/39). the most common form of bullying involved being "teased, called names or someone has said mean things to me" (31/39). whilst food allergens were involved in bullying in many cases (24/39), there were no reports of children being forced to eat food to which they are allergic. of concern however, two adolescents reported experiencing an allergic reaction as a result of the bullying. the majority reported experiences of sadness from bullying (30/39) while seven stated that it had no effect. conclusions: our current research shows that 45% of children and adolescents with food allergies experience bullying, and that 22% (21/97) experience bullying specifically because of their food allergies. this indicates a significant social problem that requires addressing to positively assist those children living with food allergies. introduction: recently we demonstrated that intake of specific foods, types of fat and micronutrients was associated with inflammation and mucosal integrity in adults with eosinophilic oesophagitis (eoe). the current study aimed to compare dietary intake of these patients with dietary guidelines and intakes of the general dutch population to further investigate our hypotheses on the protective or allergy-provoking role of specific nutrients in eoe. results: the total faqlq score was low when assessed by teenagers and children (4.0 and 3.9, respectively) and moderately low when assessed by parents (2.7). experience of anaphylaxis and having multiple food allergies impaired hrql according to faqlq parent form (p<.05). gender, having prescribed an adrenaline-auto injector, experience of food provocation test, peanut allergy and faim did not contribute to different hrql. hrql in kindergarten and schools were moderately diminished (sum score 2.6 in schools and 2.2 in kindergartens) (p>.05). perceived disease severity was moderately present with total faim scores being 3.4, 3.6 and 3.9, when assessed by children, teenagers and parents, respectively (p>.05). 68% of participants' reported at least some possibility of dying if child/teenagers would accidently eat a food allergen. after fulfilling faqlq and faim, all participants expressed content, ten children/teenagers decided to approach food provocation tests de novo, employees of children's schools/kindergartens were encouraged in written invitations to assess anaphylaxis training programs, and four families accepted additional psychological support. conclusions: food allergies impair hrql in children and teenagers. allergies to multiple foods and experience of anaphylaxis were associated with more severe impairment of hrql. hrqlq and faim are useful, additional tools to assess and discuss child's/teenager's/parent's fears and obstacles because of food allergy and identify further needs of support. introduction: fruit allergy is the most common cause of food allergy in children older than 5 years and adults. regional variations have been observed in europe but there are few studies in pediatric population. objectives: in the context of a prospective and multicentric study on pollen and vegetable food allergy in spain, we enrolled 45 patients (median age 12, range 2-18, female 64%), who had suffered at least two episodes of immediate symptoms after ingestion of fruits and had positive skin test to the implicated fruits. immunocap isac was analyzed in all patients. our aim was to describe the clinical characteristics with the fruits involved and the usefulness of the allergens included in the immunocap isac to improve its characterization. symptoms were categorized into oral allergy syndrome (oas), systemic symptoms (ss) and anaphylaxis. results: a total of 45 patients were included. all of them had symptoms with more than one fruit. 42 patients had pollen sensitization. the main offending food associated with allergic reactions were peach (49%), kiwi (27%), melon (24%), apple (22%) and banana (15%). 5 allergic patients to peach had oas, 13 ss and 4 anaphylaxis, were recognized prup3 in all patients with anaphylaxis, in 4 patients witch oas and in 10 with ss, also prup3 associated with abstracts | 235 prup1 in 2 patients with ss. for allergy to kiwi, 9 patients had oas and 3 ss, were recognized actd2 in 1 patient with sao and 3 patients with ss. actd1 in 1 patient with ss. conclusions: in our population, the most prevalent fruit allergy was the peach, as in spanish adults. patients allergic to peach were the ones that presented the most ss and anaphylaxis, followed by allergic to apple. as previously have been reported most of them had sige to its components in isac; being prup3 the most prevalent (9% had prup1). only patients with ss with kiwi were sensitized to kiwi allergens .the majority of patients allergic to apple, melon and banana were not diagnosed by immunocap isac. introduction: studies have shown that asthma and allergy are prevalent among production workers processing seafood, particularly in workers processing crustaceans. a major ige-reactive proteins is the muscle protein tropomyosin. specific ige to tropomyosin is suggested as a central marker for crustacean allergy, however it is not the only protein characterised as an allergen in crab processing. objectives: the aim of our study was to characterise tropomyosin exposure and prevalence of sensitisation to allergens in workers processing king crab (paralithodes camtschaticus) and edible crab (cancer pagurus) in land based processing plants in norway. results: personal air samplers collected air from the workers' breathing zone during crab processing. workers' blood was collected for ige testing. extracts of both king crab and edible crab raw meat, cooked meat, intestines and shell were made in our lab and used for skin prick testing and immunoblotting. while processing cooked crab yielded highest tropomyosin levels in the edible crab plant, processing raw crab yielded highest levels in king crab plants. ten (12.8%) edible crab and 11 (9.7%) king crab workers had positive ige test (>0.35 ku/l blood, immunocap systems) to crab. four (10%) of skin prick tested king crab workers and 15 (19%) of skin prick tested edible crab workers had one or more positive reactions to edible crab extracts. more workers reacted to cooked crabmeat extracts than to raw crabmeat extracts. immunoblotting showed ige binding to a large number of proteins in all four extracts of both king and edible crab. binding was found to high molecular weight proteins in all four extracts of the crab tested, and the ige-reactive proteins differed between king crab and edible crab. conclusions: workers are exposed to tropomyosin in their breathing zone during crab processing. both king crab and edible crab workers are sensitised to crab, shown with immunocap specific ige test to crab, as well as positive skin prick tests and immunoblots to four different crab extracts made in our lab. workers processing crab in norwegian processing plants have an increased risk for developing sensitisation to crab. objectives: the aim of the study was to assess frequency of skin symptoms in surgery clinic employees, to evaluate burnout as a predictor of the frequency of skin symptoms, and to determine latexspecific ige in surgery nurses with skin symptoms. results: skin symptoms were significantly more frequent in surgery nurses (25%) than in surgeons (2.5%), other physicians (0), and other nurses (6.7%) (v 2 =18.16; p=.001). skin symptoms were also significantly more frequent in workers with high/medium than in workers with low emotional exhaustion (14.3% vs 5.2%; v 2 =4.32; p=.038), as well as in participants with burnout than in subjects without burnout introduction: baker's asthma sensitization pattern is changing due to the introduction of different types of grains and seeds. objectives: a 43 year-old ecuadorian man showing ocular, nasal and pulmonary symptoms when handling grain flours (with or without seeds), while baking for the last 8 years. he tolerated grain flours oral intake, but had oropharyngeal symptoms, rhinoconjunctivitis and dyspnea when eating sunflower and sesame seeds, mustard, and beer with alcohol. he tolerated alcohol-free beer. we performed an allergy study: prick-test with commercial extracts of pollens, dust and storage mite, fungus, animal danders, cereals, yeasts and mustard. prick by prick with patient's products: wheat, multicereals and seeded flour, sunflower seeds, regular and alcoholfree beer spirometry and niox. serial peak flow measurement at and away from work, handling tests with wheat flour and sunflower seeds. laboratory studies: specific ig e to cereals and seeds (cap-isac-microarrays). immunoblot with regular beer (at room temperature and boiled), wheat flour and sunflower seeds, and sequential chromatography. results: skin tests were positive with commercial mustard and all provided products except for the alcohol-free beer. spirometry was normal. niox: 116 ppb. peak-flow monitoring showed a 27% variability during working period, remaining stable during holidays. handling tests with wheat flour and sunflower seeds were positive. specific ig e was positive for grains, malt, gluten, mustard and sunflower seed. the specific determinants were positive to 7s-viciline, 11-s globulin, several prolamins (2s-albumine, alfa-amylase inhibitors and gliadin) and ltp. immunoblot detected a band lower than 14 kda in both regular beer extracts (not detected in alcohol-free beer) identified as barley's ltp, a band of 18 kda in the sunflower seed extract (2salbumine), and two bands lower than 14 kda in wheat flour extract (two kinds of alfa-amylase inhibitors). we present a non-atopic baker with occupational rhinoconjunctivitis and asthma due to prolamins (alfa-amylase inhibitor and gliadin of wheat flour together with 2s-albumin sunflower seed), and anaphylaxis when eating seeds (2s-albumins, 7s-vicilin and 11s-globulin) or drinking beer (sensitization to barley's ltp). it is interesting that the manufacturing process of non-alcoholic beer (high temperature and high pressure) seems to degrade barley's ltp, as suggested by both tolerance to its ingestion and loss of immunoblot band. objectives: the main objective of this study is to evaluate longitudinal change of lung function in workers employed in food preparation and distribution potentially exposed to food allergens. spirometries performed between 2012 and 2015 as part of medical surveillance of 58 food-handlers workers were evaluated. data about occupational task, work years, smoking habits and diagnosis of atopy, asthma and copd were collected from a clinical database. differences in prevalence were calculated by chi-square test, differences in means were calculated using spirola software referred to european predicted values. results: the majority of workers were females (n=49; 84.5%) and caucasians (n=57; 98.3%). 25 (43.1%) subjects were current smokers, 6 (10.3%) were ex smokers, 9 (15.5%) were atopic and no one reported a diagnosis of asthma or chronic obstructive pulmonary disease. 69% workers were canteen service employees and 31% were cookery employees. mean yearly values of the pair-wise within person variation of fev1 and fvc were respectively à248 ml and à266 ml. 6.9% of last observations had a fev1 below lln and 8.6% of last observations had a fvc below lln. conclusions: this study may help in planning preventive programs and in facilitating early recognition and diagnosis of work-related respiratory diseases. wheat, foods and latex allergens may determine decline in fev1 and fvc; furthermore, in our study, a significant proportion of workers reported exposure to tobacco smoke. excessive loss in fev1 over time should be evaluated using a percentage decline (15% plus loss expected due to aging) that we will make afterwards adding more years of follow up spirometries. intervention of smoke avoidance are needed. 0288 | prevalence of wood dust sensitization in occupationally exposed workers in germany-what can be tested? objectives: in 373 serum samples from patients with suspiciously allergic symptoms to wood dust overall 2797 specific (s)ige-tests with standardized wood-dust extracts coupled to streptavidin-immu-nocaps were conducted. additionally, ccd as known source of non-protein ige-target was evaluated. sensitization rates were calculated for 21 different wood species. most frequently requested wood dust allergens were obeche (n=198), beech (n=186), oak (n=173), spruce (n=175) and pine wood (n=147) followed by 80-100 requested sige-tests to mahogany, ash, larch and maple wood. results: overall wood dust sensitization rate was about 11% (range: 0-29%) with obeche, box wood and kambala as most prominent sensitization sources obtaining each more than 20% sensitization. no sensitizations were detectable to red cedar and meranti wood in more than 50 requested tests, respectively. in 81 patients at least one sige-sensitization to any wood was measured. there from 77 were additionally tested with ccd resulting in 47% positive and 53% negative ige responses to ccd. some wood species were exclusively recognized by ccd-positive subjects: ash, maple, alder, mahogany, teak, mansonia and palisander. whereas other woods were recognized by sige of subjects with / or without sige to ccd: obeche, box wood, spruce, oak, beech, limba, pine and kambala. relevance of wood sensitization next to ccd was investigated in eight double positive subjects (wood + / ccd +). specific ige-binding to wood allergens was completely inhibited by ccd in three samples. these subjects were supposed to have no clinically relevant wood sensitization. whereas in five samples sige-binding to selected wood species was not significantly reduced by ccd. in four of these patients skin prick tests (spt) and challenge tests (bronchial and/or nasal) with corresponding wood allergens were performed. three of four challenge tests were positive with the respective wood extract and all spts with wood extracts whose sige-binding was not affected by ccd inhibition showed positive reactions. here clinical relevance of sige-mediated wood sensitization could be demonstrated. conclusions: in summary, our data demonstrate that standardized wood extracts and ccd tools are necessary for valid in-vitro diagnosis of wood dust sensitization. introduction: respiratory symptoms have been reported frequently among seafood processing workers. since seafood processing workers handle the raw material and participate in processing activities during work, they are exposed to inhalable bioaerosols. this put them at risk of developing respiratory symptoms, asthma and allergy. there is little knowledge about the respiratory health status among fish production workers on board fishing trawlers. objectives: the aim of this study was to assess the respiratory health status among norwegian fish production workers, processing fish on board fishing trawlers. the study population consisted of 92 fish production workers, 21 machinists, 22 support crew members and 38 non exposed controls, all were males. written informed consent was the fish production workers had a significantly decreased fev 1% predicted compared to the non-exposed control group, b=à5.9, 95% ci [à11.2, à0.6], when controlling for age, pack-years and family history of asthma/allergy/eczema. the effect did not change when controlling for doctor diagnosed asthma or after dividing fish production workers by doctor diagnosed asthma. machinists and support crew members showed a similar decrease in fev 1% predicted, but the difference from the non-exposed control group was not statistically significant. furthermore fish production workers, reported a non-significantly increased prevalence of wheezing and daily morning cough compared to the non-exposed control group. conclusions: fish production workers, processing fish on board fishing trawlers, showed reduced lung function values compared to a non-exposed control group, and this finding is in accordance with previous findings in seafood industry worker populations from our research group. results: study group comprised 264 patients with work-related respiratory symptoms suggesting wra. the research completion with sic allowed to recognise wra in 164 persons (108 oa and 56 wea) and to exclude asthma in 100 cases qualified to reference group (gr). workers with wea occupationally exposed do lmw-a manifested the highest level of baseline non-specific bronchial hyperresponsiveness (nsbhr) in comparison to the other groups (table 1) . patients with oa exposed to lmw-a more frequently than exposed to hmw-a revealed nsbhr before sic (p=.036) with lower level of median (me) provocative methacholine concentration value causing 20% fall in fev 1 (pc 20 induced sputum (is) was obtained before and 24h after sic from 159 patients (38 gr and 121 wra). in all gr samples and samples possessed before sic from wea subjects exposed to hmw-a, intermediate profile of is (neutrophils (ne)<61% and eosinophils (eo)<2%) dominated ( results: eg: in "granulation" exposure is relatively high and the number of different enzymes handled is low; here the risk of sensitization is highest. in contrast in the pilot plants the exposure compared to granulation in general is lower but the number of enzymes handled concurrently is higher. still the sensitization risk is lower than the range for granulation. conclusions: even though this approach may seem crude and not free from bias and potential misclassification, data does not support the hypothesis that the number of enzymes increases risk of sensitization, whereas increasing exposure level seems to be a risk factor. this suggests that each enzyme exposure acts as a risk in its own right and that the "cocktail effect" seems to be of minor relevance. phospholipids. bioinformatic studies of sequence homology conducted prior to this study showed no similarity between the mpla1s and known allergens including ves v 1. however, the common enzymatic activity in ves v 1 and the mpla1s might still lead to crossreactivity. the goal of this project was therefore to test for possible cross-reactions between sige towards ves v 1 and three different mpla1s. methods: serum from 10 known wasp allergic persons with sige towards ves v 1 spanning from 1.57 ku/l to 1734 ku/l were used for inhibition studies. from each, 125 ll serum was incubated with 125ll of either saline solution (negative control), 50 lg/ml alk802 soluprick solution (positive control) or one of three mpla1s, each in three concentrations (either 0.5 lg/ml, 5 lg/ml and 50 lg/ml (n=3) or 5 lg/ml, 50 lg/ml and 500 lg/ml (n=7)). the level of sige towards ves v 1 was measured using the i211 immunocap, and a decrease in this level was calculated as %inhibition compared to the sige measured from serum incubated with the negative control. inhibition by mpla1s would indicate cross-reactivity. results: the positive control caused 62.5ae28.6% (n=10) inhibition of sige towards ves v 1. this was lower than expected but was found to be caused by a few sera where the fraction of sige towards ves v 1 was <10% of all sige towards wasp venom. in the remaining sera, %inhibition was 78.1ae14.9% (n=7). for all three mpla1s, no inhibition was found for any serum tested (n=10) at the highest concentration tested with %inhibition being 3.5ae2.5%, 3.3ae2.9% and 1.8ae6.0% respectively. conclusions: no inhibition of sige to ves v 1 was found to any of the three microbial phospholipases tested. this indicates that no cross-reaction is found between the phospholipase a1 in wasp, ves v 1, and phospholipase a1 from microorganisms despite the common enzymatic activity. objectives: the aim of study was to evaluate the prevalence and the impact of polyvalent ige-mediated allergy on the course of ad and the occurrence of allergic symptoms from other organs and systems in infants and young children. conclusions: polyvalent ige-mediated allergy is common in young children with ad and seems to be a risk factor for the severe course of the disease. introduction: non-steroid anti-inflammatory drugs (nsaid) are the second most common cause of drug allergies in childhood. objectives: the aim of the study is to determine the frequency of nsaid hypersensitivity in asthmatic children. results: 976 patients who were being followed up for asthma were included in this study. the mean age of the patients was 10.61ae4.21 years, while 59.5% (575) were male. 1% (n=10) of the patients had a reaction history to nsaid (ibuprofen in 4, flurbiprofen in 2, diclofenac potassium in 1, metamizole+acetylsalicylic acid in 1, paracetamol+acetylsalicylic acid in 1 and ibuprofen+acetylsalicylic acid in 1). nsaid sensitivity was confirmed in 9 (0.9%; 9/976) patients who were tested with suspected drugs, while the provocation test was found negative in one patient who described reaction with ibuprofen. of the 2000 children who were assessed as a control group, only 1 had a reaction history to acetylsalicylic acid and no reaction developed in the provocation test. conclusions: nsaid hypersensitivity is more common in patients with asthma. thus, these patients should be evaluated for nsaid hypersensitivity. results: from jan 2012 to dec 2013, 8840 pediatric cases were received by kaers. of 8840 pediatric patients, 56.4% were male, 42.0% were female and 1.6% were unknown. these 8840 pediatric cases included a total of 17 319 adr events with an approximate average of 1.9 adr events per report. of those 8840 cases, 21.2% were in infants (age 0-1 years), 27.8% were in young children (age 2-7 years), 24.3% were in old children (age 8-13 years), 22.7% were in adolescent.(age 14-18 years) and unknown were 4.0%. male to female ratio was 1:0.8 and the mean age was 8.3ae6.3 years. regarding categorical ranking of reported adr agent groups, the most common group were antibiotics (24.4%) followed by antineoplastic agents (14.8%), vaccine (11.6%), antipyretics (7.1%), opioids (5.4%), sedatives (3.1%), antiepileptic drugs (2.9%), contrast media (2.3%), steroids (2.0%). the most common adr symptoms were gastrointestinal system disorder in 33.2%, skin-appendage disorder in 19.5%, abstracts | 249 body as a whole-general disorder in 9.5%, central-peripheral nervous system disorder in 7.5%. regarding seriousness of adrs, 610 events (6.9%) had episodes requiring hospitalization and were considered life threatening. of these, 126 cases had anaphylaxis or anaphylactoid reactions. introduction: multiple drug allergy is an adverse reaction to two or more structurally unrelated drugs that appears to occur by immune mediated mechanism. patients with a history of reaction to two or more drugs often apply to allergy clinics. objectives: the aim of this study is to evaluate the test results of the patients who have a history of multiple drug allergies and underwent drug provocation tests. results: during the study period, drug provocation tests were performed in 889 patients (1014 drug provocation tests). of these patients, 106 (11.9%) had a history of drug reactions to 2 or more drugs. the mean age of the patients who had a history of reactions to two or more drugs was 8.48ae3.94 years, and 58.5% (n=62) toms, and autoimmune manifestation in comparison to igm/iga responders (respectively, pneumonia: 64%, 31% and 0%; chronic diarrhea: 25%, 14% and 0%; autoimmunity 41%, 29% and 0%; autoimmune cytopenias: 17%, 8% and 0%). malignancies were found more frequently in the non-responders and igm-only responders groups in comparison to igm/iga responders (respectively, 23%, 14% and 0%). eleven (15%) patients died during the study time. survival analysis according to the igm/iga responder status showed that the 6-years estimated survival for non-responders vs igm-only vs igm/iga responders was respectively after one year 98%, 87% and 100%; after two year: 93%, 87% and 100%; after three years: 91%, 80% and 100%%; after 4 years: 87%, 80% and 100%; after 5 years: 87%, 80% and 100%; after 6 years: 83%, 80% and 100%. interesting, in our series only two deaths were due to infective complications: five were consequent to malignancies, one to autoimmune cytopenias and three to not-cvid related conditions. between-infusions intervals (10-14 days) than pid patients (6-7 days). finally, a small number of patients with anti-cd20-related sid was able to discontinue scig replacement therapy after recovery of spontaneous igg production. conclusions: this is, to our knowledge, the biggest single center cohort of scig-treated patients ever described. results suggest that safety and effectiveness of scig is similar in pid and sid, irrespective of the mechanisms underlying igg depletion. moreover, in sid a lower igg dosage is required and ig replacement does not always need to be lifelong, with obvious pharmacoeconomic implications. 0685a | should we screen children with bronchial asthma for primary immune deficiencies? miteva d 1 ; perenovska p 1 ; papochieva v 1 ; georgieva b 1 ; lazova s 1 ; naumova e 2 ; petrova g 1 the patient became febrile and cultures were repeated, being positive to campylobacter jejuni, resistant only to ciprofloxacin (blood) and to campylobacter coli, susceptible only to gentamicin and amoxicillin/ clavulanic acid (stools). treatment was thus switched to amoxicillin/ clavulanic acid (1875/125mg 8/8h). the patient became apiretic at day 2 and improvement of local inflammatory signs was noticed, treatment was prolonged for six weeks. one week after cessation, skin lesion worsened again in the same location, in association with fever. blood and stool cultures were repeated and gentamicin (240mg/day; iv) and cefixime (200mg 12/12h) were started, in agreement with previous cultures results. curiously, there was no history of diarrhea, but the patient referred a period of recurrent abdominal colicly pain, before cutaneous lesions appear. conclusion: bacteremia with campylobacter species requires specific laboratory workup. 7diagnosis of campylobacter jejuni bacteremia should be considered in hypogammaglobulinemic patients with recurrent fever, particularly when typical copper color erysipela-like skin lesions occur. campylobacter eradication can only be achieved with prolonged antibiotic therapy guided by antibiogram in cultures. conclusions: in this study, genetic defects of five higm patients have been identified, for other patients further genetic investigation such as next generation sequence (ngs) is required. the study results can help diagnose of the disease more definitively and also can provide valuable information for genetic counseling especially for those who have a history of immunodeficiency in their families and also for prenatal testing. conclusions: mutation analysis of unc13d gene can help the families with hlh patients give genetics counseling for carrier detection and prenatal diagnosis. woelke s 1 ; valesky e 2 ; bakhtiar s 3 ; bader p 3 ; schubert r 1 ; zielen s 1 1 department for children and adolescents, division of allergology, pulmonology and cystic fibrosis, goethe university hospital, frankfurt, germany; 2 department of dermatology, venereology and allergology, goethe university hospital, frankfurt, germany; 3 department for children and adolescents, division for stem cell transplantation and immunology, goethe university hospital, frankfurt, germany introduction: ataxia telangiectasia (a-t) is a devastating multi-system disorder characterized by progressive cerebellar ataxia, growth retardation, immunodeficiency, chronic pulmonary disease and genetic instability with an increased risk for malignoma. as described in other primary immunodeficiencies cutaneous granulomas are a known phenomenon also in a-t. still treatment indication and strategies remain controversial. objectives: from our cohort of 60 classical a-t patients, eight patients in the aged 2 to 11 years presented with granulomas. histopathology of the lesions confirmed the presence of granulomatous inflammation without detection of any microbiological agent in all patients. five patients suffered from cutaneous manifestation, in two patients we detected a bone and in one a joint involvement. both patients with bone involvement (patients 1 and 2) as well as one patient with massive skin manifestation (patient 3) were treated with tnf inhibitors (infliximab). the patient with granulomas in his finger joint (patient 4) was bone marrow transplant (bmt) for other reasons. year led to a total remission for three years now. in patients 2 and 3 treatment with tnf inhibitors led to a partial regression of granulomas. treatment interruptions caused deterioration again. in the course of treatment the effects of infliximab diminished most likely caused by drug antibodies. after changing treatment to subcutaneous adalimumab a further regression could be detected. in patient 4 granulomas totally disappeared with immune reconstitution after successful bmt. partially successful in treatment of granulomas. due to the known immunodeficiency in a-t patients, indication for immunosuppressive therapies as tnfa inhibitors should be held strictly. woelke s 1 ; hess u 1 ; knop v 2 ; krausskopf d 3 ; kieslich m 3 ; schubert r 1 ; zielen s 1 of 1 to 38 years regarding c-reactive protein (crp), liver enzymes, abdominal ultrasound and neurological status (ataxia score). we divided the patients into two age groups of 27 a-t patients aged 1 to 11 years and 26 a-t patients aged 12 years to 38 years. ataxia score (r=0.34), although the underlying pathomechanism is unclear. ultrasound revealed nonalcoholic fatty liver disease in only one young patient (3.7%) compared to 11 older patients (42.3%). one female patient aged 37 years died due to a hcc. conclusions: liver disease is present in almost all older a-t patients. structural changes, nonalcoholic fatty liver disease and fibrosis are frequent findings. there is a considerable risk for hcc. prospective studies are necessary using noninvasive techniques for the assessment of liver fibrosis (eg transient elastography) and to establish the risk of hcc in a-t patients. objectives: in this study, it was aimed to determine the frequency of pollen-food syndrome in children who have sensitization to pollens. results: 672 pollen-sensitized patients were included in this study. the mean age of the patients was 11.82ae3.90 years, while 63.1% (n=424) were male. in 45.2% (n=304) of the patients, allergic rhinitis was concomitant with asthma. 4.3% (n=29) of the patients described symptoms related to pfs. 31% (9/29) of them had a history of anaphylaxis with suspected food. the mean age of the patients describing pfs was 12.22ae4.26 years and 55% (n=16) of them were female. in 17 (58.6%) of these 29 patients, skin tests performed with suspected food was positive, but in one patient the skin test was negative while specific ige was positive. suspected food was fruit/ vegetables in 21 patients. in patients with pollen allergy, oropharyngeal symptoms related to fresh fruit, vegetables, dried fruits and nuts should be enquired. it should be noted that these patients might experience serious systemic reactions including anaphylaxis. patel nb 1 ; vazquez-ortiz m 1 ; lindsley s 1 ; abrantes g 1 ; bartra j 1 ; dunn galvin a 2 ; turner pj 1 conclusions: there is no evidence that the occurrence of anaphylaxis at fc, and self-treatment with an adrenaline auto-injector device, result in adverse impact on hrql measures. the impact of a reaction at food challenge appears to confer greater benefit on the parent than the child. the relationship between confidence in management and hrql needs further assessment, since it is likely that these outcomes will be affected in different ways following therapeutic interventions. results: fifty-one patients (23 females, 28 males) (median age: 6.5 years, range 0-18) with cma were studied. spt to cm was 7.3ae3.3 mm as mean diameter. forty-eight out of fifty-one (94.1%) patients underwent dm-opt (3 patients refused to underwent opt due to positive spt or s-ige to dm introduction: bovine milk is the most common food allergen in children under 3 years of age. milk allergy is treated by eliminating milk from the diet. the milk elimination diet endangers the child's energy intake and also exposes the child to shortage of multiple nutrients. this study was needed because there are no previous systematic reviews about this subject. objectives: the aim of the present study was to examine if the milk allergy or the other factors associated with milk elimination diet have an influence on child's growth. the present study was conducted according to international guidelines for systematic reviews. results: a total of 646 studies were initially identified, of which three fulfilled our criteria. these three studies included 186 children with cow's milk allergy and 122 control children. in all these three studies, children with cow's milk allergy were lighter than controls. in addition, in two studies, the growth of the children with cow's milk allergy was stunted. in two studies the milk elimination was substituted with special infant formula. also in one study where both the growth and the weight were stunted, no major differences in energy or nutrient intake between cow's milk allergic cases and controls were reported. conclusions: current evidence suggests that milk allergy is associated with stunted growth in childhood, but reasons for this are unclear. in order to clarify the effect of cow's milk elimination diet on growth in childhood and the underpinning mechanisms, more studies need to be conducted. in addition, special attention to the diet and growth of children with cow's milk allergy is needed. results: a total of 158 817 children were surveyed in this 6-year period (annual average: 26 470). in 2011, 704 children (2.6%) were diagnosed with food allergy, including 159 cases of pfas, 376 cases of egg allergy, and 235 cases of dairy-product allergy. in 2016, 939 children (3.6%) were diagnosed with food allergy, including 344 cases of pfas, 385 cases of egg allergy, and 249 cases of dairy-product allergy. over this 6-year period, the prevalence of pfas increased 2.2fold (from 0.59% to 1.31%). among the pfas cases, the prevalence of rosacea and apple allergy increased 2.9-and 3.3-fold, respectively. the most prevalent was apple allergy (0.76%), followed by peach (0.59%), loquat (0.53%), plum (0.44%), pear (0.40%), and strawberry (0.18%). the prevalence increased significantly for pfas but not for other types of food allergy (egg and dairy-product allergy). in the future, nationwide studies are needed to further elucidate the relationship between pfas and allergic rhinitis. 0327 | immune profile after oit in children with cow 0 s milk allergy patients with elimination diet, group 3: patients with natural tolerance, group 4: healthy control). in all groups specified laboratory tests were performed at onset and also at 6 month to treatment groups. in desensitization group at 6 month of treatment we evaluated increase in total ige level, sp iga and igg4 antibody responses, decrease in cow's milk spige levels and an increase in il-2, il-10, tgf-b cytokine responses without a difference in cd4+cd25+fox-p3% levels. il-13 levels were similar with pre-treatment levels whereas foxp3 mrna expression was similar with tolerance group. in elimination group at 6 month treatment, there was a decrease in cow's milk spige whereas there was no change in sp iga levels and a minimal increase in igg4 levels. there was no change in il-2 and il-10 cytokine levels. and an increase in tgf-b cytokine response less than group 1, decreased il13 response, a foxp3 mrna expression differed from tolerance group was identified. objectives: although hyperuricemia has a significant prevalence in the general population, and has been related to exercise-induced asthma, could be related to bronchial asthma and nasal polyposis. hitherto, its possible association with hypersensitivity to nsaids and its convenience as biomarker have not been acquainted. conclusions: in our population, hyperuricemia has not demonstrated to be a reliable biomarker related to nsaids allergy and could not be used as a risk factor for assessing the triad nsaids allergy, asthma and nasal polyps. to study the vas of the total score was seen significant variance in: nsaid-cu (3.38pt) and nsaid-pa (6.57pt) (p=.046), nsaid-cu conclusions: data support that cutaneous manifestations have a common response with aerd to cox inhibitors. conclusions: this study showed that in a positive drug oral provocation test, respiratory symptoms were accompanied with nitric oxide changes in both nasal and exhaled way. barrionuevo e 1 ; doña i 1 ; salas m 1 ; bogas g 1 ; guerrero ma 1 ; sanchez mi 1 ; cornejo-garcia ja 2 ; torres mj 1 1 allergy unit, regional university hospital of malaga-ibima, malaga, spain; 2 research laboratory, ibima-regional university hospital of malaga-uma, malaga, spain introduction: non-steroidal anti-inflammatory drugs (nsaids) are the most frequent triggers of drug hypersensitivity reactions, being cross-hypersensitivity reactions (chr) the most frequent. the categories included in chr are nsaids-exacerbated respiratory disease (nerd); nsaids-exacerbated cutaneous disease (necd) and nsaids induced urticaria/angioedema (niua). however, it has been reported patients with chr to nsaids who developed a combination of skin and respiratory symptomatology (blended reactions). objectives: our aim was to analyse the characteristics of patients with blended reactions and compare with those developing symptoms exclusively respiratory (nerd) or cutaneous (niua). episodes of cutaneous and/or respiratory symptoms after the intake abstracts | 265 of ≥3 different nsaids included strong cox-1 inhibitor (acetylsalicylic acid (asa) and/or indomethacin); ii) if they had <3 episodes of cutaneous and/or respiratory symptoms induced by <3 different nsaids, a positive drug provocation test (dpt) with asa was required; iii) if patients had respiratory symptoms accompanied or not by cutaneous involvement, a positive nasal provocation test with lysine aspirin (npt-lasa) was required. atopy was assessed by skin prick test using a panel of inhalant and food allergens. objectives: subjects with nsaids hypersensitivity were divided into two groups: a) those from 2 to 14 years and b) those from 15-20 years. diagnosis was established by a clinical history and controlled challenge with asa. atopic status was verified with a detailed allergological study including skin testing to inhalant allergens. clinical entities were classified in three categories: urticaria/angioedema, anaphylaxis and respiratory (asthma and/or rhinitis). cases. no differences were observed in the atopic status between both groups. there were significant differences between males/ females (p<.05). when we compared the clinical entities there were more cutaneous manifestations, mainly angioedema, in the group a) and more anaphylaxis in group b) although there were no significant differences due to sample size. conclusions: significant sex differences between hypersensitivity reactions to nsaid occurs with predominance of males in the first group (a). although there are also a predominance of clinical entities, an increase number of cases is needed to establish significance. studies on this direction are in progress. show an increase in all age groups. etiologic analysis was limited as the study was carried out using the icd-10 code (nhic records) and database of self reporting systems (kaers). so, further study was needed. introduction: genetic variants from the 17q21 locus are the strongest known genetic determinant for early-onset childhood asthma, and have also been associated with uncontrolled asthma despite asthma treatment. objectives: the aim of the study was to assess whether there is an association between a single nucleotide polymorphism (snp) in the 17q21 locus (rs7216389) and asthma exacerbations despite the objectives: our hypothesis is that the arg16 allele is associated with increased use of prescribed asthma medication, over a 9-year period. to explore this hypothesis, we have undertaken a secondary analysis of breathe, a study of gene-environment associations with asthma severity. breathe data were collected on participants with asthma, aged 3-22 years, between 2003 and 2005, in tayside conclusions: in children and adults, the homozygous arg/arg status is associated with long-term increased prescribing for asthma medication compared to those carrying at least one gly allele. defining subgroups of individuals requiring more medicines could help predict treatment costs and develop targeted management strategies. objectives: considering the role of ptgdr in allergy, the goal of this study was to analyze the effect of ptgdr expression on cytokine levels in the a549 cell line. analyze ptgdr expression in a549 cell cultures. cytokine production assays in the culture supernatant were measured by cytometric bead assay using the bioplexpro tm human cytokine standard 27-plex, group i. the assays were conducted with bioplex high-throughput fluidics system, powered by the luminex technology. every sample was run at least in triplicate. the ptgdr expression in the transfected cells with the haplotypic variants differed by 5 orders of magnitude relative to control cells (p<.001). we found significant differences in ptgdr expression between ctct and cccc haplotypic variants. the cccc (à613 c, à549 c, à441 c, and à197 c) introduction: c159t polymorphism in the cd14 gene has been suggested in susceptibility to asthma. cd14 is a multifunctional receptor endotoxin, which is expressed on the surface of macrophages, monocytes and neutrophils. it is likely to play a role in the inflammation pathway. though data is available regarding association of cd14 gene with asthma but independent studies are in conflict. objectives: the present study was conducted to examine the association of promoter c159t single nucleotide polymorphism (snp) in the cd14 gene for indian children with atopic asthma. we characterize the c159t polymorphism in children with asthma (50), cohort group (20) and healthy control group (50) by pcr rflp. association analysis was performed using v2 tests. we also analyzed the association of cd14 (c159t) with total ige levels by elisa and foxp3 expression using flow cytometry. in this snp a 497 base pair (bp) pcr product was generated using the standard primers. after restriction products showed that homozygous c allele was appeared as a single 497bp band, the homozygous t allele as bands of 144 bp and 353 bp, and heterozygous exhibits all three bands (144, 353 and 497 bp). the or of cc genotype frequency abstracts | 271 was 0.84 in study group and 0.78 in cohort group and the or of c allele frequency was 2.38 in study group and 2.52 in cohort group. total ige level were found to be significantly higher in cc genotype compared to ct and tt genotype. foxp3 level is significantly higher in control group in all genotypes compared to cohort and study group. conclusions: the present study concludes that in cd14 gene polymorphism cc genotype was not significantly associated with asthma but other factors ie total ige and foxp3 showed significant association of cc genotype with asthma. on the other hand, there was significant association of c allele with asthma. 0362 | the disbalance of tlr2, tlr4 gene expression and cytokines production in children with bronchial asthma svitich oa 1 ; gankovskaya lv 2 ; namazova-baranova ls 3 ; bragvadze bg 2 ; alekseeva aa 3 ; gankovskii va 3 objectives: examined were 38 patients with bronchial asthma aged from 3 to 12 years and 10 healthy children of the same age. cytokines were determined by elisa. determination of mrna expression in scrapings from the mucous membranes of the respiratory tract and in peripheral leukocytes was carried out polymerase chain reaction in real time. results: in scrapings from the mucous in patients with moderate to severe asthma found a significant increase in the gene expression of tlr2, 3 times, the gene tlr4 in 10 times in comparison with the control group. in children with severe asthma also found a significant increase in the gene expression of tlr2 4.8 times compared to healthy children, p≤.05). indicators of tlr4 gene expression in this group of patients have a tendency to increase, but not statistically significant. when comparing the indicators of innate immunity in samples with a leukocyte mass in the group of children with severe asthma showed a decreasing expression of tlr2 compared with the index in healthy children. also decreased the expression of tlr4. in children with moderate ba similarly, a significant decrease of tlr4 gene expression in 18 times. the trend towards reduced expression of tlr2 remains in this group, but is not reliable. in washings from the nasopharynx shows that patients with bronchial asthma il-1 is increased 4.5 times compared to the norm, to 45 pcg/ml, tnf increased in 6 times and 18 pcg/mg in severe asthma, and 7.7 pkg/ mg-for mild, il-17 increased in 3 times (16 pcg/mg), pkg of 7.5/ mild blood, il-10 also increased 4.5-fold and equal to 22.5 pkg/mgwith heavier with easy-7.5 pkg/mg, normal à5 pkg/mg. ie is an increase in proinflammatory and anti-inflammatory cytokines. conclusions: the overexpression of tlr2, tlr4 accompanied by increasing, the production of cytokines. this is a violation of mechanisms of innate immunity at the level of the mucous membrane of the nasal cavity on the role of inflammation in the pathogenesis of tlr. 0364 | sustained reduction in risk of experiencing asthma symptoms and using asthma medication in years following grass slittablet treatment-results from the paediatric gap trial were: wheezing, cough (for more than 10 consecutive days), shortness of breath, chest tightness. the odds ratio for having asthma symptoms, using asthma medication, or having asthma symptoms and using asthma medication was significantly lower in the grass slit-tablet group during the 2 followup years. for asthma symptoms, the results were: or=0.52, p=.016 days with csms<2 were defined as "no or minimal symptoms" and days with csms >6 were defined as severe symptoms. csms score was significant lower in the ilit group than in the placebo group for 2014, 2015 and 2016. in 2014 mean csms was 4.05 roth-walter f 1 ; schmutz r 2 ; mothes-luksch n 2 ; zieglmayreer p 2 ; zieglmayer r 2 ; jensen-jarolim e 3 objectives: here, we investigated whether the immune molecule lipocalin 2 (lcn2) may discriminate between allergic and sensitized individuals, and between responding and non-responding patients. results: lcn2-concentrations were assessed in sera of healthy and allergic subjects (n=160) as well as of house dust mite (hdm) allergies that underwent hdm-sublingual immunotherapy (slit) in a randomized, double-blind, placebo controlled trial for 24 weeks. sera pre -, post-slit and at least 3 months after slit were assessed for lcn2 and correlated with total nasal symptom score (tnss) obtained during chamber challenge at week 24 in patients receiving hdm-(n=30) or placebo-slit (n=10). allergic individuals had significant lower lcn2-levels than healthy controls, with women having lower lcn2-levels than men in the patient cohort. hdm-allergic patients who received hdm-slit had a significant increase in hlcn2 6 months after termination of hdm-slit, whereas in subjects receiving placebo no increase in hlcn2 was observed. within the hdm-slit treated group, lcn2-levels were significantly higher in patients whose symptoms improved during slit in contrast to those in which symptoms became more severe. hence, time-course of lcn2 in an allergic individual was predictive to assess clinical reactivity to hdm. objectives: here, we present the benefits of treatment in terms of nnt to prevent one additional child from having asthma symptoms and asthma medication use. children treated with grass slit-tablet had a reduced risk of asthma symptoms and asthma medication use during the 2-year follow-up period compared with placebo (or=0.28 [0.14, 0.57] for sq grass slit-tablet (n=377) vs placebo (n=398), p<.001, relative risk reduc-tion=71%). the risk reduction was independent of age at treatmentstart. younger children had a higher predicted probability of developing asthma symptoms and asthma medication use than older children. thus, the younger the children were at treatment-start, the greater the percentage was prevented from having asthma symptoms and asthma medication use during follow-up off treatment. for children aged 5 at treatment-start, the risk was reduced from 40% to 24% and for those aged 12 it was reduced from 10% to 5%. consequently, the nnt to prevent one additional child from having asthma symptoms and asthma medication use during the 2-year follow-up increased with age, with nnt=6 for children aged 5 and nnt=20 for children aged 12. conclusions: the grass slit-tablet reduced the risk of asthma symptoms and asthma medication use during the 2-year follow-up period; the risk reduction was independent of age. however, the nnt increased with age as younger children had a higher risk of developing asthma symptoms and asthma medication use, emphasising the importance of treatment-start early in life. results: 226 participants were screened for birch and grass allergy, of whom 93 ultimately met randomization criteria and were treated with either slit-t or placebo for 4 months. treatment was preceded by a successful baseline birch pollen challenge in the eeu where a minimum tnss of 6 was achieved in the first 2 of 5 hours of pollen exposure. 87 participants attended the post treatment challenge in the eeu, also 5 hours in duration. no significant differences were noted in the reduction of birch-induced tnss compared to baseline between the slit-t and the placebo treated participants (the primary outcome measure). adverse events with a minimum 5% frequency occurred in 50% of participants in the placebo arm and 70% of participants in the active arm, with upper respiratory tract infection (32% in active arm and 24% in placebo arm) being the most common. oropharyngeal itch was the most common adverse event with causality at least possibly related to study medication (23% in active arm and 2% in placebo). no serious adverse events occurred including no anaphylaxis. objectives: here, we present a pooled subgroup analysis in adolescents from 2 phase ii/iii-iii trials with the hdm slit-tablet (12 sq-hdm dose), p001 in north america and to-203-3-2 in japan. results: to-203-3-2 was a randomised, dbpc phase ii/iii trial investigating the efficacy and safety of the hdm slit-tablet in japanese adolescents and adults (12 to 64 years) with moderate-tosevere hdm ar (n=946, of which 302 were adolescents). subjects were randomised to treatment with the hdm slit-tablet in doses of 6 sq-hdm, 12 sq-hdm or placebo for 1 year. p001 was a randomised dbpc phase iii trial investigating the efficacy and safety of the hdm slit-tablet in north american adolescents and adults (≥12 years) with moderate-severe hdm ar with or without asthma (n=1482, of which 189 were adolescents). subjects were randomised to treatment with 12 sq-hdm or placebo for up to 1 year. in both trials, the primary endpoint was the average total combined rhinitis score (tcrs) during the last 8 weeks of treatment. the pooled analysis was performed on mean values using a linear mixedeffects model. treatment with 12 sq-hdm of the hdm slit-tablet resulted in a statistically significant reduction in the average tcrs of 1.04 (22%, p=.002) compared to placebo in the last 8 weeks of treatment. statistically significant differences were seen for both components of the tcrs, the rhinitis medication score (difference=0.06, p=.038) and rhinitis symptom score (difference=0.87, p=.004). furthermore, treatment with 12 sq-hdm resulted in a statistically significant reduction of the conjunctivitis symptom score compared to placebo (differ-ence=1.10, p=.026). treatment was well tolerated. the most frequent adverse events were mild-to-moderate local allergic reactions. the pooled subgroup analysis showed that the hdm slit-tablet (12 sq-hdm) was effective in treating hdm allergic rhinitis in adolescents (12-17 years old). the reduction in the primary endpoint tcrs was statistically significant and comparable to what has been observed in adults. results: at the time of the data-cut for this analysis, a total of 179 european patients were screened (58% male). 56% of the subjects were aged 4-11, 28% were aged 12-17, and 16% were adults. the mean age of the sample was 11.4 [sd 6.9] years, with a minimum of 4 and a maximum of 49 years. in europe were children. many were allergic to foods other than peanut, and most had at least one other atopic condition. even if allergic to multiple foods, patients and their families were nonetheless keen to participate in the trial. the majority of the screened patients were highly sensitive to peanut, reacting to 144mg (cumulative) or less of peanut protein but a significant proportion of screening failures were due to lack of reactivity to this dose. 0372 | efficacy of 300ir 5-grass pollen sublingual tablet: improvement in subjects with grass pollen-induced allergic rhinoconjunctivitis based on well days and severe days evaluation objectives: four phase ii/iii dbpc studies, 3 in adults and one in children/adolescents, were conducted worldwide. participants were abstracts | 277 randomised to receive the 300ir tablet or placebo starting 4 months (4m) prior to the pollen season and continuing for its duration. data from the first season of the 3 trials in adults were pooled. the well days were defined as those with not more than one moderate symptom or 2 mild symptoms of the 6 evaluated symptoms (sneezing, rhinorrhoea, nasal pruritus, nasal congestion, ocular pruritus, watery eyes) and no use of rescue medication. the severe days were defined as either at least one moderate symptom in subjects using rescue medication, or at least 2 moderate symptoms or one severe symptom whether rescue medication was taken or not. for each subject, the proportions of well days and those of severe days were evaluated during the pollen period while on treatment. treatment groups were compared using a wilcoxon 2-sample test. introduction: the safety of subcutaneous immunotherapy (scit) has been proven in several studies, but the occurrence of side effects (se) remains a concern in daily clinical practice and understanding of their risk factors and avoidance strategies remains limited. objectives: the aim of presented study was to assess the incidence and risk factors of early and late side effects in patients undergoing scit. we conducted a 2 year-long observation of over 1300 patients undergoing scit in our outpatient clinic. we recorded detailed information for each administration and screened subjects for both immediate and late reactions. we compiled the records with medical histories to build a database, which was analyzed using multiple logistic regression. casein is a major cow 0 s milk allergen and very resistant to high temperatures. higher levels of ige towards caseins have been reported to associate with persistent cow 0 s milk allergy and higher risk of adverse reactions before and during the milk oit. a follow-up study on oit to milk started in 2005 with a six-month built-up phase. seventy-six children (mean age 9.7 years) with challenge-verified cma participated the milk oit and their immunological changes were analyzed employing crd. during the year 2016, long-term follow-up report was collected by questionnaires (73%, n=49) and blood samples (46%, n=35). specific antibody responses were characterized before oit and on long term follow up and compared to long-term questionnaire results: milk consumption (yes/no) and side-effects from milk from past 12 months (yes/no). objectives: to define the utility of crd in long-term follow-up after milk oit. results: mean follow-up time was 8 (5-11) years. ten patients (20%) avoided milk completely and 39 patients (80%) reported routine consumption of dairy products. side effects after milk consumption from last 12 months were reported by 39% of the patients. increased specific ige levels towards caseins were seen among patients who did not consume milk at the long-term (p=.03*). there was no significant association between the long-term milk consumption and ige levels to whole milk (p=.08), caseins (p=.06), alpha-lactalbumin (p=.25) and beta-lactoglobulin (p=.08) measured before the oit in this small sample. patients who consumed milk at the longterm follow-up and reported side effects had higher specific ige levels towards caseins before oit (p=.02*). conclusions: there was a high incidence of side effects even after eight years of milk consumption, which may indicate desensitization instead of true tolerance. component-resolved diagnostics may corroborate in predicting prognosis, as suggested by higher incidence of side effects among patients with high levels of ige towards caseins also in the long-term follow-up. objectives: retrospective study of 346 patients who underwent subcutaneous ait for allergic rhinitis (20% had concomitant asthma). patients with less than 4 months of treatment were excluded. large local reactions (wheal≥25 mm) and systemic reactions were defined according to who grading system. patient's satisfaction was defined by vas score. results: the mean age of patients (54% males) was 28ae13 (range 5-72) years (11%<16 years).the most prevalent immunizing allergens were house dust mite (92%), olive (26%) mix of grasses (23%) and pets (17%). 47% of patients were immunized against a single allergen whereas 12% were immunized with≥4 allergens. patients were followed for 24ae18 months. following ait the vas score decreased from 7.2ae2.3 to 3.6ae2.5 (p<.0005). 92% of the patients declared that they will recommend immunotherapy to their relatives. systemic adverse reactions (37% class i, 62% class ii) were observed in 120 introduction: metabolomics, one of the core disciplines of system biology, is a high-dimensional biology method that may allow hypothesis-free profiling of biomarkers, rather than a traditional hypothesis-driven approach. objectives: this study aimed to apply the metabolomic approach to serum to longitudinal alterations during allergy immunotherapy (ait) in dermatophagoides pteronyssinus (der p) sensitized asthmatic children. results: a robust hydroxyeicosatetraenoic acids (hetes) of inflammatory responses was found for discriminating during ait, including 5-hete, 12-hete and 15-hete. 12-hete and 15-hete were significantly decreased continuously from 6 through 12 months of ait. moreover, compared with baseline of ait 5-hete was detected in very low level during 6 and 12 months. the metabolomic profiling could clearly longitudinal alterations biochemical-metabolic profiles in der p-sensitized children during ait. these markers might be involved in asthma pathophysiology but also represent the therapeutic target for ait. background: metabolomics, one of the core disciplines of system biology, is a high-dimensional biology method that may allow hypothesis-free profiling of biomarkers, rather than a traditional hypothesis-driven approach. this study aimed to apply the metabolomic approach to serum to longitudinal alterations during allergy immunotherapy (ait) in dermatophagoides pteronyssinus (der p) sensitized asthmatic children. methods: in this longitudinal study, we recruited 58 der p-sensitized asthmatic children with ait for 12 months. serum samples were analyzed using a metabolomic approach based on mass spectrometry. results: a robust hydroxyeicosatetraenoic acids (hetes) of inflammatory responses was found for discriminating during ait, including 5-hete, 12-hete and 15-hete. 12-hete and 15-hete were significantly decreased continuously from 6 through 12 months of ait. moreover, compared with baseline of ait 5-hete was detected in very low level during 6 and 12 months. the metabolomic profiling could clearly longitudinal alterations biochemical-metabolic profiles in der p-sensitized children during ait. these markers might be involved in asthma pathophysiology but also represent the therapeutic target for ait. we performed desensitization with asa according to the wong protocol (doses of 0. 1, 0.3, 1, 3, 10, 30, 40, 81, 162, 325 mg of asa at intervals of 10-20 min). we pre-medicate with cetirizine 10 mg. our patient successfully reached the necessary dose: 164 mg of asa (0. 1, 0.3, 1, 3, 10, 30, 40, and 80 mg) conclusions: approximately 10% of patients with asthma undergo respiratory symptoms due to exposure to aspirin, meanwhile 0.07% and 0.2% of the population shall undergo hives when exposed to it. desensitization with aspirin is an efficient and safe treatment in patients with hypersensitivity type i, iii and iv. due to the benefits and low toxicity of the wong protocol, we recommend this protocol in order to desensitize patients with allergy to aspirin who undergo rheumatologic or cardiovascular disorders and need antiplatelet treatment. we finally recommend our patients to take 150 mg of asa premedicated with 10 mg of cetirizine every day. we warn that if you interrupt the administration of asa for more than 48 hours, it shall have to be administered again under medical supervision. semedo fm 1 ; cruz c 2 ; reis r 2 ; tomaz e 2 ; in acio f 2 horiuchi t 1 ; takazawa t 2 ; saito s 1 1 department of anesthesiology, gunma university hospital, maebashi, japan; 2 intensive care unit, gunma university hospital, maebashi, japan introduction: sugammadex is a synthetic c-dextrin derivative that is designed to selectively bind to steroidal neuromuscular blocking agent molecules. although sugammadex has been used in many cases of general anesthesia, there are several reports of anaphylaxis following its use. skin testing is the gold standard for detecting the causative agent of anaphylaxis. however, the test itself sometimes precipitates serious complications, including recurrence of anaphylaxis. hence, development of a novel test that can be performed in vitro without causing such complications is desired. recently, the basophil activation test (bat) has been established as a tool to detect the causative agent of anaphylaxis with high sensitivity and specificity. yet, there are few studies examining the utility of the bat in diagnosing sugammadex-induced anaphylaxis, besides our previous report. although both cd63 and cd203c are currently used as the major markers for activated basophils, which one of them is more suitable for the bat depends on the targeted drugs. objectives: the aim of this study was to investigate whether bat could be utilized to diagnose sugammadex-induced anaphylaxis. in addition, we compared the capability of cd203c and cd63 as markers for activated basophils. seven patients with perioperative anaphylaxis demonstrating a positive skin test for sugammadex were included. furthermore, 21 individuals who tolerated sugammadex and had a negative skin test for allergy to this drug were enrolled as controls. results: the ratios of activated basophils in the patients were much higher than those in controls (mann-whitney u test, p<.005). cd203c up-regulation. this was also true for cd63. in the case of cd203c, the sensitivity of bat for sugammadex was 83% and specificity was 100%, while sensitivity and specificity for cd63 were 71% and 100%, respectively. there were no significant differences between cd203c and cd63 in the areas under the roc curve. conclusions: this study showed that bat is a reliable instrument to diagnose sugammadex-induced anaphylaxis. we did not find any difference between cd203c and cd63 as markers for activated basophils in the bat for sugammadex. objectives: we report a retrospective study of 10 patients who were referred to our allergology departments between 2012 and 2016 with a suggestive history of immediate hypersensitivity to ppis. our purpose was the analysis of the clinical presentations and the allergological investigation performed in order to confirm the diagnosis of drug hypersensitivity to ppis and to study the cross-reactivity among ppis. results: the culprit drugs were pantoprazole (n=5), omeprazole (n=3) and lansoprazole (n=2). the allergological investigation confirmed the diagnosis of hypersensitivity to ppis in 5 patients (4 by skin tests and 1 oral challenge). we observed cross-reactions between omeprazole, pantoprazole and esomeprazole (n=1), omeprazole and pantoprazole (n=2), respectively omeprazole and esomeprazole (n=1). in 5 patients the severity and the recurrence of the reaction did not allowed the provocation test with the culprit drug. two oral challenges allowed the use of an alternative ppi (based on the pattern of less cross-reactivity depending on the chemical structure: pantoprazole for a patient who had a grade iii anaphylaxis to lansoprazole and lansoprazole for a patient who had a grade ii anaphylaxis to pantoprazole). conclusions: a complete allergological investigation (skin tests and cautiously, oral challenge) is needed in order to confirm the diagnosis of drug hypersensitivity to ppis and to take a therapeutic decision. the diagnostic approach is limited by the low sensitivity of skin tests and the patient's background (comorbidities and severity of the reaction) which do not always allow the oral provocation test. an ige dependent mechanism may be involved in hypersensitivity reactions to ppis or their metabolites. herrero-lifona l 1 ; muñoz-rom an c 2 1 hospital quironsalud campo de gibraltar, los barrios, spain; 2 hospital regional universitario de m alaga, m alaga, spain introduction: hypersensitivity reactions to beta-lactams are an important problem to study, especially in children, given that these antibiotics are the gold standard for the treatment of many infectious diseases in the infancy. most hypersensitivity reactions to betalactams in children are due to non-immediate response and to diagnose them is essential to perform a drug challenge test. although hypersensitivity is usually ruled out in children by drug challenge test, it is positive test up to 5%-10%. objectives: a 6 year-old boy is suspected to have experienced two drug reactions after the intake of amoxicillin with and without clavulanic acid for pharyngitis treatment. in the first one, he presented a maculopapular eruption in the back after one day treatment with amoxicillin-clavulanic acid. in the second reaction, two hours after the intake of amoxicillin, it appeared an itching maculopapular eruption in the back that was resolved with symptomatic treatment. in both cases, the patient tolerated treatment with cefuroxime afterwards. results: intradermal test with amoxicillin was negative in immediate and delayed reading. oral drug challenge test with amoxicillin (50 mg/kg/day, total cumuoral drug challenge test with penicillin v (total cumulative dose 250 mg): it was well tolerated and the patient continued taking it for epicutaneous patch testing with amoxicillin in the lesion area and in an unaffected area: in the lesion area, it appeared mild erythema, but it was considered a negative result in both areas. conclusions: we report a case of an amoxicillin-induced multiple fixed exanthema: an unusual non-immediate reaction in childhood. most cases of non-immediate hypersensibility need to be confirmed by drug challenge test, given that skin testing lacks sensitivity both intradermal and patch tests. the patient presents a selective hypersensitivity to amoxicillin, being tolerant to penicillin and cephalosporins. jimenez-rodriguez t 1 ; soriano-gomis v 1 ; gonzalez-delgado p 1 ; cueva-oliver b 1 ; venegas-diaz ij 1 ; fernandez j 2 results: data from 62 patients were analyzed, of which 64.5% (40) were women. the overall mean age was 46.1ae16.9 years, with no statistical difference between sexes. the 69.4% (43) of the patients presented symptoms with a single group of nsaids, and 30.7% (19) with 2 or more different groups. the 90% (56) of patients presented a history of atopy. in patients with rhinitis 58% had symptoms with only one nsaid and 42% with two or more groups of nsaid, while patients with asthma, 83% reacted to one nsaid and 17% to two or more groups. the most frequent clinical manifestations were: urticaria/angioedema in 71% (44), pruritus in 35.5% (22), bronchospasm in 19.4% (12), other respiratory symptoms in 16% (10) and anaphylaxis in 13% (7) patients. the most frequently involved nsaids were: metamizole (46.8%) and ibuprofen (37.1%). skin tests were performed in only 24 patients, of whom 13 (54%) were positive to metamizol. dpt was performed in 66.1% (41) objectives: fifty patients diagnosed with "dress" (2012-2016), in a tertiary center were retrospectively analyzed, with 31 cases meeting the regiscar criteria. we collected demographic, clinical, laboratory and therapeutic data from the electronic medical records. results: all cases occurred during hospitalization and in several hospital areas. the mean age was 49.16 years (7-94) with 58.06% women and 95% of caucasian origin. reported clinical manifestations were skin rash (97%), fever (48.39%), digestive symptoms (22.58%), respiratory (12.9%), neurological (9.68%), head and neck (6.45%), urological (6.45%), ophthalmologic (3.23%) and musculoskeletal (3.23%). the most relevant laboratory findings were eosinophilia (77%), elevated transaminase levels (77%), lymphocytosis (53%), altered coagulation (34%) and altered renal function (32%). virus serology was positive in 4 cases (12.9%) involving hhv-6, ebv, cmv and hiv. antinuclear antibodies were positive in 2/13 cases (15.38%). skin biopsy, performed in 12 cases (38.7%) revealed findings suggestive of drug induced skin reaction. suspected culprit drugs were antibiotics (45%), nsaids (26%), antiepileptic drugs (13%), and antiparasitic agents (10%). one case was related to the administration of heparins and other to a monoclonal antibody. in 10% of cases, the episode was not related to a particular drug. treatment was accomplished by the administration of corticosteroids (97%), antihistamines (96%), and immunosuppressant drugs in 2 cases. fluids and other medications were administered attending to symptoms. death occurred in 3 patients, although only in 1 case it was related to dress syndrome. the average time from reaction to death was 4.33 months. allergy evaluation, performed in 11 cases addressed the potential role of drugs. skin tests were positive in 3/11 patients (28.6%) and basophil activation test was negative (2/2 cases). results: from 17 patients admitted with possible diagnosis of scar, only 8 met the inclusion criteria (6f/2m, age 15-81, average 49.1 years-old). they were all admitted to a medicine ward. five patients had diagnosis criteria of dress, 2 of sjs and 1 of ten. as for the drugs related with the reaction, antiepileptic drugs were the most frequent (4 patients); allopurinol (1), betahistine (1), ciprofloxacin+nimesulide (1) were the causative drugs in the remaining patients. average time to the beginning of symptoms was 30.7 days (2 patients unknown). in 1 patient the cause was unknown (he had criteria of ten and also diagnosis of malaria and was transferred to another hospital). there were no deaths. objectives: the objectives of the present study were to determine the efficacy of nfeno to: 1. establish the diagnosis of rhinitis; and 2. discriminate allergic rhinitis (ar) from non-allergic rhinitis (nar). material and methods: prospective and controlled study with healthy subjects, which included patients with rhinitis. ar and nar were phenotypically defined according to positive or negative prick test results, respectively; the control group was collected from people without upper or lower respiratory tract disease and the prick test was negative. in all sample included the following measurements were performed: feno and nfeno (novario analyzer) were performed; spirometry; eosinophil counts in blood and nose (by nasal brushing); bilateral nasal endoscopy; and acoustic rhinometry. results: we included 147 cases (ar=61, nar=53 and controls=33), with a mean age of 37 (sd 11.2) years, 66% men. the table below shows the results of the variables analyzed by group. patients with rhinitis compared to controls had significantly greater feno production, as well as a higher proportion of eosinophils in blood and nose, but not in nfeno production. however, when the two subgroups of rhinitis were compared, ar patients had significantly higher feno and nfeno than nar, in addition to blood and nose eosinophils. there were no differences in acoustic rhinometry values between groups. conclusions: although nfeno does not appear to identify patients with rhinitis, it may be useful in discriminating ar from nar. in routine clinical practice, it could help guide to identify an ar in cases with inconclusive results of the complementary tests commonly used in its diagnosis. introduction: fractionated exhaled nitric oxide (feno) is used as a marker of eosinophilic airway inflammation in asthma, whereas clinical presentation of nasal no (nno) is unknown. objectives: the objective of this study was to evaluate the factors influencing nno levels. in patients with chronic nasal symptoms, total-nasal-symptom-scores (tnss) were calculated; skin-prick-test conclusions: in conclusion nasal no is useful in allergic inflammation in the absence of sinus obstruction in nasal cavity. however, its value is limited with paranasal sinus ostium occlusion. were recruited across australia and the uk via a patient panel. the aim was to assess which ar treatment attribute(s) drove patient preference. results: table 1 shows the willingness to pay (wtp) for each attribute. all attributes were significant predictors of treatment choice, except administration method. however, patients in both countries showed a considerable preference for treatments that were more efficacious, fast acting and affordable. conclusions: although treatment relief remains of primary concern, time to treatment benefit and cost could dictate treatment preference. these data may be of value in optimizing the acceptability of future ar treatments and informing trial endpoint selection. australia ( izquierdo l; chiriac am; molinari n; demoly p introduction: allergic rhinitis is a frequent disease with an important impact on quality of life. self-administrated control assessment tests can help achieve a better management of this disease. however, none of these tools has been validated in teenagers. test in its original version, following the same protocol as the original study in adults. we designed a multicentre, observational, crossconclusions: while the number of included patients is low, the first results are promising. indeed, a significant improvement of the rhinitis control score was found between d1 and d15. this led us to the hypothesis that this questionnaire could be used as is to estimate the control of the allergic rhinitis in teenagers. analyses concerning the validation of the questionnaire itself do not reach at the moment the threshold of significance, the recruitment is on-going, to increase its power. objectives: the objective of this study was to evaluate the role of serum vitamin d in patients with symptomatic allergic rhinitis and active asthma during the allergy season and observe the effect of montelukast 10 mg daily as treatment. results: this study included 130 asthmatic and seasonal allergic rhinitis patients following a single-blind, placebo run-in period of 3-5 days, patients were randomized to oral montelukast 10 mg (n=70) or placebo (n=60) daily during the 2-week, double-blind, active-treatment period. the serum vitamin d was also evaluated in both the groups. the serum vitamin d levels were found to be higher in patients taking montelukast compared to placebo after 2 weeks (p<.001). montelukast reduced the daily rhinitis symptoms score: difference between montelukast and placebo (p<.001). similar improvements were seen in daytime nasal symptoms (p<.001) and nighttime symptoms (p<.001). conclusions: montelukast provides significant relief from symptoms of seasonal allergic rhinitis, while also conferring a benefit for asthma, in patients with both allergic rhinitis and asthma. further, it has a beneficial role in improving vitamin d levels. venegas-diaz ij 1 ; jimenez-rodriguez t 1 ; canto-reig vj 1 ; lindo-gutarra m 1 ; soriano-gomis v 1 ; gonzalez-delgado p 1 ; cueva-oliver b 1 ; fernández j 2 1 allergy section. general hospital alicante. isabial, alicante, spain; 2 allergy section. general hospital alicante. isabial-umh, alicante, spain introduction: local allergic rhinitis is an accepted entity, which only can be recognized by nasal provocation test (npt) in patients with clinical rhinitis with negative skin tests or specific ige (sige). our aim was study this entity in our patients in alicante, spain. objectives: 100 patients with symptoms of rhinitis with skin tests, and sige negative for common aeroallergens were selected, since 2015. half of them (47) most were young adults, 50% belonging to the range of age between 18-30 years; more than 43% had family history of atopy; the mean age of onset of symptoms was 25 years and up to 18.7% had had symptoms before the age of 14 years; 56.2% were nonsmokers. regarding comorbidity, 62.5% of the patients presented with concomitant symptoms of conjunctivitis and 6.2% of asthma. symptoms in 93.7% of the patients were persistent and most of moderate (50%) to severe (43.7%) intensity. the majority of patients (87.5%) presented perennial symptoms and a tpn positive to mites in 37.5%, to salsola pollen in 25% and to cypress pollen in 12.5%. but 3 patients (18.75%) were simultaneously positive to 2 allergens. conclusions: local allergic rhinitis represents an important proportion of patients with clinical rhinitis with negative skin tests and sige. we have to pay attention to identify clinical and demographic factors of ral and to use npt to demonstrate it. objectives: we report the extent of sinus involvement at baseline (bl) in pts with bilateral np refractory to intranasal corticosteroids from a dupilumab phase 2a study (nct01920893). ct scans from enrolled pts, 59 adults <65 years with nasal polyp score of ≥5/8, were pooled and analyzed at bl. for opacification, standard lund-mackay (lmk) scoring (0=normal, 1=partial opacification, 2=total opacification) in maxillary, anterior/posterior ethmoid, sphenoid, frontal sinuses was used. ten sinus scores plus bilateral ostiomeatal complex (omc) score (0=not occluded, 2=occluded) were summed to a bilateral total lmk (0-24). zinreich modified lmk score (zlmk), providing more granularity on opacification degree, was evaluated post-hoc; each sinus was given a 0-5 score based on opacification % from mucosal thickening (0=0%, 1=1%-25%, 2=26%-50%, 3=51%-75%, 4=76%-99%, 5=100%); omc results: the prevalence of asthma at the age of 12 years was 6.4%. 15% of them had an act tm value below 20, ie uncontrolled asthma, median 22.0 (range 12-25). independent risk factors for uncontrolled asthma at the age of 12 were current doctor diagnosed rhinitis (adjusted or, aor 2.8; 95% ci 1.1-7.0), wheeze triggered by exercise (aor 5.6; 1.9-16.6) and cat at home (aor 3.5; 1.2-10.0). if at least one of the parents had higher education the risk of uncontrolled asthma was decreased (aor 0.3; 95% ci 0.1-0.8). six children reported hospitalisation due to asthma during the last 12 months (ie 2.6%) at 12 years of age. hospitalisation was more common in individuals with uncontrolled asthma (or 12.3; 2.2-70.5) or when mites (or 9.8; 1.9-51.5) or pollen (or 5.8; 1.0-32.5) was reported as trigger factors. also, oral corticosteroids (betamethasone), in the last 12 months increased the risk for hospitalisation (or 8.2; 1.4-48.7). to have a parent with asthma (17% compared to 37%, or 0.3; 0.04-2.9) or higher education (40% compared to 62%, or 0.3; 0.07-2.5) was numerically less common for children who were hospitalised for asthma but did not reach statistical significance. conclusions: uncontrolled asthma was associated with current allergic rhinitis, having a cat and exercise as trigger factor. at least one parent with higher education reduced the risk. hospitalisation due to asthma was more common in individuals with uncontrolled asthma. abstracts 0404 | adolescent asthma in relation to severity and gender-data from a prospective population based cohort study introduction: asthma often debuts early in life, but recent studies show that the development of asthma is a dynamic process with disease turnover throughout child-and young adulthood. objectives: to describe adolescents' asthma with focus on severity and gender. the study population consisted of 3115 adolescents participating in the cohort, followed since birth up to 16 years of age with questionnaires and clinical investigations. blood samples from 2452 adolescents (78.7%), sera analyzed for specific ige against common inhalant allergens. asthma at 16 years was defined as fulfilling at least 2 of the following 3 criteria: symptoms of wheeze and/or breathing difficulties in the last 12 months, ever doctor's diagnosis of asthma and/or asthma medicine occasionally or regularly last 12 months. uncontrolled asthma was based on parental information on symptoms of asthma in the last 12 months prior the 16-year follow-up, including 3 or 4 features: nocturnal asthma, activity limitation, wheeze 4 times and hospitalization due to acute asthma. we looked into 2 phenotypes; late-onset, defined as asthma at 8, 12 or 16, but not at 1, 2 and 4 years of age and persistent, defined as asthma at 1, 2 or 4 and 8, 12 or 16 years of age. severe asthma, defined as asthma as above combined with prescribed and dispensed corticosteroids used within the last 18 months plus uncontrolled asthma and/or lung function (fev 1 <80% of predicted). results: at 16 years of age, 14.2% (n=437) fulfilled the study definition of asthma, 49.3% late onset and 50.7% persistent asthma. persistent asthma was more frequent among boys than girls 59.1% vs 43.3% (p=.001). overall ige sensitization was common among adolescents with asthma, 70.1% were sensitised to common inhalant allergens, and equally common in late-onset and persistent asthma (71.7% vs 68.8%, p=.54). however, more boys than girls were sensitised (79.9% vs 62.6%, p<.001). in total 8.1% (n=25) adolescents had severe asthma, 11.2% (n=15) boys and 5.8% (n=10) girls (p=.08). the overall prevalence of severe asthma in the cohort was estimated to 1.0%. severe asthma did not significantly differ among adolescents with late-onset compared to persistent asthma (17/25, 8/25, p=.09). conclusions: among adolescents with asthma, late-onset (age ≥8 years) and persistent asthma were equally common. persistent asthma were more common among boys. there were no difference in asthma severity, or proportion of ige sensitization among adolescents with late-onset or persistent asthma. however, data investigating associations with wheeze and asthma in later childhood are scarce. objectives: our aim was to explore the association of maternal milk fatty acid composition with childhood wheezing phenotypes and asthma up to age 13 years. breast milk was collected 6 weeks and 6 months post-delivery in the ulm birth cohort study (n=720 and n=454, respectively). concentrations of 10-24 carbon atom chain length fatty acids were measured by high-resolution capillary gas-liquid chromatography. to control for constant sum constraint, concentration data were transformed using the centered log ratio method. compositional biplots and correlation matrices were used to group fatty acids based on within sample correlation. adjusted risk ratios with parent-reported wheezing phenotypes and doctor-diagnosed asthma were computed using a modified poisson regression. results: we observed no straightforward evidence of associations between overall breast milk fatty acid composition and specific wheeze phenotypes or doctor-diagnosed asthma. conclusions: despite our use of sophisticated statistical methodology, our results may have been biased toward the null by several cohort-specific factors associated with breast milk collection and fatty acid composition. to overcome potential selection bias by maternal lifestyle, further research should investigate fatty acid intake during the first year of life including sources other than breast milk among children who were never or not exclusively breastfed. introduction: fall is the most common season for asthma exacerbation. previous studies found that exposure and sensitization to house dust mites (hdms) can exacerbate asthma. the seasonal variation in indoor hdm concentration is highest in the fall, correlating with the incidence of asthma exacerbation. most of the studies conducted to date have focused on the effect of hdm exposure on the incidence of acute asthma exacerbation, but reports about the effect of hdm sensitization are few. thus, we aimed to determine whether sensitization to hdms acts as a risk factor of asthma exacerbation in the fall. in addition, we investigated whether asthma exacerbation in the fall had any distinctive features by comparing levels of various cytokines and chemokines with those in other seasons. objectives: we enrolled 55 children aged 3-14 who visited the emergency department because of acute asthma exacerbation from january 2008 to december 2013 (63.6%, males; mean age, 6.0ae2.8 years). they were treated in accordance with the standardized treatment protocol. blood samples were collected from the children during the course of treatment. by using residual sera from the blood samples, we measured the levels of total immunoglobulin e (ige), hdm-specific ige (sige), eosinophil cationic protein (ecp), and various cytokines and chemokines, and classified them according to season. we compared the date divided into fall group (from september to november, n=31) and other season group (from december to august, n=24). ci, confidence interval; or, odds ratio; der f-sige, dermatophagoides farinae -specific immunoglobulin e; der p-sige, dermatophagoides pteronyssinus-specific immunoglobulin e; ecp, eosinophil cationic protein; ige, immunoglobulin e. data are presented as n (%) or as meansaesems and median (range). p value refers to the difference between the fall and "other season" groups and was calculate by the chi-square statistics, fisher's exact test, student's t-test, or wilcoxon rank-sum test. a adjusted for total ige. results: this retrospective study obtained archived nasopharyngeal aspirate (npa) samples from patients aged below 18 years who were hospitalized for acute respiratory illnesses in a university-affiliated hospital during the periods september-november 2014 and january-april 2015. their clinical information was retrieved from computerised record. hrv was detected by rt-pcr, and isolates were sequenced to determine the genogroups and serotypes. ninety patients whose npa was positive for hrv and 160 patients being negative for an extended panel of respiratory viruses by multiplex pcr method were identified. mean age of these groups was 3.6 years and 3.5 years respectively. hrv infection was significantly associated with asthma exacerbation (or 16.54, results: a total of 203 children were included: 73.4% were boys; 26.6% aged 6 months to 2 years, 51.0% aged 3-6 years, 20.1% aged 7-13 years and 2.4% aged 14-18 years; 44.0% were hospitalized, results: the long-term remission (≥5 years without treatment) rate 16 years after initiating early anti-inflammatory therapy was 88.1% (intermittent asthma, 100%; mild persistent asthma, 72.2%; moderate persistent asthma, 90.0%; severe persistent asthma, 66.7%). longterm remission rates improved compared with past asthmatic convaobjectives: the aim of this study is to explore the potential value of feno level for diagnosing chronic cough in children. objectives: in this study, we aimed to compare the efficacy of classical spirometry and impulse oscillometry (ios) in evaluation of late reversibility in children who received treatment with the diagnosis of atopic asthma. we enrolled 83 patients aged 7-17 years who were diagnosed with atopic asthma. exclusion criteria were having received asthma treatment during the previous two months, having acute asthma exacerbation findings, having any other respiratory disease or cardiac disease that may affects the lung function test results. allergic sensitization was determined by skin prick test performed according to eeaci guidelines. lung function test measurements were performed at enrollment and after two months of inhaled steroid treatment. conclusions: classical spirometry is more valuable compared to ios in evaluation of late airway hyperreactivity in children with atopic asthma in children older than seven years age. 0413 | computer bronchophonographyfrequency analysis of the respiratory cycle. objectives: we performed mct in 144 children with symptoms suggestive of asthma and 30 without respiratory symptoms. after each inhalation step oscillometry and spirometry was performed. parameters analysed for ios were z5, r5, r20, x5, x15 and ax (the integrated impedance reactance at r5 and above) and fev1 for spirometry. a fall of 20% in fev1 from baseline after mtc was considered as a positive challenge. pc20-fev1 and pc40 r5, x5 and ax were calculated. results: a total of 174 patients, 79 female, with a mean age of 9.5 (ae3.03) years were enrolled. 132 had a ≥ 20% fall in fev1 after mtc. the mean variation in fev1 was 7% (-12.2%/ +45.8%), the mean variation in z5, r5, r20, x5, x15, ax and fres were 21.88% objectives: the objective of our study was to synthesize cationic peptides and study their antiviral activity (aa) in vitro. results: 16 peptides were synthesized by solid phase method with different structures (linear, helical and dendrimeric). cytotoxicity of the peptides was studied by mtt assay using hela cells. objectives: the aim of the study is to evaluate the changes of ilresults: 48 subjects aged 18-65 years were enrolled in this study, which were divided into 4 groups: 23 patients with diagnosed moderate to severe ba (1st group), 6 ba patients with rvi (2nd group), 8 subjects with rvi only (3rd group) and 11 healthy volunteers (4th group). all patients with ba from group 1 and 2 received inhaled corticosteroids. clinical blood test revealed increase of eosinophils in patients with ba and ba accompanied with rvi up to 7% and 4%, respectively. fev1 was decreased in 1st and 2nd groups to 77% and 79% compared 98% and 97% for 3rd and 4th groups, respectively. conclusions: this study is alarming for asthmatic nosocomial hazards in this govt. hospital. identification of ige specific reactive components of predominant fungal allergens and cross-reactivity among each other, delined in this study could minimize the hazard of therapeutic and diagnostic use of these cross-reactive components, in fungal allergen-specific immunotherapy. objectives: we conducted a longitudinal prospective study to examine the development, composition and diversity of the gut microbiota in healthy and allergic children. we followed 93 children from 4 months to 8 years of age with clinical evaluation; specific ige levels and skin prick testing. fecal samples were collected at 4, 6, 13 months and 8 years. 16s rrna sequencing was used to profile the gut microbiome using illumina miseq. the composition and diversity of the gut microbiome were assessed using quantitative insights into microbial ecology (qiime). comparisons between groups were made using the lefse pipeline; non-parametric factorial kruskal-wallis test, unpaired wilcoxon rank test and linear discriminant analyses (lda) with score >2.0. to assess the interaction effect, the likelihood ratio test (lrt) was applied using r statistical program. p<.05 was considered significant after correction for multiple testing. results: to achieve our aim we divided balb/c mice into 4 groups: mice with viba (1st group), mice with viba treated with nonspecific sirna against gfp (sigfp) (2nd group) and against il-33 (siil-33) (3d group). 4th group was intact mice. groups 1-3 were i.p. sensitized on days 1, 14, 28 with ovalbumin (ova) mixed with aluminum hydroxide and i.n. challenged with ova on days 40-42. the same mice were i.n. infected with 5910 6 tcid 50 /mouse rsv strain a2 on day 39. mice from group 2 and 3 were i.n. treated by sirnas on days 38-42 in dose 120 lg/mouse. on day 43 hyperresponsiveness (ahr) to methacholine was measured. on day 44 and lungs were removed for histological analysis. viral rna (vrna) load and il-33 gene expression were evaluated by qpcr in lungs. bronchoalveolar lavage (bal) was collected for differential cell count by light microscopy. so i.n. administration of siil-33 suppressed il-33 gene expression in lungs by 50% compared to sigfp treated mice. there were no significant changes in body weight and lung vrna amounts between mice received sigfp and siil-33. mice treated with siil-33 demonstrated the tendency to improve lung function compared to mice of group 1-2, that expressed in 13% reduction of specific resistance of airways and 15% increase of peak expiratory flow. bal cell count revealed decrease of total cell number, eosinophils and lymphocytes in mice received siil-33 by 55%, 90% and 63% compared to sigfp treated mice, that indicate reduction of inflammation, that was confirmed by histopathological studies showed 50% leukocyte reduction. downregulation of il-33 resulted in 2-and 1.7-fold decrease of bronchial epithelium metaplasia and hyperplasia. and femur length measurements were collected from routine antenatal screenings. these and derived head to abdominal circumference ratio and estimated fetal weight were converted into z-scores adjusted for gestational age and gender and categorized as "low" (≤1 sd below mean), "normal," or "high" (≥1 sd above mean). ad cases were children with parent-or pediatrician-report of physician ad diagnosis assessed yearly up to age 3 years and supplemented by clinical diagnoses during dermatological exams at 0.5, 1, and 2 years. modified poisson regression models were used to compute risk ratios (rr) adjusted for potential confounders. conclusions: these results provide further evidence for a role of fetal growth as an influence on atopic disease outcomes. unlike previous studies, our data suggests several patterns of fetal growth beginning as early as the 1st trimester may influence ad outcomes. objectives: we aimed to examine the role of eosinophil cationic protein (ecp), eosinophil derived neurotoxin (edn) and total immunoglobulin (ig) e as a bio-marker of disease severity. we examined the difference in level of total ige, ecp and edn between the two groups and whether any correlation existed between disease severity and ecp or edn. objectives: we aimed to identify the subgroup of ad patients with a good clinical response to probiotic treatment. we recruited children who suffered from moderate to severe ad with the scoring ad (scorad) index of 20 or higher. after 2 weeks of washout period, all patients were given lactobacillus plantarum cjlp133 at a dosage of 1910 10 colony-forming units once a day for 12 weeks. we measured eosinophil counts in the peripheral blood, the proportion of cd4 + cd25 + foxp3 + regulatory t (treg) cells in cd4 + t cells, serum total ige levels, and specific ige to common allergens before the start of the treatment (t1) and at discontinuation (t2). logistic regression models were used for the statistical analysis. seventy-six patients (48 boys and 28 girls) with a mean age of 8.7ae4.7 years completed the study. there were 36 responders and 40 non-responders after probiotic treatment. the median scorad was reduced from 29.5 (range 20.6-46.3) at t1 to 16.4 (range 6.3-30.8) at t2 in the responder group (p<.001). in multivariable logistic regression analysis, a good clinical response was significantly associated with high total ige levels (aor 5.1, 95% ci 1.1-23.6), increased expression of , and high proportion of cd4 + cd25 + foxp3 + cells in cd4 + t cells (aor 3.7, 95% ci 1.1-12.7). in responder group, the proportion of cd4 + cd25 + foxp3 + cells of cd4 + t cells were significantly increased after 12 weeks of treatment (p=.004), while the levels of tgf-b mrna expression were decreased (p=.017). there were no differences in total ige levels between t1 and t2 (p=.414) conclusions: the therapeutic effect of l. plantarum cjlp133 on ad is more pronounced in children with high total ige levels, objectives: the objective of the study was to examine the effect of a specific synbiotic mixture of short-chain galacto-, long-chain fructo-oligosaccharides (scgos/lcfos, ratio 9:1) and bifidobacterium breve m-16v on the severity of ad and correlation to serum chemokines in infants with moderate to severe ad and elevated ige. in an exploratory randomized, double-blind, placebo-controlled trial the effect of extensively-hydrolyzed whey-based formula without intervention. serum obtained prior to start and at the end of intervention were analysed using luminex. six chemokines and nine ratio's thereof were correlated to ad severity (sample size=24). introduction: dyshidrotic eczema is one of the most common skin conditions. contact allergy is often associated with dyshidrotic eczema although the exact impact and the influence of contact allergens in different forms of dyshidrotic eczema remain unknown. hypersensitization to nickel is one of the most common contact allergies associated with pompholyx. the standard of care protocol is to use a medical treatment with topical corticosteroids and calcineurin inhibitors to treat the symptoms, together with occlusive barrier creams to avoid skin exposure to the allergens. after the symptoms have been cleared with the topical treatment, the recommendation is to use occlusive barrier creams to prevent recurrence of the symptoms. objectives: a new emollient with specific metal-scavenging agents and no occlusive ingredients has recently been developed and made commercially available. the aim of this study was to evaluate the effect of such cream to provide relief for patients with dyshidrotic eczema associated with nickel allergy. results: thirty-two subjects with dyshidrotic eczema and a positive patch test ppt (contact sensitized) reaction to nickel were selected. these were divided into two randomized groups, group-a was given nickel-scavenging cream (skintifique creamtm, paris) after medical treatment, (n=9) and group-b followed the standard protocol for pompholyx, (n=23). hand eczema was scored according to the dyshidrotic eczema area and severity index (dasi). dasi scores were evaluated at the beginning of the study (day-0), after the medical treatment (day-15) and two months after the end of medical treatment (day-75). results show a significant difference in the efficacy of treatment between the two groups at day-75. a higher percentage of at least 75% reduction of initial dasi score (77.8%) and a higher percentage of total clearance (56%) in patients using nickel-scavenging nonocclusive moisturizing cream was observed as compared to standard-of-care occlusive creams (26.1% and 22%, respectively). objectives: the goal of this study was to investigate whether long-term emollient therapy is associated with alterations of skin barrier function and shifts of the skin microbiome in infants at high risk for developing ad. we prospectively enrolled newborns with a family history of ad to be randomized to either emollient treatment group or control group. at 6 months of age, we tested the skin barrier (transepidermal water loss/tewl, water capacitance/cap, ph) and skin microbiome (16s rdna sequencing of skin swabs from cheek, dorsal and volar forearm). results: the emollient group (n=10) had significantly lower skin ph compared to controls (n=9) (p=.02), but without a statistically significant difference in tewl or cap. the emollient group had higher numbers of different bacterial taxa (chao richness) at cheeks (p=.003), dorsal forearms (p=.008), and volar forearms (p=.003) as compared to controls. both streptococcus pneumoniae and s. salivarius statistically significantly contributed to the observed skin microbiome differences between patient groups. s. salivarius was significantly more abundant in emollient subjects at all sampling sites (p=.02). we then analyzed our previous larger cohort of older children with ad and also observed higher s. salivarius proportions in ad patients with treated and less severe disease (p=.01). objectives: to evaluate the effect of overnight treatment with a temperature-controlled laminar airflow (tla) device in children/adolescents with severe eczema over a 12-month period. in an open-label study, 15 subjects aged 2-16 years (median 10 years) with longstanding severe eczema attended 3 visits during the run-in period lasting 6-10 weeks (median 7.14 weeks) to optimize eczema management. the run-in was followed by a 12month treatment period using overnight tla device (airsonett ® , sweden), which included 8 study visits. we used scorad-index results: the median duration of eczema was 116.5 months (interquartile range 82-145.5). all subjects were sensitised to ≥1 perennial allergen, and had multiple comorbidities (15/15 rhino-conjunctivitis, 14/15 food allergy, 11/15 asthma). there were no significant changes during the run-in period in any of the outcome measures. we observed a significant improvement in scorad after the 12-month tla-treatment period, from 34.9 [28.75-45.15 ] to 17.2 [12.95-32.3] , p=.015. iga improved significantly from a median of 4 [3-4] to 2 [1] [2] [3] , p=.001. improvement in symptoms was paralleled by a significant reduction in medication usage. by 12 months, there was a significant improvement in .0] to 12 [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] , p=.032), and an improvement in cdqli (marginal, p=.084). however, we observed no changes in poem (p=.196) . post-hoc cluster analysis of the patterns of changes in scorad over the 12month treatment period identified two clusters, with 9 participants classified as responders and 6 as non-responders. introduction: intestinal degradation has been shown to determine allergenicity of food allergens. however, it is unclear how allergens are degraded inside pivotal immune cells such as dendritic cells (dc), and how this affects the subsequent immune response to these allergens. in our studies, we determined whether we are able to measure uptake and degradation of allergens inside dc and whether differences in above mentioned factors exist between allergens. objectives: using mouse bone marrow-derived dc and fluorescent-labeled proteins, we studied the cellular uptake of the peanut proteins ara h 1, 2, 3, and 6. results: first, we observed that dc uptake of ara h1 was much higher than ara h2, 3 and 6. using blocking reagents and receptor binding assays for various uptake routes in dc, we observed that one of the principal routes of uptake for ara h 1 was the mannose receptor. other uptake routes, and the routes of uptake for ara h2, 3 and 6 are currently under investigation. second, using proteins coupled to beads we observed that intracellular protein degradation was higher for ara h1 and ara h3 than for ara h2 and 6. finally, cd4+t cells from ara h 1, 2, 3 or 6 sensitized mice were added to matching allergen-pulsed dc. we observed that while ara h1, 3 and to lesser extend ara h6 elicited strong th2 type responses, ara h2 did not elicit any t cell responses. conclusions: together, we show that allergenicity of (peanut) proteins may be, at least partly, determined at the level of allergen uptake and breakdown inside the antigen presenting cell. these findings may be relevant to risk evaluation of existing allergens but also of novel or modified proteins. this also illustrates the usefulness of in vitro, cell based assays to examine initial processes of allergenic sensitization to proteins. 0445 | sensitising capacity of unmodified and acid hydrolysed gluten through the skin-a comparative study in na€ ıve vs tolerant brown norway rats ballegaard ar; madsen cb; bøgh kl national food institute, technical university of denmark, søborg, denmark introduction: allergic sensitisation to foods may occur in infancy without prior oral exposure to the offending food. this has led to the assumption that food allergy sensitisation may occur through alternative routes, such as the skin, supported by the observed correlation between skin barrier disruption and food allergy. recently, concerns have been raised regarding the safety of use of cosmetic and personal care products containing hydrolysed wheat proteins, since these products have been shown to induce allergy towards acid hydrolysed wheat through the skin, and even to cause an abrogation of the already established oral tolerance against unmodified wheat. objectives: the aim of the study was to compare the sensitising capacity of an unmodified and an acid hydrolysed wheat product via slightly damaged skin, in order to evaluate differences in conditions necessary for skin sensitisation in na€ ıve vs tolerant individuals. brown norway rats were raised and bred on either (1) a diet free from wheat, resembling individuals with a na€ ıve immune system, or (2) a conventional wheat containing rat chow, resembling individuals tolerant to wheat. results: in the na€ ıve rats both products were able to induce a statistically significant specific antibody response after application of the products on the slightly damaged skin, whereas in the wheat tolerant rats, only the acid hydrolysed wheat product was able to induce a statistically significant antibody response. for both the na€ ıve and the wheat tolerant rats the response was dose-dependent. in the na€ ıve rats both products were able to sensitise through the skin, inducing a specific ige response, whereas in the tolerant rats only the acid hydrolysed product were able to induce a specific ige response, though this ige response was much lower than in the na€ ıve rats. results from competitive elisas demonstrated that new epitopes had developed as a result of acid hydrolysis, though original epitopes were maintained at the same time. this may explain why only the acid hydrolysed wheat could induce specific antibody responses in the tolerant animals. conclusions: this study showed that the sensitising capacity through the skin of two different wheat products is heavily influenced by the tolerance status of the immune system and the degree of modification of the wheat products. results: using a germ-free c3h/hen mouse model of food allergy, we examined the presence of a major peanut allergen, ara h 2, in the blood after intraperitoneal injection in previously sensitized and control (non-sensitized) mice using an untargeted, quantitative proteomic approach. previously sensitized mice underwent physiological (core temperature decrease, clinical symptoms) and biochemical (mast cell protease increase, ara h 2 specific ige positivity) changes associated with severe allergic reactions. we were able to confidently detect multiple peptides derived from the ara h 2 protein after intraperitoneal injection in both control and ara h 2 sensitized mice. however, the ara h 2 protein was present at 15-40 fold higher levels if mice were previously sensitized, suggesting increased transit across the peritoneal mesothelium with sensitization. an untargeted proteomic approach also allowed changes in the blood proteome of mice undergoing a severe allergic response to be examined. we identified proteins with significantly altered quantity in serum between control and sensitized mice and were therefore apparently associated with the allergic response. we demonstrate the applicability of untargeted proteomics to the study of the allergen transport and proteomic changes which co-occur with a resultant allergic reaction. the transit of allergens into the bloodstream is heavily dependent upon previous sensitization. we are continuing this work to examine the specificity of observed increases in trans-mesothelial transport and to address transport of allergens after intragastric challenge. 0447 | iga to cow's milk differs between breast milk and serum for its epitope specificity objectives: we sought to assess whether the profile of epitopespecific iga differs between mother's serum and bm. we also examined how infants' food epitope-specific iga develops in early infancy and the relationship of iga epitope recognition with development of cow's milk allergy (cma). results: . we measured iga specific to an array of overlapping peptides in major cow's milk allergens (alpha s1-, alpha s2 -, betaand kappa-caseins and beta-lactoglobulin). diversity of peptide-specific iga (ie epitope diversity) was determined in paired maternal and infant sera as well as breast milk samples in 31 mother-infant dyads within the first 15 postpartum months utilizing peptide microarray. microarray data was converted to z-scores and filtered for noise. peptide epitopes were determined based on jaccard distance between neighboring peptides, and intra individual correlation between sample types was estimated using phi coefficient. comparisons between groups and individuals was done using non-parametric tests. we noted marked discordance in epitope recognition in paired breast milk and maternal serum samples. at least one shared epitope was recognized by both milk and serum samples ranging from 13% of mothers for alpha-s1 casein to 73% for kappa-casein. epitopespecific iga was detectable in infants' sera starting at less than 3 months of age. sera of mothers with a cma infant had increased binding of epitope-specific iga to cow's milk proteins compared to those with a non-cma infant (p<.05 for all five proteins). conclusions: these findings support the concept that mothers' milk represents a product of the mucosal immune system that has an antibody repertoire distinct from that of peripheral blood. results: multiple ige-binding proteins were detected in the different wn preparations and many of which were dissemblance in 2dblotting. profiles of detectable proteins (peptides) of raw, roasted and boiled wn extracts were profoundly different in emi analysis. introduction: consumption of tree nuts is on the rise due to their beneficial health effects. however, tree nuts can led to severe allergic reactions in sensitized patients. thermal processing can modify the structure and function of food proteins and may alter (increase or decrease) their allergenic properties. knowledge about the effects of thermal processing on tree nuts such as cashew or pistachio is rare and based on traditional in vitro immunoassays. objectives: to elucidate the influence of thermal treatments (boiling and heat / pressure) on the ige reactivity of cashew and pistachio proteins, by means of traditional in vitro immunoassays and mediator release assays (mra). results: the allergenicity of untreated and treated cashew and pistachio nuts was evaluated by ige-elisa, ige-immunoblot and elisa inhibition assays using sera from spanish patients with clinical allergy to cashew and pistachio. rat basophilic leukaemia cell line transfected with the a-chain from the human high-affinity ige receptor fceri, was sensitized with a pooled sera and used for mra. sensitized cells were stimulated with untreated and treated protein extracts, in order to investigate the capability of untreated and treated cashew and pistachio proteins to cross-link ige on effector cells. the results showed that heat and pressure treatment at the harshest conditions considered in this study produced a higher decrease of the ige-binding capacity of cashew and pistachio proteins than boiling without pressure or soft conditions of heat and pressure. interestingly, although the treatments of heat and pressure seemed to affect cashew allergens to a greater extent than pistachio allergens (evaluated by ige-elisa and elisa inhibition), the results of mra using the cell line rbl-48 indicated that cashew proteins treated with heat and pressure, still retained some capacity to cross-link ige. introduction: previous research has indicated an important role for dietary non-digestible oligosaccharides in decreasing the incidence of atopic dermatitis in children at risk of allergy. it is assumed that these prebiotics promote colonization of beneficial bacteria in the gut. children with atopic dermatitis receiving a diet of galacto-and long chain fructo-oligosaccharides (scgos/lcfos) with bifidobacterium breve m-16v had enhanced serum galectin-9 levels. galectin-9 has ige-binding capacities and can hereby suppress degranulation of mast cells and basophils. next to their function in the gut, oligosaccharides may also affect other immune cells directly, since they were found in plasma and urine. objectives: we investigated whether non-digestible oligosaccharides or galectin-9 can have a direct effect on immune cells, by determining the effect on basophil degranulation in peanut-allergic patients. whole heparinized blood samples were collected from 12 peanut-allergic adult patients and incubated for 24 hours with either a mixture of 0.05% 9:1 scgos/lcfos or scfos/lcfos, or galectin-9 (1 or 5 lg/ml) at 37°c in the presence of il-3 (0.75 ng/ml). after 24 hours, a basophil activation test (bat) was performed. basophils were stimulated for 30 minutes at 37°c with increasing concentrations of whole roasted peanut extract or human anti-ige. degranulating basophils were determined as cd63+ cells and calculated as percentage positive cells. results: in each patient, the concentration of anti-ige or peanut extract that induced maximal degranulation in the untreated control sample was used as reference value to compare degranulation of the samples pretreated with scgos/lcfos, scfos/lcfos, or galectin-9. pre-treatment of whole blood with scgos/lcfos resulted in an average decrease in degranulation of approximately 8%, while a significant reduction of 19% was observed after pre-treatment with scfos/lcfos (p<.05). pre-treatment with 1 lg/ml galectin-9 decreased basophil degranulation with 12%, whereas 5 lg/ml galectin-9 caused a significant decrease of 25% (p<.05). no differences were observed in the ec50, indicating that the basophils are not becoming less sensitive to the peanut extract or anti-ige. the prebiotic mixture scfos/lcfos and galectin-9 can contribute to decreased degranulation of basophils in a igemediated bat assay using whole blood. further analysis is warranted to define the exact working mechanism of these oligosaccharides. introduction: the intestinal mucosa plays a key role in the development of food allergies. we studied the interaction between intestinal epithelial cells (iecs) and pbmcs of peanut-allergic patients in a transwell co-culture model. exposure of iecs to a mixture of galacto-and/or long chain fructo-oligosaccharides (scgos/lcfos) in combination with synthetic cpg dna (tlr9 ligand),modulated the cytokine response of activated pbmcs, driving away from the allergic phenotype. objectives: our aim was to compare the efficacy of scgos/lcfos with a scfos/lcfos mixture and to evaluate these effects in an allergen-specific co-culture model. iecs (ht-29, human colon adenocarcinoma) were grown on transwell filters until confluence. iecs were apically exposed to 0.5% 9:1 scgos/lcfos or scfos/lcfos either or not in combination with 2.5 lmol l à1 cpg dna to mimic presence of dna of beneficial bacterial in the gut. these iecs were co-cultured with basolateral pbmcs from peanut-allergic patients, either activated with anti-cd3/cd28 (24 hours) or peanut-extract (pe, 6 days).cytokines ifn-c, il-10, il-13 and tnf-a were measured in the basolateral supernatant and t-cell polarization of the pbmcs was determined (th2, th1, treg and tfh). results: apical exposure of iecs to cpg dna increased basolateral ifn-c and il-10 production by anti-cd3/cd28 activated pbmcs (p<.01), and was enhanced by both oligosaccharide mixtures (p<.01). cpg exposure in transwells with pe stimulated pbmcs also increased ifn-c and il-10 production, which was further enhanced by scfos/lcfos (p<.05). in this pe-specific model, percentages of th1 and treg cells increased upon cpg exposure of iecs, and th1 frequency was increased by scfos/lcfos (p<.05). cpg dna exposed iecs suppressed il-13 and tnf-a production by anti-cd3/ cd28 activated pbmcs. both scgos/lcfos and scfos/lcfos reduced tnf-a production in combination with cpg dna (p<.01). tfh cells can produce il-21, inhibiting class-switching to ige2. upon cpg exposure of iecs, we observed an increase in tfh cells (p<.01) and similar tendency for cd4 + il-21 + cell frequency in anti-cd3/ cd28 activated pbmcs. conclusions: epithelial exposure to both scgos/lcfos and scfos/lcfos enhances the cpg dna induced th1 and regulatory il-10 response in an anti-cd3/cd28 co-culture model, whereas only scfos/lcfos was effective in an peanut-specific co-culture model. introduction: in areas of spain with high level of grass pollen exposure, 60% of grass allergic patients were sensitized to profilin, and most of them developed severe profilin mediated food reactions. this specific population of patients constitute an ideal model to study the relation among respiratory and food allergy objectives: our aim here was to analyze the links between epithelial barrier integrity and inflammation in oral mucosa. methods: 30 allergic patients and 6 controls were included in the study. allergic patients were stratified into mild or severe according to their clinical history and response to profilin oral challenge test. immunohistochemistry (ihc) for cd11c, cd3, cd4, claudin-1; and dapi nuclear staining were performed in formalin-fixed, paraffin embedded sections of oral mucosa biopsies. rt-pcr was performed to analyze il1b and il33 gene expression and the number of circulating cd4+ cells in pbmc was measured by flow cytometry. additionally, basophil activation test was carried out in whole blood samples upon profilin stimulation and the ec50 was calculated. results: regarding epithelial barrier integrity, claudin-1 expression resulted inversely proportional to pollen-associated food allergy severity. furthermore, by dapi staining, we noticed a lower number of epithelial cells in allergic patients than in non-allergic, and the gene expression of il1b and il33 resulted significantly increased in oral mucosa from severe group. as for immune response in oral mucosa, the number of cd11c and cd3+ cells resulted significantly higher in severe group. in allergic patients, double ihc for cd11c-cd4 showed an increase colocalization of t cells and apcs in the interface between epithelium and connective tissue. a decrease in blood circulating cd4 + cells was detected in allergic patients compared to non-allergic. as for the basophil sensitivity, ec50 in severe patients was 10-times lower than in mild. our results show that damage in oral mucosa epithelium, probably induced by high grass pollen exposure, might allow profilin to penetrate inside oral mucosa and induce inflammation with local recruitment of immune cells. furthermore, analyzing the immune response developed by effector cells, basophils from severe group result more sensitive to profilin as they react to a lower allergen concentration. these data explain the differences in food allergy severity between mild and severe group and propose oral mucosa as a new sensitization route. introduction: th2 cells producing the hallmark cytokines il-4, il-5 and il-13 have been found to constitute the majority of the allergen-specific th cell responses in allergic diseases. subpopulations of the th2 responses have been described with an early primed th2 subtype characterized by production of il-4 and il-13, and a highly differentiated th2 subtype, which in addition produce at least il-5. objectives: we aimed to investigate the polarity of tree nut and peanut allergen-specific th cells in subjects with confirmed tolerance or allergy to multiple nuts, and hereby detect differences in allergenspecific th cell responses within the same study population. we also wanted to stress the question whether a th2 phenotype dominates in asymptomatic sensitization. methods: pbmcs from 35 donors all assessed for clinical reactivity to hazelnut, walnut, cashew nut, pistachio nut and peanut was stained with cfse and stimulated (2910 6 cells/ml) with and without whole nut extracts (50-200 lg/ml) for 7 days. allergen-specific cd4+ t cell phenotypes and cytokine release was analyzed with flow cytometry and luminex, respectively. the allergen-specific th cells of the allergic donors showed a trend of more highly differentiated il-4+il-5+ th2 cells and higher abstracts | 319 release of il-5 than in the tolerant donors. unexpected, except in the cashew nut stimulated cells, no difference was found in the relative percentage of the less differentiated th2 cells (single il-4+ allergen-specific cd4+ t cells) when comparing allergic with tolerant donors. when subdividing the tolerant donors into asymptomatically sensitized or ige-negative (<0.35 kua/l), increased frequency of highly differentiated il-4+il-5+ allergen-specific th2 cells were found in asymptomatically sensitized compared to tolerant-ige-negative donors. interestingly, a positive association of the allergen-specific ige level and the frequencies of allergen-specific il-4+il-5+ and il-4+ th2 cells were found in hazelnut, pistachio nut and cashew nut but not in walnut and peanut allergic subjects. conclusions: an overrepresentation of allergen-specific highly differentiated il-4+il-5+ th2 cells and an elevated il-5 production were observed in allergic subjects compared to subjects that tolerated the nuts. we furthermore found a trend that subjects asymptomatically sensitized to nuts differed from tolerant-ige-negative subjects by having relatively more highly differentiated il-4+il-5+ allergen-specific th2 cells. introduction: it remains largely unknown which features of food proteins that render them allergenic vs tolerogenic. however, it has been suggested that the protein-chemical features affects protein uptake in the intestine, and that protein uptake route may impact on the risk of sensitisation. objectives: the aim of this study was to investigate the interplay between protein-chemical characteristics, the allergenic vs tolerogenic properties and the intestinal uptake of two protein products. the allergenic vs tolerogenic capacity of a heat-treated whey product, consisting of partly denatured and aggregated proteins, was compared to an unmodified whey product in: (1) results: though this study showed that both unmodified and heattreated whey had immunogenic, sensitising and eliciting capacities as well as tolerance inducing capacity, significant differences between the two products were observed. the heat-treated product was found to have a lower allergenicity combined with high tolerogenicity compared to the unmodified product. competitive igg1 elisas indicated that heat-treatment of whey induced de novo epitopes while the original epitopes were maintained. newly established methods to study in vivo intestinal uptake were successfully applied to compare the uptake kinetics of the two products in different small intestinal tissues and serum. collectively the in vivo and in vitro uptake experiments suggested that uptake kinetics and the major intestinal uptake route differed between the heattreated and unmodified product. conclusions: this study showed that heat-treatment, which induces partly protein denaturation and aggregation, changes the immunological properties and intestinal uptake of a whey protein product. the heat-treated product was found to have a lower allergenicity combined with high tolerogenicity compared to the unmodified product, which highlights this products promising potential for induction of cow's milk tolerance. objectives: in this study, we enumerated tregs in esophageal tissue of patient with eoe, gerd and normal controls. ten patients with eoe, 10 patients with gastroesophageal reflux disease (gerd), and 8 patients with normal endoscopy and normal esophageal tissue were included. tregs were enumerated in paraffin embedded esophageal biopsy blocks, using immunohistochemistry assay. tregs were identified as foxp3+, cd3+ cells. results: tregs were counted in 3 high power fields (hpf, 9400) for 28 patients and the average of 3 hpf was recorded. the number of tregs in esophageal tissue of patient with eoe (mean 10.9 cells/ hpf) was significantly more than gerd(mean 2.77 cells/hpf) and control groups(mean 0.37 cells/hpf) (p value <.001). conclusions: there is an increase in number of regulatory t cells in esophagus of patients with eoe in comparison to gerd and control groups. the presence of these cells might be due to eosinophilic inflammation and help controlling the inflammation. objectives: to evaluate whether anti-cd38 (daratumumab) treatment results in a reduction of total and specific ige levels. results: samples from patients with relapsed/refractory multiple myeloma, treated with daratumumab monotherapy or daratumumab plus lenalidomide-dexamethasone in the umc utrecht between april and august 2014, were tested for total ige levels as well as presence of specific ige against common inhalant allergens. in patients with detectable ige at baseline, the total and specific ige levels were evaluated during treatment up to 20 weeks. of eight patients receiving treatment, four had detectable ige levels at baseline. one patient demonstrated sensitization to common inhalant allergens. for this patient, levels of total ige gradually decreased during 20 weeks of treatment (from 356 to 44 ku/l; 88%), as well as specific ige against timothy grass (9.8-1.7 ku/l; 83%) and house dust mite (3.2-0.4 ku/l; 88%). a second patient, not sensitized to common inhalant allergens but with ige levels of 41 ku/l at baseline, also demonstrated a decrease in ige levels, to 5 ku/l (88%). the last two patients had total ige levels <10 ku/l at baseline, which dropped below detection limit after eight weeks of treatment. conclusions: this proof of concept demonstrates that (specific) ige depletion occurred during treatment with anti-cd38 (daratumumab). anti-cd38 could potentially play a role in the management of severe ige-mediated diseases. objectives: following individual and assessment, patients established and stable on omalizumab have been commenced on home therapy. training and education in self-administration has been provided. a service assessment has been carried out to review the ongoing safety, quality and patient experience of the service. results: to date, over 90 doses of omalizumab have been self administered in the community with no adverse events or incidents related to home therapy. conclusions: self-administration of omalizumab at home by patients offers the potential to improve quality of life while also providing efficiency savings. introduction: chronic idiopathic/spontaneous urticaria (csu) is a chronic urticarial subtype, defined as itchy hives that last for at least 6 weeks, with or without angioedema, and that have no apparent external trigger. although csu is more frequent in adult populationup to 0.5%-1%-, it can affect children and generally has a prolonged duration and has a detrimental effect on patients' quality of life. before the fda and ema approval of the anti-ige monoclonal therapy omalizumab for adults and children 12 years and above, nonsedating h1-antihistamines were the only agents licensed for use in patients with csu. however, a majority of patients did not respond to these drugs, even when they were administered at three to four times their licensed dose. objectives: we present 3 pediatric patients (≥12 years old) with csu non-responding to antihistamines, treated with omalizumab. results: at the diagnosis of csu, the patients were 11, 13, 14 years old, respectively. a trial with non-sedating h1-antihistamines, administered up to three to four times their licensed dose, were performed for all patients, without clinical efficacy. omalizumab was started at 12, 14, 14 years, respectively. before anti-ige therapy, the urticaria activity score (uas) was 5, 4, 5 respectively, indicating poor symptom control. omalizumab therapy was administered every 4 weeks for 6 months at the dosage of 300 mg s.c. after 1 month of therapy, all 3 patients were symptom free with uas 0; the patients remained asymptomatic for all the 6 months of duration of monoclonal therapy and antihistamines were discontinued. by now, after 2, 5, 6 months respectively from discontinuation of omalizumab, all 3 patients are asymptomatic with uas 0. introduction: mepolizumab is a humanized monoclonal antibody directed against il-5, and is licensed for the treatment of severe asthma in patients aged >12 years (eu only adults) with an eosinophilic phenotype as an add-on treatment. we were interested to know whether the substance has an antiallergic effect, too. objectives: here, we report the case of a 60 year old man (nonresults: in march 2016 he was switched from omalizumab to mepolizumab (100 mg/month) 4 weeks after the last omalizumab because of two asthma exacerbations under omalizumab in the last 6 months and 380 eosinophils/ll blood under 10 mg prednisolone/day. after two injections of mepolizumab his fev1 increased from 55% to 64% pred., the act from 14 to 21 points, feno decreased from 48 to 32 ppb and the amount of prednisolone from 10 mg to 5 mg/day. but -the patient reported new nasal symptoms after the 2nd injection of mepolizumab, mainly blocked nose which has not been observed under omalizumab. he agreed to be challenged in the mobile gae²len exposure chamber* with house dust mite allergen for 40 min. the total symptom score increased from 2 to 7 points after 20 min exposure time remaining stable till the end, the positive nasal inspiratory flow decreased from 90 to 50 l after 30 min and 40 l after 40 min, the fev1 decreased from 62% to 51% pred. following the inhalation of salbutamol the fev1 reversed. conclusions: mepolizumab has an anti-asthmatic effect but the anti-allergic efficacy seems to be small or absent. methods: all patients treated with omalizumab for severe allergic asthma or chronic spontaneous urticaria at the department of respiratory medicine and allergy at aarhus university hospital (n=64) were grouped after their home municipality. the number of omalizumab treated patients/inhabitant in these municipalities was correlated to the distance to the treatment centre at aarhus university hospital. results: mean distance to the treatment centre was 53.5 km for all inhabitants in the central region, while patients treated with omalizumab lived in average 38.7 km away. we found a negative linear correlation between the number of patients treated with omalizumab/inhabitant and the distance from the municipality to the treatment centre (slope: à0.038 95%ci: à0.072 to à0.003), p=.034, n=64). conclusions: patients living at long distance from the treatment centre are less likely to be offered omalizumab treatment for severe allergic asthma or chronic spontaneous urticaria. objectives: demographics, clinical characteristics, and response to mepolizumab, were evaluated for atopic and non-atopic subgroups. sensitization to any one of the following; house dust mite, dog dander, cat dander, alternaria, or cockroach was considered as atopic, as assessed by specific serum ige of ≥0.35 ku/l. mensa (nct01691521) was a gsk sponsored study. results: of the 576 severe asthma patients, 275 (48%) were considered atopic, 272 (47%) were considered non-atopic and atopic status was missing for 29 (5%) patients. the majority of atopic patients (n=147) were sensitized to ≥3 antigens. compared to the non-atopic sub-group the atopic sub-group was younger with a mean age of 46 vs 54 years of age, had a longer mean duration of asthma (21.6 vs 18.4 years), and a higher total baseline ige level (293 u/ml vs 85 u/ml). mean number of exacerbations in the 12 months prior to the study was similar in the atopic and non-atopic subgroups (3.6 vs 3.8) as was the mean baseline peripheral blood eosinophil level (300 cells/ll vs 300 cells/ll). with mepolizumab an 80% reduction in eosinophils was achieved by week 4 irrespective of atopic status and maintained throughout the treatment period. mepolizumab reduced the rate of exacerbations relative to placebo by 48% in the atopic subgroup and by 54% in the non-atopic subgroup. conclusions: the mensa study recruited an equivalent portion of atopic and non-atopic severe asthma patients. the atopic population was younger and had a longer duration of asthma than the non-atopic subgroup. while the baseline total ige level was >3 times greater in the atopic subgroup, the pharmacodynamic and efficacy response to mepolizumab treatment was similar. introduction: a treatment goal in the management of oral corticosteroid (ocs) dependent severe asthma is to reduce daily ocs use due to the side effects associated with long term use. anti ige treatment is used in atopic patients to reduce daily ocs. this analysis characterizes ocs reduction and asthma control in the sub-set of atopic and non-atopic ocs-dependent severe eosinophilic asthma (sea) patients from the 24-week sirius ocs reduction study. objectives: sirius study participants (n=135) were sub-grouped by atopic status in a post-hoc analysis; demographics, clinical characteristics, and response to mepolizumab were evaluated. sensitization to any one of the following; house dust mite, dog dander, cat dander, alternaria, or cockroach was considered as atopic, as assessed by specific serum ige of ≥0.35 ku/l. sirius (nct01691508) was a gsk sponsored study. results: of the 135 ocs-dependent sea patients, 49 (36%) were considered atopic (61% female), 77 (57%) were considered non-atopic (51% female), atopic status was missing for 9 patients (7%). compared to the non-atopic sub-group, the atopic sub-group was younger; mean age of 46 vs 52 years of age, while the mean duration of asthma was the same irrespective of atopic status (19 years). the mean ocs daily dose and acq-5 score at baseline were similar between subgroups (12.6 mg vs 13.2 mg and 2.16 vs 2.04, in the atopic and non-atopic subgroups respectively). the mean baseline peripheral blood eosinophil level was comparable in both subgroups (250 cells/ll vs 220 cells/ll) while the total ige level was higher in the atopic subgroup (182 u/ml vs 86 u/ml). mepolizumab lead to a ≥ 80% reduction in eosinophils by week 4 irrespective of atopic status and eosinophil reduction was maintained throughout the study. mepolizumab reduced the ocs dose in the atopic group and non-atopic subgroups (odds ratio of a greater ocs reduction category of 5.6 (95% ci 1.71, 18.49) and 1.6 (95% ci 0.66, 3.93), respectively) and led to improvement in asthma control with a change in acq-5 of à0.60 (95% ci à1.20, 0.00) in the atopic subgroup and à0.45 (95% ci à0.94, 0.04) in the non-atopic subgroup. in an ocs dependent sea population mepolizumab reduced eosinophils independent of ige level and atopic status. in this limited post-hoc analysis, mepolizumab was an effective ocs sparing agent while improving asthma control in both atopic and non-atopic patients. patients who responded to retreatment had a similar mean time to response between the 1st dosing period (3.5 weeks) and 2nd dosing period (3.1 weeks). of all patients who were retreated (n=56), symptom control (uas7 ≤ 6) after two doses was achieved in 80% (1st period) and 85% (2nd period) of patients; complete response (uas7=0) occurred in 63% (1st period) and 56% (2nd period) of these patients. omalizumab was well-tolerated during both dosing periods. conclusions: omalizumab retreatment is safe and effective in patients with ciu/csu who respond to initial treatment and relapse after withdrawal, with most patients regaining symptom control after a 2nd course of omalizumab. : total ige reactivity of the grass allergoid formulation was diminished compared with native unmodified extracts. a difference in igg profiles was observed and indicated enhancement of accessible reactive igg epitopes across size distribution profiles of the grass allergoid formulation. detailed analysis of the epitope specificity showed retention of six lol p 1 igg binding epitopes in the grass modified extract. all epitopes were mapped on the solvent exposed area of lol p 1 homology model accessible for igg binding. one of the epitopes was identified as an "immunodominant" lol p 1 igg binding epitope (62-ifkdgrgcgscfeik-76) and classified as a novel epitope. lastly, lol p 1 igg antibodies showed functional capacity to block up to 50% of ige binding sites which provides evidence in protective function of immunotherapy induced antibodies against native allergens. the structural and immunological changes which take place following the grass allergen modification process were further unravelled revealing distinct igg immunological profiles. the results from this study support the concept that modification not only enhances the safety profile of scit but allows shorter-course objectives: design targeted sirna delivery system into liver cells. results: liposome surface was modified by lactose derivatives with different structures: lac(c 16 ) 2 and (lac) 7 lac(c 16 ) 2 . the basic physicochemical and biological properties of the carriers have been examined. it is shown that glycoconjugate introduction has no effect on the physico-chemical characteristics. however the carbohydrate modification of the liposomal surface leads to increasing in transfection efficiency on a specific cell line hepg2. moreover, the introduction of mono-carbohydrate derivative increases the transfection efficiency better than using a branched derivative of lactose. in the pharmacokinetic study target effect also was shown. unmodified liposomes start to be detected in the liver at 10 minutes after administration, whereas modified liposomes were detected at 2 minutes after administration. similarly, the excretion of modified liposomes from the liver was more slowly. also worth noting the high concentration of modified liposomes in the liver. furthermore liposomes modified by carbohydrates reduces the intensity of its accumulation in the lung. conclusions: it was shown that increasing attraction of drugs to the liver cells can be achieved by using liposome modification with lactose derivative. 0472 | sialylated fetuin-a is a candidate predictive biomarker for successful grass pollen allergen immunotherapy objectives: to identify new biomarkers of ait efficacy, pre-treatment sera obtained from 82 grass pollen allergic patients responding or not to sublingual ait were differentially assessed by 2d-dige or label-free mass spectrometry. the role of fetuin-a in allergy physiopathology was studied by using gene silencing in a mouse asthma model, human dendritic cell stimulation assays and surface plasmon resonance. results: using comparative proteomics, we provide evidence for an increased o-linked sialylation of fetuin-a in sera collected before treatment from patients exhibiting clinical responses, when compared with low responders. whereas feta may either inhibit or promote chronic inflammation, no specific role in allergy had been ascribed to it until now. in ovalbumin-sensitized mice, silencing of the fetuin-a gene increased airway hyperresponsiveness and th2 responses. fetuin-a, but not its non sialytated counterpart, synergizes with lps and grass pollen or mite allergens in a tlr4-dependent pathway to enhance the proallergic profile of human monocyte-derived dendritic cells. conclusions: quantification of sialylated fetuin-a glycoforms in the blood before treatment allows to identify patients more likely to benefit from grass pollen immunotherapy. validation of the hypothesis that this marker associated with "an inflammation status" can be used to predict ait efficacy is ongoing in larger cohorts of patients. introduction: kawasaki disease (kd) is a vasculitis that mainly affects small to medium-sized vessels, particularly the coronary arteries, and is a leading cause of acquired heart disease in children. previously, we found that the development of kd is associated with an elevation of both th1 and th2 immunity. gene hypomethylation is abstracts | 329 an important form of epigenetic regulation, which results in increased gene expression. because m1 macrophages are associated with inflammation and th1 immunity while m2 macrophages are associated with immune regulation and th2 immunity, we hypothesize that kd is associated with hypomethylation of both m1 and m2 macrophage related genes. objectives: our objective was to investigate the methylation profile of m1 and m2 related genes in patients with kawasaki disease. twenty-four patients with kd and 12 age-matched healthy controls (hc) were included in this study. in patients with kd, blood was sampled 24 hours before ivig therapy (kd1) and 21 days after ivig therapy (kd2). after dna extraction, samples were analyzed using human methylation bead chip 450 (illumina) to examine the methylation ratios of genes related to m1 macrophages (64 genes, 1536 cpg sites) and m2 macrophages (46 genes, 1329 cpg sites). cpg sites with more than 10% difference in methylation levels and a pvalue less than 0.05 between groups were considered significant. objectives: primary aim of the study is the identification of differentially expressed genes (deg) associated with allergic rhinitis (ar) by using genome-wide transcriptomics data from blood immune cells. this set of candidate genes will then be used to define gene networks relevant for onset, severity and potential treatment outcome of house dust mite associated ar. with different ethnicity or populations exposed to a different environment is currently in preparation. introduction: allergic patients display abnormal immune responses to harmless antigens, leading to various symptoms from hay fever to life-threatening conditions. these responses include abnormal type 2 immunity polarization and induction of allergen-specific memory t and b cells, resulting in development of allergy instead of immune tolerance. allergen-specific immunotherapy (ait) is currently the only causative treatment of allergic disorders. yet, in depth understanding of the underlying differences in allergen-specific cd4+ t cell and treg responses between allergy and tolerance and their changes during immunotherapy is lacking. objectives: we investigated whole-genome transcriptomics of circulating birch (bet v 1) and grass (phl p 5a)-specific cd4+ t cells in allergic patients before and at 3, 6, and 12 months of ait, as well in non-allergic healthy controls in corresponding seasonal time points. detailed immunophenotyping with flow cytometry and cd4+ mhc class ii tetramer staining with low rna/single cell next generation sequencing were performed. results: at baseline, out of the pollen season, there were more allergen-specific cd4+ t cells in allergic patients than in controls. at this time, over 1500 genes were significantly changed in allergenspecific as compared to total cd4+t cells in patients, yet we found substantial differences in signal transduction and inflammatory response gene expression when compared to healthy controls. during ait we noted significant increase of allergen-specific cd4+ cells in patients with subsequent gene expression changes in the immune tolerance pathways. finally, we found increase in allergen-specific treg cells in patients upon ait, but not in tolerant controls in corresponding seasons. of interest yet, at early ait time points, allergenspecific treg cells displayed gene profiles suggesting their insufficient suppressive functions. conclusions: in summary, in vivo allergen exposure causes profound changes in the transcriptomic profiles of allergen-specific t cells. these gene profiles seem to be deficient at baseline in allergic patients, but ait is skewing them into the tolerant controls levels. introduction: the variability of the pharmacological response to beta 2 (b2)-agonists may be due to the polymorphism of the gene of results: singled out statistically significant differences of the genotype distribution. the gly/gly16 homozygous allele was discovered twice as often in the group with an insufficient response to b2-agonists than in the group with a good response (66 vs 38%, p<.001), while the distribution of heterozygous allele was detected the opposite pattern (55 vs 28%, p<.001). in the arg/arg16 genotype distribution, there were no considerable differences in both groups (6% in each group). in the subgroups of children, receiving the high doses of the inhaled glucocorticoids, there was a trend for the prevalence of gly/gly16 homozygous allele prevalence. we have discovered the association of the gly/ gly16 genotype of the adrb2 gene with an insufficient effect of broncholytic therapy by means of short-term b2-agonists; we also revealed the participation of the gly16 allele in the phenotype formation with the severe run of bronchial asthma and tolerance towards the therapy both by b2-agonists and inhaled glucocorticoids. mckenna oe 1 ; posselt g 1 ; lackner p 1 ; schmitt a 2 ; h€ ollbacher b 1 ; briza p 1 ; wessler s 1 ; gadermaier g 1 ; ferreira f 1 1 universit€ at salzburg, salzburg, austria; 2 georg august-universit€ at g€ ottingen, g€ ottingen, germany introduction: an excess of 100 million people worldwide have a reported allergy to birch pollen. proteases in such allergen sources have been suggested to contribute to primary sensitisation and exacerbation of allergic disorders. until now the protease content of betula pendula, a species endemic to the northern hemisphere, has not been studied in detail. hence, we aim to identify and characterise pollen and bacterial derived proteases found within betula pendula pollen. objectives: birch pollen transcriptome was constructed via de novo transcriptome sequencing. reads were assembled using the trinity software suite.. analysis of the birch pollen proteome was achieved via mass spectrometry and use of zymographic gels with the embedded substrates gelatinase and casein, which enabled visualisation of proteolytic activity. further to this, protease activity was quantified using a fluorescently labelled casein substrate protease assay. results: by using mass spectrometry, we were able to identify up to 26 proteases within birch pollen. we could cluster the proteases into specific families based on their distinct proteolytic activities. further comparative analysis of the proteome and transcriptome revealed the relationship between transcript levels and the proteins they encode. zymographic methods enabled distinct visualisation of proteolytic activity for both casein and gelatin substrates. using fluorescently labelled casein, the birch pollen protease activity was quantified as 0.68 lg/ml when compared to a trypsin standard curve. additionally, 26 bacterial isolates of the birch pollen were identified, and the proteolytic activity analysed. we report successful discovery of pollen and bacterial derived proteases endogenous to betula pendula. whilst none of the known birch pollen allergens have been recognised as a protease, we aim to investigate the role of tight junction degradation within epithelial cells and further enhance understanding of proteolytic activity on immune-polarization. objectives: to investigate the frequency and reasons of shortand long-term reintroduction failure in adults after a negative fc. method:: these are preliminary results of an ongoing prospective study. after a negative fc, patients receive standardized aftercare consisting of an introduction scheme to introduce the food at home and consultation by phone for advice and support 24 hours, 1-3 weeks and 6 months after the fc. short-term data about the frequency that patients failed introduction, defined as not completing the introduction scheme or patient-reported allergic complaints repeatedly during introduction, was obtained using a telephone interview. long-term data (5-12 months after negative fc) about frequency and reasons of reintroduction failure in daily diet, defined as not eating the food or only eating products with traces of the food, was obtained using a patient-reported questionnaire. results: from 2014 until now 38 patients were included (mean age: 34 years, male: 26%), who underwent a total of 110 fcs with: hazelnut (23%), other nuts (17%), fruit (7%), composite meals (7%), fish and crustaceans (7%), cow's milk (6%), hen's egg (5%) and other (28%). in 96 (87%) of the negative fcs, introduction using an introduction scheme was advised. in 13%, patients did not receive standardized aftercare for different reasons, eg negative fc with a composite meal. in 19%, introduction with an introduction scheme failed. long-term information was available for 40 fcs. introduction failed in 12 fcs (30%), including 1 patient that even avoided traces of the food. patient-reported reasons for introduction failure were (n=11): symptoms after ingestion of the food (n=8), fear for allergic reactions (n=2) and not like the taste of the food (n=1). conclusions: short term introduction with an introduction scheme failed in 19%. however on the long-term in almost one third of the negative fcs, patients failed to reintroduce the food in daily diet, despite careful aftercare. it is recommended to give these patient even more intensive and tailored support. introduction: in order to help allergic patients manage often severe symptoms, food manufacturers are required to list allergens on labels and take precautions to avoid inadvertent contamination of foods with allergens. existing tools using generic immunoassays do not provide precise identification or quantification of specific food allergens. furthermore, existing elisa immunoassays are not able to be run simultaneously and are often unreliable. objectives: our goal was to develop and validate an accurate, sensitive and high throughput immunoassay that would enable simultaneous quantification of multiple allergens in foods. fluorescent beads coupled to allergen specific monoclonal antibodies were used to develop a multiplex array for simultaneous quantification of major allergens from peanut (ara h 6), milk (bos d 5), egg (gal d 2), and shrimp tropomyosin (pen a 1). target allergens were detected using biotinylated antibodies and streptavidin conjugated fluorochrome. the array was quantified using highly purified natural allergens as standards. allergen content was measured in various samples including samples spiked with purified allergen and allergen incurred food matrices. the results were compared to elisa. a multi laboratory validation was performed to validate the performance characteristics of the assay. results: there was a high correlation between the multiplex array and allergen specific elisa. the limit of detection of the array was as low as 20 pg/ml. no significant cross reactivity was observed between the various food allergen assays. the recovery of allergen from spiked samples was generally between 70 and 130%. inter and intra assay variability was observed to be less than 15%. in conclusion, an accurate, sensitive and reliable multiplex array for major food allergens was developed and validated. the flexibility of the microsphere technology allows for further expansion to produce a comprehensive array for the most important food allergens. this quantitative multiplex array may help to reduce the risk of inadvertent contamination of food. objectives: our aim was to create a food allergy web-based educational program for both schools and restaurants professionals. results: an interactive platform that hosts a free learning program, conclusions: the program and the toolkit are currently available online and are being implemented in schools at the north of portugal. we expect that fac program will give us an important insight on the professionals' knowledge about food allergy. additionally, acting as free integrated service and awareness effort, this program could be an educational tool easily adapted and disseminated, which may improve professionals 'commitment and skills to deal with food allergy in the community. 0495 | development of parallel reaction monitoring (prm) methods for soy and milk detection: consideration of allergen-derived ingredients chen s 1 ; krawitzky m 1 ; yang ct 2 ; downs m 1 1 university of nebraska-lincoln, lincoln, united states; 2 thermo fisher scientific, san jose, united states introduction: the presence of undeclared food allergens poses both regulatory and health risks. in order to assess the magnitude of these risks, accurate quantitative detection methods are required. for some allergenic foods, the food industry uses not only the allergenic source but also a number of source-derived ingredients. some detection methods (both immunoassays and mass spectrometry methods) may fail to accurately detect and quantify these allergen-derived ingredients if they are not taken into consideration during development. objectives: the objective of this work was to select peptide targets for parallel reaction monitoring (prm) mass spectrometry methods that are suitable for detecting a variety of soy-and milk-derived ingredients. six soy-derived and six milk-derived ingredients were obtained for this study. the ingredients were extracted (50 mmol l à1 tris-hcl, ph 8.6, with 6 mol l à1 urea, 20 mmol l à1 dtt, and 1% pvpp) and subjected to in solution trypsin digestion. discovery proteomics analysis was conducted by lc-ms/ms using a q exactive tm plus orbitrap tm running in top 10 data-dependent acquisition mode. peptides were identified using proteome discoverer 2.1 and relative, labelfree quantification was conducted on high-confidence (fdr<0.01) peptides. selected peptides were subsequently analyzed in a targeted prm mode. results: the relative abundance of identified peptides varied among both the soy-derived and milk-derived ingredients. in the case of soy ingredients, for example, there were particularly marked decreases in the abundances of numerous peptides, across different proteins, in a hydrolyzed soy protein isolate. in the milk ingredients, variation in peptide abundance could be more directly attributed to differences in product protein fractionation (eg a decrease in abundance of whey proteins in a sodium caseinate product), although some peptides and proteins maintained consistent abundance across ingredients. after applying specificity and performance criteria, 57 peptides from 14 soy proteins and 64 peptides from 10 milk proteins were selected for further analysis in a targeted prm method. conclusions: peptide abundances vary widely among ingredients derived from allergenic foods. consideration of these peptide differences during ms method development by incorporating discovery proteomics may lead to more versatile and widely-applicable quantitative detection methods for food allergens. introduction: milk and its derivates are usual ingredients in many food products, which must be excluded by cow's milk allergic (cma) patients. oit protocols in patients with cma appear to be safe and effective in inducing desensitization and milk introduction in the diet. objectives: we conducted a survey in cma patients after successful completion of an oit programme, to assess their dietetic profile after introduction of fresh milk and dairy products (unrestricted diet) we considered 42 cma patients (pts), 32 males and 10 females, age 5-29 (median 12.5), who successfully completed the oit protocol. these patients were on an unrestricted diet for milk and derivates, and they had been recommended to assume at least 100 ml of fresh milk or yogurt every day. patients were given an ad hoc questionnaire to assess the milk/dairy products intake at least 24 months after oit completion. results: from our investigation all of the pts have been assuming milk protein everyday without significant reactions after oit. 71% of the interviewee (30 pts) referred to be drinking fresh milk at least three times a week, in a quantity of 100 ml or higher. of note, 85% have to add cocoa powder (14 pts) or coffee (11 pts) to mask milk taste. dislike of milk taste was the cause of the refuse to take fresh milk in 10 pts (over 12 patients that didn't take milk at all); 5 pts who didn't drink milk had at least 125 ml yogurt instead, almost every day. fresh cheese was eaten at least once a week by 50% of all the pts; hard cheese was eaten as main course almost once a week by 62%. 86% of patients consumed biscuits and sweet baked products containing milk/derivates at least once a week, 62% every day. pizza was also present in the diet of the majority of pts (86%), once a week/month. ice cream was appreciated by all the patients and regularly assumed especially during the summer time. conclusions: taste seems to be the main factor that directs the daily choice of milk derivates or milk containing products. all pts easily consume baked products containing milk/derivates, and the majority of them accept fresh milk as advised in order to maintain unresponsiveness. our survey confirms that oit is effective in expanding food choice, but for some patients the change of dietetic habits is hampered due to taste reasons. a more detailed, qualitative and quantitative analysis of the milkunrestricted diet will derive from the 7-days food diary given to these patients. 0497 | frozen-defrosted dried skimmed milk is a suitable product for sublingual immunotherapy for cow's milk allergy introduction: sublingual immunotherapy (slit) is a promising treatment for cow's milk allergy (cma) due to its favourable safety profile. however, its efficacy is limited-probably due to the small volumes and doses that can be delivered sublingually, especially in children. milk products with preserved allergenicity that allow higher protein concentrations in smaller volumes might potentially improve the efficacy of slit for cma. dried skimmed milk (dsm) could fulfill these characteristics. in addition, once dsm is reconstituted, freezing individual vials from the same batch for further administrations could increase dose-consistency throughout the treatment, which would help ensure safety. however, little is known about whether processing to produce dsm, and further freezing-defrosting, may alter its allergenicity. objectives: to evaluate the allergenic protein composition of dsm, including once frozen-defrosted, in comparison to fully-allergenic usually consumed fresh milk. methods: sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) followed by silver staining was performed following the laemmli method to determine the soluble protein composition of the following products: fresh pasteurized milk (friesland campina, amersfoort, the netherlands), dsm (marvel, the premier foods group ltd, london, uk) and frozen-defrosted dsm to identify all protein bands present. western blot with anti-whey and anti-casein antibodies was performed to identify the specific allergenic proteins. results: no significant differences were found amongst the milk products tested, with sds-page displaying all the bands corresponding to the major allergenic proteins in milk (alpha-lactalbumin, beta-lactoglobulin and alpha-, beta-and kappa-caseins) and the western blot showing recognition to all proteins with similar intensity. the major allergenic proteins present in unprocessed milk are well-preserved in dsm, even after freezing-defrosting, making it a convenient product for sublingual immunotherapy. results: nineteen children were randomized into the low dose group (n=11) and the elimination group (n=8). there were no significant differences in background between these groups. after 24 weeks of therapy, the rate of passing the oral food challenge test with 1/8 th of a whole egg was significantly higher in the low dose group (11/11 (100%) vs 4/8 (50%), p=.018). ovomucoid-specific ige levels in the low dose group after 24 weeks were significantly lower than those at baseline. adverse events associated with both therapies did not occur during the study period. conclusions: these results show that low dose ingestion of egg is safe and effective for tolerance or desensitization induction in children with egg allergy, without the need for dose elevation. 0499 | another brick in the wall: toward a national food allergy strategy for canada introduction: the world is experiencing an apparent epidemic of food allergies. with rising prevalence and increasing global spread, basic scientists continue to search for causes while clinical and social scientists continue to study the consequences. these include life-long chronic illness, fear and anxiety, social exclusion and stigma, all of which are underscored by inequalities across vulnerable groups (eg, low income families, immigrants, indigenous peoples). concomitantly, consumer organizations and patient support groups attempt to influence policy in order to maximize choice and minimize risk for individuals and families affected by food allergy, both directly and indirectly. this includes food labeling legislation, food safety regulations, and policies and practices in public places such as schools, restaurants and transportation modes (eg, airplanes). objectives: in canada, with the support of 10+ years of science undertaken by the allergy genes and environment (allergen) networks of centre of excellence in allergic disease, we are leading a national team that aims to establish the building blocks for a national food allergy strategy. conclusions: the greatest challenges to building a national food allergy strategy are not those related to the basic or clinical science, but rather the activities and commitment of individual stakeholders. while gaps remain in the science, the challenges of transdisciplinary integrated knowledge translation hinder progress. we present lesions learned regarding culture shifts that will facilitate the progress we need to maximize choice and minimize risk for canadians affected by food allergy. 0500 | component resolved diagnostics reduces diet restrictions by half among finnish school children savolainen j 1 ; mascialino b 2 ; pensamo e 3 ; hermansson l 4 ; silvan m 3 ; borres mp 4 ; korhonen k 5 1 university of turku, turku, finland; 2 department of allergology, uppsala, sweden; 3 thermo fisher scientific-immunodiagnostics, turku, finland; 4 university of turku, uppsala, sweden; 5 thermo fisher scientific-immunodiagnostics, lieto, finland introduction: there are 50 000-100 000 special diets because of food allergy in finnish schools. the finnish allergy program 2008-2018 was launched to reduce problems and costs induced by allergies. one of the special aims was to reduce diets caused by food allergy will by 50%. the h€ ark€ atie social and health care service region schools have required doctor's certificates for diets for over abstracts | 337 10 years. all diets are listed in a register and checked on a regular basis. objectives: the purposes of this study were to evaluate whether it is possible reduce the special diets when the special diet system appears to be working well and to assess the added value of immu-nocap ® isac allergen component diagnostics in the intervention. results: there were 2885 children attending the schools in the h€ ark€ atie region. there were 205 children with diet due to food allergy. children were recruited to study from the diet register and contacted by a nurse's phone interview. there were 48 children who refused the study leaving 157 children for the assessment of the diet. 23 children were not following any diet and in 44 children the diet was not regarded necessary by the study nurse. 90 children agreed to take part in the study and were referred to laboratory tests for food specific ige and isac. 7 children dropped out leaving 83 children in the study. after the food specific ige results were available, children were contacted by physician. based on the results and/or interview a free diet was allowed for 3 children. 15 children were eating small amounts of the food and were encouraged to increase the use of the foods. 48 children were advised to avoid the foods only if they caused symptoms. only 17 children were advised to continue diet. after the results of isac were available, children conclusions: the study confirmed that it is possible to have diets decreased over 50% in accordance to the finnish allergy program. additionally, the study showed that food allergic children can benefit from the use of component resolved diagnostics. 0501 | omalizumab treatment for severe food allergy caused by lipid transfer protein: a preliminary case series mari a; zennaro d; ferrara r; bernardi ml; alessandri c caam-centri associati di allergologia molecolare, rome, italy introduction: lipid transfer proteins (ltp) are allergens from plantderived foods causing symptoms ranging from oas to anaphylaxis. ltp are present in almost all kind of plant species used for human feeding. ltp allergic patients suffer of reactions to a broad variety of foods, with a very personal reactivity profile which can involve few or many foods. in addition, patients who start to record severe reaction to several foods begin to be afraid of eating any other related or non-related food, leading to a poor diet. omalizumab (ozm) has been documented to be effective in treating food allergies with sensitization to other allergens. objectives: to document the approach for recruiting, studying, monitoring ltp allergic patients, and do a preliminary evaluation of the clinical impact of ozm therapy. results: six adult patients with documented reactions to plantderived foods in the last 12 months and diagnosed to be ige positive to multiple ltp by using multiplex testing, namely isac112 at the beginning and faber244 during the follow up, were recruited. ozm was offered as an off label treatment adopting an open label study design. a questionnaire was submitted to each patient before, during and after the treatment. foods listed as "no more eaten" where considered for reintroduction, starting from those excluded because of fear, going for those with an increasing risk of reactions. re-introduction was done at home after receiving detailed instructions, having all rescue medication at hand. the allergist was connected real time with the patients using one or more ict tools. one patient dropped out because was not complying with the scheduled reintroduction. three patients completed the treatment with a successful re-introduction of all or almost all excluded foods, in two cases peach was reintroduced. the last two patients reintroduced 50%-60% of the excluded foods, including some of those previously causing reactions. the attempt of re-introducing the most risky foods failed causing local allergic reactions promptly controlled by the therapy. all foods re-introduced were tolerated once the treatment was stopped. conclusions: ozm seems to be a promising treatment for severe ltp allergics, improving their qol. starting from the recruitment phase to the re-introduction, the overall procedure looks quite complicated and deserve much resources. ige sensitization to ltp, carefully defined before treatment, can be monitored during the ozm course as the drug doesn't interfere with faber test ige detection. 0502 | oral immunotherapy with peach-juice in lipid transfer protein (ltp) allergy: is it possible to reach tolerance? introduction: food allergy to rosaceae fruits and nuts, due to sensitization to lipid-transfer protein (ltp), is frequent in the mediterranean area countries. based on milk allergy oral immunotherapy (oit) protocols, a study is proposed to obtain an oit regimen in patients allergic to ltp. objectives: we included patients with anaphylactic reactions due to ltp-food allergy, from january/2015 to october/2016. skin prick test (spt) was performed with a food and inhalant battery, ltp bial-aristegui ® (0.1 mg/ml), prick by prick (pbp) with a specific commercial peach-juice (dilutions to endpoint), and determination of pru p3 ige levels (immunocap). the presence of pru p 3 protein in the peach-juice, was confirmed by sds-page and elisa method, and quantified with anti-pru p 3. we elaborated an oit guideline with progressive administration of peach-juice, 1-2-4-5 drops (5drops=0.13 ml), sublingually, starting concentration chosen according to the endpoint spt results, up to 5 ml daily dose. the dose reached at the allergy service, was continued at home, daily, for 1-2 weeks. all the increasing doses were performed at the allergy service, after pbp with peach-juice and ltp control spt. after a time, an oral challenge up to 250 ml peach-juice was performed. patients were instructed on the importance of maintaining regular intakes and avoiding cofactors. results: 16 patients started this protocol (6 male/10 female), aged 7-38 (media 19.67). peach-juice analysis in agarose gel electrophoresis, showed a 10 kda band quantified as 21.16 lg/ml of ltp. there was no difference between wheal diameter on spt for ltp bial-aristegui ® and pbp with commercial peach-juice along all the study. average concentration on pbp to endpoint: 1/1000 (4), 1/100 (8), 1/10 (4). pru p 3 ige level average: 30.22 ku/l. none anaphylactic or serious reactions during the oit protocol appeared. only five patients (31%) reported mild occasional symptoms (oral pruritus and mild located urticaria). 11 patients reached 5 ml daily dose (68.75%), and 4 of them (25%) completed oral food challenge with peach-juice up to 250 ml, with good tolerance. this pattern also allowed us to reintroduce withdrawn foods from the diet due to previous reactions, with good tolerance. results: 60 children (age 10-18 years) sensitized to dog dander extract (median 11.5 ku a /l), with or without known dog induced allergic airway disease, were included. nasal provocation testing with dog dander extract was performed. measurement of ige to dog dander extract and to can f 1-can f 6 was performed with immunocap. an ige level ≥0.1 ku a /l was considered positive. among all 60 children sensitization to can f 1 (65%) and can f5 (62%) was most frequent. corresponding numbers for can f 4, can f 2, can f 6 and can f 3 were 48%, 47%, 47% and 27% respectively. based on the results from the nasal challenges three groups were identified; no (n=21), mild (n=14) and strong reaction (n=25). the median ige levels to dog dander and to all 6 allergen molecules were higher in the strong reaction group than in the mild and the no reaction group. among children with a strong reaction, ige to can f 4 was found in 68% (17/25) compared to 24% (5/21) among children with no reaction (p=.003). ige to can f 6 showed a similar pattern (p=.006). 40% (10/25) of the children with a strong reaction were sensitized to can f 3 compared to 9.5% (2/21) of the patients with no reaction (p=.01). no associations were found between the ige levels to can f 1, can f 2 and can f 5 and the no reaction or strong reaction groups. using multiple regression analysis, with all 6 allergens in the model, sensitization to can f 4 showed a statistically significant difference between the groups. conclusions: molecular allergology may improve diagnostics of dog allergy in children. sensitization to the lipocalin can f 4 was significantly associated to a strong positive nasal reaction implying its usefulness as a marker of clinically relevant dog allergy. tsolakis n 1 ; malinovschi a 2 ; nordvall l 1 ; janson c 2 ; mattson l 3 ; lidholm j 3 ; borres m 3 ; alving k 1 1 uppsala university, women's and children's health, uppsala, sweden; 2 uppsala university, medical sciences, uppsala, sweden; 3 thermo fisher scientific, uppsala, sweden introduction: cat allergy is common worldwide and a major trigger of asthma in many countries. molecular patterns of cat sensitisation vary between individuals but their relationship with allergic inflammation has not been extensively studied. objectives: the aim was to investigate the prevalence of ige to different cat allergen components and their relationship to type-2 inflammation and bronchial responsiveness in young asthmatics. conclusions: ige sensitisation to cat serum albumin (fel d 2) and cat lipocalins (fel d 4, fel d 7) , but not to secretoglobin (fel d 1) or cat dander extract, were independently associated with feno and b-eos count. we suggest that cat serum albumin and cat lipocalins can be used as markers for increased risk of type-2 inflammation in young asthmatics, as shown in multiple regression analyses. 0505 | complete sequence and recombinant production of horse dander allergen equ c 2 lidholm j; lundgren t; larsson h; mattsson l thermo fisher scientific, uppsala, sweden introduction: horse dander is an increasingly important cause of respiratory allergy. equ c 2 was one of the first horse allergens to be recognised but only a small part of its amino acid sequence has been reported. objectives: the aim of this study was to determine the complete sequence of equ c 2 and express it as an immunoreactive recombinant protein. methods: equ c 2 was purified by size exclusion, hydrophobic interaction, anion exchange and reversed phase chromatography. recombinant equ c 2 was expressed as a hexahistidine tagged protein in e. coli and purified by immobilized metal ion affinity and ion exchange chromatography. ige antibody reactivity to natural and recombinant equ c 2 and other horse dander allergens was determined in sera of 25 subjects allergic to horse. results: a putative equ c 2 sequence predicted from genomic data revealed a lipocalin protein of 159 amino acids with a highest sequence identity among known lipocalin allergens of 33% to can f 4. n-terminal sequencing and mass spectrometric analysis of purified natural equ c 2 confirmed 97.5% (155/159 residues) of the predicted sequence. recombinant equ c 2 displayed ige antibody binding activity comparable to that of purified natural equ c 2 (r=.98). of the 25 horse allergic subjects studied, 19 (76%) showed ige antibody binding to equ c 1, 13 (52%) to equ c 2, 5 (20%) to equ c 3 and 7 (28%) to equ c 4. the complete sequence of equ c 2 was established. as a fully immunoreactive recombinant protein, it represents an important addition to the panel of allergens useful in the diagnosis of allergy to horse. 0506 | component resolved diagnosis using guinea-pig allergens elucidates allergen sensitization profiles in allergy to furry animals objectives: to identify major guinea-pig allergens and to evaluate their potential as reliable markers for a specific ige-diagnosis in comparison to dander extracts. results: forty-three patients with a clinical history of allergy to guinea-pig and 45 patients allergic to cat and/or dog were recruited for the study. major guinea-pig allergens were identified by ige-immunoblot and n-terminal sequencing of ige-reactive proteins. corresponding cdnas were cloned and allergens were expressed as recombinant proteins in e. coli. specific ige to animal dander, fel d 2 and can f 3 were determined, specific ige to fel d 4, can f 6 and to guinea-pig allergens were quantified by elisa. two new guinea-pig lipocalin allergens, cav p 1 and cav p 6, were identified in guineapig dander. the combination of 4 guinea-pig allergens, the 2 new allergens and the previously isolated lipocalins cav p 2 and cav p 3, enabled the identification of 39 out of 43 patients sensitized to guinea-pig. the vast majority of the patients had specific ige to cav p 1 (84%). cav p 6 shares 53% sequence identity with fel d 4 and can f 6 and was found to be cross-reactive with these cat and dog allergens. in the group of cat and/or dog allergic patients, 87% had also specific ige to guinea-pig dander. nearly half of those (47%) had ige to cat serum albumin fel d 2 or to fel d 4 (58%) and to can f 6 (56%), explaining the high degree of cross-reactivity to guinea-pig dander. only 25% of the cat/dog allergic patients with a positive isle test to guinea-pig dander had specific ige to any of the non crossreactive guinea-pig allergens cav p 1, cav p 2 or cav p 3. however, none allergen has been characterized from mongolian oak. objectives: in this study, we tried to characterize a major allergen from mongolian oak. results: a molecule homologous to pathogenesis-related protein 10, a putative que m 1, was cloned by rt-pcr and its recombinant protein along with que a 1, an allergen from white oak (q. alba) was produced. cloned que m 1 sequence shares 57.5%-96.2% amino acid sequence identity (96.2%) with pr-10-like allergens from various plants. allergenicity and diagnostic value of recombinant que m abstracts | 341 1, que a 1 and bet v 1 proteins were compared by elisa using sera from oak sensitized subjects. specific ige to recombinant que m 1, que a 1, and bet v 1 were detected in 90.0%, 78.0%, and 94.0% of 50 serum samples from korean tree pollinosis patients. recombinant que m 1 was able to inhibit ige reactivity to que a 1 and bet v 1, indicating its strong cross-reactivity. activation pattern of basophils from five patients was similar in terms of cd203c expression and protein concentration of challenged bet v 1 and que m 1. objectives: over the course of one year, all patients who were seen at our immunoallergology clinic for the first time underwent spt with our standard series, to which four olive tree cultivar extracts were added (arbequina, blanqueta, hojiblanca e picual). we then recorded wheal size diameters, considering a wheal >3 mm to correspond to a positive test. we recorded 832 individual sessions of spts, in which 613 presented at least one positive result. two hundred and thirtysix of these patients (38.5%) had a positive spt for olive tree pollen, only one of them being monosensitized. when looking only at pollen-sensitized patients, twenty-two patients (5.9%) tested positive solely for olive tree pollen. in all allergic patients, the most frequent cultivar sensitization was to the cultivars hojiblanca (31.5%) and arbequina (31.3%), followed by the cultivars picual (29.2%) and blanqueta (27%). twenty-six patients (11% of all olive pollen sensitizations) had a positive spt for the conventional extract and negative spt for the cultivars; 192 patients (81.4%) had a positive spt for both. we noted that 7.6% (n=18) of patients sensitized to olive tree pollen had a negative spt with the conventional extract and positive with one of the cultivar extracts. the cultivar hojiblanca was the most frequent in this group (66.7%, n=12), followed by the arbequina cultivar (55.6%, n=10). in the group as a whole, there was a positive correlation between the results of the spts with the conventional extract and each of the cultivar extracts. this correlation was weaker with the cultivar hojiblanca (r=.785). conclusions: some patients, sensitized only to the pollen of certain olive tree cultivars, are not identified with the conventional extract. spt with the hojiblanca cultivar could identify most of these patients in our country, and therefore should be considered in patients with a history of pollinosis and a negative spt for the common extract of olive tree pollen. 0509 | structural and immunological comparison of heat treated pru p 3 and art v 3, the non-specific lipid transfer proteins of peach and mugwort pollen wildner s 1 ; stock l 1 ; regl c 2 ; alessandri c 3 ; mari a 3 ; huber c 2 ; stutz h 2 ; gadermaier g 4 objectives: recombinant art v 3.0201 and pru p 3.0102 were expressed in e. coli rosetta-gamib plyss and purified using cation exchange chromatography. proteins were analyzed in gel electrophoresis and mass spectrometry. proteins were incubated at 95°c in time intervals up to 120 min using buffers at ph 3.4 and 7.3. physico-chemical properties of native and heated allergens were analyzed by circular dichroism spectroscopy, dynamic light scattering and size exclusion chromatography (sec). using sera from italian patients sensitized to pru p 3 and art v 3 (n=26), ige binding to native and heat-denatured allergens was investigated in elisa. results: highly pure recombinant pru p 3 and art v 3 were obtained as non-tagged proteins from e. coli. identity and formation of disulfide bonds was verified by mass spectrometry. circular dichroism showed high thermal stability of both proteins at acidic ph. the alpha-helical fold of art v 3 was lost upon heating for 15 min at ph 7.3 while pru p 3 was already altered after 5 min. purified pru p 3 and art v 3 are monomeric molecules with a hydrodynamic radius of 1.6 and 1.8 nm, respectively. structural relaxation is observed upon heat treatment which is not attributed to protein aggregation as determined by sec. the ige reactivity to both allergens was largely unaffected upon heating at ph 3.4. notably, ige reactivity to art v 3 was already significantly decreased upon 15 min heating and was completely abrogated to both proteins after 120 min denaturation at neutral conditions. conclusions: even though the fold of pru p 3 is more compact compared to art v 3, susceptibility to structural changes upon thermal treatment at neutral conditions are more pronounced which do however not directly translate to lower ige binding capacities. particularly the buffer environment needs to be considered when formulating ltp-containing products which undergo heat treatment. objectives: we sought to determine the ige binding capacity and potential diagnostic value of a recombinant hybrid molecule. results: the codon-optimized nucleotide sequences of a hybrid molecule comprising the full sequences of blo t 5 and der p 2 at the amino and carboxyl ends respectively, here named bp-2, was cloned into a plasmid vector and expressed in escherichia coli as a 6xhis tag protein. two hundred and thirty three sera from colombian (n=118) and cuban (n=115) allergic patients were tested by elisa for ige reactivity. thirty seven sera from non-allergic subjects and negative skin test (spt) to mites were used as controls. all subjects provided written informed consent to their participation in this study. hdm allergy was diagnosed on the basis of clinical symptoms in combination with mite extract spt. potential diagnostic value of bp-2 specific ige was determined by receiver operating characteristic (roc) analysis and area under roc curve (auc) calculated. positive serum ige values to hybrid molecule were defined as optical density (od) higher than 0.13 (mean od plus 3 standard deviations in 15 nonallergic subjects). in respiratory allergic patients, the overall frequency of positive ige reactivity to bp-2 was 70.9%, in non-allergic subjects the frequency was 21%. serum ige levels to bp-2 were positively correlated to spt to b. tropicalis (spearman r=.54, p=.001), and to d. pteronyssinus (spearman r=.4, p=.001). using spt to mite extracts as gold standard, the sensitivity and specificity of serum ige levels to bp-2 were 71.4% and 94.1% respectively, with an auc of 0.82 (95% confidence interval 0.74-0.89). conclusions: these data suggest that bp-2 could be a useful reagent for identifying allergic patients sensitized to b. tropicalis and/or d. pteronyssinus. 0511 | igg, ige and igg4 specific antibodies to molecular allergens of aspergillus fumigatus introduction: in clinical allergy, alongside with skin prick tests, in vitro determination of specific ige for a particular patient contributes to the diagnosis and helps to estimate the risk associated with different food allergens. however, with commercial methods of specific ige antibodies detection (component-resolved diagnosis, crd), the clinician is typically limited by the list of the available allergens. objectives: to overcome this limitation, we developed two component-resolved diagnostic tests for food allergy in which natural extracts can be used. in the first developed method, the crd is performed using immunoaffinity capillary electrophoresis (iace) coupled with matrixassisted laser desorption/ionization mass spectrometry. meanwhile, the second method is based on in-tube immunomagnetic separation (ims) with mass spectrometry identification (mass spectrometry or peptide mass fingerprinting). in both techniques, magnetic beads coated with antihuman ige antibodies are used to extract the ige antibodies from the blood serum of the allergic patient. then, the immunocomplex, obtained on the magnetic beads, is used to quantify the total ige level or to probe the ige binding with standard allergens or natural allergenic extracts. afterwards, the identification of the extracted proteins, ie potential allergens, is performed by mass spectrometry with or without ce separation. after optimisation, the proposed methods have been successfully applied to a commercial blood sample of a patient with a known allergy to cow's milk, with results confirmed by standard tests. as a proof-of-concept, the sensitization profile of a patient suffering from protein contact dermatitis to the cow's whey fraction has been determined. we confirmed the presence of circulating ige antibodies binding lactoferrin and bovine serum albumin. cross-reactivity tests were also performed using goat and sheep milk and revealed the patient sensitivity to serum albumins from these two milks. such approaches open the possibility for direct identification of ige-bound allergens molecular mass and structure. these methods allow the discovery of yet unknown allergens and could be useful for precise personalized allergy diagnosis, allergens epitope mapping, and cross-reactivity studies. objectives: the objective of this study was to investigate the validity of cord blood ige for predicting atopy at 6 years of age. methods: a total of 385 children born in 2010 participated in the longitudinal investigation of global health in taiwanese schoolchildren (lights) cohort. total ige was measured in umbilical cord blood at birth. perinatal history was collected from medical records in the chang gung memorial hospital, taiwan. total and specific serum ige and questionnaires were carried out at 6 years of age. receiver-operating characteristic (roc) curves were used to determine the validity of cord blood ige for predicting atopy at 6 years of age. logistic regression models were applied to assess the association between cord blood ige and atopy at 6 years of age. results: cord blood ige levels was significantly associated with total serum ige level at 6 years of age (r=.314, p<.001). the cord blood ige levels in atopic children aged 6 years (meanaesd, 1.61ae6.2 ku/l) were significantly higher than those in nonatopic children (0.36ae0.94 ku/l) (p<.001). the area under the receiveroperating characteristic (roc) curve of cord blood ige for predicting atopy at 6 years of age was 0.702. the sensitivity, specificity, and positive and negative predictive values of cord blood at the optimal cutoff of 0.34 ku/l on the roc curve for predicting atopy were 50.9%, 88.1%, 92.1%, and 39.8%, respectively. higher cord blood ige levels (≥0.34 ku/l) was associated with a higher likelihood of atopy at 6 years of age (or=7.66; 95% ci: 2.81-20.90; p<.001). our results indicate that cord blood ige is a potential predictor of atopy at school age, with an optimal cutoff of 0.34 ku/l. bogomolov a vinnitsa national pirogov memorial medical university, vinnitsa, ukraine introduction: allergen sensitization is being diagnosed by commonly available methods in clinical practice-skin prick tests (spts) and specific immunoglobulin e test (sige). recently, a new thermographic (th) method for the assessment of spt was developed, and it was demonstrated that the th measurements of forearm temperature distribution during spt, supported by a mathematical model, offer a new quantification method of allergen-induced skin reactions. objectives: the aim of this study is a comprehensive comparison of the th method with spt and sige techniques. the group of patients who were participated in this study consist of 45 patients. among them were 24 patients (53.3%) with allergic rhinitis and 21 patient (46.7%) with asthma, 35.5% of them were men and 64.5% were women aged 18-53 years (mean age 38.3ae6.5 years). spt and sige testings were performed by the standard techniques. for th analyses, set of thermograms of both forearms were acquired after prick and analyzed with the use of developed software. all results were converted into categorized scale for comparison. after counting patients who were true positive (tp), true negative (tn), false positive (fp), and false negative (fn), the sensitivity, specificity, and accuracy were calculated according to the following formula using the results of spt as the standard; sensitivity=tp/(tp+fn), specificity=tn/(tn+fp), and efficacy=(tp+tn)/(tp+tn+fp+fn). the results showed high correlation coefficients between the methods equal to 0.73-0.97. the sensitivity and accuracy of the th assessment in respect of both the classical methods is at a good level (0.70-0.94). the acceptable level of specificity 0.60-0.88 was also achieved for the majority of allergic reactions. the best accordance was observed between th and sige results (r=.92), while th-spt was the most divergent pair r=.85. in case of particular allergens, the biggest correlation was 0.99, while the smallest value amounted to 0.76. the results of diagnostic indicators of thermographic measurement of skin reactivity in comparison with the classical methods of determining the sensitivity to allergens show the prospect of using the method in routine practice. the main advantages of this method are its higher measuring ability and objectivity, by which the possibility of making error in diagnosis is significantly reduced. introduction: chronic urticaria symptoms may be worsened by factors such as temperature, exercise, hormones and stress. a salicylate rich diet has been reported to worsen symptoms in these patients. the mechanism by which natural salicylates do this is unclear but, like aspirin, is thought to be due to their ability to interfere with the arachidonic pathway via cyclooxygenase inhibition. studies have shown that low dose aspirin increases serum il-3 levels in patients with antiphospholipid syndrome. il-3 is important in basophil and mast cell function, inducing mediator release and cd203c upregulation in the absence of ige stimuli. objectives: the gold standard for diagnosing salicylate exacerbated chronic urticaria is by challenge testing. there is no in vitro laboratory test approved for routine diagnosis. this study investigated whether il-3 levels are raised in patients with chronic urticaria and if these levels were affected by salicylate intake. we aimed to find an optimum method of measuring il-3 levels by comparing levels in serum and salivary samples. the quantikine human il-3 enzyme linked immunosorbent assay (elisa) was validated and used on both saliva and serum of patients with chronic urticaria and normal controls. this was a case control study of 19 medicated patients with chronic urticaria and 26 controls at university hospital southampton, to see whether there were any correlations with il-3, and degree of salicylate intake (based on a questionnaire). introduction: since the introduction of molecular components in allergy, a big challenge of allergy diagnostics is to connect clinical symptoms with optimal test use and correct interpretation of results. objectives: the aim of the study was to (1) develop an algorithm that would meet that need, and (2) to evaluate the effect of introduction of algorithm to clinical practice. the algorithm was developed which groups clinical symptoms into six categories: rhinoconjunctivitis/ asthma, oral allergy syndrome (oas), urticaria/angioedema, eczema, anaphylaxis, and a combination of symptoms and combines them with knowledge of possible allergen specificity. this information is combined with two basic allergen mixtures (panels), reflex testing of selected food molecular components and accompanied by interpretative comments. the introduction of our algorithm led to less inhalation screenings, more food screenings and an increase in the requested molecular components. the oas was seldom recognized or used as a symptom by specialists. the reduction in costs, by using the possibility that the disease presentation may be a consequence of an relatively not dangerous oas, was therefore not achieved. all pr-10 positive proteins in various allergen sources showed also positivity for birch antigen. the screening based on this algorithm has potential to enable clinicians/general practitioners with a tool to increase the pre-test probability of allergy for the most frequently occurring allergens. allergy diagnostics may be more efficient if pr-10 component of birch (r bet v 1) is included in early screening and can help in early recognition of oas. helbling a 2 department of otorhinolaryngology-head and neck surgery 0492 | clinical and immunological evolution of patients who failed milk-oral immunotherapy there is lack of evidence on evolution among failures. objectives: to analyze clinical and immunological evolution of patients who failed milk-oral immunotherapy. data were obtained from medical records of a cohort of 20 patients who failed moit in the past 10 years in hospital infantil universitario niño jesus 14(70%) patients failed during build-up phase [13(92%) due to adverse events (ae) and 1(8%) to family decision. 6 failed during maintenance phase: 3(50%) due to eosinophilic esophagitis, 1(16%) to family decision, 1 to psychiatric disorder and (range 5-1023). the most frequent aes were cutaneous and gastrointestinal symptoms. 10/20 (50%) patients underwent a second moit and was successful in 5. the second moit was performed between 2 and 9 years after the first one. there was no statistical differences between specific ige(ku/l) levels at baseline and 12 months after the moit end portugal introduction: fish allergy is common in countries where consumption is high. parvalbumins present in fish muscle are the major allergens. allergy to multiple fish species is caused by parvalbuminspecific cross-reactive ige. cross-reactivity with parvalbumin from baltic cod retrospective study of patients with fish allergy followed in our immunoallergology department. fish tolerance acquisition was evaluated by oral food challenge. statistical analysis was performed using spss version 23 (descriptive statistics, student test results: 81 pts were included (55 male, 26 female), 62 children and 19 adults (age 14ae9 years). 63(78%) had previous history of rhinitis, 35(43%) of asthma and 54(67%) of eczema age of first contact with fish averaged 8.9ae4.0 months (min4, max36) and the possible types of contact were: oral in 78(96%), cutaneous in 22(27%) and inhalation of cooking fish vapours age of first clinical manifestation (excluding the 4 pts who developed allergy in adulthood) was at 22ae25 months (min4, max132) the clinical manifestation of the reaction was: angioedema/urticaria 58(72%), gastrointestinal symptoms 28(35%), eczema 27(33%), respiratory symptoms 19(23%), oral allergy syndrome 10 (12%), cardiovascular symptoms 2 (2%) age at the first immunoallergology out-patient clinic consult averaged 7ae9 years (min 0.4, max 48) and time from first symptom to first thermo-fisher) was evaluated before and after acquisition of tolerance to at least 1 fish. before tolerance, sige (ku/l) averaged 21 roc curve (area under curve 0.854) showed that, for gad c 1 105 ku/l, pts had a sensitivity of 90.2% and specificity of 62.5% that they would have a negative oral food challenge to a fish an sige<0.635 ku/l had sensitivity of 98% of a negative challenge 34 ku/l had specificity of 92.9% of a positive challenge. conclusions: fish allergy is a common allergy in early childhood however, acquisition of tolerance is possible. rgad c 1 appears to be a good marker for fish tolerance and could help allergologists as to when start testing for fish tolerance key: cord-019347-tj3ye1mx authors: nan title: abstract book date: 2010-02-19 journal: ann allergy asthma immunol doi: 10.1016/s1081-1206(10)61294-x sha: doc_id: 19347 cord_uid: tj3ye1mx nan introduction: the effect of anti ige has been described as a function of complexing free ige to reduce mast cell implantation and consequent reduction of mast cell degranulation upon exposure to antigen. theoretically, as total free ige drops below 10 ng/ml, improvement occurs as free and cell bound ige equilibrate and allergic reactions subside. initial observations ( togias a et al. j allergy clin immunol. 1998 ;101:s171)suggested that prick skin tests consistently reached their low point at 98 days with significant reduction in size. laynadier (leynadier f, doudou o, gaouar h, le gros v, bourdeix i, guyomarch-cocco l, trunet p : effect of omalizumab in health care workers with occupational latex allergy.j allergy clin immunol 2004;113:360-1) noted some reduction in skin testing in sixty percent of patients treated over a six month period with monoclonal antiige. but clinicians since approval of the drug in 2002 have noted that even in the presence of good clinical response to asthma, skin test reactivity is still obvious, and in many cases unchanged. methods: following the suggestions for standard clinical follow up by lanier and marshall ( annals may 2003) , routine skin prick skin testing was completed after informed consent on 24 patients at onset of anti-ige therapy, and repeated at 6-7 months. in all instances were skin tests done and photographed in a standard manner. in a few cases, skin tests were repeated on patients receiving anti ige for as long as five years. results: photographic evidence will be presented. in 22 of 24 patients on current therapy, prick skin testing remained at an almost identical photographic level to the baseline analysis, but there was a correlation between the patients with the lowest serum ige and the likelihood of apparent reduction. there was no correlation to reduction of skin testing and clinical response to anti ige since all 24 patients had experience significant quality of life improvements. conclusion: anti ige has variable effects on reducing prick skin testing, with a greater likely hood associated with low or extremely low initial total ige levels. skin testing is more sensitive for detection of allergen-specific ige than is immunoassay for allergen-specific ige. for some assay methods, the qualitative cutoff of 0.35 ku/l is inappropriately high. this study was conducted in order to determine whether a particular assay system can be used to measure lower levels of allergen-specific ige. the pharmacia unicap system was studied. all reagents were purchased from the manufacturer, and the study was approved by a local human assurance committee. to determine background of the calibration curve, the fluorescent unit (fu) response of 6 replicates of assay diluent measured with an anti-ige solid phase was determined. the background responses of 7 arbitrarily selected allergen solid phases (oak, timothy and short ragweed pollen; cat; peanut; yellow jacket venom; penicillin g) were also measured. lower detection limits (lld) were calculated using the mean background measurement + 3 standard deviations (sd). to examine linearity of a low-range calibration curve, 1:2 dilutions to extinction were made, starting with the 3.5 ku/l calibrator. the mean background of the anti-ige solid phase was 15.4 fu, sd 2.7 and coefficient of variation (cv) of 18%; the lld was 24. this lld corresponded to a level of approximately 0.01 ku/l of ige. the lld of the allergen solid phases ranged from 17.2 fu (yellow jacket venom) to 71.6 fu (short ragweed); this corresponded to about 0.08 ku/l ige. the low level dilution curve exhibited parallelism with a curve constructed using a zero (diluent) calibrator as a 7th point in the assay's reference curve. a low level method is capable of measuring specific ige levels lower than the manufacturer's 0.35 ku/l cutoff. this would seem to be particularly important in research applications, and in the analysis of certain highrisk allergens. the clinical significance of very low levels of specific ige in the serum warrants study. allergists/immunologists are often consulted on patients with rashes or recurrent infections. the differential diagnosis can comprise a variety of disorders, some of which are rare syndromes that require early diagnosis and specific management. a 3 mo old wm developed persistent rash and worsening eczema. later, he had recurrent severe skin infections, skin abscesses, recurrent sinusitis, and chronic otitis media that required multiple placement of tympanostomy tubes, yet had a persistent tympanic membrane perforation. recurrent wheezing was noted from 3-7 yr of age. he had several episodes of pneumonia since 3 yr of age affecting different lobes. he failed to shed the primary teeth and had history of periodontitis and oral thrush. he developed scoliosis and multiple fractures of the upper extremities and ribs. at 12 yr he had staphylococcal bacteremia and osteomyelitis of the acetabulum. in spite of antibiotics prophylaxis, he continued to have recurrent skin infections and lymphadenitis. laboratory evaluation revealed eosinophilia (up to 3138/mm3), normal levels of igg, iga, igm & igg subclasses, except for decreased igg2 (51 mg/dl). he had protective levels of anti s. pneumoniae and h. influenzae, but low anti-tetanus and anti-diphtheria titers. at 4 yr, total ige level was 42, 500 iu/ml which supported the diagnosis of hyper ige (hie) syndrome; it decreased to 197 iu/ml by 12 yr. rast was positive to hd mite, cat, dog, egg, milk, and pollens. flow cytomerty, nbt and phagocytic index were normal; ch50 was low (66 mg/dl). dexa scan showed osteopenia. chest x-ray showed bilateral infiltrate, atelectasis and scoliosis of the thoracic spine. during his hospitalization at 13 yr, his skin was fair, lichenified with widespread maculopapular erythematous rash. the palms and fingers showed open cracks and pustules, but no weeping lesions. in addition to coarse facial features, his face was eczematous. conclusion: hie syndrome is an autosomal dominant disorder that mimics atopic dermatitis but has severe course, multiple infections, and several complications. although a markedly elevated total ige level introduction: mannose-binding lectin (mbl) is a serum protein in the lectin complement pathway. it is important in innate immunity, and is thought to be particularly relevant in young children during the development of adaptive immunity. deficiency in mbl has been reported in population-based studies as a risk factor in children for infection and hospitalization. additionally, age-dependent variability of mbl has been previously noted. this study evaluates the prevalence of mbl deficiency in children with established recurrent infection who were referred for evaluation of immunodeficiency. method: we prospectively evaluated mbl status of children referred for recurrent infection. serum was collected from october 2002 to september 2003. children with known primary or secondary immunodeficiencies were excluded. mbl analysis was performed by standardized elisa using mbl oligomer assays. we performed chart and laboratory review for comorbid diagnoses, quantitative immunoglobulin levels and subclasses, and complement function with ch50 and ah50. results: two-hundred thirty five children were evaluated. mean age was 4.5 years (range 0.08-17 years). mean mbl was 1780 ng/ml (range 17-4806 ng/ml). thirty-one of 235 children (13.1%) were mbl deficient, levels <200, and among this group the mean mbl level was 61.3 ng/ml (range 17-163 ng/ml). mean age in this group was 3.6 years (range 0.3-16 years). of the children with mbl deficiency, 13 (5.1%) children had levels <50. the m:f ratio of children with abnormal mbl levels was 1.08. linear regression analysis showed no correlation of mbl level with age. comorbid diagnoses were variable, including asthma, allergy, and atopic dermatitis. none of the children had symptoms compatible with connective tissue disease. no child with an abnormal mbl level was found to have significant deficiency of igg, iga, or igm. several children had low igg4, which were within normal physiologic range. no other concomitant complement pathway disorders were detected. conclusions: our study did not reveal any correlation between mbl level and age. in children with recurrent infections, mbl deficiency was approximately twice the estimated rate of the general population. contrary to previous studies, no other significant immunologic disorders were identified. therefore, mbl deficiency alone is a risk factor for infection in children. t.b. fausnight * , hershey, pa. introduction: the incidence of perioperative anaphylaxis is estimated to be between 1 in 10, 000 and 1 in 20, 000 procedures. approximately 60% of cases of perioperative anaphylaxis are attributed to neuromuscular agents. very little information is reported in the literature regarding pediatric perioperative anaphylaxis. i describe a pediatric patient with suspected perioperative anaphylaxis to rocuronium. methods: a 10 year-old girl with a history of sacral agenesis and neurogenic bladder was scheduled to have bladder augmentation surgery. the patient was taken to a latex-free operating room. during induction of general anesthesia, she was found to be difficult to ventilate. she also became hypotensive. examination of the patient revealed urticaria on her right arm. she was given epinephrine, diphenhydramine, and dexamethasone. the procedure was aborted. the reaction was believed to be from either rocuronium or propofol. results: because of the high incidence of anaphylaxis to neuromuscular agents, allergy skin testing was performed for rocuronium, vecuronium, and succinylcholine. the patient had negative percutaneous skin tests (1:10) for rocuronium, vecuronium, and succinylcholine. she had a negative intradermal skin test to rocuronium at the 1:1000 dilution. she had a positive intradermal skin test to rocuronium at the 1:100 dilution. she had negative intradermal skin tests to both vecuronium and succinylcholine at the 1:1000, 1:100, and 1:10 dilutions. she underwent surgery 2 weeks after skin testing. she received a test dose of vecuronium and had no reaction. she received 3 doses of vecuronium and multiple doses of morphine without any adverse reactions. propofol was avoided. the surgery was completed without difficulty conclusions: this case illustrates the usefulness of skin testing for neuromuscular agents in a pediatric patient. introduction: extrapulmonary pneumocystis jiroveci infection is rare in non-hiv infected individuals and, to our knowledge, it has not been reported before in a patient with good's syndrome. we report a case of extrapulmonary pneumocystis in a patient with good's syndrome. case report: a 44-year-old african american male patient with a history of good's syndrome presented with left flank pain of 3 months duration. the pain was constant and associated with night sweats, fever, and chills. furthermore, the patient also reported a 20-pound weight loss. on exam, patient was found to have multiple hypopigmented areas over his abdomen and left lower extremity, bitemporal wasting, sunken eyeballs, and oral thrush. the patient was also found to have left costovertebral angle tenderness with a palpable solid fixed mass along the left mid axillary line overlying the splenic area. computedtomography (ct) scan of the chest and abdomen showed a 2.2 x 2.9 cm soft tissue mass at the left lateral aspect of the t11 vertebral body and 7.0 x 5.2 cm soft tissue parasplenic mass. the parasplenic mass involved the inferior anterior aspect of the left 11th and 12th ribs (see figure) . the giemsastained biopsy of the parasplenic mass revealed pneumocystis jiroveci and was confirmed using immunohistochemical stain with monoclonal antipnumocystis antibodies. the patient's symptoms of night sweats and loss of appetite improved within 48 hours following initiation of trimethoprim-sulfamethoxazole therapy. a ct of the chest and abdomen, repeated six months post treatment, confirmed the resolution of both the paravertebral and the parasplenic masses. conclusion: to our knowledge, this is the first case of extrapulmonary pneumocystis presenting in a patient with good's syndrome. although it is rare, extrapulmonary pneumocystis should be considered in the differential diagnosis of patients with good's syndrome and chest or abdominal mass. introduction: t cells are regulated by cellular interactions with the environment during development. they play a critical role in the regulation and development of autoimmune diseases. we report inflammatory myositis in a 10-year-old caucasian female with primary t cell-deficiency since infancy. methods: at nine months of age, our patient developed lymphoid interstitial pneumonitis. immunologic evaluation revealed isolated t-cell deficiency. during the first 3 years of life, she had failure to thrive, recurrent sinusitis, oral candidiasis, fungal skin infections, and pseudomonas pneumonia. at 5 years, autoimmune conditions, characterized by a purpuric rash over the nose; face and exposure area of elbows; knees and fingers; raynaud's phenomenon; and nasal septum perforation, developed. inflammatory markers were persistently elevated and autoantibodies detected. by age 9, she developed proximal muscle weakness with distal joint contractures. dry gangrene of the fingers from a thrombotic incident occurred. results: serial immunologic evaluation revealed low cd4 9-36%, # 153-335 (normal 36-61%, # 900-2860 cell/mm3), low cd8 5-23%, #142-237 (normal 16-34%, # 630-1910 cell/mm3) , decreased lymphocyte transformation to antigens but appropriate to mitogens. igg 1320-2560 (normal 667-1179 mg/dl); iga 470-780 (normal 79-169 mg/dl), and igm 215-340, (normal 40-90 mg/dl) with appropriate antibody responses to vaccine antigens. bone marrow and thymus biopsies were normal. further evaluation was not consistent with known primary or secondary immunodeficiencies. several skin biopsies revealed nonspecific dermatitis without vasculitis. mri of lower extremities showed abnormal signals involving bilateral muscles of thighs and calves. muscle biopsy revealed inflammatory myositis with plasma cell predominance, inconsistent with dermatomyositis or polymyositis. aldolase 8-10 iu/l (< 5), crp 8-16 mg/dl (< 0.5), esr 50-70 (< 20), rf 1:1280 (< 1:40) and type ii collagen ab 26-35 ei/ml (< 20) . ana, anca and ace were within normal range. antibodies for myositis and myositis related-antibodies were negative. diagnosis of nonspecific plasma-cell inflammatory myositis was made. a trial of monthly ivig 2 gm/kg resulted in clinical improvement. conclusion: this novel plasma cell myositis occurring in a child with primary t cell deficiency underscores the role t cells play in the development of autoimmune diseases. introduction the incidence of hypersensitivity reactions (hr) is increased in patients treated with multiple courses of carboplatin. the purposes of this investigation were to evaluate the effectiveness of a 6-hour, 12-step desensitization protocol and to characterize the immune mechanism of carboplatin hr. methods we analyzed ten consecutive patients over a two year period with documented hr to carboplatin who required continued treatment with a platinum agent. the patients were treated with carboplatin using a 6-hour, 12-step desensitization protocol. skin tests were performed on five patients. results ten patients successfully completed 35 planned courses of desensitizations to carboplatin, 31 of which were without reactions. four patients had symptoms during their first (n=3) and third (n=1) desensitizations but tolerated the re-administration of infusions without further reactions. for subsequent courses, the protocol was modified for two patients who had extracutaneous symptoms during desensitization and was unchanged for the patient who had mild urticaria. these three patients tolerated subsequent courses of desensitizations without reactions. the fourth patient with symptoms during desensitization no longer required carboplatin. of the five patients who were skin tested to carboplatin, four had positive wheal and flare reactions. in one patient, the skin test response to carboplatin became negative after desensitization. conclusions the 6-hour, 12-step desensitization protocol is safe and effective for treating patients with carboplatin hr. positive skin tests to carboplatin suggest a mast cell/ige-mediated mechanism. conversion of the positive skin test to a negative response after desensitization supports antigen-specific mast cell desensitization. hypothesis: there is an association between food allergies and acid reflux in atopic adults study design: a retrospective chart review of 60 patients was conducted. 30 people who tested positive and 30 people who tested negative for food allergy were included. the prevalence of gastroesophageal reflux disease (gerd) in the total group and each of the study arms was compared to population prevalence. methods: results of 70 allergen specific ige tests (pharmacia immunocap, nj) run for food allergies were reviewed to help locate charts of 60 atopic subjects, 30 with positive, and 30 with negative food allergy results. we reviewed charts for history of heartburn and acid regurgitation or the diagnosis of gerd, laryngopharyngeal reflux (lpr) or peptic ulcer disease (pud). population prevalence (19.8%; ci 17.7-21.9) of acid reflux was estimated from a historical comparison that studied adults in a similar geographical location. results: in the food allergy positive group, 26.7% of the subjects (95% ci 11.8-41.6) had either a history of heartburn and/or a diagnosis of gerd, lpr or pud. in the food allergy negative group, 40% (95% ci 25.1-54) had acid related disorders. in the total study group of atopic subjects, the prevalence of heartburn, gerd, lpr or pud was 33.34% ). on chi square analysis, the prevalence of acid reflux disorders was significantly higher in the total study group when compared with population prevalence (p=0.013). the prevalence of acid reflux disorders between the food allergy study group and in the population shows no significant difference (p=0.41). the prevalence of acid reflux disorders was significantly higher in the food allergy negative group when compared with the prevalence in the population (p=0.003). there was no significant difference in the prevalence of acid reflux disorders between the two study groups with and without food allergy (p = 0.27). conclusions: the prevalence of acid reflux disorders was higher in people with food allergy when compared to the population, but missed statistical significance. patients without food allergy had a significantly higher prevalence of acid reflux disorders compared to the population. atopic individuals have a statistically significant higher prevalence of acid reflux disorders, but there is no statistically significant difference between atopics with and without food allergy. abstract background: analysis of dispensing patterns of injectable epinephrine offers a method to study the characteristics of school children with allergic or anaphylactic reactions. objective: to analyze the demographics of children prescribed injectable epinephrine in massachusetts school districts with diverse racial and ethnic enrollment patterns. methods: school nurses in 44 schools (grades pk-12) enrolling 21, 870 students recorded the characteristics of students prescribed injectable epinephrine including the number and racial mix of students in each school, student age, grade level, race, sex, and allergic disorder requiring epinephrine. surveyed school districts were two predominately white (98%) suburban districts enrolling 5855 students and one urban area with a minority population of 60% enrolling 16, 020 students. the use of epinephrine for peanut allergy was analyzed in detail. results: a total of 181 of 21, 875 (0.83%) students in three school systems were dispensed injectable epinephrine. males outnumbered females (110 to 71). whites outnumbered non-whites 153 to 28. two thirds (n=116) of children dispensed epinephrine had peanut allergy. the second most common allergy was stinging insect allergy (n=34). the rate of dispensed epinephrine for peanut allergy was lowest in the urban school district (0.30%) versus the two suburban districts, 1.1% and 1.26% respectively. whites with peanut allergy outnumbered nonwhites 99 to 19. males outnumbered females 69 to 49. the lowest rate of prescribed injectable epinephrine for peanut allergy in all three school districts was found in 9612 non-white school children-0.17%. eighty-nine of 118 (75%) school children with peanut allergy were enrolled in grades pk through 5. there were twice as many white versus non-white (32 to 16) school children in the urban system with prescribed injectable epinephrine for peanut allergy. only eight (.11%) of 7209 hispanic and asian students in the were dispensed injectable epinephrine for peanut allergy. conclusions: this is the first study to suggest that there may be a racial disparity in the prevalence of childhood peanut allergy. one possible explanation for this disparity is that varied feeding practices in minority infants and children may induce a state of tolerance and lead to a lower incidence of peanut allergy. f.i. hsu * , h.j. burstein, m.c. castells, boston, ma. introduction: trastuzumab is a humanized igg1 kappa monoclonal antibody specific for human epidermal growth factor receptor 2 protein, her2, used in the treatment of her2/neu positive breast cancer. we present the first report of desensitization to trastuzumab in a patient with an ige-mediated reaction to trastuzumab and documented igg-anti-igg1 human antibodies. meth-ods: a 37 year old woman with metastatic invasive ductal breast cancer (er/pr positive, her-2 strongly positive), unresponsive to conventional therapy, presented with an anaphylactic reaction to trastuzumab and was evaluated for rapid desensitization by skin testing and serum specific igg antibodies. the patient had previously received trastuzumab. results: the anaphylactic reaction to trastuzumab consisted of diffuse erythema, urticaria, respiratory distress and laryngeal edema. premedication with steroids, h1 and h2 blockade, and slow infusion did not prevent a subsequent reaction. skin prick testing with trastuzumab (21mg/ml) was positive with 2 negative controls, confirming an ige-mediated mechanism. igg anti-human igg1 antibodies (haha) to trastuzumab were confirmed by elisa. the patient was desensitized to trastuzumab 2 mg/kg with an intravenous protocol that started at 0.5 mcg/h, and increased in rate every 15 minutes until a final rate of 30 mg/h, for a total infusion time of 6 to 8 hours. premedication included diphenhydramine, prednisone, famotidine, and montelukast. desensitization was confirmed by negative skin prick and intradermal tests (2 mg/ml and 21 mg/ml), with positive histamine control. the patient tolerated a total of 10 weekly doses of trastuzumab 2 mg/kg. intradermal skin testing prior to her 5th and 10th courses showed reactivity, indicating resensitization. serum levels of tratuzumab were undetectable at 1 week after desensitization. conclusion: allergic reactions to trastuzumab are rare but can include anaphylaxis. in patients with documented haha and/or ige-mediated reactions to trastuzumab and clinical symptoms of type i/mast cell mediator-related symptoms, desensitization can allow continued administration of this treatment by providing tolerance. the clinical effectiveness of desensitizations in patients with ige and haha antibodies remains to be defined. in contrast to reports in the medical literature, details of the medical aspects were limited. there were 2 attacks on infants bringing the total to 3 reported infant attacks to date. two of the 3 infants suffered long term morbidity and 1 died. like those reported in the medical literature, the majority of adults were in long term care facilities, although 2 were in hospitals. overall, 6 of the 20 individuals stung died within one week of stings. no significant medical consequences of stings were reported in 6 of 10 of the newspaper reports as opposed to 2 of 10 reports in the medical literature. conclusion: our data suggest that increasing numbers of fire ant attacks are occurring in medical facilities, where chronically ill, frequently immobile patients come in contact with foraging ants. unattended infants in private homes in fire ant endemic areas also appear at risk. the factors that determine why individuals are stung and the severity of injury after attacks remain uncertain. the presence of fire ants inside health care facilities and homes is a harbinger for fire ant attacks of disabled or infant occupants. we hypothesize that morbidity is determined by the number of stings, the condition of the patient and the type of treatment administered. purpose: to determine if gender confers a risk for positive penicillin (pcn) skin test. method: rates of positive pcn skin tests, according to gender, were determined in patients with a history of pcn allergy undergoing an allergy pre-operative evaluation from june 2002 to june 2004. during this period, 19, 429 patients were seen in the pre-operative evaluation clinic in which 1921 had a history of pcn allergy and comprise our study population. a univariate logistic regression analysis was employed to calculate the odds ratio (or) and the 95% confidence interval (ci) for gender differences in the rates of positive pcn skin test and a multivariate logistic regression analysis was used to adjust for age and history of multiple drug allergies. p-value of 0.05 or less was considered statistically significant. results: of the 1921 patients, 1759 underwent skin testing for pcn, 157 patients did not, and 5 charts were not available for review. the mean age of the study group was 60 years. sixtyfour (3.6%) patients had a positive skin test to pcn. of these, 53 (83%) were females and 11 (17%) were males (or 3.6, 95% ci 1.9-7.2, p = 0.0001). of those with a negative/equivocal pcn skin test, 960 (57%) were females versus 720 (43%) males. in a multivariate logistic regression analysis adjusted for age and history of multiple drug allergies, female gender again was more likely to have a positive pcn skin test (or 4.7, 95% ci 2.3-10.5 p < 0.0001). 157 patients did not undergo pcn skin testing, 62 (40%) were male and 95 (60%) were female. conclusion: this is the first report showing that a greater risk for a positive skin test to pcn exists in association with female gender. age and a history of multiple drug allergies are unlikely to be confounding factors to the observed gender risk. further studies are needed to identify other possible confounding factors and/or mechanisms that can explain this risk. a. fiocchi 1* , p.a. restani 1 , s. cucchiara 2 , g. lombardi 3 , g. magazzu' 4 , g.l. marseglia 5 , k. pittschieler 6 , s. tripodi 2 , r. troncone 7 , a. vierucci 8 , 1. milan, italy; 2. roma, italy; 3. pescara, italy; 4. messina, italy; 5. pavia, italy; 6. bolzano, italy; 7. napoli, italy; 8. firenze, italy. background: cow milk substitutes for children allergic to cow milk proteins (cmp) include soy-based formula and cow s milk hydrolysates. neither can rule out a sensitisation risk. objective: prospective assessment of clinical tolerance to a rice-based hydrolysate formula by children allergic to cow milk proteins (cmp) who consume rice openly. patients and methods: ninety-seven children aged 4 to 136 months with immediate reactions to cow milk confirmed during dbpcfc were assessed for clinical tolerance to cow milk by spt with whole milk, -lactalbumin (ala), -lactoglobulin (blg), -and -casein ( -cas, -cas) (sigma chemical, st. louis, mo). whole milk, ala, blg and cas specific ige determinations were performed using cap test (pharmacia, uppsala, sweden) . similarly, sensitisation to rice and hrf were investigated by spt and cap test. patients sera were investigated by immunoblotting for cmp, rice and hrf (heinz-plada, milan, italy). dbpcfc was carried our with 24 g rhf powder masked in neocate tm (equivalent to 180 ml reconstituted formula). results: spt: all patients were positive to cow s milk and/or cmp fractions (>3 mm wheal diameter). ige determinations gave positive results with cow milk and/or cmp fractions (72/84 patients tested), rice (16/81) and with hrf (2/85). immunoblots (n=87) were positive for -cas (n=46), -cas (n=34), ala (n=39), blg (n=34) and bovine serum albumin (n=52). similarly, although patients sera largely recognized rice (78/87), only one weakly reacted with rhf. challenge with rhf was negative in all cases. conclusions: we conclude that, despite their frequent sensitisation to rice, children with cma tolerate both rice and rhf clinically. hydrolyzed rice formulas may thus represent an alternative protein source for children with cma. r.c. cartwright * , w.k. dolen, augusta, ga. introduction: conventional treatment of human seminal fluid allergy includes abstinence, barrier protection, or subcutaneous immunotherapy with fractionated seminal fluid. treatment using local intravaginal desensitization with unfractionated seminal fluid has recently been described, but experience with this desensitization method is still limited and little has been reported as to its long-term results. methods: a 30-year-old woman with a history of allergic rhinitis and asthma experienced anaphylaxis following her first unprotected intercourse since the birth of her first child. ige-mediated sensitization was demonstrated through the use of specific ige testing (pharmacia cap system) and skin prick testing using undiluted seminal fluid obtained from the patient's husband. after approval from the human assurance committee, the patient underwent rush intravaginal desensitization with steadily increasing concentrations of seminal fluid, beginning with a 1:10, 000 v/v concen-tration. results: her specific ige level to human seminal fluid was 0.26 ku/l. skin prick testing was positive with a wheal of 10 mm diameter with pseudopods and a flare of 25 mm diameter. desensitization was successful and the patient tolerated local application of whole semen without significant reaction. following desensitization, the patient reported that she and her husband engaged in unprotected intercourse without local or systemic symptoms. over the last year since the desensitization, she has not experienced further anaphylaxis, but she has developed local symptoms if her exposure to seminal fluid was delayed past 5 days. the longest time period between exposures has been 2 weeks. she became pregnant 5 months ago and has not had any pregnancy complications. conclusions: local intravaginal desensitization was a safe and effective treatment for human seminal fluid allergy in this patient. a delay in seminal fluid exposure greater than 5 days was associated with the return of symptoms emphasizing the need for frequent seminal fluid exposure to maintain desensitization. l. terracciano, t. sarratud, a. fiocchi * , p. restani, s. guerci, milan, italy. background kiwifruit allergy in children has been seldom reported and the reactions observed are usually mild. anaphylaxis has not been described. we document the case of an infant who developed anaphylacic symptoms within minutes of his mother eating two kiwifruits and initiating breastfeeding. case history in his fourth month, the boy was admitted into an emergency department with dysphonia, breathing difficulties, generalised urticaria and angioedema of the lips and face. this episode was treated as an anaphylactic reaction with epinephrine, chlorpheniramine and hydrocortisone sodium succinate administered via a percutaneous catheter and symptomatic control was achieved within 30 minutes. after 15 days a second anaphylactic episode of similar severity occurred under the same circumstances. neither episode required critical care. the boy presented two months later for clinical evaluation in our paediatric allergy unit. skin prick tests (spt) were positive only with egg white and yolk while negative to cow s milk (and protein fractions), beef, chicken, pork, codfish, rice, wheat, soybean, maize, potato, carrot, tomato, bean, pea, celery, peanut, dermatophagoides pteronyssinus and d. farinae, grass and banana. spt with kiwifruit was specifically ordered because exquisite contact was suspected, and induced a positive wheal (>3 mm diameter). positive specific ige determinations (cap-feia from pharmacia, sweden) with kiwifruit (0.71 ku/l), cat dander (1.97 ku/l) and egg white (1.97 ku/l) were returned but determinations with other inhalant and food allergens were all below the cut-off point of 0.35 ku/l and total ige levels were 155 ku/l. strict avoidance of kiwifruit by the breastfeeding mother proved effective and nothing untoward happened in the intervening year. currently aged 2.5 years, the boy is free from food-related symptoms. prick-byprick tests with native allergens and spt carried out with commercial extracts of allergens associated in the literature with kiwifruit allergy were all negative. comment there are no reports of immediate reactions to kiwifruit under two years. in this case, severe reactions via breastmilk in an infant monosensitised to kiwifruit indicate that nursing may represent a hidden source of exposure. in older children monosensitisation without prior sensitisation to pollen has been described as the major risk associated with severity of symptoms. m. sikora * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: treacher-collins syndrome (tcs) is an autosomal dominant disorder with an abnormality of craniofacial development during early embryogenesis. there is a known relationship between new bone formation and development of lymphocytes and cytokines. the association of tcs and humoral immunodeficiency has not yet been reported. we present a novel case of a 12 year-old caucasian female patient with tcs and common variable immunodeficiency. methods: our patient presented with midface hypoplasia, micrognathia, microtia, conductive hearing loss and cleft palate with a history of recurrent upper and lower respiratory infections. patient had a 10-year history of chronic sinusitis, recurrent otitis media and pneumoniae which resulted in bronchiectasis. haemophilus influenza and staphylococcus aureus were persistently isolated from bronchial fluids. laboratory work-up for immunodeficiency was initiated. results: immunoglobulin analysis revealed low igg 450 (528-2190 mg/dl); low iga 42 (44-441mg/dl); igm 65 (48-226mg/dl); igg 1 354 (165-1440 mg/dl); low igg 2 59 (71-460 mg/dl); igg 3 85 (28-125 mg/dl); and low igg 4 <8.1 (2-143 mg/dl). patient had no detectable response to protein-derived vaccines (diphtheria and tetanus) and to polysaccharide-derived vaccines (pneumococcal) at baseline and at 4-6 weeks after immunization. t and b lymphocyte enumeration, ch50, ah50, and mannose-binding lectin were all within normal limits. laboratory findings were consistent with the diagnosis of common variable immunodeficiency. patient began receiving monthly doses of 550 mg/kg/dose of intravenous immunoglobulin resulting in clinical improvement. our patient no longer requires antibiotic therapy for her respiratory infections; pulmonary function has improved and bronchiectasis resolved 6 months after initiation of ivig. conclusion: our finding shows that tcs can be associated with common variable immunodeficiency which suggests a link between skeletal dysplasia and immunodeficiency. a.s. hartel * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: streptococcus pneumoniae is the most common cause of invasive bacterial infection in humans. however, incidence of s. pneumoniae infections in healthy adolescents is low (5/100, 000 per year). mannose-binding lectin (mbl) is a c-type lectin which plays a central role in the innate immune response by activating the classical complement pathway and acting as an opsonin by binding c1q receptors. several studies have demonstrated an association between invasive bacterial infections, including s. pneumoniae and a homozygous mutation of the mbl gene. however, this association has not previously been described in patients with the heterozygous mutation. methods: a 13-year-old caucasian female presented with a second episode of meningitis over a 4-year span. streptococcus pneumoniae was isolated from peripheral blood cultures on both occasions. lumbar puncture revealed wbc 22, 600; 6% bands; 83% pmns; glucose 3 mg/dl, protein 329 mg/dl; these results consistent with bacterial meningitis. extensive evaluation for predisposing causes revealed benign arnold-chiari type1 malformation. further immunological evaluation was initiated. results: evaluation revealed igg 867 mg/dl (normal 528-2190); iga 67 (44-441); igm 181 (48-226), and normal igg subclasses. antibody responses to diphtheria and tetanus vaccines were adequate. antibodies response to pneumococcal vaccine given 4 years prior were protective to all 10 common serotype tests (>1.4 mcg/ml). lymphocyte subset analysis was within normal range. howell-jolly bodies were not detected from peripheral blood smear. evaluation for secondary immunodeficiency was negative, including hiv antibody by elisa. complement analysis showed ch50 88 u/ml (65-95); ah50 71% (66-129%), and markedly low mbl of 74 ng/ml (>1000). genetic analysis of her mbl revealed heterozygous mutation in codon 54 and mutations in two promoter regions (homozygous mutation on h/l variants and heterozygous mutation on p/q variants). conclusion: heterozygous mutation of mbl codon when associated with mutation of promoter regions can result in severe impairment of mbl protein production, and may lead to increased susceptibility to invasive bacterial infections and meningitis. rationale: patients with similar symptoms may have allergic, non-allergic, or mixed rhinitis triggers and can differentially respond to distinct medications. we assessed st in our clinic patient population to characterize factors that influence appropriate diagnosis and treatment of rhinitis type. methods: we used a validated commercial questionnaire and chart review of 230 patients seen in an academic allergy clinic, to assess the number of allergic vs. irritant st and demographic and historical factors (including pharmacotherapy) associated with differences in symptoms. results: the population (n=189: 138 female, 51 male) consisted of individuals with a mixed rhinitis history. women had higher st scores than men, including: total scores [10.44+/-0.51 vs. 7.20+/-0.65, p=0.0001 (unpaired t-test)]: allergen scores (4.56+/-0.30 vs. 3.51+/-0.37, p=0.0055); and irritant scores (5.58+/-0.29 vs. 3.69+/-0.41, p=0.0003). further, patients treated with both azelastine (az) and intranasal steroids (ins) had lower st scores than patients treated with either alone (total st: az 10.06+/-0.94, ins 10.3+/-0.97, both 8.0+/-0.88, p=0.0348; allergen st: az 4.69+/-0.54, ins 5.05+/-0.37, both 3.11+/-0.50, p=0.0416; irritant st: no significant difference). conclusions: female patients have significantly higher symptom scores; total, allergic and irritant. rhinitis monotherapy (ins or az) is minimally effective in reducing st but is more effective when used in combination. these data demonstrate rhinitis population heterogeneity and address differential responsiveness to similar medications. increased response to combined drug therapy support the heterogeneous pathophysiology of mixed rhinitis features and may relate to a combination of multiple aeroallergen and air pollution exposure in the houston area. introduction: interaction between eye & nose warrants attention with regard to the propagation and treatment of allergic reactions. the role of topical therapy for rhinitis and conjunctivitis is becoming more widely considered and questions of therapeutic route have been raised. purpose: to elucidate the anatomic and pharmacokinetic interactions of conjunctival & nasal mucosa leading to more rational selection of routes of medication administration. methods:our studies have investigated the effect of ocularly instilled allergen inducing signs and symptoms of rhinoconjunctivitis. 1 study compared effects of allergen administered via conjunctival allergen challenge (cac) or nasal allergen challenge (nac) and analyzed tear & nasal secretions for ecp & tryptase. studies have also used the ability of the cac model to induce rhinitis signs & symptoms to evaluate the relative effects of medication routes: 1) ocular v. nasal spray v. systemic; 2) ocular + nasal spray v. systemic + nasal spray; 3) ocular v. placebo. results: the nac/cac study revealed that, following cac (n=34), significant ocular and nasal signs & symptoms were noted; following nac (n=39), only nasal symptoms were clinically significant. nasal symptom scores between cac & nac differed significantly at 1 timepoint, representing lag in allergen & mediator movement from eye to nose. measurable levels of ecp & tryptase were found in tears and nasal secretions for cac, but only in nasal secretions (with exception of 1 subject) for nac. in cac studies: 1) ocular therapy exhibited greater efficacy in ocular itching relief (n=73;p<0.05) and was not significantly different from nasal or systemic therapy in nasal symptom relief. 2) eyedrop+nasal spray combination exhibited significantly greater prevention of overall rhinoconjunctivitis signs and symptoms than nasal+systemic therapy (n=80). 3) ocular therapy offered greater protection from nasal signs & symptoms compared to placebo (n=32;p<0.05). conclusion: nac and cac results support the unidirectional flow from eye to nose, the ability of cac to yield nasal symptoms, and the efficacy of topical therapy. tearing, due to inflammation of the inferior turbinate would be the only ocular symptom resulting from nasal challenge. these results offer insight to the nature of the connection between ocular and nasal mucosa and the efficacy of varied medication administration routes for management of rhinoconjunctivitis symptoms. introduction: asthma disease management programs frequently target high utilizers because they are responsible for a large amount of asthma costs. once identified, such "frequent fliers" usually are offered interventions including case management. programs using this approach usually demonstrate reductions in utilization. though the interventions may cause this decline, it could also be due to regression to the mean (rtm) which is a tendency for outliers to become more like the mean over time. in this study we measured rtm in a medicaid hmo asthma population to determine whether targeted case management is effective independent of this phenomenon. we hypothesized that directed case management provides additional utilization reduction beyond rtm. methods: a weighted asthma utilization score was determined quarterly for members of an hmo with asthma from 2000 to 2004. rtm was measured by determining how many patients were persistent high utilizers quarterly for 1 year after baseline. to determine the effect of utilization-directed case management, the number of frequent fliers at baseline for each quarter also was determined. results: a total of 296 asthma frequent fliers were identified on january 1, 2001. by september 1, 2001 only 15 of these individuals continued to be frequent fliers. similar decreases in utilization were seen for frequent fliers identified at the beginning of each quarter of 2001. the mean decrease in the number of frequent fliers is shown in the table. this represents a substantial regression to the mean. the total number of high utilizers at baseline decreased by 27% after implementation of utilization-directed case management in 2002 independent of regression to the mean. this also represented a decrease from 1.6% of health plan members with asthma to 0.6% by the start of 2004 suggesting that the decline is not a result of diminishing health plan membership. the benefit appears to be the result of early intervention with members before they become frequent fliers. conclusions: utilization-directed case management can reduce overall asthma utilization by preventing members from becoming high utilizers at an early stage. programs that claim to intervene with plan members who already are high utilizers are likely to be taking advantage of regression to the mean. studies indicate a high incidence of asthma(as) among school-aged children. with the prevalence increasing, significant numbers remain unidentified. they experience morbidity, including school absenteeism, which may be preventable, in part, by adherence to national asthma guidelines. we implemented a pilot study to detect as, as control and initiation of appropriate health care among 7th grade students in a suburban population. the study was coordinated with the middle school staff and the local county health department. the screen parameters included: student questionnaires, peak flows, exercise with peak flow assessment (frast)2, and spirometry as indicated. environmental tobacco smoke (ets) was recorded. results: 196 students screened. 131 no as history and negative screen (d). 31 as history and negative screen (e). 5 as history and positive screen (a). 23 no as history with suggestive written screen and negative screen on exercise (b). 6 no as history and positive screen (c). ets in groups a, b, c: 40%, 32%, 60%. ets in groups d, e: 23%, 16%. individual student results were mailed home with medical follow-up recommended for a positive screen. parents of the 34 children who failed the questionnaire or exercise screen (groups a, b, c) were phoned at a 6-12 wk interval. no student in-group a or b had medical follow-up. 2(33%) students in group c had medical follow-up. conclusion: this as screen of 7th grade students identified 6(3%) as having significant, undetected as. 5(14%) with known as had uncontrolled as at the time of screen. 23(11.7%) students with strong suspicion of as based on questionnaire had an acceptable exercise screen. only 2 of the 34 children with a screen suggestive of as or uncontrolled as had medical follow-up. ets was increased in the homes of students with a positive screen and remains a serious health issue. school screening for as has merit, but mail and phone follow-up was insufficient to intervene or initiate acceptable as treatment. references 1. redline s. et. al. development and validation of school-based asthma and allergy screening instruments for parents and students. ann allergy asthma immunol. 2003; 90: 516-528 2. tsanakas.j.n., et al. free running asthma screening test. arch diseases in childhood.1988; 63:261-265 3. american college of allergy, asthma, and clinical immunology screening test ages (8-14) acaai.org. introduction. some laboratory evidence suggests that desloratadine is effective in inhibiting of inflammatory mediators, which play an important role not only in allergic but also in virally induced inflammation. the purpose of this study was to assess its efficacy in acute bronchiolitis developed in young children suffering from concomitant atopic dermatitis (ad). meth-ods. participants were 34 young boys and gilrs aged 18-36 who suffered from acute bronchiolitis as established by wheezing, rhinitis and fever. all patients also had concomitant ad as established by hanifin and rafka criteria. patients were allocated to receive syrup formulation of desloratadine (erius, schering plough) 1, 25 mg/day for 5 days (active group n=17) or no desloratadine treatment (control group n=17) using quota allocation system. we calculated physical global symptom score (combination of cough, wheezing, chest retractions, nasal flaring, blocked nose, runny nose, sore throat -0-5 scale) and respiratory distress assessment instrument (rdai) to examine the patient at baseline and on day 5th after therapy was initiated, day of normalization of body temperature, respiratory rate, heart beat rate, and use of albuterol. results. both group of patients were comparable on age, gender, family history of asthma, time of onset of the acute respiratory illness, extent of medication taken prior to entering the study, global symptom score and rdai index. all children were evenly treated with oxygen, oral theophylline (10 mg/kg/day) and adequately rehydrated. on day 5th global symptom score of patients receiving desloratadine was 2, 51â±0, 51 vs 3, 42â±0, 62 in control group (p=0.035). on day 5th it was also significant difference between active and control groups on rdai index (4, 44â±1, 24 vs 7, 23â±2, 30; p=0.046) especially for significant drop in wheezing score in active group. day when respiratory/heart rate normalized, temperature returned to normal, use of albuterol did not differ significantly in these groups. conclusions. our preliminary study is the first to show that desloratadine is an effective agent in viral lower respiratory tract infections of young children suffering from ad. it encourages further gcp trials to explore action of desloratadine in infantile bronchiolitis and concomitant ad. h.j. su * , w.t. lin, p.j. tsai, c.y. huang, p.c. wu, tainan, taiwan. increasing prevalence of childhood asthma has been observed across the world, and found to be associated with, partly, indoor pollution, including bioaerosol exposure. meanwhile, adequate ventilation is shown to be effective in diluting most indoor air pollutants, while only limited data are available addressing directly how the ventilation rate is implicated with childhood respiratory symptoms. this study aimed to examine the concentration distribution of selected indoor air pollutants, including bioaerosols, in domestic environment, and further to assess the effects of ventilation rate, characterized by a co2 trace gas concentration decay method, on concentration variations of the above-mentioned air pollutants. study subjects were chosen from a prior city-wide questionnaire survey based on positive response to inquiry for physician-diagnosed asthmatic status and wheezing symptoms in the past 12 months. environmental assessments, including ventilation and air quality measurements, were conducted twice, 1 in early winter and the other on early summer. respiratory health diary and pefr (peak expiratory flow rate) were recorded for 1 week concurrent with the sampling activity. increasing ventilation rate is statistically associated with decreasing indoor concentrations of co2 and tvocs. after adjustment for sex, age, and selected housing characteristics, the or between tvocs concentrations and reporting cough of study children is 9.47, and 12.84 between co2 and nasal congestion. the or between indoor bacterial concentration and the morning pefr less 80% is 10.98 in the similar multivariate logistic regression for data collected from winter study. in summer, the only significant relationship is between ventilation rate and the morning pefr less 80% of study children, or= 0.17, in a multivariate logistic regression. this study has identified less reporting of childhood respiratory symptoms, especially for coughing and the morning pefr less 80% are associated with increasing ventilation rate, and higher levels of indoor air pollution appear to be present with greater frequency of the above symptoms. this study suggest quantitatively that proper management of ventilation efficiency may be beneficial for the control of childhood respiratory illnesses. *adjusted for: sex, age, environmental tobacco exposure, use of incense and air conditioner **:p<0.05 ns:no statistical significance with whole model test background: moderate-to-severe allergic asthma can have a substantial impact on a patient's asthma-related quality of life (arql). in addition to asthma symptoms, allergic rhinitis, rhinosinusitis and other related comorbidities are often apparent in patients with more severe disease making it difficult to treat. despite guideline-consistent care, many patients still experience variability in asthma control signaling an unmet need within this population. omalizumab (xolairâ®) has recently demonstrated clinical efficacy and safety in treating asthma. objective: the aim of this paper is to summarize the arql outcomes associated with omalizumab therapy in moderate-to-severe allergic asthma. methods: we performed a systematic review of arql data from the clinical study reports and published clinical trials on omalizumab. arql was measured by the juniper-asthma quality of life questionnaire (aqlq). results: statistically significant results for arql endpoints consistently favored omalizumab over placebo. the magnitude of the changes in arql were consistently aligned with clinical endpoints. moderate to large effect sizes in the omalizumab groups were maintained throughout the 28-week clinical trial program and during the 24-week double-blind extension phase. however, the placebo groups also experienced within-group improvements and moderate effect sizes. a meta-analysis indicated a 1.6 to 2.0 fold increase in large (>1.0 point) improvements in overall aqlq scores in the omalizumab-treated group compared with placebo during the stabilization and steroid-reduction phases of the clinical trials. conclusions: the consistently positive impact of omalizumab on arql outcomes during the clinical trial program provides evidence of its value as an adjunct therapy in patients with moderate-to-severe allergic asthma. significant differences and large effect sizes were observed despite the fact that the control group received active, guideline-consistent treatment producing a substantial placebo effect. improvements were observed in overall, symptom, activity, emotional and environmental dimensions of the aqlq indicating that omalizumab produced benefits in arql in patients with moderate-to-severe allergic asthma. background: omalizumab, a monoclonal anti-ige antibody, significantly improves asthma-related quality of life (arql) for patients with moderatesevere allergic asthma who express symptoms despite moderate-high inhaled corticosteroids (ics) doses. mean scores can mask underlying variability in arql outcomes. this investigation examined variability in outcomes to elucidate the specific impact of omalizumab treatment. methods: aqlq data (n=948) from two randomized, double-blind, placebo-controlled clinical trials were pooled to assess underlying variability in the mean scores and to identify key drivers of arql treatment-effect differences (juniper-asthma quality of life questionnaire (aqlq)) between omalizumab and placebo (active control) patients. results: correlations between aqlq and other clinical outcomes were low to moderate at best (r=0.14 to r=0.60). aqlq assessment captures patient benefit that supplements clinical outcome measures. across all component items of the aqlq patients receiving omalizumab improved more than patients receiving placebo (active control) (p<0.05). omalizumab patients reported the greatest improvement for reducing waking with symptoms in the morning (symptoms domain: 2.06 vs. 1.50; p<0.001), limitations in all activities done (activities domain: 1.18 vs. 0.68; p<0.001), the fear of not having medication available (emotions domain: 0.99 vs. 0.60; p<0.01), and symptoms from being exposed to dust (environment domain: 1.31 vs. 0.88; p<0.001), compared to placebo (active control) patients. conclusion: arql assessment provides complementary and non-overlapping information on clinical benefit that is distinct from other clinical outcome measures. examination of underlying variability in aqlq mean scores and item-level response extend previously published results on omalizumab treatment effect by showing that aggregate arql improvements for omalizumab patients are strongly influenced by symptom and activity improvement. a. brimer 1 , k. malhi, c. adams, c. dinakar, kansas city, mo. introduction: the desire to belong to a group is a very powerful motivator and is exceptionally strong in the adolescent population. asthma is a disease that makes people feel different. this perception may impinge on patient adherence with medication regimens. we hypothesize that belonging to a club where every member has asthma may encourage identification of the adolescent asthmatic with their peers, and mitigate the perception of being different. objectives: (1) to investigate the factors that make the asthmatic adolescent feel different (2) to explore the hypothesis that group activities, such as an asthma club, would help adolescent asthmatics feel less different. methods: as part of an ongoing survey, children with asthma between the ages of 8-18 years were offered an anonymous questionnaire in the primary care and adolescent clinics at our hospital. the questionnaire included both multiple-choice and open-ended questions designed to explore the feelings of the respondents. the responses were numerically tallied and reported as percentages. results: at the present time, 31 surveys out of a proposed 100 have been completed. one third of the youth with asthma answering the survey had negative feelings regarding their asthma. nearly forty percent of the respondents reported that their diagnosis made them feel different from their healthy peers. forty-five percent responded that they have felt restricted or excluded from school activities, athletics, and clubs due to their asthma. over one-third of them feel uncomfortable taking their inhaler in front of their friends. most respondents (93.6%) indicated that they enjoy group activities. the majority of respondents (89.7%) rated playing sports as their favorite group activity. conclusion: almost forty percent of asthmatic youth surveyed indicated that having asthma made them feel different and resulted in restriction/exclusion from school activities, athletics, and clubs. an overwhelming majority expressed a preference for participation in group activities, particularly recreational sports. this social preference towards group activities may be incorporated into an intervention, such as an asthma club, to help asthmatic youth adjust to the disease and its treatment regimen. introduction: airway hyperresponsiveness (ahr) is an exaggerated narrowing of the airways in response to stimuli, such as allergens, histamine, and cold air. ahr is a characteristic feature of asthma linked to chronic airway inflammation. phosphodiesterase 4 (pde4) is an enzyme found in key inflammatory cells involved in the pathophysiology of asthma. inhibitors of pde4 prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde4 inhibitor, which has shown anti-inflammatory activity in vitro and in vivo. this study examined the effect of a single dose of roflumilast on changes in ahr following allergen-induced asthmatic reactions in patients with mild asthma. methods: this double-blind, randomized, crossover study consisted of 2 treatment periods separated by a 2-to 5-week washout period. a total of 13 patients (forced expiratory volume in one second [fev 1 ] 70% predicted) who were hyperresponsive to histamine (provocative concentration causing a 20% drop in fev 1 [pc 20 fev 1 ] 16 mg/ml) were randomized to receive a single dose of oral roflumilast 1000î¼g or placebo on day 1 of each treatment period followed by an allergen challenge 60 min after medication. histamine provocation was performed before and 24 h after intake of study drug. results: there was no change in fev 1 60 min after roflumilast administration, suggesting the absence of direct or acute bronchodilation. allergen challenge elicited early and late asthmatic reactions that were attenuated by a single dose of roflumilast 1000î¼g. the histamine pc 20 fev 1 in patients treated with roflumilast decreased to a lesser extent than in those patients treated with placebo. the change in pc 20 fev 1 from baseline after challenge was 2.51 â± 2.95 mg/ml (mean â± sd) with placebo and 1.23 â± 2.75 mg/ml with roflumilast. the magnitude of the change in pc 20 fev 1 was statistically significantly different between the placebo and roflumilast treatment groups (p=0.002). thus, roflumilast decreased the development of ahr by approximately 1.1 doubling-dilutions. conclusions: a single dose of oral roflumilast 1000î¼g attenuated allergen-induced ahr. these data provide further evidence that roflumilast may provide anti-inflammatory activity in vivo and may be an effective treatment for patients with asthma. introduction for the past 7 years we have been tracking pediatric asthma admissions and evaluations at the huntington memorial hospital. during the fall and winter months (oct-march) from 1996 to 2002, we noted a 1.6 x increase in the number of asthma admissions and evaluations compared with the spring and summer (april -september; 4, 993 patient encoun-annals of allergy, asthma & immunology ters in 7 years). we have analyzed potential causes for this increase. diesel particulate was estimated in 1998-9, and a 2.5-fold increase in the fall versus spring was found in burbank, a city adjacent to pasadena. pollutant particles from the combustion of fossil fuels may act as immuno-adjuvants to allergen exposure as has been demonstrated experimentally in mice and in human nasal exposure studies. methods computerized analysis of asthma admissions and evaluations were calculated according to established codes for acute and chronic reactive airways disease. infectious diseases in patients were analyzed by standard asthma questionnaire. also, pollen and mold counts, as well as diesel particulates and meteorological conditions were studied. results similar numbers of viral infections occurred in the fall of 2001 and spring of 2002. among the most prevalent pollens and molds are chinese elm pollen (sept -oct) weed pollens (july -dec), and a newly recognized aureobasidium mold (nov -march). pollen grains can fragment and release respirablesized debris that are loaded with allergens (taylor et al 2002 (taylor et al , 2004 . the conidia of aureobasidium are also of respirable size and were identified by sequence analysis. fine particulate air pollution (pm2.5), containing diesel particles, is increased in the fall and winter in southern california. con-clusions the incidence of asthma outbreaks may vary with air pollution levels in the immediate environment. pollen fragments and particles from fossil fuel combustion can deposit in similar regions of the lower airways. rainfall increases in the fall and winter and this coincides with increased molds and aureobasidium. aureobasidium was recently discovered in high concentrations in pasadena, is known to be allergenic and could be a factor in increased asthma. a mixture of pollens and molds and fine combustion particles may be relevant to this increased incidence of asthma in the fall and winter months in pasadena. background we have previously noted that tree and ragweed pollen grains can be airborne for most if not all daily periods during their respective seasons (aaaai, 2003) , (acaai, 2003) . because grass levels are lower than those of trees & weeds (aaaai / nab), we chose a longer daily interval to examine (six hours) that we had for trees (one hour) and ragweed (three hours). methods twenty-four hour microscope slide samples were collected using a burkard 7 day air sampler from 05/01/04 to 06/30/04. the slides were examined @ 100 x along a single longitudinal traverse. the presence or absence of grass pollen was noted per six-hour segment (six successive fields). results the presence of airborne grass pollen during the 4 daily segments was sparse the first two weeks of may. it gradually increased during the next 10 days, and then was detected during most of the daily segments through to the end of june. # ammophila arenaria (aa) is a highly resilient grass with habitat in europe, north america, australia, new zealand, south africa and the mediterranean, used predominantly for dune stabilization. patients with atopic diseases including allergic reactions to pollen are transferred to coastal regions in order to minimize pollen exposure. in spite of the presence of aa pollens, patients experience allergy relief at the coast. our study examines the contradiction between the presence of strong grass allergens and the absence of allergic symptoms in atopic patients, and whether allergic cross-reactions among different types of grass pollen include aa pollen. 9 adult patients presenting symptoms of grass pollen allergy underwent prick testing and rast testing to grass pollen mix and extracted aa pollen. 4 subjects showed positive results in prick and rast testing to aa extracts and were subsequently tested via rhinomanometry for reactions to aa using prick test solutions. 2 subjects showed positive reactions to prick tests for aa extract and grass pollen mix, but did not show specific antibodies. all other sera showed elevated specific ige levels, with specific reactions on 8 protein bands of aa. in sera incubated with grass pollen extract, almost all specific bands previously detected with aa were now inhibited. 3 patients with high levels of total and specific ige to aa showed weak bands after inhibition, demonstrating the allergenicity of aa. comparing data from coastal and mainland weather stations in june and july from 1961 to 1990, coastal wind speeds average 6.6 to 6.9 m/s while inland wind speeds average only 3.6 to 3.7 m/s. high wind speeds likely dilute pollen concentrations. based on findings of an inverse relationship between wind speed and pollen concentration in the dispersion of ragweed pollen, we hypothesize that concentrations of aa pollens may be similarly influenced. no sensitized patient reported allergic symptoms in coastal areas inhabited by aa plants, indicating that under natural conditions, either the plant modifies its pollen allergenicity or that environmental conditions including salt aerosols, wind patterns, topography or light exposure cause the modification. as such patterns are likely to become more dramatic as the effects of global climate change transform the natural environment, these findings may also become relevant for other grass allergy types. asthma is the most common chronic inflammatory disorders of the airways with increased prevalence in the past decade. it is characterized by airway obstruction, airway inflammation and airway hyperresponsiveness (ahr) to non-specific stimuli. in this study, we examined the effect of a novel class of molecule, ocid1001, in inhibiting antigen-induced early and late allergic response (ear and lar), ahr, and airway eosinophilia in mouse and guinea pig models of asthma. pulmonary functions were measured in conscious unrestrained animals by whole-body plethysmography. animals were sensitized with ovalbumin (ova; 20mg, intraperitoneally) with 2mg alum followed by treatment with ocid1001 (120mg/kg, i.p. twice daily for 10 days). after the last dose, animals were challenged with ovalbumin. pulmonary functions were recorded for ear and lar and 24 hrs later for ahr. this was followed by bronchoalveolar lavage, blood and lung tissue collection. treatment with ocid1001 (120mg/kg) significantly attenuated lar in ova-sensitized and challenged mice or guinea pigs with no effect on ear. ahr to methacholine in mice and to histamine in guinea pigs were prevented by treatment with ocid1001. ocid1001 attenuated the rise in total number of inflammatory cells in the lung and almost ablated the rise in bal eosinophilia in the lung due to antigen sensitization and challenge. effect of ocid1001 on pulmonary functions and airway inflammation in ova-sensitized and challenged mice were comparable to that of dexamethasone in both models of asthma. these data suggest that ocid1001prevents the underlying pathophysiological changes in allergic airway inflammation and therefore could prove beneficial in the treatment of bronchial asthma. ma; 2. madison, wi; 3. portland, or; 4. milwaukee, wi; 5. normal, il; 6. denver, co; 7. los angeles, ca; 8. fremont, ca. introduction. daclizumab (zenapaxâ®), a humanized monoclonal antibody directed against the il-2 receptor chain (cd25), is approved for prevention of renal allograft rejection and is under evaluation for treatment of asthma. daclizumab inhibits activation of human t lymphocytes by blocking il2induced proliferation, and by reducing production of th2-and th1-associated cytokines. we recently reported that daclizumab improved pulmonary function in a phase ii trial of patients with moderate to severe chronic persistent asthma (jaci, 2004, 113 (2):s286). we now report additional data from this trial on the possible role of daclizumab as an anti-inflammatory agent that affects asthma outcomes. methods. 116 non-smoking asthmatics age 18-70 with baseline fev1 50-80% predicted despite use of 1200 mcg daily inhaled triamcinolone (taa) or equivalent were enrolled in a randomized, multi-center, double-blind, placebo-controlled trial. patients were randomized (3:1) to i.v. daclizumab (2 mg/kg followed by 1 mg/kg every 2 weeks) or placebo added to stable dose taa. starting at week 12, patients underwent 25% reduction of taa every 2 weeks while continuing study drug to week 20. results. patients on daclizumab demonstrated a prolonged time to exacerbation requiring systemic steroid rescue compared to placebo patients (p=0.024). exacerbation rates were reduced in the daclizumab group compared to the placebo group for the 20-week steroid-stable and steroid-taper phases (11.6% vs. 28.6%, p=0.09). patients on daclizumab demonstrated decreased peripheral eosinophil counts from baseline to week 20 (-30â±20 /mm 3 vs. placebo +60â±30 /mm 3 , p=0.004). daclizumab-treated patients with elevated baseline serum eosinophil cationic protein (secp) had a significant reduction in secp from baseline to day 56 compared to placebo patients (p<0.01). peripheral eosinophils decreased significantly in daclizumab patients who had no asthma exacerbations compared to an increase in daclizumab-treated patients with at least one exacerbation (p=0.032). conclusions. daclizumab reduces time to and frequency of exacerbation in treated asthmatics. the mechanisms of this effect remain to be fully elucidated, but initial findings suggest that associated reductions in circulating eosinophil and eosinophil products may play a role in these therapeutic effects. hae is a genetic deficiency causing a decrease in c1 esterase inhibitor levels. it is a rare condition (approximate prevalence 1:10000 to 1:50000 individuals). it is manifest by acute attacks of swelling which can involve the larynx (a potentially life threatening condition), the gi tract (causing a syndrome similar to an acute abdominal catastrophe) or the skin and soft tissue of the patient including the limbs, face and external genitalia. there is no approved therapy for acute attacks in the usa. pathogenesis of this potentially fatal condition is thought due to excessive activity of plasma kallikrein. dx-88 is a specific and highly active (ki 40 pm) recombinant inhibitor of human plasma kallikrein undergoing evaluation in hae and cardiopulmonary bypass. it is an animal free product. a double blind, randomised (5:1 drug to placebo) placebo controlled dose ascending study of dx-88 in acute attacks of hae was run in the usa and the european union. four dose groups of 12 patients were to be included in the study. the doses were 5, 10, 20 and 40 mg/m2. the primary outcome variables were proportion of patients achieving a significant clinical response within 4 hours of administration of therapy, and safety. secondary endpoints included site response, dose response, and median time to significant response by site and dose group. dx-88 met its primary endpoint; 72% of dx-88 patients had a significant improvement within 4 hours, (placebo response rate 25%, difference 47% p= 0.0169). patients receiving dx-88 responded in a median time of 70 minutes. there was no difference in proportions of cases that responded within 4 hours between the three anatomical sites. time to significant response did not significantly differ between dose groups and anatomical sites. the safety profile was comparable for patients treated with dx-88 and placebo, in terms of saes and aes. in conclusion, dx-88 in this double blind study was shown to be statistically superior by 47% to placebo and to be at least as safe as placebo. the drug is effective at treating any hae site, including the larynx. dx-88 represents an important advance in the management of hae. ar is among the most common chronic childhood disorders, and is most effectively treated with intranasally inhaled glucocorticosteroids (ics). recent evidence suggests that intranasal ics therapy may suppress hpa axis function and decrease growth velocity. this study reports 1-year follow-up data on 24 children (12 female, 9 african american), aged 6 to 14 years (mean 10.4 years) at entry, enrolled in a long-term growth trial of intranasal taa for treatment of ar. primary measures included height velocity, bone mineral density (bmd), serum osteocalcin and salivary cortisol levels. all subjects followed their expected age-appropriate growth velocities. average growth velocities were 5.6 and 5.8 cm/year for girls and boys aged < 12 years, respectively, and 5.5 and 7.7 cm/year for girls and boys aged > 12 years, respectively. mean (+ std) bmd was 1.27 + 0.12 and 1.22 + 0.14 gm/cm2, mean serum osteocalcin levels were 89.1 + 25.5 and 114.5 + 32.7 ng/ml, and mean salivary cortisol levels were 16.7 + 8.0 and 11.5 + 6.5 nm/l at entry and 1-year follow-up, respectively. these results demonstrate no significant effect of one year of intranasal treatment with taa on growth velocity or hpa function in children with ar. 13 patients 6 males, 7 females ranging in age from 66 years to 12 years, received (o) in doses ranging from 2 to 17 injections over 4 to 34 weeks. patients were evaluated with symptoms scores, pulmonary function (pft), blood eosinophil count (bec), medication use, and allergy skin test. st were initially performed by prick and if negative, by intradermal (id) (1/1000 w/v) and if further negative by id (1/500 w/v). skin tests were performed immediately before and 20 minutes after the administration of o. there was no change in pft or bec. however there were significant reductions in symptom scores, including nocturnal asthma (<.0001), exercise tolerance (<.0001), sense of well being(<.0001). in addition, parenthetically there was a reduction in nasal symptoms (<.0001). there were also significant declines in medication use especially for albuterol (<.0001). st declined in all patients evaluated and dramatically in many. for several individual allergens st went from prick positive to id (1/500 w/v) negative. moreover st declined in all instances further, 20 minutes after the administration of o except for 2 patients. in addition to asthma one of the patients had allergic bronchopulmonary aspergillosis and another had allergic fungal sinusitis. three of the patients tested positive on prick test to mouse antigen and in each instance this became negative after administration of o with all 3 patients tolerating o without problem. we conclude: (1.) administration of o is associated with an improvement in symptoms and decreased use of medications (2.) in addition there is a prominent decline in st which is more marked 20 minutes after administration of o compared to immediately prior to administration the explanation of this finding is not apparent. (3.) o appears to be safe to administer to patients even if they demonstrate specific ige to mouse antigen by st a.p. baptist * , t.s. tang, j.l. baldwin, ann arbor, mi. introduction: academic medical institutions are under pressure to shorten or eliminate resident elective rotations due to federal work-hour restrictions. it is unknown if this will affect knowledge and referral patterns for resident and faculty physicians. the objective of this study was to examine the factors associated with resident and faculty perceived knowledge and referral patterns towards allergy/immunology (a/i). methods: a questionnaire was sent to 375 primary care physicians at one academic center. it addressed past history of a/i referrals, referral intentions for conditions that may be seen by allergists, and perceived a/i knowledge. independent variables included history of an a/i rotation, gender, department, years in training/practice, and history of referral to an allergist. results: 228 (61%) completed surveys were returned. using logistic regression with forward selection, we found in the resident physician cohort those with advanced years in training or history of an a/i rotation were more likely to have increased past history of referral to an allergist (or = 4.09, or = 3.81), increased referral intention for chronic sinusitis to an allergist (or = 3.51, or = 5.18), and increased perceived a/i knowledge (or = 2. . for the faculty physician cohort, those with a history of an a/i rotation were more likely to have an increased perceived knowledge about a/i (or = 5.64-6.18). in addition, pediatric faculty physicians were more likely to refer asthma (or = 5.62) and chronic eczema (or = 17.09) to an allergist than faculty from other departments. finally, faculty physicians with a past history of referral to an allergist were more likely to have refer asthma (or = 10.64) and allergic rhinitis (or = 9.78) to an allergist. conclusion: the factors associated with resident and faculty physician perceived knowledge, referral history, and referral intentions towards a/i differ. for residents, senior training level and a history of an a/i rotation appear most important. for faculty, history of an a/i rotation, pediatric department, and past history of referral to an allergist appear most important. given that a history of an a/i rotation may increase perceived knowledge and referral patterns towards a/i, eliminating a/i rotations in medical institutions may have important consequences for patients and the field of a/i. because recent anecdotal reports suggest that hbv may be an effective treatment for patients with multiple sclerosis (ms), there has been a movement of patients to zealous lay practitioners to receive multiple and repeated bee stings. since this practice has real risk of possible fatal allergic reactions as well as emotional and economic costs, properly conducted studies of safety and efficacy are needed. the purpose of the present phase i pilot study was to evaluate the safety of hbv extract in patients with pfms. a total of 9 evaluable bee venom non-allergic patients with pfms (21-55 years) were enrolled and were randomly divided into 4 groups, each receiving an increasing allergen dose immunization schedule for one year. hyperreactivity to hbv was evaluated by questionnaire, px and hematologic, metabolic and immunologic tests including skin tests. any possible beneficial responses to therapy were evaluated by questionnaire, functional neurologic tests (fnt) and changes in measurement of somatosensory-evoked potentials (seps) prior to and at the completion of the study. no serious adverse allergic reactions were observed in any of the 9 subjects even at the highest doses of bee venom therapy. although 4 of 9 subjects had worsening of neurologic symptoms during the course of bee venom therapy, requiring termination, this response could not be ascribed to side effects of the hbv or to a spontaneous worsening of the neurologic disease independent of treatment since there was no correlation of these events with the bee venom injections. of the remaining 5, 3 felt that the therapy was beneficial.there were no changes either in fnt or seps measured during the study. the present report represents the first controlled study evaluating the safety of hbv as a possible adjunctive treatment for multiple sclerosis. while this preliminary safety study suggests that administration of repeated injections of hbv in a step-up dosage regimen in appropriately selected non-hbv allergic patients with ms had no serious adverse allergic reactions, because of the small number of subjects studied, it does not permit conclusions regarding efficacy and therefore provides little evidence to support the use of hbv in the treatment of ms. much larger carefully conducted multi-center studies would be required to establish efficacy. i. finegold * , new york, ny. rush immunotherapy (rit) has benefits for inducing immunologic desensitization in shorter periods of time than conventional immunotherapy. however, there is an increased risk of systemic reactions utilizing accelerated schedules. in the past radiocontrast media reactions have been significantly reduced using a standardized protocol. a modification of this protocol was used prior to rit. the oral premedication consisted of 50 mgm prednisone 12 hours, 7 hours and 1 hour prior to rit, fexofenadine 180 mgm at 7 hours and again 1 hour prior to the procedure, and ranitidine 300 mgm, 7 hours prior to rit. patients tolerated the premedications well. a signed consent was obtained prior to rit. patients were desensitized in an office setting with appropriate therapy for anaphylaxis available without an indwelling intravenous line. injections generally began with 1/100 dilution of the anticipated maintenance solu-tions and were doubled every 20-30 minutes for about 2-3 hours and then the patients were observed for 1 hour or more prior to discharge. in this manner patients were desensitized in 2-3 half day sessions. the patient was injected again in 1 week, 2 weeks and then 4 weeks. doses were increased if they were not at a full maintenance dose. if reactions occurred this process was appropriately decreased. utilizing this technique 46 patients were treated. the average age was 35.5 years old (14-56 years of age) 72 % were males.72% of patients had allergic rhinitis, 25% asthma, 3% insect allergy. patients with complicated medical illnesses were excluded. nine patients had systemic reactions requiring an injection of epinephrine. among the symptoms experienced were wheezing, nasal congestion and flushing. no patient required a second injection of epinephrine, intravenous fluids, or hospitalization. the patient reaction rate was 21 % of patients treated or 9 in 1073 injections or 1% of all injections given during the rush protocol. these results are typical of the increased rate of reactions to rit. however, these systemics were mostly very mild and responded to therapy and in only one case was there a delayed 4 hour reaction. thus premedication while not preventing systemic reactions seemed to modify them to make rit in an office setting a practical and effective therapy. we have previously shown that oligonucleotides consisting a novel 3'-3'linked structure and synthetic immunostimulatory motif cpr (r is a synthetic purine moiety), referred to as second-generation immunomodulatory oligonucleotides (imos), induce potent th1 immune responses and prevent ovainduced allergic asthma in mouse models. in the present study, we examined local and systemic immune responses of imos following intranasal (i.n.) administration to naive mice. these studies showed that imos produce higher levels of serum and local il-12 compared with il-6. we next examined the ability of s.c. and i.n. administrated imos to reverse ova-induced th2 immune responses in a murine model of asthma. treatment of ova-sensitized and challenged mice with imos by either route of administration suppressed il-5 and il-13 levels with an increase in ifn-gamma secretion in spleen cell cultures and lung homogenates. imos decreased levels of serum ige and igg1 and induced higher levels of total and ova-specific igg2a titers in serum and balf. while both routes of imo delivery showed similar efficacy on serum and balf immunoglobulin levels, s.c. delivery resulted in stronger systemic effects on the spleen cell cytokine production and the i.n. route of administration produced stronger local effects on the lung cytokines. imos also decreased eosinophils in balf and suppressed inflammatory cell infiltration and goblet cell hyperplasia in lungs. these effects in lung were superior with i.n. administration of imo than did with s.c. administration. further studies to understand the effect of low multiple doses against a single higher dose of i.n. administered imos in naive mice suggest that low multiple doses induce strong th1 responses locally while the single higher dose produces higher systemic responses. these findings suggest that second-generation imos containing cpr dinucleotides potently reverse ova-induced th2 immune responses with strong th1 type cytokine induction in ova-sensitized and challenged mice and i.n. delivery is superior to s.c. delivery in reversing ovainduced airway inflammation and mucosal secretion. showed ait was medically inappropriate, lacked documentation of necessity for initiation or continuation and/or had strong contraindications in 12/18 (67%) of the reviewed records. method: we audited a convenience sample of our own records for documentation of necessity for (continuing) ait, using a checklist based on the oig report which included the following 6 criteria: an appropriate diagnosis; specific justification; exclusion of strong contraindications; signed, informed consent; a written physician order, and at least annual re-evaluation for continuing ait. results: the first 50 charts in our alphabetized file of 80 total ait charts were reviewed. the patients (21 m, 29 f) ranged in age from 9-63 yr (mean, 40 yr). the mean duration of ait was 2.3 yr (range, 0.25-12 yr). indications for ait included allergic rhinitis alone (68%) or with asthma (26%) or chronic sinusitis (2%), asthma alone (2%) and venom anaphylaxis (2%). all had initial documentation of necessity. seven charts (14%) had no written order to initiate ait. nine (18%) lacked a signed consent form. no strong contraindication was found. (peak flow documentation showed the asthma cases were well-controlled. three episodes of ait-induced anaphylaxis requiring epinephrine had occurred, but ait was subsequently resumed and well-tolerated.) seventeen (34%) charts had no documentation of re-evaluation during the preceding 6-12 months, including 3 with no documented re-evaluation during the previous 24 months or more, of ait. discontinuation of ait was "considered" for 3 patients after 1.5, 7, and 10 yr of ait, respectively, but all were still receiving maintenance doses. the estimated time for completing this review was 15-20 min per chart. inter-pretation: an internal chart review for adherence to ait practice parameters using a checklist such as ours can quickly and easily assess documentation for medicare reimbursement and patient safety. objective(s): immunotherapy is an accepted mode of treatment for children suffering from allergic rhinitis and allergic asthma. this study demonstrates that rapid allergen vaccination (rav) can be as safe as conventional allergen vaccination (cav) in children. rav may also improve patient adherence. study design: 148 pediatric patients, 1-18 years of age, diagnosed with allergic rhinitis and/or mild to severe asthma underwent rav over a 2 1/2 hour period in an office-based setting. all patients were premedicated with prednisone and h1 antagonists for 3 days prior to the procedure. patients were monitored for reactions during the procedure and continued on a cav schedule. adherence was reviewed subsequently. results: a total of 148 pediatric patients underwent rav utilizing a 2 1/2 hour protocol. of the 148 patients, 88 of them were male (59.5%) and 60 of them were female (40.5%). 143 (96.6%) of the patients had allergic rhinitis, 118 (79.7%) had asthma, and 23 (15.5%) had chronic sinusitis. during the procedure, 8 patients (5.4%) experienced systemic reaction, and none experienced true anaphylaxis. seven of the eight patients who suffered a systemic reaction were patients with asthma on inhaled corticosteroids, three of the eight patients were male (37.5%) and five of the eight were female (62.5%). every systemic reaction occurred within 15 minutes of the injection. treatment usually included one or a combination of the following: nebulized breathing treatment with albuterol, two sprays in each nostril of azelastine, and diphenydramine taken orally or intramuscularly. every patient that was treated was discharged within two hours, and no one required treatment with subcutaneous epinephrine, treatment for recurrent symptoms or hospitalization. all of the patients continued with a conventional allergen immunotherapy regimen following the rapid protocol to reach their maintenance dose. typically, 6 months of build-up period was saved. patients reached efficacious dosages almost immediately. adherence rates were 95.3%, 90.5%, and 79.7% at 3, 6, and 12 months respectively. conclusions: effective doses of allergen vaccine can be safely reached using a 2 1/2 hour protocol annals of allergy, asthma & immunology for children. advantages of rav over cav include improved adherence with almost immediate clinical efficacy, and decreased costs. introduction: studies involving allergen immunotherapy (ait) have furthered our understanding of cat allergen, proteases, and dust mite allergen. the impact of these data has not been assessed. objective: to evaluate ait prescribing trends over 12 years (1992) (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) focusing on new prescriptions before and after published data regarding specific prescribing recommendations. methods: a retrospective review of 38, 400 ait prescriptions from a centralized allergy and extract laboratory database was performed with respect to published literature on findings and recommendations regarding the ubiquitous nature of cat allergen, effective dosing of cat antigen, combining protease containing extracts with those susceptible to degradation, dust mite antigen dosing, and the use of house dust versus dust mite antigen. results: 1) in 1993, cat allergen was included in 10% of new allergy immunotherapy prescriptions reviewed; in 2003, it was included in 45% of new prescriptions, a statistically significant increase (p<0.00001). 2) over the past 11 years, the mean quantity of cat antigen included in new prescriptions has been unchanged at 1ml/prescription. only 5% of new prescriptions were written at the manufacturer recommended maintenance dose of 4ml, significantly less than those written below this level (p <0.00001). 3) there was no significant change in the percentage of extracts combining antigens with proteases with antigens susceptible to degradation. in 1992, 64% of prescriptions containing alternaria and/or cockroach antigen were mixed with one or more antigens susceptible to degradation; in 2003, 56% of these extracts were still being combined. 4) the mean volume of dust mite mix contained in these prescriptions was between 2-2.99 ml/10ml. 5) prescriptions containing dust mite rose from 20% in 1992 to 65% in 2003. the use of house dust was unchanged over the same period at 1.5% of prescriptions. conclusions: although the percentage of cat containing extracts has increased significantly, dosing of cat allergen has remained unchanged despite published literature recommending higher volumes. protease-containing allergen prescribing patterns have not significantly changed from [1996] [1997] [1998] [1999] [2000] [2001] [2002] [2003] young stage of life is a crucial period for aeroallergen sensitization, considering the immaturity of the neonatal immune system which may lead to t-cell anergy or a deviation towards th2-type response in mice. the aim of this work was to evaluate the influence of oligodeoxynucleotides containing cpg motif (cpg-odn) on ovalbumin (ova) and blomia tropicalis (bt) immunization in early life compared to adult stage. three days old a/sn mice were immunized with ova in al(oh)3 and boosted on 10th and 30th day after immunization (dai) and bled on 37th dai. groups of mice received 4mg of cpg-odn or control-odn associated with ova on immunization and boost. some animals from the three groups (ova, ova+cpg, ova+co) were killed at 20 days old and the spleen was collected and prepared to culture. eight to 10 weeks old female a/sn mice were immunized with ova in al(oh)3, boosted on 14th dai and bled on 21th dai. groups of mice received 50mg of cpg-odn or control-odn associated with ova on immunization. animals from the three groups were challenged 3 months after immunization and bled 7 days later. similar protocols were performed using blomia tropicalis (bt) extract in the place of ova. neonate and adult co-administration of cpg-odn with ova or bt were able to significantly decrease specific ige antibody levels and increase igg2a production. moreover, cpg-odn decreased specific igg1 levels in the bt immunization. the co-administration of control-odn in neonates decreased anti-ova igg1 production. after ova-challenge 3 months later of adult immunization, a similar response was detected in the group that received cpg-odn associated with ova, which showed a decreased anti-ova ige and igg1 and enhanced igg2a levels. analysis of cell division of neonate lymphocytes by flow cytometry showed a decreased proliferation in ova+cpg mice group under ova stimulation. this effect was seen either in b cells and t cells. the results showed that immunization with both allergens, ova and bt, associated with cpg-odn decreased the type i hypersensitivity response. the pattern of antibody production suggests th1-type response induced by cpg-odn, and the establishment of memory th1 response. this findings may imply that the use of cpg-odn in early life seems to be beneficial as an strategy to modulate or to prevent the development of allergic diseases. n. horne * , a. capetandes, m. frieri, east meadow, ny. introduction: it has been shown that dust mite allergens can affect the functioning of airway epithelial cells (winton et. al. br j pharm 124:1048 , 1998 . previous experiments showed ca549 aggregate in the presence of dermatophagoides pteronyssinus (dp) (capetandes et. al. am j clin path, 121:25, 2004) . it is hypothesized that epithelial damage is associated with airway remodeling characterized by fibroblast dysregulation. to evaluate the response of fibroblasts to damaged airway epithelial cells, the bioactivity of serum-free conditioned media from dp-treated ca549 cells (dpcm) was assayed with nhlf. methods: all experiments used insulin-transferrin-selenium supplemented dmem (its). dpcm (generated with ca549 treated with 300 au/ml dp; alk-abello) was added to 50% confluent nhlf for 24 hours at 37oc and 5% co2. its from cultured ca549 without dp (its cm) was added to 50% confluent nhlf (control). cell morphology and density were evaluated by microscopy and mtt assay, respectively. data were analyzed by anova followed by student-neuman-keuls (snk) at p<0.05 with power analysis. results: 50% confluent nhlf treated with dpcm showed decreased cell density (figure 1) , and increased aggregation relative to its cm or its alone. nhlf in its alone or with direct addition of 300 au/ml dp to its (dp its) showed no or weak aggregation. aggregated nhlf showed 100% viability and grew to confluence when subcultured to serum-supplemented media. conclusion: nhlf aggregation was greater, and cell density was lower with dpcm than with its, its cm, and dp its. this suggests that dp-treated ca549 cells release an unidentified factor or factors that contribute to nhlf aggregation and possible apoptosis. identification of these factors would increase the understanding of the fibroblast response to epithelial cell exposure to dp which may be involved in airway remodeling, a feature of chronic severe asthma. j.t. zimmermann * , y.c. huang, m. frieri, east meadow, ny. introduction: budesonide has been demonstrated to inhibit il-8, tgf and gm-csf in ragweed and dust-mite (dm) stimulated human alveolar epithelial cells (j allergy clin immunol 209:3a, 2002; ann allergy asthma immunology 90: p79, 2003) . rantes production and expression in dm and il-1 -stimulated a549 cells has recently been shown to be inhibited by budesonide (allergy asthma proc, in press 2004). histamine is known to influence immune response by regulating cytokine synthesis (allergy 47:024-1992) . in this study we examined the effect of budesonide in the presence of histamine on il-8 production and expression by a549 cells. methods: a549 pulmonary epithelial cells were cultured in dmem for 24 hours in 5% co2 in the presence of 1:20 of 10, 000 au/ml dm, 10 -6 m histamine and 10 -7 m budesonide. il-8 production was measured by a sensitive elisa and il-8 mrna was measured by qualitative rt-pcr using standardized primers for il-8 with a gapdh control. results: a549 cells were stimulated by dm (65-101 pg/ml) (p<0.01). budesonide alone decreased il-8 levels to 38 pg/ml (p<0.05), and in combination with histamine further decreased il-8 levels to 23 pg/ml (p<0.001). relative intensity of il-8 mrna expression was reduced 12-fold in dm-stimulated cells and 2-fold in control cells by budesonide. conclusion: budesonide in combination with histamine showed greater inhibition of il-8 production by a549 cells than budesonide alone possibly by increasing cell membrane permeability. c.r. oliveira * , a.e. fusaro, j.r. victor, e.a. futata, c.a. brito, a.j. duarte, m.n. sato, sã£o paulo, brazil. antigen-driven bystander suppression induced by oral tolerance could be an interesting approach in the allergy field, considering the high incidence of new allergens sensitization in atopic individuals. to address the influence of non-related allergen exposure on the type i hypersensitivity response to the mite blomia tropicalis (bt) or ovalbumin (ova) in mice and to verify oral tolerance effect in the bt/ova co-immunization model. groups of mice were immunized with bt extract and two weeks later submitted to ova-immunization, or first immunized with ova or co-injected with bt and ova. ova feeding was performed five days prior co-immunization. ige abs were estimated by means of passive cutaneous anaphylaxis reaction and specific ab and cytokines secretion by elisa. mice sensitized with bt and then exposed to ova developed an enhanced ige response to itself and to ova, but such response has not been observed when ova-immunization was prior to btimmunization. co-injection of bt and ova led to a dominant ige response toward ova over bt and vice-versa for the igg1 response. ova feeding prior co-immunization decreased ige, igg1 and igg2a ab levels against ova in parallel to a bystander suppression, which avoided the outcome of bt-sensitization. these mice showed increased ifn-?secretion levels induced by antigen-specific stimulus. furthermore, effectiveness of oral tolerance was also related with ova amounts employed in the co-immunization since ova feeding prior co-immunization with low amounts of ova led to inhibition of ige ab response to both allergens, whereas inhibition of specific and non-related antigen igg ab response was broken. the results evidenced that, depending on allergenic potential, new allergen exposure may exert an adjuvant effect on the primary sensitized allergen. the bystander effect to non-related allergen by oral tolerance should be an interesting mechanism to control new allerrationale. cd4 + cd25 + regulatory t cells from patients with atopic asthma undergo apoptosis when stimulated by specific allergen. antihistamines are used to control allergic inflammatory diseases, but their influence on treg cells is currently unknown. the present study investigates the influence of desloratadine (d) on apoptosis of cd4 + cd25 + regulatory t cells in atopic patients having dust mite induced allergic disease, including allergic asthma. methods. patients (n=6) with positive skin prick tests to house dust mite allergens and a clinical history of allergic upper and/or lower respiratory symptoms were treated with d 5mg (schering-plough, usa) once daily for 10 days. no patients used systemic corticosteroids, while theophylline and other medications were stopped at least 72 hours before blood collection. blood was sampled before and after treatment with d. the control group was comprised of 6 individuals without allergic respiratory symptoms and with negative skin prick-tests. peripheral blood mononuclear cells (pbmc) were isolated over a ficoll density gradient and stimulated by specific allergen (dermatophagoides farinae) and in a control series by phorbol myristate acetate (pma). pbmc were labeled with anti-cd4, cd25, cd95, and bcl-2 monoclonal antibodies. the annex-inv-propidium iodide (anv-pi) test was done. lymphocyte subpopulations and apoptosis were analyzed by flow cytometry. results. after treatment with d, atopic patients had no significant differences in the number of cd4 + cd25 + cells. during co-culturing of pbmc from patients treated with d with specific allergen a significant increase in cd4 + cd25 + cells was observed. simultaneously, treatment with d led to a significant increase in expression of the antiapoptotic protein bcl-2 in cd4 + cells. this data paralleled the decrease of cd95 expression on cd4 + cells. there was also a decrease in treg cells in the late stages of apoptosis (anv + pi + cells) in d treated patients. conclusions. the antihistamine preparation desloratadine prevented allergen-specific apoptosis of cd4 + cd25 + t regulatory cells in patients with atopic asthma. the type 1 histamine receptor may be involved in the regulation of apoptosis and/or survival of cd4 + cd25 + t cells. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: solar urticaria porphyrin corresponds to sun sensitivity to a 4000 a wavelengths and is due to disturbances of posphorin metabolism. photosensitivity can cause urticaria, erythema, polymorphic solar eruption and in more severe cases vesicles and bullae. photosensitivity was confirmed by light test. methods: protoporhyrin in rbc, uro and coproporphyrins in urines, copro and protoporhyrins in faeces and porphyrin precursors have been studied un all the cases of solar urticaria seen in the last few years. results: in 10 patients, 8 female, 2 males, a diagnosis of porphyria has been confirmed by laboratory methods. clinically 4 patients presented solar urticaria and 6 solar erythema or polymorphic solar eruption. 7 patients, 8 female, 2 males (21-54) presented also neuro visceral symptoms: abdominal pains (7) vomiting (4) asthenia (7) constipation (3) muscle pains and paresia (3) depression (2) anesthesic reactions (2). in 2 cases the symptoms were associated with anticonceptional drugs. the conjunction of clinical history with laboratory data has allowed to confirm the diagnosis of 2 cases of protoporphyria erytheropoietica, one triggered by anticonceptionals, 6 cases of coporporhyria hereditaria and 2 cases of porphyria variegata. this group comprises one case of erythropoietic protoporphyria induced by estrogens not previously reported. conclusions: research of porphyrins must be done in all the patients with solar urticaria and erythema. the incidence of sun sensitivity in mixed hepatic porphyriaalso presenting neuro-visceral symptoms which can be drug dependent suggests that porphyria study must be mandatory in suspected cases. a.r. narayan 1* , j. kaplan 1 , v. sirvan 1 , a. chandrasekaran 2 , c. goodwin 2 , l. goodwin 2 , l. guida 3 , m. frieri 1 , 1. east meadow, ny; 2. manhasset, ny; 3. bayshore, ny. rationale: our division has reported that nitric oxide (no) from tracheal epithelium can mediate induction of il-8 (american journal of respiratory critical care medicine 151:642a, 1995) . increased levels of il-8, ltb-4, and no in mononuclear cells (mnc) from cystic fibrosis (cf) patients were noted.(pediatric asthma allergy immunology 10: 101-7 1996) . no in mnc from cf was increased by stimulation with aspergillus fumigatus (asp) and rhdnase (j. clin allergy immunol 105:320p 2000). tnf-is produced from bronchial epithelial cells (bec) in the presence of mnc of normal controls (nc). rantes, a chemokine that facilitates leukocyte migration, is associated with airway inflammation in cf, and asp sensitization in cf patients could amplify pro-inflammatory cytokines such as il-8, tnf-, and rantes. methods: we studied the mrna and protein expression of tnf-, il-8 and rantes in a 65 year-old cf patient and a nc. 1x10 6 mncs from the patient and nc were stimulated with 21î¼g/ml of asp with bec at 10x10 5 and 10î¼g/ml rhdnase. mrna expression was studied by real time pcr (taqman chemistry abi prism 7700) and protein levels by elisa. results: tnf-production in supernatants of mnc with bec from nc increased from 8 pg/ml to 64 pg/ml with rhdnase. whereas in cf patients the tnf-mrna expression was greatly enhanced over nc but declined in the presence of rhdnase (fold difference: 8.37-7.70). there was no difference in expression levels of nc (fold difference: 4.0-3.9) with rhdnase treatment. il-8 expression in mnc with bec of patients increased 2.4 fold compared to nc (1.5 fold). rhd-nase decreased asp stimulated levels to 1.72 fold in patients compared to nc (2.9 fold). mnc and bec rantes production in patients increased from 49 to 1025 pg/ml and decreased to 570 pg/ml with rhdnase, but increased from 1134 pg/ml to 1775 pg/ml in nc. in contrast, rantes mrna expression in all groups was higher in nc but decreased with rhdnase in both cf and nc (37-26 fold vs. 14-10 fold). conclusion: rhdnase can increase no and decrease pro-inflammatory tnf-and rantes in cf patients stimulated with asp. rhdnase could lead to augmented bactericidal activity and epithelial defense by enhancing no production and decreasing the expression and production of tnf-, il-8 and rantes. this is a case report of two steroid dependent atopic dermatitis patients who both responded to treatment with omalizumab. patient a is a 39 year-old white male who presented with a history of severe atopic dermatitis for 10 years along with concomitant mild persistent asthma and allergic rhinitis. he had previously received monthly triamcinolone injections, methotrexate and doxycycline with limited response. on presentation he had mild improvement on a regimen of alternate day prednisone 30mg, fexofenadine 180mg bid, and zafirlukast 20mg bid. however, attempts at weaning prednisone were unsuccessful. omalizumab was initiated at a dosage of 150mg every four weeks. the patient remains prednisone dependent yet free from atopic dermatitis. patient a's diagnostic work up determined a total ige of 33.1 ku/l. the patient's specific ige tests were positive for grass mix, weed mix, maple, white pine, peanut, strawberry, gluten, soybean, wheat, oat, and dog dander. specific ige tests were negative for cat dander, egg white, milk, goose feathers, chicken feathers, mold mix, dust mix, and fish mix. patient b is a 23 year-old white male who presented with a history of severe full body atopic dermatitis along with mild persistent asthma and allergic rhinitis. he also was receiving triamcinolone injections with limited success. he responded to alternate day prednisone 30mg, desloratidine 5mg bid, and zileuton 600mg bid. attempts at weaning prednisone failed until initiation of omalizumab 375mg every two weeks. his atopic dermatitis is now under control with once daily desloratidine and omalizumab every two weeks. he was successfully weaned off of corticosteroid medication and has begun an immunotherapy regimen. patient b's diagnostic work up determined a total ige level of 1159 ku/l. patient b's specific ige tests were positive for weed mix, tree mix, maple, peanut, strawberry, dust mix, cat dander, dog dander, egg white, milk, oat, wheat, goose feathers, and chicken feathers. specific ige tests were negative for grass mix, white pine, mold mix, gluten, soybean, and fish mix. these two case reports reveal significant response to omalizumab in severe steroid dependent atopic dermatitis. further research is strongly indicated considering the quality of life issues with severe atopic dermatitis and potential side effects to long-term corticosteroid treatment. eosinophilic esophagitis (ee) has been described in children and is characterized by high levels of eosinophils (>20-24 eosinophils/high powered field [hpf]) in the esophageal mucosa. a recent report indicates that the combined prevalence of the eosinophilic gastrointestinal disorders may be higher than that of inflammatory bowel diseases (ibd). the presenting symptoms of ee mimick those of gastroesophageal reflux disease (gerd), and patients of all ages may experience a delay in time from onset of symptoms to diagnosis of ee. there is a paucity of data in the literature regarding the delay in time from symptom onset to diagnosis of ee. we report the data on four children three years of age and under with ee who experienced a significant diagnostic delay. four young children were referred to the pediatric allergy clinic with a diagnosis of ee (table) . three of the patients were male and one was female. the patients were 17-36 months of age at the time of diagnosis, and the diagnostic delay was 15.5-33 months (average delay 23.6 months). the most common presenting symptom was vomiting, and three of the four patients had a history of respiratory obstructive symptoms. all of the patients had received conventional treatment for reflux disease, and one had undergone a nissen fundoplication prior to diagnosis. in all four patients the esophageal biopsy revealed >20 eosinophils/hpf. three out of four patients had a family history of atopy, and two patients had a known history of a food allergy. skin tests to foods were positive in two patients and rast (radioallergoabsorbent) testing to foods was positive in one patient. recent data suggests that the diagnostic delay in ibd is decreasing as much as 50%. it is hypothesized that this may be due in part to an increased index of suspicion by health care providers. there is little data available regarding the diagnostic lag in children with ee. it is currently believed that chronic ee can lead to progressive esophageal scarring and dysfunction. stricture formation has also been described in children less than two years of age. given the reported increased incidence of this allergic gastrointestinal disease over the past decade, more data regarding the diagnostic delay of these conditions may be instrumental improving health care providers' awareness of this disorder. a. kohli-pamnani * , e. cooney, p. huynh, f. lobo, new haven, ct. introduction: cutaneous hypersensitivity reactions to amprenavir, an hiv-1 protease inhibitor, are reported in up to 28% of treated patients, of whom 4% have severe or life-threatening rashes, with treatment discontinuation required in 3% of cases. we report a case of successful desensitization to amprenavir, for recurrent maculopapular exanthem, in an hiv-infected patient with late stage disease and limited antiretroviral (arv) agent options. methods: the patient is a 40 year-old caucasian female with late stage hiv disease (absolute cd4 count 30 cells/mm 3 , hiv rna 200, 000 copies/ml) and multiple arv intolerances, who developed a severe generalized maculopapular eruption sparing mucous membranes six days following initiation of a regimen comprised of amprenavir, lopinavir/ritonavir, zidovudine, and lamivudine. a similar reaction occurred following re-challenge with amprenavir alone (600 mg oral formulation bid via percutaneous endoscopic gastrostomy (peg) tube), despite concurrent administration of oral prednisone 20 mg/day and loratidine 10 mg/day. results: skin prick testing with amprenavir 0.01 mcg/ml was negative, whereas intradermal testing with 0.1 mcg/ml was positive with a 7 mm wheal and 20 mm flare. percutaneous and intradermal testing with normal saline was nonreactive. the positive histamine control (skin prick only) yielded a 5 mm wheal and 20 mm flare. subsequently, incremental doses of 0.025 mg, 0.1 mg, 0.25 mg, 1 mg, 2.5 mg, 7.5 mg, 25 mg, 50 mg, 100 mg, 300 mg, 600 mg, and 1200 mg of amprenavir oral solution were administered via peg tube at 20 to 30 minute intervals (table) . the patient successfully tol-erated amprenavir desensitization and has remained on therapy without recurrence of rash out to 16 months of follow-up. conclusions: desensitization may permit continued use of amprenavir in patients with a history of amprenavirinduced maculopapular eruptions who have limited alternate treatment options. efforts aimed at characterizing the mechanism of amprenavir cutaneous hypersensitivity reactions seem warranted, given the frequency of reactions and the limited number of arv agents available for patients with late stage hiv disease. doses of oral solution were administered by peg tube at twenty to thirty minute intervals. introduction: beta-lactam (bl) allergy is the most common drug allergy. in most cases, ige antibodies are specific to the bl nucleus. however, sidechain-specific ige (scsige) to bl has been described. despite this, skin testing (st) to bl other than penicillin (pcn) is not commonly performed. we report a case of a 31 year-old female with a selective allergy to pip, and describe the utility of st to this agent to confirm scsige. methods: st to prepen (pp) and pcn g was carried out with percutaneous (pc) testing followed by intradermal (id) testing. st was also carried out with ampicillin (amp; 1 mg/ml), pip (60 mg/ml at pc level; 1 mg/ml at id level-a non-irritating concentration), and pip/tazobactam (tbm; 60 mg/ml at pc level; 1 mg/ml at id level) to exclude the possibility of selective allergy to tbm. case report: a 31 year-old white female with crohn's disease was hospitalized for treatment of intra-abdominal abscesses. she had immediate flushing and urticaria during an infusion of pip/tbm approximately 2 years prior. the allergy/immunology service was consulted for pcn st because her primary service preferred to empirically treat with pip/tbm. she had received imipenem approximately 8 months prior without untoward reaction. st to pp and pcn g was performed with negative responses and adequate controls. she subsequently received pip/tbm, but developed flushing and urticaria during her initial infusion, consistent with an ige-mediated reaction. two months later, st to pp and pcn g was repeated. in addition, st to amp, pip, and pip/tbm was performed. she had positive responses to pip and pip/tbm with negative responses to pp, pcn g, and amp, implying selective ige-mediated potential to pip. she tolerated an oral challenge with pcn vk 250 mg immediately following st without untoward reaction. conclusion: we have described a case in which st to pip was useful for diagnosing scsige in our patient, who had 2 prior reactions consistent with ige-mediated pathogenesis. this information will be helpful in identifying antibiotics she can safely receive in the future. this case supports the utility of st to bl in addition to pcn, in evaluation and management of patients with a history of adverse reaction to bl that may reflect presence of scsige. a.r. vaishnav * , b.s. bochner, baltimore, md. we report the case of a 39-year-old caucasian male with a 15-year history of asthma, two episodes of eosinophilic pneumonia and chronic peripheral eosinophilia with baseline eosinophil counts around 1000/î¼l who developed amnesia and elevated cardiac enzymes in february 2004. another physician had added montelukast in january 2004 and because of a good response advair was decreased from 500/50 to 250/50 bid. in february his eosinophil count increased to 3430/î¼l and soon he developed left arm numbness, diplopia as well as left arm and leg weakness. at his local hospital, he was found to have elevated troponins and cpks. cardiac catheterization showed normal coronary arteries and good left ventricular function. soon after discharge, he developed confusion and global amnesia. brain mri showed diffuse uptake consistent with global inflammation and/or vasculitis. upon hearing this story, we told him to take 60 mg of prednisone and urgently come to our hospital for admission. within hours, his mental status and visual symptoms improved. physical examination was unremarkable except for subungual splinter hemorrhages. montelukast was stopped and 1 gm/day solu-medrol iv was started. endomyocardial biopsy 2 days later showed mild hypertrophy and fibrosis without eosinophils. repeat brain mri and mra were normal. chest ct showed multiple patchy infiltrates with a new central cavitary lesion in the right lobe. other labs included a negative anca, ana of 1:40, normal complements and csf. our differential diagnosis included churg-strauss syndrome (css) versus hypereosinophilic syndrome (ihes) with myocardial, neurological and pulmonary involvement. serum tryptase was normal as was fluorescent in situ hybridization for the fip1l1-pdgfr fusion gene. based on this, along with the new pulmonary cavitary lesion on chest ct, the diagnosis of css was made. after 3 days of iv steroids, he was switched to 60 mg/day of prednisone. upon discharge his eosinophil count was 350/î¼l on 60 mg of prednisone. after all procedures were completed, he was also started on aspirin 325 mg daily to prevent thrombotic and thromboembolic complications. he was seen in follow-up in clinic and cytoxan 100 mg daily was started. his prednisone is being tapered. he is tolerating the treatment well and so far has had an excellent clinical and laboratory response. introduction-c1-esterase inhibitor (c1-inh) deficiency is a rare disorder classified into acquired and hereditary forms. both entities are distinguished by recurrent angioedema without pruritus or urticaria. the upper airway, head, neck, extremities and gi tract are typically involved. the inherited form usually presents in the first or second decade accompanied by a family history. the acquired form more commonly presents after the fifth decade. in acquired c1-inh deficiency, serological evaluation reveals low levels of c4, c1-inh, and c1q and a normal c3 level. levels of c1q are normal in the hereditary form. the acquired form may be associated with lymphoproliferative disorders and autoimmune disease. acquired c1-inh deficiency is typically recognized before the underlying malignant condition is diagnosed. clinical regression has been reported in patients whose underlying disorder responds to treatment. methods-a case report of a 57-year old female who developed repeated episodes of facial angioedema requiring hospitalization preceded by one year of vague abdominal pain and cramping. data-laboratory investigation of this patient revealed c4<10mg/dl (16-47 mg/dl), c1q<3.5mg/dl(5.0-8.6 mg/dl), ch50<20u/ml(31-66 u/ml), and c1-inh at 3 mg/dl(6-25 mg/dl) with a 51% activity (>68% normal). c3 was 138 mg/dl(90-180 mg/dl). other laboratory evaluation was notable for a normal cbc with diff, comprehensive metabolic panel, amylase, lipase and spep pattern. ige was elevated at 173 ku/l. hematology was consulted. ct of chest, abdomen, and pelvis were nondiagnostic. peripheral blood flow cytometry revealed a small distinct pop-ulation consistent with a clonal b-cell lymphoproliferative disorder. a repeat test showed skewing towards lamba light chain expression. bone marrow biopsy and aspirate were essentially normal except for erythroid hyperplasia on danazol treatment. the physical examination was without any masses or lymphadenopathy. the patient remained asymptomatic after beginning danazol although elevations in rbc, hgb, hct and absolute lymphocyte count have developed. conclusion-acquired c1-inh deficiency is rare cause of recurrent angioedema that has been reported in small cohorts and case presentations. we report another case report that reinforces the need for physicians to evaluate for concomitant lymphoproliferative disorders. chronic urticaria is a distressing condition usually associated with poor quality of life and poor response to symptomatic therapy. a wide variety of causes and mechanisms have been described and in some patients the cause remains unknown. rare cases have been associated with thyroid antibodies and some responded to thyroxin, even in the absence of overt thyroid disease. case report: a 54-yr-old obese white female presented with a history of persistent urticaria/angioedema for 4 mo. urticaria involved various parts of the body and individual lesions usually lasted < 24 hr. it was often accompanied by facial edema. oral diphenhydramine 25mg qid caused only little improvement. the patient could not suspect any offending factors. review of systems and past medical history were unremarkable, except for hyperthyroidism at age 12 yr that was treated with "medication" for 3 yr. on physical examination there were several urticarial lesions though she has been taking diphenhydramine. the thyroid appeared normal regarding size, shape and texture. various second generation antihistamines and doxepin were of little help. laboratory evaluation revealed total serum ige of 7 iu/ml (normal <200 iu/ml) and ch50 of 73 u/ml (normal 22-60 u/ml), but high tsh of 15.2 iu/ml (normal 0.4-5.0 iu/ml) and low free t4 of 0.58 ng/dl (normal 1.45-3.48 ng/dl). her antithyroglobulin titer was 32 iu/ml (normal <100 iu/ml) but the antimicrosomal titer was highly elevated at 382 iu/ml(normal <20 iu/ml) consistent with hashimoto's thyroiditis. thyroxin therapy was initiated at a dose of 100 mcg/d which resulted in marked improvement within one week and the patient was able to discontinue doxepin and other antihistamines. because of marked drop in tsh to 0.08 iu/ml, the thyroxin dose was reduced to 50 mcg/d. her thyroid function tests became normal within two months. she did not experience any recurrence of urticaria or angioedema during over 6 mo of follow-up so far. conclusion: patients with chronic urticaria/angioedema, especially women, should be screened for thyroid autoantibodies and if positive, thyroxin therapy might bring impressive remission in urticaria. hypersensitivity pneumonitis (hp) results from an abnormal immunologically mediated response to an environmental antigenic trigger. typically patients with hp experience transient fever, hypoxemia, muscle and joint pain, difficulty breathing, fatigue, weight loss, and cough. there are two clinical presentations of hp differentiated by onset and resolution of symptoms. patients experiencing acute hp experience the onset of symptoms 2 to 9 hours following exposure to a particular antigen and resolve in 1 to 3 days without specific treatment. however, patients with chronic hp experience symptoms that persist for months to years when exposed to a recognized cause of hp. a 55 year-old caucasian male was referred to our practice with acute bronchitis. his referral was secondary to a history of allergic rhinitis, chronic asthma, gastro-esophageal reflux disorder, and sinus surgery. this non-smoking male was a machine operator at a local factory. he was doing well until he began working in the presence of a heat induction machine and metal lubricating spray called multan ea20 (hinkle surface technologies), i.d. no.: 238073. multan ea20 is a product containing naphthenic petroleum distillates, amine salts, amine soap, triethanolamine hexyl, hexylene glycol, ethanol, sodium petroleum sulfonate, and triazine. this lubricant is known to irritate the eyes, skin, and respiratory tract. recent studies indicate that thermal decomposition of triazine, which readily occurs during metalworking, results in the production of formaldehyde. formaldehyde is a known carcinogen, as well as respiratory, skin, eye and digestive tract irritant. the patient developed serious respiratory health problems resulting in work absence and eventually hospitalization. while hospitalized he received a high resolution ct scan which showed diffuse ground glass appearance, and multiple attenuation areas of the lung which are consistent with hypersensitivity pneumonitis. the patient was treated with corticosteroids, and antibiotics with eventual normalization of lung parenchyma by chest ct. this represents the first reported case of hypersensitivity pneumonitis resulting from exposure to the metalworking fluid and respiratory irritant multan ea20. a.j. ham pong 1* , f. chan 1 , s.l. bahna 2 , 1. ottawa, canada; 2. shreveport, la. sexual intercourse has been known as the route for semen hypersensitivity reactions to the seminal fluid protein or to a contaminating drug or food. we report a case of anaphylaxis to cephalexin-containing semen by ingestion. history of present illness: a 37-year-old woman developed a systemic reaction after swallowing semen. since the couple frequently practiced fellatio without any reactions, her husband suspected cephalexin that he was taking over 2 days (500 mg qid). her reaction began in less than 10 min and peaked over 50 min; first as itchy oral mucosa followed by wheezing, flushing of the face and upper chest, and nausea. diphenhydramine 50 mg was administered po at 30 min and the reaction subsided over 1 hr. past medical history: she had generalized urticaria to oral penicillin more than 15 yr earlier and had positive penicillin skin test. she also had allergic rhinoconjunctivitis, mild intermittent asthma, and positive skin test to house dust mite, cat and dog epidermals, and pollens of grasses, trees, and ragweed. she also had oral allergy syndrome to certain fresh fruits and tree nuts; hazelnuts caused also diarrhea and colic. neither the patient nor her husband ate any nut-containing food on the days preceding the reaction. family his-tory: allergic rhinoconjunctivitis in the mother, sister and brother. eval-uation: the patient sought allergy evaluation about 2 yr after the reaction. she and her husband gave a consent. her serum ige was 108 iu/ml and skin test positive to penicilloyl polylysine 6x10-5 mol id, but negative to cefazoline 10 mg/ml for prick and 3 mg/ml for id. she had negative prick test to her husband's seminal plasma both before and after his intake of cephalexin 500mg qid for 2 days. using a cephalexin bioassay sensitive down to 6.25 mcg/ml, the medication level in the husband's urine at 120 min post last dose was 2400 mcg/ml and in his serum at 135 min was 12 mcg/ml, but was undetectable in the semen collected at 90 min. conclusion: this is probably the first case report of systemic reaction to ingested semen. the reaction occurred in an atopic, penicillin-sensitive woman and seems to be caused by cephalexin excreted in the semen or through urine contamination (1 drop = 120 mcg). in addition to her avoiding penicillin and cephalosporins, she was advised to avoid her husband's semen while him taking such drugs and for at least 3 days afterwards. background:asthma causes serious morbidity & mortality all over yet most asthma educational evaluations and programs have an urban rather than rural focus.there is lack of data on rural north dakota(nd). this nd survey aimed to study knowledge & awareness of management strategies for asthma like use of metered dose inhalers, spacer devices and peak flow meters. methods:the qualitative survey addressed attitudes and beliefs on asthma & its triggers;knowledge of medication delivery routes & use of hospitals and provider visits.a simple questionnaire was self-administered at 6 rural clinics in small towns in southeastern north dakota.10 questions explored asthma knowledge, extent of family history of asthma & factors aggravating asthma.it was voluntary & the population surveyed included patients, family, teachers, employees at nursing homes, the local hospital & clinics. results:of 297 surveys completed 61% had no asthma in the family.of those with a family history(39%), 59% had 1 person with asthma, 28.6% had 2 & 12.3% had 3 or more.respondents were aged 18-90 years & 81.1% were female.see table. discussion:our survey was rural & comparison with urban areas may help in planning for asthma education & resource allocation.61% denied asthma in their family. similarly, nonurban alaskan natives have a lower incidence of asthma compared to nonnatives.our results show a lack of awareness in our area.grain dust exposure was perceived as an asthma trigger but without evidence, local research is needed.in our study smoking was considered a trigger by 91.5% & this may be real.there was lack of awareness of peak flow meters & their role in asthma care.a study showed that compared to other areas even rural nurses used peak flow meters less often to assess and monitor asthma.this suggests a need for comprehensive asthma educational programs in rural areas that are based on national guidelines.we had only a moderate followup rate at 60%.in comparison, one study had 21% missed scheduled follow-ups. exercise induced asthma was known to only 50% of our group. conclusion:the need for better patient-provider communication has been highlighted by the lack of awareness of proven strategies to combat asthma.the use of a simple survey has revealed many unknown facts about asthma awareness in rural nd.further study to determine cost effective solutions to achieve national targets for asthma management are essential. aim: in most studies of asthma, the emphasis was on changes in large and middle airways. the aims of this study:(1)to observe the morphologic changes in small airways and lung tissue(salt) in guinea pig asthma models(gpam); (2)investigate the role of vcam-1, eotaxin, nf-b and ap-1 in the inflammation of asthma; (3)explore the functional variation of alveolar type 2 cells in asthma; (4)evaluate the effects of inhaled glucocorticoids on the above annals of allergy, asthma & immunology parameters in salt of asthma models. methods: (1)the gpam were established by ovalbumin challenge. five groups were divided: control, asthma day 4 and day 14, intraperitoneal dexamethasone, and budesonide inhalation group. (2)the expression of vcam-1, eotaxin, nf-b and ap-1 was determined by immunohistochemical technology and rt-pcr; the dna binding activity of nf-b and ap-1 by electropharetic mobility shift assay. (3)the balf phospholipide concentration was measured by phosphorus detection. results: (1)significant inflammatiom with infiltration of eosinophils and lymphocytes in salt was observed in asthma groups. (2)the protein levels of vcam-1, eotaxin, nf-b and ap-1 expressed in the salt were significantly elevated in asthma groups than those in control. (3)the mrna expression of vcam-1 and eotaxin of lung tissue homogenate was significantly increased in asthma group. (4)the dna binding activity of nf-b and ap-1 of lung homogenate was significantly increased in asthma group. (5)the balf surfactant represented by phospholipides was significantly decreased in asthma groups. (6)glucocorticoids in different ways of intake provided significant effects on the inflammatiom of salt. conclusion: (1)widespread and significant inflammation with eosinophilic infiltration existed in the salt in gpam, indicating asthma is a disease involving the whole airway and lung system. not only there were structural changes, but also impaired function of alveolar cells. the role of small airway inflammatiom may be of great importance. (2)eotaxin and vcam-1 actively mediated the process of inflammatiom, nf-b and ap-1 played important roles in the regulation of vcam-1 and eotaxin. the up-regulation of the above mediators in gpam was expressed in salt similar to that in central airways. we have recently reported that immunomodulatory oligonucleotides (imos) consisting of a novel structure and synthetic cpr or r'pg (r and r' are synthetic purine moieties) stimulatory motif effectively prevent ovainduced asthma in mouse models. in the present study we examined whether these novel imos (hyb2055 and hyb2087) can reverse established allergic airway inflammation in mice. balb/c mice sensitized and challenged with ovalbumin (ova) were evaluated for airway hyperresponsiveness (ahr) to methacholine. following ova-sensitization, mice were randomized and treated with placebo or 30 mg or 60 mg/dose of hyb2055 or 2087 s.c. during the following 10 days. two days after the final treatment, mice were rechallenged with ova and pulmonary functions were recorded. mice treated with either imo were significantly protected from both early (ear) and late (lar) allergic response, airway hypersensitivity and hyperreactivity to methacholine, bal and peribronchial eosinophilia, bal and serum il-5, and total serum ige as compared to vehicle-treated ova-sensitized and challenged animals. there was a significant increase in immature lung dendritic cells (cd11c+cd45r+) together with increase in serum il-10 levels and significant decrease in lung dc2 type cells (cd11c+ cd11b+cd8a-) as compared to vehicle-treated ovalbumin-sensitized animals in the lungs following treatment with either imo. these data suggest that both imos are effective and potent in attenuating key features of established allergic airway inflammation in bronchial asthma, and this effect could be mediated via decreasing lung dc2 cells and increasing immature dendritic cells. additionally, imos contain a novel 3'-3'-attached structure that provides higher metabolic stability and may permit lower and/or less frequent dosing. hyb2055 was evaluated for its safety and immunopharmacology in a phase 1 clinical trial in healthy human volunteers. introduction -hemoglobinopathies are common in southern europe and mediterranean area the more frequent being thalassemia and sickle cell disease. aside of the major hematological diseases of homozygotic patients minor forms are frequent, thalassemia minor and sickle cell trait. in these cases mycrocytosis with decrease of red cell volume and mean corpuscular volume or abnormal erythrocytes are found and can lead to hemorheologic disturbances in bronchial circulation and bronchial hypereactivity. the rationale of this study is to evaluate the incidence of asthma in hemoglobinopatic patients allergic to house dust mites.methods-from 4 000 patients seen in the last 4 years in an out-patient allergy clinic 44 cases of hemoglobinopathies have been confirmed by red cell count, hemoglobin electrophoresis, assays of hemoglobin a2, f, and s, and sickle cell test.all these patients had allergic disease characterized by clinical history, skin prick test to aeroallergens total and specific ige (rast-cap-feia) and respiratory function evaluation. results -hemoglobinopathies: betathalassemia 39 cases, betadelta thalassemia 2, sickle cell trait 2, hemoglobin c.1. aside of 4 cases of urticaria, all the patients presented respiratory allergy, rhinitis in 12 cases of thalassemia and 1 hemoglobin c, asthma with or without rhinitis in 25 cases of thalassemia and 2 cases of sickle cell trait. therefore asthma was present in 67, 5%. in a group 491 of respiratory allergic patients without hemoglobinopathies, 57% had asthma and 43% only rhinitis. conclusions -the prevalence of asthma is higher in hemoglobinopathies.(p<005 square chi test). hemorheological changes probably greater rigidity of red blood cells and capillary bed can contribute to bronchial hypereactivity. detection of hemoglobinopathies must be done in asthmatic patients with slight anemia or mycrocytosis. we investigated the role of aspirin-exacerbated respiratory disease (aerd) as a risk factor for the development of airway remodeling. patients with aspirin intolerance develop hyperplastic sinusitis with fibrosis and nasal polyposis. we speculated that similar mechanisms could be acting in the lower airway and that these individuals would demonstrate more severe asthma and evidence for airway remodeling. the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) study is a multicenter observational study of subjects with severe or difficult-to-treat asthma. baseline data were compared between subjects 18 years who reported asthma exacerbation following aspirin ingestion and those who did not. the primary measure of asthma remodeling was the maximally achieved post-bronchodilator spirometry. adult subjects with aerd (n=469) were compared with aspirin tolerant subjects (n=3009). subjects with aspirin intolerance demonstrated evidence for airway remodeling as shown by lower post-bronchodilator predicted fev 1 . in addition, they were more likely to have physician-assessed severe asthma, to have been intubated, and to have required high-dose inhaled corticosteroids or oral corticosteroids in the previous 3 months. we conclude that aspirin intolerance is associated with remodeling of both the upper and lower airways. asthma is a complex and variable disease with two main components, airway inflammation and smooth muscle dysfunction. according to national and international asthma guidelines, subjects with persistent asthma can be classif ied into one of three categories (mild, moderate, or severe) based upon lung function, symptoms, nighttime awakenings, medications and exacerbations. though it is widely believed that there is a high degree of variability in both pediatric and adult subjects with asthma, few studies have compared variability between them. therefore, an analysis of previously conducted asthma studies was undertaken to evaluate pediatric subjects aged 4-11 years (n=276) and adult subjects (n=85) previously receiving short-acting beta 2 -agoinsts alone in seven double-blind, randomized, 12-week trials. the analysis is limited to subjects who were randomized to placebo in these trials. during the study, subjects exhibited marked fluctuations in asthma severity. despite the fact that all subjects met criteria for moderate or severe asthma at baseline, 27%, 18%, 48% and 8% of weeks for pediatric subjects and 9%, 14%, 71%, and 6% of weeks for adults were spent in the intermittent, mild, moderate and severe categories, respectively. a summary of severity classification based upon symptoms and albuterol use is presented below. in addition, based upon pef % predicted, 62% and 52% of weeks were spent in the intermittent/mild category for pediatric and adult subjects, respectively. however, fluctuations in pef occurred frequently, with 46% of pediatric subjects and 30% of adult subjects experiencing 10 changes in severity based on pef over 12 weeks, indicating more variability in pediatric subjects. this analysis clearly demonstrates that asthma is a variable condition and that both pediatric and adult subjects frequently move between severity categories. furthermore, there are marked differences in severity classifications between pediatric and adult subjects. asthma severity, and consequent optimal therapy, cannot adequately be assessed by discrete, point-intime assessments of lung function, frequency of albuterol use, or asthma symptoms, especially in the pediatric age group. studies suggest that there may be an association between single nucleotide polymorphisms (snps) in the beta 2 -adrenergic receptor gene (adrb2) and the response to beta 2 -adrenergic bronchodilators. polymorphisms at codon 16 have been at the center of this debate. therefore, a retrospective analysis of six large, randomized trials was conducted to evaluate clinical responses to salmeterol administered with fluticasone propionate (fsc) 100/50mcg bid for 12 weeks in patients ( 12 yrs) with moderate or severe asthma and differing adrb2 polymorphisms at codon 16. baseline demographics were similar for all genotype subgroups. all measures of asthma improved over baseline and were similar across arg16/gly subgroups at 12 weeks. pairwise comparisons were conducted between genotypes and there were no differences other than fev 1 as noted in the table. findings from this retrospective analysis show that regardless of arg16/gly genotype, clinical response to salmeterol with an ics was similar during chronic dosing. although prospective studies are needed to fully understand the effect of adrb2 polymorphisms on response to therapy with a long-acting beta 2 -agonist, this analysis suggests that therapy with salmeterol and an ics together is appropriate for caucasian patients with differing arg16/gly genotypes. coronary artery disease(cad) and asthma commonly coexist in adults. iv dipyridamole thallium scintigraphy is considered a safe non-invasive technique in the evaluation of cad when patients can't exercise. dipyrdamole is a purine that blocks reuptake of extracellular adenosine increasing serum adenosine levels after iv administration.this results in a transient coronary vasodilation increasing the sensitivity of the thallium study. methylxanthines reverse the effects of endogenous adenosine by competitively antagonizing adenosine at local purinoreceptors. we report a case of a 69 yr.old female with a 30 year history of stable mild persistant asthma treated with daily salmeterol and low-dose fluticasone. she was referred to cardiology for atypical chest pain. within minutes of a standard iv dose of dipyridamole the patient reported chest tightness, cough, and wheezing. all these symptoms, typical of her past asthma flares, were abolished within 5 minutes of an aminophylline infusion and before albuterol was administered.the stress test was completed and was normal. inhaled adenosine induces bronchconstriction and is used as a probe for bronchial hyper-responsiveness. commercial iv adenosine preparations used in treating supraventricular tachycardia are reported to induce bronchospasm in known asthmatics. since serum levels of adenosine are transiently increased following iv dipyridamole, bronchospastic symptoms during dipyridamole stress tests should not be unexpected. an earlier study found an increased incidence of wheezing in 39% of patients with known copd/asthma undergoing dipyridamole stress tests despite pretreatment with beta agonists. the marked decline of theophylline use for chronic asthma in recent years may actually be increasing the incidence of this risk. cardiologists performing thallium stress tests are familiar with the risk of asthma flares after dipyridamole. they use iv aminophylline frequently to reverse several types of clinical dipyridamole reactions, including bronchospasm. on the other hand, we are impressed that allergists are relatively unfamiliar with this association. allergists and asthma specialists as well as asthmatic patients should be aware of risk of acute dipyridamole induced bronchospasm during elective cardiac stress testing. it has been shown that adhesive molecules are involved in inflammatory diseases of the lungs such as bronchial asthma. the purpose of the study was to measure and establish possible difference in serum levels of soluble icam-1 in 42 atopic patients (patients with allergic rhinitis and patients with bronchial asthma) in comparison with 28 patients without atopy (patients with asthma without rhinitis); whether there is a difference in sicam-1 levels between groups of 26 patients with allergic rhinitis and asthma in comparison with group of 16 patients with allergic rhinitis only and also in comparison with 10 healthy controls. results of the study have substantiated statistically significant difference in sicam-1 levels between all groups of patients in comparison to healthy control, but no statistically significant difference in sicam-1 levels between patients with and without atopy (z=-1.738) or between patients with allergic rhinitis and bronchial asthma in comparison with group of patients with allergic rhinitis only (z=0.00). conclusion: icam-1 is an important marker of inflammation in patients with allergic rhinitis as well as in those with bronchial asthma. atopic status does not influence differences in sicam-1 levels. although mean sicam-1 levels were higher in patients with allergic rhinitis and bronchial asthma (312.71 ng/ml) in comparison with mean sicam-1 levels in patients with allergic rhinitis only (279.69 ng/ml), no statistically significant difference was noted in sicam-1 levels between these groups of subjects, i.e. asthma itself did not contribute to statistically significant increase of sicam-1 levels. k. nadarajah * , g.r. green, m. naglak, abington, pa. objective: to study the various clinical outcomes of penicillin skin testing (pst) in a community-based hospital and to determine the percentage of patients who have an antibiotic modification and the choice of antibiotic used following the result of pst. method: this study is a retrospective chart review of all in-patients who were penicillin skin tested during a period of 6.6 years(jan 1997 to july 2003). information was collected on 101 patients using a detailed data collection form. data was summarized using descriptive statistics including frequencies and percentages. results: of the 101 patients penicillin skin tested, 92 had a negative test, five had a positive test and in four patients the test was indeterminate(histamine controls were negative). eighty six percent of the patients had a history of penicillin allergy, 7.9% had a history of cephalosporin allergy and 5.9% had a history of both penicillin and cephalosporin allergies. the duration of antibiotic prior to pst ranged from zero to 18 days. there was a 72.7% (67/92) reduction in the use of vancomycin, a 24.9% (23/92) reduction in the use of floroquinolones and a 7.6% (7/92) reduction in the use of aminoglycosides following pst. aztreonam was used in 19.6% (18/92) of patients before pst and in zero patients after pst. use of penicillin-based drugs was 49% (45/92) after pst and cephalosporin use increased from 4.4% (4/92 (all third generation cephalosporins)) to 47.8% (44/92( second and third generation cephalosporins)). i.e., 97% of patients with a negative pst received a penicillin or a cephalosporin. vancomycin usage was higher among pst positive patients. endocarditis was the diagnosis in 22% of all patients skin tested and staphylococcus aureus (23.8%) and enterococcus (16%) were the most common organisms on culture. there were no serious adverse reactions to the use of penicillins or cephalosporins when used following a negative pst, and there were no adverse reactions to penicillin skin testing. conclusion: in the population studied, pst lowers the usage of vancomycin, floroquinolones and aminoglycosides and increases the use of penicillins. third generation cephalosporin usage was increased by pst in our study. overall, pst results in antibiotic modification that could lower the emergence of multi-drug resistant organisms and vancomycin resistant enterococcus. the aim of the study was to find a new marker which could be easily done to predict about possible allergy development in infants. preventive procedure is always economically better than treatment itself.food allergens are able to stimulate lymphocytes even in prenatal period. immunological maturity of newborns is still in the center of our interest because its dependence on many different factors. the question was if cd30 activity in cord blood and in 1-year-old children correlates with development or not of allergy? the examined group consists of 120 newborns(58, 2% of boys). breastfed were only 87 children until 3-months-old and 62 until they were 6-monthsold. total ige from cord blood and mothers' blood taken at delivery were measured using unicap. immunological detection was done using fluorocytometry(becton nad dako). additionally parents were questionaired( family atopy). our reaults show that positive family atopy history(group a) or elevated level of ige( group b) or symptoms of allergy in first 3 months of life(group c) does not correlate with cd30 antigenicity. in all subgroups cd30 frequency was 1%. our findings show unfortunately that cd30 cannot be a predictive marker for allergy development. rationale: the etiology of eosinophilic esophagitis (ee) is unknown and the relationship to a type i allergic response is unclear. comparison of patients with positive and negative type i allergy testing may further clarify ee and determine what are the most common food allergens. methods: this is a retrospective chart review of medical records from january 2000 to january 2001 of children 1 year of age with biopsy confirmed ee (n = 42). ee was defined as having 15 eosinophils per high power field on esophageal mucosal biopsy. patients were grouped according to positive (n = 26) and negative (n = 16) allergic responses on skin or radioallergosorbent testing (cap rast, pharmacia). skin testing with commercial extracts (hollister-stier laboratories and greer laboratories) was performed in an allergist's office. a wheal of 3mm greater than the negative control on skin testing or ige > 0.35 ku/l on rast was considered positive. we performed fisher exact analysis to determine if associations existed between a type i allergic response and factors such as age, symptoms, peripheral eosinophilia, and personal and family history of atopy (asthma, allergic rhinits, and atopic dermatitis). results: ee patients with a positive type i allergic response were significantly younger than those with a negative response (mean 4.6 yo, median 4.5 yo, range 1 to 10.3 yo versus mean 8.5 yo, median 7.8 yo, range 1 to 21 yo; p = 0.0065). vomiting as a presenting symptom was significantly increased in the allergic population (85%, 44%; p = 0.014) and abdominal pain as a chief complaint was significantly increased in the non-allergic population (31%, 69%; p = 0.026). personal and family history of atopy and peripheral eosinophilia were similar between groups. the most common allergens were cow s milk (54%), peanut (46%), egg (42%), soybean (38%), and wheat (27%). conclusion: patients diagnosed with ee who present at a young age or who present with symptoms of vomiting may have a type i allergic response contributing to the esophageal eosinophilic inflammation. consistent with food allergies in children, milk, peanut, egg, soybean, and wheat were the most common foods found with allergy testing. because the positive predictive accuracy of food annals of allergy, asthma & immunology testing is only about 50%, the challenge remains to develop a specific plan to confirm causative foods such as through oral challenges or elimination trials. rationale: the relationship between specific ige and igg levels in atopic individuals is unknown. increasing antigen exposure is expected to increase igg production, however, the influence on ige levels is unclear. to further clarify this relationship the following studies were conducted. methods: three hundred and sixty tandem determinations of specific ige and igg levels in 65 individuals were collected using the immunocap 100 instrument (pharmacia diagnostics) and commercially available reagents. only subjects who had ige levels > 0.35 ku/l and igg determinations > 2 mg/l to the same specific allergenic species were included in the study. specific ige and igg determinations were to alternaria alternata, aspergillus fumigatus, penicillium notatum, cladosporium herbarium, felis domesticus, canis familaris, dermatophagoides farina, and periplaneta americana. correlation coefficients were calculated using excel (microsoft). results: the review of this data set yielded 55 tandem determinations of specific ige and igg levels in 25 atopic individuals. the most common ige sensitization was to alternaria. sixtyfour percent of individuals had specific ige directed against alternaria. the lowest ige response rate was for cat and roach. only 20% of individuals had an ige response to those specific species. correlation coefficients (cc) were calculated between specific ige and igg levels and were positive for all eight species tested. the highest cc was for dog (n = 6, cc = 0.92) followed by aspergillus (n = 13, cc = 0.71), penicillium (n = 6, cc = 0.69), alternaria (n = 13, cc = 0.62), cladosporium (n = 8, cc = 0.35), cat (n = 5, cc = 0.31), and roach (n = 5, cc = 0.16). the lowest correlation was for dermatophagoides farina (n = 7, cc = 0.03). conclusion: when individuals with measurable specific ige and igg levels are considered, there appears to be a positive correlation between specific ige and igg levels for many allergenic species. factors that influence the correlation are likely to be both genetic and environmental. identifying this link and a clinical application are our next challenge. recently, protein microarray tests are competing with traditional allergenspecific in vitro assays. while the advantages of microarrays in allergy testing are attractive, microarray analysis alone has not been very effective in reducing analysis time and automated microarray equipment typically is much larger than its benchtop counterparts. we have incorporated microarray technology into an automated microfluidic cartridge that provides rapid allergen testing using a compact, low-cost, desktop instrument. the injection molded microfluidic cartridge (fig. a) contains arrays of miniature pumps and valves that direct reagents independently to a solid phase reaction area. standard ige (nibsc) as well as allergens were immobilized within the cartridge to form a protein microarray. a small desktop analyzer actuated the pumps in the cartridge to automatically carry out a chemiluminescence-based elisa reaction. total ige quantitation was performed in a 10 minute reaction. fig.b shows the resultant image of a dilution series of immobilized ige. concentrations ranged from 0.625 to 1000 iu/ml corresponding to 1.9 fg to 3 ng ige per spot. the average cv value for ige quantitation was 12% showing good linearity (r2 = 0.99) and 6 fg sensitivity. this quantitative ige curve is used to eliminate the effects of cartridge variability. specific ige detection was demonstrated using 3 extracts, d. pteronyssinu(dp), a.fumigatus and b. verrucosa(bv). a 2-step, 20 minute reaction elisa technique was employed. fig. c and d show the resultant images for bv and dp positive serum, respectively. the sensitivity of the dp specific ige test was further investigated using a positive class 1 serum sample confirmed by mast. dilution of the class 1 serum with negative control serum could then be detected on the cartridge down to an 8 fold dilution, resulting in a limit of detection in the range of 0.08-0.31 iu/ml for dp specific ige. we have demonstrated total ige and allergen-specific ige detection with total analysis times less than 30 minutes in a convenient, low cost system using a microfluidic-based microarray cartridge. such rapid diagnosis allows physicians to provide treatment while the patient is still in the office. background: accurate allergen skin tests (ast) are the basis of optimal care of the allergic patient. completing these tests on the first visit can expedite the diagnosis and treatment and offer patients(pts.) efficient use of their time and increase satisfaction. appropriate pre-visit preparation is necessary to reduce the variables that affect ast outcomes. both positive and negative skin test controls are necessary to assure the ast are reliable. methods: we conducted a retrospective chart review of 1, 248 sequential pts. skin tested at an allergy practice, in order to examine the success of our pre-visit instructions and to identify other medications that may affect ast. pts. were given verbal and written instructions to discontinue antihistamines and other histamine-1 receptor antagonist medications (h-1a) 5 days before their visit. they then underwent ast only if adequate positive (histamine) and negative (saline/vehicle) controls were obtained. results: only 53(4.2%) of the 1, 248 pts. had inadequate histamine response (ihr). of these 53 pts., 23(1.8%) had used h-1a within the prior 5 days. 18(1.4%) pts. had taken h-1a in the recent past, but stopped them at least 5 days prior to testing. 12(1.0%) pts. had no exposure to h-1a. the use of psychiatric medications in the pts. with an ihr was also examined. of the 18 pts. who discontinued h-1a for more than 5 days, 13(76%) were also taking various medications drugs used in the treatment of psychiatric disorders (ssris, benzodiazepines, atypical antidepressants & antipsychotics) which are not usually associated with h-1a. the group of 12 of the pts. with no prior use of h-1a included 10 (83%) who were also on various psychiatric medications. the high prevalence of psychiatric medication use in these two groups is in contrast to the to 23 pts. with recent use of h-1a in whom 43% were on psychiatric medications. conclusion: pre-visit patient education about discontinuation of h-1a can lead to successful first visit ast in the overwhelming majority of patients (95.7%).failure to stop h-1a at the appropriate time occurred in only 1.8% of the pts. 1.4% of pts. discontinued h-1 a for the recommended 5 day interval, but still had ihr. another 1% of pts. had an ihr yet no obvious use of h-1a. a few pts. taking psychiatric medications not normally associated with h-1a had ihr. further investigation into this issue is warranted. a. blaziene * , a. chomiciene, l. jurgauskiene, n. ciaponiene, vilnius, lithuania. background: sublingual specific immunotherapy (sit) is accepted as an alternative treatment to subcutaneous sit of seasonal allergic rhinitis. the aim of this study was to evaluate changes in allergen-specific ige and basophil degranulation test (bdt) before and after 1 year of sit with a grass pollen mix. methods: 6 patients (3 male and 3 female, aged 25-44 years) having sensitization to grass pollen with seasonal allergic rhinitis were treated with standardized grass pollen extracts. the blood samples were collected before and after 1 year of sit assessing allergen-specific ige using an elisa method and bdt using a direct immunofluorescent method employing monoclonal antibodies. results: the sit was well tolerated by all patients. an increase in total ige after sit was observed in all patients. specific ige concentration was increased in 2 (33.3%) patients, while the bdt result was greater in 3 (50%) patients after 1 year of sit. conclusions: allergen-specific ige and bdt may serve as markers to indicate the clinical efficacy of sit for seasonal allergic rhinitis patients. a.g. palma-carlos * , s.l. silva, m.l. palma-carlos, lisboa, portugal. introduction -the incidence of primary immunodeficiencies in patients attending an out-patient center for clinical allergy and immunology depends on the recruitment and on patients refered. methods -in the last 3 years 3 000 patients have been observed in lisbon clinical allergy center reporting allergic diseases or repeated infections or refered by specialists (ent, gynaecology, internal medicine, pediatrics, or gp.). screening for primary immunodeficiencies has been done by electrophoresis, assay of immunoglobulins and complement, igg subclasses and flux-cytometry for t, b and nk cells. results -102 cases (3, 4%) of primary immunodeficiencies have been diagnosed. humoral: 13 deficits of iga (12, 7% of immunodeficiencies), 7 of igg (6, 8%) 16 of igg subclasses (15, 7%) 11 of common variable immunodeficiency cvi-(10, 8%), 2 of igm (2, 0%). complement: 4 cases of c1 esterase inhibitor deficiency (3, 9%) cellular: 45 cases of mucocutaneous candidiasis (44, 1%) in fertile females, 2 cases of cd4 deficiency (1, 9%). combined: 2 cases of deficiency of the couple cd40/c40 ligand with igg deficiency (1, 9%).conclusions -in the present series chronic mucocutaneous candidiasis is the prevalent primary immunodeficiency, due to the number of patients refered by gynaecologists. aside of this group where a decrease of nk cells was the more common immunologic pattern, humoral immunodeficiencies are frequent, mainly cvi, iga, igg and igg subclasses deficiencies. the search for immunodeficiencies must be done in all patients with repeated infections attending immuno-allergology departments. a case of atypical c2 complement deficiency. c.c. randolph * , waterbury, ct. introduction:c2 complemennt deficiency occurs in 1 in 10, 000 individuals .it results in decreased opsonization and chemotaxis with increased prevalence ofsle and other rheumatic disordersas well as enhanced vulnerability to pyogenic infection.there are two types of c2complement deficiency :type 1(90%associated with sle)with no protein translation and type ii with absence of protein secretion.we present a 15 year old white female otherwise healthy with recurrent urticaria and angioedema with c2 complement deficiency. method:case report:a 15y/o w/f athlete presented with a two month history of recurrent hives and angioedema which she associated with ingestion of halloween candy .one week before evaluation she had hives with coconut as well.her history was othewise unremarkable except for recurrent uti's, annual sinusitis, pneumonia in 1998 as well as migraines.she denied sexual activity.her physical exam was normal.results:an evaluation for autoimmune disease revealed normal esr, ana, dsdna, mono and hepatitis serology as well as lyme titers however her ch50 was low17u/ml(normal 26-58u/ml)and evaluation of complement revealed c4 14mg/dl(normal 16-47mg//dl)and c2 <1.3mg/dl(normal 1.6-3.5mg/dl)with normal c3, c5-c9.her father had nor-malc4 but c2 was 1.4mg/dl (normal 1.6-3.5mg/dl)her sister had c2 of 1.5mg/dl and normal c4 and her mother had normal c2 and c4.her workup included positive prick skin test to ragweed, ash and grass and she was started on rhinocort and clarinex seasonally.she has been followed for one year with resolution of hives and is asymptomatic.her diagnosis had been confirmed by a pediatric rheumatologist.conclusion;we present an atypical case of c2 complement deficiency in an currently asymptomatic individual. background: we diagnosed a 10 month old male with cgd and aspergillus brain abscesses and pulmonary infiltrates. review of the literature suggests he is one of the youngest cases of cgd complicated by cerebral aspergillosis. case report: a ten month old male previously seen for unexplained persistent pulmonary infiltrates since 4 month of age presented to our hospital with lethargy, fevers, and increased irritability. ct scan of the head revealed severe hydrocephalus. multiple brain abscesses were found on surgical exam and cultured for aspergillus fumigatus. he had a history of failure to thrive and hypotonia since birth. family history was significant for parents that were second cousins. there was no family history of recurrent infections or childhood deaths. physical examination was significant for a child with weight and height in the 25% and 75%, respectively with persistent fevers >38.5 c, hypotonia, hepatosplenomegaly, and left lower lung field rales. initial immune workup was normal except for elevated total ige of 215 ku/l. cd4+ (526/m3) and cd8+ (332/m3) t cells were initially low, but later increased to normal levels without intervention. neutrophil oxidase activity assessed by dihydrorotamine 123 (dhr) oxidation was 0% of control. superoxide production assessed by cytochrome c reduction was zero. the patient was treated with interferon ? for presumed cgd. his aspergillus brain abscesses improved with intravenous voriconazole and caspofungun. the responsible organism for his recurrent pulmonary infections was not identified, but improved with antifungal therapy and broad spectrum antibiotics. the dhr test of both parents and siblings were normal. antibody testing showed a complete deficiency of the p67 protein with normal levels of gp91, p22, and p47 proteins. evaluation of the exons of the ncf-2 gene that encodes the p67 protein were normal. conclusion: mutations due to p67 protein deficiency are responsible for 3% of cases of cgd. there has been only one previously reported case of p67 deficiency without ncf-2 exon mutations in which a single point mutation in an intron of the ncf-ii gene was identified. fungal infections may complicate cgd, however cerebral aspergillosis is seldom encountered. this case annals of allergy, asthma & immunology reports a 10 month old with cgd due to a p67 deficiency without exon mutations complicated by cerebral aspergillosis. introduction: lymphoid interstitial pneumonia is an uncommon condition which is considered both as a disease per se or as an inflammatory pulmonary reaction to various external stimuli or systemic diseases; however, at the present time most of the cases remain idiopathic. we present a case of an infant who developed a lymphoid interstitial pneumonia associated to a deficit of interferon-production. methods: we describe a clinical case and review the medical literature. results: we present the case of a five months old male with a history of cough, respiratory distress and four previous hospital admissions regarded as a 'pneumonic' events from two months of age and four siblings dead (two of them with 'abdominal disease' and one of them with candidiasis) during their first year of life. the parents referred no consanguinity. the physical examination showed a malnourished child with signs of bilateral lung consolidation. oxygen supplementation and intravenous antibiotics were started. our patient didn't have neonatal history related to the present compliant. the chest film revealed a diffuse bilateral interstitial pattern which was confirmed by pulmonary ct scan. sweat chloride test, hiv and epstein barr virus serology test were all negative. an initial immunologic evaluation reported slightly increased leukocytic count, hypergammaglobulinemia, lymphocityc flow citometry and nitro blue tetrazolium reduction test in normal parameters. the open lung biopsy showed a thicked pulmonar interstitium with moderate number of lymphocytes with not atypical pattern. our patient was discharged with clinical improvement, ambulatory oxygen supplementation and inhaled fluticasone-salmeterol. in an ambulatory follow-up we evaluated lymphocytic production of cytokines and we found no levels of interferon-. we started weekly administration of oral transfer factor. the patient showed an excellent clinical improvement evidenced by no more oxygen dependence, weight gaining and absence of further hospital admissions. con-clusions: our patient represent a new linkage between lymphoid interstitial pneumonia and primary immunodeficiency characterized by interferonproduction deficit, maybe with a non previously described molecular defect and a probably autosomic recessive inheritance pattern; also we confirmed the transfer factor usefulness to induce gamma interferon endogeous production. objective: marijuana is a schedule class 1 psychoactive control substance more frequently used by the oriental societies( in the event of jubilation) causing altered state of conscience, euphoria, its prolonged use is followed by addiction and dependence.it contains more than 426 chemical entities with over 60 are of the cannabinoid i.e, cannabidiol (cbd), cannabinol (cbn), and delta-9, tetrahydrocannabinol (thc) the later on use has been associated with craving for further use of narcotics just to enhance the euphorient effects .the active ingredients i.e, delta-9-tetrahydrocannabinolthc) and other cannabinoids(thc) are liquid soluble at high concentrations which alters membrane function, resulting in alterations in immune cell response. cannabinoid has immunosuppressant properties causing impaired cell-mediated and humoral immune system activities, cytokine production, leukocyte migration and natural killer-cell(nk) activity resulting in reduction in the host resistance to bacterial and viral infection, (pms)with hiv infection are at higher risk of developing aids, infection by opportunistic bacteria, fungi, or viruses (pms), when compared to non marijuana smokers, have more respiratory ill-ness.cannabinoids also characteristically as being immunomodulators i.e, generally suppressing but occasionally enhance some immunological responses, some have suggested that the immunosuppressive effects of cannabinoids might be useful clinically; for example, in treating multiple sclerosis.as per clinical response cannabinoids had been found exacerbating existing allergies from antigenic complex (eliciting formation of specific antibodies/metabolites as a hapten, combining with a body proteins). methods .in the follow up studies including 18individuals(all males age25-60 years) with(pms).of more than 6 months having serum level of tch >10um, there have been 20 times reduction in the proliferation of t lymphocytes with a proportionate increase in the proliferation of b lymphocytes, reduction in the cytotoxic activity of t lymphocytes, reduction in macrophage activities i.e, phygocytosis rationale: patients with xla are subject to arthritis and cellulitis. these three relatives have had similar courses, suggesting infectious etiology. methods: two brothers and a cousin, from an african-american family known to carry xla, have been diagnosed with xla and chronically treated with ivig. all three have developed arthritis and cellulitis of a lower extremity. the eldest, now 23 years old, had a 5-month waxing and waning arthritis and cellulitis that was refractory to the oral antibiotics attempted. his younger brother had not yet accomplished pubertal changes at the age of 16, and was below 3rd percentiles for weight and height. he also had several months waxing and waning arthritis and cellulitis refractory to oral antibiotics. he and his cousin have had esophogastroduodenoscopies that show gastritis and duodenitis with heavy growth of an organism visualized by specific staining for h. pylori. the cousin has also experienced more recent weight loss and arthritis/cellulitis. results: the younger brother had a blood culture that grew a curved gram-negative rod. a subsequent culture at the state lab grew a similar organism that was urease-negative. the two brothers are at or near completion of a six-month course of ertapenem and gentamicin; they have had resolution of their arthritis and cellulitis. the younger has gained 10.3 kg and experienced his pubertal changes at the age of 17 years. con-clusions: there are prior reports of several different related organisms that can cause arthritis and cellulitis in patients with xla. these include helicobacter, campylobacter, and flexispira species. the urease-negative organism would not be flexispira, but may be a campylobactor species or helicobacter canis. the results from this family suggest that long-term combination iv antibiotics may be indicated for patients with this syndrome. slow virus infections have been reported to affect the central nervous system. parvovirus b19, herpes and cmv are usually not included in the diagnosis of cns diseases nor has been associated with cns manifestation in an immuno-compromised patient. in this abstract, we report on a neurological manifestation that can be linked to ebstein-barr/herpes virus and parvovirus-b19 in an immune deficient patient. a 50 year old female presented to our clinic with a history of chronic fatigue symptoms, daily arthralgias, frequent sinus infections and idiopathic tremors for the past 6 years. the patients neurological evaluation, including mris was found to be within normal limit, despite worsening tremors of her head and arms. a full clinical and labora-tory evaluation was performed which revealed igg subclass, low t-cell numbers and functioning, low response to specific antibodies and positive igm for ebv, parvo and cmv. the patients common immune deficiency coupled with chronic viral infection and worsening tremors led us to try high dose ivig (2g/kg divided over 3 days on cycles of every 3 weeks). within three months of starting ivig, the patient had a large reduction in her tremors and negative igms for parvovirus, herpes and cmv. given our findings, we suggest that ivig may play a role as a neuro-immune modulator, as has been shown in other neuro-immune diseases. we further suggest that the interaction between parvovirus b-19, herpes and cmv as part of the slow viruses, combined with underlying immune disorder may lead to neurological presentation and high dose of ivig can reverse the syndrome. purpose: to date, only two patients older than fifty years of age have been diagnosed with velocardiofacial syndrome (vcfs); this case represents the third such patient. methods: physical and laboratory findings of the patient are presented as a case report. results: we describe a sixty-six-year-old male, recently diagnosed with vcfs, confirmed by fluorescent in-situ hybridization (fish), was referred by his psychiatrist for comprehensive care. he had a history of cleft palate and learning disabilities as a child, with the onset of psychiatric illness in his late teens. although there was no history of cardiac disease, the patient had agenesis of the left renal artery as well as other vascular anomalies, including hypoplasia of the left a1 segement of the anterior cerebral artery. other findings included hypothyroidism, hypoparathyroidism, sensorineural hearing loss, and typical facies. he also suffered from chronic candidiasis. immunologic laboratory studies revealed over a 2:1 ratio of cd8:cd4 t cells with a decreased cd4 percentage, markedly diminished b cell percentage, decreased t cell mitogen responses, and markedly decreased b cell mitogen responses. nevertheless, total serum igg and specific antibody responses remained normal, with a low serum igm. conclusions: this patient meets the criteria for the diagnosis of vcfs; only the third reported case diagnosed over the age of fifty. though his immunologic findings may be consistent with his diagnosis, they may be due in some part to immunologic senescence given his age. background: the classic presentation for patients with xla and mutations in the btk gene includes marked hypogammaglobulinemia, absent b cells, and significant sinopulmonary infections beginning at 4-5 months of age. typically, mds presents with anemia, leukopenia, monocytosis, and thrombocytopenia with recurrent infections, skin rash, and hepatosplenomegaly. many of these subjects demonstrate chromosomal abnormalities including monosomy 7. we describe a case of mds presenting with some features of both conditions. clinical history: we present a 2 year old male with a suspected diagnosis of xla, chronic sinopulmonary disease beginning at 12 mo, diffuse bronchiectasis, and agammaglobulinemia with absent b cells. he had wbc =3750 cells/ul, with 60% monocytes and platelet count of 122, 000 /ul. he had no anemia, hepatosplenomegaly, or skin rash. bone marrow biopsy showed mds with absent plasma cells and monosomy 7 in 95 % of his cells. btk expression and sequence analysis were normal. conclusion: while xla is the most likely primary immune deficiency that would present in a male with the clinical picture described above, this case illustrates the importance of maintaining an expanded differential diagnosis in patients with presumed primary immunodeficiency. j. wang * , l. mayer, c. cunningham-rundles, new york, ny. background: chronic granulomatous disease (cgd) usually results in acute or chronic infections with a defined spectrum of bacteria or fungi. other characteristics include inflammatory disorders, including genitourinary or mucosal inflammation resembling inflammatory bowel disease. gm-csf has been used in the treatment of mucosal inflammation in glycogen storage disease ib and crohn's disease with some success. objective: to explore the use of a novel therapy in the treatment of mucosal inflammation associated with cgd. methods: the patient was treated with daily gm-csf (0.6 mcg/kg/dose subcutaneous injection) along with parenteral antibiotics and total parenteral nutrition. after 4 days on gm-csf, hydrocortisone enemas were added due to continued pain and swelling. results: rectal and abdominal pain significantly improved, blood streaked stools decreased; he tolerated a regular diet and was discharged home 10 days after starting gm-csf. he now has no rectal or abdominal pain and no blood in the stool. conclusions: gm-csf may be a useful therapy for the management of mucosal inflammation in cgd patients. it appears safe and well tolerated and permits avoidance of immune suppressive alternatives. introduction: management of autoimmune cytopenias in patients with cellular immunodeficiency may be very challenging. treatment of these cytopenias with corticosteroids may potentiate the immune dysfunction leading to further infections. methods: we describe a 15 month-old female with a cellular immunodeficiency and autoimmune thrombocytopenia / hemolytic anemia being treated with steroids and ivig without improvement. rituximab, a monoclonal antibody that binds to b-lymphocyte cd20 surface antigens, was initiated. results: this patient presented at 11 months of age with failure to thrive, eczema and recurrent bacterial pneumonias. she was diagnosed with a t lymphocyte immunodeficiency with decreased absolute numbers of cd3 (493), cd4 (365), and cd8 (80) lymphocytes. t cell function was markedly decreased as measured by pha, cona, and pwm. she developed chronic thrombocytopenia with platelets of less than 20, 000 and coombs positive anemia with hemoglobin of 6 g/dl. she was placed on 4mg/kg/day of prednisone with minimal improvement and continued to develop severe pneumonias. rituximab 375 mg/m 2 /week was initiated for 5 doses. her cytopenias improved with an increase in both platelet count (229, 000) and hemoglobin (15.1g/dl). her absolute cd19 count fell from 1319 to 0. she was weaned off steroids permanently. she has also continued on ivig, prophylactic antibiotics, and as needed rituximab pending bone marrow transplant. conclusions: rituximab, a monoclonal anti-cd 20 antibody, may be helpful in treating autoimmune cytopenias in patients with cellular immunodeficiency in which steroids need to be avoided. ivig antibody replacement substitutes for the subsequent humoral antibody depletion due to induced secondary b cell lymphopenia. introduction: the patient is a 3 month old male born at full term. during his prenatal course he was noted to have a pulmonary abnormality in his left lower lobe at approximately 12 weeks of age. serial ultrasounds and fetal mri were consistent with the diagnosis of congenital cystic adenomatoid malformation (ccam). histology from elective resection of the lesion performed at 2 months of age revealed no evidence of ccam. silver stain revealed florid pneumocystis jiroveci (carinii) infection. the patient was completely asymptomatic. the differential diagnosis for this infection in the newborn period includes hiv infection, severe combined immunodeficiency, and x-linked hyper-igm syndrome. the infection has also occurred in newborns with apparently normal immune systems. methods: immunology evaluation was performed to evaluate the patient for the listed diagnoses. a complete blood count was performed. lymphocyte subsets were performed by flow cytometry. quantitative immunoglobulins g,a, m and e were measured by nephelometry. specific antibodies to tetanus and diptheria were determined by elisa. hiv status was ascertained by western blot and dna pcr. dichlorofluorescein assay was performed. fluorescenceactivated cell sorter technique was used to evaluate cd40 ligand. lymphocyte stimulation to mitogens and tetanus were performed. results: the patient had negative hiv1/2 antibodies and a negative hiv dna pcr. the result of the complete blood count was normal with an absolute lymphocyte count of 6, 750. the patient had normal percentages and numbers of cd3, cd4, cd8, cd19, and natural killer cells. lymphocyte stimulation to mitogens and tetanus was normal. dcf assay was normal. facs revealed normal levels of cd40 ligand. at 5 months of age he had protective titers to diptheria and tetanus titers of 0.52 iu/ml (protective >0.6 iu/ml). at 5 months igg, a, m and e were 235 (normal 218-636), <6, 36, and <5 respectively. conclusion: immunologic testing revealed no evidence of severe combined immunodeficiency, hiv infection or x-linked hyper-igm syndrome. the patient remains well clinically with normal growth and development with no subsequent infections. pneumocystis jiroveci pneumonia can be seen in infants with apparently normal immune systems. commercial preparations of igg produced for iv use (ivig), must fulfill regulatory requirements. the method of preparation, however, may produce alterations in the content or function of igg subclasses such as disturbed composition which can be reflected as a lowered clinical effectiveness of the product. we report 2 patients with specific igg3 immunodeficiency, that, when changed to a new ivig preparation, had lessening of clinical effectiveness of the new product but who also experienced recovery after they were changed to a different ivig product. case 1. a 53 y/o male with hx of cervical lymphadenopathy associated with recurrent uri, fatigue, cognitive alterations and hypercholesterolemia. he was dx in 1993 with a specific igg3 immunodeficiency for which he was started on ivig infusions 400mgxkg q/4 w which brought his igg3 levels to normal values 21 mg/dl, (18-95 mg/dl) with good clinical improvement. when he was changed to a different ivig product with lower iga content his initial symptoms returned with decrease of his igg3 to 17 mg/dl (41-129 mg/dl) he was changed to a different ivig product with higher iga content with disappearance of all his previous symptoms. case 2. a 47 y/o female with history of chronic yeast infection, fatigue, joint pain, asthma, ge reflux, depression, hypothyroidism and shunt for hydrocephaly. she was diagnosed with igg1 and igg3 immunodeficiency and started on ivig 400 mg x kg x q/4 w. when changed to another ivig with lower iga content she experienced worsening of her symptoms during the 2 months that she was receiving it. she was changed to a different ivig product with a higher iga content with complete improvement of her symptoms. although the content of iga in product 1 (50-150 ug/ml) was significantly lower than in prod-uct 2 (720ug/ml), the total igg and igg subclass distribution (including igg3) were comparable therefore, the lack of clinical effectiveness of product 1 would appear to be related to qualitative alterations in the product related to methodological preparation possibly in removal of the iga or other physicochemical alterations affecting biologic activity which contributed to a lessened clinical efficacy of the product. we present these cases to alert the allergist-immunologist to these observations when treating patients with igg or igg subclass deficiencies. background: development of atopy has been known to occur in nonatopic recipients of bone marrow transplants ( bmt) from atopic donors. the reverse condition, with atopic recipients losing evidence of specific ige after bmt from non-atopic donors is quite unique. case report: ph is a 37 year old male referred for recurrent nasal congestion. as a teenager, the patient was treated for chronic allergic rhinitis and asthma, atopic dermatitis diagnosed as severe, and multiple food allergy. skin testing done as a teenager showed 3+ reactions to multiple pollen, dog, cat, most seafood, cashew, walnut and pecan. at 16 years of age, he underwent an allogeneic bmt from his non-atopic brother for acute myelogenous leukemia. asthma and atopic dermatitis were observed to clear almost completely and allergic rhinitis improve after the bmt. his blood type changed from 0+ to 0-. skin testing done on his current visit showed unremarkable responses to all pollen, cat, dog, dust mites and foods with good histamine control. discussion: the negative skin test results suggests that his current nasal symptoms are vasomotor in nature. considering the past severity of his symptoms, it appears unlikely that he lost his specific-ige sensitivity spontaneously. transfer of atopy is known to occur in non-atopic recipients of bmt from atopic donors. in a study of 12 patients undergoing allogeneic bmt for hematologic malignancies, nonatopic recipients developed positive skin tests with profiles similar to atopic donors. 1 a possible mechanism is passive transfer of memory b-cells which initiate specific-ige production with a donor pattern. a reverse of this mechanism could occur with the recipient gaining lymphoid precursors with no atopic tendency leading to clearing of atopy. the literature yielded one report of asthma resolving after high-dose chemotherapy and autologous stem cell transplantation the authors suggested that chemotherapy could have resulted in immune system reconstitution, normalization of the t-cell repertoire and resolution of asthma. introduction: primary central nervous system (cns) lymphomas constitute only a small percentage of central nervous system tumors in adults and are seen more frequently in aids patients and immunodeficiency states. they are extremely rare in children, even those with primary immunodeficiency. we present a 4-year-old female with combined immunodeficiency who developed an eber+ (ebv-associated) large b-cell lymphoma that was confined to the cns. methods: the patient is a 4-year-old female that was being evaluated for combined immunodeficiency who presented to our institution with acute fever and seizure activity. results: the patient had a history of recurrent pneumonia, otitis media, sinusitis, and upper respiratory infections. she also exhibited failure to thrive, chronic diarrhea, and sen-sorineural deafness. she was found to have a combined immunodeficiency with severe neutropenia and lymphopenia, low iga, low igm, and poor specific antibody response to protein and polysaccharide antigens. she had no response to a candida delayed hypersensitivity skin test. hiv tests were negative. she was thought to have acute meningoencephalitis causing the fever and seizure activity, however bacterial, viral, and fungal studies were negative. she received multiple anitbacterial, antifungal, and antiviral agents. she died secondary to brainstem compression due to severe cerebral edema. autopsy revealed an eber+ large b-cell lymphoma that involved about 80% of her brain and spinal cord. no tumor cells were found elsewhere. con-clusions: this case represents a rare manifestation of combined immunodeficiency: the development of a primary cns lymphoma. the tumor cells were found to be eber+ (ebv-associated). ebv is known to be associated with lymphoma, especially in aids and immunocompromised patients. only 6.5% of primary tumor sites in severe combined immune deficiency patients involved the cns in the immunodeficiency cancer registry that was instituted in the 1970s. v. litvinova * , g. muzlaev, krasnodar, russian federation. introduction: glyoma is one of the most prevalent diseases among all brain tumors and more than 35% of them are malignant. in the previous investigations it has been shown the immune disorders in patients with glyoma tumor. at the same time it was suggested the possible anti-tumor activity of some proinflammatory cytokines (tnf, il1, il8), which can penetrate via haematoencephalic barrier and induce the lysis of tumor cells. the aim of this investigation was to study the serum and spinal fluid concentrations of one of the key immunoregulatory cytokines -gamma ifn and il18 in patients with glyoma tumor. methods: the concentrations of the gamma ifn and il18 have been studied in serum and spinal fluid of 16 patients with glyoma by eliza method. in control, the same parameters have been studied in 6 patients with brain trauma. results: it has been shown that concentrations of gamma ifn and il18 in serum and spinal fluid was 1.5-2 times higher than in trauma patients (p<0.001). the serum levels of gamma ifn and il18 in glyoma patients were 82.8 and 28.5pg/ml, accordingly. in trauma patients-44.3 and 16.3pg/ml. the concentration in spinal fluid of the studied cytokines was 1.8 time higher than in control patients. conclusion: proinflammatory cytokines gamma ifn and il18 may be involved in pathogenesis of glyoma and can participate as possible anti-tumor factors of immunity in glyoma patients. a. arrey-mensah * , r.u. sorensen, new orleans, la. rationale: immunodeficiencies need to be ruled out in infants that present with failure to thrive. patients with t-cell lymphopenia, hypogammaglobulinemia and pancytopenia may have a primary immunodeficiency such as scid, or a secondary immunodeficiency that may need to be managed differently. methods: evaluation of cellular and antibody-mediated immunity of a 15 month old aaf admitted with failure to thrive and chronic diarrhea. ohistory of duodenal atresia corrected by creating a blind duodenal loop and anastomosis of the stomach to the jejunum at birth. o mass in hypogastrium. results: immunologic evaluation revealed: " lymphopenia ranging 210 to 350cells/ul " anemia: hemoglobin 7.6g/dl, retic 6.8 " ancs ranging 700 to 2100 " thrombocytopenia 54000l to 26500l " cd4+: 80 " cd8+: 50 " cd4/cd8r: 1.5 " cd19: 290 " cd56: 190 " mitogen responses were normal: " pha 46, 397cpm " con-a, 7, 690cpm " pwm, 36, 168cpm immunoglobulins: igg 102mg/dl iga 80mg/dl igm 55mg/dl ige 20 iu/ml total protein was 3.4g/dl, albumin was 1.2g/dl the immunoglobulin-g half-life study was 7 days in our patient: metabolic imbalance: hypokalemia (1.8mmol/l) hyponatremia (127mmol/l) hypocalcemia (4.6mg/dl) blood, stool, urine cultures normal. stool ova, parasite, virus were negative. hiv-pcr (-) radiological evaluation: superior mesenteric vein thrombosis, chronic malrotation and volvulus, dilated duodenal blind loop with possible lymphatic obstruction. the patient improved clinically and all immunological markers normalized after surgical removal of adhesions and obstruction. conclusion: the patient had a secondary immunodeficiency due to lymphangiectasia. lymphangiectasia should be considered in the presence of a lymphopenia with normal lymphocyte function and hypogammaglobulinemia accompanied by hypoproteinemia and hypoalbuminemia. hypogammaglobulinemia and hypoproteinemia were secondary to gastrointestinal losses. the immunological component of 22q11.2 deletion syndrome (also known as digeorge syndrome;dgs), hypoplasia of the thymus, is quite variable among patients and provides the opportunity to determine the relationship between thymic function and t cell receptor (tcr) repertoire diversity. using a novel measure of repertoire diversity based on cdr3 length polymorphism called hamming distance, tcrbv repertoire diversity in dgs was found to differ from control subjects by having an overall skewing of receptor expression. as expected from clinical outcomes, there was also great intra-individual variability in dgs tcr repertoires. the degree of repertoire diversity was directly correlated with thymic output as measured by t cell receptor excision circles (trecs), i.e. greater thymic output resulted in more diverse repertoires (see figure below). this result demonstrates a quantitative relationship between thymic function and repertoire diversity in humans and may reflect the balance between thymic output and peripheral expansion to maintain an adequate tcr repertoire. in addition, it may suggest a basis wherein limited repertoire diversity mediates both immune deficiency and autoimmunity. tcr repertoire diversity in dgs, as measured by hamming distance, correlates with thymic output, as measured by trecs (plotted on a logarithmic scale) a. sabra 1* , s. sabra 1 , h.j. castro 2 , j. malka-rais 2 , j.i. mendez-inocencio 2 , g. santos 1 , j.a. bellanti 2 , 1. rio de janeiro, brazil; 2. washington, dc. a major investigative effort of our laboratory has been directed to the study of non-ige mechanisms and their role in the immunopathogenesis of food allergy (fa). we have previously reported th1 and th2 cytokine alterations associated with several clinical entities that had overlapping disease manifestations affecting the mucosal-associated lymphoid tissues (malt), of the gi tract (galt), skin (salt), nasal (nalt) and bronchial tissues (balt). the objective of the present study was to evaluate specific immunologic alterations in a group of patients with non-ige fa. peripheral blood cd4 and cd8 lymphocyte subset analyses were performed in 10 patients with fa documented by double-blind placebo-control food-challenge (dbpcfc). all patients were treated with an amino-acid based formula (aabf) and then received an open challenge using a panel of commonly offending allergenic food allergens in a normal diet.the clinical picture of all 10 patients with fa were linked to malt-related manifestations; 8 with galt symptoms of diarrhea, vomiting, abdominal pain and ftt, 4 with balt symptoms of asthma, 4 with salt symptoms of eczema, 3 with nalt symptoms of rhinitis and 2 with edema, ascites and anaphylaxis. all subjects had normal serum ige and eosinophil levels, negative ige food rast tests, normal cd4 (mean 1562 + 368) and very low cd8 (174 + 42) levels in peripheral blood. abnormal cd4/cd8 ratios >3.5 were observed in all patients. age-and gender-matched controls revealed cd4/cd8 ratios ranging from 1.5 to 2.5. both patients with anaphylaxis had cd4/cd8 ratios >6. all patients responded well to aabf. open challenge to common offending foods from a regular diet (milk, soy, wheat, egg, nuts, beef and chicken), revealed multiple food allergies. after two years of follow-up on an aabf regimen, the 10 patients remain well but allergic to multiple foods. very low cd8 levels remain as the unique immunological alteration in all 10 patients.these studies suggest that abnormalities of very low cd8 distribution may play a pathogenetic role in non-ige mediated fa. since cd8 lymphocytes play a role in immunologic tolerance (it), it is tempting to speculate that the very low cd8 levels may signal the failure of development of it in our patients predisposing them to the development of allergies to multiple food components. background: mixed connective tissue disease (mctd) is a disease taht have caused controversy, while some authorities consider it a distinct rheumatic disease, others believe that it's an early stage of a fully defined autoimmune disease. the distinctive feature is the presence of the u1 small nuclear rnp autoantibodies. clinical features involve raynaud's is phenomenon, swollen hands, sclerodactyly, esophageal hypomotility, polyarthritis, and myositis, allof them can be present in others well deined rheumatic diseases. only aew cases have been described in the pediatric population. objetive: to determine the frecuency of mixed connective tissue disease in mexican.children in a tertiary level institution according to kasakawa's criteria, alarcon-segovia's criteria and sharp's criteria and establish if a diagnosis of a well defined autoimmune entity was made during the follow up. methods:medical charts were assessed with the diagnosis of mctd between 1988 and 2003 in our hospital. results: between 1988 and 2004, 9 , 919 cases of autoinmune diseases were treated; 310 with systemic lupus erythematosus(sle), 6544 with rheumatoid arthritis(ra), 1, 128 with scleroderma and 1, 937 with dermatomyositis. we found only four cases, 3 of them did not complete the kasakawa's criteria but the diagnosis was probable according to alarcon-segovia and sharp's criteria. one of them developed sle after one year of follow up. the case that fulfilled the diagnosis criteria of mctd; raynaud's phenomenon, rnp antibody positive, arthritis, lymphadenopathy, restrictive pulmonary disease, sclerodactily and muscle weakness developed a full blown sle at 10 years follow up. discussion: the disease is extremely rare in children. we conclude that at least in pediatric age the disease may not exist by it's own, but it's an early stage of a defined autoimmune disease, and the terminology "un differentiated connective tissue disease" is more appropriate to define this cases. a. baysan * , h.y. song, s. gupta, l. yel, irvine, ca. hereditary angioedema (hae) is an autosomal dominant disease characterized by episodic angioedema of the skin or mucosa of the respiratory and the gastrointestinal systems. hae is caused by a quantitative (type i) and/or functional (type ii) deficiency of plasma protein c1 inhibitor, an early component of the classical complement pathway. attacks of hae may be lifethreatening and even cause death when the airway is involved. here, we report a 67 year-old female patient with hae type ii, who has seven affected family members, two of whom died of laryngeal angioedema. the patient had a history of recurrent swelling of the eyelids, lips, tongue and extremities, and respiratory distress since five years of age. she was hospitalized on several occasions one of which required intubation and assisted ventilation. laboratory studies, between the attacks, revealed normal serum ch50 and complement c3 levels. complement c4 level was decreased to 5 mg/dl (n:16-47 mg/dl). c1 esterase function was impaired, 46% (n: greater than 68%) in contrast to normal quantitative c1 esterase. the patient was on long-term danazol treatment for ten years and experienced side effects, most notably hirsutism. currently, there are limited efficacious and safe treatment options for hae. the treatment of choice for acute attacks and prophylaxis appears to be the c1 inhibitor concentrate, which is not yet licensed in the us. the present patient emphasizes the need to establish the correct diagnosis and an appropriate management plan in recurrent angioedema. j. hajsam * , l. ponomarjev, krasnodar, russian federation. background: the previous investigations indicate on the positive effects of ncir in different chronic inflammatory and infectious diseases. nevertheless, the mechanisms of the clinical efficacy of ncir remain still unknown. the aim of this investigation is the study of the immune disorders in patients with chronic tonsillitis and the immunomodulatory effects of the complex treatment in combination with ncir. methods: 55 children with chronic tonsillitis in the age from 7 to 14 years old were under the observation. the t cell receptors (cd3+, cd4+, cd8+, cd16+, cd25+, hla-dr+) have been studied using flow cytometry method. the cytokines (il6, gamma ifn and il18) have been investigated by eliza method. the treatment include traditional methods in combination with ncir. control group (without tonsillitis) consists of 56 children of the same age. results: it has been shown that in chronic tonsillitis was dcrease of the number of cd3+, cd25+ and hla-dr+ cells. the decrease of cd3+ cells was mainly due to decrease of cd4+ cells. at the same time it has been shown the increase in number of cd8+ cells. in chronic tonsillitis have been determined the increase in serum proinflammatory cytokine il6 level in 3.6 times (p<0.001). at the same time the levels of gamma ifn and il18 were lower than in control up to 3-4 times. the studied treatment method including ncir resulted in increase in the number of cd4+ and cd25+ cells. the level of il6 decreased from 95 pg/ml to 28.4 pg/ml. at the same time the serum concentration of gamma ifn and il18 increased up to 2.4 and 1.9 times, accordingly. conclusion: in chronic tonsillitis it has been shown the immune disorders in t cell's subpopulations and cytokine production. the efficacy of ncir mainly depends on the normalisation in t cellular subpopulations and increase in the concentration of gamma ifn and il18. introduction: viral hepatitis is characterized by suppression of cd4+th1cell function related to disease severity. the aim of our research was the determination of total ige concentration and anti-c1q-autoantibodies levels in patients with viral hepatitis c (vhc) and mixed viral hepatitis (vhb+c) and the investigation of their correlation with t cell parameters. methods: 31 patients with vhc and 11 patients with vhb+c confirmed by pcr were examined. evaluation of serum total ige level was performed by elisa kits produced by "vector-best", russia. immunophenotyping of peripheral blood mononuclear cells (pbmc) was done by cytometry with monoclonal antibodies to cd3, cd4, cd8, cd11b, cd16, cd20, cd25, cd95 and hla-dr-antigens. results: the level of serum total ige in patients with vhc and vhb+c was significantly increased in all groups studied, especially in acute hepatitis c (526.8â±129.4 mu/ml, p<0.05) compared with the control group. analysis of pbmc subpopulations in patients with vhc and vhb+c was done related to the total ige level: group i -0-200 mu/ml; and group ii ->200 mu/ml. in patients with viral hepatitis and high total ige level, the content of cd3+t-lymphocytes, cd4+t-cells and cd4/cd8 ratio were significantly decreased compared with the control group (p<0.05). more notable changes were found in patients with acute vhc and vhb+c. the increase in cd20+-cell content was seen in groups with both low and high levels of total ige. the content of cd16+-cells in patients with high levels of total ige was also increased (p<0.05). conclusion: patients with vhc and vhb+c had significantly greater levels of total ige compared with the control group (p<0.05). the increase in total ige levels in patients with viral hepatitis is associated with imbalances of t-lymphocyte subpopulations, including a decrease in cd4+t-cells, and an increase in b-and nk-cells. title: occupational airway allergy among health care workers (hcw) with latex allergy. introduction: for the last years the frequency of latex allergy has increased. health care workers (hcw) is the risk group of this diseases. latex allergy symptoms occure in different organs -including skin, conjunctive, nose and bronchi. study aim:the aim of this study was to estimate the incidence of airway allergy in group of hcw with latex allergy. materials and methods: the investigations were carried out in a group of 252 hcw, aged 21-67 (average age 36, 3). there were two hundred and eight women and forty four men in the group. investigation consisted of questionaire examinations, skin prick tests (latex), patch tests (rubber additives), sige (latex) and spirometry. results: seventy eight (31%) hcw reported undesirable effects after the contact with latex products. fourty (15, 9%) hcw reported symptoms of airway (nose and bronchi). latex allergy (spt and/or sige and anamnesis positive) was diagnosed in 49 (19, 4%) cases. the symptoms concerned with: skin, nose and conjunctive (12 cases, 25%); skin and conjunctive (2 cases, 4%); nose and conjunctive (2 cases, 4%); nose and skin (5 cases, 10%); bronchi, skin, nose, and conjunctive (2 cases, 4%) and only skin in 26 cases (53%). conclusions: the incidence of occupational airway allergy in group of health care workers with latex allergy is high (43% of all cases). latex allergy symptoms usually affect skin, but sometimes it includes also other organs -conjunctive, nose and seldom with bronchi. the incidence of anaphylaxis is increasing. the food allergy and anaphylaxis network wishes to expand the use of injected epinephrine by first responders to allergic emergencies. in indiana, there are 7, 500 first responders, 14, 900 basic emts, 1, 350 advanced emts, and 2, 500 paramedics. the use of injected epinephrine was only permitted by paramedics and advanced emts (17% of all responders). in 2002 a bill was introduced to expand the use of injected epinephrine by ems personnel in the event of an allergic emergency. it was sponsored by the indiana allergy asthma and immunology society and the emergency medical services commission of indiana. on july 1st 2003 senate bill no. 213 took effect permitting all first responders to administer, without restrictions, injected epinephrine. once the legislation passed it became the responsibility of the medical director (md) of each ambulance service in the state to implement the change. in an attempt to assess the impact of this legislation we surveyed each of the mds in the state 9-12 months after the passage of the bill. mds were notified of the legislation by memo and public meetings. in addition each md received a copy of the legislation. of the 266 mds, 56 (25%) responded to the survey. results: 1. unaware of the legislation: 14 (25%) 2. aware of legislation but no implementation: 9 (16%) 3. aware of legislation with implementation restricted to basic emts: 29 (52%) 4. aware of legislation and implementation at all levels: 4 (7%) conclusions: twenty-five percent of mds were unaware of legislation. among those that implemented changes the majority (52%) permitted use by basic emts only. allergists, lay organizations, and ems commissioners need to assure implementation of legislation with all mds within the state. a. khadavi 1* , b. silverman 2 , a. schneider 2 , 1. great neck, ny; 2. brooklyn, ny. rabbit anaphylaxis is extremely rare, with one documented case upon inhalation only. we describe a patient with severe anaphylaxis upon consumption of a rabbit. a 6-year-old female with a 3-year history of asthma and allergic rhinitis was presented for evaluation. the patient complained of worsening asthma and rhinitis symptoms in the home and upon exposure to outdoor pollen. further history revealed the family had a rabbit as a pet. laboratory testing showed her total ige was 865 ku/l, rast results were normal for tree, ragweed and molds (<0.35 kiu/l). positive results were found for ragweed, dust, cockroach, cat, dog, mouse, peanut and rabbit epithelium (8.43 kiu/l, class iv). among other environmental control measures, the family was advised to eliminate the rabbit from the home environment, as it could be a potential trigger for their daughters allergy symptoms. two days later, the patient presented to the emergency room with wheezing, coughing and angioedema of the hands and face. she was treated with albuterol, diphenhydramine and oral steroids. the parents said they followed all of our instructions and did not know why anaphylaxis occurred. further questioning revealed that the family consumed the pet rabbit on the same night preceding the anaphylactic reaction. this was the first time the daughter ate rabbit. the parents assumed that only exposure to the live rabbit would worsen her allergy and asthma symptoms, never expecting an allergic reaction via ingestion. they were advised not to feed their daughter rabbit again and were given a prescription for self-injectable epinephrine. this demonstrates either complete identity, partial similarity or cross reactivity between inhaled and food allergens, as has been noted previously with certain other foods such as garlic and crustacean proteins. physicians need to advise food allergic patients that an allergic reaction can develop upon inhalation of the food, as seen with peanuts. but also respiratory sensitization to an allergen can lead to allergic symptoms upon its ingestion. t. nsouli 1* , j. scheiner 2 , j. malka-rais 2 , j.a. bellanti 2 , 1. burke, va; 2. washington, dc. the safety of selective cyclooxygenase-2 (cox-ii) inhibitors in patients with known nsaid-induced allergic reactions has not been definitely established and is still open to debate. in the present report, we describe two patients with hypersensitivity reactions to naproxen, the first characterized by a systemic anaphylactic reaction and the second by localized urticaria following ingestion of the drug. the first case was a 56 y/o wf with a history of osteoarthritis who, 15 minutes after the ingestion of 375 mg of naproxen, developed generalized pruritus, urticaria, laryngeal edema and hypotension. she was treated in the er with epinephrine, diphenhydramine and iv corticosteroids. epicutaneous and intradermal skin testing to celecoxib revealed negative results similar to a control. an oral challenge with celecoxib was well tolerated by the patient without any adverse responses. the second case was a 57 y/o wf with a known history of chronic urticaria and osteoarthritis requiring regular use of naproxen. a complete allergic and immunologic workup was negative. upon discontinuation of the drug there was resolution of the urticaria. an oral challenge with celecoxib was well tolerated by the patient without adverse sequelae. these two case reports exemplify two extremes in the spectrum of adverse allergic reactions to naproxen, a non-selective cox-i and cox-ii inhibitor, one systemic, the second localized and suggest that the pathogenesis of these symptoms was most likely pseudo-allergic in nature and not immunologically-mediated. the dissimilar chemical structures of naproxen and celecoxib together with their differing mechanisms of action suggest that the absence of allergic reactions to challenge with celecoxib, a cox-ii inhibitor, may be related to a lack of cross-reactivity between the two drugs. although these findings suggest that oral celecoxib could be a possible safe alternative in patients with naproxen-induced drug reactions, it would be prudent to first conduct careful challenges with the drug in a well-equipped medical setting where clinical acceptability and tolerability could be safely assessed. introduction: most fixed and removable dentures are made from casting alloys. many orthodontic appliances are also fabricated from metallic biomaterials. it has been documented in vitro and in vivo, that metallic restorations release metal ions mainly due to corrosion. those metallic ions may be distributed systemically and locally and could pay a significant role in the induction of oral or/and systemic immunoinflammatory conditions. this study determines the frequency of sensitization to metal salts and clinical characteristics in the group of patients with complaints related to adverse effects of dental alloys. methods: 31 patients (29 women and 2 men) aged 35-71 years with symptoms assumed to adverse effects of dental alloys were studied. all patients were studied with base metal salts, including cu 2+ , co 2+ , cr 6+ , mg 2+ , mn 2+ , ni 2+ , ti 3+ , zn 2+ using patch tests. all patch tests substances were 3% salts in petrolatum. the patch tests were conducted in accordance with recommendations of the icdrg. occlusion time was 2 days, and patch tests were read when removing the patches (finn chambers on scanpor, epitest ltd oy, tulusa, finland) and 2 to 4 days later. the total number, percentage of irritant and allergic patch test reactions were calculated. results: in 25 of 31 patients (80%) sensitivity to base metals used in dental restorations was noted. symptoms included burning mouth (45%), metal taste (19%), electrical sensations (11%), dry mouth (9%), and taste irritation (12%), but 16/31 patients (54%) had no symptoms. local gingivitis (19.3%), anomalies of the tongue (12%), stomatitis (12%) and lichenoid reactions (6%) were often seen. the most frequent patch test reactions were caused by ni (45%), cr (41%) and co (19%) . conclusion: this study demonstrated higher frequency of hypersensitivity reactions to ni, cr and co in this group of patients often having symptoms such as burning mouth, metallic taste, electrical sensation, local gingivitis, and anomalies of the tongue. w.y. mak * , s. kearney, b. silverman, a. schneider, brooklyn, ny. the process of intravenous drug desensitization often involves simple but tedious calculations. miscalculations may arise due to human error. for patients who are truly allergic to the drug in question, such errors can be life threatening, if not fatal. we propose the use of a spreadsheet to minimize such calculation errors. spreadsheets, such as microsoft excel, ibm lotus 1-2-3, and corel quattro pro, are used extensively in finance for tedious and repetitive calculations. this property of a spreadsheet makes it an ideal tool to assist with any drug desensitization protocol. we chose microsoft excel for its availability at our institution. a general template was initially created with equations in specific cells which were based on the protocols listed in patterson's allergic diseases, 6th edition and middleton's allergy: principles and practice, 5th edition. by inputting specific numbers, such as the amount of drug and volume of diluent into key cells of the spreadsheet, the program will automatically calculate the protocol for the given intravenous drug. an example of our pipericillin protocol is listed below. we find that the use of a spreadsheet not only minimizes calculation errors and hence reduces the likelihood of avoidable reactions; but also decreases our preparation time for the desen-sitization protocol. we recommend its use for all allergists performing drug desensitizations. states 25 years ago, the infestation of homes across the northeast, southeast and midwestern states with these insects during the fall and winter months has become increasingly common. in the last 5 years, several investigators have published case reports of patients with allergic rhinitis, conjunctivitis and asthma symptoms associated with suspected inhalational exposure to high levels of proteins from these beetles. we report a series of 5 patients who presented with a spectrum of various allergy complaints ranging from symptoms of allergic rhinitis, asthma, urticaria, angioedema and acute anaphylaxis (with documented elevated serum tryptase) on exposure to high numbers of multi-colored asian ladybeetles(malb.) methods: we performed western blotting with the patients' serum and a whole-body ladybeetle extract made from confirmed h. axyridis obtained from one of the infested homes in that region. results: blots with the patients' serum revealed ige binding to 3 different proteins with molecular weights approximately 8, 28 and 78 kd. the serum from two patients bound a 28 kd protein possibly similar to the 30 kd protein previously identified by yarbrough et al. jaci 1999; 104; 704-5 . ige from four patients bound to an 8 kd protein not previously reported. lastly, serum from two patients revealed ige binding to a 78 kd protein possibly similar to the heavier proteins mentioned in an abstract by magnan et al. jaci 2002; 109; 580 . conclusion: we present five patients with specific ige to malb and allergic symptoms on exposure to high levels of malb. we conclude that malb are likely a significant source of several different allergenic proteins and that malb are increasingly becoming a significant cause of a wide variety of hypersensitivity reactions across the united states. as multiple exposed subjects and several entomologists report that these beetles bite humans, we speculate that a wide range of ige-mediated symptoms including urticaria, angioedema and anaphylaxis can occur by exposure to proteins by inhalation, direct contact and possibly by inoculation of these proteins into the skin by the bite or scratch of this beetle. a case report and literature review. c.s. taylor 1* , s. ramesh 2 , 1. getzville, ny; 2. buffalo, ny. introduction: lentils belong to the legume family and are the staple ingredient of the ethnic indian diet. lentils have been shown to cause allergic reactions and even anaphylaxis. however, little research has been done to distinguish the types of lentils used commonly in the indian diet and their various hypersensitivities. some of these lentils include the black gram (phaseolus mungo), mung bean and split chick peas (bengal gram). case report: we report a 19-month-old indian boy who presented with severe atopic dermatitis since the age of four months. his dermatitis was exacerbated by the ingestion of peas and beans and resolved with the avoidance of such. at nine months of age, the child was introduced to boiled mung beans and subsequently developed lip swelling within a few minutes. a similar reaction occured with split chick peas. physical exam at consultation revealed severe eczema. skin tests using commercial extract revealed 5+ response to peanut (he had never eaten peanuts), soybean, pea and egg. subsequent skin tests at the follow up visit to prepared reagents revealed much greater than 5+ response to mung bean, chick pea, split chick peas, and black gram. the patient developed a systemic response during testing which required epinephrine. discussion: legume allergy (other than peanut, soy and peas) is rare in the unites states but has been reported in asia and the mediterranean area. it has been reported in one case series that patients with lentil allergy react to more than one lentil. there is a five percent cross reactivity between peanut and other legumes such as soy and peas. however, the extent of cross reactivity between peanut and the other legume sub-groups (ie. lentils) is not well documented. there also appears to confusion in the labeling of the various lentils used in ethnic diets. conclusion: this case has been presented to make allergists aware that there are many differnt types of lentils that can cause hypersenstivity reactions and the importance of considering ethnicity and dietary habits in evaulating for food allergy. background: epinephrine is the drug of choice for the treatment of anaphylaxis however it is frequently underutilized. one possible reason is the fear of adverse cardiac effects. the most common side effects of epinephrine are palpitations, tachycardia, sweating, nausea, vomiting, respiratory difficulty, pallor, dizziness, weakness, tremor, headache, nervousness, anxiety and arrhythmias. a previous study showed that administration of epinephrine, in a small number of healthy adults did not cause any significant cardiac adverse events and vitals sign changes were not clinically significant. the purpose of this retrospective analysis is to determine the safety profile of epinephrine in a large number of patients that were administered epinephrine for treatment of anaphylaxis that occurred in a physician's office. methods: all patients in an allergy office, that were administered epinephrine for acute anaphylaxis between 1999-2004 were selected for this retrospective analysis. a chart review for adverse events and vital was conducted. vital signs and side effects had been monitored every 5 to 10 minutes for minimum of 30 to 90 minutes after the administration of epinephrine. results: 105 patients between the ages of 8yrs to 55yrs received 128 injections of epinephrine. after an injections of epinephrine 60% of the patients had a pulse between 50-90, 27% between 72-100, and 13% between 102-110. systolic blood pressure determined 81% of patients to be between 80-140, with 10%, between 142-160, and 7% between 162-170, and 2% between 172-180. concurrently, diastolic blood pressure was found to have 94% between 50-90, 3% between 92-100 and 3% betweem 102-110. the most common reported side effects were tremor, headache and pallor. any rise in blood pressure and heart rate after epinephrine was transient and returned to normal within 90 minutes of observation. there were no serious side effects. all patients responded to the epinephrine and were able to go home. conclusions: this retrospective analysis revealed that the administra-tion of epinephrine is safe and effective for the treatment of acute anaphylaxis in an outpatient setting. the use of epinephrine for treatment of anaphylaxis is life-saving and its use to treat non-cardiac or elderly patients who have anaphylactic reactions should be encouraged. purpose: a clinical pathway was established to decrease the use of vancomycin in surgical patients with self-reported penicillin (pcn) allergy. methods: in 2001, our institution developed a preoperative evaluation (poe) clinic for elective surgical patients. in june 2002, on-site, same-day allergy consultation and penicillin skin testing was made available for preoperative patients with self-reported pcn allergy. we reviewed the antibiotic recommendations, the actual administration of vancomycin, and compliance by the surgeons with our recommendations from july 1, 2002-september 16, 2003. results: during this time, 11, 819 patients were seen for their preoperative medical exam at the poe clinic, and 1204 were evaluated for pcn allergy. of these, 1120 patients met irb standards to participate in the study. the mean age of the patients was 60 years. the top three surgical specialties represented in the poe clinic were orthopedic (28.4%), urology (22%), and neurosurgery (15%). of the 1120 patients, 1031 underwent skin testing for pcn allergy. eighty-five percent (85%) or 951 of these patients with a history of pcn allergy were recommended to use -lactams such as cefazolin, and 164 (15%) were recommended to avoid -lactams. forty-three (43) or 4% had one or more positive skin tests to pcn. of the 1120 patients, 957 patients actually received pre-operative antibiotics. of these 957 patients, 718 (75%) of those received cefazolin, 60 (6%) received clindamycin, 33 (3%) received ciprofloxacin, 25 (2%) received levofloxacin. some patients received more than one antibiotic for prophylaxis. only149 (16%) patients received vancomycin. conclusions: establishment of a clinical pathway in a preoperative clinic that includes allergy testing and consultation reduced vancomycin use to only 16% in surgical patients with a history of penicillin allergy. h. yarmohammadi * , a. nowak-wegrzyn, new york, ny. introduction: anticonvulsant hypersensitivity syndrome is a potentially fatal drug reaction with cutaneous and systemic reactions to the arene oxideproducing anticonvulsants. in most cases, the hallmark features of fever, rash, and lymphadenopathy are accompanied by multi organ-system abnormalities. fatal outcomes are most often associated with liver failure. recognition of the syndrome, which may have variable presentations, is the key to prompt discontinuation of the drug, close monitoring, and management. case 1: a 16y/o male received dilantin for seizure prophylaxis following craniopharyngioma resection. fourteen days later he was readmitted for fever and csf leak from surgical site. he was started on ceftriaxone and vancomycin empirically; an lp and pan culture was done. he continued to have low grade fever and, on the 6th day of admission, developed a maculopapular rash on trunk. on day 8th lfts increased and cbc showed eosinophilia. antibiotics were stopped but lfts continued to rise. on day 10, dilantin was stopped and lfts normalized in 2 days, fever stopped and rash disappeared. case 2: a 17 y/o girl was admitted to the hospital with generalized rash, facial edema and fever (39 degrees c). she developed a pruritic maculopapular erythematous rash over her trunk and face 2 weeks prior to admission. she then developed high fever. three months prior to this visit she had been started on phenytoin (300mg/kg) for control of grand mal seizure. physical exam revealed cervical and axillary lymphadenopathy. she had elevated wbc (13, 400), eosinophilia (20 %), and elevated lfts. phenytoin was stopped upon admission but 24 hours later she continued to have fever, elevated lfts and devel-oped erythema in her mouth. treatment with ivig and prednisone was initiated and resolution of symptoms was seen within 2-3 days after therapy. conclusions: the timely recognition of anticonvulsant hypersensitivity syndrome is important, because accurate diagnosis prevents potentially fatal re-exposure and influences subsequent anticonvulsant treatment options. ivig and prednisone should be considered in situations where prompt improvement of the lfts or clinical symptoms is not observed. the recently published results of a telephone survey about the prevalence of seafood allergy in the us indicate that seafood allergy is a significant health concern. aim of the present study was to retrospectively review our data on the topic. we have interviewed 7391 subiects attending our allergy outpatients about any suspected food allergy. over 95% were 14 years or older. any reaction to food was reported by 33% of the patients, more frequently by women. of these 2419 patients, 125 reported reactions to seafood (5%) with an overall prevalence of seafood reactions of 1.7%: 50 to fish (0.7%), 58 to shellfish (including mollusks) (0.8%) and 17 to both (0.2%). in the case of the reactions to fish it is quite possible that shellfish is also included, as the patients were often unable to tell the role of finfish from shellfish apart. this is most probably due to the fact that seafood dishes or a complete seafood meal in italy generally include both shell and finfish. in only less than half cases there was a convincing relationship between the ingestion of seafood and the reaction. the reactions reported were: gastrointestinal (17), non life-threatening angioedema (15), mild oral allergy syndrome (13), acute urticaria (9), asthma (3), rhinoconjunctivitis (2). the gastrointestinal reactions might not all be true (ige-mediated) allergic reactions, but also toxic. in conclusion, even in a selected population like that attending an allergy clinic and using a broad definition of adverse reaction, seafood allergy appears to be a rare phenomenon and of limited clinical impact, the prevalence of moderate to severe reactions (angioedema and asthma) in the whole selected population being 0.2%. clopidogrel (plavix) is an antithrombotic agent currently used to prevent thrombotic cardiovascular events by inhibiting adenosine diphosphate (adp)dependent platelet activation. clinically, it has been used in patients with aspirin intolerance or who developed neutropenia from ticlopidine. there have been reported cases of clopidogrel causing rash and urticaria. often these patients are told they are allergic to clopidogrel and should not take it again, despite the fact that no workup was ever performed to elucidate whether the reaction was indeed immunologic in nature. a review of the literature revealed no reported attempts at desensitizing a patient to clopidogrel after a presumed immunologic drug reaction. we present the case of a 49 year-old female who initially took clopidogrel (75 mg. p.o. daily) for transient ischemic attacks. after tolerating the medicine for five days, it was replaced with an aspirin/warfarin combination, which she took for the next five days. reintroduction of clopidogrel a week later was uneventful, until she developed a pruritic, maculopapular rash on the 5th, through 7th days of restarting therapy. at that time, she was not taking any other medications, and had no cardiopulmonary or gastrointestinal complaints. she had discontinued the clopidogrel and was asymptomatic during our consultation. skin testing was done using clopidogrel prepared at concentrations of 1 mg/ml and 1/10 mg/ml. at the same time, control skin testing on three non-atopic subjects was performed and produced no reaction to either epicutaneous or intradermal testing. by contrast, the patient had a positive skin reaction at both concentrations on intradermal testing. the patient was hospitalized for an oral desensitization where clopidogrel dilutions were prepared by the hospital pharmacy. the patient tolerated an initial dose of 0.02 mg. serial three-fold increases in concentration were given every 15 minutes, until a total cumulative dose of 77 mg. was reached. the patient tolerated the entire procedure and suffered no adverse reactions upon continuation of the treatment. this demonstrates the utility of oral desensitization to clopidogrel in patients with a positive skin test who require this medication. lamotrigine is a non-aromatic anticonvulsant with desirable pharmacological profile. the most common idiosyncratic reaction in children is rash (10-20%). severe cutaneous adverse reactions and systemic hypersensitivity reactions are uncommonly reported. method: case presentation an 11-yearold caucasian female was prescribed lamotrigine in escalating dose for her first generalized seizure. a week later she developed a pink rash on her cheeks gradually progressing to her trunk, hands and feet. three days later she was seen in the er and treated for possible streptococcal-pharyngitis with fever and rash. oral penicillin-v treatment was initiated. the rash continued to spread all over her body with mild pruritis and sores on lips and mouth. few blisters were noted in left ear, hands and feet. later lamotrigine was discontinued. oral steroids were prescribed. she continued to develope new blisters, rash and hemorrhagic plaques and dysuria. she was later transferred to our institute. the physical examination was significant for afebrile girl without pallor and icterus. bilateral conjunctivitis without keratitis evident. tender cervical lymphadenopathy was palpable. multiple ulcers on lips and gingiva were seen. several targetoid lesions on trunk and extremity were noted along with few hemorrhagic plaques on extremities. superficial sloughing of distal fingers and toes was noted. nikolskys sign was not demonstrable. the systemic examination was unremarkable. laboratory tests: hemoglobin 14.2g/dl, wbc-normal range without eosinophilia. normal pt/aptt and inr. liver function tests showed elevated sgpt-1380iu/ml and sgot-225iu/ml with normal bilirubin. urine analysis was normal. serology for cmv, ebv, hsv and hepatitis a and b was negative. skin biopsy showed full thickness epidermal necrosis and sub epidermal clefts. aggressive supportive therapy was initiated. corticosteroids were continued for five more days. prior to being discharged from hospital the rash had dried and most lesions faded. the blisters and oral ulcers had healed. the liver enzymes had decreased. conclusions: we report an occurrence of stevens-johnson syndrome with lamotrigine in a young child. in the literature severe reactions are associated with higher doses or rapid escalation of the dose, and concomitant use of valproate. early recognition and withdrawal of medication is necessary to improve the outcome. introduction: in patients with a history of penicillin (pcn) allergy and negative pcn skin tests to major and minor determinants, 97-99% of patients will tolerate pcn administration without risk of an immediate reaction. in fact, middletons allergy principle & practice reported that no life-threatening false-negative reactions have been reported when pcn was administered after a negative pcn skin test. we describe a case in which a patient with a history of pcn allergy and negative pcn skin tests to the major and minor determinants experienced life-threatening anaphylactic shock when administered piperacillin/tazobactam. case history: a 38-year-old woman with crohns disease was admitted for treatment of an enterocutaneous fistula. three months before admission, the patient reported a severe reaction to either piperacillin/tazobactam or intravenous (iv) lorazepam needing respiratory support in the intensive care unit. in order to delineate this problem, an allergy consultation was obtained. serum ige antibodies to pcn, measured by a commercial cap system radioallergosorbent test (rast) fluoroenzymeimmunoassay (feia; pharmacia and upjohn, uppsala, sweden), and pcn skin tests to major and minor determinants were negative. a skin test (prick and intradermal) to piperacillin/tazobactam at 4.5mg/ml was also negative. five minutes into receiving 3.375 grams of piperacillin/tazobactam iv, the patient reported feeling lightheaded, flushed, nauseated, and diaphoretic. the blood pressure decreased to 80/50 from a baseline of 110/60, heart rate 150/minute and appeared toxic. no wheezing or rash was noted on physical examination. patient was treated with iv epinephrine, diphenhydramine, and dexamethasone and recovered without sequela. serum tryptase, drawn 1 hour after the beginning of the reaction, was elevated at 56.3 ng/ml but decreased to 17.6 ng/ml 12 hours later. complement levels were normal. conclusion: despite a very high negative predictive value of a negative pcn skin test to the major and minor determinants and reports that no life-threatening false-negative reactions have been reported when pcn is administered after a negative pcn skin test, physicians need to be very cautious in administering piperacillin/tazobactam and other b-lactams in patients with a history of severe reactions such as anaphylaxis to past pcn administrations. a. majmundar * , d.a. khan, dallas, tx. introduction: a variety of adverse drug reactions have been reported after therapy with allopurinol. successful protocols for desensitization to allopurinol have been developed. we report a case of a patient who was successfully desensitized to allopurinol only to develop dress after four months of allopurinol therapy. methods: a 57 year old man was referred to our department with a remote history of rash and fever resulting in hospitalization after initiation of allopurinol. due to severe gouty arthritis unresponsive to colchicine and requirement of chronic steroids, it was recommended to attempt allopurinol desensitization. based on the history of his prior reaction, a slow desensitization protocol was performed beginning with allopurinol 10î¼g and increasing the dose weekly to 25î¼g, 50î¼g, 100î¼g, 200î¼g, 500î¼g, 1mg, 5mg, 10mg, 25mg, 50mg, and 100mg. the patient tolerated the entire desensitization protocol without adverse reaction and was initiated on daily allopurinol at 200 mg per day. results: four months after desensitization and daily allopurinol use, the patient developed fevers and an acute maculopapular eruption on his back and abdomen without mucosal involvement. laboratories demonstrated eosinophilia of 936 cells/mm 3 , elevated ast of 101, alt of 102, and ggt of 163 u/l. he was treated with prednisone 80mg a day which was tapered weekly over 5 weeks with successful resolution of his symptoms, eosinophilia and transaminitis. conclusion: while desensitization to allopurinol can be safely accomplished, allergists need to be cognizant of the potential for delayed serious drug reactions such as dress. wiskott aldrich syndrome is an immunodeficiency characterized by eczema, pyogen infections, and mixed immunodeficiency.we describe a male seven-month old, perinatals antecedents without importance who had an ulcer in site of application of bcg. non-blood relatives, healthy parents. at twomonths-old, he initiated with continuous fever, not quantified, treated with multiples antibiotics without resolution, he was hospitalized, plaquetopenia and anemia were diagnosed, he received a red globules and plateles transfusion, one week after he presented a disseminated dermatosis characterized by erythema and desquamation, at four-month-age presented right axillary adenomegaly, hepatoesplenomegaly and recurrent bilateral media otitis for what was hospitalized in our institute. he was malnutrition, bad general condition, febrile, with disseminated dermatosis affecting the head, trunk and extremities characterized by erythema and desquamation, in addition he had left ankle cellulitis, right axillary adenomegaly, hepatoespenomegaly. during his hospitalization he presented left hand cellulitis, hairy skin abscess, oral candidiasis, required surgical treatment by econdary compartimental syndrome because cellulitis of left ankle. persistent hemogram reported thrombocytopenia with normal platelet volume, blood cultives were positive for grampositive bacterias, isoaglutinines, were normal. immunoglobulines were elevated for the age range, he received antimicrobial and antifungic treatment. but he died. in the autopsy timic alymphoplasia was reported, cortical lymphoid depopulation in lymphatic ganglia and spleen, disease by disseminated cytomegalic inclusion, multifocal pulmonary pneumocystosis, bcgitis, disease graft versus guest. . with the previous features we concluded in a compatible mixed immunodeficiency with wiskott-aldrich syndrome with particular characteristics that make this case interesting. the patient course with cellular immune deficiencie with thrombocytopenia and eczema, even when he didn't have platelet sizing diminished, we consider that the patient had a severe of wiskott s aldrich syndrome and at the moment we are awaiting result of genetic study uasp gene. background : hypersensitivity to mosquito bites (hmb) is a disorder characterized by necrotic skin reaction and systemic generalized symptoms subsequent to mosquito bites. it has been suggested that hmb is associated with chronic epstein-barr virus (ebv) infection and natural killer cell leukemia/lymphoma. we describe here a korean child who had hmb associated with chronic ebv infection and natural killer cell lymphocytosis. case : a 5-year-old male was admitted with well-demarcated necrotic skin lesions and severe swelling on right ear lobe developed after mosquito bites. he had suffered several similar symptoms since last summer, which complicated as deep scars on skin. hepatosplenomegaly or peripheral lymphadenopathy was not detected. laboratory tests showed wbc 7, 280/mm3 (neutrophil 39%, lymphocyte 56%), total eosinophil count 156/mm3, ige by prist above 1, 000 iu/m. immunoglobulin levels were normal. specific ige for aedes communis by cap was negative. lymphocyte subset analysis demonstrated increased nk cells (cd16+cd56, 43%) and decreased cd3 and cd4 cells. igm for anti-nuclear antigen (ebna), igm for viral capsid antigen (vca) and igm for anti-early antigen (ea) dr to ebv were negative. but the levels of anti-vca igg (> 200 u/ml), anti-ea dr igg (> 150 u/ml) and anti-ebna igg (62 u/ml) were increased. type a eb virus was demonstrated in blood mononuclear cells by dna pcr method, and eber in situ hybridization was negative in necrotic tissues. immunostaining with nk-cell marker (cd56) revealed many immunoreactive cells with the perivascular inflammatory infiltrates in tissue. skin patch tests for mosquito allergen (aedes togoi and culex pipiens) showed positive response to c. pipiens. introduction: scimitar syndrome is a congenital anomaly resulting in anomalous pulmonary venous return from the right lung to the inferior vena cava. recurrent respiratory infections have been associated with scimitar syndrome. methods: we report on a 16 year-old adolescent female who presented to immunology clinic with recurrent pneumonias. results: the patient presented with numerous recurrent pneumonias, multiple er visits, and hospitalizations. she complained of intermittent chest pain, cough, fatigue and exercise intolerance. the patient had a large secundum atrial septal defect surgically corrected at 5 years of age. a cardiac echo obtained at 7 years of age revealed rvh, but was normal at 9 years of age. she was a known atopic asthmatic. previous immunologic workup was normal with iga 183 (33-202), igg 1290 (633-1280) and igm 97 . at presentation to our clinic pulmonary functions were fvc of 79% and fev1 of 78%. review of previous chest radiographs showed chronic changes with an opacity partially obscuring the right hemidiaphragm. a high resolution chest ct-scan showed a large irregular venous structure extending through the right chest joining the inferior vena cava above the liver consistent with scimitar syndrome. the patient was referred to pediatric cardiology who recommended surgical correction. conclusion: scimitar syndrome may present as recurrent pneumonias and chronic lung disease. a high resolution chest ct scan may be useful in delineating this disorder. background: laryngomalacia is the most common cause of stridor in infants but only rare reports exist of clinically relevant laryngomalacia in adults. objective: to present a case of laryngomalacia in an adult with significant respiratory symptoms initially attributed to asthma. methods: an 18 year-old female with a history of allergic rhinitis and gastroesophageal reflux disease presented to the allergy clinic for further recommendations regarding a prior diagnosis of asthma poorly controlled on inhaled fluticasone, montelukast and albuterol. the patient was clinically diagnosed with asthma at age 13 due exercise related symptoms. the symptoms progressed and intermittent trials of various inhaled steroids provided minimal relief. on evaluation, the patient described constant wheezing which occurred only on inhalation and originated from the throat. symptoms did not respond to albuterol use three to four times a day, rhinitis control and long-term, high-dose, antireflux therapy. baseline spirometry was normal. histamine bronchoprovacation and fiberoptic laryngoscopy were performed for further evaluation. results: histamine challenge was positive with a 33% decrease in fev1 with 1 mg/ml histamine. however, laryngoscopy revealed redundant airway tissue most notable over the right arytenoid cartilage, consistent with laryngomalacia, which prolapsed into the laryngeal vestibule significantly obstructing the airway on inspiration only. the patient was referred to otolaryngology and surgical excision using a carbon dioxide laser was performed with subsequent improvement in symptoms and decreased asthma medication use. conclusions: we report an unusual case of laryngomalacia in an adult presenting as asthma, which was successfully treated with laser surgical excision. laryngoscopy of the patient revealing redundant airway tissue most notable over the right arytenoid. c. so 1* , s. kuhl 2 , 1. davis, ca; 2. mather, ca. c. so, s. kuhl u.c. davis medical center, sacramento, ca & sacramento va hospital, mather, ca background: wheezing is an uncommon manifestation of phrenic nerve dysfunction. objective: we offer a description of wheezing attributable to phrenic nerve dysfunction to remind clinicians that dyspnea and wheezing can be caused by cor pulmonale which can be caused by phrenic nerve dysfunction. methods: a 71-year old male non-smoker presented with chronic dyspnea and occasional wheezing for the last decade. the patient had a remote history of pericardial stripping for presumed tuberculous pericarditis. he also had a non-productive cough and orthopnea. dyspnea was exacerbated by putting his hands over his head and bending over. he had been treated with inhaled corticosteroids and bronchodilators without relief. results: repeated chest x-rays showed a chronically elevated right hemidiaphragm. pulmonary function tests showed a restrictive pattern with: fev 1 1.2 (40%), fvc 1.59 (36%), tlc 3.23 (49%), dlco/va 4.54 (125%) and no bronchodilator response. left heart catheterization was normal while right heart catheterization showed elevated pulmonary artery pressures (56/20) and he was subsequently diagnosed with cor pulmonale. cardiopulmonary exercise testing showed an increase in minute ventilation which was achieved predominantly by an increase in respiratory rate rather than to an increase in tidal volume suggesting restrictive or interstitial lung disease. chest ct showed left ventricular enlargement and no evidence of interstitial lung disease. a fluoroscopic sniff test was performed and showed paradoxical movement of both diaphragms. he was diagnosed as having diaphragmatic dysfunction as a result of phrenic nerve injury from prior pericardial stripping. conclusions: wheezing and chronic dyspnea can be related to phrenic nerve dysfunction. a review and discussion of various causes of phrenic nerve dysfunction, including autoimmune causes, is offered. patients with a history of prior cardiothoracic surgery who present with recalcitrant dyspnea and wheezing may benefit from evaluation for phrenic nerve dysfunction. background: sudden sensorineural hearing loss (ssnhl) is defined by a loss of at least 30 db in 3 contiguous frequencies over a time course of 72 hours or fewer. etiologies of ssnhl include viral infections, ototoxic drugs, autoimmune diseases, trauma, neoplasms, and vascular occlusion, but viral labyrinthitis is the most common cause. in cases of sudden hearing loss, herpes infections can be reported in approximately 70% of cases caused by viral infections. typically, sensorineural hearing loss is not recurrent. we report a case of recurrent ssnhl is which oral herpes lesion preceded the onset of symptoms on three consecutive episodes. case report: a 55-year-old male with a history of hypertension, hypothyroidism and chronic tinnitus of the left ear (since a gunshot wound 18 years prior) presented to clinic with a complaint of recurrent episodes of sensorineural hearing loss. the first episode of bilateral hearing loss occurred 14 months prior. an otolarnolgologist treated with a steroid taper and valacyclovir and the hearing loss resolved after one day of therapy. since the initial presentation, the patient reports three subsequent episodes of ssnhl, with two of the episodes responding to prednisone and valacyclovir and one episode responding to steroids alone. oral herpetic lesions preceded at least three of the episodes one day prior to the hearing loss. laboratory data was significant for an elevation of varicella-zoster igg, and of hsv igg. hsv igm was not performed. rpr was non-reactive and ana was negative. a mri of the head was normal. audiogram demonstrated 30db increase and speech discrimination improved from 80% to 100%. the rest of the laboratory data was unremarkable. the patient has been maintained on daily valacyclovir therapy and has had no further episodes of hearing loss. conclusion: our patient experienced hearing loss with concomitant evidence of hsv-1 stomatitis. this suggests a cause and effect relationship. we found that the antiviral therapy was effective for treatment of the ssnhl in this patient as demonstrated by the absence of further symptoms while on antiviral prophylaxis and conclude the most likely etiology of the recurrent hearing loss was secondary to the recurrent herpes simplex infections. abstract the illness was described for the first time in 1937 in the chinese literature by kimm, and szeto, the definitive histological description was published by kimura in 1948, this illness is endemic in asia, but rare, about 200 cases had been reported. kimura disease is extremely sporadic in the rest of the world. the etiology of this disease is ignored but it is believed that there is an aberrant immune reaction to an unknown antigenic stimulus, however epstein barr's virus, human herpes virus 8 and candida albicans had been involved in certain cases. the mast cells had been implicated in its pathogenesis and a th2 cytokine pattern with the production of interleukin 4, 5 and rantes which regulate the synthesis of ige and orchestrate the eosinophilic infiltration. on the other hand it is suggested that the eosinophils had undergone an accelerated apoptosis in this illness. case report. it is a 7 year-old boy with a 6 months evolution with the presence of bilateral subcutaneous nodules of 4x5 cm in parotid and submaxillary glands, presenting hypereosinophilia (8172 total eosinophils ) and high ige ( 9187 total ige), with normal renal function and negative mycotic and parasitic tests.the histopathologic findings revealed the presence of eosinophilic infiltrates with capillary proliferation and fibrosis. discussion. for the clinical characteristics of the nodules together with the hypereosinophilia, extremely high ige and the characteristic histological lesions the diagnosis is kimura disease. the usual clinical presentation consists on several indolent subcutaneous nodules that grow very slowly in volume, located in the neck and head, accompanied by satel-annals of allergy, asthma & immunology lites adenophaties, and with increment in the salivary glands, there is renal affectation in half of the patients, and the laboratory detects hypereosinophilia and elevation of the total ige. the histological lesions, shows hyperplastic lymphoid tissue with proliferative germinal centers, with infiltration of eosinophils in their interfollicular and perivascular zones sometimes forming an eosinophil abscess and proliferation of poscapillary venules. at the moment he have been treated with prednisone (1mgkdia), with great improvement in the clinical evolution. this is the first case reported in the literature in mexico. introduction: the incidence of cow's milk protein allergy (cmpa) is approximately 2-3% and presents primarily during the first year of life. manifestations of cmpa in the neonatal period include gastroenteritis, colic, lethargy, metabolic acidosis, and hematochezia or melena and appear to be non-ige mediated. ige mediated reactions in the neonatal period, such as urticaria or angioedema, are unusual. case: a 13-day-old african-american male presented with a 3 day history of rash, swelling, and erythema overlying multiple joints. there was no history of fever, diarrhea, or eczema. he had been on no medications prior to admission. besides mother with a history of childhood asthma, there was no family history of atopy or food allergy. he had been fed cow's milk-base formula (similac â® ) since birth exclusively. physical examination revealed a diffuse erythematous, raised, macular-papular rash, with areas of duskiness and exfoliation. there was angioedema overlying the joints and periorbital areas (figure 1). laboratory evaluation included cbc with diff, hgb electrophoresis, lumbar puncture, urinalysis, c 1 q (qualitative and quantitative), c 2 , c 3 , c 4 , and cultures of the blood, csf, and urine which were within normal. percutaneous allergy skin testing for cow's milk allergy was performed revealing a 3 + reaction to cow's milk extract (greer, lenoir, nc) with positive histamine and negative saline controls. rast testing showed 8.23 ku/l for -lactoglobulin and 5.10 ku/l for cow's milk. he was placed on an elemental formula. skin lesions and swelling resolved completely within 36 hours. at 2 week follow-up the patient was thriving without complaint. conclusion: early sensitization to cow's milk protein in the neonatal period may occur, resulting in ige mediated urticaria and angioedema. the rashes may be misdiagnosed as erythema multiforme or anaphylactoid purpura, since hemorrhagic lesions and cockade pattern are common. physicians should be aware that these reactions may occur so that early recognition and management may be initiated. neonate with periorbital angioedema and exfoliating, urticarial rash. rationale: two patients, presenting with invasive fungal cns infections, were found to have nk cell dysfunction and hypogammaglobulinemia. methods: case reports results: patient #1: a 47 year old caucasian male presented with headache, double vision, periorbital swelling, and bilateral sinus disease on ct scan. biopsies showed invasive rhinocerebral mucormycosis. he continued to deteriorate in spite of iv and intrathecal amphotericin b, hyperbaric oxygen, many debridement procedures, and a left orbital exenteration. immune evaluation revealed low igg, low igm and a barely detectable nk cell killing activity. neutrophil respiratory burst was normal. he continued to worsen despite ivig replacement. he had intolerable side effects to ifn-a. gm-csf (500 mcg qod) was initiated, in order to boost nk cell activity. this resulted in stabilization of his infection. he was discharged on oral anti-fungal therapy (posaconazole), ivig, and gm-csf. sixteen months later, he continues to remain stable clinically and radiographically on ivig and gm-csf. patient #2: a 62-year-old caucasian male presented with headache, mental status changes, and ataxia. a head ct scan showed a left mass effect and edema. he underwent surgical debridement for ventriculitis and zygomycetes (the same family as mucormycosis) was found. he was started on iv amphotericin b and oral posaconazole. his immune evaluation revealed low igg and igm and low nk cell activity. neutrophil respiratory burst was normal. he was started on ivig and gm-csf after which his nk cell function improved significantly. he remains clinically stable on ivig and gm-csf with persistent radiographic evidence of enlarged ventricles. conclusion: hypogammaglobulinemia is usually not associated with invasive cns fungal infections, suggesting that nk cell dysfunction was likely responsible for the clinical courses of these patients. nk cell deficiency has been reported to be associated with recurrent mucosal candidiasis, suggesting an important role for these cells in the control of some fungi. the spectrum of the clinical presentations of nk cell deficiency is not known since it is not normally included in immune system evaluations. these patients illustrate the importance of including functional nk cell assessment in any evaluation of immune function. introduction: to report a case of successful systemic hydrocortisone desensitization, since allergic reactions and systemic desensitization to corticosteroids have rarely been documented. method: we present a patient with multiple medical problems who has a history of both radiocontrast induced anaphylactoid reaction and corticosteroid allergy. this patient had to undergo cardiac catheterization and corticosteroid desensitization was performed prior to the procedure. results: skin testing to radiocontrast is not considered helpful, therefore patients with suspected reactions to radiocontrast are generally premedicated with corticosteroids and antihistamines to decrease the risk and severity of a reaction. 1, 2 since this patient experienced an allergic reaction to a corticosteroid previously, she was skin tested to two different corticosteroids. the least reactive skin test revealed a 3+ positive immediate reaction to hydrocortisone. cardiac catheterization with contrast was considered absolutely necessary in this case and corticosteroid desensitization was performed. the half-life of hydrocortisone is the shortest among the tested corticosteroids (80-118 minutes), so a protocol was developed with short intervals of escalating doses. each dose was diluted yielding a total volume of 75ml to avoid fluid overload because patient has renal failure. during desensitization, patient developed pruritus and erythema between the 3 rd and 4 th dose that resolved immediately with 50mg diphenhydramine. after desensitization, the patient continued to be on hydrocortisone 200mg intravenously every four hours. one hour prior to the procedure, the patient was premedicated with hydrocortisone and diphenhydramine and was administered radiocontrast without any adverse reactions. conclusion: we successfully desensitized our patient to a corticosteroid and premedicated her with hydrocortisone and diphenhydramine before administering radiocontrast. this case illustrates that intravenous desensitization may be a suitable approach to therapy in corticosteroid allergic patients who require systemic corticosteroids administration. autoimmune neutropenia is defined as a decrease in the absolute number of peripheral neutrophils caused by an immunologically-mediated mechanism. autoantibodies directed to neutrophils can lead to the peripheral destruction of neutrophils and/or inhibit myelopoesis in the bone marrow. although recurrent aphthous stomatitis is often the heralding sign of neutropenia, the diagnosis of ain requires the demonstration of specific antineutrophil antibody which acts by promoting the immune destruction and clearance of neutrophils by mononuclear phagocytes. the present case report describes the rare clinical association of ras in an adult. a 66 yr-old black male presented with a 3 year history of recurrent and repeated painful multiple oral ulcers. initially the oral ulcers occurred on a monthly basis then over time the ulcerations on the oral mucosa and tongue began to appear weekly and later continuously. past medical history revealed no drug allergies but a positive history of hypertension. physical exam revealed an otherwise healthy male with no lymphoadenopathy or splenomegaly. laboratory workup revealed : hiv negative, viral culture for h. simplex negative, mild increase in cd8, cyroglobulins negative, anti dsdna negative anti-smith and rnp negative, wbc count 3300/ml, neutrophils 29% (anc 957), lymphocytes 54%, monocytes 11%, and platelets: 243, 000. bone marrow biopsy revealed a normal production of neutrophils. a direct neutrophil antibody assay: revealed an elevated value of 6, 576 (n= <4, 000). although following initiation of prednisone (60 mg) an immediate increase in anc was seen, the levels fell as the dosage was tapered. the figure below shows the time course and dose-response relationship of anc and prednisone dosage. this case report illustrates the importance of recognition of the relationship of ras and neutropenia, an association that can masquerade as other clinical entities. background: dyspnea, wheezing, and decreased fev1 are suggestive of asthma. it is essential for the clinician to consider a broad differential diag-nosis as the outcome could be catastrophic if the correct diagnosis is missed. case presentation: we present a case of a 48 y.o. filipino female who was referred to our clinic for the evaluation of cough, shortness of breath, and wheezy respiration associated with changes in voice quality, nasal and palatal pruritus, and postnasal drainage. her initial evaluation revealed mold spore hypersensitivity by prick puncture testing and spirometry with an obstructive pattern with fvc-3.05 l (99%) and fev1-1.25 l (50%) predicted and a 15% reversibility post nebulized albuterol. an initial diagnosis of allergic rhinitis with adult onset asthma was made and she was started on salmeterol, budesonide, montelukast, and pirbuterol. her symptoms persisted and rabeprazole was added to treat possible laryngopharyngeal reflux. repeat spirometry revealed fev1-0.84 l prompting treatment with systemic corticosteroids again with no improvement. fiberoptic laryngoscopy was within normal limits. a high resolution computed tomography was obtained and showed a mass in the left side of the trachea which was obstructing 60% of the airway. bronchoscopy revealed a tumor 4-5 cm below the vocal cords with the appearance of adenoid cystic carcinoma which was confirmed by pathology. the tumor was resected by removal of 7 cm trachea with re-anastomosis, followed by a 6 week course of radiation therapy. all medications were discontinued. her symptoms of wheezing, dyspnea, and cough completely resolved. repeat spirometry was within normal limits and she remained asymptomatic. surveillance bronchoscopies have been negative for any recurrence. discussion: adenoid cystic carcinoma (acc) is an uncommon form of malignant neoplasm that occurs within the salivary glands. tracheobronchial acc typically presents with symptoms of cough, dyspnea, and hoarseness. due to its slow growth, acc has a relatively indolent course. in a recent study of a cohort of 160 acc patients, survival was 89% at 5 years but only 40% at 15 years. standard therapy is surgical resection often followed by radiotherapy. conclusion: in patients who fail conventional therapies for asthma it is important to entertain other diagnosis and have a systematic approach to establish the correct diagnosis. ipex is an extremely rare, hereditary condition characterized by immune dysfunction, polyendocrinopathy, enteropathy and x-linked recessive inheritance that leads to death without prompt diagnosis. patients usually present by 4 months with severe diarrhea, failure to thrive, and early onset iddm. most children die by one year without a bone marrow transplant. immunologic evaluation is typically normal except for elevated ige, eosinophilia, and autoantibodies. we report a case of ipex in an infant who presented at birth and died at 79 days of multi-organ system failure. this male infant was born at 30 weeks due to chorioamnionitis and prom. at birth, copious green fluid appeared from his rectum and ng tube which evolved into a secretory diarrhea. workup for fistula was negative. at 2 weeks, the patient developed ascites and explorative laparotomy revealed an inflamed appendix. after the laparotomy, the patient had no further stool output and never tolerated enteric feeds. he remained intubated and had problems with apnea and coagulapathy. pathology of the appendix showed an excess of lymphocytes. immune system investigation showed elevated ige (5320) and igg (979). serum anti-enterocyte igg antibody was positive in the patient and negative in his mother. based on this data, ipex was suspected which autopsy seemed to confirm. autopsies are scarce in patients with ipex. the findings revealed many organs affected by fibrosis but lymphocyte infiltration of only the pancreas and gi tract. the pancreas revealed almost complete loss of the exocrine structure, with invasion of fibrosis and chronic inflammatory cells. the mucosa of the gi tract from the stomach to rectum showed columnar epithelium taken over by fibrosis, capillaries and chronic inflammation. these inflammatory cells were cd3+ lymphocytes and plasma cells on immunochemistry. the lymphoreticular system was consistent with lymphoid paucity in the thymus, lymph nodes and spleen. preliminary data suggests this patient has a splice mutation of the foxp3 gene. ipex is an extremely rare disease, often difficult to diagnose while a patient is alive. infants will present in early infancy with diarrhea and endocrinopathies. without prompt diagnosis, death is inevitable. as a result, one must be aware of atypical presentations and considered in patients with total villous atrophy and one other clinical feature such as iddm or autoimmunity. introduction: digeorge syndrome (dgs) is characterized by thymic hypoplasia, parathyroid hypoplasia, and conotruncal cardiac defects, but has a wide variety of clinical manifestations. there is also an increased risk for autoimmune phenomena in later life due to thymic hypoplasia. case report: a 13 year-old aa girl with tetralogy of fallot (repair at age 2), developmental delay, asthma, recurrent sinopulmonary infections/skin abscesses, gerd, arthralgias and seizure disorder (due to hypoxic encephalopathy during cardiac surgery) presented to allergy/immunology clinic for immune workup. there was no history of documented hypocalcemia. at age 10, she developed persistent annular patches on her left leg. a skin biopsy appeared consistent with sarcoid dermatitis. there was no other evidence of sarcoidosis except for slightly elevated ace level. given lack of systemic involvement, the skin lesions were not treated, but resolved spontaneously. at age 12, she developed swelling of the right mandible, and a bone biopsy revealed garre's osteomyelitis (sterile hyperproliferative osteomyelitis), likely triggered by dental caries, with elevated esr (40) and polyclonal hypergammaglobulinemia (igg 2640), but normal crp. immune workup revealed a decrease in cd4 and cd8 cells (cd4/cd8 ratio 2.44), slightly elevated b cells, high-normal range nk cells, normal range t cell cytokine production in response to mitogens and il-12, but excessive production of proinflammatory cytokines in responses to lps. in conjunction with facial dysmorphism, dgs was suspected, and fish analysis revealed 22q11.2 microdeletion. a repeat workup did not reveal evidence of systemic sarcoidosis, and autoantibody screening was negative including lupus anticoagulant. she was treated with a cox-2 inhibitor, secondary to gerd and mild thrombocytopenia, and her joint symptoms resolved with a concurrent decline in esr (to 30) and igg level (to 2390) after 2 months. conclusion: recurrent infections with fragmented care and resultant chronic inflammation (hence overstimulation of the immune system) may have led this dgs patient to develop atypical autoimmune phenomena and other unusual clinical manifestations. this case illustrates the importance of recognizing the phenotypic features of dgs early in life, and of providing close monitoring and coordinated care. rationale: we report a case of a patient with celiac disease who continues to have symptoms of fevers, nausea, vomiting, night sweats and fatigue despite being on a gluten free diet whose symptoms have been responsive to antihistamines. methods: case report. results: in 1998, this 41 year-old white male suffered from mononucleosis and episodes of prostatitis. he began suffering from fatigue and fevers and was followed at a chronic fatigue syndrome center in 1999. in november 2000, patient was placed on famvir alleviating his sore throat. he was later placed on interferon gamma which was discontinued due to increased fevers, nausea and vomiting. after stopping medication, symptoms abated for sometime. in 2002, patient's father was diagnosed with celiac sprue. in april of 2003, the patient developed a pruritic rash on his right arm. biopsy revealed subepidermal vesicles with pmn's at the tips of dermal papillae. in may of 2003, he developed oral ulcers as well as joint pains. patient underwent endoscopy with biopsies revealing intraepithelial lymphocytosis in the duodenum. patient has been on a strict gluten free diet since october 2003. he reports that some symptoms have improved: skin lesions, itchy eyes, and oral ulcers. however, he has begun to suffer from constipation and continues to intermittently have night sweats, fevers, nausea and vomiting. in february of 2004, he had pruritus that was not alleviated by hydroxyzine. a regimen of benadryl and pepcid was started to aid with the pruritus. the patient reported in the improvement of his symptoms of pruritis, sweats, and emesis. conclusions: diagnosis: celiac disease(cd) patient with persistent nausea, vomiting, sporadic fevers, and fatigue despite maintaining a strict gluten free diet has shown improvement of symptoms with antihistamines. patient has history of chronic infections: prostatitis and chronic ebv. patient also reported alleviation of symptoms after interferon therapy suggesting some autoimmune component to his current illness. cd prevalence in the united states is much higher than once thought 0.5-1% of the u.s. celiac disease has been associated with increased risk of lymphoma and malabsorption leading to neurological diseases. this is a rare case of cd associated pruritus responding to antihistamines. rationale: eosinophilic cystitis is a relatively rare condition in children and adults with a varied course. it usually responds to short-term nsaid and steroid therapy. we report a man with a severe case who responded to prolonged oral steroids. case report: a 54 year old caucasian man with a prior esophageal cancer s/p esophagectomy, diabetes, hypertension, allergic rhinitis and chronic obstructive pulmonary disease presented with suprapubic pain, urinary frequency, dysuria, and hematuria. urinalysis showed numerous red blood cells and bacteria but no malignant cells or eosinophils. he was treated with antibiotics with resolution of symptoms. several weeks later he experienced severe suprapubic pain and hematuria resulting in a symptomatic drop in his hemoglobin. he underwent a cystoscopy and biopsy that revealed a chronic cystitis with an inflammatory infiltrate containing numerous eosinophils. he was unresponsive to treatment with nsaid and intravesicular dmso and was then referred to our service. we started prednisone 20 mg/day but the dysuria and hematuria persisted. prednisone was doubled plus a third generation quinolone was added. three weeks later the hematuria and dysuria resolved and he was asymptomatic. the antibiotic was stopped and prednisone was gradually tapered over several weeks. whenever his steroid dose dropped below 20 mg/day he experienced an exacerbation of his symptoms. over the last three years this dose of prednisone has kept his symptoms abated and his renal function stable. conclusion: eosinophilic cystitis is an uncommon diagnosis of unknown etiology. we describe a patient with debilitating suprapubic pain and symptomatic anemia from the hematuria associated with eosinophilic cystitis. for over three years since we first saw him, continued therapy with 20 mg of prednisone/day has prevented exacerbations. this case is unique in the severity of the hematuria experienced and the prolonged relatively low steroid dose needed to suppress exacerbations. we propose that in eosinophilic cystitis patients with severe hematuria who may otherwise be candidates for a cystectomy, a trial of prolonged oral prednisone may be beneficial. rationale: allergic reactions to insulin occurred more frequently in the past, with porcine and bovine preparations. in contrast, allergic reactions to human insulin preparations are now reported in <1% of patients treated with insulin. insulin allergy may be manifested as an immediate-type 1 ige-mediated reaction, delayed type hypersensitivity or as serum sickness, varying in severity from mild discomfort to life-threatening events. we present a case to illustrate that an insulin allergy may complicate hospitalization and often be misdiagnosed. methods: a 66 y.o. diabetic female with a history of "insulin allergy" was evaluated. the patient is a long standing diabetic controlled on oral hypoglycemics but required insulin during acute illnesses and hospitalizations. the patient was unable to recall previous types of insulin she had received. during previous hospitalizations, the patient complained of vague symptoms of fatigue, parasthesia, sweating, anxiety, and palpitations. on one occasion the patient had a syncopal episode with hypotension and on another occasion the patient developed a rash and dyspnea after receiving sq insulin. the physcian intrepreted the findings may be due to hypoglycemic. an allergic reaction was not suspected and the patient never underwent any testing. during a recent hospitalization, the patient's history was reviewed and a formal allergy consult was obtained. she underwent epicutaneous and intradermal testing to human insulin preparations. insulin antibody levels were also obtained. results: the patient had negative epicutaneous testing to all human insulin preparations. however, on intradermal testing, the patient had positive reactions to lispro, nph, and lente and negative intradermal tests to insulin glargine and regular insulin. igg and ige insulin antibody test results were < 1. conclusion: hospitalized patients receiving multiple medications commonly experience pharmacologic, adverse and/or allergic reactions. it is necessary to obtain a thorough history and document all reactions that patients experience to determine what type of event occurred. with a suspicion of drug allergy, skin testing and/or rast assay may provide insight into possible ige mediated reactions. in this case we advised the patient that she may use regular insulin during hospitalizations and that insulin glargine can be used to help achieve optimal glycemic long term control. background: hereditary angioedema type iii (hae iii) is a recently described form of angioedema occurring exclusively in females and characterized by normal c4, c1 inhibitor (c1 inh) protein and function. hae iii is thought to have an x-linked or autosomal dominant mode of inheritance. we evaluated a 13 year old female with recurrent facial swelling, abdominal pain and laryngeal edema with a family history of similar symptoms in several female relatives. case report: a 13 year old african american female presented with a two year history of recurrent lip, tongue and facial swelling. she also had abdominal pain, diarrhea and shortness of breath. episodes were not associated with hives. her symptoms predated menarche and did not correlate with her menstrual cycle. at the time of presentation she described an increase in frequency of her symptoms that did not respond to antihistamines (diphenhydramine, cetirizine) or prednisone. the patient had no other medical problems. family history was significant for recurrent episodes of facial, lip and tongue swelling in a maternal aunt, grandmother and great grandmother. the patient's great grandmother required tracheal intubation with ventilator support for upper airway compromise. the patient's physical exam was unremarkable. laboratory values drawn during an acute episode of swelling revealed: c1 inh function = >68% (normal >68%), c1 inh protein = 323mg/ml (normal 158-413 mg/ml), c4= 21.70 mg/dl (normal 20-59 mg/dl). dna sequencing at exon 8 to investigate the possibility of an unusual c1 inh mutation with normal c1s binding but abnormal kallikrein inhibition was negative. other lab tests included a normal mast cell tryptase of 2.9 mcg/l, a negative rf and ana, a normal angiotensin converting enzyme of 62 u/l (normal 6-64 u/l) and positive skin prick tests to a variety of foods which the patient tolerates. based on two case reports of treatment of hae iii with androgens, the patient was started on danazol 200mg daily with symptomatic improvement. conclusion: hae iii is a rare disease that affects females exclusively. clinically it is indistinguishable from c1 inh deficiency. the mechanism of inheritance remains to be elucidated. it is unclear why danazol appears to ameliorate symptoms even though there is no evidence for c1 annals of allergy, asthma & immunology inhibitor dysfunction in this disorder. we believe this to be the first kindred of hae iii reported in the united states. r. dworski * , m. peters, nashville, tn. a four-month-old female identical twin was evaluated for noisy breathing and recurrent cyanosis. she was delivered at 32 weeks of an estimated gestational age after an uncomplicated pregnancy. at birth she was intubated for 3 hours for respiratory distress but the remainder of her neonatal period was uneventful. at age 3 weeks she developed a noisy breathing often associated with cyanosis, particularly in a supine position or while crying. treatments with inhaled albuterol and prednisolone were ineffective. she had no respiratory infections or symptoms of gastroesophageal reflux disease. her growth was normal. her twin sibling was well. the family history was negative for allergies or respiratory conditions. initially she was diagnosed with tracheomalacia. however, the history of cyanotic episodes prompted a search for a definitive diagnosis. she underwent bronchoscopy which showed tracheomalacia when breathing spontaneously and circumferential narrowing of lower trachea likely due to compression. echocardiogram revealed a double aortic arch. the finding was confirmed by computed tomography angiography which demonstrated the presence of a vascular ring composed of double patent aortic arches, each giving rise to the ipsilateral carotid and subclavian arteries. the airway was normal at the aortic inlet, but narrowed markedly at the level of the two arches. a surgical division of the ductus ligamentous and distal anterior vascular arch was performed. aortic arch abnormalities should be suspected in all infants with hoarse coughing or noisy breathing, especially during inspiration but sometimes also during expiration. the diagnosis should also be considered in older children with recurrent bronchitis or pneumonia. respiratory symptoms are more frequent than gastrointestinal manifestations. diagnosis usually occurs in the first year of life. a surgery is often the treatment of choice. postoperative complications are relatively rare. outcome of surgery should be judged after 12 months, including at least one winter season. malacia can delay extubation and recovery following surgery. surgical cure occurs in approximately 70% of patients. surgery is probably less successful in children with double arches and malacia. a. thatayatikom * , a.j. white, st. louis, mo. background: common variable immunodeficiency (cvid) is the commonest symptomatic primary antibody deficiency syndrome in which b lymphocytes produce low levels of immunoglobulin, leading to recurrent bacterial infection. although hypogammaglobulinemia and susceptibility to the recurrent infection are seen in all patients, other associated conditions such as a non-infectious granulomatous disease have been well described in cvid. corticosteroid therapy has been used with improvement in a subset of cvid with granulomatous disease; however, its treatment remains problematic and a new therapeutic agent is needed. tumor necrosis factor (tnf ) has been demonstrated as a primary mediator in granuloma formation and maintenance. therefore, anti-tnf medications are potentially therapeutic agents of the granulomatous disease. case report: a 22-year-old caucasian male with cvid and severe granulomatous disease was treated successfully with infliximab, a chimeric anti-tnf monoclonal antibody. the patient initially presented with high fever, chills and abdominal pain; subsequently, he developed acute respiratory failure and adult respiratory distress syndrome. the patient was hospitalized and he required intensive care with ventilatory support. his diagnostic tests revealed elevated sedimentation rate and positive epstein-barr virus (ebv) capsid igm antibody. imaging studies demonstrated bilateral diffuse pulmonary infiltrates and hepatosplenomegaly. open lung and liver biop-sies revealed non-caseating granulomatous lesions without evidence of ebv or other infections. high dose corticosteroid therapy was given with partial improvement, then high dose infliximab (10mg/kg) was given weekly with remarkable improvement. the patient was able to wean off ventilator successfully within 3 weeks and his prednisone dose was dramatically decreased. infliximab infusion (5mg/kg) every 8 weeks and low dose prednisone were continued. a follow-up liver biopsy after 6 months of the infliximab showed no granulomatous lesions. infliximab was discontinued after 12 months of the treatment. there was no serious infection or complication during the period of treatment. conclusion: anti-tnf therapy may be a safe and effective treatment and may allow corticosteroid dose reduction. future clinical studies of anti-tnf therapy in cvid with granulomatous disease are warranted. background: chrug-strauss syndrome is a disorder characterized by hypereosinophilia and systemic vasculitis occurring in individuals with asthma. objetive: to present a pediatric case suffering from a systemic vasculitis. this case fulfilled the churg-strauss syndrome clinical criteria and the histophatology findings were compatible with the diagnosis. case: a 14 year female came to our institution with the diagnosis of severe asthma, chronic sinusisits and polyps requiring high doses of steroids. there was no history of administration of antileukotriene receptor antagonists. 2 months before her admission she presented weight loss, fatigue, cephalea and cough. on physical examination, pallor, respiratory difficulty and signs of bronchospasm were evident. tachycardia and hepatomegaly were also documented. the laboratory test showed anemia, eosinophilia 1300/dl, anca+, sgot 246, stgop 253, ige elevated 1345 ui/ml. the chest-x ray showed patchy opacities in both lungs and cardiomegaly. pulmonary scintigraphy reported low perfusion in both lungs, predominantly in the left lung.echocardiography demonstrated signs of myocarditis and eyection fraction of 32%. an open lung biopsy was executed and vasculitis with fibrinoid changes affecting small and medium vessels was reported. treatment was started with oral prednisone 2 mg/kg/d and cyclophosphamide pulses with a satisfactory evolution. discussion: to our knowledge this is the first pediatric case of css reported in mexico. she fulilled the following criteria. asthma, eosinophilia and systemic vasculitis involving the heart, liver and lungs. the disease is extremely rare, specially in mexico. aggressive treatment is necessary as in this case, with a favorable outcome. introduction "all that wheezes is not asthma" is a well-known aphorism among physicians. this same principle exists for patients that present with lip swelling in the allergist's office. we describe a patient who presented with fluctuating lip swelling who was ultimately found to have cheilitis granulomatosa. case history a 26-year-old male with a history of allergic rhinitis and asthma presented to the allergy clinic with lower lip swelling and occasional upper lip swelling. he was receiving allergen immunotherapy for dust mites and trees. the swelling had been waxing and waning for 13 years, but became more persistent for the previous six months. he denied tongue/throat swelling, dysphagia, respiratory distress, or any triggers for the swelling. chapstickâ® and vaselineâ® were used topically on his lips. failed treatments included loratadine, ranitidine, cetirizine, fexofenadine, and montelukast. he was placed on a one-week course of prednisone, which decreased his lip swelling, but it recurred after completion of the treatment. physical exam was significant for diffuse, firm lower lip edema to 3-4 times the normal size. there were no oral lesions or tongue swelling. patch testing to a standard panel, preservatives, oral flavors, and dental acrylate was negative. punch biopsy revealed a noncaseating epithelioid granulomatous inflammation consistent with granulomatous cheilitis. he was placed on minocycline 100 mg by mouth twice daily with little benefit. an 8-week course of oral prednisone resulted in improvement of the lip swelling. conclusion melkersson-rosenthal syndrome (mrs) is a rare syndrome that is characterized by a triad of recurrent facial paralysis, chronic edema of the face and lips, and hypertrophy and fissuring of the tongue. cheilitis granulomatosa is considered a monosymptomatic form of mrs and manifests as a chronic swelling of the lips caused by granulomatous inflammation. the swelling is typically not tender and may be either soft or firm. allergists are often consulted for lip swelling thought due to angioedema. however, as this case illustrates, not all lip swelling is angioedema and one must consider other diagnoses such as melkersson-rosenthal syndrome and cheilitis granulomatosa. progressive multifocal leukoencephalopathy (pml) is a disorder of the nervous system that affects individuals with immune suppression. it has been associated with hiv infection and is present in nearly 10% of patients with acquired immune deficiency syndrome. the jc virus, a common human polyomavirus, causes this demyelinating disorder. progressive symptoms reflect the multifocal distribution of brain lesions, and include mental deterioration, vision loss, speech disturbances, ataxia, paralysis, and, ultimately, coma. in rare cases, seizures may occur. there is no known treatment for pml. we report a 21 year-old (y/o) male with 6 months weight loss and a sudden onset of confusion, lethargy, and progressive loss of cognition requiring hospitalization. upon questioning he was found to have had recurrent upper respiratory tract infections since infancy successfully treated with antibiotics. as a child he had atopic dermatitis, exercise induced asthma, and myringotomy tubes placed twice. at 12 y/o, he underwent a nasal polypectomy. in 2002, at 19 y/o, a squamous cell carcinoma was removed, and he developed benign cervical lymphadenopathy and common warts. a year later he developed hsv esophagitis. the remainder of his history was unremarkable with normal development and growth and no history of drug abuse, multiple sexual partners, or homosexual contacts. on physical examination, he was thin, ill appearing, with oral ulcers, generalized scanty lymphoadenopathy, multiple common warts on both feet, and occasional ronchi. a brain mri showed a demyelinating process consistent with pml. pcr for jc virus was positive, while hiv pcr was negative; total immunoglobulins and cd4 counts were low ( we are reporting a 47 year old female with a 10 year history of moderate persistent asthma, who was started on xolair 150mg sq q 4 wks., and who then presented with a presumed allergic reaction. three hours after her second xolair injection, patient reported developing dizziness, shortness of breath, and felt like she was having an allergic reaction. she was evaluated and observed for two hours in an emergency department. the treating physician reported no wheezing and felt there was no need for treatment. to rule out psychogenic factors, she was given a placebo injection at the next scheduled visit. ten minutes later she reported developing throat tightness and shortness of breath. she had no changes in her peak flows and her lungs were clear. her "symptoms" resolved completely within 5 minutes of receiving placebo epinephrine and nebulized normal saline. patient was informed she had reacted to a placebo injection, as well as placebo epinephrine and albuterol, and counseled. the patient returned to the office every week for the next three weeks to receive blinded injections. she subsequently did not react to either doses of placebo or xolair. she has since tolerated her monthly xolair injections without incident. this case illustrates the importance of ruling out psychologic causes of presumed allergic reactions. introduction :latex allergy, type i ige mediated hipersensitivity, occurs specially in high risk populations, like in patients that have undergone various surgeries. case: a 10 year old boy with asthma and allergic rhinitis since 1996, penicillin allergy and retrospectively, his mother refers lip edema with balloon inflating.at 4 years of age (1998): left orchiorrhaphy because of cryptorchis. between 1999-2004: 4 surgeries because of sacral giant melanocitic naevus.during the fourth surgical intervention (0ct 8 -2004) to collocate a tissue expander, the patient presents perioral and fingertip cyanosis, generalized cutaneous rash and severe bronchospasm.ap:40/22 mmhg, hr 140 x/min. he was treated with iv fluids, steroids, antihistamines and inhaled racemic epinephrine.at the icu his final outcome is satisfactory. laboratory: total ige :27.4iu/l, skin prick test with glove extract, raw and natural latex extract and purified latex proteins(pseudoeveine, molecular hevein, hev b 6.02 and modified hevein)all positive +++. western blot with protein extract of latex positive and elisa with purified latex proteins ( same as above) positive. the last surgery to withdraw the tissue expander was performed with latex free surgical equipment without any problems. discussion: the patient's risk factors for latex allergy are atopy and repetitive exposure to latex articles because of surgery. he presents mild manifestations of latex allergy, till he finally develops full-blown anaphylaxis. diagnosis was made based on clinical history, skin prick test, western blot with protein extract and elisa with purified latex protein. he had a favorable outcome withdrawing latex during the last surgery. introduction: churg-strauss syndrome (css) is a form of primary vasculitis that is a rare diagnosis in an elderly patient. case report: a 75 year old woman presented with a 3 week history of fatigue, vomiting, diarrhea, abdom-inal pain, and right lower leg paresthesia. prior to admission she was being treated for left neck erythema and adenopathy presumed to be cellulitis. she was in good health with no history of atopy until the age of 72, when she developed both chronic sinusitis, requiring bilateral sinus surgery and polypectomy, * and new onset asthma, * that required systemic steroid control. prednisone was tapered 1 month prior to admission. objective findings included coalescent non-blanching petechiae on her abdomen, peripheral eosinophilia of 4800(50%), * normochromic normocytic anemia, rf=124, esr=90, ige=232, igg=1645. ana, p and c-anca were negative. ct showed ascites and pleural effusions. egd revealed duodenitis with ulceration and eosinophilic infiltration on biopsy. echo showed pericardial effusion and septal motion abnormality. troponin of 31 without cad was consistent with subepicardial myocarditis. emg confirmed right peroneal neuropathy.* skin biopsy revealed a dense superficial and mid-dermal perivascular and interstitial eosinophilic infiltrate. additional evaluation excluded malignancy, infection, and abpa. treatment with prednisone, 1mg/kg/day was initiated. a rapid clinical improvement ensued and has persisted. {*acr criteria for css}. discussion: churg-strauss syndrome is a rare form of vasculitis with mean age of onset within the third and fifth decades. it is an uncommon cause (<5%) of systemic vasculitis in patients older than 65. the formes frustes of css is a variant in which early manifestations of the syndrome are hidden by oral and systemic steroids employed in the treatment of worsening asthma often associated with css. this variant makes expedient identification of css more challenging. delayed recognition contributes to a relentless progression of this entity resulting in a systemic vasculitis with multi-organ involvement. early diagnosis, especially in the prodromal and eosinophilic phases, is essential. untreated, css has a high rate of morbidity and mortality. therefore, css and the formes frustes variant must be an integral component in the differential diagnosis of patients presenting with adult onset asthma and/or recurrent sinusitis. common variable immunodeficiency (cvid) is the most prevalent of the primary immunodeficiency diseases. cvid is a heterogeneous group of immunologic disorders of unknown etiology, characterized by impaired antibody responses, hypogammaglobulinemia with normal b cells. the common immunologic defect in patients with cvid is defective antibody formation, and many different immune system defects have been reported in this group of patients. most patients, really, have no identified molecular diagnosis. cvid consists of several different genetics defect. the immunologic defect in cvid is a failure of b-lymphocyte differentiation into plasmacells. b lymphocytes from these patients failed to differentiate into ig-producing cells when stimulated with pokeweed mitogen in vitro, even when cocultured with normal t cells. an overwhelming body of literature suggests that most patients with cvid have intact b lymphocytes of immature phenotype. however the functional classification of cvid patients on the basis of in vitro ig production is time consuming. recently has been proposed a new classification based on the quantitative repartition of memory b cell according to the dual expression of igd and cd27. we present a case of a 14 yr old boy. he presented soon in his life frequent infections, of particular severity: pneumonia, meningoencefalitis, sepsis, bronchitis, otitis, linfoadenitis. he also had a -thalassemia intermedia. this clinical manifestations suggested an immunodeficiency. for this reason at 2 years of age serum immunoglobulin and antibody detection showed a reduction in igg2 subclass and in cd19+ cells, with normal total igg, iga, igm, normal cd4/cd8 ratio, normal cd3, isohemagglutinins and in vitro t cell function. there was also a defective antibody production after tetanus, diphtheria, pertussis immunization. these laboratory findings did not allow, however, a sure diagnosis for cvid. a new immunological evaluation at the age of 11 years old, after the onset of splenomegaly, and enlarged lymph nodes, demonstrated a b memory defect, with a severe deficit of t lymphocytes function in vitro. it was also possible to find a severe deficiency of cd 27 + cells, meaning a defect in memory b cells: we can therfore label this condition as a cvid. in the past two decades there have been conflicting views regarding the clinical importance of igg subclass deficiencies in children. igg2 subclass plays a vital role in the immune response to polysaccharide antigen. isolated igg2 subclass deficiency may be widespread and often asymptomatic in children. however, in association with other subclasses and/or other immunoglobulin classes, there may be a significant, symptomatic outcome. the reported patient was diagnosed with familial dysautonomia (fd) at the age of five weeks, presenting with severe hypotonia and tachypnea. hindered by poor pulmonary function, he was hospitalized over fifteen times for recurrent pneumonias, including four lengthy intensive care admissions. daily inhaled-corticosteroids and brochodilator therapies were initiated, along with chest therapy via a high frequency chest wall oscillator. immunoglobulin levels were measured recently and point to low levels of igg2, igg4 and total iga antibodies: igg1 443 mg/dl (n 330-1065), igg2 57 mg/dl (n 57-345), igg3 50.5 mg/dl (n 7.5-125.6), igg4 <2.0 mg/dl (n 1.8-115.5), and total iga 28 mg/dl (n 33-235). since receiving monthly ivig therapy he had no further recurrence of pulmonary infections and was slowly weaned off daily brochodilator therapy. the currently accepted theory is that low igg2 subclass levels may be associated with increased risk of bacterial infections only in selective groups. fd patients may be in a distinctively susceptible population in which igg2 levels are critical. the older brother, who was also diagnosed with fd, demonstrated igg2, igg4 and iga levels that were slightly higher but nevertheless on the lower end of the normal range. he suffers from less invasive and less frequent bacterial infections. this may support a genetic association between the fd and hypogammaglobulinemia. alternatively, it may signal that fd patients may have a prolonged variant of transient hypogammaglobulinemia of infancy. follow-up immune profile studies, post-ivig trough levels and broader investigations of the fd population are necessary to determine the severity and prevalence of these findings. pulmonary failure is the dominant cause of death in patients with fd. prompt diagnosis and effective treatment of the associated immune deficiency may be proven essential in the effort to enhance and prolong their lives. s. hassan * , j.a. grant, galveston, tx. rationale: common variable immunodeficiency (cvid), a rare primary immunodeficiency presenting in young adults with repeated sinopulmonary infections as a result of profound hypogammaglobulinemia, was first described by suri et al. (ann acad. med. singapore, 1988) . we describe a young man with diagnosed but untreated cvid and its eventual course. case description: a 27-yr-old caucasian male hospitalized secondary to chronic pneumonia and respiratory failure was noted to have non-existent levels of immunoglobulins. history revealed ivig treatment at age 12, stopped after a year due to non-compliance. although untreated, he denied recurrent sinusitis, otitis media, or bronchitis for almost 14 years but notes a recent inability in keeping up with baseball practice. he is the last of ten healthy siblings. patient started monthly ivig infusions but was noted to have hypertension (150/90), tachycardia (120-130), tachypnea (25-30) on the 4th month with o2 saturation of 87-93% and po2 of 49% on room air. with a 2-day history of acute dyspnea, calf muscle and right abdominal pain, he was admitted to the hospital and pulmonary thromboembolism was ruled out. laboratory data: humoral functions (pneumococcal, tetanus toxoid, and hepvac) -undetectable t cell function (mumps, candida, ppd) -normal immunoglobulin (igg, iga, igm) -undetectable flow cytometry -b and nk cell markers normal, mild decrease in the cd4/cd8 ratio high resolution ct thorax -bronchiectasis, bronchial wall thickening, and obstructive changes with airtrapping. 6 minute walk -desaturation to 78% on 4l o2 by nc bnp -462 echocardiogramestimated ef 40-45%; severe pulmonary hypertension. cardiac catheterization -normal coronary arteries, severe pulmonary hypertension (pa pressure 70/40). conclusion: cvid patients have a reasonably good prognosis on treatment. untreated cvid is associated with chronic lung infections, bronchiectasis, pulmonary hypertension and right heart failure. although, lung transplant became available during the early eighties (nejm 1982), this extremely invasive but life saving procedure was undertaken in a patient with cvid and end-stage pulmonary hypertension in 1998 (thorax 1998). lung transplant may be the only way of ensuring survival for this patient. introduction chronic eosinophilic pneumonia (cep) is a rare disorder of unknown etiology characterized as a chronic and relapsing interstitial lung disease with blood or tissue eosinophilia. cep occurs more often in women with preexisting atopic disease. patients with cep respond rapidly to systemic corticosteroids, but often relapse with short, low-dose courses of therapy. while uncommon, extrapulmonary involvement, such as arthralgia, cutaneous purpura, pericarditis, and hepatitis, have been reported. we present a case of a patient who has cep with pericardial effusion. case report the patient is a non-smoking 60-year-old woman with a past medical history significant for allergic rhinitis and asthma who initially presented with a four-month history of worsening shortness of breath, dyspnea on exertion, dry, non-productive cough, and weight loss (approximately five pounds). her symptoms were refractory to increased dosages of inhaled fluticasone. she then developed intermittent fever up to 102â°c. chest x-ray revealed bilateral apical infiltrates. treatment with levofloxacin for seven days resulted in no improvement of symptoms or roentographic findings. thereafter, she presented with chest and abdominal pain, hypotension, and hypoxia. blood work revealed a white cell count of 6800 c/mm 3 with a differential significant for 34% eosinophilia (absolute eosinophil count of 2300 c/mm 3 ). chest ct showed dense consolidation predominantly along the peripheral aspect of the upper and superior segment of the lower lobes, and pericardial effusion. moderate pericardial effusion without evidence of tamponade was confirmed on echocardiogram. left upper lobe wedge biopsy findings included significant tissue eosinophilia, scattered foci of active organizing exudates, and no evidence of granulomatous or necrotizing vasculitis. the patient was treated for cep with a six-month course of prednisone, starting at 60 mg daily, resulting in rapid improvement of her pulmonary and systemic symptoms. background: immunologists are consulted for evaluation of immunodeficiency in patients with recurrent skin infections. disorders of the phagocyte system may be associated with cutaneous infections. methods: case report case: a 15-month-old african american girl (twin a) presents with recurrent skin abscesses. at 13 months of age, she had her first buttocks abscess, which required incision and drainage with oral antibiotics. a month later, she developed another abscess and was found to be neutropenic, with an absolute neutrophil count (anc) of 264/î¼l. cyclic neutropenia was considered and her pediatrician monitored cbcs, which all showed persistent neutropenia (ancs between 68 and 264). at 15 months of age, she was hospitalized for fever with neutropenia. immunology was consulted for evaluation of neutropenia. the rest of the past medical history was unremarkable. she was healthy appearing and growth parameters were appropriate for age. her physical examination was unremarkable. immunoglobulins, b-and t-cell markers, nitroblue tetrazolium, complement assay, hemoglobin, platelets and the peripheral smear were normal. antibodies for hiv, cmv, ebv and parvovirus were undetectable. anti-neutrophil antibodies were positive, establishing the diagnosis of primary autoimmune neutropenia (ain). the abscess healed with oral antibiotics. severe neutropenia (anc 0-280) persisted for three subsequent months without further infections. twin (b) was also found to have persistent severe neutropenia without morbidities, suggestive of primary ain. primary ain is less known among physicians and is typically diagnosed after extensive investigations that exclude other causes of neutropenia. the exact incidence of ain is unknown. it is usually seen in children between 5 and 38 months of age, often with severe neutropenia and self-limiting bacterial infections. the clinical course and presence of antibodies to neutrophil antigens (na1, na2 or cd11b/18) is diagnostic. familial occurrence of primary ain is not reported in the literature. conclusion: primary ain may remain under diagnosed due to lack of characteristic clinical features. although a benign clinical course is likely, severe infections, including pneumonia, sepsis and meningitis, have been reported. genetics may play a role in this disease, as we present primary ain in twins. background: atopic dermatitis (ad) is a chronic inflamatory disease of skin that affects 5% of the wordl population.the natural history of ad in some patients, evolve to the coexistence with other allergic diseases: allergic rhinitis, allergic conjunctivitis and asthma. the sublingual immunotherapy has demonstrated utility in some patients; however, semi-rush immunotherapy to pollens has only showed utility in one animal case published few years ago. case report: a 2-year-old infant was referred to us. he began one year before with skin lesions compatible with ad, six months later began perennial rinhorrea and nasal itching. multiple treatments with topic corticosteroids, moisturizing, antihistamines and topic/systemic antibiotics did not demonstrate utility. our evaluation revealed ad lessions that affected 60% of the total body surface and clinical features of allergic rhinitis (ar).the lab tests revealed eosinophylia (600cell/mm3) in blood cell count, normal levels of total ige but specific ige to dermatophagoides pteronissinus (dpt) was high. the skin prick test reveales the same results. we added environmental control, oral costicosteroids and transfer factor. despite our treatment no improvement was observed. we considered dpt as the principal factor in the maintenance of ad lessions and ar episodes. in the absence of sublingual immunotherapy in our hospital, we decided for semi-rush immunotherapy schedule. we began from 0.1 ml of 1:10, 000 w/v concentrations of dpt until 0, 5 ml of 1:100 w/v concentrations in two months receiving three doses per week. no local or systemic adverse events was reported and the ad lesions and ar symptomatology disappeared in the first month of treatment. at this time, no exacerbations have been documented. conclusion: the semi-rush immunotherapy can be useful and safe for treatmente of ad in some patients in whom specific ige to aeroallergens has been demonstrated. introduction: eosinophilic gastrointestinal disorders are a rare group of disorders that can involve the entire gastrointestinal tract. presentations are varied but may include vomiting, dysphagia, abdominal pain, diarrhea and failure to thrive. the diagnosis is made by endoscopic biopsies which reveals eosinophil rich inflammation in the absence of known causes for eosinophilia. peripheral eosinophils and ige may be elevated but can be normal. we report a patient with eosinophilic gastroenteritis associated with an ampullary tubulovillous adnenoma. methods:a 71-year-old white male with allergic rhinitis and a family history of atopy was admitted for profuse watery diarrhea. he denied any new medications, eating raw foods or recent travels. eosinophils were elevated to 2.4(29% of wbc) and ige was elevated to 3259. multiple stool specimens were negative for ova & parasites and enteric pathogens. serology was negative for strongyloides, trichinella, e. histolytica and toxocara. ast, alt & bilirubin were elevated and a ct scan showed dilated billiary ducts with a possible ampullary mass. biopsy of the ampullary mass revealed a tubulovillous adenoma. biopsies of the duodenum, terminal ileum, colon and rectum were remarkable for focal eosinophilic cryptitis & chronic inflammation in the lamina propria consisting of eosinophils, scattered lymphocytes and histiocytes. all specimens were negative for parasitic infections including duodenal aspirates. he was empirically started on metronidazole and singulair with gradual improvement of symptoms, eosinophils and liver tests. two months after discharge, the patient remained diarrhea free with a normal eosinophil count. conclusion: we report a patient with eosinophilic gastroenteritis and an ampullary tubulovillous adenoma with obstruction of the biliary system. this unique presentation illustrates the diverse nature of gastrointestinal manifestations seen in eosinophilic gastroenteritis. background: zonisamide is an anti-seizure medication chemically classified as a sulfonamide and unrelated to other ant seizure agents. we report a case of hypersensitivity to this agent in a child. method: case report results: this patient is a 22-month-old girl who developed "peeling of her lips" three weeks after starting zonisamide. one week later she developed a rash that began on her face and generalized over several days to her neck, trunk and extremities. there was no respiratory distress, joint complaints and no angioedema associated with the episode, but fever to 103 prompted referral to our hospital on day 6 of the rash. the rash was macular-papular without discrete urticarial lesions. the rash coalesced with underlying erythema on face, chest and neck. the patient has a known history of seizure disorder, asthma, mild eczema, gastro esophageal reflux, development delay, lactose intolerance and failure to thrive. her other medications were, lansoprazole, topiramate, and albuterol. labs revealed a normal white cell count, an elevated sed rate ( 51) and elevated lft's, i.e. sgot 80 and sgpt 180. the only new medication was zonisamide that was discontinued. she was treated with iv steroids and hydroxyzine. the rash started fading by day 2 and the patient's fever resolved by the third hospital day. liver enzymes returned to normal by day 7. conclusion: this relatively new anti-seizure agent can be associated with hypersensitivity reactions in children. introduction: kawasaki disease (kd) is an acute chilhood vasculitis. in addition to the diagnostic criteria a broad range of nonspecific clinical features may be observed including aseptic meningitis, vomiting, diarrhea, abdominal pain, sterile pyuria, arthralgia and arthrtis, pulmonary infiltration, pleural effusion and nonspecific paralytic ileum as manifestation of gastrointestinal vasculitis. we describe a child who developed all features of kawasaki disease included the most rarely reported. patient report: a 2 year-old female presented 15 days of high fever, nonsuppurative cervical lymphadenopathy, petequial rash in legs, swelling of feet, distended abdomen, vomiting, obnubilated and hypoactive, incongruent speech, fisured lips and distended abdomen. lab tests showed: anemia (9.8g/dl), high wbc count (24, 200cells/mm3), thrombocytopenia (47, 000/mm3), hypoalbuminemia (1.1g/dl), lactate dehydrogenase (ldh) 209mcg/l, glutamin transferase (ggt) 190. csf total proteins 129, glucose 60, cells 23, pm 5%, mn 95%, seric complement 88, cultures were negatives. she developed myocarditis, aneurysms in the right and left coronary arteries. on the 25th day presented cardiac failure, pleural effusion, paralytic ileum, hydrops vesicular, mechanic ventilatory assistance was required. the first dose of intravenous immunoglobulin (ivig) (2g/k) was infused, heparin and hydrocortisone. on 45 day a second doses of ivig was infused, because of fever, and abdominal vasculitis. steroids ware discontinued, heparin was suspended and aspirin was added as antiaggregant. discussion: our patient presented an unusual and severe presentation of kd with pleural effusion, nonspecific ileum, cardiac failure secondary to myocarditis, aseptic meningitis and thrombocytopenia; all those manifestations had rarely been reported at the same time. she presented with a devastating evolution. complications were resolved. the lastest studies have shown that treatment with ivig plus corticosteroids significantly reduce serum concentrations of proinflamatory cytokines. in this case antiinflamatory doses of aspirin were contraindicated and steroids were used with satisfactory outcome. limited data is available for nonresponding patients to guide therapy. although multiple doses of ivig are sufficient in some patients, some of them remain refractory to therapy and they need corticosteroids to control the vasculitis process eosinophilia is defined by an absolute eosinophil count above 0.7 x 10 9 and can be seen in association with a broad spectrum of disorders ranging from allergic to malignant. idiopathic hypereosinophilic syndrome (hes) should be considered in any patient with an eosinophil count above 1.5 x 10 9 for more than 6 months without commonly recognized causes of eosinophilia and with evidence for organ damage not otherwise explained in the clinical setting. it is potentially an aggressive disease with mean survival of less than a year without treatment. we present a 39 year old male horse breeder, with eosinophilia lasting more than 10 years. prior to coming to our institution, he underwent extensive medical evaluation including bone marrow and gi biopsies, multiple imaging studies with mri and ct scans of the chest and the head as well as detailed evaluation of his cardiac status. all these tests were normal and the patient was empirically started on treatment for possible hes including trials of prednisone, hydroxyurea, interferon alfa, and imatinib, all without lasting resolution of his eosinophilia and causing significant side effects with profound depression of his immune status. finally, in light of the patient's profession, a strongyloides enzyme immunoassay was done and found to be remarkably positive. duodenal drainage confirmed the infestation with this nematode. within a week of starting treatment with ivermectin, his eosinophil count came down by 50% and eventually normalized. we learn that one should be persistent in excluding all common causes of eosinophilia before considering hes. in case of parasite infestation, premature treatment with immunosuppressors can result in worsening of the infection with potential for poor and even fatal outcome. stool evaluation might not be sensitive enough for detection of parasites and it is therefore necessary to complete a diagnostic work up with appropriate serology. doxil is the pegylated liposomal form of doxorubicin and has been used successfully as a cancer chemotherapy agent in many types of tumors. a hypersensitivity reaction can occur, usually during the first infusion, and appears to be rate related. the symptoms include dyspnea, tachypnea, facial swelling, chills, hives, chest pain, and back pain. we report a case of a hypersensitivity reaction to doxil in a 26 year-old woman with hodgkin's lymphoma. during her first outpatient doxil infusion at 1 mg/min, she developed urticaria, chest tightness, dyspnea, and back pain. these reactions persisted despite being medicated with antihistamines and steroids and immediately resolved during pauses in the infusion. after 23 mg of doxil, the infusion was discontinued. six days later, she was admitted to complete the other half of the dose. she had a negative intradermal skin test to a 1:100 dilution of doxil. she was then premedicated with diphenydramine, dexamethasone, acetaminophen, and famotidine. the doxil infusion was started at 0.4 mg/min and was soon stopped due to flushing of the hands and face. the infusion was decreased to 0.2 mg/min. she was able to tolerate this slow infusion with only mild and tolerable symptoms. when her symptoms worsened, the infusion was stopped for 30 to 60 minutes. she completed the 23 mg infusion of doxil after 13 hours. pre-infusion and post-infusion complement levels were drawn during this second administration of doxil. her pre-infusion c2, c3, c3a, c4, c5, c5a, and bb levels were all normal. her pre-infusion c4a and sc5b-9 levels were high, indicating that she might have had some residual or persistent complement activation caused by her first doxil infusion. her post-infusion c2, c3, c3a, c4, c5, c5a, and bb levels were all normal. however, her post-infusion sc5b-9 levels significantly increased, suggesting complement was activated during the second doxil infusion. given her reaction during her first doxil infusion and a negative skin test to doxil, it is highly unlikely that her doxil hypersensitivity was an ige-mediated process. therefore, in patients with a similar doxil hypersensitivity, we suggest a slow rate of infusion of 0.1-0.2 mg/min, toleration of mild symptoms, 30 to 60 minute pauses during more severe symptoms, and continuation of premedication during the entire lengthy infusion. introduction eosiniphilic esophagitis (ee) is an isolated, severe esophageal eosinophilia. patients are usually young males presenting with vomiting, epigastric or chest pain, dysphagia and obstructive respiratory problems. they are often initially misdiagnosed with and treated for gastroesophageal reflux disease (gerd). distinction between the two diseases can be made with biopsies of the esophageal mucosa. while any eosinophils in the esophageal mucosa indicate pathology, gerd typically presents with up to 7 eosinophils per high powered field (hpf, 400x) while ee most often presents with greater than 20-24 eosinophils per hpf. case report the patient is a 3 and one half year old boy who has experienced severe symptoms of gerd from the age of 6 months. he vomits after meals at least 1-2 times per day. he coughs when he lies down at night and regurgitates phlegm in the early morning. he has complained of discomfort in his lower chest after eating. his weight has remained at 35 pounds for the last six months. the patient was diagnosed with asthma at age 2 and a half; however, there is no family history of asthma or allergies. the patient initially experienced improvement on lansoprazole, but his symptoms recurred when the medication was discontinued and subsequent courses were ineffective. his physical exam was normal barring slightly edematous nasal turbinates. an endoscopic biopsy showed "numerous eosinphils" (later clarified to 38 eosinophils per hpf) in his distal esophagus. the patient showed allergy to milk and wheat on radioallergosorbent (rast) testing. the patient was started on swallowed fluticasone 2 puffs twice daily and advised to see a nutritionist regarding a wheat and milk elimination diet. conclusion ee is an important differential of gerd-like symptoms in childhood. to avoid misdiagnosis it is critical to evaluate the number of eosinophils present in a biopsy specimen to help differentiate between gerd and ee. children with ee are at increased risk of developing esophageal dysmotility and esophageal strictures. patients often have positive skin prick or rast tests to foods and aeroallergens. alternative treatments such as food elimination diets and glucocorticoids (systemic or topical) are effective in treating symptoms which may not respond to reflux medications. introduction in 1992 asherton introduced the term catastrophic antiphospholipid syndrome (caps) to describe patients sharing clinical evidence of multiple (three or more) organ involvement and/or histopathological evidence of multiple vessel occlusions. case report we present a 13 year old female, with lumbar pain, arthralgias, weight loss, fever, malaise, raynaud phenomenom, alopecia, oral ulcers and hepatomegaly. on arrival, she was polypneic with tachycardia, basal hypoventilation, and hepatomegaly was evident. hb: 8.8, leucocytes: 39.300, total lymphocyctes: 8, 300, total neutrophyles: 28, 700, platelets 393, 000. coombs positive. urin exam: proteinuria, leucocyturia and erythrocyturia. creatinine 1.3. diagnosed as sle with pericarditis, cardiac failure and acute pulmonary edema, urinary tract infection and pneumonia, requiring mechanical ventilation and inotropic support, intravenous gammaglobulin and hydrocortisone. acute renal failure and hemodialysis was begun with improvement. suddenly she presented seizures crisis, stuporous, livido reticularis skin and acrocyanosis, external opthamalplexia, bilateral facial diplexia, ocular fundus with arteriolar vasospasm. right facio-corporal hemiparesia, cortical and progressive medular annals of allergy, asthma & immunology segment changes. ct showed multiple left fronto-occipital parietal hypodensities suggestive of lacunar infarcts. diagnosed as neurolupus and caps. initially anti b2 glp1 and anti clp were negative with later positivization. urinary tract infection contraindicated high doses of steroids and, intravenous gamaglobulin and anticoagulation were started. with significant improvement. currently the patient is evolving in a satisfactory way. discussion the literature establishes that catastrophic aps is characterized by elevated mortality. in this patient damage was evident to the cns, pns, kidneys and the skin. with the presence of positive antiphospholipid antibodies with an energic antiinflamatory, immunoregulatory and immunosupressive therapy, the function of each affected organ completely recovered. this case exemplifies that the therapy of caps should be undertaken in a sufficient and early manner given the elevated mortality of this syndrome. patient, a 70-year-old white, male non-smoker physician on high-dose regimen of advair and singulair presents with an 8-day history of progressive chest tightness. pulmonary function tests showed normal (fev 1 of 96%) lung function. in the past, whenever inhaled steroid dosages were lowered, patient experienced a reoccurrence of asthma symptoms, despite consistently normal lung function results. to rule out the possibility of a psychologically induced asthma exacerbation, the patient's fractional concentration of exhaled nitric oxide (feno) levels were measured. the patient's feno level was elevated at 48.9 ppb. values greater than 30 ppb have been described as consistent with airway inflammation. with an increase in the patient's inhaled steroids, the patient had a remission of symptoms within a week. this case is illustrative of an increasingly common clinical picture where a symptomatic asthmatic may have normal spirometry but elevated feno. as devices for measuring feno become more available in the outpatient clinic setting, elevated feno may be an excellent diagnostic marker in assessing whether airway inflammation is being adequately treated in situations where spirometry values are within normal ranges. introduction the autoimmune thrombocytopenic purpura (atp) is characterized by thrombocytopenia and megakaryocytic hyperplasia. the first choice of treatment consists of intravenous gamma globulin (ivig), corticosteroids and anti-d antibodies and the second line measures are immunosuppressant drugs, splenectomy and danazol. case report a 4 years old male presented in the first year of life ecchymosis in several parts of the body intermittently. in april 2003 he presented ephistaxis and lower gastrointestinal bleeding. complete blood count showed platelet count of 45, 000/ul. prednisone was started (2 mg/kg) with no improvement. at that time, danazol, anti-d antibodies, and ivig (2 g/kg) were added. subsequently, the platelet average count diminished to 5, 000. the patient was transferred to our hospital. at his admission he presented cushingoid habitus (figure 1) and acanthosis nigricans. the immunological tests (aan, ch50, c3, c4, immunoglobulins, anticardiolipins and b2 glycoprotein) showed no alterations. bone marrow aspirate demonstrated megakaryocytic hypercellurarity. prednisone dose was tampered when the patient presented secondary glaucoma. patient continued his treatment with danazol and ivig (2 dosages of 2g/kg each), hydroxychloroquine and cyclophosphamide with no improvement. thus, 3 months after the immunosuppressant treatment, splenectomy was performed, obtaining partial improvement. at that time ranitidine and hydroxychloroquine were suspended and cyclophosphamide was changed to azathioprine. last platelet count was 106, 000/ul. conclusion chronic atp in childhood as the present case account for approximately 4-5% of the total atp patients. chronic atp that does not respond to conventional treatment is a therapeutic challenge. in this patient we used first choice and second choice drugs with no improvement, consequently a splenectomy was indicated, not obtaining the desired response at first. the use of immunosuppressant drugs is not common for this disease, but it could be a good alternative for atp resistant to conventional treatment. this are the most important laboratory test of our patient. background: budesonide is the only corticosteroid available for inhalation by jet nebulizer and is indicated for the treatment of asthma in children. objective: to evaluate the distribution and clinical efficacy of inhaled budesonide administered by nebulization with a modified commercial device. methods: a 23 year old male with severe persistent asthma underwent a lefort procedure for multiple craniofacial abnormalities. the external device maintained his mouth open impeding the proper use of controller medications. as a result he developed an increase in his asthma symptoms. he was subsequently treated with nebulized budesonide delivered with a modified jet nebulizer through the end of a plastic tube in a flow-by manner. we then performed dynamic ventilation imaging after administering 33.40 mci of nebulized technetium 99m-dtpa diluted in two ml of normal saline. images were obtained for five minutes at three seconds per frame. spirometry monitoring was not possible given the obstructive nature of the facial device. results: the patient demonstrated improvement of his asthma symptoms. the ventilation scan showed that the patient breathed the technetium dtpa through the specialized device with delivery to his full lung volumes within 12 seconds. conclusions: we report the successful treatment of a patient unable to use the commercially available methods for administration of inhaled steroids. rationale: hp is a non-ige mediated inflammatory response in the lungs due to a variety of organic antigens, including metal working fluids. the wideranging clinical features include acute, subacute, and chronic forms. elevated antineutrophilic cytoplasmic antibodies and platypnea, defined as dypsnea induced by the upright position and relieved with recumbency, have not been previously reported in patients with hp. case: 35-year-old white male tool and dye machinist presented with progressive cough, weakness, dyspnea on exertion, and platypnea. symptoms began 15 weeks earlier with coryza and diffuse myalgias. he had lost 12% of his body weight since symptom onset. examination revealed a pulse of 140, respiratory rate 18, and right basilar crackles. resting pulse ox on room air was 95%, but dropped to 91% upon ambulation. pft's revealed severe obstruction (fev1 42% predicted) with significant reversibility (fev1 +19%), and a dlco of 82% (adjusted for va and hemoglobin). hemoglobin was 17.5 with a normal leukocyte count and differential. c-anca (anti-pr3) was 19.3 (<5), and p-anca (anti-mpo) was 15.9 (<15), both performed by elisa. echocardiogram showed an ef of 50-55% with mild pulmonary hypertension; no shunt was present. chest roentogram was normal, but a chest ct revealed a diffuse ground-glass pattern with scattered centrilobular opacities. biopsy was consistent with hp. he was removed from his work exposure to metal working fluids with full recovery of lung function and resoulution of symptoms. conclusions: hp presents as a constellation of symptoms without a single, unique identifying pattern. platypnea and elevated anca's have been observed in a wide range of disorders, all of which were excluded in this patient. platypnea has been associated with hereditary hemorrhagic telangiectasia, pulmonary avm, hepatopulmonary syndrome, recurrent pulmonary emboli, and patent foramen ovale. elevated anca's has been associated with wegener's granulomatosis, goodpasture's syndrome, churg-strauss vasculitis, drug-induced vasculitis, inflammatory bowel disease, and others. elisa is a more specific modality for anca's than indirect immunofluorescence, but it is less sensitive. the possibility of hp should be considered in patients with either of these two abnormalities. rationale: heart disease is the leading cause of death in america and 70% of persons between 70 and 80 years of age have coronary athersclerosis at autopsy. the presentation in the elderly is commonly atypical. 45% of myocardial infarctions were silent or unrecognized in the framingham cohort. in patients 65 and older, it is estimated that 8-25% will present with dyspnea without any associated chest pain. we present a case of unstable angina presenting as exercise-induced asthma. case: an 81 year-old white male with moderate persistent asthma, hypertension, dyslipidemia, and a long history of allergic rhinitis presented having had an abrupt increase in his usual exercise-induced asthma symptoms four weeks prior. asthma had been diagnosed at age 69 with spiromety showing moderate obstruction and significant but incomplete reversibility. he had a remote history of pipe and cigar smoking, but had quit at age 50. he had been well-controlled since that time with his most recent regimen consisting of fluticasone 100 mcg/salmeterol 50 mcg diskus, one inhalation twice daily. his typical exercise-induced asthma symptoms included dyspnea on exertion and chest tightness without radiation, and were relieved with rest and albuterol. the amount of exertion needed to trigger his symptoms, however, was much less than he had previously experienced, and this remained constant during the four weeks prior to his presentation. one week prior he had a normal ecg evaluation by his primary care provider. six months prior he had a normal nuclear cardiac stress test. physical examination was unremarkale except for moderately decreased aeration and 1+ pitting edema of his lower extremities. cardiology performed a nuclear stress test the next day which was abnormal. catheterization revealed 99% steonsis of his proximal lad. he succefully underwent cabg and is doing well on follow-up. conclusion: the elderly present many challenges to the diagnostician; these include multiple co-morbidities as well as atypical and often late disease presentations. the key to raising suspicion for cardiac involvement in this case was the recognition of the patient's cardiac risk factors in the setting of an abrupt onset of exercise symptoms while lacking other asthma symptoms such as nocturnal cough. cold urticaria is an uncommon form of physical urticaria. this case of a 9-year-old with cold urticaria and angioedema provides additional information regarding an unusual disorder in the pediatric population. an otherwise healthy 9-year-old female presented with a complaint of urticaria precipitated by cold exposure over the preceding 5 weeks. she had no recent illnesses and a past medical history significant only for cat allergy. on multiple occasions the patient noted erythema and pruritus of her arms and face after walking through the freezer aisle of a grocery store. urticaria would then develop on regions where she scratched, spontaneously resolving in 2-3 hours. on one occasion, urticaria appeared diffusely while taking a shower after the patient had been swimming. the urticaria resolved within a few hours after the patient was given diphenhydramine by her mother. three days prior to presentation the patient experienced upper lip angioedema with erythema, globus sensation and difficulty swallowing after drinking a strawberry slushy. the patient denied any respiratory complaints at that time and her symptoms again annals of allergy, asthma & immunology resolved spontaneously. family history was significant for a maternal history of seasonal allergies. upon physical exam the patient was well appearing. she had 2-3 discrete urticaria on each calf. the patient's mother noted that recently these would appear on "cold and rainy" days, attributing them to the fact that the patient's pants left her lower legs exposed. the remainder of her exam was normal and dermatographism was absent. laboratory evaluation consisted of cryoglobulins and strawberry rast, both of which were negative. application of an ice cube to the patient's forearm for 5 minutes resulted in a 9x6 centimeter wheal noted 3 minutes after ice removal. a diagnosis of cold urticaria with associated angioedema was made. the patient's mother opted to use diphenhydramine as needed and an epinephrine autoinjector was dispensed. by 3 months after symptom onset, the patient's only complaint was pruritus of her hands if they became too cold. no urticaria were noted. at 6 month follow-up the patient denied any symptoms for the preceding 2 months and had a negative ice cube test. cold urticaria in the pediatric population is a rare entity and not well understood. this case of a 9-year-old with cold urticaria and angioedema offers additional insight into this unusual disorder. a. khuntia * , m. mcmorris, ann arbor, mi. introduction: chronic granulomatous disease(cgd) is a heterogeneous group of disorders characterized by genetic defects in the ability of phagocytes to generate microbicidal reactive superoxide anions and its metabolites. it manifests early in life, primarily as recurrent infections, caused by catalase-producing bacteria such as staphylococcus aureus, burkholderia cepacia, and serratia marcescens and fungus such as aspergillus fumigatus. the disease may be inherited in an x-linked or autosomal recessive manner, with x-linked disease accounting for 65-70% of cases. the us incidence of cgd is 1/250, 000 live births with an average age at presentation of 3 years for xlinked and 7.8 years for autosomal recessive disease. case report: 18 year old male with history of three separate episodes of pneumonia beginning at age 16. each episode resulted in a hospital admission and intravenous antibiotic therapy after failed oral antibiotic therapy. an extensive pulmonary evaluation was initiated after the third episode of pneumonia, including a chest ct, viral, bacterial and immunodeficiency studies. cbc, complement, immunoglobulins, flow cytometry, viral and bacterial studies were all normal. the ct scan revealed dense nodular opacities in the right upper lobe with surrounding ground-glass opacification and mild bronchiectasis. a subsequent bronchoscopy demonstrated necrotizing granulomatous inflammation. open lung biopsy grew burkholderia cepacia on tissue culture. the clinical history, tissue histopathology and atypical organism found on culture were all suggestive of an underlying immunodeficiency. a neutrophil oxidative burst assay was performed which demonstrated minimal neutrophil activity upon stimulation, suggestive of the diagnosis of cgd. a chemilluscence assay verified the diagnosis of cgd, with minimal fluorescence noted on flow cytometry after neutrophil stimulation. dna analysis demonstrated a p47-phox deficiency, resulting in one of the autosomal recessive and less clinically severe forms of the disease. conclusions: this case of cgd is unusual because of the delayed presentation. it demonstrates the importance of a complete immunological evaluation including an evaluation for neutrophil disorders such as cgd in patients of all ages who present with recurrent and recalcitrant episodes of pneumonia, especially when atypical organisms such as burkholderia cepacia are found on culture. autoimmunity may play a role in the development of premature ovarian failure (pof), but the exact mechanism is not well understood. pof is mainly diagnosed after 19 years of age and most women complain of secondary amenorrhea. pof has been reported in combination with presence of ana and autoimmune diseases, but rarely with jra. here we report two cases of pof and positive ana in pediatric patients, one with clinical features of jra. the first patient, an african american 17-year-old girl, height in 50th percentile, weight in 10th percentile, with tenosynovitis of wrists and arthritis of knees and elbows for the past two years, was referred for further evaluation and management. she did not have her menarche yet and laboratory investigation revealed positive ana. the second patient, an african american 17-year-old girl, 50th percentile for height and weight, was referred to the immunology clinic with chief complaint of primary amenorrhea and delayed development of secondary sexual characteristics and was found to have positive ana without clinical findings of jra. both patients were tanner stage 2 for breasts and tanner stage 2-3 for pubic and axillary hair. both had elevated fsh and lh, karyotype 46xx and small uterus and small ovaries on pelvic ultrasound. antiovarian antibody was not detected in any of the two patients. the bone age was significantly delayed. pof in karyotypically normal women is frequently seen in combination with elevated serum ana. the clinical spectrum of rheumatoid disease associated with pof ranges from asymptomatic ana positivity to typical presentation of jra. women with pof should be monitored for the emergence of autoimmune disorders including jra, and women with jra should be followed for menstrual irregularities and signs of pof. introduction: many u. s. military personnel deployed to the middle east continue to develop infection with leishmaniasis, a parasite transmitted by the sand fly. pentavalent antimonials have been used as an effective treatment for leishmaniasis for many years. in the united states, sodium stibogluconate (pentostam) is the pentavalent antimonial of choice, and is currently being administered under an ind protocol. side effects of therapy include myalgias, arthralgias, rash, malaise, abdominal pain, pancreatitis, and hypersensitivity reactions. the true incidence of hypersensitivity reactions is not currently known. case reports: two u. s. soldiers receiving pentostam for the treatment of cutaneous leishmaniasis were evaluated in our clinic at walter reed army medical center after experiencing urticaria, angioedema, wheezing and dyspnea after medication infusion during the 20-day course of daily therapy. due to the concern of a potential ige-mediated reaction, skin testing was performed. after informed consent, skin testing included a prick test at full strength, followed by intradermal (id)testing. soldier #1 was a 23-year old male reporting lip swelling, throat tingling, dyspnea and chest pain 7-8 hours after treatment #10/20. skin testing to both lots used during the treatment course showed positive values of 8x20mm and 9x14mm respectively at id 1:1000. soldier #2 was a 28-year old male reporting diffuse pruritus, hives, dyspnea, and chest pain 15 minutes after infusion #16/20. skin testing showed positive values of 7x14mm and 8x12mm respectively at id 1:1000. due to clinical symptoms and positive skin testing, therapy was discontinued in each case. one control individual showed negative testing to prick at full strength, id 1:1000, and id 1:100. conclusion: skin testing with pentostam may provide an objective tool for accurate classification of adverse reactions as igemediated. reliance on skin prick testing alone may not be sufficient to detect pentostam skin test reactivity, as both of these patients reacted to id testing only. a prospective study including pre-and post-treatment skin testing should provide more information on the value of skin testing in providing objective evidence for an ige-mediated process and determining the incidence of hypersensitivity to pentostam. introduction: a 3-year-old girl with a history of multiple infections was hospitalized with respiratory distress and hypoxia. her past medical history was significant for hypothyroidism, psoriasis, asthma and multiple pneumonias. a cbc revealed an absence of lymphocytes. laboratory: t and b cell subsets showed no b-cells and very low t cells (<100 cells). inadequate lymphocytes were present for mitogen and antigen studies. serum immunoglobulins were normal and she had antibodies to streptococcus pneumoniae and tetanus. antibodies to rsv, influenza and mycoplasma were absent. chest x-ray revealed interstitial infiltrates bilaterally. a high resolution ct scan revealed septal thickening and confirmed interstitial infiltration. open lung biopsy was consistent with non-specific inflammation with extensive lymphocytic infiltration. bal fluids and biopsy were negative for bacteria, fungi and opportunistic pathogens. clinical course: the patient did not improve with antibiotics and steroids were started. the patient improved rapidly and was discharged to home. biochemical analysis demonstrated a deficiency of adenosine deaminase (ada), a form of severe combined immune deficiency (scid). the patient was started on replacement ada, adagen. a repeat high resolution ct scan showed some improvement. however, the patient continues to be steroid dependant to control her pulmonary symptoms. lymphocyte numbers remain low despite effective ada replacement and the absence of serum datp. she remains clinically stable and receives adagen injection twice weekly. discussion: ada deficiency is a condition, which leads to accumulation of the metabolite datp, which is toxic to lymphocytes. this disease most commonly presents in the first year of life as scid and is fatal unless treated. our case is unusual due to the late onset of severe disease, normal serum immunoglobulin and the presence of some protective antibodies. despite adequate replacement of ada the patient continues to be profoundly lymphopenic, most likely due to steroids. although we do not yet completely understand the underlying lung disease we suspect that the patient has an autoimmune process causing interstitial inflammation. background: atopic dermatitis has a broad range of differential diagnoses. human sarcoptic infestation is characterized by severely pruritic lesions of variable appearance and distribution and may masquerade as eczema. infestation may be difficult to confirm and eradicate. animal transmission has been reported as a source of human infection. objective: to report a case of persistent sarcoptic infestation masquerading as eczema and associated with delusional parasitosis. methods: a 58-year-old female was referred to allergy clinic for evaluation with a two year history of recurrent, pruritic rash thought to be refractory atopic dermatitis. previous ineffective treatments included topical steroid creams, lindane, topical anti-fungals and multiple otc antiitch preparations. at initial evaluation, she had widespread excoriated papules in various stages of healing over 70% of her body. she reputed her dog was diagnosed with recalcitrant mange, which necessitated giving him medicated baths twice daily. results: a clinical diagnosis of subacute sarcoptic infection was made and the patient was prescribed two courses of elimite followed by oral ivermectin. her rash quickly resolved except for post-inflammatory hyperpigmentation. three weeks after resolution of primary lesions, she again complained of pruritic eruptions occurring on easily accessible areas and began bringing in medicine bottles of skin debris and scabs for examination. scrapings, koh preparation and skin biopsy examined microscopically showed no evidence of sarcoptic re-infestation. a diagnosis of delusional parasitosis was made. conclusions: the animal to human transmission of sarcoptic infection seen in this patient is rare and responded quickly to appropriate treatment. despite eradication of the infection, she developed delusional parasitosis, a rare psychiatric disorder characterized by fixed, false belief of an infestation by insects or other creatures. she displayed the classic matchbox sign in which samples of skin, scabs and other detritus are brought in for examination. she is currently receiving psychiatric care. background: thimerosal is a mercury derivative that has been used since the 1930s. it is a commonly used preservative in ophthalmic solutions, otic drops, and vaccines due to its bactericidal property. objective: to report the first case of a generalized reaction to thimerosal found in an influenza vaccine. methods: we present a patient who developed a generalized maculopapular eruption after receiving a thimerosal containing influenza vaccine. patch testing was performed to determine if there was an allergy to thimerosal. results: patch testing confirmed a type iv (t cell mediated) sensitivity to thimerosal, further supported by the prior history of a reaction to a thimerosal containing contact lens solution. the patient was asked to avoid thimerosalcontaining products, including vaccinations, unless the benefit clearly outweighed the potential risk of a reaction. conclusion: physicians need to be aware that thimerosal is found in many products including vaccinations. clinicians should also be aware that allergic reactions do occur with exposure to thimerosal even in vaccines. this is the first case report in the literature of a generalized reactions to thimerosal from an influenza vaccine angioedema is a rare condition that has been described in the literature and exists in both inherited and acquired forms. a defect of the innate immune system, more particularly the complement system, is the inciting culprit. the acquired form of c1 esterase inhibitor deficiency has been divided into two classes and is generally not commonly seen until after the forth decade of life. type 1 acquired angioedema has been described in association with lymphoproliferative disorders, while type 2 is related to excessive complement activation and consumption due to autoantibodies. our case is a 67-year old man referred from an outside physician for further management of idiopathic edema. he first experienced facial edema in april 2002 attributed to sweet myrrh root ingestion. subsequently, in november 2002 he developed diffuse swelling of his upper extremities and tongue without airway compromise. a minimal work-up at that time was inconclusive. he fortunately remained asymptomatic until january 2004 at which time he experienced two episodes of tongue swelling without etiology. he was seen in his local emergency department and treated with diphenhydramine, corticosteroids, and epinephrine on both occasions with gradual improvement of his symptoms. the patient was not on medications commonly associated with angioedema and did not report insect envenomation. subsequently, he was seen by his primary care physician who ordered a number of laboratory tests including a ch50, which was significantly suppressed. in light of this finding, he was referred to our clinic for further evaluation. at the time of presentation to our office, the patient was symptom free. his physical exam was within normal limits. further laboratory evaluation was essentially unremarkable with the exception of comple-ment studies, which are listed in the table. our case demonstrates an elderly patient with evidence of idiopathic swelling. we arrived at our diagnosis of acquired angioedema based on clinical presentation and confirmatory serum complement levels. a low ch50 at time of presentation allowed us to further delineate the etiology of complement deficiency. the fact that our patient did not present with swelling until after age 60 and the paucity of a family history of idiopathic angioedema makes the diagnosis of acquired angioedema probable. measure of serum c1q level confirmed the diagnosis. introduction: certain diseases, widely believed to be of allergic etiology, including atopic dermatitis and episodes of wheezing might be the result of interplay of genetic and environmental factors, at least partially. we describe a child with a rare chromosomal disorder presenting with typical features of atopic dermatitis and recurrent mild wheeze. materials and methods: a new born african-american male was noted to have unusual facial features immediately after birth. the baby was born naturally, without antenatal and neonatal problems. on physical examination, the infant had unusual facial characteristics with tight and taut facial skin, relatively diminished facial pad of fat, pointed chin, and markedly hypertonic extremities. additionally, cardiac exam revealed mumur consistent with uncomplicated asd. frequent reassessments of the infant in the outpatient clinic were done. the child had repeated bouts of wheezing attacks, and facial rashes compatible with the diagnosis of atopic dermatitis. the wheezes were treated in the clinic with nebulaized bronchodilators, and the atopic dermatitis responded reasonably to topical steroid applications and moisturizers as needed. chromosomal analysis of the peripheral blood of the chid confirmed the diagnosis of deletion of long arm (q) of chromosome 1 [46, xy, del (1)(q42q43)]. karyotypic analyses of the mother and father were normal. the child exhibited features of developmental delay, and seizure activities. anti-epileptic drugs (aed) were instituted. initial eeg was normal and the subsequent eeg showed findings of static encephalopathy. ct scan of the brain revealed absent corpus callosum. neurologic evaluations and physiotherapies were requested for improvement of fine motor skills. he did not seem to suffer from any serious infectious or immunodeficient illnesses. his cbc was normal. he continued to have fair gains in his weight, height, and head circumference. his atopic dermatitis and wheezing episodes remained under control. there were a few hospitalizations for break-through seizures and dehydration from gastroenteritis. a subsequent echocardiography confirmed closure of asd. con-clusion: a child with chromosomal anamoly, atopic dermatitis, and mild intermittent wheeze is reported. despite multiple congenital problems, the child continued to have a stable clinical course. etoposide is a chemotherapeutic agent used to treat many solid tumor malignancies. hypersensitivity reactions have been well described and there are a few reported deaths from anaphylaxis. some suggest that the hypersensitivity is an anaphylactoid type reaction as it may occur during the first dose. case reports of cutaneous complications include stevens-johnson syndrome, radiation recall and diffuse erythema. there are four cases in which diffuse erythematous papules developed after etoposide therapy. all rashes spontaneously resolved within three weeks and biopsies demonstrated keratinocytes in a starburst pattern. we report the first case of an immediate etoposide induced skin reaction that evolved into long lasting hyperpigmented plaques. pretreatement was able to prevent this immediate and late reaction on subsequent exposure to etoposide. a 27 year old female with ovarian cancer was treated with bleomycin, etoposide and vinblastine. three hours after initiation of the third dose of etoposide, patient developed pruritic, erythematous macules on her chest, abdomen, face and extremities. the infusion was stopped and decadron administered. over forty-eight hours, the pruritic macules became hyperpigmented plaques on her chest, abdomen, extremities and face. pruritus resolved after a slow taper of prednisone. the darken plaques were treated with multiple topical preparations but persisted for about three months. biopsies demonstrated superficial perivascular infiltration of lymphocytes and a few eosinophils suggestive of a drug eruption. etoposide was considered essential for this patient so allergy was consulted. the literature supports cautious readministration of etoposide with pretreatment and slower infusion rate to prevent immediate hypersensitivity. we could not guarantee prevention of the late hyperpigmented reaction. the patient was pretreated with prednisone and cetirizine. etoposide was administered in an icu with a slower rate of infusion. etoposide was tolerated without immediate pruritus or erythematous reaction. the patient did not develop the delayed darkened plaques. cautious administration of etoposide after premedication and a slow rate of infusion prevented both the immediate and late reaction previously experienced by this patient. eosinophils normally comprise 1-3% of peripheral white blood lymphocytes. peripheral blood eosinophilia is defined as an absolute eosinophil count >500 cells/mm3 and is most often caused by atopy, helminth infections, or collagen vascular diseases. less common causes include adrenal insufficiency and neoplastic processes. eosinophilia can be characterized as mild (<1500 cells/mm3), moderate (1500-5000 cells/mm3) or severe (> 5000 cells/mm3). although severe eosinophilia has been reported in association with adult hiv infection, studies of hiv-infected children have not shown peripheral blood eosinophilia to be a feature of pediatric hiv infection. we report an unusual case of severe peripheral blood eosinophilia in an adolescent male who was subsequently found to be hiv-infected. a previously healthy 15-year-old male presented with 2 week history of fever, diarrhea, cough, vomiting, abdominal pain, anorexia and a 5lb weight loss over the previous 2 months. the patient had recently emigrated from guyana and denied sexual activity, intravenous drug abuse, or other hiv risk factors. there was no known maternal hiv infection. repeated stool specimens were negative for ova and parasites. serologies for e. histolytica, t. canis, and s. stercoralis were negative. an abdominal ultrasound, chest x-ray, serum electrolytes, and liver function tests were all within normal limits. total white blood cell was 16, 500 with 59% eosinophils (absolute eosinophil count of 9, 735 cells/mm3). elisa and western blot were positive for human immunodeficiency virus (hiv-1). cd4+ tlymphocyte count was 1277 cells/mm3 with an hiv-1 rna level of 11, 000 copies/ml. the patients symptoms resolved over the next 10 days without treatment. he was started on combination antiretroviral therapy (zidovudine, lamivudine, abacavir, and efavirenz). absolute eosinophil count continues to slowly decrease with the last count of 3, 605 cells/mm3 three months following the introduction of antiretroviral therapy. severe peripheral blood eosinophilia may be a presenting feature of hiv infection in adolescents. hiv testing should be considered in cases where more common causes of eosinophilia such as atopy and parasitic infections are excluded. triad asthma is well described in adults but not in the pediatric literature. this case highlights the successful treatment of a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. a 13 year-old female presented with severe persistent asthma, eib, allergic rhinitis, chronic sinusitis, nasal polyps, and a history of pneumonia. her asthma symptoms were minimal from age 2 until age 9. she then started flovent and required increasing amounts of inhaled and oral steroids. she required 6 courses of oral steroids per year by age 13. in addition, she had snoring, fatigue, chronic nasal congestion, rhinorhea, and sneezing despite treatment withallegra and rhinocort. she had received immunotherapy from age 8 to 10 with no clinical improvement. since age 8 she had recurrent sinusitis and had required 2 polypectomies. she noted aspirin caused nasal stuffiness and mild wheezing and therefore avoided it. on exam she had allergic shiners, dennie lines, boggy turbinates, nasal polyps, and diffuse wheezing. on evaluation she had severe airway obstruction. her fev1 increased from 36% to 51% with albuterol. her chest ct had a mosaic pattern due to severe air trapping, and her no level was 177. a sleep study showed severe hypopneas, and she had pan-sinusitis on ct. she had multiple positive spts, an eosinophil count of 1100 and an ige of 700. she had a normal sweat chloride and ph probe.the differential diagnosis included churg-strauss, abpa, cystic fibrosis, bronchiolitis obliterans, and triad asthma. after a thorough evaluation, she was diagnosed with triad asthma. with 6 weeks of treatment with oral prednisone, her fev1 improved from 36% to 83%. her inhaled controller therapy was increased and she was placed on xolair. she had a polypectomy and then underwent aspirin desensitization. one year after starting treatment her fev1 remains 83%. she requires albuterol 1x/month and has not required prednisone. her eib, allergic rhinitis and congestion are markedly improved. she has had no further episodes of sinusitis, and a repeat sleep study was normal. in conclusion, we treated a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. this is not frequently reported in the pediatric population, and raises questions about the incidence, optimal long term treatment of triad asthma, and the differences from the adult onset of this disease. a.a. white * , r.a. simon, la jolla, ca. background: human disease from mold has traditionally been isolated to infection, allergic disease, or hypersensitivity pneumonitis. specific diseases or pathologic findings other than those listed above have not been well described. we report a case of acute eosinophilic pneumonia related to mold exposure. case presentation: a 50 year old woman developed dry cough and shortness of breath after stachybotrys mold was discovered in her home. a chest radiograph showed bilateral upper lobe infiltrates which worsened two weeks later. treatment with macrolide and flouroquinolone antibiotics was ineffective. a white blood cell count was 12, 000/cumm with 35% eosinophils. an erythrocyte sedimentation rate was 99 mm/hr. aspergillus ige was negative. treatment with prednisone led to complete resolution of the chest radiographic abnormalities and improvement in pulmonary function testing. this patient was given a diagnosis of acute eosinophilic pneumonia with mold as a likely causal factor. discussion: there is dispute amongst health care professionals regarding the significance of environmental mold contamination in the etiology of human disease. this case represents well characterized disease occurring in the setting of mold exposure. while a causal relationship cannot be established, the temporal relationship of mold contamination, symptom onset, and disease progression is compelling. interestingly, a recent report of mold contamination leading to nonspecific interstitial pneumonia/fibrosis has been described. we have observed a patient in our clinic with similar pathology on biopsy and temporal relationship to mold exposure. to our knowledge, acute eosinophilic pneumonia has not been reported in conjunction with mold exposure. conclusion: this case highlights a new condition in which mold may have a causal role. the mechanism is unknown, but likely is through a non-ige mediated immunologic pathway. public awareness of mold as a health concern is increasing. perhaps similar cases will emerge as a history of mold exposure is offered by patients at the time they are evaluated for lung disease. a stronger correlation may then emerge. scuba diving is a commonly practiced activity which normally carries only minimal risks. any severe allergic reaction such as anaphylaxis, however, occurring during this activity could be a particularly dangerous not only because the swimmer is submerged but also because of the lack of proximity to medical care. we report a case of anaphylaxis occurring during scuba diving resulting from an unsuspected hypersensitivity to a latex component of the scuba diving suit. a 21 yr-old white male developed a severe generalized urticarial rash with angioedema of his lips and eyelids, and difficulty breathing within 5 minutes of his applying the suit and entering the water. after being rescued, he was transported to a nearby emergency department where he received epinephrine, antihistamines, corticosteroids and iv fluids with gradual improvement over a 4 hour period. the patient denied being stung by a marine aquatic organism and there was no prior history of allergy or medications usage prior to his reaction. since subsequent investigation revealed that the scuba diving suit contained latex (brazilian rubber), a specific ige rast was found to be strongly positive (class v) to latex. therefore, the patient was advised to use a suit made of neoprene synthetic rubber (polychloroprene) which is a nonlatex containing product. this case report illustrates the importance of a diligent search for hidden sources of latex products which can produce life-threatening allergic reactions in sensitized patients. there has been considerable debate concerning the safety of immunizing egg-allergic children with the combined mmr vaccine. this concern derives from the possibility of an anaphylactic reaction since the mmr vaccine is prepared from attenuated viruses grown on chick embryo fibroblast cell cultures. we have previously reported the safe administration of the mmr vaccine to 6 severe egg-allergic children without development of an adverse reaction (nsouli, tm, et al. ann allergy asthma immunol. 2004; 90:163) , a finding consistent with the current report of the committee on infectious diseases, american academy of pediatrics, 2003. the present case report describes an anaphylactic reaction in an egg allergic 4 yr-old-white male consisting of generalized urticaria, angioedema, wheezing immediately following the administration of a second mmr vaccine. the history of hives following ingestion of eggs was confirmed by positive specific ige rast testing. the patient's anaphylactic reaction necessitated emergency treatment including epinephrine, diphenhydramine, and corticosteroids in addition to iv fluids. although the administration of mmr vaccine in egg-allergic children is not considered as an absolute contraindication, the present case report suggests that caution should be observed when administering the mmr vaccine in such patients and that careful medical observation be included together with the ready availability of emergency medical equipment. p. buddiga * , r. turbin, a. baisre, l. bielory, newark, nj. introduction: sarcoidosis is a chronic granulomatous disease of unknown etiology that may have a multi-organ system manifestation and is characterized by the histopathological evidence of nonnecrotizing granulomas. case report: a 53 year old african american woman with a 10 year history of type ii diabetes mellitus, hypertension and sinusitis recalcitrant to multiple courses of antibiotics over 3 months was admitted to the hospital with complaints of right eye proptosis, diplopia, headache and right facial numbness.her exam was consistent with an ipsilateral mild optic neuropathy, complete sixth (vi)nerve palsy, trigeminal, ophthalmic and maxillary division numbness.ct and mri of the face, orbit and brain revealed an extensive process infiltrating ethmoid, maxillary and frontal sinuses;orbits and deep facial structures.chest ct revealed bilateral interstitial nodules and symmetric hilar adenopathy. differential diagnoses included sarcoidosis, lymphoma/tumor, wegener's granulomatosis or fungal infection.labs-purified protein derivative test=negative(neg), antineutrophil cytoplasmic autoantibodies=neg. angiotensin converting enzyme=83[8-52 u/l], fungal & anaerobic and acidfast bacilli culture of sinus secretions=neg.ethmoid, adenoid and maxillary sinus biopsies=multiple nonnecrotizing granulomas. on the basis of compatible clinical and radiographic findings, histopathological evidence and exclusion of other diseases with similar findings, the diagnosis of sarcoidosis was established. she was started on parenteral methylprednisolone and subsequently tapered to oral prednisone after 5 days.concomitantly she was started on methotrexate as a steroid sparing agent.most recent chest x-ray after 4 months of treatment reveals near complete resolution of the hilar lymphadenopathy.at 5 months her optic neuropathy and facial dysesthesia had resolved, and she was left with mild persistent vi nerve dysfunction. conclusion:sarcoidosis that manifests itself as sinusitis is an uncommon presentation and the mechanism involved is thought to be a consequence of the destruction of cilia and mucus producing glands by the granulomatous process.review of the literature indicates that this is the eighth case reported and illustrates that a high index of suspicion of other etiologies must be maintained when there is a refractory response to multiple courses of antibiotics in the treatment of sinusitis. j.b. hein * , p. patel, l. bielory, newark, nj. introduction: cid may result in opportunistic infections such as cryptococcal meningitis. we present an unusual case of cryptococcal meningitis in an hiv-negative patient with severe cd4 lymphocytopenia. case: a 40 yearold male with a three year history of sarcoidosis presented with acute onset of right-sided body numbness. the patient had been on prednisone 40 mg/day for 5 months prior to presentation. ct and mri scanning showed no vascular defects, meningeal enhancement, hydrocephalus or mass lesions. gallium scanning revealed normal uptake in the liver and spleen, mild uptake in the lungs and nasopharyngeal region, and asymmetric uptake in bilateral kidneys. the patient's initial wbc was 8, 000 cells/mm 3 , composed of 6970 neutrophils/mm 3 , 50 eosinophils/mm 3 , 50 basophils/mm 3 , 530 lymphocytes/mm 3 , and 400 basophils/mm 3 . repeat studies revealed the total lymphocyte count decreased at 240 cells/mm 3 with cd19 (pan b) cells decreased at 29 cells/mm 3 and cd3 (pan t) cells decreased at 189 cells/mm 3 . cd4 count was 144 cells/mm 3 and cd8 count 50 cells/mm 3 with a cd4/cd8 ratio of 2.9. igg levels were normal at 716 mg/dl. elisa was negative for hiv, and hiv-1 rna by pcr was not detected. serum ace level was 19 u/l and csf ace level was 23 u/l. csf obtained by lumbar puncture stained positive with india ink and culture revealed cryptococcus neoformans. the patient responded to amphotericin b lipid complex 5 mg/kg/day, and his neurological status eventually returned to baseline. conclusions: the severe lymphopenia in this patient caused predisposition to infection with cryptococcus neoformans. the etiology of the profound lymphopenia likely was multifactorial, including mild sarcoidosis activity (lung uptake on gallium scan) and chronic corticosteroid therapy. however, once cryptococcus became entrenched in the patient's csf, the infection itself likely depressed peripheral lymphocyte numbers even further. this case demonstrates the importance of exploring a broad differential diagnosis when faced with lymphocytopenia. background: isosulfan blue 1% is a common dye used in sentinel lymph node dissection. the usage of the procedure and dye has increased in numbers, and although rare, several cases of anaphylactic reaction have been reported. objective: we are reporting a patient who had an anaphylactic reaction to isosulfan blue while undergoing breast cancer excision with sentinel lymph node biopsy. methods: the patient is a 44 year-old woman with breast cancer. she underwent breast mass excision with sentinel lymph node biopsy using the lymphazurin 1% blue dye (isosulfan blue). she has a history of penicillin induced hives but has no other drug allergy. as soon as the dye was injected, she became flushed, hypotensive, and tachycardic. hypotension was refractive to fluid challenge. she was then treated with epinephrine as well as intravenous steroids and cimetidine with relief of symptoms. subsequently, she was evaluated in allergy and skin tests with isosulfan blue 1% at 1:100, 1:10 dilution, and undiluted were performed using histamine as positive control and saline as negative control. this procedure was also performed on two control subjects. results: the patient had a positive skin test (wheal and flare) to isosulfan blue 1% (undiluted) with the control being appropriately positive for histamine and negative for saline. control subjects had negative response to dye and saline and positive response to histamine. conclusions: isosulfan blue 1-% dye may cause anaphylactic reactions in patients undergoing sentinel lymph node dissection. . the positive skin test result to the dye plus the negative skin test responses in the controls suggests that the reaction may be immunoglobulin e (ig e) mediated. eosinophilic duodenitis (ed) and gluten-sensitive enteropathy (gse) or celiac disease (cd) are distinct clinical entities with well-defined clinical and laboratory parameters. ed is a rare condition of unknown etiology, which is manifest by eosinophilic infiltration of the gastrointestinal tract and peripheral eosinophilia. gse or cd is a form of non-ige food allergy caused by immune hypersensitivity to ingested gluten. the simultaneous occurrence of the two entities, however, is a rare event. the following presentation is a case report in which both entities were found in the same patient. an 11 y/o white hispanic male presented with severe, chronic, colicky abdominal pain and headache of 5 months duration. hematologic and immunologic studies were within normal limits. serum ige levels were 356 iu/ml (n= < 200 iu/ml), anti-endosomial ab (+), igg antigliadin: 16 u/ml (n=: 0-12 u/ml), skin tests for food and inhalant allergens were weakly positive (1+). biopsy of the inferior third of esophagus revealed chronic moderate esophagitis; biopsy of gastric antrum revealed lymphatic hyperplasia; duodenal biopsy showed shortening of the villi with the presence of eosinophils. following treatment with esomeprazole 40 mg bid, famotidine 20 mg qd, montelukast 20 md qd, lactobacillus, a diet free of gluten, rofecoxib 25 mg qd and betamethasone for 15 days, betamethasone the patient improved with partial resolution of symptoms. the presence of duodenal eosinophils persisted despite a gluten free diet, and continued to require repeated bursts of prednisone. since to our knowledge this is rare finding in which ed occurred in association with gse, a high index of suspicion for simultaneous occurrence of ed should be raised in any case of gse that fails to respond to a conventional gluten free regimen. we report the evaluation of a 6 month old male presenting with a pustular rash and choking episodes from birth. by age 6 weeks, he had experienced two pneumonias, one with fleeting infiltrates requiring intubation. persistent eosinophilia (5000-9000/ml) and eosinophils on pustule biopsy were noted. persistence of these and subsequent rsv pneumonia and recurrent draining otitis media led to referral. physical examination showed a thriving male infant with multiple erythematous papules and pustules along the scalp, face, axilla, and trunk. eosinophilia was confirmed. quantitative immunoglobulins were abnormal for igg 179 and ige 255 iu/ml. peanut cap rast was 23 kua/l. hib post-vaccination titer, t cell enumeration/stimulation, and nbt were normal. hiv testing, stool eosinophils, o&p, and hemoccult were negative. cxr, hrct, ekg, and echocardiogram were normal. pustule cultures for bacteria, virus, and fungus were negative. skin biopsy revealed numerous eosinophils in the pustule, dermis, epidermis, and perifollicular region. cd1a+ and s-100 staining were negative for histiocytic infiltration. nemo defect/incontinentia pigmenti were considered but testing was negative and karyotype 46, xy. bone marrow biopsy revealed numerous eosinophils at different stages of maturation, and no myeloproliferative or neoplastic changes. bronchoscopy was remarkable for 15% eosinophils on balf. 24-hour ph probe and impedence evaluation was negative. egd with biopsy was normal except for mild eosinophilic infiltration of the proximal and distal esophagus. with the clinical picture of recurrent pruritic crops of sterile pustules and characteristic skin biopsy demonstrating eosinophil infiltration, the diagnosis of eosinophilic pustulosis (ep) of childhood was made. despite no longterm sequelae or other end-organ involvement in ep, the degree and duration of eosinophilia, and presence of eosinophils in the airways and esophagus, raises the concern for other eosinophilic syndromes. following cardiac, cns, pulmonary, and gi systems is warranted. the infants pneumonias were felt to be due to aspiration, and ear infections the result of humoral immunity nadir or draining pustules in the external auditory canals. immunoglobulin levels will be monitored. this case illustrates the heterogeneity of eosinophilic diseases and raises the question of what drives the mechanisms behind malignant and benign disease. introduction: behcet's disease is a chronic, relapsing vasculitic disease characterized by recurrent oral, genital, and gastrointestinal ulcerations, a wide variety of skin lesions, uveitis, and arthritis. pediatric cases of behcet's disease are uncommon with an estimated prevalence of 1 in 600, 000 children under the age of 15. although the disease in children shows similar characteristics as adults, the diagnosis of behcet's disease in the pediatric population remains a challenge. this report describes an 18 year old girl referred to our pediatric immunology clinic for evaluation of recurrent painful oral ulcerations since the age of 7 with no genital ulcerations. the oral ulcers would last for two weeks and heal spontaneously but would reappear 2 to 3 weeks later. the patient had a history of raynaud's phenomenon for the last 6 to 7 years and the recent onset of joint pain. physical examination revealed 4-5 white elliptoid lesions 5-7 mm in diameter on an erythematous base on the tongue and soft palate. skin examination was significant for hyperpigmented patches over the neck, abdomen, and back. there were erythematous, serpigenous lesions on the palms and punctuated necrotic lesions on the finger-tips. pathergy test was positive. laboratory investigation was unremarkable and cultures from the oral ulcers remained negative. the patient was diagnosed with juvenile behcet's disease. she was started on immunosuppressive therapy with low dose prednisone and responded. conclusion: behcet's disease is a difficult diagnosis to make in the pediatric population. this case demonstrates that in children, recurrent oral ulcerations may be the only initial manifestation of behcet, and an important clinical marker for the disease. rationale: relapsing polychondritis is an uncommon severe inflammatory condition with unknown etiology that can present in a variety of manners. we report a 14 year old patient who initially presented with signs and symptoms of anaphylaxis to shellfish and was later diagnosed with relapsing polychondritis. case report: a 14 year old african-american boy with a 6 year history of asthma and fish and shrimp allergy presented to the pediatric intensive care unit on 4/23/03 after an episode of severe shortness of breath. his symptoms started shortly after accidental exposure to shrimp. in the intensive care unit, he was noted to be wheezing and stridorous. an initial chest xray as well as subsequent fiber optic laryngoscopy showed sub-glottic stenosis. he was intubated and received mechanical ventilation for greater than a week. after extubation, he stated that he felt fine, but continued to demonstrate audible stridor. pulmonary function tests demonstrated extra-thoracic obstruction, laryngoscopy continued to show sub-glottic stenosis, and esophagogastroduodenoscopy showed erosive esophagitis consistent with reflux. initial lab tests demonstrated a normal eosinophil count, elevated ige (969 iu/ml), and positive immunocaps testing to multiple foods. the patient was discharged home with minimal stridor and no wheezing. over the next nine months, the severity of his stridor waxed and waned, but in general it worsened in spite of a strict elimination diet and anti-reflux therapy. on 9/25/03 he received an emergency tracheostomy. on 1/26/04, the patient was again admitted to the hospital. at this time he complained of bilateral knee pain as well as significant weight loss. physical exam demonstrated arthritis with effusions of both knees as well as unilateral auricular chondritis and bilateral episcleritis. antibodies against type ii collagen were positive (42.1 eu/ml). the diagnosis of relapsing polychondritis was suggested. conclusion: relapsing polychondritis is a rare inflammatory disorder of the cartilage and connective tissue with an unknown etiology. the wide array of presenting complaints as well as the relapsing nature of this disorder often causes significant delay in diagnosis and treatment. in our case there was a period of nine months between the initial presentation and the time when the diagnosis of polychondritis could be made. d.k. geller * , m. ballow, buffalo, ny. introduction: an 11 yo male previously diagnosed with pandas presented to our immunology clinic for ivig. the patient was healthy until age 8 when he developed facial motor tics associated with group a beta hemolytic strep pharyngitis. he was treated with antibiotics and the tics resolved completely. he has had multiple recurrences associated with strep and other viral infections. the tics improve or resolve completely when he is infection free. he has no history of vocal tics, attention deficit/hyperactivity disorder, or obsessional thinking or compulsive behaviors. laboratory: multiple throat cultures positive for group a beta hemolytic strep, positive antistreptolysin and antideoxyribonuclease b titers. discussion: pandas identifies a subgroup of children with an obsessive compulsive disorder and/or tic disorder whose symptoms seem to be triggered by streptococcal infections. the proposed pathophysiology is an immune-mediated mechanism in which antistreptococcal antibodies, antistreptolysin and antideoxyribonuclease b, cross react with the basal ganglia of genetically susceptible hosts. a few studies have looked at immunomodulatory therapies including ivig for neuropsychiatric symptoms including tic disorders secondary to post-streptococcal autoimmunity. we plan a trial of ivig for this patient given the recurrent nature of his tics and the relation to streptococcal and other viral infections. introduction: the chronic granulomatous disease (cgd) is an inheritable disorder of phagocyte cell respiratory burst that result in life-threatening infections. the pulmonary infection is the primary cause of death in greater that 50% of the cases and the role of surgery in management of this entity remains undefined. case report: a lobectomy was performed in a 2 year-old male who presented a persistent opacity of the medial right lobe with fever, cough, malaise an rapid onset of respiratory failure; skin abcesses were concomitant. his familiar history was unremarkable. a chest tube was placed in a first instance in order to drain empyema, but no progress was observed. a ct scan showed necrotizing pneumonia of the right lung, mediastinal and retroperitoneal limphadenopathy and bronchopleural fistula. a second surgical intervention was undertaken to correct the fistula and pleural debridement was done. at this time, serratia marcenses was isolated from blood culture and lung; a primary immunodefiency was suspected. our evaluation showed nbt reduction on 0% and dyhidrorhodamine assay (dhra) didn't demonstrate and effective oxidative burst. the subsecuent management was based on specific antibiotic to serratia and prophylaxis with tmp-smz and itraconazole. transfer factor to improve the ifn levels was initiated. the patient's mother showed on dhra two granulocyte populations, with and without oxidative burst. a x linked cgd was consistent. medical progress was observed in the next days. conclusion: despite the poor utility showed by the surgical procedures in the complicated pneumonia in cgd patients in many series, attending to the unusual nature of the pulmonary infections and the high mortality and morbidity associated with thoracic surgery; the management of this case showed that an aggressive approach in the diagnosis combined with some procedures used in immunocompetent patients pneumonia may improve the clinical condition in cgd patients. background: takayasu arteritis is a large vessel vasculitis primarily affecting the aorta and its branches. it is most prevalent in women in the second and third decades of life. initial symptoms are systemic and often self-limited, but the disease may progress undetected over years until signs of vascular insufficiency develop. arteritis is commonly seen in the aortic arch and its branches, although the disease is a panarteritis and vascular compromise can occur in many organs. pathologically, involved vessels show intimal proliferation and fibrosis, and scarring of the elastic lamina. case report: we report the case of a 31 year old southeast asian woman who presented with diplopia, ptosis, dizziness, and progressive dyspnea. past medical history was significant for rheumatic fever complicated by aortic valve insufficiency and hypertension. physical findings on admission included hypertension, asymmetric upper extremity blood pressure (left arm 95/50mm hg, right arm 200/50 mm annals of allergy, asthma & immunology hg), wide pulse pressure and a harsh diastolic murmur. admission labs showed anemia (hemoglobin: 11g/dl, hematocrit 33%) and an elevated erythrocyte sedimentation rate of 31mm/hr. transesophageal echocardiography revealed severely dilated aortic root aneurysm with secondary severe chronic aortic valve insufficiency and calcified aortic leaflets not typical of rheumatic heart disease. resection of the aortic valve and aneurysm was performed. pathologic examination of the aortic aneurysm revealed intimal and adventitial fibrosis with focal chronic inflammation and partial loss and fibrosis of media, findings compatible with healed takayasu arteritis. the patient was started on prednisone 100mg by mouth daily for takayasu arteritis and discharged in stable condition. discussion: this is a case of takayasu arteritis masquerading as rheumatic heart disease. the episode of rheumatic fever was likely the initial presentation of takayasu arteritis, as the systemic symptoms of these diseases can overlap. takayasu arteritis is an insidious disease that often leads to a delayed diagnosis with considerable morbidity for the patient. since takayasu arteritis may go undiagnosed until ischemic symptoms develop, physicians should be alert to the possibility of this disease in young women to avert end organ damage and achieve early remission with drug therapy. we present a fifteen year old boy with disseminated papillomatosis and idiopathic cd4+ lymphocytopenia (icl). the warts have been present since he was one year old and have progressively worsened. there are more than fifty warts on each of his hands. his legs have multiple warts and about ten warts recently appeared on his lips and around his mouth. his past medical history is significant for no hospitalizations and no blood transfusions. he has never had problems with other infections, and he had a benign course of chicken pox that spontaneously resolved. he has been on cimetidine for six months without improvement. several topical therapies, including imiquimod, have failed. he has a total lymphocyte count of 1484/ul (normal range, 1288-4512/ul) and a cd4+ count of 301/ul (normal range, 361-1715/ul). the cd8+, natural killer cells, and cd19+ cells were normal. his hiv test is negative. the serum immunoglobulins were normal as well. lymphoctye proliferation studies reveal an absent response to antigens (candida and tetanus) with a normal response to mitogens. further studies showed no other cause of cd4+ lymphocytopenia. this case shows that the diagnosis of idiopathic cd4+ lymphocytopenia should be considered in any patient with widespread viral infection whose hiv test is negative. appropriate evaluation of the cd4+ count should be pursued. j. ko * , a. nowak-wegrzyn, new york, ny. introduction: approximately 40% of children with moderate to severe atopic dermatitis (ad) have food allergies. complementary and alternative medicine (cam) is utilized by an estimated 16-27% of patients with allergies. we present a case of a 4 year-old boy with ad referred after receiving a diagnosis of food allergy by a cam practitioner. methods/case: a 4 year-old boy was referred for evaluation of mild ad and possible food hypersensitivity. his ad started at 1 year of age and was limited to the face. he was initially breast-fed and was switched to milk-based formula at 4 months of age. solids were introduced at 5 months of age without difficulty. he had no immediate reactions or noted worsening of ad due to foods. the patient presented to a naturopath for allergy evaluation. based on electrodermal skin testing results, he was reported to be allergic to milk, egg, peanut, rice, and beef (all of which he had tolerated previously). he was restricted from milk and egg for 4 weeks without noticeable change in his ad, which was limited to the cheeks and controlled on topical pimecrolimus. results: his weight and height were both 75th percentile. physical exam was normal except for 2-3 cm dry, erythematous patches on both cheeks and mildly dry skin on flexor/extensor surfaces of both arms. skin prick testing revealed negative tests to milk, egg, peanut, and dust mite. serum ige testing was also negative. since he had no evidence of ige sensitization to commonly allergenic foods, he was recommended to continue an unrestricted diet and discontinue use of a "sippy" cup. his ad subsequently improved on a skin care regimen of postbathing moisturization and topical pimecrolimus prn. asthma and allergies are the #2 reason for cam use in the us. electrodermal skin testing is a method utilized by naturopathic doctors to detect allergen "sensitivity". however, in two double-blinded trials examining atopic and non-atopic patients, electrodermal testing did not correlate with skin prick testing results, regardless of inter-operator variability. conclusions: allergy patients are seeking cam treatment, and it is important for physicians to be aware of the safety and efficacy of alternative medical practices. the use of electrodermal skin testing has not been proven to detect allergen sensitivity and use of this modality should be discouraged. e.e. mcgintee * , k.e. sullivan, philadelphia, pa. introduction: hematopoietic stem-cell transplantation causes profound tcell immunodeficiency due to the rigorous conditioning involved. following transplant, the t-cell compartment is initially reconstituted through expansion of mature donor-derived t-cells. however, thymopoiesis is necessary to generate naive t-cells with a diverse repertoire. factors affecting thymic function impact the ability of the body to reconstitute the immune system. we report a case of severe t-cell immunodeficiency after two stem-cell transplants for neuroblastoma in a patient with a history of thymic hemorrhage secondary to mediastinal surgery. case: a 5-year-old female with a history of high-risk neuroblastoma was referred for immunologic evaluation due to a significant infectious history since completing her neuroblastoma therapy. she initially presented at 21 months of age with a right atrial mass that was presumed to be an atrial myxoma. she underwent mediastinal surgery to resect the tumor, which was found to be neuroblastoma extending from her right adrenal gland along the vena cava. a ct scan following her surgery revealed an area of hemorrhage in her right thymus. she subsequently received high-dose chemotherapy and two autologous stem-cell transplants. her infection history was significant for multiple episodes of upper respiratory illnesses, sinusitis, and otitis media requiring myringotomy tube placement on two occasions. immunologic evaluation revealed a dramatically low absolute lymphocyte count with deficits primarily in the t-cell compartment, and reduced proliferation in response to mitogens. immunoglobulin levels were normal; she formed protective titers to diphtheria and tetanus but not to any of 14 pneumococcal serotypes. conclusion: stem-cell transplantation often results in severe t-cell immunodeficiency. the thymus plays an important role in reconstituting the t-cell compartment with naive t-cells generated from hematopoietic stem-cells, which restores tcr diversity. as this case illustrates, damage to the thymus can significantly impair the ability to reconstitute the t-cell compartment. a.k. knight * , c. cunningham-rundles, new york, ny. rationale: this is the first case report of oxcarbazepine induced immunoglobulin deficiency. methods: a 49 y/o white female was referred for further investigation of low serum immunoglobulin found as part of an evaluation for chronic bacterial vaginitis. she was taking oxcarbazepine for chronic pain. this was discontinued and immunoglobulin levels and b cell numbers were tested at intervals. specific antibody responses to pneumococcal vaccine were tested. results: at presentation, on oxcarbazepine, immunoglobulin levels were low [igg 576, iga <11, and igm <4 mg/dl] and she had a b cell deficiency [1%, 18 b cells (normal 5-15%, 75-375 cells/cu mm)]. antibody response one month after pneumococcal vaccine was poor (protective antibody to 2/12 serotypes). (7%)] with protective antibody responses to 5/12 pneumococcal serotypes. she continued to have iga deficiency. conclusions: the patient's initial evaluation suggested the diagnosis of common variable immune deficiency with hypogammaglobulinemia and specific antibody deficiency. however, these defects reversed when oxcarbazepine was discontinued. it is unclear if persistent iga deficiency was a pre-existing condition, possibly predisposing her to this adverse reaction to oxacarbazepine, or induced by the oxacarbazepine. immunoglobulin deficiency is a known, though rare, reaction to carbazepine, the parent drug of oxacarbazepine; this adverse reaction can occur with its derivative oxcarbazepine as well. secondary hypogammaglobulinemia should be considered before diagnosing primary immunodefiencies such as cvid and committing the patients to lifelong immunoglobulin therapy. introduction: interferon and glatiramer acetate (copaxone) are indicated for the treatment of relapsing-remitting multiple sclerosis (ms). anaphylactic reaction has been reported as a rare complication of interferon and copaxone use. we report a case of interferon -1a (rebif) and copaxone hypersensitivity associated with positive skin tests and desensitization to interferon -1b (betaseron). case report: the patient is a 28 year-old woman with asthma and allergic rhinitis who was diagnosed with ms in oct '04 after an uncomplicated pregnancy and was subsequently placed on rebif. one month after starting therapy, patient developed wheezing and generalized urticaria after receiving a dose of rebif. the symptoms recurred the next day. her neurologist stopped the rebif and started her on copaxone. two months later she developed episodes of generalized urticaria. the patient was then evaluated in our center and underwent skin testing with interferon -1a intramuscular (avonex), interferon -1a subcutaneous (rebif), betaseron, and copaxone. she had a positive skin prick reaction to copaxone and positive intradermal skin tests to avonex (1:10 strength), rebif (1:1), and betaseron (1:1) after 24 hrs. the intradermal reactions to all 3 interferon formulations continued to progress upto 48 hrs. her neurologist felt that she would benefit from betaseron therapy. the positive intradermal skin test to betaseron was sufficient to warrant desensitization to prevent immediate hypersensitivity reactions. she underwent subcutaneous desensitization as shown in the table. the desensitization was halted at 240 minutes after the patient developed itching of the hands.* she returned in 24 hrs and we restarted by administering 0.1 ml of 1:1 strength betaseron. increasing doses were given until the patient received a full therapeutic dose (0.3 mg in 1 ml). she has since done well with daily doses of betaseron (4.5 mil units). conclusion: we report a ms patient who developed urticaria and asthma exacerbation in response to rebif and urticaria to copaxone. skin tests confirmed an ige-mediated allergic reaction. she underwent successful desensitization to betaseron. to our knowledge, this is the 1st report of desensitization to betaseron as well as extension to previous reported cases of systemic reaction to interferon and copaxone. pentoxifylline (ptx) is a phosphodiesterase inhibitor that has been used for ischemic vascular disease because of its effects on red blood cells and platelets. it has been used for systemic inflammatory diseases such as sarcoidosis because of its ability to inhibit production of cytokines such as tumor necrosis factor (tnf-a). we decided to offer a trial to a patient with chronic urticaria since agents that increase intracellular camp have been shown to inhibit mast cell degranulation. we report a case of a 50 year-old female with a history of allergic rhinitis, hypothyroidism, and diabetes mellitus with recurrent episodes of chronic urticaria since adolescence. she had known allergies to various antibiotics but otherwise had an unremarkable history, family history and social history. she was being treated with fexofenadine 180mg qd, azelastine nasal spray, zafirlukast 20mg bid, hydroxychloroquine 200mg bid, levothyroxine 25mcg qd, doxepin 25mg qhs, metformin 500mg bid, and spironolactone 25mg qd at the time of her initial evaluation. her physical exam was notable only for scattered 2-3 cm urticarial skin lesions as well as areas of hypo and hyperpigmentation from previous excoriations. her nasal turbinates were mildly congested with dull membranes. a previous skin biopsy showed only urticaria with increased numbers of mast cells. her workup included normal cbc, urinalysis, spep and complete chemistry profile, as well as negative ana and anti-thyroid antibodies. pentoxifylline 400mg tid was added to the patient`s regimen. her urticaria resolved within 2-3 weeks and was no longer visible at 2 months follow-up. pentoxifylline is a safe medication with few side effects that may benefit patients with chronic urticaria via several mechanisms, including the inhibition of mast cell degranulation and secretion of various cytokines and chemokines. the beneficial effects of pentoxifylline in the treatment of this patient`s urticaria have been seen in other patients. further study is indicated to determine which patients with urticaria are most likely to benefit from pentoxifylline, as well as elucidate the mechanisms of action by which pentoxifylline ameliorates symptoms of chronic urticaria. c.m. mjaanes * , m. boguniewicz, denver, co. we report the case of an 11-year-old male who since the age of 6 years has suffered from recurrent episodes of left tongue swelling. onset of the swelling is usually abrupt, and generally occurs during the night, awakening him from sleep. he describes a sensation of pain in his tongue but denies any pruritus, throat, lip or eyelid swelling. he has no cough, dyspnea, wheezing, rash, or itchy/watery eyes. the episodes occur infrequently, approximately once every spring . they tend to resolve spontaneously within 4 to 6 hours, however, on 2 occasions, the swelling has lasted for 7-21 days. the patient's current episode has been present for 3 weeks and is progressing. today he reports more pain and increased swelling. the child reports no benefit from oral antihistamines. he was treated with dexamethasone during his initial episode and experienced gradual resolution of the swelling. he has never been treated with topical or systemic epinephrine, or additional courses of systemic steroids. there is no family history of angioedema. the child was referred for evaluation of an immunologic/allergic etiology of his unilateral tongue swelling. laboratory studies obtained early in the course of his current episode revealed the following: c3 level 84 mg/dl; c4 level 14.4 mg/dl; c2 level 22.5 mug/ml; c4d level 0.94 mug/ml; c1 esterase inhibitor function 115% of normal. c1 esterase inhibitor level 17.4 mg/dl; ch50 223 units/ml; ana 1:40, negative; beta-tryptase < 1.0 ng/ml; total tryptase 7.0 ng/ml (all normal). initial evaluation revealed marked swelling along with erythematous and violaceous discoloration of the left lateral and anterior portions of the child's tongue. the remainder of his examination was normal. the patient was referred to the pediatric otolaryngology clinic with a presumptive diagnosis of a glossal hemangioma versus lymphangioma. he underwent a magnetic resonance imaging study which revealed a poorly defined, mass-like enlargement of the anterior and left aspect of the tongue. he was treated with a five day course of prednisolone. after initial regression of the lesion a planned surgical excision was carried out without any complications. in conclusion, this rare case illustrates the unique presentation of glossal hemangioma presenting as recurrent angioedema. highlighted are the differential diagnoses, laboratory studies and clinical features of oropharyngeal swelling. severe tongue swelling. rare skin conditions such as leprosy need to be considered in the differential diagnosis of apparent urticaria and angioedema that is atypical in appearance or response to therapy. a 28 year old male originally from laos presented with chronic recurrent nonpruritic indurated plaques on his face and trunk, and was referred to allergy by his primary physician with a diagnosis of urticaria and angioedema to rule out an allergic reaction to foods. he was otherwise healthy and on no medication, and had a negative personal and family history of atopy. he had moved to the united states from southeast asia in 1990, and visited for several weeks again in 2003. he was treated with prednisone and hydroxyzine without benefit; skin testing to foods was negative, and cbc, differential, sedimentation rate, antinuclear antibody, and liver function testing was normal or negative. a skin punch biopsy from an indurated area on the back showed granulomas with clusters of acid-fast organisms on afb stain consistent with tuberculoid leprosy. as the patient was g6pd deficient, he could not be treated with dapsone and was treated alternatively with minocycline 100mg, rifampin 600mg, and clofazimine 50 mg daily. he was subsequently started on prednisone as he was determined to be having a reversal reaction; his lesions continue to improve. this patient had a rare condition, leprosy, which was confused with urticaria and angioedema. in patients presenting with atypical apparent urticaria or angioedema, especially if response to standard pharmacologic treatment is poor, a skin biopsy is indicated, and may be diagnostic as in this case. introduction: cutaneous flushing about the face of a toddler within minutes of eating specific foods prompts parents and clinicians alike to pursue food allergy testing. auriculotemporal syndrome, also known as frey syndrome, is an isolated and transient facial erythema about the distribution of the auriculotemporal nerve following mastication. we report a child who was referred for food allergy testing and was diagnosed with auriculotemporal syndrome. case history: a 2 yo wf, prior full-term forceps-assisted delivery, has a history of facial flushing within minutes following ingestion of specific foods. the flushing can be induced by a variety of foods, specifically spaghetti, crackers, potato chips and hard candies, and typically resolves within minutes after eating. the child has no respiratory or gastrointestinal distress during the flushing episode. there is no angioedema, urticaria, or other rash elsewhere on her body. within ten minutes of eating a lollipop in clinic, an erythematous, warm macular eruption appeared in a band-like region anterior to her ear extending from her temporal bone to her mandible. this response occurred bilaterally, with a mildly greater intensity on the right side of her face. no sweating or other symptoms developed, and the flushing began to diminish after thirty minutes of observation. discussion: auriculotemporal syndrome is commonly seen in patients who have undergone facial surgery, specifically about the parotid gland. it is believed to be secondary to a disruption in the fibers of the auriculotemporal nerve. it is theorized that the nerve regeneration following an injury may join the parasympathetic fibers of the salivary gland with sympathetic fibers of eccrine sweat glands. mastication then could result in flushing and sweating over the cutaneous distribution of the auriculotemporal nerve that extends from the temporal region to the mandible, anterior to the ear. although rare in children, auriculotemporal syndrome has been associated with forceps delivery. therapy is seldom of benefit or needed, and the syndrome often resolves spontaneously over many years. conclusion: auriculotemporal syndrome leads to a cutaneous eruption temporally related to the ingestion of foods. allergists should maintain an awareness of this rare syndrome to minimize food allergy testing or eliminate unnecessary food provocation challenges or restrictive diets. m. al-ahmad * , s.s. mace, toronto, canada. introduction: ranitidine is a well-known h2-receptor antagonist. anaphylactic reactions are seldom reported despite widespread use of the drug. we report a patient with anaphylactic reaction to ranitidine methods: we report a case of anaphylactic reaction with ranitidine. results: a 45-year-old female with a history of urticaria over one year period, presented with 4 episodes of anaphylactic reactions of increasing severity over 1 year, after ranitidine ingestion. the first two episodes, occurred one hour after ranitidine ingestion, began with a sensation of burning, and itching in the head followed by dizziness, hypotension and near loss of consciousness. the patient had no significant pulmonary or laryngeal symptoms. the fourth episode, occurred 12 minutes after taking ranitidine tablet, was characterized by severe hypotension. two episodes were managed at the emergency department. a skin prick test with a crushed ranitidine tablet demonstrated a positive 20 mm wheal response, which was negative in a control. investigations for carcinoid syndrome and systemic mastocytosis were negative. conclusion: an ige mediated allergy to ranitidine is possible. anaphylactoid reaction to ranitidine is a well recognized entity. however, to our knowledge, few cases of anaphylactic reaction to ranitidine have been described. hypersensitivity reaction to ranitidine should be considered in patients suspected of having drug-related allergy. introduction: severe combined immune deficiency(scid) and cystic fibrosis(cf) may both present in infancy with a history of failure to thrive, diarrhea, and recurrent respiratory infections. although cf is the most common genetic disease occurring in caucasians with an incidence of 1 in 2500 births, scid is a rare condition estimated to occur between 1 in 50, 000 to 1 in 500, 000 births. we report a case of x-linked scid where the diagnosis of cf was originally entertained due to similar presentation and misleading laboratory results. case: 5-month-old caucasian male with 3 month history of recurrent respiratory illnesses, fever, loose stools, thick nasal discharge and failure to thrive. this was his second admission for a respiratory infection. relevant lab results consisted of cultures which grew parainfluenza a virus on np wash and pseudomonas aeruginosa on deep throat culture, chest xray showed patchy infiltrates and a borderline sweat test of 51 mmol/l. despite being treated with broad spectrum antibiotic coverage, albuterol and pulmozyme, his respiratory symptoms were not improving. physical exam revealed a thin infant with palpable though small lymph nodes cervical and groin, diffuse scattered rhonchi and liver edge palpable 3 cm below the costal margin. quantative immunoglobulins were obtained and resulted as an igg of 75, iga of <10, and igm of 13. review of his chest x-ray was significant for absent thymic shadow. lymphocyte count since admission ranged from 400-1000. flow cytometry revealed a cd3/cd4 count of 0%, cd3/cd8 count of 0%, cd56 of 1% and cd19 of 99% of all lymphocytes. t-cell stimulation tests were markedly diminished to both antigen and mitogen. a presumed diagnosis of x-linked scid was made and patient undrewent haploidentical bone marrow transplantation. subsequently, cf gene analysis resulted as negative. discussion: as outlined in the case it is essential to recognize the similarities between the presenting symptoms of cf, a relatively common genetic disease and scid, an uncommon one. although pseudomonas is seen in increased frequency in patients with cf, it is essential to recognize that it is also a leading pathogen affecting patients with antibody deficiency. review of the literature did not reveal any previous cases of individuals with scid reported as having an increased sweat chloride, nor any explanations of why this would occur. while immunodeficiency has previously been associated with some forms of dwarfism, we report the first described case of common variable immune deficiency in a patient with seckel syndrome (bird headed dwarfism). the diagnosis of seckel dwarfism, an autosomal recessive disorder, was made at 6 months of age in this boy based on intrauterine growth retardation, proportional dwarfism, microcephaly, micrognathia, and narrow face with "bird-like" large eyes and beaking of the nose. hematologic abnormalities are reported in an estimated 15% of such patients, and this child developed thrombocytopenia at the age of 3 years. by age 7, he had pancytopenia with hypocellular bone marrow. a low cd4 count (117/ul) was noted and both bactrim and neupogen were begun. his only significant infections, rotavirus and salmonella gastroenteritis, occurred at that time along with frequent otitis leading to pe tube placement at ages 7 and 8 but which subsequently resolved. he has never had opportunistic infections or thrush. by the age of 10 years, he required monthly red cell transfusions for severe anemia. after several months of transfusions, the blood bank reported that he no longer had detectable blood group antibodies during crossmatch; this led to measurement of immunoglobulins. igm was undetectable with low iga (35 mg/dl) and low igg (545 mg/dl). he demonstrated no protective titers to any pneumococcal serotypes after either conjugated or unconjugated pneumococcal vaccines. response to diphtheria, tetanus, rubeola, and influenza vaccines was adequate. total hemolytic complement was normal. he remains lymphocytopenic (alc = 552/ul) with low cd4 (211/ul). after five doses of ivig at 400mg/kg monthly, platelets have remained between 15-20 k/ul and there has not been any improvement in the anemia. although the mechanism for the bone marrow failure in these patients is presumed to be chromosomal breakage, this has not been demonstrated in this child. his karyotype is 46xy with no chromosomal fragility or deletions detected to date. hypogammaglobulinemia should be investigated in any patient undergoing frequent transfusions who loses blood group antibodies, and suspicion of immune deficiency should remain particularly high in patients with severe growth retardation or dwarfism. n.l. rider * , t. craig, hershey, pa. the objective of this study was to assess the effectiveness of physicians at a university primary care clinic in diagnosing and managing adult patients with asthma. a retrospective chart review of 63 adult patients from this clinic was performed. each chart was evaluated using a survey instrument developed from the national asthma education and prevention program (naepp), which consisted of 22 queries. of the charts evaluated 50 met our entry criteria. overall compliance with the naepp recommendations was 34%. adherences to the asthma guidelines in the following areas were: diagnosis (42%), treatment/disease control (60%), monitoring (15%), and education (18%). these data suggest that there is an opportunity to improve the care provided to patients with asthma, especially in the areas of asthma education and monitoring, even in a university outpatient facility. these data also suggest that naepp guidelines have not been effectively incorporated into primary care practices. b.m. wahlers * , l. sherwood, t. craig, hershey, pa. objective: our aim was to evaluate adherence to the national heart lung and blood institute (nhlbi), national asthma education and prevention program (naepp) diagnosis and management guidelines, regarding asthma admissions at a teaching hospital. methods: a retrospective chart review of 197 patients over the age of 18 years admitted to the hershey medical center between 1997 and 2002 with a primary diagnosis of asthma or asthma exacerbation was conducted using a 21-item questionnaire focused on key aspects of asthma care as outlined in the naepp guidelines. results: overall compliance to the guidelines was 61.5%. maximal areas of compliance were noted in regards to pharmacologic treatments utilized (99%, 95%). much lower levels of compliance were noted in areas of patient education (58%), instruction in written action plan prior to discharge (11%), provision of peak flow meter for home use (47%), assessment of asthma symptoms and severity (58%), and inhaled steroid prescription on discharge (69%). conclusion: adequate care in terms of pharmacologic treatments is being given but sub-optimal cares in other areas of the guidelines exist. there continues to be room for improvement in regards to asthma management, most notably in the area of education, documentation of triggers, and preparation for discharge with adequate tools to monitor and control symptoms. background: asthma is one of the most common problems of childhood, responsible for a significant proportion of absence from school because of chronic illness. objective: this study was carried out among the school-aged children (7-18 years) in tehran schools during 2002-2003, in order to determine the frequency of asthma. methods: according to the recommendation of who, a questionnaire was designed, containing 8 standard questions, and the students were given necessary information to complete the questionnaires. the guidance and high school students completed the questionnaires but the parents of primary school students completed them by themselves. results: seven hundred and eight children out of 2000 children had asthma (35.4%); this prevalence was higher in the boys (37.1%), when compared to the girls (33.5%). the prevalence of this disease has been estimated about 39.5% in guidance schools, 35.4% in high schools and 31.6% in primary students. based on this survey, the most common clinical manifestations in asthma were included: prolonged cough lasting more than 10 days (22.4%), and exerciseinduced wheezing or dyspnea (16.9%), followed by repeated dyspnea or wheezing (6.4%). based on the drug responses after receiving solbutamol, the prevalence of asthma was evaluated in the range of 32.2% in primary schools, 16.7% in guidance schools and 22.9% in high schools. conclusions: the prevalence of asthma is high among the students of tehran schools and it needs more careful screening programmes and either more information given to the patients and parents about the disease. in the us, asthma is the most common chronic disease of childhood and affects approximately 5 million children. reasons for inadequate asthma control include: inappropriate therapy, incorrect inhaler technique, poor compliance with treatment, and exposure to environmental triggers. rates for asthma prevalence, hospitalization, and death are highest among children residing in inner cities, and important risk factors for asthma-related mortality include being poor and black. the communities of braddock, north braddock and rankin are among the poorest in allegheny county and are designated areas of greatest health risk. recent statistics have demonstrated an increase in the number of asthma hospitalizations in these communities: 13.6 children per 1000, which is double the average for allegheny county and greater than seven-times the overall us rate of asthma hospitalizations. our goals were to assess asthmatic severity and appropriateness of treatment, provide asthma education, and to ensure access to healthcare for asthmatic children living in these medically underserved and predominantly african-american communities. twenty-seven asthmatic children were identified. of the children assessed 7% were under the age of 2 years, 19% were aged 2-5 years, and 74% were 6-14 years of age. based on nhlbi guidelines the severity of each child's asthma was determined: 41% had mild-intermittent asthma, 15% had mildpersistent asthma, 26% had moderate-persistent asthma, and 18% had severepersistent asthma. the appropriateness of treatment based on severity was also determined. we found that 27% of the children with mild-intermittent asthma, 50% of children with mild-persistent asthma, 60% of children with moderate-persistent asthma and 100% of children with severe-persistent asthma were receiving inappropriate treatment. furthermore, of the inappropriately treated children 92% were undertreated. following the assessment, patients and parents were educated with regard to asthma triggers, pathophysiology, use of peak flow meters, inhaler technique and pharmacologic treatment. patients were also scheduled for outpatient follow-up care. these results demonstrate that inappropriate treatment, especially undertreatment, may be a significant cause of the increased asthma morbidity in this population and underscore the need for aggressive education and innovative methods of ensuring health care. w. li-ling * , t. keng-leong, f.c. stephanie, e. philip, singapore. background: asthma admission is an important indicator of asthma morbidity. little is known about the risk factors associated with asthma admission among high-risk asthmatics. purpose: 1) to characterise the profile of high-risk asthmatics who had previous asthma hospitalization. 2) to identify predictors and risk factors that are associated with asthma hospitalization. methods: data for consecutive high-risk asthmatics who were enrolled into our asthma program from october 2001 to may 2004 were retrieved from our prospective database. high-risk asthmatics were defined as patients who had a clinical diagnosis of asthma and who had at least one hospital admission for exacerbation of asthma in the preceding 12 months or at least one severe exacerbation of asthma in the preceding 6 months requiring unscheduled visit for beta2-agonist nebulisation. a comparison was made among high-risk asthmatics who had at least one or more hospitalization for asthma in the past 12 months prior to the asthma program enrolment with those who were not hospitalized. statistical analyses were performed using spss version 10.1 for windows. results: among 521 high-risk asthmatics, 252 (48.4%) had at least one or more asthma hospitalization in the past 12 months prior to the enrolment into the asthma program. hospitalization was significantly associated with female gender (63.1% with asthma admission v 43.1% without asthma admnission). a significantly higher proportion of asthmatics with no formal education (19.4% v 17.7%), primary education (23.8% v 16.6%) and secondary education (32.1% v 29.3%) were hospitalized for asthma as compared to the those who had tertiary education (24.6% v 36.5%). those admitted were predominantly in lower income group, had poor inhaler technique and have no ownership of an asthma action plan (33.3% v 76.6%). those hospitalized were also younger, median age 37years (19, 62) v 35years (15, 84) and had a lower first peak flow reading, 260l/min (130, 500) v 300l/min (150, 480) . conclusion: among high-risk asthmatics, certain population subgroups are at greater risk for hospitalization for asthma. intervention aimed to reduce asthma morbidity should take the above findings into consideration. introduction an association between asthma symptoms and air quality is well established, but controversy exists concerning the role of various air quality indicators. the association of san antonio air quality with emergency department (ed) visits for asthma at our military medical center has not been defined. the objective of this study is to determine the correlation of selected air quality indicators in san antonio with ed visits for asthma for both the general population and for the pediatric population. methods selected air quality indicators were the 8-hr air quality index (aqi) for ozone, 24-hr aqi for particulate matter < 2.5 î¼m, pollen counts, mold spore counts, and daily high temperature. the number of daily ed visits coded for asthma was obtained retrospectively. pediatric visits (patients < 18 years-old) were evaluated as a subgroup. pearson correlation coefficients (r) were calculated for all data pairs. results during the 331 days of the study period, there were 491 visits for asthma. of these visits, 151 were pediatric. the number of daily visits ranged from 0 to 6 for all visits and from 0 to 3 for the pediatric visits. r values for all visits were -0.067, -0.069, 0.110, -0.011, and -0.218; for pediatric visits, -0.055, -0.036, 0.033, -0.010, and -0.074 for the 8-hr aqi for ozone, 24-hr aqi for particulate matter < 2.5 î¼m, total pollen grains/m 3 , mold spores/m 3 , and daily high temperature, respectively. in addition to calculating r values for same-day air quality indicators and ed visits, r values were also calculated for a 3-day average of air quality indicators with the ed visits. for the 3-day averages, r values for all visits were -0.113, -0.117, 0.127, -0.071, and -0.267; for pediatric visits, -0.081, -0.011, 0.025, 0.017, and -0.063 for the 3-day averages of the 8-hr aqi for ozone, 24-hr aqi for particulate matter < 2.5 î¼m, total pollen grains/m 3 , mold spores/m 3 , and daily high temperature, respectively. conclusion there was no significant correlation between the selected air quality indicators and ed visits for asthma, either for the general population or for pediatric visits. this study provides no evidence that air quality is linked to ed visits for asthma in san antonio but the degree to which air quality in san antonio affects asthma symptoms remains unclear. introduction: the aim of this study was to evaluate the level of no in the exhaled air of patients suffering from chronic cough. methods: the study was performed on 213 young (mean age 28.5 +/-8.2 years), nonsmoking patients with chronic cough referred to the allergy clinic for evaluation. bronchial provocation challenge with histamine was performed according to the method of ryan. exhaled no was measured on-line using a chemiluminescence analyzer (sievers, usa). all patients had resting spirometry within normal values. results: significant bronchoconstrictive response to histamine at a concentration equal to or lower than 8 mg/ml (pc20 8mg/ml) was found in 65 patients (30.5%). these patients had a significantly greater mean concentration of no in the exhaled air (80.6+/-59.4 ppb) than those with a pc20>8mg/ml (28.4 +/-29.2 ppb; p<0.0001). receiver operating characteristic (roc) curve analysis revealed that it is possible to identify from among patients suffering chronic cough those who have significant bronchial hyperreactivity (pc20 8mg/ml). using 40 ppb as a cut-off value for the exhaled no concentration, the specificity for bronchial hyperreactivity was 86.5% and sensitivity 72.3%. conclusion: assessment of no concentration is helpful in the assessment of bronchial hyperreactivity in patients having chronic cough. l. abetz 1* , j. bousquet 2 , e. juniper 3 , e. bateman 4 , h. boushey 5 , w. busse 6 , t. clark 7 , r. pauwels 8 , s. pedersen 9 , 1. manchester, united kingdom; 2. montpelier, france; 3. ancaster, canada; 4. cape town, south africa; 5. san francisco, ca; 6. madison, wi; 7. london, united kingdom; 8. ghent, belgium; 9. kolding, denmark. introduction: the acq has been developed as a measure of asthma control for use in clinical practice or in clinical trials. the reliability, validity and responsiveness have previously been demonstrated for the original 7 item acq, the 6 item (minus fev1 question) and 5 item (minus fev1 and short acting bronchodilator use questions) versions. data from the 1-year gaining optimal asthma control (goal) study was used to assess the predictive value of the acq s 7, 6, and 5 item versions in determining asthma control status. method: receiver operating characteristic curves (roc curves), plotting true positive rates versus false positive rates for different acq cut-points, were used to determine optimum cut points for totally controlled and well-controlled asthma. scores for the 7, 6, and 5 item versions of the acq were examined at 0.25 intervals. results: when predicting totally controlled asthma, the areas under the roc curves (arocc) were 0.88/0.88/0.86 for the 7, 6 and 5 item versions, respectively; and when predicting well-controlled asthma the arocc were 0.86/0.86/0.84 for the 7, 6 and 5 item versions. in both predictive models, the 7 and 6 item versions provided the best arocc. for the 7 and 5 item versions, the best cut-off point to predict totally controlled asthma was <=0.75, with arocc of 0.81/0.79, and corresponding sensitivity of 0.74/0.71 and specificity of 0.89/0.88, respectively. for the 6 item version the best cut-off point was <=0.5, with arocc of 0.82, sensitivity of 0.76 and specificity of 0.87. the best cut-off points for predicting well-controlled asthma were <=1.25 for the 7 item version (arocc=0.77; sensitivity=0.70; specificity=0.83), and <=1 point for the 6 and 5 item versions (arocc=0.77/0.75; sensitivity=0.70/0.69; specificity=0.83/0.81, respectively). conclusion: results indicate the sensitivity and specificity of the acq in predicting asthma control status. a 29 yo black male with asthma and allergic rhinitis developed gradually worsening cough productive of clear to yellow sputum despite treatment with high dose fluticasone, salmeterol, monteleukast, and prn albuterol. asthma history was significant for an intubation at age 10 and pneumonia at age 28. physical exam revealed pale turbinates and expiratory wheezes. pulmonary function test showed a severe obstructive lung defect with fev1 1.52 (38%), improving by 4% after bronchodilator and fev1/fvc ratio 54%. a chest ct revealed significant bronchiectasis in the right middle lobe, lingula and both lower lobes. evaluation for bronchiectasis showed normal quantitative immunoglobulins, subclasses, and humoral responses, rendering innate immunodeficiency less likely. the diagnosis of allergic bronchopulmonary aspergillosis was entertained, but ige was 500ku/l and aspergillus titers were negative. a sinus ct failed to show active disease, yet the patient reported chronic yellow nasal discharge despite courses of antibiotics. although he was sexu-ally active with several male partners, hiv testing was negative 2 times, 6 months apart. evaluation for cystic fibrosis (cf) showed no symptoms of malabsorption and a negative sweat test. other tests revealed normal -1 antitrypsin level, p-anca, esr, ace level, and negative sputum for afb and mycobacteria, helping to exclude other conditions such as 1-antitrypsin deficiency, vasculitis, sarcoidosis, and chronic infection. with no definitive answer, the diagnosis of cf was pursued, but genetic screening as well as mapping were negative. the diagnosis of primary ciliary dyskinesia was then entertained; however, a mucosal biopsy of the nose did not reveal any structural abnormalities. finally, a sperm analysis revealing azoospermia confirmed the diagnosis of young's syndrome, a rare disease with features similar to cf including bronchiectasis, chronic sinusitis and azoospermia. in young's syndrome however, there is an obstructive process rather than a lack of vas deferens resulting in azoospermia and normal sweat chloride, genetic, and pancreatic testing. this case demonstrates the importance of investigating a persistently productive cough in an asthmatic patient and the differential diagnosis as well as the appropriate work up for bronchiectasis. a final diagnosis is important since appropriate management in each situation may affect long term outcome. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: bronchial challenges are currently done in allergic asthma with allergen, histamine or metacholine.bronchial reactivity to allergens and histamine can probably be variable. purpose to evaluate if the dose of allergen and histamine triggering a significant bronchial obstruction are always correlated in asthmatic patients. methods: a vitalograph model compact has been used throughout the study. allergen challenge has been done with an acqueous solution of house dust mite. bronchial challenges with placebo (sodium chloride) histamine or allergens have been done in all patients. for the provocations with histamine or allergens the threshold dose, inducing a decrease in fev1 greater than 15% has been determined in all the cases, as well for histamine as for allergens. a second challenge has been done in all patients with a supra-threshold dose of histamine or allergen corresponding to the double of the threshold. results: 30 provocations have been done in 10 patients either with histamine or allergen. 6 were allergic and 4 non allergic. the threshold dose for histamine were between 5 and 25 ug. in allergic patients and 250 and 500 ug. in non allergic patients.in allergic patients after histamine threshold challenge mean decrease was for fev1 19, 2% and for fev1/vc 17, 3%. for supra-threshold dose fev1 decreases 37, 8% and fev1/vc 32, 8%. after allergen challenge fev1 decreases 20, 3% and fev1/vc 15, 8%. with supra threshold doses fev1 decreases 28, 6% and fev1/vc 29, 3%. in 4 non allergic patients there was no changes after allergen challenge. a good correlation in constriction induced by histamine or allergen either for threshold or supra threshold doses (p<0.001) was observed but not between the threshold doses of histamine and allergen. conclusions: these results confirm that bronchial obstruction can be triggered by allergens and mediators that the sensitivity of fev1 and fev1/vc for evaluation are roughly comparable after challenge and points to a better sensitivity of a supra threshold dose of allergen or mediators. allergen and histamine challenges don't give the same information. introduction: peak expiratory flow rate (pfr) and forced expiratory volume in the first second (fev1) are currently used in functional evaluation of asthmatic patients but his degree of correlation in obstructive, restrictive and mixed spirometric ventilatory patterns are not well known. the purpose of this study was to evaluate if the correlation between pfr and fev1 2 markers of global airways obstruction is comparable in asthmatic patients with obstruction restriction or both. methods: 152 asthmatic patients, 69 males, 83 females have been studied by spirometry with a vitalograph compact in absence of bronchodilatory or anti-inflammatory therapy. patients have been classified in 4 functional patterns according to vc, and fev1/cv: normal : vc greater than 90% of expected value and fev1/vc greater than 70%, obstructive:vc greater than 90% and fev1/vc greater than 70% restrictive vc, less than 90% and fev1/vc greater than 70% and mixed vc less than 90% and fev1/vc less than 55% presenting a so called functional emphysema. results: according to these criteria 15 patients were normal, 44 restrictive, 15 obstructive and 78 mixed. in all the group the correlation between pfr and fev1 was statiscally significant (p<001) but the correlation coefficient variable. in functionally normal patients r =+0, 74 in restrictive patients + 0, 67 in obstructive + 0, 66 in mixed + 0, 84 and in the sub-group with functional emphysema + 0, 96. for this sub-group the correlation coefficient r allows to define fev1 = 91 + 5, 6 pfr. conclusions: the report between the two most usual assays of global bronchial obstruction depends on the balance between restriction, (either by interstial fibrosis or hyperinflation) and obstruction and is more close when a more marked obstruction coexist with a restrictive pattern (functional emphysema). in practice pfr has the same value that fev1 only in more severe cases of ventilatory failure. the dispersion of values and the standard error or regression do not allow to correlate both data in most patients. introduction: the tenor study longitudinally observes the natural history of subjects with severe or difficult-to-treat asthma. this analysis assessed the association between previous and future asthma exacerbations in tenor. methods: subjects eligible for this analysis were 12 years of age at baseline and had at least one follow-up assessment in year 1 and year 2. recent asthma exacerbations in the past 3 months were defined as: asthma-related emergency room (er) visits, nights of hospitalization, unscheduled physician office contacts; or as a composite measure of at least one of the previous exacerbation events. relative risks (rrs) and 95% confidence limits (95%ci) were generated comparing exacerbations in year 2 relative to year 1. exacerbation rates were defined as the number of events divided by total patient follow-up time. no adjustment was performed for baseline characteristics. results: 2826 subjects were eligible for this analysis. rrs in year 2 vs. year 1 were: 3.9 (95%ci: 3.3-4.6) for unscheduled office contacts, 4.1 (95%ci: 3.48-4.82) for the composite exacerbation measure, 10.2 (95%ci: 7.8-13.4) for er visits and 15.1 (95%ci: 9.8-23.3) for nights of hospitalization. over 37% of subjects with 5 or more exacerbations (composite measure) in year 1 had a similarly high rate in year 2 compared to 3% of patients without an event in year 1 who went on to have 5 or more exacerbations in year 2 (see table) . conclusion: tenor subjects who experienced an asthma exacerbation in year 1 were at statistically significantly increased risk of subsequent exacerbations the following year compared to subjects not experiencing an exacerbation in year 1. this increased risk was consistent for all asthma exacerbation outcomes and most elevated for hospitalizations due to asthma. assessment of recent asthmarelated healthcare use is a critical component of the clinical evaluation of subjects with severe or difficult-to-treat asthma. funded by genentech inc. and novartis pharmaceuticals corp. background: preliminary studies investigating yoga and breathwork for asthma have been promising. several randomized controlled trials have shown a benefit from yoga postures and/or breathing versus control, but the control in these cases involved no intervention other than usual care. this study advances the field by providing an active control. methods: a randomized, controlled, double-blind clinical trial was conducted from october 2001 to march 2003 to determine the effectiveness and feasibility of a yoga and breathwork intervention for improving clinical indices and quality of life for adult patients with mild to moderate asthma. random assignment was made to either a 4-week yoga intervention that included both postures and breathwork, or a stretching control condition. outcome measures were assessed at 4, 8, 12 and 16-weeks and included the mini asthma quality of life questionnaire (mini-aqlq), rescue inhaler use, spirometry, symptom diaries, and health care utilization. results: sixty-two participants were randomized into the intervention and control groups, and 45 completed the final follow-up measures. intention-to-treat analysis was performed. significant within-group differences in post-bronchodilator fev1 and morning symptom score were apparent in both intervention and control groups at 4 and 16 weeks; however, no significant differences between groups were observed on any outcome measures.conclusions: iyengar yoga conferred no appreciable benefit in mild to moderate asthma. circumstances under which yoga is of benefit in asthma management, if any, remain to be determined. in order to investigate asthma mortality trends for the u. s. hispanic population, i have collected and graphed data from the national center for health statistics. mortality data for the hispanic population have been available for the entire united states only since 1997 and readily available for asthma only since 1999. these data indicate decreases in deaths from asthma (j45-j46) from 320 in 1999 to 274 in 2001 with decreases in the non-hispanic population from 4324 in 1999 to 3976 in 2001. rates of death from asthma decreased for the hispanic population from 1.0 per 100, 000 in 1999 to 0.7 in 2001, while that for the non-hispanic population decreased from 1.84 to 1.6. rates for non-hispanic whites decreased from 1.5 to 1.4 in 2001. rates of death from asthma have been twice as high among hispanic women as men. rates of death from asthma for non-hispanic blacks have been more than twice as high as those for non-hispanic whites. (national center for health statistics data dictate racial terminology). data for people of hispanic origin include people of any race. these data are affected by both underreporting of hispanic origin on death certificates and undercoverage in the census and resultant population estimates for a net correction of 1.6%. thus, rates of death from asthma have been lower and have been decreasing faster among hispanics than the rest of the population in the united states. allergic rhinitis and asthma are both highly prevalent diseases and often coexist in patients. rhinitis symptoms have been shown to impact the lower airway. as such, the impact of rhinitis on asthma control may be the greatest in patients with the most severe rhinitis symptoms. therefore, this analysis was performed to determine the impact of baseline rhinitis severity on asthma control in patients with both asthma and allergic rhinitis who received either fluticasone propionate aqueous nasal spray (fpans) or montelukast (mon) added to fluticasone propionate/salmeterol 100/50 mcg (fsc). a total of 863 patients (>15 years) with persistent asthma and seasonal allergic rhinitis received fpans 200mcg qd, mon 10mg qd or placebo (pbo) in addition to fsc 100/50mcg bid for 4 weeks. at baseline, total nasal symptom scores (tnss) ranged from 44 to 400. the analysis was restricted to patients whose pre-enrollment asthma therapy did not include fsc. regardless of baseline rhinitis severity, in patients with both asthma and allergic rhinitis, mon added to fsc resulted in no additional improvements in overall asthma control compared with fsc alone. these data suggest that optimal treatment of the individual conditions should be the goal of treatment for patients with coexistent allergic rhinitis and asthma. (sam40066) introduction recent studies have demonstrated that parainfluenza and coronaviruses are as important triggers of asthma. parainfluenza viruses are one of the main triggers of virus-induced asthma at summer. parainfluenza viruses often cause severe low respiratory tract infections in immuncompromised patients and in patients with bone marrow transplantation. a retrospective study found that 41% of pediatric bmt patients with hpiv infection (47% of viral respiratory infections) developed pneumonia and 6% died. both viruses contributed to fatal asthma. materials and methods for amplification of these viruses, primers which anneal to specific regions of viral genomes: hn-gene for piv1, piv2 and piv3 and spike glycoprotein gene for coronavirus oc43 and nucleocapsid glycoprotein gene for coronavirus 229e were used. pcrdiagnostics was performed on nasal and throat swabs taken from children with atopic asthma exacerbation. results from 02/04 to 05/04 a total of 56 samples (including 28 negative controls) were tested by pcr. 11 positive for respiratory viruses samples noted in children having asthma exacerbations including 23.9% of all tested samples. piv3 was detected in 54.5% of all positive samples, piv2 in 18.2%, and coronavirus oc43 in 27.3%. piv2 and coronavirus 229e were not detected during this study. for negative controls samples were taken from children with atopic asthma in remission. all 10 controls were found to be negative by viral pcr. conclusions respiratory viruses are an important factor in asthma exacerbations in children. piv3 was the most frequently detected among the positive samples. although hpiv-2 was less often positive than hpiv-1 and hpiv-3 infections in this study, the frequency of the detected coronaviruses may have been influenced by the seasonal activity of these viruses. introduction. in budapest all children come under the regular supervision of a specially trained paediatrician. each paediatrician is responsible for an average of 950 children, often seen up to the age of 18 years. methods. a questionnaire was sent to the district paediatricians of budapest in 1995 budapest in , 1999 budapest in and 2003 . the total number of children in their practice and the number of the asthmatics was assessed. the diagnosis of asthma in every case was established in a paediatric hospital, or a special allergy or pulmonology outpatient clinic. results. in 1995, replies were received from 118 paeditricians, who were responsible for the supervision of 104, 087 children, of which 1.88 â± 0.87% had been diagnosed as having asthma. in 1999 replies were sent by 153 physicians, who had a total of 142, 684 children under their care, including 3, 228 asthmatics, a prevalence of 2.26 â± 0.95%. at the end of 2003, 151 paediatricians having 141, 276 children answered, noting 3, 831 asthmatics, a 2.71 â± 1.2% prevalence of asthma. conclusion. the current survey of prevalence of asthma in childhood is by far the largest that has been made. an increasing prevalence of the diagnosis of asthma based on clinical investigations was noted, the differences between the investigated years being highly significant. panel report guidelines for the diagnosis and management of asthma have been available since 1991, to standardize and improve the quality of asthma care. however, asthma remains the leading cause of hospitalization for new york city children. implementation of the guidelines has not been fully embraced in the primary care setting. we attempted to increase primary care practitioners' compliance with the guidelines through extensive training. a hospital based pediatric clinic and 4 school based health clinics in the brooklyn inner city, participated from april 2002 to march 2003 in the program as part of new york city's education and quality improvement project (equip). initially an asthma physician specialist and asthma educator trained the primary care physicians and nurse practitioners in the guidelines. the training was reinforced during monthly luncheon sessions. clinical exam rooms were also supplied with asthma education materials, peak flow meters, and asthma action plans. goals were to identify asthmatics, document asthma severity, give persistent asthmatics written management plans, and utilize appropriate controller medications. compliance was measured by tracking asthma visits with an asthma intake form. prior to this project no consistent attempt had been made in the clinics to regularly classify asthmatic severity, provide written asthma action plans or to place patients on controller medications. after onset of the project a total of 216 asthma visits were evaluated; 104 were from school based health centers and 113 from hospital based pediatric clinic. severity was classified in 83%(179/216) of asthma visits. patients classified as persistent received updated written management plan during 90%(100/110) of asthma visits and 92%(102/110) were placed on controller medications. this asthma management program demonstrated success in improving primary care practitioners' compliance with the naepp asthma guidelines. further studies are needed to determine if compliance with the guidelines persisted after cessation of the extensive training and if such compliance improves asthma outcomes. numerous studies have associated asthma and obesity. although obesity has been identified as a risk factor for asthma, there is limited information on the impact of obesity on childhood asthma. this study examines the effect of body composition on asthma severity and pulmonary function in children. we retrospectively reviewed charts from asthmatic children ages 5 to 18 years, referred to a community-based pediatric pulmonology practice between 1999 and 2003. data were included if asthma was the the primary diagnosis and a baseline spirometry was available. asthma severity was classified and body mass index(bmi) was classified as normal, overweight and obese. spirometry results were reviewed. eighty-five patients were reviewed. thirtyone(36.5%) patients were normal weight; 21(24.7%) were overweight and 33(38.8%) were obese. baseline characteristics such as age, gender and race/ethnicity were similar. asthma severity classification did not differ between normal, overweight and obese children. overall, 34% were classified as intermittent, 53% as persistent mild asthma and 13% as persistent moderate-severe asthma. 21% of children with intermittent asthma were receiving controller therapy compared to 62.5% with persistent mild and 81.8% with moderate-severe asthma(p=0.0001). although healthcare utilization for asthma(emergency room visits/admissions) were significantly different between children with intermittent, persistent mild and moderate-severe asthma(p=0.0004), there was no difference when normal, overweight and obese children were compared. spirometry results showed comparable peak expiratory flow rates(pfr) in all groups; 75% of predicted in normal weight and 79% of predicted in both overweight and obese. mean forced vital capacity(fvc) was 93.9%, 88.5% and 95% and the mean forced expiratory volume in 1 second(fev1) was 85.9%, 81.2% and 86.6% respectively. there was no difference in fev1/fvc; 82.3%, 83.1% and 81.8% and forced expiratory flow in mid-lung volumes (fef25-75); 74.4%, 73% and 76.9% of predicted. in this study we retrospectively reviewed asthmatic children and compared bmi, asthma severity and spirometry. we found no difference in asthma severity classification between normal and overweight/obese patients. regardless of the bmi, all indices of spirometry were similar. further studies are needed to examine the impact of obesity on different asthma related disease outcomes. our objective is to further investigate the effect of budesonide, formoterol, and levalbuterol, alone, and in combination, on tgf-1 production and expression in ragweed (ra) stimulated a549 cells. meth-ods: a549 cells were cultured in duplicate for 24 hours at 37 degrees celcius with 5% co 2 in serum free dmem with or without the following: 10î¼g/ml of ra, 1.0 x 10 -7 m of budesonide, 1.3 x 10 -7 m formoterol, and 1.0 x 10 -5 m levalbuterol. tgf-1 production and expression was measured by a sensitive elisa and mrna assay in cell supernatants and pellets. results: tgf-1 production and expression from a549 cells rose markedly in the presence of ra (952.35 -1268 pg/ml) (59 -71 amol/ml) with significant inhibition following the addition of budesonide, and the combinations of budesonide and formoterol, budesonide and levalbuterol, and budesonide, formoterol, and levalbuterol (p<0.05). combined treatment with budesonide and levalbuterol versus budesonide alone reached significance for production and expression (p<0.05). budesonide and formoterol compared with budesonide alone reached significance for tgf-1 production (p<0.05). conclusion: combination therapy with budesonide and a long or short acting beta-agonist showed greater effect of tgf-1 inhibition compared with budesonide alone. this synergistic effect on the distal airways may prevent a subset of asthmatics from developing airway remodeling. g. tamura 1* , y. sano 2 , k. hirata 3 , s. ishioka 4 , m. nakashima 5 , t. miyamoto 2 , 1. sendai, japan; 2. tokyo, japan; 3. osaka, japan; 4. hiroshima, japan; 5. hamamatsu, japan. tulobuterol tape is the world's first long-acting transdermal preparation of a beta2-agonist designed to release tulobuterol in an optimal fashion. when it is applied once daily at bedtime, the blood concentration of tulobuterol peaks early in the morning and is kept at effective levels for 24 hours. tulobuterol tape has milder and less frequent adverse events than conventional oral tulobuterol preparations, and when used at bedtime can prevent marked drop in peak expiratory flow (pef) early in the morning. consequently, tulobuterol tape has been commonly used in japan as a long-acting beta2-agonist. in the present study, to evaluate its efficacy as a long-acting beta2-agonist and to compare its effects at two different doses, we administered tulobuterol tape at doses of 1 or 2 mg/day to patients with persistent asthma already using inhaled corticosteroids. this study was a randomized, double-blind, double-dummy, parallel-group, multicenter trial of 4-week duration. mean pef in the 1 and 2 mg/day groups were significantly increased from the baseline value by 15.1 and 28.2 at week 1, 19.5 and 32.6 at week 2, 22.6 and 35.3 at week 3 and 23.8 and 35.9 l/min at week 4, respectively. the increase in mean morning pef in the 2 mg/day group was significantly higher than that in the 1 mg/day group at every point of determination. the mean evening pef was significantly increased in both treatments groups compared with baseline values at every point of determination. although the increase in the 2 mg/day group was greater than that in the 1 mg/day group at each point of determination, the difference between groups was statistically significant only at week 1. the safety profiles of the two treatments were similar. in patients with persistent asthma who require inhaled short-acting beta2-agonists while receiving inhaled corticosteroids, tulobuterol tape 2 mg/day significantly improved pef compared with tulobuterol tape 1 mg/day. introduction: on an average, 4% of the 1500 children admitted annually for asthma to children s hospital require admission to the pediatric intensive care unit (picu). these admissions are highest in the months of august, september and october. aeroallergens such as alternaria and ragweed predominate during this season, and allergies to these allergens may account for the increased number of picu admissions for asthma. objective: we hypothesized that the seasonal increase in the admission rate could be related to allergen sensitivity, particularly to alternaria and/or to ragweed that predominate during late summer and fall. method: data was collected from a retrospective chart review of all patients admitted to the picu for asthma exacerbation between 1997 and 2003. skin prick testing (spt) within one year of picu admission was the criteria for inclusion in this study. results: there was a higher prevalence of admissions to the picu for asthma exacerbation during august, september and october (168 out of 416 admissions = 40% of all admissions, p<0.001). sixty-one subjects met the one-year spt criteria for analysis. subjects admitted during august, september and october were categorized as group a, and all others were categorized as group b. sensitivity to a total of 11 aeroallergens (tress, grasses, weeds, ragweed, outdoor molds, indoor molds, alternaria, cat, dog, roach and dust mites) was compared between the two groups. there was no statistical significance in aeroallergen sensitivity to alternaria or ragweed between subjects admitted to the picu in august, september and october (group a) and subjects admitted during the other months of the year (group b). conclusion: asthma exacerbation requiring picu admissions is more prevalent during the months of august, september and october. the increased rated of picu admissions did not correlate with the aeroallergen sensitivity to the prevalent allergens during august, september and october. therefore we suspect other factors such as, viral upper respiratory infections, in addition to aeroallergen sensitivity, which may contribute to severe asthma exacerbation during the late summer and fall months. k. kuzume * , shigenobu, ehime, japan. infantile wheezing may be the result of different phenotypes. the aim of this study was to evaluate the risk factors for allergies and the results of allergyrelated blood tests among infants with different types of allergy symptoms. 2130 infants were examined physically at birth and at 1, 3, 6, 9, and 12 months of age, and questionnaires about number of siblings, the family history of allergy, and feeding methods were given. allergic diseases were diagnosed at 12 months of age, and the subjects were divided into 4 groups: infants with atopic dermatitis (ad) only (a group, n=447), infants with both ad and wheezing (a/w group, n=175), infants with wheezing only (w group, n=155), and infants without allergic symptoms (c group, n=1353). risk factors were then evaluated. 332 patients (198 from the a group, 109 from the a/w group, and 25 from the w group) were given allergy-related blood tests, total serum ige levels, and rast with egg white, milk, and house dust mites at 6 and 12 months of age. the results of the blood tests in 36 control subjects at 6 months of age were compared to the other groups. as shown in table1, there were more male infants in the a/w and a groups than in the c group (p<0.001, a/w vs. c; p<0.01, a vs. c). numbers of siblings were greater in the w and a/w group than in the a or c group (p<0.0001, w vs. a and w vs. c; p<0.01, a/w vs. a; p<0.05, a/w vs. c). the rate of positive family history of allergic diseases was high in the a and a/w groups, compared to the w or c group (p<0.0001, a vs. c and a/w vs. c; p<0.05, a/w vs. w). the rate of breastfeeding at 3 months of age was high in the a group compared to the others (p<0.0001, a vs. c). patients in the w group had lower levels of total serum ige at 12 months of age, compared to patients in a or a/w (p<0.01, w vs. a/w and w vs. a). also patients in the w group had lower levels of rast with egg white at 12 months of age, compared to patients a or a/w (p<0.0001, w vs. a/w and w vs. a). the median of total serum ige levels at 6 months of age was higher in a and a/w but not in w, compared to c (p<0.001, a/w vs. c and a vs. c). in conclusion, there were two different phenotypes of wheezing in infants before 12 months of age. wheezing with ad might be "allergy-related", while wheezing without ad may be related to other factors. as compared to c group: a), p<0.05; b), p<0.01; c), p<0.001; d), p<0.0001 as compared to a group: 1), p<0.05; 2), p<0.01; 3), p<0.001; 4), p<0.0001 as compared to a/w group: f), p<0.05; g), p<0.01; h), p<0.0001 a group, infants with atopic dermatitis only; a/w group, infants with atopic dermatitis and wheezing; w group, infants with wheezing only; c group, infants without allergic symptoms. rast, radioallergosorbent test, n/a, data not available r. amelio 1* , c. capristo 1 , a. capasso 1 , m. miraglia del giudice 2 , n. maiello 1 , f. decimo 1 , 1. naples, italy; 2. napoli, italy. forced oscillation technique (fot) is considered a sensible and specific method to estimate breathing functionality in asthmatic children aged 3 to 6 years, because it doesn't need special collaboration. the aim of our study was to value baseline respiratory resistances with the fot in preschool-aged children with asthma under high dose of budesonide and flunisolide treatment. at this purpose, 40 asthmatic children aged 3 to 6 years were selected: at a first examination (t0) all the patients showed basal value fot at 6hz frequency (rr6) changes major or equal than 35% under 200 mcg of salbutamol treatment. 30 days before the study, children selected didn't take systemic and inhaled steroids, cromons, leukotrienes antagonists, teophylline or anti-histamines and they didn't present upper and lower airways infections; then, two weeks before run-in, all selected patients took beta-2-agonists at least 3 times per week. all the patients were divided in two groups: group i (20 children) under inhalation of flunisolide 40mcg/kg/dose + salbutamol 1500 mcg b.i.d. for 7 days and, for the following two weeks, under inhalation of flunisolide 20 mcg/kg/dose + salbutamol 200 mcg by pmdi+spacer prn.; group ii (20 children) under inhalation of budesonide 0, 5 mg b.i.d. + salbutamol 1500 mcg b.i.d. for 7 days, and for the following two weeks, under inhalation of budesonide 0, 25 mg b.i.d. + salbutamol 200 mcg by pmdi+spacer prn. moreover, we gave diary-card with a simple symptoms score (at t0 and t7 ), to get the real perception of the symptoms in the course of study. however, during the treatment, 4 children have ritired from the study. the results obtained were statistically analysed (t student's test). significant rr6 pre beta-2-agonists and ? value reduction was obtained at t7 and t21 vs. t0. group i had (at t7) such a quick action than group ii reducing airways resistances (p<0, 01). children treated with flunisolide had lower frequency of breathless and nocturnal cough at t7 and lower salbutamol use from t7 to t21 than budesonide group (p=n.s.). in conclusion, fot is actually a safety method to value efficacy of inhaled steroids in preschool-aged children with asthma. introduction: approximately 7.5% of u.s. adults and 6.0% of louisiana (la) adults have current asthma, and over 25% currently smoke cigarettes, according to the 2002 behavioral risk factor surveillance system (brfss). the purpose of this study is to compare asthmatic smokers vs. nonsmokers in la and the u.s. here we address whether asthmatic smokers utilize more medical care services in the er and outpatient clinics, and whether they were able to fully participate in activities of daily living compared to nonsmoker asthmatics. methods: brfss is a state-based, telephone survey of u.s. adults. the survey collects self-reported information about modifiable risk factors for chronic diseases. this study analyzed data from the 2002 brfss survey using sas software. data: out of the current asthmatics, 25% are cigarette smokers in the u.s. in louisiana, 31% of asthmatics are currently smoking, which is significantly higher than the national average (p<0.0001). within the past year, the average number of emergency room visits due to asthma was similar for both locations (la 0.53, us 0.48, p=0.46) . nationally, smokers visited the er significantly more frequently than nonsmokers (s 0.61, ns 0.43, p<0.01). in la, smokers visited the er twice as often as nonsmokers (s 0.80, ns 0.40, p<0 .01) the number of annual routine outpatient checkups for asthma was similar based on location (la 1.39, us 1.66, p=0.06). smokers and nonsmokers had a similar number of checkups nationally (s 1.74, ns 1.64, p=0.32) and in louisiana (s 1.79, ns 1.21, p=0.06). the number of days where asthmatics were unable to perform their usual activities was significantly fewer in la than nationally (la 3.6, us 11.6, p<0.001). smokers had a significantly higher number of missed days nationally (s 17.8, ns 9.6, p<0.0001). in la, there was not a significant difference in the number of missed days based on smoking status (s 4.9, ns 2.9, p=0.47). conclusion: even though louisiana has a lower prevalence of asthmatics compared to the national average, significantly more of our asthmatics are smokers. asthmatic smokers in la and the u.s. utilized the er more than their nonsmoking counterparts. smokers and nonsmokers had similar numbers of routine outpatient visits. asthmatic smokers missed more days, but this was only significantly different at the national level. other research has shown that young age is highly associated with improper use in children using a mdi and holding chamber (arch pediatr adolesc med 2002; 156:378) . the objective of this study was to compare health outcomes achieved by children with asthma using inhaled corticosteroids (icss) delivered by a nebulizer compared with outcomes of children using icss delivered by non-nebulized device. methods: using a managed care organization database (pharmetrics integrated outcomes database), we identified children aged 8 years with an asthma diagnosis and asthmarelated hospitalization/emergency department (ed) visit (july 2000 -june 2002 and with a prescription claim for an ics within 30 days of discharge. we compared relative risk of hospitalization/ed recurrence from day 31-180 (cox proportional hazards regression, covariates=sex, age, current and prior asthma medications, prior oral corticosteroid and short-acting 2 -adrenergic agonist use, initial type of index event) for patients receiving nebulized ics vs other ics by age groups (0-4 years and 5-8 years). results: of 1552 patients with claims for ics, 729 received nebulized ics, of which 480 were aged 4 years; 823 received non-nebulized ics, of which 292 were aged 4 years. postindex hospitalization/ed rates were 12.4%. refill rate was higher for patients using nebulized ics. after model risk adjustment, patients using nebulized ics had a 53% risk reduction for hospitalization/ed recurrence vs those not using nebulized ics (hr: 0.47, 95% ci: 0.28, 0.78). in the 0-to 4-year age group, patients on nebulized ics had a 62% risk reduction compared with patients not using nebulized ics (hr: 0.38, 95% ci: 0.21, 0.69). in the 5-to 8-year age group, patients on nebulized ics had a 52% risk reduction (hr: 0.48, 95% ci: 0.16, 1.46). conclusion: in actual practice, treatment with nebulized ics after an asthma exacerbation is associated with a significant reduction of recurrent hospitalization/ed visits in young children, possibly due to improved technique and compliance. introduction: tenor is a 3-year, multi-center, cohort study of patients with severe or difficult-to-treat asthma. the objective of the tenor study is to better understand the natural history of patients with severe or difficult-totreat asthma. this analysis assessed the frequency of skin testing in this population and characterized the differences between the positive (st+) and negative (st ) subjects. methods: subjects were asked whether they had ever been skin tested and, if so, the test results. those who were st+ were compared to both st and those never tested (stnd) using clinical and other asthma-related characteristics. subjects 12 years of age were included in this analysis. results: 2985 subjects were eligible for this analysis. 85.8% were skin tested in the past, with stnd frequency of 5.1% from allergist sites and 33% from pulmonologist/other sites. of those tested, 93.5% were positive (allergist 95.7%, pulmonologist/other 87.3%). baseline ige for st+ subjects was 104.6 iu/ml vs. 32.4 iu/ml for st ; p<0.0001 (table) . as shown, the age at asthma onset, duration of asthma, rate of atopic disorders, and the rate at which asthma was triggered by aeroallergens differentiated the st+ from the st group. disease severity as evaluated by fev 1 , healthcare utilization, and medication use, however, was similar between the two groups. in general, stnd were more likely to have values closer to the st+ group, suggesting that the majority of those not tested would have been st+, if administered a test. conclusions: the prevalence of st+ subjects from both allergy and pulmonary practices was high, demonstrating that the majority of these severe or difficult-to-treat patients have allergic asthma. st+ patients showed differences in clinical characteristics compared to st , including a greater likelihood of their asthma symptoms being triggered by aeroallergens. these data also show that the clinical profile of stnd patients may be similar to that of st+ patients, suggesting the utility of a more universal allergic evaluation in severe asthmatics. funded by genentech and novartis pharmaceuticals corp. background current national guidelines for the diagnosis and management of asthma such as the naepp epr 2002, classify asthma severity based on frequency of asthma symptoms, medication use, and measurements of lung function by spirometry or peak expiratory flow variability. recently, the utility of spirometry measurements for assigning asthma severity has come into question. here we evaluate the correlation of spirometry measurements with asthma severity in school-aged children who are mostly naive to anti-inflammatory therapy. methods children were participants in a school-based lowincome asthma mobile van program, the breathmobile. recruitment was through referrals by school nurses and community public health clinics, parental response to flyers, and asthma screening questionnaires. spirometry was performed on all children greater than 4 years of age as part of a comprehensive asthma evaluation. asthma severity was assigned based on symptoms only, according to the naepp epr 2002 . results from april 2002 to april 2004 of the 620 children evaluated on the breathmobile, 540 patients were diagnosed with asthma. classification of severity by symptom frequency according to naepp epr guidelines resulted in 28% as mild intermittent (mi), 28% as mild persistent (mip), 32% as moderate persistent (mop), and 12% as severe persistent (sp). the percentage of patients and their mean lung functions at baseline evaluation without bronchodilator challenge are shown in the table. there were statistically significant differences (p<.05) between severity groups which was most pronounced for the fef25-75% when comparing the severe persistent group and the intermittent group. however, mean values appear to be "normal" for all degrees of asthma given current accepted cut-off values, fvc 80%, fev1 80%, fev1/fvc 80%, and fef25-75 60%. conclusion in our study, airflow impairment did correlate with asthma severity, although it was "normal" (fev1 80%) even in children with severe persistent asthma. therefore, a "normal" lung function measurement may be misleading as sole criteria for asthma severity classification. perhaps a higher cutoff point (fev1<90%) might be a better indicator of asthma severity in children. asthma is the most frequently chronic disease in childhood.our main was to know the prevalence of bronchial asthma in children (6-7 and 13-14 years) in the north zone of mexico city and to compare the prevalence obtained by the written questionnaire versus the video questionnaire in the group of 13 to 14 years, according to methodology proposed by isaac. material and methods: by means of a validated and standardized questionnaire (isaac) that was applied to 3500 children from 6 to 7 years and 3899 from 13 to 14. the questionnaires of 6 and 7 years were filled out by their parents. the group from 13 to 14 years answered a questionnaire and a video questionnaire. according to isaac specification and based on a studied population, it was calculated by statcal program the size of the sample. it was choose a haz-ardous sample of 3000 children between 6-7 years and 3000 of the 13-14 group years, both sexes in elementary and high school. measures of central tendency and chi2 were used. results: the final sample size for both groups was 7110 children (3211 of 6-7 and 3899 adolescents), 51.5% men and 48.5% women. the prevalence of the asthma diagnosis for teenagers was of 8 % (p<0.05 ic 7.1-8.7) and it was 4.5% in children (p<0.05 ic 3.8-5.2), wheezing in the last 12 months was 6.8% (p<0.05 ic 5.9-7.6) in children and of 9.9% (p<0.05 ic 9-10.8) for 13-14 years. wheezing induced exercise appeared in 13.1% (p<0.05 ic 12-14.1) in teenager and 3.4 % (p<0.05 ic 2.7-4) in the other group. the severity of asthma showed by nocturnal awakness was 4.3% and 2.6% (p<0.05), number of crisis in the last year 6.3% and 9.3% for children and teenagers respectively (p<0.05). in the video questionnaire of teenagers 7.3% (ic 6.5-8.1) answered affirmative on have displayed a shaken breathing on the last year resting and only 6.8% (ic 6-7.6) in the last month. about exercise question 16.5% confirmed have displayed symptoms, 14.6%(ic 13-15.8) in the last year and 11.1% (ic 10.1-12.1) in the last month. wide-awake at night 7.5% (ic 6.7-8.3) in the last year and 5.2% ) in the last month. conclusions: the prevalence of asthma by diagnosis was higher in teenagers group than in children group. the prevalence of asthma was higher also in this group. rationale: we investigated the relationship of pet exposure and healthcare utilization (hcu) in a cohort of pediatric patients with severe or difficult-totreat asthma in the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) observational study. we hypothesized that pet exposure would increase hcu due to increased airway inflammation. methods: tenor is a 3-year multicenter cohort study of patients with severe or difficult-to-treat asthma. children ages 6-12 were interviewed at baseline regarding asthma-related hcu in the previous 3 months. patients with pet exposure (ppe, n=370) were compared with patients with no pet exposure (pnpe, n=382). responses were analyzed using fisher's exact test. results: ppe were less likely to have severe asthma by physician assessment (32% vs. 40%; p=0.01). in addition, ppe were less likely to have an emergency room (er) visit (18% vs. 26%; p=0.006) or to have been hospitalized (7% vs. 12%; p=0.02) in the previous 3 months. more pnpe had an ige level >100 iu/ml (74% vs. 63%; p=0.001). ppe and pnpe were similar with regard to presence of allergic rhinitis and skin test positivity. compared with pnpe, fewer ppe with two or more pets had er visits and hospitalizations (table) . among ppe, there were no differences in ige levels or in asthma severity related to the number of pets. conclusions: pet exposure was associated with reduced hcu in the tenor pediatric cohort, with the most pronounced effect seen in reduced er visits and hospitalizations needed by those with multiple pets. ppe had significantly lower ige levels compared to pnpe, regardless of the number of pets. these data support the hypothesis that exposure to pets may paradoxically protect individuals from the development of severe asthma. alternatively, these data may reflect a self-selection in patients with severe or allergic asthma who are likely to avoid having a pet. however, there may be other confounding factors in families with pets that confer a protective effect on asthma severity. introduction: in asthma and other chronic obstructive airway diseases, phosphodiesterase 4 (pde4) is involved in the pathophysiology of the disease and is expressed abundantly in key inflammatory cells. inhibitors of pde4 are investigational, anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde4 inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity, which may translate into clinical efficacy in asthma therapy. this study examined the ability of roflumilast to exert direct or acute bronchodilatory activity in patients with mild to moderate asthma. methods: this was a double-blind, randomized, placebo-controlled, crossover study consisting of three treatment periods of one day each, separated by a 7-to 14-day washout period. during each treatment period, 15 patients with a forced expiratory volume in one second (fev 1 ) of 50% to 90% of predicted received either oral roflumilast 1000 î¼g, roflumilast 500 î¼g, or placebo. the fev 1 was measured twice prior to administration and periodically up to 6 h following treatment. after 6 h, patients inhaled 200 î¼g salbutamol from a metered-dose inhaler; fev 1 was measured 15 min later. adverse events, vital signs, and electrocardiogram results were monitored throughout the study. results: median baseline fev 1 was similar for the three treatment periods. both doses of roflumilast did not lead to statistically significant differences versus placebo in the time-averaged fev 1 over the first or up to 6 h after drug intake (p > 0.05). thus, there was no evidence of a direct or acute bronchodilatory effect with either single doses of roflumilast 1000 î¼g or 500 î¼g. in contrast, inhalation of the short-acting bronchodilator salbutamol led to a distinct improvement in fev 1 versus baseline in all treatments groups with median fev 1 increases of 19%, 21%, and 14% in the roflumilast 1000 î¼g, roflumilast 500 î¼g, and placebo groups, respectively. roflumilast was well tolerated. conclusions: oral, once-daily roflumilast exhibits no direct or acute bronchodilatory activity in patients with mild to moderate asthma as could be achieved with short-acting 2 -agonists. these data support the proposed mechanism of action of roflumilast as an antiinflammatory agent. south africa; 2. guadalajara, spain; 3. munich, germany; 4. weinheim, germany; 5. budapest, hungary; 6. konstanz, germany. introduction: phosphodiesterase 4 (pde4) is found in key inflammatory cells involved in the pathophysiology of chronic obstructive pulmonary disease and asthma. inhibitors of the pde4 enzyme are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, oncedaily pde4 inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity. this study examined the dose-related efficacy of roflumilast in patients with asthma. methods: patients with stable asthma (forced expiratory volume in 1 second [fev 1 ] 50% to 85% of predicted) were enrolled in this randomized, double-blind, dose-range finding study. after a single-blind placebo run-in period of up to three weeks, patients received oral roflumilast 100 î¼g, 250 î¼g, or 500 î¼g once daily (n = 229, 228, and 233, respectively) for 12 weeks. efficacy was assessed by change from baseline in spirometric lung function fev 1 and forced vital capacity (fvc), as well as morning and evening peak expiratory flow (pef) recorded in patient diaries. safety and tolerability parameters were monitored throughout the study. results: treatment with roflumilast led to dose-dependent and statistically significant increases in fev 1 , fvc (both p < 0.0001), and in morning pef (p < 0.01). at last visit, fev 1 improved from baseline by 260 ml (11%), 320 ml (13%), and 400 ml (16%) in patients treated with roflumilast 100 î¼g, 250 î¼g, and 500 î¼g once daily, respectively. similarly, dose-dependent improvements of 10 l/min, 12 l/min, and 20 l/min in morning pef from baseline were reached. roflumilast was well tolerated at all dose levels tested. the most frequent drug-related adverse events were headache followed by gastrointestinal disorders such as diarrhea and nausea. there were no clinically relevant changes in vital signs, electrocardiogram, or laboratory parameters. conclusions: oral, once-daily roflumilast was associated with dose-dependent, clinically relevant improvements of lung function in patients with stable asthma. roflumilast was well tolerated. j.l. izquierdo 1* , e.d. bateman 2 , p. magyar 3 , u. harnest 4 , p. hofbauer 5 , a. varga 6 , c. schmid-wirlitsch 7 , d. bredenbroeker 7 , t.d. bethke 7 , 1. guadalajara, spain; 2. cape town, south africa; 3. budapest, hungary; 4. munich, germany; 5. weinheim, germany; 6. tatabanya, hungary; 7. konstanz, germany. introduction: phosphodiesterase 4 (pde4) inhibitors are a new class of anti-inflammatory agents for therapeutic use in inflammatory airway diseases. in several studies, the investigational, oral, once-daily pde4 inhibitor roflumilast has provided clinically meaningful improvements in patients with chronic obstructive pulmonary disease and asthma. this study examined the long-term safety and tolerability of roflumilast over 40 weeks in patients with asthma. methods: patients with persistent, stable asthma (fev 1 50% to 85% of predicted at randomization) participated in a double-blind, randomized dose-range finding study and were treated with oral roflumilast 100 î¼g, 250 î¼g, or 500 î¼g once daily for 12 weeks. patients completing the 12-week study per-protocol, then continued treatment in this open-label 40-week extension study. all patients received oral roflumilast 500 î¼g once daily during the extension period. adverse events (aes), clinical laboratory parameters, vital annals of allergy, asthma & immunology signs, and ecg were assessed throughout the extension period. results: a total of 456 patients were enrolled in the 40-week extension study. overall, the most common aes were related to the respiratory system. only a small number of patients (6%) experienced aes that were assessed as at least likely related to study medication. the most frequent drug-related adverse events were headache, diarrhea, and nausea as reported by 3%, 1%, and 1% of patients, respectively. most aes were mild to moderate in intensity and transient in duration; 6% of patients discontinued the study due to aes. most (60%) of these aes leading to discontinuation were assessed as not related or unlikely related to study drug. out of 456 patients, 16 reported serious aes, which were all assessed as not related or unlikely related to roflumilast. no clinically relevant changes in clinical laboratory parameters, vital signs, ecg, or physical examination occurred. conclusions: oral, once-daily roflumilast 500 î¼g administered for 40 weeks was well tolerated in patients with persistent, stable asthma. this study provides evidence that roflumilast is associated with a low incidence of aes, which are mostly mild to moderate in intensity and transient in nature, thus, supporting the potential therapeutic use of roflumilast in asthma. paris, france; 3. madrid, spain; 4. guadalajara, spain; 5. harrow, united kingdom; 6. weinheim, germany; 7. augsburg, germany; 8. munich, germany; 9. kaufbeuren, germany; 10. konstanz, germany. introduction: in asthma, inhaled corticosteroids (ics) have been the mainstay of maintenance treatment. new therapeutic agents are needed that target key inflammatory processes in asthma as effectively as ics but overcome known limitations of ics. phosphodiesterase 4 (pde4) inhibitors are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde4 inhibitor for potential use in anti-inflammatory asthma therapy. this study compared the standard corticosteroid treatment of twice-daily, inhaled beclomethasone dipropionate (bdp) with oral, once-daily roflumilast in patients with asthma. methods: in a randomized, double-blind, double-dummy study, patients (forced expiratory volume in one second [fev 1 ], 50% to 85% of predicted) received either oral roflumilast 500î¼g once daily (n=207) or inhaled bdp 200î¼g twice daily (400î¼g/day; n=214) for 12 weeks. mean change (lsmean and sem) in lung function parameters fev 1 , forced vital capacity (fvc), and morning and evening peak expiratory flow (pef) from baseline was determined after 12 weeks of treatment. further, symptom score and rescue medication use were assessed. results: both roflumilast 500î¼g and bdp 400î¼g improved fev 1 from baseline to clinically meaningful levels (300 â± 40ml and 370 â± 30ml, respectively; both p<0.0001). similarly, roflumilast and bdp improved fvc (300 â± 40ml and 360 â± 40ml, respectively; both p<0.0001) as well as morning and evening pef (p 0.0003). roflumilast 500î¼g was statistically non-inferior to bdp 400î¼g. roflumilast and bdp led to statistically significant and comparable improvements in asthma symptoms and use of rescue medication. adverse events were generally mild to moderate; the most common drugrelated adverse events reported in the roflumilast group were nausea, headache, and diarrhea. there were no clinically relevant changes in vital signs, ecg, or laboratory parameters. conclusions: roflumilast 500î¼g provided clinically meaningful improvement of lung function parameters, reduced asthma symptoms, and decreased the need for rescue medication. oral, once-daily roflumilast was as effective as inhaled, twice-daily bdp in the treatment of asthma. oral roflumilast 500î¼g was well tolerated. rationale: evaluation of medical claims from commercial health plans permits assessment of therapeutic interventions on resource utilization. this study investigated the impact of controller therapy in children starting asthma maintenance medications. the risk of obtaining prescriptions for oral corticosteroids (ocs), short-acting beta-agonists (saba) or adding another asthma therapy was evaluated. methods: this was a retrospective observational study utilizing medical and pharmacy claims from a large representative managed care plan from 1/1/2000-5/31/2003. children aged 4-17 years old with an asthma diagnosis (icd-9, 493.xx) and an initial pharmacy claim for one of the following regimens: fluticasone/salmeterol in a single inhaler, n=1, 168 (fsc), fluticasone propionate alone, n=2, 473 (fp), montelukast, n=4, 246 (mon), any inhaled corticosteroid plus montelukast, n=1, 009 (ics+mon), and an ics plus salmeterol from separate inhalers, n=296 (ics+sal) were included in the analysis. subjects were excluded if they had received any asthma controller medication in the 6 months prior to the initiation of therapy. regression was used to estimate the incidence rate ratio (irr) for ocs and saba use (negative binomial) and the odds ratio (or) of adding a controller (add) and an ed or hospitalization (ip) event (logistic). all models controlled for demographics, pre-controller asthma-related medications and events, and baseline total health care costs. results: the ratios in the table with a confidence interval excluding unity indicate significantly increased use or likelihood of an event compared to the fsc cohort. controller naã¯ve children started on fsc were less likely to add another controller than mon, fp or ics+sal, and had less use of ocs or saba than the 4 cohorts when studied for 12 months after the initiation of controller therapy. in addition, children treated with ics + mon had a significantly greater or of an ed/ip visit compared to fsc. conclusion: use of fp + sal (fsc) in a single inhaler assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding the potential for selective discontinuation of ics in the 2 multiple controller cohorts. a.s. nayak 1* , r. nathan 2 , j. williams 3 , s. kundu 3 , m. lloyd 3 , d. banerji 3 , 1. normal, il; 2. colorado springs, co; 3. bridgewater, nj. introduction: inhaled corticosteroids (ics) are recommended firstline therapy for severe, persistent asthma. systemic exposure to ics may suppress hypothalamic-pituitary-adrenal (hpa)-axis function, particularly at doses required to control severe asthma. ciclesonide (cic) hydrofluoroalkane (hfa) metered dose inhaler (mdi) is a novel and effective ics that is converted in the lungs to its active metabolite, desisobutyryl ciclesonide (des-cic). previously, in short-term studies, cic has been shown to have no effect on serum or urinary cortisol levels, which may be attributed to the low oral bioavailability, high serum protein binding and high clearance rate of cic and its active metabolite. this hpa axis analysis was part of a long-term study evaluating the safety of cic and beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallel-group, 12-month extension of a 12-week double-blind trial of patients 12 years with severe persistent asthma. patients were randomized in a 2:1 ratio (cic:bdp) to receive cic (320 g bid) exactuator or bdp (320 g bid) ex-actuator. after 2 weeks, the doses of both medications could be titrated to 160 g bid as needed for asthma control. hpa-axis function was assessed at selected centers in a subset of patients at baseline and end of study (at month 12 or early termination) by measuring both peak serum cortisol induced by low dose (1-î¼g) cosyntropin and 24-hr urinary free cortisol corrected for creatinine. results: data were available for a small number of patients at 13 centers evaluating hpa-axis (table) . mean baseline levels and change from baseline to end of study values in low-dose cosyntropin peak serum cortisol levels for cic and bdp were comparable. likewise, baseline levels and mean change from baseline to end of study values in 24-hr urinary free cortisol corrected for creatinine were comparable among the two treatment groups. conclusion: these findings demonstrate that cic 320 to 640 î¼g daily for 12 months is safe and has no significant effect on hpa-axis function. a. long 1* , a. rahman 2 , 1. boston, ma; 2. wilmington, de. introduction: little information is available regarding the relationships between asthma severity, disease control, and compliance with medications. methods: physicians' perceptions regarding these variables were determined by internet-based general asthma medication usage survey and patient-specific asthma medication usage surveys between december 18 and 29, 2003, for 406 physicians (100 pcps, 106 pediatricians, 100 allergists and immunologists, and 100 pulmonologists). the patient-specific surveys were based on chart information of 3 randomly chosen patients per physician on controller medication. results: of 1218 patients, 12%, 31%, 43%, and 14% were categorized by their physicians as having mild intermittent or mild, moderate, or severe persistent asthma, respectively. overall, 45% of patients were categorized as having "very controlled" asthma and 58% as being "very compliant" with their current regimen. worse asthma control, decreased compliance, and increased physician visits were all associated with increased asthma severity classification. physicians reported that only 5% of patients with severe persistent disease (n=169) had "very controlled" asthma in contrast to 77% of patients with mild intermittent asthma (n=143). patients with mild intermittent asthma, and mild, moderate, and severe persistent asthma, had a mean of 2.9, 3.4, 4.5, and 5.5 physician visits for asthma, respectively, within the past year. physician perception of patient compliance varied less across the groups, with 55% of patients with severe persistent asthma and 66% of patients with mild intermittent asthma being rated as "very compliant." the incidence of allergic rhinitis was similar among all severity levels (range: 50%-56%), but patients with severe persistent asthma were more likely to have comorbid conditions, including hypertension, chronic obstructive pulmonary disorder, chronic bronchitis, and osteoporosis, compared with patients in other asthma severity levels. conclusions: decreased asthma control and rates of com-pliance, as well as increased physician visits and comorbid medical conditions, may be associated with increased asthma severity classification. rationale: children with asthma frequently have co-morbid allergic conditions requiring medications. the purpose of this study was to assess whether the controller asthma medication selected would reduce the utilization of intranasal steroids (ins) and prescription nonsedating antihistamines (nsa) for children treated for co-morbid allergy. methods: this was an observational retrospective study that utilized the pharmetrics integrated outcomes database that contains administrative medical and pharmacy claims data from over 30 managed care plans across the united states. children age 4-17 years old with a new diagnosis of asthma (icd-9, 493.xx) were identified and observed for 12 months after their initial diagnosis and treatment of asthma (post-index). four cohorts were established based on their controller medication dispensed: montelukast, n=1906 (mon), fluticasone propionate, n=2455 (fp), fp+mon n=287, fp/salmeterol in a single inhaler, n=599 (fsc). results: baseline comorbid diagnosis of allergic rhinitis was observed in 14-20% of the children. the patterns of use of ins and nsa were similar in the 12 months before and the 12 months after the initial asthma diagnosis and treatment. children with a diagnosis of allergic rhinitis were nearly twice as likely to receive a nsa or ins. all 4 treatment cohorts used a similar amount of each allergy medication. the presence or absence of a diagnosis of allergic rhinitis did not alter the findings. the adjusted odds ratio (95%ci) of using a nsa or ins relative to the use of fsc in the post-index period was mon: 0.989 (0.809, 1.208); fp: 0.828 (0.682, 1.007); fp+mon: 1.095 (0.804, 1, 489 ). the table below shows the percent of children dispensed a nsa and/or an ins. the number of units of each allergy medication was also similar across all 4 cohorts. conclusion: the use of mon, fp, fp+mon or fsc for asthma did not alter the rate or quantity of either intranasal corticosteroid or nonsedating antihistamines dispensed to children over the 12-month period. although allergic rhinitis is a common comorbidity of pediatric asthma, the selection of a regimen containing montelukast did not reduce the use of either nsa or ins compared to asthma treatments with fp or fsc. rationale: medication compliance is recognized as a significant challenge in pediatrics.the purpose of this study was to compare inhaled corticosteroid (ics) persistence in pediatric patients using a single inhaler, containing both an inhaled corticosteroid (fluticasone propionate, fp) and an inhaled long-acting beta-agonist (salmeterol, sal) (fsc), to patients receiving fp alone, fp + sal from separate inhalers, or ics + montelukast (mon). methods: retrospective 24-month pre-post database study utilizing medical and pharmacy claims. a total of 4946 subjects 4-17 years of age with a diagnosis of asthma (icd9 493) were grouped into 4 cohorts: fsc [n=1168]; fp only [n=2473] ics+sal [n=296]; and ics+mon [n=1009]. patients were controller naã¯ve for 6 months prior to the index event (the first prescription of the medication of interest). subjects were required to have continuous enrollment of 6 months pre-and 12 months postindex. subjects with cystic fibrosis, copd, bronchopulmonary dysplasia or respiratory distress syndrome were excluded. ics refill rates, as a measure of persistence, were compared between fsc and the ics components of the other cohorts over a 12-month follow-up period. results: mean refill rates over the 12-month follow-up period was significantly greater (p=< 0.05) for fsc (4.48) compared with the mean ics refill rate in the fp alone (3.39) cohort, the ics + sal (3.61) and the ics + mon (3.92) cohort. patients on fsc filled 32% more ics prescriptions than patients on fp alone, 24% more than ics+sal and 14% more than ics + mon. mean refills were generally higher than the median fills as a considerable number of children had only one fill: fsc (35.6%), fp (49.1%), ics (48.3%) + sal (50.0%), ics (36.0%) + mon (18.6%). conclusion: patients using fsc, are likely to fill their inhaled corticosteroids more often over 12-months compared with patients using ics + sal in 2 separate inhalers, ics+mon, and fp as monotherapy. improved persistence with ics has been shown in other studies to decrease morbidity and mortality of asthma. use of fsc, a single inhaler, assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding selective discontinuation of ics that may occur when two medications are dispensed. the national health interview survey (nhis) estimates 14.5 million united states residents with asthma. noncompliance with treatment has been estimated as between 20 and 80%. the consequences of noncompliance include absences from work or school, increased emergency room visits, more severe attacks, increased drug side effects, greater cost of care, and death. we questioned compliance in a 47yo man with severe, prednisone dependent eosinophilic asthma because he had persistent symptoms despite treatment with fluticasone propionate/salmeterol xinafoate 500/50 bid, prednisone 20mg to 40mg qd, and budesonide (200 mcg/puff) 2 puffs bid. after discontinuation of budesonide and prednisone and initiation of methylprednisolone 16mg bid for 24 hours and then 16mg qd and beclomethasone dipropionate 2 puffs (80mcg) hfa bid with a spacer, clinical improvement was unexpectedly abrupt. fev1 increased from 58% to 90% of predicted. sputum eosinophil counts decreased from 78% to 2%. because of the sudden improvement with the change to methylprednisolone, compliance to prednisone and fluticasone was questioned. to evaluate compliance, the patient's blood, urine, and sputum were tested for synthetic corticosteroids, without his knowledge, using mass spectrometry. the blood level of methylprednisolone was 2.6mcg/dl and prednisolone was 0.35mcg/dl, documenting use of methylprednisolone and the recently discontinued prednisone. the urine levels were 13mcg/dl of methylprednisolone, 1.3mcg/dl of prednisolone and 0.74mcg/dl of prednisone that further confirmed recent use of prednisone. the sputum testing revealed 0.8mcg/dl beclomethasone, 33mcg/dl fluticasone and 1.8mcg/dl methylprednisolone confirming compliance to inhaled fluticasone and beclomethasone at the time of the test. thus, contrary to our clinical suspicion, the patient was indeed compliant with his inhaled glucocorticoids and prednisone and subsequently with the methylprednisolone. to our knowledge, this is the first case report to document compliance to inhaled and oral corticosteroids by analysis of synthetic corticosteroid concentrations in blood, urine, as well as sputum. if compliance could be documented with certainty, it could potentially minimize the adverse effects of needless escalating steroid doses, reduce the cost of treatment, and minimize morbidity and mortality as well. rationale:the burden of pediatric asthma extends beyond those children with an asthma diagnosis. children with wheezing frequently have a delay in the diagnosis of asthma that may impede instituting appropriate therapy and reducing disease morbidity. this observational study was designed to assess the treatment patterns of children 4-17 years old receiving asthma medication(s) without a diagnosis of asthma compared with children diagnosed with asthma and children without claims for asthma. methods:this was a retrospective cross-sectional study that utilized the pharmetrics integrated outcomes database containing administrative medical and pharmacy claims data from over 30 managed care plans across the united states. three cohorts were selected: children with an asthma diagnosis (icd-9, 493.xx) (dx cohort), children with prescription claims for asthma controllers or rescue medications without an asthma diagnosis (rx cohort) and children with neither an asthma diagnosis nor prescription claims for asthma medications (control cohort). utilization of asthma medications, asthma specific costs and total costs of care were assessed. results: a total of 295, 000 children were identified: 6.7% in the dx cohort, 4.4% in the rx cohort and 88.9% in the control cohort. the potential asthma cohort was 11.1%. total annual non-asthma related costs for the dx cohort was $1, 642 for the rx cohort was $1, 306 and for the control was $802. only 19% and 5% of the total healthcare charges in the dx and rx cohorts retrospectively were asthma related. non-asthma charges were significantly higher in both the dx and rx cohorts compared with the control cohort. in the rx cohort, the ratio of saba prescription claims to asthma controller claims were 1.85-fold higher than in the dx cohort. conclusion: children treated with asthma medications without an asthma diagnosis consume greater health care resources resembling the pattern of health care utilization of children with an asthma diagnosis more closely than controls. further, children with treatment in the absence of an asthma diagnosis appear to be under-treated with controller therapy as recommended by national and international guidelines. background: a recent retrospective study assessed asthma variability in inner-city patients 6 months before and 6 months after enrollment into an naepp guidelines-directed clinical management and educational program. while guidelines-directed care improved asthma symptoms and outcomes, significant variability in disease indices were observed over the 6-month period. the present analysis evaluates resource utilization associated with this variability. method: economic end points, including hospital/emergency department (ed) visits, total unscheduled office visits, sick visits, and days lost from work or school, were collected from 125 inner-city patients aged 18 years (74% female, 69% minority, 80% treated by primary care physicians) enrolled in a guidelines-directed asthma clinical management and education program aimed at minimizing barriers to adherence. patients were stratified into 2 groups: those with high variability in asthma (n=62) and those with low variability in asthma (n=63), with variability defined as number of fluctuations in naepp symptom class in the 6-month postintervention period (high variability = patients with fluctuations higher than the mean; low variability = patients with fluctuations lower than the mean). results: guidelines-directed therapy was associated with improvements in asthma during the 6-month treatment period for both groups. patients in the high-variability group had more ed visits, sick visits, total unscheduled visits, and office visits compared with patients in the low-variability group (see table) . conclusions: despite guidelines-directed therapy and overall improvement in asthma control, patients experienced variability in asthma, indicating that even when their disease is stable, their symptoms continue to fluctuate. as a result, asthma variability may contribute to increased resource utilization. introduction: inhaled corticosteroids (ics) are considered first-line therapy for patients with persistent asthma. ics can lead to oropharyngeal adverse events, which may affect treatment outcomes and adherence. the occurrence of these local adverse events is dependent upon several factors, including dosage and duration of ics treatment. ciclesonide (cic) hydrofluoroalkane (hfa)-metered dose inhaler (mdi) is a novel and effective ics, with relatively low oropharyngeal deposition. cic is converted in the lungs to its active metabolite, desisobutyryl-ciclesonide (des-cic). furthermore, cic undergoes limited conversion in the oropharynx, which may account for its improved safety profile. this oropharyngeal safety profile analysis was part of a long-term study evaluating the safety of cic hfa-mdi vs beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallelgroup, 12-month extension of a 12-week double-blind study of patients 12 years with severe persistent asthma. patients were randomized in a 2:1 ratio (cic:bdp) to receive cic (320 g bid) or bdp (320 g bid) (both ex-actuator). after 2 weeks, the doses of both medications could be titrated to 160 g bid as needed for asthma control.) oropharyngeal adverse events were monitored, and suspected oral fungal infections were verified by positive culture. results: the incidence of oral candidiasis was lower in subjects receiving cic (4.1%), compared with those receiving bdp (10.4%) ( table) . the incidence of pharyngitis and hoarseness was 3.6% and 2.5%, respectively, for the cic group, and 5.2% and 1.0%, respectively, for the bdp group. all local adverse events resolved without sequelae, and there were no withdrawals due to oropharyngeal treatment-emergent adverse events. conclusion: after 12-months of treatment with cic 160 î¼g or 320 î¼g twice-daily, the incidence of oropharyngeal adverse events was low. cic treatment resulted in a much lower incidence of oral candidiasis, compared with similar doses of bdp, reflecting a better local tolerance. objective: to determine the prevalence of asthma and asthma-related morbidity, treatment and asthma-risk factors in a selected population. method: a routine health screening, including tests for asthma, was conducted at the new orleans center for creative arts high school. participants (204) identified their medications and asthma tools in addition to completing the isaac questionnaire. prevalence data included lifetime wheezing, 12 month wheezing, and previous asthma diagnosis. asthma-related morbidity included sleep disturbance, wheezing with exercise, asthma attack rate and night awakening. results: " participants were aged 13-9 years (50.5% african american, 45.1% white) with 31.4% male, 68.6% female. " cumulative asthma prevalence was 18.8%, lifetime wheezing (24%), 12-month wheezing 12.7% with girls reporting 3.36 times more often (95% ci: 1.54, 7.36), and wheezing more than 4 times in 12 months 4.7%. " there was a significant association between race and wheezing in the last 12 months (p < 0.024) with whites reporting 3.78 times more often (95% ci: 2.01, 7.10). asthma morbidity was reported as follows: a. night cough -10.5% b. wheezing with exercise -10.9% " parents with a less education (high school or less) were 8.33 times more likely (95% ci: 7.46, 9.30) to have children who developed wheezing in the past 12 months. " higher body mass index (bmi = 25) was associated with wheezing after exercise (p < 0.008) with a 3.27-fold increase (95% ci: 2.46, 4.31). " among those with current asthma (15/204), 4 were not on any medication, 10 were using bronchodilators, and 5 were on anti-inflammatory medications. three reported using a spacer and 6 reported using a peak flow meter. conclusion: asthma prevalence is higher in this school population than the national average. less parental education, female gender, and bmi = 25 were associated with greater asthma morbidity. the majority of the participants with current asthma reported receiving episodic and inadequate treatment with inhaled corticosteroids. objectives: to determine the prevalence of asthma and asthma related symptoms; to assess its severity among new orleans school children. methods: seven elementary, middle, and high schools in new orleans participated in the screening of 1511 students, 54% female, 45% male, ages 5-18 in the fall, 2000. the 8-item questionnaire was designed by the international study of asthma and allergies in childhood (isaac) to determine asthma prevalence and severity in children. the isaac questionnaire is a validated protocol used on over 500, 000 children in 56 countries. asthma is defined as cur-rent wheezing for the purposes of this study. data was entered using spss 10 and sas 8 software for analysis. results: table: presence of asthma symptoms by ethnicity conclusion: asthma prevalence is significantly higher in inner-city school children in new orleans when compared to the national prevalence (24.6% to 26.4% vs. 7.5%). asthma prevalence and severity do not differ significantly between african-american and caucasian children in new orleans even after removing the effect of gender and age. video is an effective method of teaching pollen identification. projected digital images offer three-dimensional views of unique pollen detail similar to focusing a microscope. the national allergy bureauâ�¢(nab) currently provides pollen counts to the media. these reported levels are obtained by standardized counting methods rather than forecasts based on historical pollination predictions and weather patterns. the american college of allergy, asthma and immunology and the american academy of allergy, asthma and immunology have an interest in ensuring consistent counting and accurate reporting practices. both organizations offer pollen identification training in conjunction with their annual meetings and have used the video for initial training sessions and for experienced counters in advanced courses. there are 112 certified pollen counting stations in the united states and canada with approximately 80 currently active locations. the nab requires the demonstration of ability to count and accurately identify pollen on test slides. an updated recertification process using an interactive web site is currently being developed. ongoing pollen identification training is essential for the continued success of this aeroallergen network. most observers found that the video provided a quality emulation of microscopic viewing and enhanced the depth and detail of individual pollen characteristics. the video received the highest possible ratings by course attendees. in conclusion the video plays a positive role in pollen identification training and the continuing education of experienced counters. the diagnosis and treatment of mold allergies are complicated by the genetic diversity of individual fungal species and the influence of endogenous fungal proteases on extract compositions and potencies. studies examining the biochemical comparability of mold extracts from different sources and their compatibility with other allergens in immunotherapy mixtures are essential to the clinical effectiveness of these products. compositional comparisons of extracts prepared from alternaria, aspergillus and penicillium source materials by 7 u.s. allergen manufacturers revealed variable sds-page protein banding patterns and noticeable differences in total protein and carbohydrate concentrations. alt a 1 levels in alternaria extracts did not correlate closely with total protein levels or with ige-binding potencies measured by elisa inhibition. immunoblot profiles of fungal extracts were more closely related to one another compared to sds-page patterns, suggesting that similar allergenic or antigenic epitopes may be retained in molecules of varying size. parallel elisa inhibition dose-response curves provided statistical evidence that a repertoire of ige epitopes is conserved in many of these products. variations in the potencies of fungal extracts from different manufacturers may result from differences in source materials and/or conditions of extraction and storage. the stability and compatibility of allergen mixtures containing mold extracts were assessed after storage for up to 6 months at 2-8â°c using specific immunoblot and elisa procedures. grass and mite allergens compromised by mixing with mold extracts were stabilized by glycerin. alternaria extracts from different sources produced similar effects on grass allergens when added at comparable strengths. degradative effects caused by aspergillus or penicillium products were more closely related to total fungal protein concentrations than to extraction ratios. structural epitopes on cat, ragweed and fungal allergens were stable after mixing with protease-containing mold extracts, indicating the presence of natural protease inhibitors or allergenic protein sequences distinct from those recognized by these enzymes. allergenic extracts labeled as weight/volume or by pnu have no regulatory requirement for determination of activity. alum-adsorbed allergenic extracts are labeled in pnu and are felt to be depot formulations. the purpose of this study was to develop methods to measure important allergen proteins and specific ige binding capability of these alum-adsorbed allergenic extracts and to begin to assess the potency of these non-standardized extracts. allergen proteins are adsorbed to alum particles making their measurement difficult. in this study allergens were released from center-al â® alum precipitated allergenic extracts using 0.3 m citrate buffer, ph 5. the major allergen contents of several lots of each product were measured using monoclonal antibody elisas for group 5 grasses, cyn d 1 bermuda, bet v 1 birch, ole e 1 olive, and pla l 1 english plantain. these assays were developed and validated by alk-abello and optimized for the citrate releasing buffer. direct binding ige was performed by immobilizing serial dilutions of extract to microtiter plates and then adding specific atopic sera and enzyme labeled anti-ige. the methods used were able to measure in vitro allergen activity in the alum-adsorbed extracts. major allergen content was successfully measured in the extracts and the amount was related to the pnu content. as expected, the variability of the major allergens within a particular extract species was higher than in standardized extracts that are adjusted for potency. the extracts demonstrated specific ige binding ability in the binding assay. the ige binding capability at various dilutions was related to the major allergen content. in conclusion, methods were developed to release adsorbed allergen proteins from alum extracts. the extracts were then analyzed for major allergen pro-teins and the ability to bind ige. major allergen content is currently used to monitor the activity of aqueous and glycerinated extracts and this study demonstrates that implementing these testing procedures will improve the consistency and quality of alum-adsorbed extracts. introduction there are over 5000 species of smut and rust fungi. ustilago maydis, or corn smut, is a basidiomycete fungus that infects ears of corn. it is responsible for a percentage of grain loss in the united states but eaten as a delicacy in mexico. it grows into large tumor-like structures, called galls, dispersing soot-like spores responsible for the common name, "smut." it is readily airborne and believed to be a causal agent for allergic rhinoconjunctivitis. "corn smuts" was added to the standard screening panel for patients presenting for evaluation of rhinitis in the region of middle tennessee. methods using greer laboratoriesâ�¢ corn smut extract 1:20 w/v, patients were tested by prick/puncture method with the hollister-stier quintipâ�¢ device. if negative, intradermal testing was performed. positive and negative controls were assessed. based on current national recommendations, wheals 3 mm greater than negative control were considered positive for prick/puncture testing and wheals 8 mm greater than negative control were considered positive for intradermal testing. results 105 patients were tested between november, 2003 and march, 2004 . 14/105 (13.3%) met criteria for prick/puncture positivity. 52/105 (49.5%) met criteria for intradermal positivity. patients prick positive to corn smut had the following prick positive tests: dust mites 12/14 (85.7%); cat 11/14 (78.6%); local grass mix 10/14 (71.4%); local tree mix 10/14 (71.4%); local weed mix 10/14 (71.4%), mold mix 8/14 (57.1%); cockroach 7/14 (50%); and dog 4/14 (28.6%). discussion allergy testing for aeroallergens is available to a limited number of antigens, of which, only a few are standardized. as time passes, relevant antigens are discovered and their importance further elucidated. this assessment reveals a significant presence of corn smut ige largely accounted for by intradermal positivity which may or may not reflect clinical sensitivity. these numbers are provided so that other clinicians may compare to prevalence in their geographical area. further studies are needed to determine the association of corn smut ige with clinical symptoms. h 1 antihistamines are the mainstay of therapy for allergic disorders, including skin diseases. the most common side-effect of marketed antihistamines is sedation, especially when the clinical symptoms require a higher dose than recommended, a condition commonly encountered in dermatological disorders. the present study describes the pharmacology of a new non-sedating h 1 antihistamine, r129160 (hivenylâ�¢). r129160 binds to the cloned human h 1 receptor with a similar affinity (ki: 19 nm) as the reference antihistamines cetirizine (ki: 50 nm) and loratadine (ki: 37 nm). in vivo, r129160 protects rats and guinea pigs from lethal shock, induced by compound 48/80 and histamine, respectively (ed 50 : 0.06 and 0.055 mg/kg respectively). the compound is at least as effective as cetirizine and loratadine. in rats, r129160 inhibits the histamine-and allergen-induced cutaneous reactions (ed 50 : 1.4 and 2.3 mg/kg) with a similar potency as cetirizine (ed 50 : 0.7 and 2.7 mg/kg) and loratadine (ed 50 : 1.8 and 1.6 mg/kg). even so, in guinea pigs the compound inhibits the histamine-and allergen-induced skin reactions (ed 50 : 0.14 and 1.2 mg/kg) to a similar extent as loratadine and cetirizine. however, in dogs r129160 is more potent in inhibiting the ascaris allergen-induced wheal reaction (ed 50 : 0.024 mg/kg) than cetirizine (ed 50 : 0.14 mg/kg) or loratadine (ed 50 : 0.20 mg/kg). r129160 fails to occupy central h 1 receptors in the guinea pig cerebellum up to 40 mg/kg, in contrast to loratadine (ed 50 : 2.2 mg/kg). in vitro and in vivo cardiovascular safety experiments indicate that r129160 lacks the intrinsic capacity to prolong the qt-interval, even at high doses. as such, r129160 (hivenylâ�¢) is characterized as a potent, non-sedating and cardiosafe h 1 antihistamine. it has been selected for further clinical development, mainly in the field of dermatology. the compound will be a suitable tool to explore the activity of a selective h 1 antihistamine in various indications, without the contamination of the sedative activity often observed with other marketed antihistamines when increasing the dose. ciu represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. we have previously reported the clinical efficacy of fxt (prozac), an ssri widely used for the treatment of depression, in the management of ciu (nsouli tm, et al. ann allergy asthma immunol 2002; 88:60) . in this presentation we report 2 additional cases of ciu which responded dramatically following the use of fxt. a 41 yr-old female and a 21 yr-old male presented with ciu of 18 and 24 months duration, respectively, requiring oral corticosteroid (cs) therapy for control of their ciu after failure of high dose anti-h1 (hydroxyzine) and anti-h2 (ranitidine) agents (table) . testing for food and latex allergy, viral hepatitis, autoimmune thyroid disease and parasitic infection were all negative. a skin biopsy performed in subject #1 was consistent with an urticarial vasculitis. following one week of oral fxt (40 mg qd [subject #1] 20 mg qd [subject #2]) a striking and complete resolution of urticaria in each patient was observed within 7 to 10 days during which time it was possible to successfully taper the cs. both patients have been maintained on fxt therapy with complete control of their ciu. the very favorable response to fxt therapy in these 2 patients in addition to our first case report suggests that this drug may have a new therapeutic application in the management of recalcitrant ciu. background: ipratropium bromide nasal spray (ib) is indicated for treatment of rhinorrhea caused by common cold (cc), seasonal and perennial allergic rhinitis (ar) in adults and children age 5 and up. symptoms of rhinorrhea from cc or ar in children are similar to those in adults, yet there is little data on the use of ib in children under 5 years of age. objective: evaluate the safety and efficacy of ib nasal spray 0.06% in 2-5 year-old children with symptoms of rhinorrhea from cc or ar. methods: a total of 230 children (43 cc and 187 ar) were treated in an open-label, multi-center study. the cc patients received ib nasal spray (84 mcg per nostril) tid for 4 days, the ar patients received ib nasal spray (42 mcg per nostril) tid for 14 days. effectiveness was measured using a global assessment questionnaire and daily symptom scores reported by the parent. results: from the global assessment questionnaire, 91% and 90% of the parents found ib either "very useful" or "somewhat useful" in the cc and ar groups respectively. regarding effectiveness, 98% (cc) and 87% (ar) of the parents reported that ib had either a "good effect" or "excellent effect" in treating rhinorrhea. moreover, 67% (cc) and 91% (ar) of parents found administration of a nasal spray either "extremely easy" or "very easy." eighty-one percent (cc) and 89% (ar) of the parents reported they would use ib again for their child's allergy symptoms. the daily symptom score (0 = none to 5 = unbearable) for rhinorrhea decreased from 2.9 to 1.3 (-55%, p<0.0001) for cc and from 2.1 to 1.1 (-48%, p<0.0001) from baseline compared to the average on-treatment score, with decreases also seen for stuffy nose and sneezing. the nasal spray was well tolerated with adverse events (ae) reported in 28% of cc and 35% of ar patients. the aes were mostly mild to moderate and no potentially systemic anticholinergic or serious aes were reported. conclusions: ib nasal spray 0.06% administered at a dose of either 42 or 84 mcg per nostril tid is an easy to use, safe, and effective therapy for control of rhinorrhea in children 2 to 5 years of age with common cold or allergic rhinitis. chronic idiopathic urticaria (ciu) represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. the pathogenesis of the condition derives from the release of potent vasoactive substances including histamine, and products of arachidonic acid metabolism, e.g., prostaglandins and thromboxanes formed by the action of the enzymes cyclooxygenase (cox) of which cox-2 is responsible for pseudoallergic and other inflammatory responses. although a number of therapeutic options exist owing to the plethora of mediators produced, treatment has focused largely on the use of h1 antihistamines and, unsurprisingly, at times without complete resolution of symptoms. in this presentation we report the successful use of a cox-2 inhibitor for the treatment of chronic urticaria. a 10 y/o white hispanic female presented with a 4 month history of chronic urticaria predominantly on the soles of the feet, with unknown precipitating factors, and fail-ure to respond to prior treatment with: cetirizine, steroids, benadryl, ebastine and epinastine. the patient received a blood transfusion 3 years ago and there was no prior history of allergies. skin testing revealed 3+ reactions to dust mite, pollen, cockroach, shellfish, 2+ reactions to corn, milk and ige = 262 iu (nv < 90 iu), aso = 400 ui (nv < 200 ui). after 2 weeks of treatment with rofecoxib (vioxx) 25 mg, and benadryl, the rash resolved. vioxx was continued for 2 more weeks until complete resolution of symptomatology. this case illustrates that the addition of a selective cox-2 inhibitor (i.e., rofecoxib) with an h1 antihistamine may be a more effective regimen for patients with ciu who fail to respond adequately to conventional therapy. introduction: elderly asthmatic patients whose symptoms are controlled by inhaled corticosteroid (ics) therapy may still have breathlessness on exertion. we randomized elderly asthmatic patients stabilized by medium-dose ics therapy into two groups, treated one group with medium-dose ics therapy plus montelukast, a leukotriene receptor antagonist, and the other with increased-dose ics therapy, and compared the effects of the treatment regimens on exercise tolerance. methods:the subjects were 24 patients with bronchial asthma (16 males and 8 females, 70.6â±3.9 years) stabilized by ics therapy (with fluticasone proprionate, fp; 400 mg/day) for three months or more with low peak expiratory flow (pef) rates (<80%predicted, variability<15%). they were randomly divided into two groups (12 patients each) to be treated with ics therapy plus montelukast (400 mg/day fp + 10 mg/day montelukast; m group) or with increased-dose ics therapy (600 mg/day fp; f group). pulmonary function tests, a six-minute walking test, respiratory gas analysis during incremental (15w/min) cycle ergometer exercise were conducted, and exhaled nitric oxide (no) levels were measured before and after two weeks of the study treatment. results: pulmonary function tests showed significant increases in maximal mid-expiratory flow (mmf) and forced expiratory flow at 50% vital capacity (v50) in the m group (p<0.01) but no significant changes in the f group. exhaled no levels decreased significantly in both groups (40.7â±13.9 to 27.5â±9.1 ppb in the m group and 53.1â±17.6 to 38.0â±10.4 ppb in the f group; p<0.01). the six-minute walking distance extended from 531â±64 to 575â±58 m in the m group and from 553â±60 to 570â±58 m in the f group.the peak oxygen uptake (peakvo2) increased significantly in the m group (%peakvo2/w from 76.2â±12.7 to 84.4â±14.6%; p<0.01) but not in the f group (%peak vo2/w from 76.2â±10.7 to 76.4â±10.3%). the peak exercise load also increased significantly in the m group (76.6â±22.0 to 96.1â±23.1 w; p<0.01) but not in the f group (81.2â± 16.2 to 82.2â±14.3w). conclusions: the results indicate that concomitant administration of montelukast is more effective than dose escalation of ics on exercise tolerance in elderly asthmatic patients under medium-dose ics therapy. e. meltzer 1* , y. luo 2 , l. shen 2 , z. guo 2 , c. schemm 2 , y. huang 2 , k. chen 2 , p. king 2 , r. nave 3 , d. banerji 2 , s. rohatagi 2 , 1. san diego, ca; 2. bridgewater, nj; 3. konstanz, germany. introduction: inhaled corticosteroids (ics) are first-line treatment for persistent asthma. ciclesonide (cic) is a novel and effective ics under development. freely circulating, unbound ics is available to cause systemic adverse effects, such as hypothalamic-pituitary-adrenal (hpa) axis suppression. hence, it is important to determine the free fraction of ics in plasma. in separate studies, the protein binding of the active metabolite of cic, desisobutyryl-ciclesonide (des-cic), was evaluated, and the effects of inhaled cic on hpa axis function were determined. methods: human plasma protein bind-ing of des-cic (0.5-500 ng/ml) was determined using equilibrium dialysis. dialyzed samples were analyzed by liquid chromatography with tandem mass spectroscopy to determine free and bound des-cic. in 3 separate clinical studies, the effects of cic (hfa; 320-1280 î¼g daily) and placebo (pbo), via metered-dose inhaler (ex-actuator doses), over 9 days, 4 or 12 weeks, on basal hpa axis function (24-hour area-under-the-curve [auc0-24h] serum or urinary cortisol corrected for creatinine) or stimulated (low-dose [1 î¼g] cosyntropin) serum cortisol were investigated in patients ( 18 years) with persistent asthma. results: the mean % of human plasma protein binding for des-cic was 99%. in 2 studies measuring serum cortisol auc0-24h, there was no difference between pbo and cic (320-1280 î¼g). similar results were observed for 24-hr urinary cortisol corrected for creatinine. in the 3rd study measuring low-dose (1 î¼g) cosyntropin-stimulated peak serum cortisol, after 12 weeks of treatment, there was no significant difference in the mean change from baseline versus placebo for either cic320 (p=0.383) or cic640 (p=0.911). conclusions: the favorable pharmacokinetic profile of cic, in particular the high protein binding of des-cic, may explain the lack of hpa-axis suppression. this appears to result in greater systemic safety. purpose: unscheduled office and ed visits for urgent asthma care are an ongoing point of concern. determining preventive variables regarding these unscheduled visits could have a significant impact on asthma costs and quality of life. objective(s): this research addresses the following question: when stratifying by race, gender, age, metropolitan/rural place of residence and comorbidity, do adults with asthma have fewer ed or unscheduled office visits for urgent asthma care if they: a) have an identified primary care provider, or b) have health insurance? method(s): univariate and stratified bivariate contingency table analyses were performed on weighted 2001 behavioral risk factor surveillance survey (brfss) data. result(s): adults with asthma who had an identified primary care provider were more likely to have no unscheduled office visits (or=1.87) or ed visits (or=2.07) for urgent asthma care. this was also true for adults with asthma who had health insurance (or=1.38 for no unscheduled office visits and or=1.71 for no ed visits). these relationships held when stratifying by race, gender and age. the relationships also held for metropolitan residents. the analysis was inconclusive for rural residency and the existence of co-morbidities. conclusion(s): despite race, gender, age and metropolitan residency, having a primary care provider or having health insurance impact whether or not adults with asthma are more likely to have unscheduled office or ed visits for urgent asthma care. further investigations are needed to examine how these factors impact adults with asthma who are rural residents or who have co-morbidities. d. bukstein 1* , g.a. cherayil 2 , 1. madison, wi; 2. brookfield, wi. introduction: costs for plans to process prior authorizations for non-formulary medications, has been estimated to be $20 to $25 per request. costs for physicians to process these requests has not been extensively studied. methods: dr.bukstein, board certified allergist, developed a data collection tool. the form was utilized by physicians and nurses to document time spent on processing prior authorizations. data collected included, class of medicines requiring the pa, nursing time spent on calling the patient, pharmacist, health plan, nursing time spent completing forms, nursing time clarifying the information for the pa, as well as physician time spent completing pa activities. results: data was collected over 8 weeks in 2003 and 117 requests were processed.the class of medicines most often processed was antihistamines, comprising 66% of requests. nursing calls were tracked and calls to and from patients were the most common call documented. they averaged 5.6 +/-6.5 calls per day per nurse. the nurses spent an average of 17 minutes per patient call. calls to health plans averaged 1.8 +/-1.5 calls per nurse per day and time spent on these call was 8.4 +/-9.5 minutes per call. physician calls documented included 154 calls averaging 1.9 +/-1.2 calls per physician per day. these calls averaged 5.8 +/-5.0 minutes per call.often the results of the prior authorizations were not known on the day of the request. originally 30.8% of requests were granted the same day. retrospective review revealed 98.7% were approved the first time they were processed. salary and benefits were calculated for nurses and physicians. the hourly rate was defined as $21.50 per hour for nurses and $150 per hour for physicians. the costs for the time spent on the 117 prior authorizations were calculated. during the 8 week study period, over 40 hours was spent by nurses on 231 calls and over 8 hours was spent by physicians on 154 calls during the same time period. the total nursing and physician cost in this specialty practice was $17.77 per prior authorization. conclusion: there are substantial costs with processing of prior authorization requests for non-formulary drugs on the physician office side of managed care as well as on the insurance side of the process. specialty physicians should have a different process for obtaining non-formulary medications since almost 100% of their requests are granted. introduction: diabetes mellitus can adversely impact the course and outcome of myocardial infarction (mi). one of the mechanisms underlying this phenomenon is alteration of the course of inflammation and the reparative process following myocardial necrosis. abnormal wound healing, tissue reparation and immune responses in diabetic patients have been intensively studied, but the cellular and the molecular mechanisms are still unclear. transforming growth factor-beta (tgf-beta) is a multifunctional cytokine which plays a critical role in coordination of the course of inflammation and reparation, acting as a potent depressor of inflammation and a stimulator of regeneration. this study investigates the dynamics of serum concentrations of the active form of tgf-beta1 during the period up to the 20th day after the onset of a mi in diabetic and non-diabetic patients. results: in non-diabetics a significant increase was observed in tgf-beta1 on day 2 (5-fold greater than in controls; 1370.0â±306.2 and 269.3â±214.5 pg/ml respectively) with further increases reaching a peak on day 7 (1723.1â±127.6 pg/ml). on day 20 tgf-beta1 decreased to levels less than on day 2, but was still greater than in healthy controls (1265.3â±369.8 pg/ml). in diabetics, concentrations of tgf-beta1 on days 2 (939.7â±155.2 pg/ml) and 7 (965.8â±150.4 pg/ml) after mi were similar to diabetics without mi (724.6â±233.5 pg/ml). only on day 20 was tgf-beta1 increased to levels (1502.8â±285.6 pg/ml) which were 2 fold greater than in diabetics without an mi. thus, in diabetic patients serum concentrations of the active form of tgf-beta1 are much greater than in non-diabetics. mi in patients with diabetes mellitus is associated with a reduced and significantly delayed increase in tgf-beta1. conclusion: tgf-beta deficiency may be a factor associated with low activity of tissue reparation after mi in diabetic patients. introduction helicobacter pylori (hp) is the most common gastrointestinal infection worldwide, but only 10-15% of those infected develop chronic gastritis or peptic ulcer disease. the pathogenesis of ulceration, mechanisms of hp lifelong persistence in gastric mucosa and local immune disturbances induced by this infection are well known, but the mechanisms of resistance and elimination of this infection have not been extensively studied. most study is based only on phenomenological findings, such as absence or low hp colonization in subjects spontaneously producing high levels of il-2. the aim of this investigation was the analysis of the efficacy of the recombinant interleukin (ril-2) roncoleukin (biotech, russia) in treatment of hp-associated gastric ulcer disease. methods 108 patients were randomly divided into two groups. the first group of patients was treated with standard therapy including of two antibiotics (claritromycin and amoxicillin), proton pomp inhibitors and h2 receptor antagonists. patients of the second group were treated with the same therapy, but instead of antibiotics they received 0.1 mg roncoleukin into four to six areas submucously using a gastroscopic method and 0.4 mg roncoleukin dissolved in 400 ml of 0.9% nacl with 4 ml 10% human albumin infused intravenously. this procedure was performed three times at an interval of 72 hours. results immunological findings demonstrated that roncoleukin results in an increase of cd25+, hla-dr+ and cd16+cd56+ cell levels. there was an increase in the serum concentrations of il1 (3 fold), il6 (4 fold) and ifn (more than 20 fold) while the level of tnf and il8 profoundly decreased. one month after the end of treatment, the group treated with ril-2 had hp eradication achieved in 95.4% in comparison to 81.5% of the control patients. in the ril-2 treated group, the ulcer epithelization period was 10.79â±0.46 days while in the normal treatment control group it was 35.23â±1.58 days (p<0.001). conclusion immunotherapy with ril-2 is a more effective method of treatment of helicobacter pylori-associated gastric ulcer disease when compared with traditional methods of treatment employing only antibiotics. introduction the role of different cytokines and the growth factors is now appreciated in progression of essential hypertension. the participation of et-1 and tgf 1 in pathogenesis of essential hypertension especially in the process of fibrosis, hypertrophia of vascular smooth muscular fibers, and cardiomyocytes, and the activation of renin-angiotensin system is now recognized, in addition to effects on myocyte cultures. the aim of the investigation was the study of serum et-1 and tgf 1 levels in patients with essential hypertension. materials and methods 60 patients with essential hypertension (40 males and 20 females) with average age 54.0 â± 5.3 years were studied. all patients suffered from left ventricle hypertrophy documented by echocardiography. the control group consisted of 20 healthy volunteers similar to the investigated patients in sex and age. in all patients the serum concentrations of et-1 and tgf 1 were determined using elisa (biomedica, biosource). results an increase in the serum concentrations both growth factors were noted in the studied group when compared with the control group. the average concentration of et-1 in patients with essential hypertension was 0.64 (0.32-0.91) pmol/l. the level of et-1 in the control group was 0.1 (0.05-0.17) pmol/l (p=0.04). the concentration tgf 1 in essential hypertension patients was 224.2 (125.4-314. 3) pg/ml and in control group was 68.2 (42.5-81.8) pg/ml (p=0.02). there was a positive correlation between the concentrations (spearmen's rank coefficient of correlation was 0.42; p=0.01). con-clusion the increase of the serum concentration of growth factors et-1 and tgf 1 and their co-influence in patients with essential hypertension, suggests a role of these growth factors in the pathogenesis of arterial hypertension. u. kaza 1* , c. lauter 2 , 1. bloomfield hills, mi; 2. royal oak, mi. introduction: few studies have examined the referral patterns for allergy and immunology inpatient consultations in a community hospital. consequently, an invaluable part of physician and housestaff education is missing. our objective was to examine the number of inpatient allergy and immunology consultations, the reasons for consultations and the outcome of the patients in order to improve physician education. methods:we performed a retrospective chart review of all inpatient allergy and immunology consultations in the years 1996-1997 and in 2002-2003 to determine the reasons for consultation, the recommendations made and if they were followed and the outcomes of the patient. results:we reviewed a total of 408 inpatient allergy and immunology consultations. in the 1996-1997 time period 26% of inpatient consults were for asthma, 22% for drug allergy, 12% for rash. in the 2002-2003 time period 25% of inpatient consults were for rash, 21% for drug allergy, 16% for asthma. the top three reasons for consultations remained the same although the order changed. consultations for immune deficiency, angioedema and rashes increased, whereas consultations for asthma and allergies decreased. there were a total of 202 consultations in 1996-1997 and 206 in 2002-2003 . the number of consultations remained the same despite an increase in overall number of hospital admissions from 44, 677 in 1996 to 58, 348 in 2003 . in greater than 95% of consultations, allergists' recommendations were followed. in both of the time periods studied, greater than 70% of patients improved, with less than 9% having no improvement, in the remainder of cases improvement was not applicable. conclusion:in conclusion, we believe that identifying the reasons for inpatient allergy and immunology consultations and examining the most common recommendations, as well as the outcomes of patients will be a valuable guide in the education of our physicians. by incorporating this information into grand rounds and resident conferences, physicians will benefit from learning about when an allergist can be helpful and how to manage some of the more common allergic and immunologic problems in patients that are hospitalized. the high percentage of providers who follow the advice of allergists indicate that allergists have a great deal of educational value to offer other physicians. while complementary and alternative medicine (cam) has generally experienced increased popularity, its utilization by allergy/asthma patients remains uncertain. our private allergy practice surveyed the use of cam in allergy/asthma patients in 1998(1). using a similar questionnaire, we assessed the current interest in cam with our allergy/asthma patients and compared the data to our 1998 survey. we analyzed 103 completed questionnaires from 113 sequential surveys administered. the results were compared to 113 questionnaires reported in 1998. they indicated that in both study periods (1998 & 2004) , the majority of patients wanted to discuss cam (65 and 69% respectively). an equal number (18%) in each study period discussed cam with their primary care provider. sixteen percent (16%) of our respondents sought a cam practitioner for general medical needs in 1998 vs. 19% in 2004. however, there was an increase from 4% to 10% of our patients seeing a cam practitioner for their allergies and/or asthma from 1998 to 2004. sixty-two percent (62%) would like to consider pursuing cam through our allergy spe-cialty practice or other provider. when asked regarding preferred treatment, 62% stated combination traditional with cam, 8% preferred traditional only, 3% cam only, and 27% did not know/doctor s choice. more patients are now seeking chiropractic care (36% to 52%) compared to our 1998 results. acupuncture was the first choice cam modality at 48% in 2004 surpassing vitamin/mineral therapy in 1998. currently, the second and third choices were vitamin/mineral therapy and deep tissue massage. while these numbers were small, we were impressed that currently 10% (two and a half times more since 1998) of patients in our practice were seeking cam allergy/asthma care from outside of our practice. these results demonstrated that more than half of our patients were interested in pursuing traditional with cam options within our office. given this trend, we have begun discussing the concept of integrative allergy, which to us means integrating evidenced-based cam modalities within our traditional allergy/asthma practice. (1) introduction: clinical immunization knowledge is complex and demands ongoing training. nationally, basic immunization and vaccine safety education is limited within traditional medical, nursing, and provider education. project immune readiness (pir), a peer-reviewed, web-based, interactive course, was developed in response to this deficit and the need for standardized resources to provide initial and sustainment training for safe and effective immunization services. it is designed for medical personnel with diverse educational preparation. currently, pir offers 21 course modules addressing 42 hours of instruction on specific vaccines, their respective diseases, and general information on immunization healthcare and vaccination procedures. methods: users completed a pre-test (establishes baseline knowledge), an interactive module, followed by a post-test (to observe change from baseline) for each course in sequence. anonymous user and score data were collected as part of a quality assurance and course validation process. learning gain indices (lgi) were calculated based on average mean pre-test and post-test scores for each module lgi of all modules demonstrated substantial increases in user vaccination knowledge. comparing pre and post-testing is an effective method to assess learning gains. the findings support pir as a successful and valid distance-learning tool that establishes and documents core knowledge of medical personnel administering vaccinations. further research is needed to assess the effectiveness of knowledge acquisition and retention, in addition to variance in vaccine delivery after training. this approach to learning may have value as a resource that supports smallpox and influenza pandemic emergency preparedness plans for just in time training. introduction: variances from practice guidelines for the prescription of auto-injectable epinephrine are well documented among practicing physicians, families, and patients. effective patient education requires provider competency. the current study was designed to survey resident physician perceptions regarding auto-injectable epinephrine education, use, and patient education requirements. methods: residents from primary care disciplines at a tertiary care medical center were invited to complete a voluntary, anonymous questionnaire. a total of 58 surveys were distributed and returned: 22 emergency medicine, 11 family practice, 9 internal medicine, and 16 pediatric residents completed the questionnaire. due to the small sample size, responses from physicians in various disciplines were reviewed as a whole. results: 40 respondents (69%) reported that they had previously prescribed auto-injectable epinephrine for allergic emergencies. the majority (63%) of these prescribers reported that their training was inadequate. 14 respondents (35%) reported no training, while 11 respondents (28%) reported that their training was less than that needed to ensure proficiency. 15 respondents (37%) reported that their training was adequate to ensure proficiency. none reported expertise. only 7 of 40 prescribers (17.5%) reported that either they or their staff always demonstrated proper medication use to the patient. interestingly, 2 of these 7 providers reported they had not been trained on proper use. the table below summarizes resident training and patient education practices. additional physician knowledge deficits included the proper site of medication administration, the proper interval for replacing medication, and the proper place for medication storage. conclusions: of the residents surveyed, who have previously prescribed auto-injectable epinephrine, 63% identified training deficiencies. only 17.5% of prescribers reported that the standard of care requirement to demonstrate proper medication use was always met. there is a clear need to improve auto-injectable epinephrine education in all residency training programs. r. bloebaum 1* , r.k. calabrese 2 , m. 1. houston, tx; 2. new york, ny. introduction: pneumocystis carinii pneumonia (pcp) is a major cause of morbidity and mortality in patients with aids. adverse reactions occur frequently to the most effective medication for both the prevention and treatment of pcp, trimethoprim-sulfamethoxazole (tmp-smx). we looked at the immediate safety and efficacy of three protocols for desensitization in aids patients. methods: by retrospective chart review, we identified 49 patients with aids who had experienced previous mild to moderate hypersensitivity reactions to tmp-smx and required desensitization. patients received one of three desensitization protocols based on illness severity or ward attending preference: a 6-hour intravenous (iv) desensitization, an 8-day oral desensitization, or a 10-day oral desensitization. results: of the 49 patients that received desensitization, 38 (77.5%) completed successfully. of these, 33 subjects had no reaction during the desensitization process; however, seven of these subjects were on steroids for treatment of other diseases. the remaining five successful patients had mild reactions which were treated symptomatically with acetaminophen, antihistamines or both. eleven patients failed to complete the desensitization: six stopped by the attending physician and four dropped out voluntarily. one patient expired during desensitization from extensive disease complications related to the admitting diagnosis. all protocols were equally successful when comparing the immediate success rates, 6/7 (86%) of the 6hour protocol, 4/5 (80%) of the 8-day protocol and 28/37 (75.7%) of the 10day protocol. the 6-hour iv desensitization protocol was most frequently used in the intensive care unit on critically ill patients. two of these patients, counted as successfully desensitized, died 5 and 28 days post protocol completion secondary to extensive comorbid conditions unrelated to the desensitization. conclusion: given the insignificant differences between the success of the 6hour iv desensitization and the oral desensitization protocols, we believe that either may be used effectively. further, in patients with mild to moderate hypersensitivity reactions to tmp-smx, an oral desensitization protocol may be used safely in the outpatient setting if given appropriate lab follow up. a. morales * , e. gonzalez, a. contreras, d. lopez, g. lopez, mexico city, mexico. introduction in 1966 davis describes job syndrome in two women, in 1971 dr buckley reports two children, being known as hyper-ige syndrome (job's syndrome or buckley's syndrome). defined as a primary immunodeficiency, dominant autosomic, characterized by multi-systematic alterations (immunological, skeletal, dermal and dental). it's diagnostic criteria are levels of ige 2000 ui/ml, chronic dermatitis, recurring respiratory infections, cold abscesses, pneumatoceles, infections caused by candida, and finally craniofacial alterations. on another front, extraordinary high levels of ige have been reported in patients with allergic illnesses that increase the risk of anaphylaxis, but do not have the job's syndrome criteria. objetive to determine if allergic patients with ige levels higher than 2000 ui/ml have diagnostic of job's syndrome. material and methods a retrospective revision was realized from may 2001 to april 2004 in files of 27 patients treated in allergy services at the instituto nacional de pediatria with a total ige greater than 2000 ui/ml, by means of a page with recollected dates. results nine women and 18 men were included with an age range of 3 to 18 years, and an average age to 9 years; 22 (81.5%) were diagnosed with allergies; of which 55.6% rhinitis allergy, 51.9% asthma, and 40.7% topical dermatitis of which co-existed in patients. 51.9% presented hereditary antecedents of atopic. the cutaneous tests were positive in 11 (40.7%) with a greater reactivity of dermatophagoids. one syndrome of hyper ige was detected. others diagnosed were found as not allergic were hunter's syndrome and toxocariasis. conclusion there are patients with allergies that have total levels of ige as elevated as 49, 560 ui/ml without correspond to job's syndrome. by which a multi-allergic clinical entity is proposed with levels greater than 2000 ui/ml. introduction home monitoring of lung function in asthmatic patients is used extensively in both clinical and research settings, however, little attention is given to device quality control. objective the purpose of this study was to determine the accuracy, precision and usefulness of the airwatch system (enact health management systems, palo alto, ca, usa). methods the subjects included in this study were submitted to spirometry following american thoracic society guidelines (ats 1995), using collins gs 4g pft system. afterwards, peak expiratory flow rate (pef) and forced expiratory volume in one second (fev1) were determined using airwatch. fev1 and pef measures from both devices were compared, by using two sample t-test and pearson correlation coefficient. results a total of 115 patients (75 females) were enrolled, and their mean age was 43.7 years (9 to 76 years). fev1 measures ranged from 0.54 to 5.81 l (mean 2.43 l), and from 0.62 to 7.44 l (mean 2.51 l), in collins and airwatch, respectively. pef ranged from 107 to 871 l/min (mean 384 l/min) in collins and from 61 to 794 l/min in airwatch (mean 353 l/min). significant difference was noted for pef measures (p< 0.05 and pearson correlation r= 0.61) between the two devices; however, we did not observe this difference when fev1 measures were concerned. regarless the degree of obstruction (high or low flow rates), these results did not change. conclusion airwatch showed great utility for fev1 measures when compared to collins spirometer. although airwatch is able to assess lung function at home, on a daily basis, it is not reliable for pef measures. introduction: epidemiologic data show that poorly controlled asthma is a serious public health problem. the degree of implementation of the naepp guidelines in primary care practice remains to be defined. the objective of this survey was to determine if introduction of an assessment tool into primary care practices along with a specially designed program to implement the guidelines would improve diagnosis and therapy. methods: the asthma care network (acn), a program designed to assist healthcare providers in the assessment and management of their patients with asthma, employs a team of specially trained respiratory care associates (rcas), 100 rns and rts, who visit primary care offices to inform staff about various components of the naepp guidelines and assist in their implementation. .a total of 4901 primary care providers in 2876 sites were recruited as part of the acn program. data from more than 60, 000 patient visits were collected and analyzed between march 2002 and january 2004. the program assessment tool surveyed asthma control and medication prescribing patterns. outcome measures included degree of symptom control, limitation of activity, sleep disruption, use of rescue medication and utilization of urgent care services. these data were collected on an office visit assessment form (ova) completed by both patient and physician. the rcas provided information, education, device training in the use of inhalers and spacers, and a ce course for the staff discussing pathophysiology, assessment and management of asthma. results: a total of 60, 248 ova forms were completed. among all patient including adults (older than 18 years of age) and children (<4-17 years of age), 74% (range 69% to 81%) reported symptoms consistent with lack of asthma control. approximately 70% of the survey group had more than 2 markers of uncontrolled asthma. as a result of this assessment, controller medication use increased by over 30%, 52% of which was an ics-containing medication. conclusion: the information provided to the primary care health care providers resulted in a considerable increase in prescription of controller therapy, and in particular, increased use of ics controller medication consistent with naepp guidelines. background: patients with allergic rhinitis (ar) demonstrate symptoms of allergy to fruits, vegetables and nuts in 48-72% of cases. oral allergy syn-drome (oas), typical for hypersensitivity to plant food, is based on cross-reaction of pollen-allergen specific immunoglobulin e (ige) antibodies with homologous food proteins. the production of th1 and th2 cytokines in allergic rhinitis patients with or without sensitization to food (fruits and vegetables) allergens was assessed. methods: fifty five patients aged 18-38 years with allergic rhinitis were observed. group i -20 patients with ar; group ii -35 patients with ar and oas. sensitivity to pollen allergens was tested by skin prick tests. the allergic reaction to food in patients with oas was proved by a positive history of oral symptoms caused by eating fruits and vegetables and a positive skin prick test with respective food allergens. blood eosinophil counts and total ige levels were determined during the peak of allergic rhinitis symptoms. il-5, il-10 and -interferon levels were measured by elisa. results: 24.5% of patients were sensitized only to grass pollen, 23.3% only to tree pollen and 52.2% reacted to pollens of grasses, trees and weeds. in patients with oas, skin tests were more often positive to birch (57.8%), alder (46.3%), and mugwort (26.7%). the most common food products implicated in oas were hazelnut (69.3%), apple (29.2%), carrot (16.4%), and peanut (12.7%). the allergy to fruits and vegetables was confirmed by positive prick test in 78.4%. during the season blood eosinophil count and total ige levels were elevated in all patients. there was an increase in the production of il-5 to 187.3â±5.4 pcg/ml in group i and to 221.5â±6.2 pcg/ml in group ii (nor-mal=74.3â±3.3 pcg/ml). the levels of il-10 increased to 186â±12 pcg/ml in group i and to 197â±10 pcg/ml in group ii (normal=5.8â±0.25 pcg/ml); the level of -ifn decreased to 287.6â±7.4 pcg/ml in group i and to 272.6â±5.2 in group ii (normal=331â±35 pcg/ml). after sit with pollen allergens the clinical manifestations of allergic rhinitis and oas decreased in 84.6% of patients. conclusion: allergic rhinitis patients' sensitivity to food allergens may cause oas in these patients associated with increased functional activity of th2 responses. patient knowledge and improvement with aller-gen immunotherapy. c.c. randolph * , waterbury, ct. introduction: there is no consensus on objective parameters for improvement in immunotherapy. similarly little is known regarding patient knowledge of immunotherapy. utilizing two published questionnaires (1-2), we assessed clinical improvement based on symptom and medication scoring and knowledge of immunotherapy. methods: the charts of 219 patients of an estimated 530(41%), 109(50%) with allergic rhinitis only and 116 (53%) with concomitant asthma, were retrospectively or prospectively reviewed who had been on immunotherapy to inhalants for 6 months to 6 years, mean 2.7 years, age range 7y-64y, mean 25y, 108 male(49%), 111 female(51%) with 213 caucasian (97%), 2 oriental (1%) and 4(2%) afroamericans .they completed symptom and medication survey (1) every 6 months with range of improvement using a decline in likert scale (+)20 to (-)104, mean 24. 186 (85%) indicated improvement in their symptoms and/or medication .111(50%) completed (2) a 7 question survey of knowledge of immunotherapy. there were 7 questions regarding the outcome of immunotherapy, the years to onset of immunity, the duration until onset of immunity, the danger of immunotherapy and the extract in the vial. the correct responses were recorded to 2/7 (2/111=1.8%), 11(9.9%) 3/7, 19(17%)4/7, 10(9%)5/7, 18(16%)6/7.39(35%) had a perfect response to all questions. 12(11%) had no correct responses. conclusion: the majority of immunotherapy patients improved (85%) by symptom and medication scoring over the mean of 2.7 years but only 35% had complete knowledge of the rationale for immunotherapy. further education and repeated surveying of patients on immunotherapy to assure comprehensive knowledge of immunotherapy and achieve better outcomes is recommended by this investigation. as is unique in this study symptom and medication scoring using the rhinitis /sinusitis questionnaire approved by the acaai and a comprehensive questionnaire assessing knowledge should be conducted periodically ie every 6 months to provide objective parameters for improvement. references: 1.santilli j, nathan r, glassheim j .patient receiving immunotherapy report it is effective as assesses by rhinitis outcomes questionnaire(raq) in private (42)) is a protein involved in the parasite invasion of host erythrocytes and is a leading vaccine candidate for the erythrocyte stage of malaria infection. an increasing number of vaccine clinical trials are being undertaken using various formulations of msp-1(42). comparison of humoral responses among these trials has been limited by the lack of a universal reference standard for specific antibody. the purpose of this study was to develop a human reference standard for msp-1(42) antibody measured in absolute quantity units that could facilitate comparison of interstudy vaccine response. method: we formulated the reference standard by pooling human plasma samples known to contain high titers of msp-1(42) antibody. the specific antibody within the pooled plasma was captured by msp-1(42) adsorbed to nickel resin in a process of immobilized metal affinity chromatography (imac). the intact msp-1(42) antibody-antigen complexes were separated from the nickel resin and total igg in the complexes measured by enzyme-linked immunosorbent assay (elisa). results: our antibody quantitation method yielded a concentration of 48.3 mcg/ml of msp-1(42) antibody in the reference standard. conclusion: the reference standard characterized in this study may be useful as a quantitative working standard for msp-1(42) antibody response in future vaccine clinical trials involving msp-1(42). this standardization may facilitate the clinical development of msp-1(42) as a candidate vaccine for malaria infection. background. specific immunotherapy (sit) is currently one of the most effective and widely used treatment methods of allergic diseases including asthma. efficacy of sit depends on the correct choice of patients, severity of asthma and patient's condition when the sit is begun. according to who recommendations, sit is approved for use in patients with mild to moderate asthma. methods. sit with a saline extract of house dust allergen was administered to 30 patients with mild persistent allergic asthma. injections were performed subcutaneously 2-3 per day. the course consisted of 6766 pnu of allergen and lasted 12-14 days. patients were repeatedly surveyed at 3, 6 and 12 months after sit was completed. dyspnea attacks occurring during daytime and at night were assessed, as was the influence of physical exertion on dyspnea and lung function, and also the number of utilizations of short-acting beta-agonists per day. pulmonary function measurements were performed as was assessment of concomitant allergic rhinitis. 50% of patients received treatment including cromones, and 30% utilized inhaled corticosteroids among whom 13.3% had a dose of 400 mcg per day and 16.7% 200 mcg per day. sit efficacy was assessed by clinical symptoms, pulmonary function measurements and amount of concomitant therapy received. results. the number of daytime dyspnea attacks reduced from 10.70 â± 3.40 per month to 1.20 â± 0.09 during the 3 months following sit, and 76.7% of patients reduced concomitant asthma therapy. at 6 months, dyspnea attacks increased to 2.90 â± 0.75 per month, still significantly less then prior to sit. nocturnal symptoms followed the same pattern, occurring 7.20 â± 1.62 per month prior to sit, 1.01 â± 0.01 per month 3 months after sit and 1.99 â± 0.25 per month at the end of the sixth month after sit. 26.7% of patients had no symptoms of bronchial obstruction during the 6 months after sit and their pulmonary function approached normal values, although 36.7% of patients returned to asthma therapy. nasal congestion decreased from 3.28 â± 1.20 points to 1.98 â± 0.08 (p<0.05), clinical improvement still present for 3 months after sit, but recurring at 6 months after sit. conclusion. sit may be an effective treatment method that improves both asthma and allergic rhinitis for more than 3 months following a brief course, allowing a decrease in the amount of symptomatic treatment. a safe therapeutic vaccine that can alter the allergic response to peanuts would serve a serious unmet medical need. peanut allergy responses are largely associated with downstream events related to antigen specific ige crosslinking of ige receptors and subsequent degranulation of mast cells and basophils. our clinical studies with ragweed have shown that linking immunostimulatory dna (iss) to allergens can decrease ige recognition of the allergen and generate an immunogen that generates protective th1 responses and reduces harmful th2 responses. to test this approach to peanut immunotherapy, we focused on the clinically relevant allergen, ara h 2, as a proof of concept. iss oligonucleotides were linked to ara h 2 at two different ratios: pic (2 iss per protein) and hpic (4 iss per protein). immunogenicity of pic and hpic was evaluated in c3h/hej female mice immunized twice with 5 ug of pic, hpic, or ara h 2. sera were analyzed for anti-ara h 2 igg1 and igg2a responses. spleens were harvested and ara h 2-specific ifng and il-5 responses were measured in vitro. mice were immunized with ara h 2 elicited predominantly igg1 and il-5 responses, indicative of a th2-type response. animals immunized with pic showed significantly enhanced igg2a responses and strong ifng responses, indicative of th1-type responses. hpic immunized mice elicited little antibody response, presumably due to iss blocking b cell epitopes, but did induce ifng responses. to assess allergenicity of pic and hpic, histamine release was measured in blood from peanut allergic donors treated in vitro with pic, hpic, and ara h 2. histamine release was detected at very low concentrations of ara h 2 (0. 01 ng/ml), 10-fold higher concentrations for pic (0.1 ng/ml) and was undetectable at concentrations up to 1000fold higher for hpic (10 ng/ml). an ige binding competition assay also confirmed reduction in allergenicity following the same trend for the iss-linked allergens. linking iss to ara h 2 increases th1 responses to the allergen, blocking ige recognition of epitopes on ara h 2. thus, iss-linked ara h 2 appears to be a promising candidate for a safe immunotherapy product for treating peanut allergic subjects. introduction: immunotherapy has been studied for its adverse effects in some sensitive patients as with worsening of therapeutic response in some amounting to withdrawal of the later. methods: in the allergy center therapeutic trials of immunotherapy(house dust, mixmite) had been undertaken since 1998, in therapeutic dose of 0.02pnu/ml, 0.2pnu/ml, 2pnu/ml, 20pnu/ml, 200pnu/ml2000pnu/ml, 4000pnu/ml(housedust), 0.01au/ml, 0.1au/ml, 1au/ml10au/ml 100au/ml 1000au/ml 2000au/ml(mixmite).patients age 2-65 years, both sex after diagnostic scratch/prick tests with appropriate antigenic preparations reported for local/systemic adverse effects the details of which were as under, results: please see the attached table for details, in some cases worsening of the existing allergic status was noted, which on analysis revealed initially a slow rise in the allergen -specific ige to be later on fol-lowed by rise of igg1 & igg4 & gradual fall of ige.only 1/100 patient could not complete immunotherapy for fear of adverse effects. conclusions: with utmost care/follow-up, no incidence of mortality outcome was reported from 1998to late 2003 the incidence of adverse effects were significantly lowered on pre-medication with anti-histamines significantly more with elderly than younger age. even with all these documented hazards the beneficial effects far exceeded the harmful effects. background: the prevalence of allergic disease in most human population is steadily increasing. seafood allergy is a serious food allergy, although hypersensitive reactions caused by seafood has long been know, biochemical and immunological studies on seafood allergies had only begun lately. shrimp and abalone are the most frequently reported causes early asthmatic response. objective: to investigate cross-reactivity of shrimp, abalone and derp1. methods: shrimp and abalone extracts were prepare from raw seafood. sera from 17 patients from hongkong were studied who had asthma after consumption of seafood. ige elisa analyses comfirmed the combined sensitization to shrimp, abalone and derp1. specific-ige elisa assays were accomplished for shrimp and abalone extracts inhibited by derp1 and derp1 elisa and immunoblot assays inhibited by shrimp and abalone extracts. results: elisa inhibition showed that most ige antibodies against shrimp and abalone were cross-reactive with derp1 and the same time, derp1 elisa was inhibition by shrimp and abalone extract. the elisa inhibition percent (%)of shrimp extract (gm:53.28%) and abalone extract(gm:36.75%) by derp1 were significantly higher than derp1 by shrimp extract(gm:26.64%) and abalone extract (gm:17.59%). (p<0.01). furthermore, and there was a significant correlation of elisa inhibition percent between shrimp extract, abalone extract and derp1 inhibited by each other; sds-page and immunoblot of shrimp and abalone is the 38 and 49kd allergen respectively. conclusion: this indicates that derp1 was the sensitive agent. shrimp, abalone and derp1 demonstrate significant cross-reactivity. these findings confirm that the primary crossreactive allergen of shrimp and abalone is the 38 and 49kd allergen respectively. b. sun 1* , a. wu 2 , n. zhong 1 , 1. guangzhou, china; 2. hong kong. background: the house dust mites (dermatophagoides farinae (derf) are a major source of aeroallergens implicated in the expression of atopic disorders, including asthma, allergic rhinitis, and atopic dermatitis . in particular, strong circumstantial evidence suggests that house dust mites antigens are important precipitating factors of asthma. many house duse mite allergens are proteases that can elicit airway inflammation by stimulating the release of cytokines in bronchial epithelial cells. objectives: we have investigated whether der f allergen proteases induced cytokine production from the epithelial cell line beas-2b. methods: cells were exposed to four different concentrations with serial additions of der f (0.02, 0.2, 2, 20ug/ml) were incubated for 24h to 96h. and compare with those without incubation of allergen. cytokine in the supernatants were assayed by elisa, reverse transcription?pcr was also performed. results: cells treated with der f allergen showed serial changes in the cohesiveness of the monolayer. there was a significant increase in the level of cytokine production compared with the untreaed sample. statistically significantly increased with addition of der f caused the release of il-6 and il-8 in time and concentration-dependent manner (p<0.05, respectively). levels of il-6 and il-8 were elevated 24 h and 48 h after allergen exposure, increasing with time, continued increased levels to be present of il-6 and il-8 in the supernatants at 72 h and 96 h. at the same time show the concentration dependence of induction of il-6 and il-8 expression as well as an increase in the expression of il-6 and il-8mrna. conclusion: hdm-induced airway inflammation may include der f-mediated release of inflammatory mediators, and the proteolytic activity of an allergen may stimulate the release of proinflammatory cytokines from human bronchial epithelium. suggesting that il-6 and il-8 production by bronchial epithelial cells may play a role in the pathogenesis of allergic asthma. the purpose of this study is to delineate the immune injury mechanisms that involved in the autoimmune inner ear disease by introducing plasmid dna encoding of th1 cytokines (inf-g) into the inner ear. b-tubulin is a microtubular protein which we found as an important autoantigenic in meniere's disease as well as other autoimmune hearing loss. hearing loss was induced in mice and guinea pigs when they are immunized with the tubulin molecules. autoimmune hearing loss could be the results of th1 cytokine responses from autoimmune injury. to test the hypothesis, guinea pigs were immunized with 200mg of tubulin in cfa and boosted once more. two weeks later, we introduced 100ug (5ul) of naked dna encoding inf-g was injected into the left side inner ear through round window. same volume of 0.1m pbs was injected into right side as control. abr was recorded before and after the injection. 15 weeks after the injection, the animals were sacrificed and temporal bones were examined with h-e and inf-g immunocytochemical staining. the ears injected with the plasmid dna-inf-g had an enhanced hearing loss (30 db), and degeneration of the spiral ganglion was found in these ears. however, the injection of the naked dna encoding inf-g did not change the expression of the inf-g in the inner ears. these results suggest that autoimmune hearing loss could be the result of th1 responses to inner ear autoantigens. -tubulin is an important molecule in the hair cells supporting cells within the sensory epithelium of organ of corti and found to be an auto autoantigen in autoimmune hearing loss including mã¨niã©re's disease. the object of the study is to induce hearing loss in mice with varying doses of antigen and evaluate the pathogenesis of autoimmune hearing loss induced by -tubulin in mice. mice were immunized with 100, 200 or 300 î¼g of -tubulin and hearing was evaluated by auditory brainstem responses (abr) and distortion product of otoaccoustic emission (dpoae). all mice had hearing loss by abr and dpoae tests and morphological study of temporal bone showed spiral ganglion degeneration and tunel staining positive cells were noted in these immunized mice. thus this study showed that -tubulin is an autoantigen for hearing loss in animal model as in human autoimmune hearing loss patients including mã¨niã©re's disease. supported by nih r0dc005010-01 introduction: oral polio vaccination (opv) in the united states is currently being replaced with inactivated polio vaccination (ipv) given parentrally. while past studies have looked into the relationship of vaccination and asthma prevalence, none have investigated this relationship with regards to vaccination route namely orally versus parentrally. this study investigates the relationship between vaccination rates for the live attenuated orally administered polio vaccine and parentrally administered vaccines(dtp, mmr)and two potentially dependent factors; asthma prevalence rate and asthma-caused death rate. methods: we looked at data from the national center for health statistics yearly publications of health, united states (1983 -1999 and the morbidity and mortality weekly report surveillance summaries . two databases were compiled to cover the 0-4 age population in the united states since this is the primary period of childhood vaccination. one database contained information for asthma related deaths and vaccination rate (dtp, mmr, opv) covering the years 1970-1999 and the other database compiled information for self reported asthma prevalence and vaccination rates(dtp, measles, rubella, opv) covering the period 1983-1999. a t-test was used for statistical analysis. results: statistically significant correlation was found between vaccination rates and asthma prevalence rates. data for dtp (p = 0.012), measles (p = 0.024), and rubella (p = 0.023) indicated a statistically significant positive correlation with asthma prevalence. the oral polio vaccine was the only one of the vaccines that failed to display a significant relationship with asthma prevalence rates (p = 0.133). statistical analysis proved that a correlation between vaccination rates of united states children ages 0-4 and asthma-caused deaths was insignificant (p > 0.05). conclusions: the opv, which is administered orally rather than parentrally, displayed no relationship with asthma prevalence. this could be due to the fact that live attenuated orally administrated polio vaccine may induce mucosal immunity, simulating a normal pathogen route of entry into the body. childhood vaccination had no relationship with asthma-caused death rates. a.s. alfrayh * , riyadh, saudi arabia. introduction: heredity plays a major role in asthma and other allergic diseases, mechanisms underlying the inheritance of these disorders are poorly understood. this study therefore analyzed the risk conferred by family history of asthma and atopy for having childhood asthma. methods : a total of 1601 children between 1-16 yrs selected randomly in three cities in saudi arabia ( hail, taif and gizan )in 1995-1996 . the questionnaire which is similar to the one used in the international study of allergy and asthma in childhood isaac. were self administerd under medical supervision.apart from the demogrphic details, the questionnaire included questions on symptoms and physician diagnosis of asthma, rhinitis, eczema and family history of these conditions. the family members were grouped as immediate family and relatives. asthma and atopy were defined as ever having had physician diagnosis of such conditions information was also available about exposure to cigarette somke at least one member was a smoker in the household and having pets. relative risk for developing asthma was estimated in terms of odds ratio by bivariate analyses using chi square test and p value was considered significant when less than 0.05. results : history of asthma in the immediate family and relatives conferred a 4 fold and 3 fold risk for development of childhood asthma odd ratio ( or )=4.2, 95% confidence interval(ci)=3.3 to 5.5, p=0.00001 and or=3.3, 95%ci=2.5 to 4.3, p=0.00001 respectively. rhinitis in immediate family and the relatives was associated with 3 folds increased risk for childhood asthma or = 3.0, 95% ci = 2.2 to 4.0, p=0.0001 respectively whereas history of eczema conferred over 3 folds risk or=3.4, 95% ci = 2.4 to 4.7, p=0.00001 for childhood asthma when present only in the immediate family. history of eczema in relatives was not associated with any risk. of the environmental factors, exposure to cigarette smoke conferred 2 folds risk of developing childhood asthma or = 2.6, 95% ci = 2.0 to 3.3, p= 0.0001, whereas exposure to pets was not a significant risk foctor. conclusion : presence of asthma and atopy either in the biological parents or relatives constitute a significant risk for childhood asthma.paricularly in the presence of evironmental risk factors. the murine local lymph node assay (llna) has been developed as an alternative to guinea pig models for the assessment of the contact sensitization potential. however, there is a need to develop a non-radioisotopic endpoint for the llna, because of the radioisotopic method's requiring the use of special facilities. in this study, we investigated to evaluate the lymphocyte subpopulations in the lymph node cells following allergen and irritant treatment. female balb/c mice were treated by the topical application on the dorsum of both ears with sensitizers, 2, 4-dinitrochlorobenzene (dncb), toluene diisocyanate (tdi), and a-hexylcinnamaldehyde (hca), and an irritant, sodium lauryl sulfate (sls), once daily for three consecutive days. the lymph node (ln) cells were harvested 72h after the final treatment. phenotypic analysis of lymphocytes subsets was performed with a flow cytometry. the allergens dncb, tdi, and hca and an irritant, sls increased cell number compared to the vehicle. there was an increase in the percentage of b220+ cells in mice treated with dncb and tdi compared to the vehicle control, but not in those treated with sls. mice were treated with dncb, hca and tdi showed a preferential increase in the percentage of b220+cd40+ cells compared with vehicle and irritant-treated mice. there was an increase in b220+cd86+ cells of mice treated with dncb, tdi and hca, but no significant increases were observed in mice treated with sls. mice were treated with dncb, and tdi showed an increase in the percentage of b220+cd23+ cells compared with vehicle and irritant-treated mice. these results suggest that analysis of b cell activation marker, cd40 on b cells may be useful in differentiating allergen and irritant responses in the draining lymph nodes of chemically treated mice. m. frieri * , y.c. huang, east meadow, ny. introduction: nitric oxide (no) is an important biomarker for inflammation in airway epithelial cells and in exhaled breath of asthmatic subjects. we have previously demonstrated no production in antigen-stimulated human bronchial epithelial cells and an effect of omalizumab (monoclonal anti-ige antibody) on no production in those cells [leyko bt et al. j allergy clin immunol 2004; 113(suppl 193) :a668]. in this study, we investigated the potential role of ige and its receptors on a549 cells by characterizing the effect of omalizumab on antigen, egf, and il-1 stimulation of a549 cells in a medium containing atopic serum. methods: a549 human alveolar epithelial cells were stimulated with 100 iu/ml of il-1 , 10 î¼g/ml of ragweed (ra), 1000 au of dust mite (dm), and 40 ng/ml of egf, and exposed to either 10 -7 m budesonide or 0.1 î¼g/ml omalizumab for 6 or 24 hours. no production was measured in duplicate by a highly sensitive elisa. results: omalizumab but not budesonide inhibited no production at 6 hours in a549 cells stimulated with il-1 (17-13î¼m, p<.05)and il-1 +dm (18-14î¼m, p=.08), but not with ra alone. however, at 24 hours omalizumab and budesonide each significantly inhibited no production stimulated by il-1 (29-9î¼m; 29-17î¼m), il-1 +dm (22-12î¼m; 20-14î¼m), and egf (17-9î¼m; 17-13î¼m) (p<.05). conclusion: no production is a marker for inflammation. omalizumab demonstrated a significant anti-inflammatory effect in distal alveolar cells by inhibiting no production stimulated by antigen, il-1 , and egf in a medium containing atopic serum. as persistent inflammation in asthma may play a role in airway remodeling, treatment with omalizumab may have a beneficial effect on chronic airway inflammation in patients with asthma. oral tolerance trigger regulatory mechanisms able to down-modulate antigen-specific t and b cell response. to address the lasting effect of several regimens of oral tolerance to ovalbumin, in naive or antigen primed mice, b-cell function has been focused. furthermore, we analyze specific antibody response up to eight months of post-immunization, proliferative response, b7 (cd80/cd86) expression on b cells and t cell ctla-4 involvement in oral tolerance. a/sn mice were immunized by intraperitoneal route with 50î¼g of ova/0, 1 mg-alum and boost 10 days after priming (dap). ova feeding was done with 25mg at different days before or after antigen priming. in others protocols, mice were fed twice, before and after priming with a total of 50mg of ova. all groups were boosted at 60 or 120 or 180 or 240 dap. the results showed that only mice fed at naive status and those fed twice before and after immunization demonstrated a long lasting of ige ab response inhibition up to 8 months of immunization. these mice showed a marked inhibition of antigen-specific proliferative response that was restored with anti-cd28 mab in vitro stimulation. evaluation by flow cytometry of spleen cells cultured for 48 hours upon ova stimulation, showed an important decrease of b 7.2 expres-sion on b cells of naive fed mice, which remained inhibited until 8 months of immunization. after addition of anti-ctla-4 mab an enhancement of b7.2 expression was detected on b cells of naive fed mice. ctla-4 molecules expression on cd4+ t cells of naive fed mice remained unchanged following ova stimulation while a peak of expression was detected at 96h of ova stimulation in control group. this finding reinforce the t cell anergic status of naive fed mice, due to the less cell division and consequently a low rate of cd4+/cd44high activated cells. the results showed that antigen feeding before immunization induce a long lasting anergy mediated by an impaired t-b cell cooperation and ab production due to the decrease of costimulatory molecules expression on b cells and negative signaling effects by ctla-4 expression. introduction: vascular endothelial growth factor (vegf), basic fibroblast growth factor (bfgf) and fibronectin (fn) can promote angiogenesis, a putative component of airway remodeling. (s)-albuterol can exacerbate airway hyperresponsiveness, bronchospasm and release pro-inflammatory cytokines from small airway and smooth muscle cells. our study evaluated the effects of (s)-albuterol ((s))-and (r)-albuterol ((r)) on secretion of these factors on normal human lung fibroblasts (nhlf) and myofibroblasts (myonhlf) in the presence or absence of tgf 2, il-1 , or allergens. methods: nhlf were stimulated to differentiate to myonhlf with 1000 pg/ml tgf . dose-dependent effects of (s) and (r) [10 -8 to 10 -4 m] were evaluated for secretion of vegf, bfgf and fn by nhlf and myonhlf with and without 1000 au/ml d. pteronyssinus (dp), 1000 pnu/ml ragweed (ra), 100 u/ml il-1 , or 1000 pg/ml tgf 2 into serum-free media (its) at 37 o c with 5% co 2 collected at 24 hr and assayed by elisa. results: in nhlf the following was observed: vegf secretion was 2-fold higher with 10 -7 m (r) relative to (s), p<0.05; bfgf secretion was increased 50%-100% by 10 -5 m (s) relative to (r), p<0.05. a lower concentration of (s) (10 -6 m) in the presence of either dp or il-1 caused a 2-fold increase in secretion of bfgf relative to (r), p=0.02. in the presence of myonhlf the following was observed: 10 -7 and 10 -5 m (s) caused a 50%-100% increase in secretion of fn relative to (r). at 10 -7 m (s), this effect was further increased with the addition of il-1 , p=0.022). conclusion: in a dose-dependent manner, (s)-albuterol stimulated the release of bfgf and fn by nhlf and myonhlf, respectively. this was enhanced by dust mite and/or il-1 , potentially contributing to the matrix remodeling observed in chronic asthma. vegf over-expression can have a protective effect against chronic hypoxia and can recruit immune cells to the alveoli. increased vegf by (r)-albuterol could contribute to such an effect in vivo in asthmatics. bfgf, in bal and sputum of asthmatics, and fn which contributes to subepithelial fibrosis, can promote angiogenesis. increased bfgf and fn by (s)-albuterol could be detrimental over time by enhancing matrix deposition and remodeling in a subset of asthmatics. o. ozdemir 1* , c. moore 2 , y. ravindranath 1 , s. savasan 1 , 1. detroit, mi; 2. new orleans, la. background: mast cells (mc) have been shown to demonstrate natural cytotoxicity against mouse fibrosarcoma cell line in culture when incubated for 24-48h. this effect has been postulated to be mediated through soluble and/or membranous tnf-. more recently; fasl, mc chymase and serine protease granzyme h with its chymase activity were proposed as mediators of mast cell-mediated cytotoxicity. thus, both 'granule-exocytosis' through chymase, granzyme h and soluble tnf-and 'death receptors' through membrane-bound tnf-and fasl pathways appear to be operative in this process. aims: following our earlier observations on long-term liquid culture-grown human bone marrow mast cell cytotoxicity against human leukemia cells in 24-48h co-incubation experiments, we investigated mast cell-mediated cytotoxicity against natural killer/lymphokine-activated killer cell-sensitive cells in short term (12h) cultures without any stimulation for the first time. methods: human bone marrow mononuclear cells were cultured in methyl cellulose supported with il-3, il-6 and scf. mast cell colonies that developed in six weeks were transferred to liquid medium and maintained for 18 weeks before experiments. cytotoxicity was investigated against k562, raji and daudi cells at 12, 24 and 48 hours of co-incubation by our established flow cytometric cell-mediated cytotoxicity assay. results: after 12h co-incubation, 61% (11% early apoptotic and 50% late apoptotic or necrotic death) and 29% (21% early apoptotic and 8 % late apoptotic or necrotic death) target cell kill was demonstrated in daudi and raji cells, respectively. daudi cell killing has stayed stable at 24h (67%; 27% early apoptotic and 40% late apoptotic). despite a small numbers of experiments, daudi cell kill was statistically significant at 12h (p:0.011) and 24h (p:0.011) compared to control. however, k562 cell elimination (18%) has not occurred until 48h. mast cell-daudi cell conjugates were seen on the wright/giemsa slides (figure) . conclusion: our results demonstrate that human mc can cause cell-mediated cytotoxicity against certain cells in relatively short-term. this further suggests possible contribution of 'granule-exocytosis' pathway to mc natural cytotoxicity, indicating a faster mc response in immune surveillance. o. ozdemir 1* , m. buyukavci 2 , y. ravindranath 1 , s. savasan 1 , 1. detroit, mi; 2. erzurum, turkey. background: the effect of melatonin (mlt) on cellular immunity has been controversial. recently, mlt has been demonstrated to activate t and nk cells through its membrane or nuclear high affinity receptors. it was also shown that pharmacological concentrations of mlt (>nm) could be cytotoxic against different human cancers. aims: our aim was to investigate the effect of mlt alone or in combination with il-2 on peripheral blood lymphocytes (pbl), lymphokine activated killer (lak) cell generation and its cytotoxicity. methods: pbl were cultured for 7 days in the presence of mlt at different concentrations (10 -3 , 10 -5 , 10 -7 m) with or without il-2 (100 u/ml). cell viability was determined by trypan blue exclusion test. cell-mediated cytotoxicity of lymphocytes/lak cells against k-562 and daudi cells was studied using our established flow cytometric cell-mediated cytotoxicity assay. results: although 10 -3 m concentration of mlt did not affect cell proliferation much on day 3, it significantly inhibited proliferation by day 7 (p<0.05) consistent with known anti-proliferative effect of mlt. 10 -5 and 10 -7 m concentration of mlt also mildly inhibited proliferation on day 3; however there was a minimal rebound with 10 -7 m concentration by day 7. consistent with the reported mlt-treated pbl's reduced response to mitogens, il-2 and mlt (10 -3 m) combination suppressed proliferation on days 3 and 7; however, with 10 -5 m mlt concentration pbl counts increased gradually from day 3 to 7. although mlt treatment alone did not enhance cell-mediated cytotoxicity, il-2 and mlt combinational treatment at both concentrations (10 -3 and 10 -5 m) increased it significantly compared to baseline activity (figure) . conclusion: il-2 and mlt combination at 10 -5 m concentration resulted in superior lymphocyte proliferation and lak cell-mediated leukemia cell kill. mlt-induced increase in il-2r-expression of pbl shown earlier might be the mechanism for our observations. mlt can be considered in immunotherapy as an adjunct to il-2 treatment. a.e. fusaro * , j.r. victor, c.r. oliveira, c.a. brito, e.a. futata, m. maciel, a.j. duarte, m.n. sato, sã£o paulo, brazil. the maternal exposure to allergens during pregnancy or even in postnatal period may influence the allergy onset to newborns, through antigen or antibody transmission. we sought to verify the effect of maternal antigen exposure before conception, during gestation or in the breastfeeding period on the offspring type i hypersensitivity response. female balb/c mice were immunized or not with ova extract/alum, boosted twice at 10th and 20 th and mated with normal balb/c male on the 21th day after sensitization (das). others groups of immunized mothers also received oral administration with ova along pregnancy, or non-immunized mothers received ova only during breastfeeding. offspring from immunized or normal mice were immunized intraperitoneally with ova at 25 do and boosted on the 10th das. the results showed a important decreased of tgf-levels in the amniotic fluid and milk from immunized mothers before mating in comparison to obtained from normal mothers. ova exposure during pregnancy of immunized mothers decrease significantly the transference of tgf-by breastfeeding, while both tgf-isoforms were founded at high levels in the amniotic fluid. similar levels of tgf-transference by placenta to the newborn was detected in both immunized mother groups. pups from mothers exposed with ag during pregnancy showed an increased spleen cell number, whereas did not produced il-2, il-4, il-10 e ifn-secretion induced by antigen neither altered responsiveness to anti-cd3 or mitogen. maternal ova-immunization induced a marked inhibition of spe-cific ige antibody response in the immunized pups, contrasting to the enhancement of ige responsiveness detected in the immunized pups from mothers which were exposed to ova only at postnatal period. these results showed that preconceptional immunization exert a protective effect on the offspring ige development and an exacerbation of ige responsiveness due to mother antigen exposure during breastfeeding. the findings suggest that rather than in utero antigen priming occurrence, postnatal period may contribute to offspring early life sensitization. financial support: fapesp and lim56-fmusp introduction: the reasons for the increased incidence of allergic diseases in westernized countries are still unknown. mercury is an important pollution factor to which humans are increasingly exposed. prior studies on the effect of mercury on mitogen stimulated human lymphocytes indicated a th2weighted immune response, but the results were inconsistent and difficult to reproduce. phorbol myristate acetate (pma) is a direct activator of protein kinase c, which has been shown to play a role in mercury induced il-4 production in animals. therefore we investigated the effect of mercury on pmaactivated human peripheral blood mononuclear cells (pbmc). methods: pbmc from 8 individuals were cultured for 4 days in culture medium containing pma and ionomycin in the presence or absence of mercuric chloride (hgcl2). il-4 and gamma-ifn concentrations were measured by elisa of culture supernatants. cell death and apoptosis were determined by 7-aad and annexin staining and fluorescence activated cell sorting (facs). cell-proliferation was assessed by 3h-thymidin-incorporation. results: after 4 days of culture, pma/ionomycin-stimulated a small amount of il-4 compared to untreated pbmc (1.7 +/-0.92 pg/ml versus 0.36 +/-1.0 pg/ml). however, mercury induced a more than 30 fold increase in il-4 production when added to pma-activated cells (57.4 +/-45.2 pg/ml, p<0.01). gamma ifn production was strongly increased in pbmc that were treated with pma/ionomycin (>3500 pg/ml versus 417 +/-1045 pg/ml in unstimulated cells) but dropped markedly in cells treated with mercury plus pma/ionomycin. in addition, mercury induced increased cell death, apoptosis and reduced cell proliferation. conclusions: hgcl2 strongly stimulates il-4 production in pma/ionomycin treated pbmc while cell viability and gamma-ifn production drop significantly. these preliminary results suggest that human exposure to mercury may be playing a role in the observed increased incidence of allergic disease in the industrialized world background: mast cells (mc) have been shown to induce natural cellmediated cytotoxicity in long-term (24-48 hrs.) in vitro assay systems. the cytotoxicity is mediated by at least two pathways: secretory via exocytosis of mc granules containing serine proteases such as granzymes, chymase and soluble tnf-and nonsecretory (cell-to-cell contact) via membranous tnfand fasl. chymase induces apoptosis in neonatal rat cardiomyocytes and human vascular smooth muscle cells. the objective of this study was to investigate mc mediated cytotoxicity against nk/lak-sensitive cells in short term (12 hrs.) unstimulated cultures. methods: human bone marrow mononuclear cells were cultured in methylcellulose supported with il-3, il-6, and stem cell factor. mast cell colonies developed at 6 weeks and were transferred to liquid imdm and maintained for 18 weeks. a flow cytometric cytotoxicity assay was used to determine cytotoxicity against daudi, raji, and k562 cell lines at 12 hrs., 24 hrs., and 48 hours. the controls consisted of cell lines without mast cells at 12 hrs., 24 hrs., and 48 hours. results: rationale: to establish the antibody response rate in children with recurrent infections and fully immunized with the pneumococcal 7-valent conjugate vaccine. methods: we have analyzed 39 patients referred to our clinic with recurrent infections despite complete immunization with the pneumococcal 7-valent conjugate vaccine for age, according to acip guidelines. we assessed the patients by checking their immunization status and the antibody titers to all 7 streptococcus pneumoniae serotypes included in the vaccine (4, 6b, 9v, 14, 18c, 19f, 23f) assessed by standardized elisa. the patients were assembled into 3 groups, a non-immunized group with laboratory data prior to the vaccine, and an immunized group consisting of responders and nonresponders according to their antibody titer (<1.3 or >1.3 iu/ml respectively). the data were analyzed using epi info and spss. results: the mean age was 3.3 years for non-responders and 3.8 years for responders. there was no significant statistical difference between the groups regarding age, race and sex. ten patients were identified who failed to respond to all 7 serotypes included in the pneumococcal 7-valent conjugate vaccine. there was no significant statistical difference between the non-immunized and the immunized nonresponders to all 7 serotypes. conclusions: we have identified a special immunological phenotype of specific antibody deficiency (sad) patients with normal total immunoglobulins and normal responses to protein antigens, but who failed to respond to conjugate pneumococcal polysaccharides. a. yates 1* , r. deshazo 1 , j. butler 1 , g. howell 1 , j. farley 1 , h. liu 1 , n. nanayakkura 2 , g.b.yi 1 , r. rockhold 1 , 1. jackson, ms; 2. oxford, ms. introduction: venom from s. invicta consists of 95% disubstituted piperidine alkaloids and is toxic to insects, birds and farm animals. recent reports of morbidity and mortality in elderly patients after massive fire ant stings suggest the potential for systemic mammalian toxicity. we evaluated the toxic responses to systemic administration of two structurally verified, synthetic s. invicta venom alkaloids, solenopsin a (trans-2-methyl-6-n-undecylpiperidine) and its cis-isomer, isosolenopsin a, in rats. methods: sprague dawley rats were anesthetized with isoflurane, paralyzed with gallamine, artificially ventilated and instrumented to record arterial blood pressure (bp; mm hg), heart rate (hr; bpm) and % change in left ventricular contractility (lvc; p/ t). in addition, a group of rats was chronically instrumented to record bp and hr while the animals were conscious and freely-moving. results: solenopsin a at 3 to 30 mg/kg iv dose-dependently lowered bp, hr and lvc. at 30 mg/kg iv, hypotension (-40â±12 mmhg), bradycardia (-27â±8 bpm) and decreased lvc (-41â±17 p/ t) were marked. isosolenopsin a, 15 mg/kg iv, produced responses similar to solenopsin a 15 mg/kg iv. solenopsin a 30 mg/kg iv elicited tonic-clonic convulsions and respiratory arrest in conscious, freely-moving rats. hematuria was seen with solenopsin a, but not isosolenopsin a. superfusion of a working, isolated, perfused rat heart with 10 um of solenopsin a elicited a marked, reversible decrease in lvc, and cardiac arrest occurred with 100 um of solenopsin a. conclusion: the results demonstrate that these alkaloids possess significant depressant activity on the cardiac and respiratory systems of rats. the neurologic and cardiorespiratory effects can account for lethality to small mammals in the wild, and may contribute to adverse cardiovascular effects noted in humans after massive fire ant stings. introduction: during asthma attacks, the ph of exhaled breath condensate (ebc) decreases two log orders (ph=5.0), returning to normal levels after corticosteroid therapy (ph=7.0). ion channels, once thought to participate only in the transport of ions, are now suspected of mediating airway inflammation in asthma as well. to determine whether allergen directly alters airway mucosal ph and ion function, we measured nasal ph and nasal potential difference (pd) before and after nasal allergen challenge (nac). methods: ten allergic rhinitic subjects (meanâ±sem age 28.3 yearsâ±2.9, 7 females) underwent a crossover, single-blinded, placebo-controlled study, where they were challenged with allergen (dust mite, grass, cat) and control diluent in two different occasions in random order via nasal spray. nasal ph was measured on the surface of nasal mucosa with a ph probe. nasal mucosa pd was measured between nasal mucosa and forearm skin. subjects also filled out a nasal symptom scale. measurements were taken at baseline, 1 hour, 4 hours, and 24 hours after nac. results: the nasal symptom score increased significantly immediately after allergen compared to control challenge (13.0â±2.4 vs. 3.7â±1.1 respectively, p=0.003). there were no statistically significant differences in the nasal ph at 1h and 4h, but a significant decrease at 24h compared with baseline (-0.2â±0.1 vs. +0.14â±0.1, p=0.02). the change in ph from 0h to 24h correlated significantly and inversely with change in symptoms (r=-0.59, p=0.007) and number of sneezes (r=-0.65, p=0.002) after challenges. nasal pd did not change significantly after challenges. conclusion: allergen decreases nasal mucosal ph in the very late phase after challenge in allergic rhinitic subjects. decrease in airway mucosal ph during asthma exacerbations may be caused by aggravation of allergic inflammation. nasal potential difference does not change after allergen challenge. funding: niaid, acaai foundation introduction: uv induces differentiation of t-and b-lymphocytes, suppresses natural killer cells, renders a tolerogenic effect and induces apoptosis resulting in local and system immunosuppression. methods: lymphocytes were studied using indirect immunofluorescence methods employing monoclonal antibodies to cd-markers cd4, cd8, cd16, cd25, cd95, hla-i, and hla-ii, from the blood of 14 volunteers (aged 18-24 years) before uv exposure (control), after an exposure of blood in vitro to a dose 1.12 kj, and after 24 hours of exposure of the medial surface of the elbow joint in vivo (s=200 cm2), to a dose of 1.12 kj. results: the direct exposure of blood results in a significant reduction in the number of lymphocytes, probably due to direct phototoxic effects. significant modifications both of the aggregate number of lymphocytes and amount of t-helpers after uv exposure of the skin were not seen. after uv the number of cells which express the marker cd8 is sig-nificantly increased. exposure to uv in vitro induces reduced number of cells bearing cd16. however on in vivo exposure, a significant increase in number of cells which express cd16 was observed. uv exposure of blood reduced significantly the hla-i (9.67â±0.72 reduced to 0.32â±0.54) and hla-ii (dr) (21.56â±1.19 reduced to 18.45â±1.15) expression. uv exposure of skin increased significantly hla-i to 11.56â±0.81, while hla-ii (dr) was insignificantly decreased to 20.65â±2.01. cd95 expression increased from 22.43â±1.12 to 25.95â±1.08 due to blood uv exposure, while there were insignificant reductions in cd4 (39.33â±2.14 reduced to 36.62â±2.34) and cd8 (36.50â±2.03 reduced to 25.75â±2.74) expression. conclusion: uv starts a cascade-like response, including apoptosis, leading to changes in nk cell, helper and suppression lymphocyte numbers consistent with an immunomodulating effect of uv radiation. background: previous investigations have shown the involvement of histamine and histamine receptors (h 1 , h 2 , h 3 , h 4 ) in ige synthesis in atopic and lymphoproliferative diseases. ige responses may depend on the concentrations of histamine and histamine receptor antagonists and agonists. the goal of this investigation was to evaluate the role of the concentration of histamine and h 3 /h 4 antagonists along with the importance of pre-existing levels of ige in determining ige responses. methods: ige synthesis was studied in mnc cultures of patients (7-14 years old) having mild atopic asthma and rhinitis. all patients had high levels of total ige and specific ige to ragweed pollen, house dust mite, epidermal or mold allergens. patients were divided into two groups according to the serum ige and levels of spontaneous ige synthesis: group a -with low levels (4.8â±1.2 iu/ml) and group b -with high levels (9.7â±1.4 iu/ml). the serum level of total ige in group a was 426.1â±24.3 iu/ml and in group b was 570.2â±26.5 iu/ml. fub 181 hydrogenmaleate was used as an h 3 /h 4 specific antagonist. results: histamine in high concentrations (10 -5 m) suppressed and in low concentrations (10 -8 m) stimulated spontaneous ige synthesis. the h 3 /h 4 antagonist fub 181 activity depends on the pre-existing levels of ige. in high concentrations (10 -5 m), the antagonist increased ige synthesis only in group a, but not in group b having high spontaneous levels of ige synthesis. the synthesis in group a increased 1.36 fold (p<0.001), but h 3 /h 4 blockade cancelled the ige suppressive effect of high concentrations of histamine (10 -5 m). the addition of histamine into the mnc culture stimulated ige synthesis 1.56 fold. fub 181 had no effect on ige-stimulatory effects of low concentrations of histamine (10 -8 m). in allergen (ragweed)-stimulated mnc culture, fub 181 had a co-stimulatory effect on ige synthesis induced by histamine. conclusions: the ige stimulating response depends on the concentrations of histamine and the h 3 /h 4 antagonist as well as pre-existing levels of serum ige and ige spontaneous synthesis. introduction: preliminary data has shown that oral contraceptives can precipitate or worsen attacks of hereditary angioedema (hae). it is thought that estrogens affect the synthesis and degradation of bradykinin with resulting edema. objective: our objective is to determine if there is a difference among the various oral hormonal preparations, namely, combined monophasic, combined multiphasic, progesterone only, and hormone replacement therapy, in regards to their effect on frequency of hae exacerbations. methods: patients in this study consisted of women over the age of 18 diagnosed with hae who receive their care at our institution and women meeting the same criteria who are active in the hae foundation and have access to this association's web page. all patients answered a sixteen item questionnaire about past or present birth control pill or hormone replacement therapy usage and its impact on the frequency of exacerbations. results: of the patients who completed the questionnaire, 94% had taken or were currently taking oral contraceptive pills or hormone replacement therapy. of the women whom had taken monophasic birth control pills, 100% worsened with increased number and severity of exacerbations. however, only 75% of the women that had used combined multiphasic birth control pills worsened. all of the women who had tried progesterone only birth control pills worsened. of those on isolated estrogen for hormone replacement, 67% had an increased number of exacerbations. when androgens were used concurrently with oral contraceptive pills or hormone replacement therapy, exacerbations decreased to 60%. conclusion: we are not able to demonstrate a statistical benefit of one oral contraceptive pill preparation over another because of our sample size. however, our preliminary data supports that the oral contraceptive pill which produces less exacerbations and less symptoms is a combined multiphasic pill with concurrent androgen treatment. introduction atopic dermatitis (ad) is associated with multiple immunological abnormalities including imbalances in the subsets of blood circulating lymphocytes forming cellular infiltrates in inflamed skin. many studies of the functional and phenotypic properties of lymphocytes in ad have been limited to either peripheral blood or skin-infiltrating lymphocytes. the purpose of our study was to evaluate and compare the content and phenotypic properties of cd4+ lymphocytes from blood and inflamed skin of ad patients. materials and methods 15 adult (age 18-43 years) patients with chronic ad were selected by the criteria of hanifin. all patients gave written informed consent. the cd4+ lymphocytes of peripheral blood were phenotyped by flow cytometry. skin biopsies were obtained from eczematous areas, then cryosected and double immuno-histochemistry was performed. for phenotyping of lymphocytes in blood and skin a panel of monoclonal antibodies was used including cd3, cd4, cd8, cd25, hla-dr and cla. results immunophenotype analyses of the peripheral blood lymphocytes showed a predominance of cd3+cd4+ cells (86%â±21.3). most cells were cd4+hla-dr+ (14%â±12.6) and cd4+cd25+ phenotype (26%â±13.5). double immunohistochemistry of the skin biopsies revealed in the epidermis rare but constant presence of cd4+cd25+cells (1.0â±6.4 cells/mm 2 ) and cd4+hla-dr+ cells (1.2â±1.3 cells/mm 2 ). in the dermal inflammatory infiltrates the predominant cells were cd4+cd25+ (21.0â±9.7 cells/mm 2 ) and cd4+hla-dr+ (45.0â±6.7 cells/mm 2 ). the dominant inflammatory infiltrate consisted of cd4+cla+ phenotype (62.9â±23.5 cells/mm 2 ) cells. conclusion in ad skin inflammation is associated with the appearance in the circulation of cd4+ lymphocytes in activated form (cd4+hla-dr+) and lymphocytes with regulatory properties (cd4+cd25+). these lymphocytes are recruited from the circulation, having the skin homing properties (cd4+cla+), and form the main constituent of the dermal inflammatory infiltrate. contact dermatitis (cd) comprises a spectrum of inflammatory skin reactions usually caused by exposure to non-immunogenic low molecular weight substances (haptens). failure to diagnose the condition may result in a chronic and disabling condition with impaired quality of life. a 28 yr-old white male presented with a severe, symmetrically distributed facial maculopapular rash with secondary excoriated lesions. prior to the appearance of the rash, the patient had been applying lubriderm as a skin moisturizer for dry skin. a standardized thin layer rapid use epicutaneous (true) test containing 23 chemical agents suspended in a vehicle and attached to an adhesive backing was applied to the patient's back. at 48 hrs, a positive reaction was observed at the skin site of the paraben mix application. the lubriderm preparation used by the patient contained paraben, in contrast to a newer preparation, advanced therapy lubriderm, which is paraben-free. complete resolution of the facial lesions occurred following discontinuation of the lubriderm and the use of oral and topical corticosteroid therapy. this case report illustrates how a commonly used moisturizer can contain a sensitizing agent that could be detected by standardized patch testing which should be a part of the diagnostic armamentarium of every allergist-immunologist. we report how a commonly used and effective moisturizer (lubriderm) can cause severe allergic cd and that the use of a standardized thin layer rapid use epicutaneous (true) patch test panel can be an effective diagnostic tool for the detection of the offending agent. rationale: this study aimed to establish the possible differences of cutaneous sensitization to common aeroallergens in children under 1 years old. methods:the study was conducted between 2003-2004 and included 120 infants from silesia/southern part of poland/.these infants were refered to our allergy unit due to respiratory symptoms like rhinitis, otitis, pharyngitis, cough, bronchitis recurring;eye's symptoms/ conjunctivitis/ and oral symptoms. the skin prick test/ spt/ to major aerollergens in our environment(hdii, birch, alternaria, cladosporium and trees)were done to 6-months-old and 1-yearold children. a spt of 3 mm or larger was considered as positive. patients were classified into three groups: i:positive family atopy ii:smoking ciggarettemother/ or father iii:cat or dog at home iv: coexisting food allergy results:58, 8 % of examined children were boys. the prevalence of sensitisation found were as follows:latex 38, 1%, birch 32, 8%, dpii-28, 6%, grass pollen 28, 1%, alternaria-8, 4%. positive spts to latex were first seen in the 6-months-old group and this prevelance doubled until they finished 1 year. conclusion: in our study, cutaneuos sensitisation start to appear in 6-months-old chlidren. background: propylene glycol (pg) may induce allergic contact dermatitis (acd) and skin irritant reactions. topical formulations frequently contain pg. it is present in low concentration (5%) in pimecrolimus cream 1%, a non-steroid inflammatory cytokine inhibitor. objectives: this study was designed to assess the incidence of cutaneous responses to pimecrolimus cream in patients allergic to pg and to determine their nature (acd or irritation) and severity. methods: in this double-blind, randomized, vehicle-controlled, withinpatient study, 20 subjects allergic to pg underwent 48-hour patch-testing (pg 30 and 100%, pimecrolimus cream and vehicle) followed by a 7-day repeated open application test (roat). application sites were assessed by the investigator using a scale ranging from 0 (no reaction) to 7 (spreading bullous reaction) at 0, 48, and 120 hours after patch removal and at the completion of the roat. results: pg allergy was confirmed by patch-testing in 16 patients. two patients showed a positive patch-test reaction with pimecrolimus cream and vehicle, indicating an acd. in contrast, no patient demonstrated signs of acd when pimecrolimus cream was applied under normal conditions, i.e. without occlusion (roat). the statistical analysis showed that there were significantly less reactions at pimecrolimus patch-test sites than at the pg patch-test sites (p<0.01 for both pg concentrations, one-sided exact binomial test) and that the median severity was lower with pimecrolimus cream vs. pg (p=0.02 and p<0.01 for pg 30% and 100% respectively, wilcoxon signed-rank test). conclusions: this pilot study suggests that pimecrolimus cream 1%, when applied under normal conditions, can be used safely in patients with pg allergy. introduction: chronic idiopathic urticaria is not always responsive to antihistamine therapy. multiple alternative agents have been tried. we report two cases where tacrolimus has been successful in treating this condition. methods: this is a case report of two patients who have chronic idiopathic urticaria and have been treated with tacrolimus. patient #1 is a 27 y/o wm who pre-sented with urticaria that had been going on several months. the duration of his urticarial lesions was <24 hours his urticaria was treated with several medications including: hydroxyzine, cyproheptadine, ceterizine, montelukast, colchicine, and dapsone. he was intolerant to hydroxychloroquine. montelukast seemed to provide some modest benefit but he continued to have daily urticaria with >50 lesions/day after two months of therapy. tacrolimus was added to montelukast at 1mg bid. patient #2 is a 64 y/o wf with a history of biopsyproven urticaria. she had suffered from episodic urticaria since the age of six that was responsive to systemic steroids. after thirty years of having no urticaria, she developed recurrent urticaria at age 62. at this time, she was treated with hydroxyzine, doxepin, montelukast, loratadine, ceterizine, fexofenadine, colchicine, dapsone, and even prednisone with very little improvement in symptoms. she was then started on tacrolimus 1mg bid as monotherapy while she was having daily urticaria. results: after one month of treatment with tacrolimus 1mg bid, patient #1 had a decrease in the number of urticaria. his dose of tacrolimus was increased to 3mg/day, and after four weeks, his urticaria resolved. he remained on tacrolimus for a total of six months which was tapered and discontinued. he continues to be in remission from urticaria. patient #2 had complete resolution of her hives after just two doses of tacrolimus. after two months, she remains free of urticaria on tacrolimus 1mg bid. conclusion: for patients with severe chronic urticaria unresponsive to multiple therapies, tacrolimus, like cyclosporine, may be efficacious. tacrolimus may also be truly immunomodulatory and capable of inducing remission of urticaria. s.v. gerasimov * , lviv, ukraine. introduction. recent studies suggest that probiotics can be useful in prevention and treatment of atopic dermatitis (ad) in children. as clinical effect of probiotics varies greatly depending on the specific strain, we are currently conduct a search for the most promising probiotic to be used as complementary therapy in infants and young children with ad. methods. we studied 23 infants aged 25-51 weeks (36â±8) with ad established using hanifin and rafka criteria. patients were evenly allocated among probiotic (n=11) and nonprobiotic (n=12) treatment groups using quota allocation system. severity of ad was defined using scorad index and infant`s quality of life was assessed using idqol index. patients were examined before and 4 weeks after the treatment with/without probiotic powder formulation (b. infantis, l. acidophilus dds-1, 10 billion cfu/day, dds-junior, uas laboratories). we compared pre/posttreatment values of indices above and amount of mometasone furoate (0, 1%) used employing a paired or unpaired t-test. results. at baseline, infants in either groups were comparable on age, gender, duration of the disease, scorad and idqol indices, and medication taken for the previous 4 weeks. before entering the study all patients were maintained on allergen elimination diet due to milk and egg white allergy. after the treatment with/without probiotics the mean scorad index decreased from 42, 2 to 32, 7 (p=0, 14) and from 51, 5 to 31, 3 (p=0, 06), respectively. however, the mean amount of mometasone furoate used in non-probiotic treatment group was significantly greater (7, 8 g vs 2, 1 g, p=0, 03), despite the same recommendation on the use of the drug was given. additionally, parents of children taking probiotics reported an improvement in infant`s quality of life as seen on the decrease of idqol index from 21, 1 to 12, 0 (p=0, 04). in non-probiotic group decrease in idqol was not significant (24, 2 to 19, 5; p=0, 14) . there were no adverse events in any of the treatment groups. conclusions. our preliminary results suggest that some probiotics may have a corticosteroid-sparing effect and improve quality of life of infants with ad. there is a clear trend towards reduction of scorad index, which did not change significantly, probably due to a limited number of patients involved. introduction : the aim of this study was to analyze the risk factors of severe atopic dermatitis(ad) in the first 6 months of life. methods : the children aged less than 6 months with ad were divided into two groups according to six area six sign in atopic dermatitis(sassad) score. children with score less than 14 was classified as mild ad(n=90) and those with score above 15 as severe ad(n=44). these patients were fed with breast milk or cow's milk formula, and no allergenic food was given except rice and some vegetables. we analyzed the gender, feeding patterns, family history of allergy, number of siblings, total ige and specific ige to common food allergens (egg white, cow's milk, wheat, soy) by cap-feia assay. total eosinophil count was 1863â±2032 /ul in severe ad and 686â±539 /ul in mild ad(p<0.001). results : 1) total ige was 180.6â±245.1 u/ml in severe ad and 32.2â±50.7 u/ml in mild ad(p=0.002). specific ige to egg white, wheat and soy (19.03â±29.72 u/ml, 4.68â±10.62 u/ml, 7.07â±22.01 u/ml in severe ad; 1.78â±3.54 u/ml, 0.15â±0.99 u/ml, 0.09â±0.30 u/ml in mild ad; p<0.05) were associated with severe ad, but cow milk(4.34â±16.6 u/ml in severe ad, 0.80â±4.17 u/ml in mild ad) showed no difference. 2) gender, feeding patterns, family history of allergy and the number of siblings were not significantly associated with severe ad. conclusion : severe ad is associated with sensitization to food allergens in the first 6 months of life, although they are not fed with those foods. background: atopic dermatitis (ad), an inflammatory skin disease diagnosed primarily in children, has been shown to have a negative impact on quality of life (qol). pimecrolimus cream 1% is a non-steroid, topical calcineurin inhibitor with demonstrated efficacy in the acute treatment and longterm management of pediatric and adult ad. in a 24-week, double-blind, vehicle-controlled study, a secondary aim was to evaluate the impact on parent's quality of life of a pimecrolimus-based or corticosteroid (cs)-based treatment regimen of children with ad. methods: 275 children aged 3 months to 11 years (mean 5 years) with mild to severe ad were randomized 2:1 to receive treatment with pimecrolimus or vehicle cream. emollients for dry skin and pimecrolimus or vehicle bid were applied at the first signs of ad. for severe flares, a mid-potency topical cs (fluticasone or mometasone) indicated for once-daily use in ad replaced the evening study drug application for a maximum of 3 weeks or until all ad resolved. parents completed the parent's index of quality of life-atopic dermatitis (piqol-ad), a 28-item validated questionnaire, which measures parent's needs-based qol, at baseline, week 12, and study completion. change in piqol-ad scores at baseline and week 24 were compared between treatments. a negative change indicated improvement. results: parents of patients in both groups reported improvement in piqol-ad scores at week 24, with greater improvement for the pimecrolimus group. the mean change in piqol-ad score from baseline to week 24 was -3.3 in the pimecrolimus group vs. -2.6 in the cs-based treatment group (37.6% vs. 26.8% improvement, respectively). ancova analysis, using treatment and center as main effects and baseline score as a covariate, compared the change in piqol-ad score in two treatment groups. pimecrolimus treatment demonstrated a more favorable change (-1.2) which approached statistical significance [p=0.056; 95%ci= (-2.5, 0.0)]. conclusion: a treatment regimen utilizing pimecrolimus cream 1% had a beneficial effect on parent's quality of life compared to a corticosteroid-based regimen. this benefit was consistent with other measures of efficacy studied. introduction: atopic dermatitis is a chronic, inflammatory and recurrent skin disorder . its prevalence has increased in recent decades but little is known about it in mexico city. the aim of this study was to evaluate the prevalence and severity of atopic eczema in a pediatric population. methods: a cross-sectional questionnaire survey (isaac phase i questionnaire) was conducted on random samples of schoolchildren aged 6 to 7 years and 13 to 14 years from educational centers of four northern counties from mexico city. those children with a positive response to being questioned about the presence of an itchy relapsing skin rash in the last 12 months were considered to have atopic dermatitis. children whose symptoms resulted in sleep disturbance for 1 or more nights per week were considered to have severe atopic eczema. statistical analyses were done with spss 6.0 for windows, chi square . the size of the sample was determined folowing the isaac specifications and calculated with the statcal program. results: complete data was available for 3211 children aged 6 to 7 years in 45 schools and 3899 children aged 13 to 14 years in 47 high schools. 51.5% males and 48.5% females. response rates were high ( 91.4 % for those aged 6 to 7 years and 100% for those aged 13 to 14 years). the prevalence of symptoms of atopic dermatitis in the last 12 months was 9.6 % at age 6 to 7 and 9 % at age 13 to 14 years. medical diagnose of atopic eczema was 4 % and 2.4 % for children aged 6 to 7 years and 13 to 14 years, respectively. reported eczema accounted for 12.4 % and 11.3 % at age 6 to 7 and 13 to 14 years, respectively. children with symptoms of severe atopic dermatitis accounted for 1 % of all those with symptoms of atopic dermatitis. we also found that the majority of the children begun with skin manifestations of atopic dermatitis before the age of 4 years old. conclusions: the prevalence of atopic eczema was very similar for both groups of ages. our results agree with those found in other two studies acomplished in other mexican cities (cuernavaca and chihuahua) and with those from other countries of latin america like brazil, chile and costa rica. although, we found lowest values than those from sweden, japan and australia. studies that include objective skin examination are required to confirm these findings. a. kaplan 1* , s. meeves 2 , y. liao 2 , s.t. varghese 2 , g. georges 2 , 1. charleston, sc; 2. bridgewater, nj. introduction: the symptoms of chronic idiopathic urticaria (ciu) can have a profound impact on patient health and quality of life. the safety and efficacy of fexofenadine (fex) bid for the treatment of ciu has been previously established in two multicenter, double-blind, randomized, placebo-controlled trials. this study evaluated the efficacy and safety of a qd dose of fex hcl 180 mg, as this dosing schedule could offer advantages in terms of patient compliance and convenience. methods: this multicenter, randomized, double-blind, parallel-group, placebo-controlled study consisted of a single-blind placebo run-in period of 2-5 days, followed by a 28 (â±4)-day treatment period. males and females aged 12 years with a diagnosis of ciu and with active disease were enrolled. patients were randomized 2:1 to receive either fex hcl 180 mg qd or placebo qd. the primary endpoints were change from baseline in mean daily number of wheals (mnw score) and mean daily severity of pruritus (measured on a 5-point scale) over the 28-day treatment period, as assessed reflectively by the patient. secondary efficacy measures included a modified total symptom score (motss), comprising sum of number, frequency, size and duration of lesions, and severity of pruritus. mnw and pruritus severity were also assessed instantaneously at trough drug levels (immediately prior to dosing). results: over the 28-day treatment period, patients treated with fex (n=167) experienced significantly greater improvements in mnw and pruritus scores compared with the placebo group (n=92) (p<0.0001 for both). similarly, over the treatment period, and at individual weekly timepoints, the mean reductions in am reflective, pm reflective and mean daily motss were significantly greater for patients in the fex group compared with those in the placebo group (p 0.0052 for all comparisons). the mean reductions in instantaneous mnw and pruritus scores were greater with those who received fex than those who received placebo (mnw: p=0.0154; pruritus score: p=0.00088). there were no significant differences in the frequency of treatment emergent adverse events between the two treatment groups, and no clinically relevant changes were observed with respect to clinical laboratory data, vital signs or ecgs. conclusion: this study demonstrated that a qd dose of fex hcl 180 mg offers effective and well-tolerated relief from the symptoms of ciu. introduction: the wheals and pruritus associated with chronic idiopathic urticaria (ciu) are often so debilitating that they have a profound impact on patient quality of life. specifically, ciu has been shown to negatively affect patient mobility, sleep, energy levels, social interaction and emotional wellbeing. the purpose of this study was to examine the impact of treatment with fexofenadine hcl (fex) 180 mg on health-related quality of life (hrql) among patients with ciu. methods: as part of a multicenter, randomized, double-blind, parallel-group, placebo-controlled study, designed to evaluate the efficacy and safety of a once-daily dose of fex 180 mg in ciu, the impact of treatment on hrql was also examined. patients were asked to complete the dermatology life quality index (dlqi) and the work productivity and activity impairment questionnaire (wpai) at baseline and at weeks 2 and 4 (final visit or early termination). the primary endpoint was mean change from baseline in dlqi total score, using the mean data of evaluations performed at weeks 2 and 4 as the post-baseline measure. secondary endpoints included change from baseline in individual dlqi domains and wpai scores. additional analyses were conducted to examine the reliability, validity and responsiveness of the hrql measures. results: a total of 254 patients were included in the hrql population: n=163 fex, n=91 placebo. patients in the fex group experienced significantly greater improvements in the mean dlqi total score than those in the placebo group (p=0.0029). this pattern was repeated with respect to the individual domains of symptoms and feelings (p=0.0071), daily activities (p=0.013), leisure (p=0.0425) and personal relationships (p=0.0023). both treatment groups reported improvements in productivity, as measured by change from baseline using the wpai. patients randomized to fex experienced significantly less impairment while working (p=0.0455) and performing activities (p=0.0088) than those who received placebo. the dlqi was demonstrated to be reliable (cronbach's alpha=0.87); both the dlqi and wpai were found to be valid and responsive instruments in this ciu population. conclusion: this study demonstrated that a once-daily dose of fex 180 mg improves the hrql of patients with ciu, as assessed by change in dlqi total score. t. algozzine 1* , a. lee 2 , s. wong 3 , l. anzisi 4 , 1. manchester, nh; 2. centerport, ny; 3. syosset, ny; 4. mamaroneck, ny. symptoms of allergic and non-allergic rhinitis may significantly impact a patient's quality of life, by causing fatigue, headache, cognitive impairment and other systemic symptoms. appropriate management of allergic rhinitis is important in the effective management of coexisting or complicating respira-tory conditions (e.g. asthma, sinusitis, or otitis media). in addition, many commonly used over-the-counter (otc) antihistamines can cause performance impairment that may impact daily activities. we designed a brief ten-question allergy survey in an attempt to determine how patients were being treated for their allergies, evaluate a patient's self-assessed impact of their allergies on their daily activities, and identify any difference in treatment outcomes between primary care and allergist practices. patients were invited to complete the surveys anonymously. completed surveys were collected and entered into a microsoft access database for evaluation. minitab was utilized for statistical calculations. four hundred and thirty seven patients completed the survey. fifty-eight percent of survey respondents were women and 89% were adults (age >18). of those patients surveyed, 53% (n=233) were under the care of an allergist. compared to primary care, patients treated by allergists reported more allergies (3.4 vs. 1.8, p <0.001) and received more medications on average (2.3 vs. 1.4, p<0.001). pollen was the most common allergy type reported among all patients. while the majority of all patients (69%) received prescription medications, more primary care patients received no therapy or only otc treatment when compared to allergist patients (46% vs. 17%, p<0.001). seventy-four percent of primary care patients reported their allergy symptoms were controlled compared to 63% of allergist patients (p<0.05). patients receiving treatment from an allergist reported less impact of their allergies on daily activities (a lower score signified less impact) compared to patients seen in primary care (2.27 vs. 3.84, p<0.001). the results of our survey suggest that allergists treat more complex patients. these patients had multiple allergies, more uncontrolled symptoms, and utilized more prescription medications. despite these findings, patients treated by allergists reported less impact of allergies on their daily activities. introduction the patogenic mechanism of nasal polyps are unknow.they frecuently are associated with aspirin intolerance, intrinsic asthma, chronic sinusitis, young sindrome, cystic fibrosis, kartagener syndrome and churg-strauss syndrome.chemical mediators found in nasal polyps are as follows: histamine, serotonin, leukotrienes, norepinefrine and possibly pgd2.recently, leukotrienes have been implicated in mediation of bronchoconstriction and inflammatory leukotriene levels have also been shown to be elevated in some patients with sinonasal polyposis (figure 1 ) hypothesis antileukotrienes might play a significant role in controlling polyposis and symptoms secundary to sinonasal disease, and they might viable alternative to longterm, oral steroid therapy and repeat surgical debridement purpose this study was undertaken to evaluate the potential role of leukotriene receptor antagonist on recurrent polyposis associated with asthma and improvement of some factor implicated with them design of study:clinical assay, prospective, triple blind. materialsand methods:the study involved 30 patients 12 (40%) males and 18 (60%) women, mean age 20.7 years, with a range 16-45 years selection criteria:inclusion criteria: nasal polyps associated with astha, allergic or non allergic.exclusion criteria: patients with any concurrent illness, use of sistemic or local corticosteroidsor any kind of antileukotriene within 1 month prior to the beggining of the study.we made an alleatory selection 10 patients recived montelukast (10 mgs/day), and nasal steroids, beclometasone (600 mgs/day) for 6 months.10 patients recived loratadine plus pseu-doefedrin5mgs/120 mgs/day and nasal steroids, beclometasone, 10 patints were operated of fees and transnasal endoscipic polypectomy plus montelukast and nasal steroids, beclometasone ige serum levels 2.skin prick test 3.sensitivity in vitro 4.ct scan 5. celullarity on nasal lavage (eosinophils and neutrophils)6.proinflamatory cytokines (il4-il5-il8) on nasal lavege by elisa test. results ther was a tendency for more improvement of the group 3 ( surgery-montelukast-local steroid) of symptoms and objective measurments, in second place of improvement the group 1 montelukast-local steroid) and the worse on improvement subjective and objetive was group 2 local steroid and loratadine-pseudoefedrine use as placebo introduction: sensory perceptions of intranasal corticosteroids (ins) vary among products and can be unpleasant and affect adherence to therapy. methods: we conducted a cross-sectional study of 120 patients across 4 allergy and immunology clinics in the united states. respondents were asked to choose between pairs of hypothetical ins that differed by sensory attribute composition. based on prior research, we measured 6 salient sensory attributes: smell, taste, aftertaste, throat rundown, nose runout, and feel of spray in nose/throat. each attribute was described in 3 intensity levels, such as "no taste" (low), "weak taste" (moderate), and "strong taste" (high) ( table) . other outcomes included an importance score for each sensory attribute and patients' willingness to adhere to an ins having the lowest levels of each sensory attribute compared to one with moderate levels. results: preferences decreased with increasing intensity level of each sensory attribute. the most important attribute was aftertaste in 28% of patients, taste in 19%, throat rundown in 18%, nose runout in 12%, smell in 11%, and feel of spray in 7%. only 5% had more than one attribute tied for most important. if instructed to take ins daily for 3 months, 77% of patients stated that they would definitely be able to follow their doctor's advice (willing to adhere) if given an ins containing the lowest level of each sensory attribute compared with 4% for one having moderate levels (p<0.01). conclusions: patients' preferences decrease with increasing intensity levels of each sensory attribute and affect patients' willingness to adhere. tailoring ins to patient preferences may lead to improved treatment satisfaction and adherence. introduction:a high prevalence of rhinitis and asthma comorbidity has been persistently noticed in epidemiological studies in last years. our objective was to evaluate the prevalence of rhinitis and asthma comorbidity in a portuguese population including both atopic and non-atopic patients. methods: a retrospective study was performed. clinical records from patients attending an immunoallergology outpatients'clinic during 39 months (from january 1998 until june 2001) were reviewed. data were collected concerning clinical history of rhinitis and/or asthma, aeroallergens'skin prick tests and respiratory function evaluation. results: among the 3582 patients attending an appointment during the study period, 2448 (68.3%) had rhinitis and/or asthma (56.2% f; 43.8% m;mean age 26 +/-19 years). patients with respiratory disease included 1983 atopic (81.0%) and 465 non-atopic 19%). diagnosis of asthma, rhinitis or of both diseases was made in 170 (8.6%), 581 (29.3%) and 1232 (62.1%), respectively, in atopic patients and in 56 (12.0%, 265 (57.0%) and 144 (31.0%), respectively, in non-atopic patients. rhinitis was diagnosed in 87.9% of atopic asthmatic and in 72-0% of non-atopic patients with asthma. in patients with rhinitis, asthma was also diagnosed in 67.9% of atopic patients and 35.2% on non-atopic patients. conclusions: in this study population rhinitis was frequently diagnosed in patients with asthma and vice-versa, thereby leading to a high prevalence of this comorbodity. this association was more frequent in atopic patients. our data are comparable to those we found in recent literature. these results suggest that clinical investigation of asthma should be mandatory in management of patients with rhinitis as well as asthmatic patients should be routinely submitted to clinical evaluation of rhinitis. introduction: cetirizine hcl (c) has been shown to be more effective than fexofenadine hcl (f) in controlling seasonal allergic rhinitis (sar) symptoms at 21-24 hr post-dose, however, the efficacy of c and f was comparable between 0-5 hr post-dose. response to treatment in the middle of the dosing interval needed to be addressed. methods: this randomized, double blind, placebo (p)-controlled study was designed to compare the efficacy and tolerability of a single dose of c 10 mg, f 180 mg, and p between 5-12 hr postdose in ragweed-sensitive sar subjects. subjects meeting entry criteria were exposed to pre-determined controlled levels of ragweed pollen in the eeu during priming and double blind treatment. subjects assessed rhinitis symptoms at half hr intervals during pollen exposure; at priming, at the qualifying period, at baseline, and from 5-12 hr post-dose. the primary efficacy endpoint was the change from baseline in total symptom severity complex (tssc) score at 12 hr post-dose. tssc score was the sum of severity ratings (0=absent to 3=severe) for 4 symptoms: runny nose, sneezing, itchy nose/palate/throat and itchy/watery eyes. results: a total of 599 subjects (mean age 32.8 y; 58.9% females) were randomized: c, 249; f, 250; p, 100. baseline characteristics were comparable among groups; tssc: c=9.2, f=9.2, p=8.9. c produced a 26% greater reduction in tssc score at 12 hr (-4.3, p=0 .001) and a 14% greater reduction overall (i.e., average over the 5-12 hr post-dose period) (-5.0, p=0.006) compared with f (-3.4, -4.4, respectively). both c and f reduced tssc score more than p (12 hr, -1.9; overall, -2.3, p<0.001) including all individual symptoms (p<0.05). c however, was more effective than f for runny nose and sneezing at 12 hr and overall, itchy/watery eyes at 12 hr, and itchy nose/throat/palate overall (p<0.05). rates of discontinuation due to adverse events (aes) were low: c, 0.4%; f, 0%; p, 1.0%. the incidence of treatmentemergent aes was similar: c, 25.3%; f, 29.6%; p, 35.0%. somnolence occurred in 0.8% of subjects on c, and 0% on f or p. conclusion: c produced a greater improvement in rhinitis symptoms compared with f and p, at 12 hr post dose and over the 5-12 hr post-dose period. all treatments were safe and well tolerated. background: medication utilization patterns of patients suffering from seasonal allergic rhinitis (sar) are not well documented, and although many anti-allergic medications are prescribed for daily use, actual usage is unknown, but recognized to be quite variable. methods: 1821 subjects with positive ragweed skin tests were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms, usage patterns and reasons for choice of anti-allergic medication. results: 550 subjects completed the survey (30.2%). the prevalence of symptoms were, in decreasing order: sneezing (91.5%), runny nose (82.4%), itchy/gritty eyes (80.4%), stuffiness (78.5%), itchy nose (71.3%), watery eyes (64.7%), itchy palate/throat (56.9%), post-nasal drip (55.6%), red/burning eyes (49.1%), headache (36.5%), itchy ears (34.0%), cough (30.0%), shortness of breath (15.7%), and wheeze (15.5%). sar patients used antihistamines most frequently (94.7%), followed by decongestants (63.1%), combination (antihistamine/decongestant) products (52.0%), and intranasal corticosteroids (42.5%). medications were mostly taken intermittently rather than daily (antihistamines 68.0%; nasal corticosteroids 71.8%), conclusion: a constellation of nasal symptoms were the most common seasonal allergic manifestations, followed by ocular, palatal and ear irritation. antihistamines were the most frequently used medication to treat symptoms, succeeded by decongestants (alone or in combination). a significant proportion of subjects took their allergy medication, including nasal corticosteroids, intermittently rather than regularly, underscoring the relevance of single-dose evaluations of drug efficacy. a.k. ellis * , e. rafeiro, j.d. ratz, j.h. day, kingston, canada. background: traditional assessment of seasonal allergic rhinitis (sar) medication efficacy utilizes randomized controlled trials over 2-4 weeks in season. an additional study method employs single-dose responses using controlled allergen challenge such as the environmental exposure unit (eeu). a comparison of allergic symptoms generated by controlled allergen challenge to those occurring in ragweed season symptoms has not been done. methods: 1821 subjects with known sar to ragweed were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms. subjects participating in a subsequent controlled allergen challenge study using the eeu, were again asked to complete a similar survey that documented symptoms generated in this model. those who completed both surveys comprised the primary analysis group. results: 550 subjects completed the ragweed season survey, 516 subjects completed the eeu survey, and 270 completed both. symptoms generated by eeu exposure were similar to those elicited during ragweed season, with the exception of cough (68% vs. 27%, respectively, p <0.01). subjects reported that symptoms were more severe in the eeu than those experienced on a typical ragweed season day, but less severe than those during peak ragweed season days. conclusion: allergic upper respiratory tract symptoms produced during controlled ragweed pollen exposure in the eeu were similar in nature and degree to those expe-rienced during ragweed season, supporting evidence that the eeu is a valid model for studying sar. r. nave 1 , m.a. wingertzahn 2* , s. brookman 3 , s. kaida 4 , t. shah 2 , 1. konstanz, germany; 2. florham park, nj; 3. princeton, nj; 4. tokyo, japan. rationale: ciclesonide (cic) is a new corticosteroid under development for treatment of allergic rhinitis (ar). cic is a pro-drug that is hydrolyzed to the active metabolite desisobutyryl-ciclesonide (des-cic) in the target tissue. cic has low oral bioavailability and is highly bound to plasma proteins; therefore cic administered as a nasal spray is expected to have minimal local and systemic effects. objective: the primary objective was to evaluate the safety and tolerability of repeated escalating doses of cic (50-800 mcg/day) given as a nasal spray for 14 days to healthy and asymptomatic subjects with sar. secondary objectives were to determine pk of cic and des-cic and to evaluate the effect of cic on endogenous cortisol. methods: this was a single-center, randomized, placebo-controlled, double blind, modified sequential dose study. six cohorts were randomized. cohorts i-v consisted of healthy subjects given doses of cic up to 400 mcg bid. cohort vi (asymptomatic sar subjects) received 400 mcg bid. each cohort was comprised of 6 subjects who received cic and 2 subjects who received placebo. safety assessments were conducted by recording adverse events (aes), clinical laboratory, eye, and nasal examination findings. serum and urine samples were taken for evaluation of cortisol levels. cic and des-cic serum concentrations were determined by lc-ms/ms. results: no trend was observed for aes when comparing cic and placebo treatment. additionally, no subject experienced a serious ae or withdrew from the study due to an ae during the trial. cortisol levels showed no differences between the dose groups or between activetreated subjects and placebo-treated subjects. additionally, serum concentrations of cic and des-cic in the majority of serum samples were shown to be below the lower limit of quantification (lloq; 25 pg/ml for cic and 10 pg/ml for des-cic), therefore no descriptive statistics could be calculated. con-clusions: ciclesonide nasal spray, at the doses evaluated, was safe and well tolerated in healthy and asymptomatic sar subjects with no detectable effects of cic on serum or urinary free cortisol concentrations. additionally, no pk parameters could be calculated for cic nasal spray, as it was virtually undetectable in serum despite the use of a sensitive assay. the preferred treatment for allergies is avoidance. air filtration is logical but room air purifiers have been of limited efficacy. zephyrâ�¢ is a new device which creates an envelope of air 99% free of allergenic particles around the head of the sleeping person. allergic rhinitis frequently causes daytime somnolence. this is a pilot study of the effectiveness of zephyr on symptoms of seasonal allergic rhinitis (ragweed hay fever) and on daytime sleepiness. methods: subjects age 12 to 45 with ragweed hay fever were studied in the ragweed season using each subject as his/her own control. usual allergy medicines were not allowed, except loratadine for rescue. outcome measures were a symptom score, juniper rhinitis quality of life questionnaire, a tolerability rating, and epworth sleepiness scale. during the first week subjects qualified by symptom scores, then entered the one-week treatment period with zephyr. the third week was a post-treatment observation period. results: of 13 participants, 10 (77%) showed symptom improvement. the whole group averaged 26% reduction in morning symptoms and 24% reduction in evening symptoms. sleepiness scores improved 29%. rhinitis qol improved 33%. the zephyr system was well tolerated as evidenced by the response to several statements regarding zephyr use and tolerability: (scoring: 1 = strongly disagree, 5 = strongly agree) "the system did not bother me while i was sleeping." (mean score 4.8) "the noise level did not affect my ability to sleep." (mean score 4.7) "the temperature was just fine for me." (mean score 4.8) "the system did not get in my way during sleep." (mean score 5.0) conclusions: zephyr significantly reduced seasonal hay fever symptoms and daytime sleepiness, improved quality of life, and was well-tolerated by subjects. zephyr may provide maximal environmental control of bedroom allergen exposure irrespective of ambient airborne allergen levels in the room. nasal congestion is an important symptom that is associated with significant morbidity in the rhinitis sufferer. disrupted sleep leading to daytime fatigue, loss of concentration, and decreased productivity are potential results of this symptom. a study employing online interviews with 1200 rhinitis sufferers from harris interactive's online database was conducted in order to understand the symptoms they identify with most and to determine the impact nasal congestion had on their daily activities. respondents were at least 18 years of age and experienced nasal congestion from seasonal allergic, perennial allergic, and/or perennial non-allergic rhinitis. the results showed that 60% of the respondents agreed nasal congestion is the most bothersome symptom of rhinitis; 37% experienced nasal congestion daily, while 35% experienced it several times per week. not surprisingly, sleep was the most important factor affected by nasal congestion. two-thirds (66%) of the respondents felt their sleep had been moderately or significantly impacted by nasal congestion, and more than half (56%) felt it was difficult to get a good night's rest because of congestion. sleep was interrupted or disturbed by nasal congestion approximately 3 nights per week, on average. furthermore, sleep disruption from nasal congestion contributed to daytime fatigue; 62% of the respondents indicated that they were typically tired or fatigued during the day when they experience nasal congestion. in addition, 42% felt that activities requiring concentration, such as reading, were moderately or significantly impacted by nasal congestion. this study confirms that nasal congestion causes the rhinitis sufferer significant problems beyond that of just a stuffy nose. consequently, healthcare providers need to ensure that their rhinitis patients who have nasal congestion as their primary complaint are managed effectively. desloratadine (dl, clarinex â® ) is a non-sedating oral antihistamine that is metabolized to 3-oh dl. however, a phenotypic polymorphism has been observed in some patients that results in reduced formation of 3-oh dl. the prevalence and safety profiles of such poor metabolizers of dl were examined in pharmacokinetic and clinical trials. a poor metabolizer was defined as a subject having a 3-oh dl to dl auc ratio of <0.10, or a dl half-life of 50 hours. in pediatric studies, where a sparse sampling approach was uti-lized to screen for poor metabolizers, a plasma concentration ratio of 3-oh dl to dl of <0.10 at 12 hours classified a subject as a poor metabolizer. a total of 3, 748 adult and pediatric subjects (2-70 years old) were phenotyped with a single dose of dl or loratadine. the overall prevalence of the poor metabolizer phenotype was 6% (228/3748). this prevalence was comparable for adult (70/1194, 6%) and pediatric subjects (158/2554, 6%), and greater in both populations among blacks (16% pediatric, 18% adult) than caucasians (3% pediatric, 2% adult). pharmacokinetic analysis found that exposure to dl was approximately 6-times higher in poor metabolizers than in normal metabolizers. there was no apparent difference in dl exposure among poor metabolizers in different age groups (6-months to <2-years, 2-to <6-years, 6-to <12-years, and 12-years) when treated with age-appropriate doses. the multiple-dose (7-35 days) safety profile of dl was examined in pediatric poor metabolizers (2-11 years) in 5 placebo-controlled trials, and in adult poor metabolizers (20-70 years) in pharmacokinetic trials. pooled ae rates were low and comparable between the poor metabolizer and placebo subjects, as shown in the table below with all aes that appeared in >2% of subjects in any treatment group (or >3% in adult poor metabolizers). there was no difference in cardiovascular safety profile or ecg results (including qtc interval) among these groups. in conclusion, (1) expression of the dl poor metabolizer phenotype is independent of age, but higher in blacks than in caucasians, (2) exposure to dl in poor metabolizers is independent of age when administered at age-appropriate doses, (3) the safety profile of dl poor metabolizers is not different from that of placebo at all ages down to at least 2-years old. these results are consistent with the high therapeutic index of dl. desloratadine (dl, clarinexâ®) is extensively metabolized to 3-oh dl and subsequently glucuronidated. the enzyme responsible for the formation of this active metabolite is unknown. poor metabolizers of dl represent a subset of the population that has a reduced ability to form 3-oh dl. a poor metabolizer was defined as a subject having a 3-oh dl to dl exposure ratio of <10%, or dl half-life of 50 hr. pk parameters from adult and pediatric poor metabolizers following repetitive administration of dl were characterized in clinical pharmacology trials and are summarized in the table below. exposure to dl [auc(0-24hr)] in poor metabolizers was approximately 6-fold greater than the corresponding values in normal metabolizers; cmax was 3to 4-fold greater. the magnitude of the reduction in the formation of 3-oh dl and the concurrent increase in exposure to dl associated with the poor metabolizer phenotype was similar in pediatric and adult subjects at age-appropriate doses. despite the increased exposure to dl in poor metabolizers, there was no increase in adverse event frequency or changes in electrocardiographic parameters. a: dose normalized to 5 mg. b: least squares mean ratio: anova of log-transformed data extracting sources of variation due to age group and metabolizer status. the ratio is a contrast of metabolizer status. c: lower and upper 90% confidence interval based on log-transformed data. introduction: many patients with seasonal allergic conjunctivitis (sac) complain of symptoms of dry eyes. we have previously reported that patients with sac experience discomfort from dry eyes anywhere between 2 to 6 days per week and that the overall severity of the dry eye symptoms tend to range from mild to severe. this preliminary cross over study evaluated the benefits of nedocromil sodium 2% ophthalmic solution used twice daily, compared with nedocromil sodium 2% ophthalmic solution used with refresh (ocular lubricant), for the treatment of dry eye symptoms in association with sac during 8 weeks. methods: patients who had a minimum of two-year history of sac and dry eyes, a positive skin prick test towards grass pollen and between the ages of 18 to 65 were enrolled. patients were evaluated on four visits and completed a daily diary, which included scales for grading allergic conjunctivitis and dry eye symptoms. at each clinic visit they completed the osdi and the rqlq (rhinitis quality of life questionnaire). the osdi (ocular surface disease index) was developed to assess dry eye symptoms and the impact on vision related functioning. the rqlq evaluates quality of life in patients with allergic conjunctivitis. at the last visit, both the patient and the physician assessed the treatment and the effectiveness, if any, of the addition of refresh to nedocromil sodium 2% ophthalmic solution. daily grass pollen counts were preformed using a burkhard sampler. results: 19 patients (7 male and 12 female) were enrolled and 3 dropped out. patients experienced minimal symptoms at the start of the season due to low concentration of grass pollen. preliminary analysis carried out using a paired t-test was preformed on the ocular average scores for the two treatment periods. there was no significant difference between the 2 treatment groups for redness, light sensitivity and tearing of the eyes. a reduction in dry eye symptoms was reported in all patients using refresh eye drops and the number of drops required varied between patients. during the treatment periods there was improvement in patients rqlq. conclusion: patients preferred the addition of refresh eyedrops in alleviating sac and dry eye symptoms. further studies need to be carried using refresh eye drops in larger number of patients with sac and dry eye symptoms. c. laforce * , raleigh, nc. introduction: the objective of this study was to determine the ability of azelastine nasal spray to improve rhinitis symptoms and quality of life parameters in seasonal allergic rhinitis patients remaining symptomatic after treatment with fexofenadine. methods: this placebo-controlled, double-blind study began with a 1-week, open-label lead-in period, during which patients received fexofenadine 60 mg bid. after 7 days, patients who improved less than 25% to 33% on fexofenadine were randomized to treatment for 2 weeks with: (1) azelastine nasal spray, (2) azelastine nasal spray plus fexofenadine, or (3) placebo. the primary efficacy variable was the change from baseline to day 14 in thetotal nasal symptom score (tnss), which consisted of runny nose, sneezing, itchy nose, and nasal congestion scores recorded twice daily in patient diary cards. in addition, quality of life was assessed using the rhinitis quality of life questionnaire (rqlq). results: after 2 weeks of treatment, azelastine nasal spray (p<.01) and azelastine nasal spray plus fexofenadine (p<.01) significantly improved thetnss compared to placebo. based on 90 patients with complete tnss and rqlq data, the overall rqlq score also was significantly (p<.01) improved compared to placebo. conclusions: azelastine nasal spray was an effective treatment for patients with seasonal allergic rhinitis who did not respond well to fexofenadine and significantly improved quality of life parameters compared to placebo. the results of this study indicate that azelastine nasal spray is an important alternative to oral antihistamines and should be considered in the initial management of seasonal allergic rhinitis. w. berger * , mission viejo, ca. objective: to evaluate improvement over time with azelastine nasal spray in the treatment of patients with moderate-to-severe seasonal allergic rhinitis (sar) who remained symptomatic after treatment with loratadine or fexofenadine. methods: the studies were 2-week, multicenter, double-blind, placebo-controlled trials that began with a 1-week, open-label lead-in period in which patients received either loratadine 10 mg qd (study no. 1) or fexofenadine 60 mg bid (study no.2). patients who improved <25%-33% with loratadine were randomized to treatment with: (1) azelastine nasal spray 2 sprays/nostril bid, (2) azelastine nasal spray 2 sprays/nostril bid plus loratadine 10 mg qd, (3) desloratadine 5 mg qd, or (4) placebo. patients who improved <25%-33% with fexofenadine were randomized to treatment with: (1) azelastine nasal spray 2 sprays/nostril bid, (2) azelastine nasal spray 2 sprays/nostril bid plus fexofenadine 60 mg bid, or (3) placebo. the primary efficacy variable was the change from baseline to day 14 in the total nasal symptom score (tnss), consisting of runny nose, sneezing, itchy nose, and nasal congestion. symptom severity was recordedam and pm in diary cards on a 4-point scale (0=none; 1=mild; 2=moderate; 3=severe). results: in both studies, patients treated with azelastine nasal spray experienced increasing improvement intnss over 14 days of treatment.the improvements were approximately 2-fold greater than placebo at each day of the study, and the differences from placebo were statistically significant (p<.05) at days 2, 7, 14, and overall. in study no. 1, 33% of patients treated with azelastine had >30% improvement in tnss compared to 17% in the placebo group. in study no. 2, 29% of patients treated with azelastine had >30% improvement in tnss compared to 12% in the placebo group. conclusions: azelastine nasal spray was effective in treating patients with moderate-to-severe sar who remained symptomatic after treatment with either loratadine or fexofenadine. azelastine demonstrated first-day effectiveness, and patients treated with azelastine experienced increasing improvements in rhinitis symptoms over the 14-day study periods.azelastine nasal spray is an effective treatment alternative to oral loratadine or fexofenadine and an appropriate first-line therapy in the management of sar. introduction: a large, open-label, azelastine (astelin) nasal spray patient experience trial was conducted in patients with sar, vmr, or mixed rhinitis (allergic rhinitis with nonallergic triggers). this analysis evaluated the effect of azelastine nasal spray in treating rhinitis symptoms in a subset of patients with a history of asthma or sinusitis. methods: patients were entered into an open-label protocol and treated for 2 weeks with azelastine nasal spray at a dosage of 2 sprays per nostril bid. after 2 weeks, the patients completed a questionnaire that assessed onset of action, symptom improvement, satisfaction with therapy, and quality of life. results: from a total of 4364 rhinitis patients who received azelastine monotherapy during the 2-week study period, data were analyzed for patients with asthma (n=260) or sinusitis (n=346). a greater percentage of these patients had severe rhinitis compared to the overall population. nasal congestion and postnasal drip were reported as the most bothersome rhinitis symptoms. after 2 weeks of treatment with azelastine nasal spray, >80% of patients with asthma and >85% of patients with sinusitis reported some or complete control of congestion and postnasal drip. in addition, >62% of patients with asthma reported chest tightness, shortness of breath, and wheezing were somewhat or completely controlled, and >77% of patients with sinusitis reported that headache and facial pain were somewhat or completely controlled during treatment with azelastine nasal spray. conclusion: azelastine nasal spray provided effective control of rhinitis symptoms, including nasal congestion and postnasal drip, in patients with a history of asthma or sinusitis. introduction: epinastine is an antihistamine with mast cell stabilization and anti-inflammatory properties. epinastine 0.05% ophthalmic solution was evaluated for treatment of allergic signs and symptoms elicited by feline dander in a cat exposure room. methods: participants (n=30) were aged 18 years, with a history of ocular allergy to cats, a positive skin prick reaction to cat dander, and an ocular itching score of 2 (on a 0-4 scale) within 30 minutes of entering the cat room. subjects wore a tb mask while in the cat room to reduce the effects of inhaled allergen. after 30 minutes of exposure, 1 drop of epinastine hcl 0.05% was instilled in one eye, and olopatadine 0.1% was instilled in the fellow eye. environmental exposure to cat dander continued for another 60 minutes. prior to instillation, and at 5, 15, 30, 45 and 60 minutes after instillation, conjunctival hyperemia and chemosis (scales of 0-3), and ocular itching, tearing, ocular burning, nasal itching and rhinorrhea (scales 0-4) were assessed. results: instillation of a single drop of ophthalmic epinastine significantly reduced ocular itching from a mean pre-instillation score of 2.27 to a mean score of 0.37 at 60 minutes after instillation (p<.001), despite continuous exposure to cat dander during the entire period. similarly, ocular burning, tearing, and hyperemia were significantly reduced by epinastine treatment (p<.002). chemosis was only weakly induced by cat room exposure, with a mean pre-instillation score of 0.167; however, epinastine treat-ment decreased that to 0 (p=.023). instillation of epinastine also significantly reduced nasal itching and rhinorrhea scores (p<.043). results for olopatadine were not statistically different; however, the change from baseline in itching scores in the epinastine-treated eyes was greater than that seen in the olopatadine-treated eyes at the majority of timepoints. conclusion: ophthalmic epinastine is indicated for the prevention of itch associated with allergic conjunctivitis.this study shows that treatment of cat-sensitive subjects with ophthalmic epinastine following environmental exposure to cat dander significantly reduced ocular itching and other signs and symptoms of allergic conjunctivitis. objective: the objective of this study was to evaluate azelastine (astelinâ®) nasal spray, cetirizine (zyrtecâ®), fluticasone (flonaseâ®), and placebo in the treatment of patients with symptomatic seasonal allergic rhinitis. methods: this was a double-blind placebo-controlled pilot trial in 60 patients with seasonal allergic rhinitis. the study began with a 1-week, placebo lead-in period, followed by a 1-week blinded treatment period (day 1 to day 7). efficacy variables were: (1) change from baseline to day 7 in the total nasal symptom score (tnss; consisting of rhinorrhea, sneezing, itchy nose, and nasal congestion); (2) onset of action based on tnss over the 4 hours following initial administration of study drugs; and (3) change from baseline to day 2 (24-hour change) in tnss. tnss was scored twice daily (am and pm) on a 4-point rating scale (0=none, 1=mild, 2=moderate, 3=severe). patients recorded a minimum 12-hour tnss of 8 on at least 3 days during the lead-in period, and a congestion score of 3 on at least 3 days to qualify for entry. qualified patients were randomized to treatment with: (1) azelastine nasal spray 2 sprays per nostril bid plus placebo capsules qd; (2) cetirizine 10-mg tablets qd plus placebo nasal spray; (3) fluticasone 2 sprays per nostril qd plus placebo capsules qd; or (4) placebo nasal spray plus placebo capsules. results: azelastine significantly (p<.05) improved the tnss compared to cetirizine, fluticasone, and placebo beginning 30 minutes after initial administration; cetirizine significantly improved tnss versus placebo at 150 minutes; fluticasone showed no significant differences from placebo over the 4-hour evaluation period. azelastine significantly (p<.05) improved the tnss at day 2 (24-hour change from baseline) compared to cetirizine, fluticasone, and placebo. conclusions: azelastine nasal spray improved the tnss in patients with moderate-to-severe seasonal allergic rhinitis. in addition, azelastine nasal spray demonstrated a 30-minute onset of action and significantly improved tnss versus cetirizine, fluticasone, and placebo 24 hours after initial administration. introduction: epinastine, an antihistamine with mast cell stabilization and anti-inflammatory properties, has been developed for the treatment of allergic conjunctivitis. the efficacy and tolerability of epinastine was assessed and compared with levocabastine. methods: eligible patients for this randomized, double-masked, parallel-group, active-controlled environmental clinical trial were 18-65 years old with a recent diagnosis of seasonal allergic conjunctivitis. patients instilled 1 drop epinastine hcl 0.05% or levocabastine 0.05% ophthalmic solution in each eye bid for 6 weeks. patients and investigators assessed efficacy and tolerability at study visits on days 0 (baseline), 7, 14, 28, and 42, and assessed overall efficacy and tolerability at study exit. adverse events were monitored. results: epinastine provided superior itch relief compared with levocabastine (p=.048; see figure) ; mean ocular itch scores over 4 treatment visits were 0.79 for epinastine and 0.97 for levocabastine (0-3 scale; 3=worst; baseline scores were 2.08 for epinastine and 2.06 for levocabastine). the mean summed score (ocular itching, tearing, and foreign body sensation) over 4 treatment visits was significantly better for epinastine than levocabastine (p=.010).at study exit, 53% of epinastine-treated patients rated overall efficacy "very good" (the highest possible rating), versus 34% of levocabastine-treated patients. at 5 minutes postinstillation, 77% of epinastine-treated and 75% of levocabastine-treated patients rated tolerability "very good". at study exit, 80% of epinastine-treated and 75% of levocabastine-treated patients rated overall tolerability "very good", with investigator ratings being similar. treatment-related adverse events occurred in 7.1% of epinastine-treated patients (most frequent: eye pain and skin itching, 1.2% each) and 10.3% of levocabastine-treated patients (most frequent: double vision, 3.4%; influenza-like symptoms, 2.3%); most aes were mild or moderate. conclusion: our results confirm the therapeutic potential for epinastine as an efficacious treatment suitable for long-term use throughout the allergy season. ophthalmic epinastine was superior to levocabastine for relief of ocular symptoms in patients with allergic conjunctivitis and was well-tolerated. since chronic inflammation is the histopathologic landmark of otitis media with effusion, clinical observations have led us to believe that the combination of a cysteinyl leukotriene receptor antagonist montelukast with an oral antibiotic may be more efficacious than monotherapy with an oral antibiotic in the treatment of serous otitis media. we studied twenty pediatric patients (age 3 years to 6 years) in a randomized open labeled 2-week trial to compare the efficacy of the combination montelukast (4 mg or 5 mg chewables tablets qd dosed according to patient's age) with an oral antibiotic amoxicillin/clavulanate potassium (90 mg/kg/day in 2 divided doses every 12 hours) to a monotherapy with an oral antibiotic amoxicillin/clavulanate potassium for the treatment of otitis media with effusion. the efficacy of treatment options was assessed using pneumatic otoscopy, impedance tympanometry, and audiometry to monitor the clinical course of the middle ear effusion in both treatment groups. in the combination group montelukast and antibiotic a resolution of otitis media with effusion occured at the 7th day. in contrast in the group treated with monotherapy with the oral antibiotic the resolution of otitis media with effusion occured on the 14th day. in conclusion, the combination of montelukast plus an oral antibiotic is more effective than monotherapy with an oral antibiotic.the combination of montelukast plus an antibiotic may be a safer and shorter therapy given the safety issues with long term use of systemic antibiotics. introduction: a randomized, double-blind, placebo-controlled study was conducted in an environmental exposure chamber (eec) to compare the efficacy of three doses of olopatadine nasal spray, a topical anti-allergy treatment for seasonal allergic rhinitis (sar), versus placebo spray. methods: patients aged 17-65 years old with a history of sar were screened, consented, evaluated for a positive skin test to ragweed allergen, and enrolled in this irbapproved study. a total of 320 "primed" patients were exposed to ragweed allergen in the eec and randomized to olopatadine 0.2% (n=80), olopatadine 0.4% (n=80), olopatadine 0.6% (n=80), or placebo (vehicle) (n=80) spray, 2 sprays/nostril once in the morning. symptoms were self-assessed using a 4point scale (total nasal symptom score, tnss, comprised of sneezing, runny, itchy and stuffy nose) via diaries at periodic intervals during the 12-hour study period. safety was also assessed. results: obvious trends indicated a dosedependent response to olopatadine 0.2%, 0.4% and 0.6%, though concentrations were not statistically different from each other. all three concentrations of olopatadine were clearly more efficacious than placebo spray at the first time point, 30 minutes, continuing to the end of the 12-hour session. olopatadine exhibited a safety profile comparable to placebo. conclusions: olopatadine nasal spray 0.2%, 0.4% and 0.6% exhibited dose-dependent responses. onset of action for all three concentrations of olopatadine was apparent at the first post-dose timepoint, 30 minutes, and efficacy was maintained throughout the next 12 hours. olopatadine nasal spray was safe, well-tolerated, and effective for the treatment of sar in the eec chamber. c. slonim * , tampa, fl. objective: to assess patient subjective responses to the treatment of allergic conjunctivitis using azelastine hydrochloride ophthalmic solution. methods: participating physicians selected 20 patients from their practice to receive azelastine hydrochloride 0.05% ophthalmic solution 1 drop per affected eye twice daily for 5 days. patients on prior ocular allergy medications were allowed to participate. after 5 days of treatment with azelastine hydrochloride, patients (n=2, 887) rated their experiences with azelastine hydrochloride via a self-administered survey. not all questions were answered by each patient. results: at baseline, 88% of patients reported that their ocular itching affected their work, school, and/or leisure activities at least "somewhat". after using azelastine hydrochloride, 70% of patients achieved either "moderate" or "complete" relief from ocular itching, including 30% who reported "complete" relief from itching. seventy-one percent (71%) of patients had been treated previously with a topical prescription anti-allergy medication for their ocular itching. seventy percent (70%) of patients (n=836) who had not been previously treated with a topical prescription anti-allergy medication treatment and 71% of previous medication users (n=2, 192) experienced at least "moderate" relief of itching when treated with azelastine hydrochloride. sixty-five percent (65%) of the previously-treated patients rated azelastine hydrochloride as "somewhat better" or "much better" than their previous medication. conclusions: results suggest that azelastine hydrochloride ophthalmic solution is an effective treatment for the ocular itching associated with allergic conjunctivitis as rated by the patient, regardless of whether they had been treated previously with a topical prescription anti-allergy medication. objective: to determine an association between food allergy and acid reflux in adults. method: we conducted a retrospective chart review of 60 atopic adult patients in an academic otolaryngic allergy practice. 30 adults who tested positive and 30 adults who tested negative for food allergy were included in the study. charts were reviewed for a diagnosis of gastroesophageal reflux disorders (gerd). this included a history of laryngopharyngeal reflux (lpr) and peptic ulcer disease (pud). population prevalence (19.8%; ci 17.7-21.9) of acid reflux was estimated from a historical study (locke gr et al. prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in olmstead county, minnesota. gastroenterology 1997; 112:1448-56) that had a similar subject population. the prevalence of gerd in each study arm, as well as in the total study group of atopic adults, was compared to the historical control. results: subjects testing positive for food allergy had a diagnosis of gerd in 26.7% (95% ci 11.8-41.6) of cases. those subjects who did not demonstrate a food allergy were positive for gerd in 40% (95% ci 25.1-54) of cases. in the total study group, the prevalence of gerd was 33.34% (95% ci 22.8-43.8). on chi square analysis, the prevalence of gerd was significantly higher in the total study group when compared with the historical control (p=0.013). those subjects who tested negative for food allergy had a statistically significant higher prevalence of gerd than the control population (p=0.003). the prevalence of gerd between the group testing positive and the historical control did not show a significant difference (p=0.41). when comparing the study arms to each other, there was no significant difference in the prevalence of gerd (p=0.27). conclusions: the prevalence of acid reflux disorders was not higher in subjects with food allergy when compared to a historical control. although a statistical significance was noted between adults who tested negative for food allergy and the control population with regards to the prevalence of gerd, this may reflect the fact that individuals examined in an otolaryngologist's office are more likely to have acid reflux disorders than the general population. overall, the atopic subjects did have a higher incidence of acid reflux disorders, but there was no statistical significance between subjects with and without food allergy. a. suryadevara * , d.l. hamilos, boston, ma. introduction: recent studies suggest that crs without nasal polyposis (crssnp) and crs with nasal polyposis (crscnp) represent distinct pathologic entities. we wished to determine whether these conditions differed in their clinical presentation. methods: over a two-year period, new patients coming to a university based specialty clinic meeting criteria for crs were enrolled in an outcomes study. patients indicated which of four major (facial pain/pressure/headache, nasal obstruction, nasal purulence/discharge, and hyposmia/anosmia) and four minor (fever, halitosis, dental pain, cough) criteria for crs they were experiencing. rhinoscopy was performed to look for nasal polyps or polypoid tissue in any sinus area. the prevalence of each symptom was compared in the groups by chi square analysis. results: the population (n=126) had a mean age of 46 +/-13.6 and was 59% female, 86% caucasian, 8.7% african-american, 1.6% asian and 1.6% hispanic. most patients (87%) were non-smokers. all had at least 2 major criteria or 1 major + 1 minor criteria for crs at enrollment. forty-one patients (32.5%) had crscnp. the mean number of major criteria was greater in the crscnp than crssnp (3.27 vs 2.91, p=0.017). nasal obstruction and hyposmia/anosmia were more prevalent in crscnp (p= 0.05, 0.025 respectively). facial pain/pressure/headache was more prevalent in crssnp (p=).025). the most prevalent symptoms in crscnp were: nasal purulence/discharge (97.6%)>hyposmia/anosmia (85.4%)>facial pain/pressure/headache (82.9%)>nasal obstruction (61%). in contrast, the most prevalent symptoms in crssnp were: facial pain/pressure/headache (95.3%)>nasal purulence/discharge (88.2%)>hyposmia/anosmia (64.7%)>nasal obstruction (42.4%). none of the symptoms were absolutely distinguishing of these conditions. no differences were found between the two groups for fever, halitosis, dental pain or cough. conclusion: we conclude that patients with crscnp have a greater burden of symptoms of crs and a much higher prevalence of hyposmia/anomsia. these findings are consistent with other studies showing that, in comparison to crssnp, crscnp tends to be more difficult to treat and have a higher rate of relapse after intensive medical therapy (subramanian et al, am j rhinology 2002;16:303). l.e. mansfield 1* , e.e. philpot 2 , c. posey 1 , 1. el paso, tx; 2. research triangle park, nc. daytime sleepiness is a common complaint in sar. patients often complain of mental slowness, difficulty in concentrating, and thinking. the present study evaluated whether effective therapy of sar would decrease dss and improve an objective measure of cp. dss was measured using the epworth sleep scale (ess). objective cp was measured using the test of variables of attention (tova), a validated test. thirty two adults (15 males, 17 females with a 2 year history of sar, a compatible physical exam, and corresponding positive allergy testing) volunteered for this 3 week randomized double blind placebo controlled study. after a one week inf placebo (pl) baseline, the subjects received either active inf or continued pl. they maintained daily nasal symptom dairies and ess. the subjects took the tova test at the end of week1 and week3. weekly nasal symptom scores significantly improved with the inf, but not the pl. w1 vs. w3 nasal congestion inf 29, 24 p=.03, pl 29, 26 p=ns; runny nose inf 22.5, 19.9 p=ns; pl 21.75, 21.38 p=ns; sneezing inf 26.5, 19 p=.01; pl 24.9, 21.1 p=ns. total weekly ess was abnormal and decreased significantly in the inf group, but not in pl group. w1 vs. w3 inf 60.5, 46.5 p=.001, pl 52.6, 46.8 p=ns. response time of the tova testing, initially somewhat slow, significantly decreased in inf but not pl treatment. w1 vs. w3 inf 435 msec, 385 msec p=.02; pl 360 msec, 359 msec p=ns. these results demonstrate that sar is associated with dss and cp problems. the mechanism is likely to be sleeping disordered breathing associated with nasal congestion and obstruction. effective treatment of nasal congestion with inf led to decreased dss and improved cognitive performance. l.e. mansfield 1* , c. graham 2 , 1. el paso, tx; 2. new york, ny. there is increasing recognition that sleep disturbance and daytime tiredness occur during active ar. the mechanism appears to be nasal congestion and obstruction leading to sleep disordered breathing and resultant poor quality of sleep. in our practice, as part of the initial history, questions regarding fatigue, snoring, sleep problems, and tiredness are addressed. sleep problems and tiredness are graded according to the following scale: effect on daily activity ; 0=not troubled;1= a little trouble; 2=somewhat troubled ;3= trou-bled a lot ; 4= total disruption. we reviewed 272 consecutive charts of patients with allergic rhinitis documented by history, physical examination and allergy testing. there were 169 females and 103 males; age range 5y to 84y. 127 (47%) of patients or parents recognized they commonly snored. 40 (15%) stated they were chronically fatigued. the graded answers concerning sleep problems and tiredness were even more revealing of ar patient's perception of their problems see table in general, the higher sleep problem responses were associated with higher tiredness scores. national surveys of unselected populations suggest that about 10 percent of adults consider themselves to have sleep problems. the high frequency of sleep related problems and tiredness in our sample has prompted us to add more detailed questions regarding sleep related events to our intake history. it is our opinion that questions specifically related to sleep and daytime tiredness should be included in all evaluations for allergic rhinitis. we conclude that sleep related problems and tiredness may be more common in patients with allergic rhinitis than previous reported. r.w. weber 1* , j. garcia 2 , r. faruqi 2 , d. banerji 2 , g. georges 2 , the study 405 investigator group 3 , 1. denver, co; 2. bridgewater, nj; nj. introduction: the intranasal glucocorticosteroid triamcinolone acetonide (taa) is a safe and effective treatment for persistent allergic rhinitis (par). a new hydrofluroalkane-134a (hfa) propellant delivery system (taa-hfa) has recently been developed. this study primarily assessed the long-term safety of taa delivered via this new device, as well as its long-term efficacy. methods: 396 patients aged 12-69 yrs (mean=32) with par enrolled in this 1-yr, open-label study at 10 centers in the us. patients received taa-hfa 220 î¼g once daily for a 2-week run-in period before adjusting the dose to 440 î¼g or 110 î¼g once daily based on symptom severity. doses were standardized to 440 î¼g once daily across all patients at ~4 months to ensure sufficient long-term safety data at the maximum dose. physical exams, including measurement of vital signs and laboratory measurements were taken at baseline, 6 months and study end. independent patient and physician global symptom evaluations were performed at baseline, week 2 and months 1-12 thereafter. patients recorded any adverse events (aes) on daily diary cards. results: of the 396 patients included in the study, 349 (88.1%) reported aes. the incidence of aes was similar to that of other comparable allergic rhinitis long-term studies. the most frequently reported aes were pharyngitis, rhinitis, local reactions, headache, epistaxis and sinusitis (table 1) . most aes were mild-to-moderate in intensity; 34 patients withdrew from the study due to aes. there were no clinically relevant changes in physical exams, vital signs or laboratory measurements. a total of 4 serious aes (saes) were reported; breast carcinoma (n=1), depression (n=1), post-operative spinal fluid leak (n=1) and staphylococcal infection (n=1). saes were thought to be not related to the study drug. at final visit, 83% of patients had either moderate or marked/complete relief of symptoms using global symptom scores. similarly, 86% of physicians rated their patients as having either moderate or marked/complete relief. conclusions: long-term administration of taa-hfa 440 î¼g exhibited a good safety and tolerability profile, while providing moderate-to-complete symptom relief in more than 80% of patients treated for par. introduction: second-generation, 'non-sedating' antihistamines (ahs) have lower tendency to cross the blood-brain barrier and cause central nervous system side effects than first-generation agents. however, studies have suggested differences between second-generation ahs regarding cognitive function impairment. methods: a medline literature search was performed using the search terms 'antihistamine and impairment', 'antihistamine and psychomotor' and 'antihistamine and central effects', as well as with individual ah names (acrivastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, loratadine, mequitazine and mizolastine). the findings for second-generation ahs were reviewed and well-designed, placebo-and positive-controlled studies in humans using objective measures of cognitive impairment were included. results: 43 publications were identified as the inclusion criteria. all included objective assessments such as driving performance, critical flicker fusion and divided attention tasks. there was a large variation in the numbers of available well-designed studies; the most rigorously assessed agents were fexofenadine and cetirizine. a number of the ahs (ebastine, acrivastine, loratadine, mequitazine and mizolastine) were not impairing at recommended doses, but were at higher doses. in a small number of available studies, the newer ahs desloratadine and levocetirizine produced no impairment at recommended doses (5 mg); however, higher doses were not investigated. cetirizine studies were variable; impairment at the recommended 10 mg dose or higher was seen in a number of studies. in contrast, fexofenadine hcl, up to a dose of 360 mg, was non-impairing in a large number of studies. only one study indicated impairment in one task (critical tracking) and this was only observed with the first doses of fexofenadine hcl (120 and 180 mg) and not subsequent doses; however, the authors concluded that doses up to 240 mg/day should be safe for patients who drive. conclusion: while second-generation ahs are less impairing than the first-generation, some newer ahs produce impairment at or above the recommended dose. these differences become important to the patient when agents cause sedation or if patients over use beyond the recommended dose. in conclusion, fexofenadine was the only ah found to be non-impairing in all studies, even at double the recommended us dose. s. shaver 1 , r.b. berkowitz 1* , c. lutz 1 , p. jones 1 , c. qiu 2 , s. meeves 2 , s.t. varghese 2 , g. georges 2 , 1. woodstock, ga; 2. bridgewater, nj. introduction: fexofenadine (fex) is a h1-receptor antagonist, with proven efficacy in the treatment of allergic rhinitis (ar). to date, no live cat-room challenge studies have assessed the efficacy of fex in cat-allergen induced ar. this study assessed the efficacy of a single dose of fex hci 180 mg in preventing and controlling cat-allergen induced ar using the cat-room challenge model. methods: this single-center, prospective, randomized, doubleblind, placebo-controlled, two-way crossover study consisted of a screening visit, one or two priming visits and two treatment periods, separated by a 14 (â±3)-day wash-out. qualifying subjects were randomized to treatment sequence 1 (placebo followed by fex) or 2 (fex followed by placebo). baseline endpoints were obtained prior to study drug administration, and 5 minutes before entering the cat challenge room for allergen challenge. allergen challenges were initiated 1.5 hours post-dose, for both treatment periods. the primary endpoint was the change from baseline in total symptom score (tss; sum of rhinorrhea, itchy nose/palate/throat, sneezing and itchy/watery/red eyes) after 30 minutes of allergen exposure at 2 hours post-dose, compared with placebo. other endpoints included changes in individual symptom scores, including nasal congestion. levels of airborne felis domesticus allergen 1 (fel d 1) were determined. results: of 211 subjects screened, 66 were randomized and 63 completed the study; 32 and 31 in sequence 1 and 2, respectively. mean change in tss from baseline was significantly less with fex compared with placebo at 30 minutes after initiation of the cat allergen challenge (p=0.0327). significantly greater percentage reductions in the individual symptom scores for sneezing (p=0.0037) and nasal congestion (p=0.0455) were observed with fex compared with placebo, 30 minutes after challenge. although levels of fel d 1 varied widely, they were balanced between treatment groups. the overall incidence of treatment-emergent adverse events (aes) was low and comparable between groups; no serious aes occurred. conclusion: this study demonstrated that a single dose of fex hci 180 mg is effective and well tolerated as a prophylactic agent for alleviating the ar symptoms induced by exposure to cat allergen. further large-scale clinical trials are warranted to confirm these findings. rationale: allergic rhinitis in children is thought to be associated with several co-morbid disorders. we conducted the following study to assess whether children with diagnosed hypertrophy of tonsils and/or adenoids evaluated by an allergist were more likely to demonstrate objective evidence of allergen sensitization than children similarly evaluated without evidence of these upper airway obstructions. methods: records from the past ten years were identified in the hospital database by presence of an allergy clinic visit and an icd-9 code for hypertrophy of adenoids and/or tonsils. we reviewed these records to confirm that the diagnosis was accurate. we included subjects if reliable skin prick or in vitro testing for specific ige to aeroallergens was performed. for comparison, we randomly obtained an age and testing-type similar sample. first group subjects were excluded from the second group. skin testing was performed with commercial allergen extracts applied with a dermapikâ©. in vitro testing was by unicapâ© feia. positive skin testing had at least a wheal 3 mm or flare 10 mm greater than the negative control. positive in vitro values were 0.7 ku/l or greater or a positive pollen mix. additionally, we performed a search in an insurance database to determine how many local children had a code for allergic rhinitis. results: of 202 pediatric allergy patients with adenoid/tonsillar hypertrophy tested, 41.6% (95% ci +/-6.8%) had at least one positive test. in 802 without adenoid/tonsillar hypertrophy, 50.7% (95% ci +/-3.5%) had at least one positive test. the observed difference was 9.1 % (95% ci +/-7.6%). the standard error of the difference in percentage was 3.94; the z score was 2.3. the corresponding p value is 0.02. the percentage of 70, 356 children with an allergic rhinitis icd-9 was 15.6% (95% ci +/-0.3%). conclusion: the number of allergist-referred children with adenoid and/or tonsillar hypertrophy testing positive for an aeroallergen is slightly less than the number of similar children without these diagnoses testing positive. it is not clear that adenoid/tonsillar hypertrophy is associated with a higher risk of allergic rhinitis. a prospective study with allergy testing of all children with adenoid and/or tonsillar hypertrophy might provide information that could alter referral patterns. w.e. berger 1* , w. storms 2 , s. kimura 3 , m. beck 4 , s. galant 5 , t. westbrook 3 , 1. mission viejo, ca; 2. colorado springs, co; 3. pensacola, fl; 4. miami, fl; 5. orange, ca. background: patients having allergic rhinoconjunctivitis are often treated with nasal spray or systemic allergy therapy, forgoing therapy specifically targeting ocular symptoms. the rhinitis quality of life questionnaire (rqlq) and allergic conjunctivitis quality of life questionnaire (acqlq) instruments can be used to quantify the relative benefit of varying medication regimens. objective: to determine the extent of benefit gained in quality of life when an eye drop treatment for ocular allergy (olopatadine) was added to rhinitis patients' preexisting regimen of nasal or systemic allergic treatment. methods: this was a four week prospective, multi-center, open-label crossover, quality of life study occurring during allergy season. at visit 1, patients completed the rqlq and acqlq questionnaires to assess baseline quality of life. patients were randomized to receive ocular allergy therapy (olopatadine, patanol bid) concomitant with their systemic or nasal rhinitis treatment(s) for 2 weeks between either visit 1 and visit 2 (group a) or between visit 2 and visit 3 (group b). at visit 2 and visit 3, patients completed the rqlq and acqlq. results: a total of 200 patients completed this study: 97 in group a, 103 in group b. of these, 181 (90.5%) experienced eye allergy symptoms at least 1 day during the previous week as reported in the baseline acqlq. baseline scores of the rqlq and acqlq for both groups were comparable. clinically significant improvement from baseline in global rqlq and acqlq was seen following addition of ocular therapy for both groups (rqlq: -1.07, -0.94; acqlq: -1.2, -1.2). similar improvement was seen across all domains of both questionnaires. the acqlq correlated with the rqlq in the applicable domains. conclusion: many allergic rhinitis patients using nasal or systemic medication also suffer from ocular allergic symptoms. for these patients, quality of life improvement is not maximized; the addition of a topical antiallergy eye drop can result in beneficial effects on quality of life. in this study, the addition of olopatadine eye drops to these patients' medication regimens resulted in significant improvement in not only eye symptom related quality of life domains but in overall quality of life. h. milgrom 1* , r. lanier 2 , f.c. hampel 3 , b. kittner 4 , 1. denver, co; 2. fort worth, tx; 3. new braunfels, tx; 4. bridgewater, nj. introduction: fexofenadine, a non-sedating, selective h1-receptor antagonist, is currently indicated for use in children aged 6-11 years with seasonal allergic rhinitis in a number of countries, including the us, and has an excellent safety profile in this age group. this study was designed to assess the safety and tolerability of fexofenadine in children aged 2-5 years with allergic rhinitis (ar). methods: the study had a multicenter, double-blind, randomized, placebo-controlled, parallel-group design. children aged 2-5 years (n=453) with ar were randomized 1:1 to either placebo twice daily (bid; n=231) or fexofenadine hcl 30 mg bid (n=222), for 2 weeks. both treatments were given orally as granulated powders (capsule content) mixed with two teaspoons of apple sauce. treatment-emergent adverse events (teaes) were recorded for all subjects by parents/caregivers and assessed by investigators. clinical laboratory variables, physical examinations, vital signs and ecg evaluations were also assessed in a subgroup of children (placebo, n=79; fexofenadine, n=71). results: baseline demographics were similar in both treatment groups. while approximately 50% of children in both groups experienced at least one teae, no unusual or unexpected teaes were observed in the fexofenadine group. when the total group was analyzed for teaes by body system, or assessed separately by age groups of 2-, 3-, 4-and 5-year-olds, no clinically meaningful differences were observed between the two treatment groups. in both treatment groups, the majority of subjects overall and in each age group experienced teaes rated as mild or moderate in intensity. few subjects experienced teaes considered possibly related to study medication (placebo: 8.2% [19/231]; fexofenadine: 9.5% [21/222]). the percentage of discontinuations due to teaes was also comparable between treatment groups (placebo: 6.9% [16/231]; fexofenadine: 5.0% [11/222] ). in the subgroup assessment, no clinically relevant changes were seen from baseline for laboratory variables, vital signs, ecgs or physical examinations in either treatment group. introduction: the efficacy and safety of fexofenadine hcl 30 mg bid has been proven in two large phase iii studies in pediatric subjects aged 6 to 11 years with seasonal allergic rhinitis. in addition, the safety of fexofenadine has been demonstrated in pediatric subjects 2 to 5 years of age with allergic rhinitis (ar). subsequently, two studies (t/3001; t/3002) have assessed the pharmacokinetics, safety and tolerability of fexofenadine 15 and 30 mg bid in pediatric subjects 6 months to 2 years of age. methods: both studies were of multicenter, randomized, double-blind, placebo-controlled, parallelgroup design and enrolled pediatric subjects aged 6 months to <1 year weighing 10.5 kg and aged â±1 year to <2 years weighing >10.5 kg. all subjects had a diagnosis of ar as assessed by previous medical history, pattern, or suggestive physical findings. subjects were randomized to receive fexofenadine hcl 15 mg (t/3001), or 30 mg (t/3002) granulation powder twice-daily, or placebo for a minimum of 7 days. safety was evaluated based on adverse events (aes), vital signs, 12-lead electrocardiograms (ecgs), and physical examinations. results: a total of 174 and 218 subjects were randomized in studies t/3001 (fexofenadine hcl 15 mg bid: n=85, placebo: n=89) and t/3002 (fexofenadine hcl 30 mg bid: n=108, placebo: n=110), respectively. in t/3001, 40.0% (34/85) of children receiving fexofenadine and 42.7% (38/89) receiving placebo experienced at least one treatment-emergent ae (teae). in t/3002, the incidences of teaes were 35.2% (38/108) and 52.7% (58/110), respectively. in both studies, most of the teaes experienced were mild or moderate in intensity. the incidence of possibly-related teaes was also similar for both treatments in each study. no clinically relevant changes from baseline to study end were observed for vital signs, ecgs and physical examinations. conclusions: the findings of this study show that fexofenadine 15 mg and 30 mg bid are well tolerated and have a safety profile comparable to placebo in pediatric subjects aged 6 months to 2 years. for seasonal allergic rhinitis (sar) patients that remain symptomatic on an h1-receptor antagonist, cetirizine, and a nasal glucocorticosteroid, mometasone furoate, the addition of omalizumab, a recombinant, humanized, chimeric, anti-ige monoclonal antibody, may provide additional efficacy in sub-optimally controlled seasonal allergic rhinitis patients. in this open labeled 12week trial, 20 patients with symptomatic sar currently using cetirizine, 10 mg qd, + mometasone furoate, 100 mcg/nostril qd, were randomized to continue the existing therapy cetirizine + mometasone or to add-on omalizumab subcutaneously (every 2 weeks to 4 weeks) dosed according to patient's weight, and baseline ige levels to the existing therapy cetirizine + mometasone furoate. the endpoints of the trial include: rhinomanometry, nasal symptom score (composite score of nasal congestion, rhinorrhea, sneezing, post nasal drip and itching) and flexible rhinopharyngolaryngoscopy examination. mean efficacy measurements at the end of the 12-week trial revealed a significant improvements in all parameters examined in the treatment group receiving omalizumab (as add-on to the existing therapy), compared to the other group. in conclusion, the addition of omalizumab to the combination of cetirizine plus mometasone furoate, is more effective than the combination of cetirizine plus mometasone furoate, for the treament of seasonal allergic rhinitis patients. it appears that when omalizumab is added to the combination h1receptor antagonist, cetirizine, and nasal corticosteroid, mometasone furoate, the primary end points (rhinomanometry and symptom scores) are significantly improved. background: based on the official statistic data, the prevalence of allergic diseases in russia has increased more than 3 times during the past 10-15 years, but still the lowest of all european countries. in some studies done in some regions of russia based on isaac program, it has been shown that the prevalence allergies is significantly higher than indicated in official statistics of health departments. the goal of this investigation was to study the prevalence of allergic diseases, in children of south russian region. meth-ods: this study was done in two steps according to isaac program guidelines. in the first step a questionnaire was given to a total of 6558 school children, ages 7 to 8 (group a) and 13 to14 years old (group b), from the two cities of krasnodar and novorossiysk in southern russia. in the second step a physical exam, skin prick tests with different allergens (pollens, molds, cat, dust mites, foods etc.), and pulmonary function tests were performed. results: wheezing was reported in 12.9% of group a and 15.3% of group b children within the past 12 months. the severity of asthma reported was mild in 72% (group a)-84% (group b); moderate in 16.7% (group a)-10.7% (group b) and severe in 3.4% (group a)-5.8% (group b) in studied children). majority of the cases of asthma was noted to be allergic asthma. in both groups of children there was a high incidence of allergies to perennial allergens such as dust mites, cats, molds and other indoor allergens, 18.7% (group a) and 77.3% (group b). the percentage of allergies to pollens was 19.1% and 33.0%, accordingly. allergic rhinitis symptoms were noted in 26.6% (group a) and in 38, 6% (group b). atopic dermatitis symptoms with skin itching observed in 8.3% (7-8 years old)and 5.3% (13-14 years old). family history of atopy was noticed in 34.6% of group a and 41.6% of group b children. conclusions: the prevalence of allergic diseases in south russia is similar to the ones in most of the european countries. the prevalence of asthma has been associated with increased incidence of allergies, due to indoor and pollen allergens. the prevalence in rhinitis and atopic dermatitis in south russia is parallel to asthma. acknowledgement: we would like to thank hollister-stier lab., greer and antigen lab. for allergen samples. objective: to examine the cost and effectiveness of telithromcyin vs. azithromycin for treatment of mild acute sinusitis under current levels of antimicrobial resistance. methods: we considered an adult with mild acute sinusitis, and symptom duration of 7 days. a decision analytic model was created to compare 2 strategies of 1st-, 2nd-and 3rd-line therapies: azithromycin/amoxicillin-clavulanate/levofloxacin (azi/amc/lev), and telithromycin/amoxicillin-clavulanate/levofloxacin (tel/amc/lev). we considered 3 outcomes: response to initial therapy, cost, and time to completion of all antibiotic therapy. clinical resolution was due to response to antibiotic, or to spontaneous resolution. we assumed bacteria that were resistant in vitro would only be resistant in vivo 50% of the time. resistance levels were based on the 2000-2001 us protekt surveillance study. model parameters, such as prevalence of bacterial infection, frequency of causative pathogens, and rates of spontaneous resolution, were based on the published literature. those failing to improve after 5 days were switched to next line therapy. we analyzed claims data from 8 managed care organizations to estimate non-drug charges for initial and follow-up care, and applied a 60% cost-to-charge ratio. drug costs were estimated using the wholesale acquisition cost plus $8 for overhead and dispensing. all costs were adjusted to year 2004 $us. results: the model predicted the tel/amc/lev strategy would result in 71.8% improving by 5 days compared to 65.4% for azi/amc/lev. the telithromycin strategy had lower mean cost, $172 vs. $176. although telithromycin cost more than azithromycin, the tel/amc/lev strategy had slightly lower total drug costs ($95 vs $96) due to less need for additional antibiotic courses. mean time to completion of therapy was 8.4 days for tel/amc/lev and 9.1 days for azi/amc/lev. sensitivity analyses showed that tel/amc/lev had superior health outcomes even when only 5% of in vitro resistant organisms were also resistant in vivo. tel/amc/lev also had lower cost if at least 30% of cases were bacterial, or if in vitro resistant organisms were at least 30% resistant in vivo. conclusion: based on results obtained using this decision analytic model, initial treatment of mild acute rhinosinusitis with telithromycin may result in improved outcomes and lower cost than initial treatment with azithromycin. rationale: "delta crud" is the term used to describe rhinosinusitis syndromes in the mississippi delta region. local perception is that it is associated with chemical crop dusting, regional produce, especially cotton, or high rates of mold allergy. the climate is extreme with mild winters, hot humid summers, and large volume rain. thirty-five percent of inhabitants live below the poverty level, 62% are african american. patients from the agriculturally intensive delta suffer from asthma at almost twice the rate of those in the neighboring hills. rates of pesticide use are among the highest in the nation. there are no prevalence estimates for rhinosinusitis in this region. "delta crud" is chronic in many patients with exacerbations occurring in the summer and fall, especially during chemical spraying and defoliation. we conducted this cross-sectional questionnaire based pilot study to begin characterization of rhinosinusitis in this population. method: the sinusitis treatment outcome questionnaire, with two modifications, was given to consecutive patients presenting to the north sunflower regional hospital er and the sunflower outpatient clinic one month prior to the beginning of summer crop dusting. the question, "do you have delta crud?" was added. the survey was anonymous, allowing irb exemption. results: 91 consecutive patients returned completed questionnaires. 46(50%) admitted to having "delta crud". patients who claimed to have delta crud had significantly more sinus headache, nasal pruritus, conjunctivitis, and chest symptoms (see table) . there was no significant difference in antibiotic prescriptions, er visits, and missed work. six patients with delta crud had been hospitalized for "allergy reasons" compared with three patients without delta crud. despite severe symptoms just 4 patients received sinus ct scans. only 10/46 patients were prescribed intranasal corticosteroids. conclusion: in our pilot study, the prevalence of chronic rhinosinusitis symptoms (delta crud) is 50%, with severe sinus, pulmonary and ocular symptoms. evaluation and treatment may be suboptimal in this economically disadvantaged rural region. further characterization of "delta crud", pollen counts, ige mediated disease, environmental contributions and comparative studies of related regions are needed. introduction: patients with rhinitis commonly experience sinus pain and pressure (sp+p). many patients with recurrent acute bacterial sinusitis (rabs) base the presence of a recurrence on the severity of sp+p and other nasal symptoms. the ability of patients to differentiate between rhinitis and rabs was evaluated by reviewing the subject screening logs of 4 previously reported clinical trials of flonase (fluticasone propionate) nasal spray, 50 mcg (fp). methods: the efficacy of fp was studied in two trials in subjects with sp+p due to allergic rhinitis and in two trials of subjects receiving cefuroxime axetil to treat an acute episode of rabs. sp+p screening logs were examined to determine how many subjects who thought they had sp+p were excluded from the study for an upper respiratory or sinus infection. rabs screening logs were examined to determine how many subjects with symptoms of an acute episode of rabs were excluded from the study for a negative sinus x-ray or ct scan. rabs symptoms experienced at the screening visit by subjects who qualified for the study were also evaluated. results: of 505 subjects screened in the sp+p studies, only 4 (0.8%) were excluded for evidence of sinus or upper respiratory tract infections, as clinically diagnosed by the investigator. out of 1502 subjects with screening log data in the rabs studies, 649 (43.2%) were excluded for a negative sinus x-ray or ct scan. of the 704 subjects who qualified for the rabs study, the most prevalent symptoms included nasal congestion (100%), mucopurulent discharge (97%), facial pain or tenderness in the sinus area (93%), sinus headache (90%) and malaise (90%). only 15% of subjects had a fever. only one symptom, nasal congestion, was rated by clinicians as severe for greater than 40% of subjects in either study (46% and 43%). conclusions: while most subjects can determine when sp+p is due to allergic rhinitis, many cannot determine when symptoms progress to a sinus infection. symptoms experienced by subjects with rabs were consistent with inflammation, but did not include fever as may be expected with an untreated bacterial sinus infection. under appreciation by patients for the role of inflammation in sinus disease may result in over self-diagnosis of sinus infection and the demand for antibiotics. liposomes are small particles consisting of lipid bilayer membranes, which are used to deliver drugs including amphotericin b, more efficiently and with less toxicity. very few cases of allergy to liposomal amphotericin b (lab) have been reported to date. although there is a report on conventional amphotericin b (cab) desensitization, to our knowledge no case of lab desensitization has been described yet. a 75 y/o patient with lymphoma was treated with lab for pulmonary aspergillosis. within 30 minutes of infusion he developed urticaria, hypotension and tachycardia for which he was treated with the appropriate drugs for anaphylaxis. a second attempt to re administer lab resulted in a similar anaphylactic reaction. desensitization to lab was then successfully completed using a modified protocol based on desensitization to cab (jaci 1995; 96:425-7) : 0.0005 mg infusion over 10 minutes 0.005 mg infusion over 10 minutes 0.05 mg infusion over 10 minutes 0.5 mg infusion over 30 minutes 5 mg infusion over 30 minutes 50 mg infusion over 30 minutes 100 mg infusion over 30 minutes 200 mg infusion over 120 minutes conclusion: desensitization to lab, a lifesaving drug for invasive fungal diseases, can be performed successfully. adverse events (aes) were recorded throughout the study. therapeutic comparability was defined a priori as a clinical response within 30% for hfa vs cfc for the primary efficacy measures. results: baseline demographics were similar between treatments for the intent-to-treat population. mean 24-h baseline symptom scores for nasal stuffiness, nasal discharge and sneezing were 2.4, 2.3 and 2.1, respectively, out of a possible score of 3. all taa-cfc and taa-hfa doses significantly (p<0.05) reduced 24-h, and am and pm 12-h reflective scores for nasal stuffiness, nasal discharge, sneezing and ni vs placebo (except cfc 14 î¼g for sneezing). taa-hfa and taa-cfc were statistically comparable (within 0.70 and 1.3 for the 2 one-sided 90% confidence interval) at doses of 110 î¼g and 440 î¼g for the primary variables of nasal discharge, sneezing and ni for the 24-h, as well as the am and pm 12-h reflective assessment, over the 2-wk period 36 * , 66 * agrawal p27, p35, 41, p58, p105, p106, p110, p180 41 * , p21, p27, p58 * p105, p106, p110, p180 p7 * finegold, i. 42 * fink p21 * 26 * sienra monge 45 * , 55, 62 * so, c. p52 * soane 70 * , p143 * staveren, a.m rates of cardiovascular mortality are higher during peak pollen times. (brunkreef, lancet 2000) . for this reason, mast cell stabilizing agents and leukotriene antagonists are under development for the treatment of myocardial infarction. conversely, ige mediated disease may be protective against sudden cardiac death.(szczeklik, coron art dis 1993) ar has not been studied in this context. we conducted a retrospective case control pilot study of va patients who were diagnosed with allergic rhinitis and had an acute myocardial infarction. methods:the electronic medical record of a large va hospital was queried for patients diagnosed with an acute myocardial infarction (ami) in the past six years. patients were divided into groups with and without ar. patients with chronic urticaria, asthma, and eczema were excluded from this study. primary outcome was all-cause mortality. secondary outcomes included lv systolic function and peak troponin levels. results: 424 patients were diagnosed with ami, 63 (15%) of which were also diagnosed with ar. patients with and without ar did not differ in terms of age, ethnicity, tobacco status, hypertension, diabetes, or lipid levels. 14/63 (22%) patients with ar died, compared to 152/361 (42%) control patients, (p-value: 0.0028). ar patients had lower mean peak troponin values (7.7 vs. 11.8), but these were not significant. both groups had similar lv function. conclusion: this pilot study suggests an association between allergic rhinitis and a decrease in ami allcause mortality independent of other factors. atopic patients have been shown to have prolonged bleeding times, reduced platelet aggregation, and delayed thrombin generation which can result in delayed clot production. (szczeklik, thromb haem 1986) possibly, patients in our study diagnosed with allergic rhinitis were more likely to monitor their health symptoms or had physicians who carefully addressed multiple issues. rigorous prospective studies are needed to determine the role of ar in myocardial infarction. purpose and methods. a formulation of olopatadine hydrochloride ophthalmic solution (olopatadine 0.2%) was evaluated in a randomized, placebocontrolled, double-masked, hybrid environmental study intended to determine efficacy and safety in 240 subjects with histories of seasonal allergic conjunctivitis or rhinoconjunctivitis. in this 12-week trial, subjects regularly assessed their ocular signs and symptoms. additionally, subjects evaluated both the frequency and severity of their nasal symptoms. daily throughout the study, ragweed pollen counts were obtained from each investigative center. repeated measures analysis of variance was used to compare treatment differences in the slopes for nasal symptoms as a function of pollen counts. results. the nasal results are presented herein. specifically, relative to placebo, olopatadine 0.2% significantly reduced the frequency of pollen effects on sneezing (p=0.0355) and itchy nose (p=0.0032), and reduced the severity of pollen effects on sneezing (p=0.0451), itchy nose (p=0.0178), and runny nose (p=0.0327). in this study, the most frequent ocular adverse event that was related to therapy with olopatadine 0.2% was ocular dryness, occurring at an incidence of 1.7%. no treatment-related, clinically relevant changes were observed for visual acuity, intraocular pressure, ocular signs, or fundus parameters. conclusion. olopatadine ophthalmic solution, 0.2% is safe, well-tolerated, and effective in reducing some effects of pollen on the nasal symptoms associated with allergic rhinoconjunctivitis. author index key: cord-022650-phsr10jp authors: nan title: abstracts tps date: 2018-08-14 journal: allergy doi: 10.1111/all.13539 sha: doc_id: 22650 cord_uid: phsr10jp nan (either in men or women) between metabolic syndrome and incident asthma. conclusion: this study confirmed the significance of obesity as a risk factor for incident asthma. moreover, obesity appeared to be a stronger risk factor than metabolic syndrome. 0638 | relationship between helminth infection, blood eosinophils and asthma symptoms in a rural community from the tropics peñaranda d; alvarez l; sierra n; lopez j; zakzuk j; caraballo l institute for immunological research. university of cartagena, cartagena, colombia background: immune response to helminths shares many features with the allergic response. in tropical regions where helminths are highly prevalent, asthma is still a major public health burden. large clinical cohorts suggest that high blood eosinophils (hbe=>400 cells/ mm 3 ) are associated with asthma exacerbations. however, the association between hbe and asthma severity in rural communities with prevalent helminthic infections is unclear. method: patients with wheezing symptoms in the last year living in a rural tropical community (santa catalina, colombia) where helminths are highly prevalent, were recruited for this study. blood eosinophils were assessed by complete blood count. parasitic infection was evaluated with two serial coprological exams (kato-katz method) and skin prick tests were conducted to determine reactivity to ascaris. results: seventy-three patients (mean age: 21; range: 2-64 years old) were recruited in this study. a. lumbricoides and t. trichuria active infection (47.9% and 16.4%, respectively) were not related to age or gender. a positive spt to ascaris extract, aba-1 and d. pteronyssinus was observed in 23%, 18.4% and 34.2%, respectively. mean eosinophil count was 621 cells/mm 3 ; 43.9% had hbe. rate of patients with at least one emergency department visit was 61.9% and hospitalization, 21.9%. blood eosinophil counts (as a continuous variable) were inversely associated with age (p = 0.03) and higher in helminth infection (p = 0.002). in crude univariate analysis, exacerbations (er and/or hospitalization) were associated with age (or: 0.96; 95% ci: 0.93-0.99, p < 0.01) and hbe (or: 2.9; 95%ci: 1.1-7.8, p = 0.04), but not with helminth infection. for a better definition of asthma, multivariate analysis done in those >7 years old indicated that hbe, helminth infection and positive ascaris spt were not associated with asthma exacerbations. conclusion: uncontrolled asthma is common in rural places of the tropics. since helminth infection influences eosinophilia, the clinical value of hbe to predict exacerbations is limited in helminth-endemic populations. castro mc 1 ; ferreira j 2 ; sarmento d 2 ; carvalho c 2 ; matos a 2 ; bicho m 2 1 chln-immunoallergy; lisbon medical school-genetic department, lisboa, portugal; 2 lisbon medical school-genetic department, lisboa, portugal background: the bioavailability of no and endothelial homeostasis depends on the functional polymorphism of 19-bp del/ins within intron-1 of dhfr (dihydrofolate reductase enzyme) (rs70991108) that could interfere in the regeneration of bh4 (tetrahydrobiopterin) from bh2 (7,8-dihydrobiopterin) and contributes to endothelial dysfunction in asthma. method: asthmatics (n = 123) compared with control group (n = 50).the polymorphism was analyzed by pcr. control of asthma assessed by (acq7 and paqlq). statistical analysis with spss 23.0 establishing a significance level of p < 0.05. results: there are 80 women and 43 males in asthmatics and 39 women and 11 males in controls (p = 0.137). in asthmatics: age ( x ± sd): 38.26 ± 19.24 ; and in control group: age ( x ± sd): 51.50 ± 13.34. the genotype frequencies in asthmatics are: dd (6.5%); id (66.7%); ii (26.8%); in control group: dd (12.0%); id (64.0%); ii (24.0%); there is no statistical difference between groups (p = 0.478). the allelic frequencies in asthmatics are: allele d (39.8%); allele i (60.2%); in control group: allele d (44%); allele i (56%); there is no statistical difference between groups (p = 0.476). the genotype frequencies in the uncontrolled asthmatics are: dd (0.0%); id (61.1%); ii (38.9%) ; in the controlled asthmatics are: dd (9.4%); id (68.2%); ii (22.4%); there is statistical difference between groups (p = 0.047). genotypes id and ii are more frequent in the uncontrolled asthmatics. the allelic frequencies in the uncontrolled asthmatics are: allele d (30.6%); allele i (69.4%); in the controlled asthmatics are: allele d (43.5%); allele i (56.5%); there is a trend to have differences between groups (p = 0.059). allele i is more frequent among uncontrolled asthmatics. the uncontrolled asthmatics are older than the controlled asthmatics (p < 0.001). there is no differences in gender distribution (p = 0.903). the genotype ii confers a risk of being uncontrolled asthmatic of 2.950 times when compared with controlled asthmatics and adjusted for age: or b : 2.950 [1.117-7.789 ]; p = 0.029. physiopathology and the emergence of evidence-based clinical guidelines. however, variation still exists among some diagnostic aspects of asthma in real life. it is unknown to what degree diagnosis is affected by the treating physician's medical specialty. results: a total of 62 gps, 239 pediatricians, 364 allergists, 161 pulmonologists and 34 otolaryngologists (orls) replied. although for general application of diagnostic clinical criteria all physicians rated similarly, in general accordance with the mag suggestions, a third of non-pulmonologist practitioners don't recognize chest discomfort as one of the clue symptoms of asthma, but they erroneously believe crackles are (p = 0.01). we found agreement in almost half of all physicians to erroneously believe that viral illness' induced wheezing in non atopic children predisposes asthma. conversely, 75-85% are aware that allergic sensitization predisposes to asthma. most specialists -except pulmonologists (p = 0.02)-incorrectly listed fev1 as the best parameter to identify airflow obstruction (ao) and fev1/fvc to assess ao severity. 20% of gps do not know peak expiratory flow (pef) measurements could be valuable, and 75% of all specialists are not aware that changes in pef can also be used to confirm ao reversibility. to classify asthma, only pulmonologists adequately considered the level of control in similar proportion than severity (81% and 83%, respectively), which is uniformly the preferred method by most other specialists. conclusion: although in general many clinical aspects of asthma diagnosis seem to be accurately assessed, there is a wide specialityspecific variation regarding some aspects of phenotyping and classification, diverging from mag's recommendations. as such, our results can help to detect knowledge-gaps and to guide the development of more focused specialty-specific learning tools to improve clinical impressions, process medical evidence, and apply it to patient care. 0652 | issues, continuous medical education on treatment of acute asthma, exercise induced asthma and asthma in pregnancy should include, per medical specialty background: to unify and improve the management of asthma, including asthma exacerbations, the mexican guideline on asthma (25.5%) of 51 employees who stated increased symptoms with flour exposure. among all workers 9 (5.5%) employees were diagnosed as asthma and 7 (4.3%) workers were diagnosed as ba. conclusion: wheat flour sensitivity is high among workers who are exposed to wheat flour, however the prevalence of ba is similar to the previous data in the literature. johnsen cr 1 ; callesen kt 2 ; jensen bm 2 ; poulsen lk 2 1 clinic of allergy, dept. of dermato-allergology, gentofte hospital, copenhagen, denmark; 2 laboratory of allergy, gentofte hospital, copenhagen, denmark background: enzymes are well known as sensitizers and causes of occupational allergy primarily in the industries producing and using the products. we present a case of occupational contact urticaria, rhino-conjunctivitis and asthma in a 32 year male chef who was using a transglutaminase enzyme powder obtained from fermentation of streptomyces mobaraense as meat glue in processing of fine culinary dishes. this transglutaminase has been used for protein food preparation in industrial settings since 1992 to improve the texture of protein rich foods such as surimi or ham. in this case it was used in small scale in a gastronomy restaurant kitchen spraying enzyme powder with a sieve over raw meat without any protective equipment in contrast to the producer's recommendation. the chef was also found allergic to dried, edible mushrooms also forming part of the meat dish prepared with the transglutaminase enzyme powder. in one occasion he experienced an oral reaction with itching and swelling of the mucosa in the mouth, stridor, angioedema of the face, and urticaria after ingestion of beef meat treated with transglutaminase and rolled in horn of plenty dried mushroom powder. no other symptoms of food allergy were reported but a known cat allergy was. background: formaldehyde and xylene are occupational skin and respiratory irritant and/or sensitizer, exposure to those may be associated with dermatitis, rhinitis and asthma. health care workers, as nurses, laboratory technicians, doctors could be exposed in different tasks in operating rooms, endoscopy and in pathology laboratory. we describe three cases of work-related rhinitis in technicians employed in the same unit of hospital pathology . first case: a woman of 38 years old underwent medical examination in our occupational allergy unit because allergy respiratory symptoms. she has been working for 8 years in pathology laboratory and was exposed to xylene and formaldehyde. she developed rhinitis, rhinosinusitis, hyposmia and cough with sputum after 5 years started work. she had negative skin prick test for common aeroallergens. lung function was normal with a fev1/fvc ratio of 80% of predict. blood cells count reveled 15% of eosinophils (980/mmc) with 6550 total leucocytes. second case: a woman of 40 years old was affected by moderate persistent allergic rhinitis with positive skin prick tests to house dust mite, dog and cat. in the last year rhinitis symptoms worsened in relation to work and improved during vacation. when she was exposed mostly to formaldehyde during shift at the end of it she usually experienced face skin and conjunctival erythema. she developed work-related symptoms after 14 years of exposure in the pathology unit. third case: a woman of 38 years old, who has been working for 14 years in the pathology unit and was exposed to formaldehyde and xylene, in the last year developed moderate-severe persistent rhinitis with hyposmia and chronic cough. she referred to otorhinolaryngologist and an irritant induced rhinitis was diagnosed. she had negative skin prick test for common allergens and normal lung function. results and conclusion: the workers experienced respiratory symptoms in relation to work exposure to formaldehyde and xylene. the suspected causal agents were monitored in the work environment and an exceeding of the recommended limit values was found. preventive measure were adopted with a reduction of exposure and symptoms improve only in the second and third case. challenge test with mannitol is considered to be more specific than test with methacholine. also, duration of procedure is shorter and safer. therefore the study aim was to compare the usefulness of these two tests in monitoring of sict. method: four bakery workers with suspicion of oa underwent single-blind, placebo-controlled sict with workplace allergens accompanied by evaluation of nsbhr with mannitol and methacholine before and after sict. clinical examination, spirometry, skin prick tests (spts) to common aeroallergens and occupational allergens, serum specific ige antibodies to occupational aeroallergens were also performed. results: positive spts results to occupational aeroallergens were found in all bakery workers, specific ige to flours were detected only in two subjects. three out of the four patients displayed positive sict reaction (in two cases early spirometric response). in all of these 3 patients, airway response to methacholine increased significantly. in the first two patients also airway reaction to mannitol was significant, whereas in one subject with early reaction there was no increase in nsbr after mannitol inhalation. the patient with negative sict results did not reveal any changes in nsbr before and after the test, neither to methacholine nor mannitol. 0668 | rice-induced occupational anaphylaxis and socio-economic impact-case report method: in this prospective study, a total of 240 students completed a self-administrated questionnaire that comprised different questions and gave information about the participants and their glove use, working habits, signs and symptoms related to these gloves, precautions taken to minimize it, etc. skin prick test is performed through commercial extract latex gloves (stallergenes), while patch test is prepared through latex gloves and adhesives. two types of gloves are used: gloves that contain latex and gloves without latex (vinyl gloves), which are used also as e negative control. results: questionnaire items and diagnostic tests revealed that one-fourth of subjects were suspicious for latex gloves hypersensitivity. their mean value for skin reactions like irritant or allergic dermatitis or contact urticaria was between 10% and 14%, while for other symptoms the mean value was under 5%. logistic regression analysis revealed an association between different questionnaire items and positive allergy tests among suspected cases and diagnosed cases of latex allergy. approximately 20% of people who work with laboratory animals experience some allergic symptoms and about 10% of animal technicians go on to develop serious symptoms of asthma. uk government guidelines state that employers must prevent or adequately control exposure of employees to animal allergens and should undertake monitoring to ensure that suitable controls remain effective. the most widely used monitoring method is personal iom filters. however, these need to be attached to a pump and carried by the technician which can be cumbersome and awkward. previous data has demonstrated that allergens from dust mite, cat, dog and pollen could be captured and quantified by a novel type of nasal filter. in this current study, we sought to assess the feasibility of using the nasal filters for the assessment of exposure to mouse allergen in a laboratory facility. method: technicians working in a laboratory animal facility were asked to wear the filters during normal routine work. for comparison, they were also asked to wear an iom filter for the same duration. allergen was extracted from nasal and iom filters by gentle rocking in pbs-tween for two hours. levels of the major mouse urinary protein (mus m 1) were quantified using our multiplex array technology, which is highly sensitive and allows for quantification of mus m 1 down to 0.01 ng/ml. results: significant levels of mus m 1 were detected in the nasal filter extracts and these levels correlated with the type of activity that was being performed by the technician, as well as the housing environment of the mice. levels were compared to the suggested 'safe' limit of allergen exposure of 5 ng/m 3 . we also found that the technicians grew accustomed to the nasal filters quickly and found them far more practical for every day monitoring that wearing the iom filter and pump. conclusion: these data indicate that nasal filters may be considered a simple and easily wearable method for monitoring laboratory animal allergen exposure. future studies are planned to assess the feasibility of wearing the filters for analysing exposure to other laboratory animal allergens from rat and guinea pig. havana university lower co 2 emission, water and feed consumption and limited waste production. insects are currently allowed both for human and animal feeding in some eu countries, including italy and the risk profile related to production and consumption of insects as food and feed, including risk of allergenicity, is currently under evaluation by efsa. both food and feed products derived from insects require multiple manipulations by the breeder and/or by the workers who transform the insect into the commercial products, thus the occupational exposure have to be considered too. the aim of this work is to evaluate the allergenicity of tenebrio molitor, one most used species for animal feeding. method: t. molitor proteins were extracted from intact dried larvae and from flour of dried larvae. the protein extracts were separated in one-dimensional electrophoresis conclusion: according to these results, the larva flour seems to be less immunoreactive than the intact counterpart, probably due to the processing that causes the degradation of protein bands over 50 kda. working in gastronomy is associated with exposure to many factors with an irritating and allergic potential influencing respiratory system. food products and organic dust are the source of inhaled allergens which may cause sensitization during apprenticeship. the study aim is a prospective observation of incidence of sensitization to selected environmental and occupational allergens among culinary school apprentices and identification of work-related allergic diseases in this group. method: the cohort comprised 374 apprentices. they were examined in the first and the second year of education. questionnaire and allergological tests [(skin prick test) spt to common and occupational allergens, ige level evaluation (total and specific for occupational allergens) and pulmonary tests] were performed]. results: the most frequent symptoms reported by examined apprentices were rhinitis (12.8%), conjunctivitis (7%), skin symptoms (6.7%), dyspnea (5.6%) and cough (2.7%). 10 subjects developed nasal symptoms during the second year of education, while in 6 cases the skin symptoms and in 4 subjects conjunctivitis appeared. in 7 cases the work-related symptoms were reported. the most frequent positive results of spts were obtained with dermatophagoides pteronyssinus 24.4%, dermatophagoides farinae 21.6%, grass pollens 18.6%. positive spt to rye and barley flour were found in respectively 2.2% and 1.4% apprentices. 4.1% of apprentices had specific ige to flours. the preliminary results indicate that work-related allergy symptoms and hypersensitivity to occupational allergens are rarely found among culinary school apprentices in the first years of education. the further observation will allow to evaluate the trends in incidence of allergy to occupational allergens, as well as the clinical presentation of allergy in that group. 0677 | how multifaceted the clinical presentation and etiology of allergic diseases could be? method: the study was done in children from west georgia randomly and on based of questionnaire of representative cohort. (2014) (2015) (2016) . the cohort was 1500 children, 1-16 years old, risk factors were studied by way of interviewing, clinical-laboratory dates. for assessing the risk factors, was used 'case control' method. the statistical processing of material was done with computer program sps/sv12. inclusion criteria for enrolment were: collectors of dust, gender, existence of moisture and mold consuming of tabasco, atopic dermatitis and seasonality. results: the groups, which we have studied, prevalence of acute respiratory viral infection was 61%, bronchitis −29.3%, allergic rhinitis 33.9%, atopic dermatitis 9.1%, food allergy 5.4%. the reliability was high (p < 0.05) in families with bronchial asthma compared with healthy population. bronchial asthma was detected in 5.7% of population. the hereditary load of allergic diseases in patients with bronchial asthma was 9.7% and in healthy cohort it was 5.7% (p < 0.001). conclusion: based on the results, we can conclude that, ecological factors and genetic predisposition significantly influences on prevalence of sensibilisation of house dust mite, molds and formation of bronchial asthma. as the genetic and environmental factors that act on an immune system are better elucidated and their roles established, the implementation of more enduring preventive efforts will be developed. however, at present, the best approach to the child at high risk for the development of allergies is to institute dietary and environmental control measures early to decrease sensitization, and to recognize and appropriately treat the evolving signs and symptoms of allergic disease. background: plantation of road-side avenue trees has become a major part of the urbanization programme in kolkata metropolis of india for megacity beautification and environmental management. due to evergreen habits, gulmohor (delonix regia) and chhatim (alstonia scholaris) are frequently selected for plantation programme to generate green belts. however, an increasing incidence of seasonal pollinosis was observed among the inhabitants living in close vicinity to these trees suggesting a possible link between the airborne pollen load and the concomitant respiratory hazards. this prompted us to investigate the allergens in the pollen of these two dominant avenue trees. method: aerobiological surveys were conducted at multiple sites of kolkata for a period of two years using seven-day volumetric burkard sampler to record the pollen concentration in the outdoor ambient air. clinical data and residual blood of pollinosis patients were collected from a public hospital. allergens were detected in the pollen proteome fractionated in 2d gel by ige-serology. the major igereactive proteins were partially purified by ammonium sulphate fractionation followed by ion-exchange chromatography. the allergenic activity of the fractions was tested by histamine release assay. results: a clear correlation was observed between the pollinosis related morbidity and the aeropollen load especially during the peak flowering period of these two trees. about 41% and 52% of the patients displayed positive spt response and ige-reactivity using pollen extracts of gulmohor and chhatim respectively. immunoproteomic analyses revealed the presence of 7-8 ige-reactive components in the 2d pollen proteome of these species. hierarchical cluster analysis with patient immunoblot data identified a 31 kda and a 25 kda protein as major allergens of gulmohor and chhatim respectively. the purified fractions containing each of these two major allergens induced histamine release from granulocytes within a range between 42 and 77%. method: immortalized human keratinocyte cell line (hacat) and primary normal human epidermal keratinocytes (nheks) were differentiated with calcium chloride for 1 and 3 days, respectively. following the differentiation, the cells were treated with il-4 (100 ng/ml), il-13 (100 ng/ml), and/or hcho (4 × 10^-4%) for 2 hours. the mrna expression of flg, ivl, lor, dsg1, dsg3, dsc1, dsc3, as well as tslp was analyzed using quantitative real-time pcr. results: hcho exposure decreased the mrna expressions of structural components (flg, ivl, and lor) and cell adhesion molecules (dsg1, dsg3, dsc1, and dsc3) in a short-period time of exposure (2 hours). we also found that hcho exposure significantly enhanced il-4-and/or il-13-induced tslp production in nheks as well as hacat. interestingly, exposure to hcho alone is enough to increase the tslp mrna expression in both cells. conclusion: our results suggest that hcho exposure might synergistically damage the skin barrier function with il-4 and il-13 by increasing tslp expression and decreasing structural components as well as cell adhesion molecules. 0685 | skin prick test reactivity to aeroallergens in adult allergy clinic in a tertiary hospital: a 12-year retrospective study results: five different human sera were screened for specific ige level against 29 different allergen sources using test methods of three different suppliers. the sensitivity of the three different methods can be arranged in the ascending order manufacturer a < manufacturer c < manufacturer b. with the test of manufacturer a, 45% of the measurements were below the detection limit (0.35 ku/l), with the test of manufacturer c, 16% of the measurements were below the detection limit, whereas the test of manufacturer b leads to values below the detection limit in 10% of the cases. in terms of variation coefficient, the test system of manufacturer c had the best performance. test systems of manufacturers a and b exhibited comparable variation coefficients, which were considerably higher than that of manufacturer c. conclusion: based on these test results, only the test of supplier c is recommendable for determination of levels of specific ige for diagnostics of allergic patients. with the test of manufacturer a, elevated levels of specific ige antibodies for many allergens cannot be detected due to the poor sensitivity of the test system. the test system of supplier b exhibits a good sensitivity but the coefficient of variation is rather high for a diagnostic test. this drawback could be circumvented by multiple determination of one test parameter. although this is an advisable strategy in general, the routine in diagnostic laboratories is incompatible with this approach, since throughput would decrease while costs would increase. this study is another good example for the need of the implementation of a characterized standard material with known values of sige, as demanded by wojtalewicz et al. method: cd203c and cd63 expression on basophils were monitored upon exposure of whole blood samples (<24 hours) to anti-ige and/or allergenic extracts. staining was conducted on exposed samples using dry room temperature stable antibody panels (dura innovations format) coated in 96 well plates, eliminating all antibody pipetting steps from the workflow. red blood cells were lysed and data was acquired (without further wash steps) on a cytoflex flow cytometer (beckman coulter). staining and lysing were automated using a biomek (beckman coulter). results: the described no-wash preparation protocol, already established for manual preparation mode in tubes, could be transconclusion: the hr-test was significantly less likely to be positive, if a patient suffered from monosymptomatic ae than in ae patients with concomitant urticaria. this could signify a higher likelihood of treatment response to antihistamine and other anti-allergic medication in the latter group. background: pathogenetic mechanisms of allergy are polymorphic. they include ige-dependent and ige-independent, allergen-specific granulocyte-mediated and lymphocytic reactions, as well as nonspecific hypersensitivity, which are realized through a variety of mediators: histamine, tryptase, etc. allergen bucal challenge mimics the natural situation and is useful for understanding the mechanisms of allergic airway inflammation and airway hyperresponsiveness (ahr).saliva used as a non-invasive readily available bio-sample for diagnosis instead of blood. biomarkers in saliva are associated with the pathogenesis and clinical outcome of allergic diseases method: aim: to examine mediators for ahr with buccal(mucosal) challenge tests. we examined 14 patients with allergic asthma(the history, positive skin prick test, serum specific ige) and 12 healthy volunteers. saliva were collected. then, both groups were subjected to buccal(mucosal) allergen challenge by a water-salt solution of the mite allergen dermatophagoides pteronyssinus. saliva was recollected in 30 minutes and 24 hours after the provocation. the level of myeloperoxidase, elastase, tryptase in saliva were determined by the elisa. that provocative test did not cause clinical symptoms development or reduction in nasal bronchial patency in any patient. results: in patients with allergopathology, an initially increased level of myeloperoxidase and tryptase in 30 minutes after the provocation, elastase increased in 24 hours (table 1) . tryptase in saliva after 30 minutes increased till 0.07 (0.04; 0.19) (me, pg/ml (lq;uq)), p = 0.0006. increased tryptase is presence of increased cellular inflammation, e.g. mast cells. its ige-dependent hypersensitivity, because there was the correlation between the elevated level of tryptase and positive prick tests. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity and ige-independent reactions. in healthy volunteers this increase was not observed. the identification of tryptase, myeloperoxidase, elastase can be used for diagnosis of types of ahr. tryptase is a mediator of early (immediate) response to allergen. increased myeloperoxidase and elastase indicates the involvement of the eosinophils and neutrophils in the oral mucous membrane in the allergic process. these mediators have additional roles in the late phase response. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity. conclusion: safe and acute in vitro methods allow to conduct early etiological diagnosis of allergy, which contributes to the effectiveness of therapy; the detection of polyvalent sensitization dictates the need for molecular diagnostics to single allergens, which has a higher prognostic level and the clinical significance of predicting the appropriateness and effectiveness of allergen-specific therapy; laboratory diagnostics of the allergy allows to reveal sensitization at the 0 (0, 0) 0 (0, 0) 0 (0, 7.28) *p = 0.002; **p = 0.008; ***p = 0.038. subclinical level, which increases early diagnosis and identify persons with a predisposition to allergy; the establishment of causal allerbackground: antibacterial chemicals like parabens and triclosan have been associated with allergic disease in children. parabens are also suspected to affect metabolic functions, possibly due to their weak endocrine disrupting properties. furthermore, a possible link has been suggested for eczema and adiposity, and thus, how body burden of chemical exposures affect both of these outcomes are of interest. we aimed to describe the association between exposure to parabens and eczema and body mass index (bmi) in an adult population in norway. method: urine biomarkers of butyl-, ethyl-, methyl-and propylparabens were quantified by mass-spectrometry in 496 adult participants (median age=29 years) from the rhinessa study in bergen, norway. linear regression models adjusted for gender, age and bmi (for eczema outcomes) and with clustering for siblings, were applied to model possible association between specific gravity standardized urine biomarker concentrations of parabens with bmi and eczema. results: propyl-(ppb) and methyl-parabens (mpb) were detected in 95% of the urine samples; ethyl (epb) in 62% and butyl (bpb) in 38% of the samples. in women, epb and bpb were detectable in 73% and 61%, respectively. participants with current eczema (15%) had lower level of several parabens compared to those without eczema (bpb for both genders; epb in women only and sum of all parabens in men only). body burden of epb (geometric mean (gm)) was 6.7 μg/l in women with current eczema compared to 22.3 μg/l in women without eczema (p = 0.03). body burden of parabens (mpb and epb) were inversely associated with obesity (bmi>30, (11.4%) ), as compared to normal range bmi (bmi=18. 5-25 (56.4%)) in both men and women. the concentration of mpb for obese women was gm=2213 μg/l compared to 11503 μg/l in women with normal range bmi. for men, the gm for mpb was 35.3 μg/l in obese compared to 134.4 μg/l in normal weight men (p = 0.03). conclusion: person with eczema or obesity had lower paraben levels in urine. we speculate that these chemicals might be stored in adipose tissue, and therefore excreted in urine in lower levels among the obese. eczema and obesity was not strongly associated in the current study. method: we retrospectively analysed medical records of 75 patients who were patch-tested with our dental screening series of 23 substances. adverse reactions to dental materials were suspected based on subjective complaints in the oral cavity and/or objective conditions of the oral mucosa. square plastic chambers on hypoallergenic tape were used. patch tests were applied to the upper back and removed by the patient after 48 hours. readings were performed 3 and 7 days after application (d3 and d7). results were evaluated according to the international contact dermatitis research group guidelines. positive patch test reactions fulfilled the criteria of at least a one plus (+) reaction on d3 and/or d7. the term »contact allergy« is usually used for such reactions. we prefer the term »contact sensitization«. clinical relevance of positive reactions to dental materials was not systematically assessed in this analysis. conclusion: we report a high frequency of positive reactions on d7 that were not seen on d3. this finding demonstrates the importance of an additional late patch test reading in patients with suspected contact allergy to dental materials. background: psoriasis is a chronic inflammatory skin disease. its etiopathogenesis is not exactly known. it is believed that the disease occurs in people with genetic tendency with the effect of a triggering factor. in some studies it is observed that contact dermatitis in psoriasis is increased with respect to normal population. for this reason it is proposed that allergen materials could trigger psoriasis. in this study it is aimed to determine contact allergy frequency in psoriasis cases using patch test. results: 62 of the cases were plaque, 5 of them were guttate, 10 of them were palmoplantar and 3 of them were inverse type. more positivity rate is observed in psoriasis cases (26.25%) than control (12%). the positively responsed materials with respect to decreasing number of patients are found as follows: nickel sulphate (16.25%), thimerosal (7.5%), peru balsam(5%), p-phenylenediamine(2.5%), colophony(2.5%), n-isopropyl-n-fenil-4-fenilendiamin(2.5%), mercaptobenzothiazole(2.5%), benzocaine(2.5%), most frequently plaque type and following guttate type positive responses are observed in evaluations with respect to clinical types. no statistical significance is found between patch test results and pasi values in psoriasis cases. conclusion: patients with psoriasis should be carefully evaluated. sometimes some materials may trigger psoriasis. the composition of the pigments that professional tattooists use are varied inorganic salts of metals or organic vegetable pigments. red tattoos, especially those that contain mercury, are the most common cause of late reactions. method: 35 year-old male patient with no previous allergy history known, who gets a tattoo on his right leg and develops within months, cutaneous erythema and pruritus on the same location as the tattoo. true test ® for skin allergy patch epicutaneous testing is performed. results: 48 and 96 hours reading: showed positiveness for mercury ++, with no late positive reactions after that. conclusion: as allergists we should be familiar with the different types of tattoos available, and know the possible cutaneous complications that each of these decorative techniques can present. it is our responsibility to be able to diagnose any complications at an early stage, establish the most appropriate treatment and, if possible, prevent them by informing the possible users. background: within otorhinolaryngological pathology chronic eczematous otitis externa is one of the most common, usually treated with topical medication successfully; however, there are cases in which the poor response to treatment, or the recurrence thereof, may be due to causes secondary to the medication itself, as observed in cases of allergic contact dermatitis caused by these drugs. case report: we present a 68-year-old male patient without relevant pathological antecedents or known allergies, who consulted the otorhinolaryngology service of our center for otorrhea of 15 days of evolution, bilateral external otitis is diagnosed and a topical otological combination is recommended (beclomethasone dipropionate 0.025% and clioquinol 1%, excipient: macrogol) with improvement. however, during the following 3 years the patient presents exacerbations and remissions of the condition, with negative or inconclusive microbiological studies. during all that time he was using the prior topical treatment and other combination treatments of topical antibiotics, corticosteroids and local antiseptics. more aggressive causes of external otitis such as malignant external otitis were ruled out. during the third year of follow-up, a clear relationship of exacerbations was observed with the use of the first combination of topical drugs, so it was decided to investigate allergic sensitization. material and methods: we perform patch tests using true test ® , standard spanish series (geidac -spanish group for investigation of contact allergy dermatitis), topical corticosteroid battery, antiseptic, as well as topical medications used by the patient. results: from the first reading on day two, positivity was observed for: mixture of quinolines ++ patient's otological combination ++ and chlorquinaldol ++; being confirmed in the reading at day four. eczematous external chronic otitis is diagnosed with allergic sensitization to quinolines (clioquinol, chlorquinaldol). we conclude that in the case of chronic external otitis, allergic contact dermatitis should also be investigated as a possible cause, and it is important to perform epicutaneous tests with the patient's own products to evaluate non-common or hidden allergens that may be relevant to their current pathology. most common causes of acd. it is important to distinguish local findings of infection from acd caused by topical antibiotic treatments. here we present a patient with acd with topical use of bacitracin and neomycin combination therapy due to recurrent blepharitis. an 11-year-old male patient presented with the complaints of itching, redness, swelling of the eyelids and facial edema. he had used various topical ophthalmic antibiotherapy and eye shampoo for 7 years due to recurrent blepharitis. five days ago, due to the redness of the eyelids, burning sensation in the eye, itching of the eyes; he was examined by an ophthalmologist. the eyelids and eyelashes were scaly and dry. the patient was treated with warm water soaked cloth dressing, mechanical eyelash cleaning and topical antibiotherapy (neomycin-simple combination therapy). after the second day of treatment, the patient's topical ophthalmic antibiotherapy was discontinued due to an augmentation of the redness in the eye0723 | contact allergy after exposure to ivy (hedera helix l) potent steroid treatment associated with systemic antihistamines, but with no improvement. on dermatological examination a small, well delineated, eczema-like plaque was noticed on a digital finger, as a new finding striking with her old burn scars. she denied any symptoms and was in good health condition. a 4 mm punch biopsy was performed and histological report established the diagnosis of squamous cell carcinoma. the patient was transferred to oncology department for further investigation and treatment. conclusion: early diagnosis and prompt surgical therapy are recommended to all patients with chronic wounds and scars who develop malignant transformation. *written informed consent for the publication of potentially identifiable personal details of patient (gender, age, illness, location) was obtained. **in relation to this presentation, i declare that there are no conflicts of interest. ertugrul a; hizli demirkale z; bostanci i dr sami ulus maternity and children training and research hospital, ankara, turkey introduction: the incidence of contact sensitization among adolescent has been increasing. nickel is one of the important causes of allergic contact dermatitis (acd) in this age group. increased exposure to nickel and deterioration of the skin barrier are among the important risk factors in children. the gold standard for diagnosis is skin patch test. we report here an adolescent patient who has allergic sensitization to nickel and cobalt. case: a 17-year-old female patient admitted in our clinic with a complaint of edema on her face. the patient had applied chickpea water to her face at least once a day for one week because of her acnes. her medical history revealed that she had experienced similar edema on her face after applications of clay mask one year ago. she was diagnosed with cellulitis and she had been treated with antibiotics for five days. on her physical examination, angioedema was observed on her face, especially on the glabellar region. eosinophilia was not found on her laboratory data. c-reactive protein (crp), c4 and c1 esterase inhibitor protein levels were also normal. the skin prick test was performed with aeroallergens, chickpea, lentil, bean and nuts, and no reaction had been observed. the patch test was performed with 'thin-layer-rapid-use-epicutaneous' (t.r.u.e) test and chickpea. the patient had positive reactions to nickel and cobalt. detailed questioning disclosed that the patient was preparing the chickpea water in a metal pot. result: chickpea water and clay mask contain varying amounts of nickel. it was thought that the edema of the patient is due to nickel allergic contact sensitization. an increased exposure to nickel and cobalt raises the frequency of sensitization. nickel allergy can cause different clinics ranging from localized lesions to systemic reactions. we want to emphasize that a detailed medical history and the patch test would enable clinicians to demonstrate hidden allergens and then make a correct diagnosis. case report: autoimmune progesterone dermatitis is a condition of hypersensitivity to progestogens. it is not an easy diagnosis given the variety of clinical presentations it may have, ranging from eczema, urticaria, erythema multiforme, folliculitis, to angioedema or even anaphylaxis. manifestations are cyclical, occurring when the levels of progesterone are higher, this is, at the luteal phase of the menstrual cycle, and disappear during menses, with the physiological decrease of the hormone. it can also be triggered by exposure to exogenous progestins. we report the case of a 49-year-old woman with a cyclical erythematous and violaceous rash related to the menstrual period. the symptoms typically began 4-6 days before the onset of menses and ended 1-2 days before. the diagnosis was based in the clinical history and intradermal skin tests: skin prick testing with levonorgestrel and medroxyprogesterone were negative, but the intradermal skin test with medroxyprogesterone was positive at a concentration of 50 mg/ml. we performed intradermal testing with the same concentration in three other women with no symptoms to exclude an irritative reaction, which were negative. autoimmune progesterone dermatitis is, perhaps, not so rare, but rather poorly recognized and reported, and thus, underdiagnosed. clinicians should be aware and include always this condition in the differential diagnosis, especially in cases of atypical or intractable skin eruptions. case report: a 46 year old male was referred to a community allergy clinic for assessment of chronic urticaria (cu). allergy assessments for foods, inhalant and inducible physical triggers revealed no association. an autoimmune workup followed, with treatment consisting of standard dose antihistamines (h1 and h2). blood work revealed a persistently low hemoglobin with low-normal ferritin. hematology consulted and followed attempted iron replacement to no avail. skin biopsy revealed neutrophilic rich urticaria with the presence of eosinophils. serum protein electrophoresis (spep) revealed a monoclonal gammopathy with elevated igm, felt to be of undetermined significance (mgus). c-reactive protein (crp) was consistently elevated (183, 256) in conjunction with anemia. rheumatology consulted and cleared of any evidence of vasculitis. hematology considered the anemia to be of chronic disease linked to cu. the cu was resistant to treatment including high dose antihistamibackground: isolated head and neck angioedema (ae) can be mediated by bradykinin (bk) or histamin (hi) . the objective of our study was to determine which etiology was most frequent in cases of death by asphyxiating ae in france. we sought all cases of death by isolated asphyxiating ae reported in france between 2000 and 2014 via death certificates and/or the national pharmacovigilance database. results: the overall mortality by asphyxiating ae for all causes was 0.36 / million inhabitants. the death rate of bkae per million inhabitants was 0.14 and lethality of 0.27 per thousand patients per year. the death rate of hiae per million inhabitants was 0.09 and lethality of 0.006 per thousand patients per year. we found a 45 times higher risk of death in case of bkae than hiae. conclusion: consequently, particularly severe episodes must be initially considered as bradykinin mediated and quickly reassess any first-line treatment that is inappropriate. case report: we present the case of a 72-year-old man who suffered recurrent abdominal pain since age of eight, leading to 3 unnecessary emergency surgical interventions and 5 endoscopies before hereditary angioedema due to c1 inhibitor deficiency (c1-inh-hae) was diagnosed at the age of 70. rare subcutaneous swellings were considered allergic reactions preventing proper diagnosis. family history, positive for recurrent abdominal pain and swellings was totally neglected until diagnosis of c1-inh-hae type i was established through appearance of severe oro-facial symptoms in the propositus' grandson. the diagnosis was suggested by the boy's mother, directed by educational materials available in the international hae patients' association website (www.haei.org). this report highlights and emphasizes the importance of accurately evaluated personal and family history to suspect condition that are scarcely known to the majority of physicians. highlights: diagnostic delay in hae and iatrogenic procedures are an underestimated problem, hiding undefined consequences, possibly destructing an entire lifetime. correct, publically available information provided by patients' associations raise awareness about the disease and could put the milestone of establishing correct diagnosis. de luque v 1 ; lara p 1 ; guardia p 1 ; jimenez ar 2 1 virgen macarena hospital, seville, spain; 2 hospital virgen macarena sevilla, seville, spain background: in the protocol for the study of patients who consult for recurrent acute angioedema with facial involvement, the contactant battery is included (epicutaneous test). we review the results in our patients with facial angioedema to evaluate the contactants to which these patients present sensitization, some of them coexisting with contact dermatitis clinic. we reviewed the patients referred to the clinic for recurrent acute angioedema with facial involvement and to whom a standard battery epicutaneous test was requested. in all these patients, other habitual triggers included in the diagnostic protocol (food, medications, autoimmune diseases, bradyinergic aea/complement deficit …) were ruled out. conclusion: it seems to be profitable to continue including in the diagnostic battery of patients who consult for aea with facial affectation, study of epicutaneous with standard battery. it is a small sample, but the data correlate with what has been published, being more frequent the sensitization to contactants in women and the contactant more frequently involved nickel sulphate. 0734 | ace inhibitor-related angioedema-the value of history taking background: angioedema is a well-recognized side effect of angiotensin-converting enzyme (ace) inhibitor therapy. although it occurs in <1% of the patients who take these drugs, it seems to be responsible for 40% of the episodes of angioedema. this entity is underdiagnosed and failure to recognize it leads to recurrence of episodes, with an impact on morbidity and increased risk of serious reactions. our objective is to analyze the clinical, therapeutic and orientation approach of patients diagnosed with ace inhibitor-related angioedema, evaluated at the outpatient consultation (oa) of immunoallergology (ia). a 3-year retrospective study was performed by analyzing the clinical files of all patients diagnosed with angioedema observed in oa of ia. the following variables were analyzed: gender; age; clinical data; evaluation in emergency department (ed); therapy in the episode; evolution and orientation. the chi-square test was used to study the association between categorical variables: "established therapy"/"disease evolution" and "place of reference"/"withdrawal of ace inhibitor". results: review of 62 cases of patients referred for angioedema. only in 29% the final diagnosis was "ace inhibitor-related angioedema". the mean age of the patients was 63.7 years and 67% were male. the location of angioedema occurred in the tongue in 33% and in the remaining sites (lip, hemiface, tongue and hemiface, tongue and lip) appeared in the same frequency, 17%. none of the patients had airway obstruction. during the episode of angioedema, 22% of patients were not referred to ed and the therapeutic approach was done with antihistamines in 75%. in patients who were referred to ed (78%), antihistamines and corticosteroids medications were administered in 85%. regarding the evolution, it was verified that the duration of the episode was independent of the established therapy (p > 0.05). regarding the place of reference, 60% of the patients were referred form hospital (ec or ed) and, in these, the ace inhibitor was suspended in 73%. in patients referred from general practitioners (40%), in none of them the ace inhibitor had been withdrawal. a causal association between the use of ace inhibitors and the episode of angioedema becomes crucial, since drug withdrawal is indicated. a reference for ai oa should be weighed. therapy with antihistamines and corticosteroids has no proven efficacy. hereditary angioedema (hae) seen by physicians belonging to the hae scientific committee of the aaaeic background: patients with c1-inh-hae frequently suffer from anxiety and stress. the impact of prophylactic treatment on anxiety and stress in c1-inh-hae patients is largely unknown. here, we analyzed data from the apex-1 study, a phase ii study that investigated the effects of the oral kallikrein inhibitor bcx7353. method: c1-inh-hae patients with a history of at least 2 hae attacks per month were randomized to receive four different doses (350, 250, 125, 62.5 mg) of bcx7353 or placebo for 28 days. the depression anxiety stress scale (dass) was administered at baseline and at day 29. the dass consists of three self-reported scales designed to measure the negative emotional states of anxiety and stress. subjects used a 4-point severity/frequency scale to rate the extent to which they have experienced each state. results: baseline dass total scores as well as anxiety and stress domain mean (sd) scores for the 125 mg treatment arm (n = 13) were 20.9 (23.7), 5.0 (5.9), and 8.9 (9.1) points respectively. placebo scores were generally similar or slightly lower at baseline than for the 125 mg treatment arm. the dass questionnaire data showed statistically significant improvements in total score vs. placebo at day 29 (−11.4 method: a two-phase mixed methods approach was used to develop the hae-rt tool including: phase 1: delphi study [hae specialists (n = 9) and national patient advocacy group members (n = 3)] was conducted to reach consensus (80% agreement) on predictor variables to include in the tool. phase 2: retrospective chart review was conducted to assess the predictive findings of the decided variables. a convenient patient sample presenting with angioedema (with and without hae) between january 2012-january 2017 were included in the study. results: nine of 12 invited experts (75%) participated in the delphi study. of 8 hae-specific predictive variables, 4 reached consensuses including: (i) recurrent angioedema; (ii) absence of urticaria; (iii) recurrent abdominal pain/swelling; (iv) lack of response to allergic therapy. the retrospective study included 85 patients (n = 46 with hae; n = 39 non-hae; overall 72% female). hae patients were significantly more likely to have a family history of hae (72% vs 0%; p < 0.0001); previous recurrent angioedema (96%; p < 0.009); present with no hives (91%; p < 0.036); previous recurrent abdominal pain (80%; p < 0.0001); and 2% responded to allergy treatments (p < 0.0001). a regression analysis categorized observed frequencies (actual patient outcomes from chart review) versus predicted (by model); plotted on a 2 by 2 table and calculated the sensitivity and specificity of the hae-rt which resulted in one hundred percent for both. conclusion: our study demonstrated that expert involvement led to the identification and prioritization of variables that when included an hae-rt tool, were associated with a high level of sensitivity and specificity when applied to known patients. the next step is to observe the effect of the hae-rt tool on patient care in the ed. method: evaluation of cardiovascular manifestation included morphology, serum level of troponin t, electrocardiography (ecg) and echocardiography. evaluation of pulmonary manifestation included spirometry, diffusing capacity of the lung for carbon monoxide (dlco) and evaluation for mastocytosis included bone marrow biopsy and serum total tryptase measurements. results: in the study there were 55 patients -35 women and 20 men between 21 and 71 years old (the average age was 45). there were 7 (12.73%) patients with mpcm, 4 (7.28%) with bmm, 42 (76.36%) with ism and 2 (3.64%) with ssm. the average level of serum tryptase was 45.1 μg/l (6.9-270) . troponin levels was within the normal range in all patients. one patient had lowered the ejection fraction (eflv=23%). no one patient had restriction. the average value of a forced lung capacity was 3.33 l (104%) and a total here, we describe a case series of twelve mis patients seen at our department over a 3-year period and report how many of these patients have sm. common phenotypical manifestations of acute hae1 episodes in this region, to review therapeutic challenges in a rural setting in comparison with world standards, and lastly to evaluate the socio-economic burden inflicted by the disease. method: a sample of 13 individuals from a total of 28. the exclusion criteria was the inability to attend booked appointments more than 3 times in 1 year (2017). the following methods were used: an interview to formulate a family tree identifying affected individuals in 4 contiguous generations, and review of the acute presentations in the past year (2017) . a questionnaire to obtain the relevant hae1 associated socio-economic burdens. a chart review to identify the therapeutic strategies in this region. c1inh levels, and complement c4 to confirm the diagnosis. results: polygamy as a local culture was found to be an important factor that perpetuated the genetic burden of the disease. c1inh and c4 levels confirmed hae1 in all participants individually. clinical features during acute attacks included swelling of extremities (100%), facial swelling (69%), neck swelling (23%), and laryngeal swelling (8%). therapeutic strategies for acute attacks included fresh frozen plasma or fresh dried plasma. danazol was used for prophylaxis. hae1 has had a significant negative impact upon the socioeconomic status of the affected individuals. conclusion: hae1 is a newly identified disorder in the broad spectrum of allergy medicine in kwazulu-natal. the diagnosis is simple to confirm but requires an initial high index of suspicion, and therapeutic management still poses a challenge in this region due to lack of resources. genetic counselling is of paramount importance during intervention since polygamy forms part of most cultures in this region. a support strategy is highly recommended in order to help alleviate the socio-economic burden posed by the disease in this region. the socio-economic burden secondary to hae1 (10 participants/5 identical questions each) question 1 (0-5 points) 3 question 2 (0-3 points) 2 question 3 (0-3 points) 1 question 4 (0-3 points) 1 question 5 (0-1 point) 1 method: a total of 172 medical faculty senior year students were included to study on a voluntary basis. students are divided into two groups. one group was given visual user guide that has not been modified, and a visual user guide on which we have modified to the other group ( figure 1 ). then they were asked to show how to use the inhaler spacer. results: the mean age of the volunteers was 25.3 ± 126 years and 104 (60.5%) were male. there were 82 students in the group without modification of the visual user guide and 90 students in the other group with modified the visual user guide. sixty-four per cent of the modified user guide group showed correct use of the inhaler spacer, while 15% of the unmodified group showed correct use (p = 0.001). the group that given modified visual user guide was more successful in all of the display steps of the inhaler spacer. conclusion: modification of the currently available visual user guide of inhaler spacer in our country will increase the correct usage rate. results: mean fev1, fvc, fev1/fvc z-score were 1.8 (1.1-3.9), 1.7 (0.9-3.7), 0.9 (0.8-0.9), respectively. restriction had 31 (57.4%) and obturation 3(5.3%) patients. fev1 (p < 0.001, r 2 = 0.37) and fvc (p = 0.001, r 2 = 0.38) decreased with age (%pv and z-score). background: children who were treated for leukemia are known to have developed long term impairment of lung function. the reasons that complication are only partially known. the aim of this study was to asses pulmonary function in children treated the lower dlco is the most frequent abnormality in childhood leukemic survivors. hsct and pulmonary infection (in particular cmv pneumonia) is a strong risk factor for impairment of dlco in children. clinical manifestation of dlco impairment is poor exercise tolerance. a screening for respiratory abnormalities in survivors following treatment for childhood haematologic malignancies, seems to be of significant importance. 0746 | phenotyping allergic respiratory diseases: an unsupervised classification using latent class analysis allergen groups was significantly associated to uawi (aor[95% ci]:2.1 [1.3-3.6] ), compared to uasi. results: 80.8% of br and 49% of py were women, median age was 32 years, 35% br and 52% py reported having more than four years of training. although they recognized the main symptoms of ar, 26% br and 100% py never asked whether the patient had a medical diagnosis of ar; 20.5% br and 100.0% py did not ask whether the symptoms occurred when close to animals or allergens; 55% br and 76% of py did not ask if the patient had a medical diagnosis of asthma; 59% br and 70% py did not ask if rhinitis worsens asthma symptoms and 51.3% br and 84.3% py did not ask whether symptoms of rhinitis interfere with their daily activities. results: there was a predominance of female (br: 73%, py 50.4%, uy: 70%) median age 31 years old, 124/235 worked in the community and 75/127 in the emergency departments, 34% of the br had more than 10 years of education, 67% from py had between 1 and 5 years, and 82% from uy had been graduated for less than 1 year. br/uy recognize the main symptoms of ar, however 67% of those from uy do not ask: if the patient has physician diagnosis of ar, 72% present shortness of breath, and 93% a medical diagnosis of asthma, 94% if rhinitis worsens asthma symptoms and 90% if symptoms of rhinitis interfere with the patient's daily activities. the prescribed treatment varied a lot, the intranasal corticosteroid use rate was: bd: 78%, pd: 92% and ud: 54%. 100% of doctors in py, 73.4% in br and 78% of uy never refer the patient to the specialist. 22.9% of pcd of br, 62% of py and 6.0% of uy are aware of aria guideline. conclusion: although ar is largely attended by pcp, recognition of symptoms and their impact on asthma, as well as the knowledge about aria guide is low and treatment is not always prescribed according to best practice. allergy education programs, with an emphasis on ar and aria guide, need to be directed to pcp in la for the better assistance of ar patients. 0749 | assessing knowledge of allergic rhinitis among final year medical and pharmacy students in croatia-curriculum change necessity? the two factor structured questionnaire was formed by the authors regarding the topics mentioned. t-test was used for statistical analysis. the global results were formed as composites of (1) ar general characteristics, (2) ar treatment approach, and (3) the participants' overall knowledge. of the 201 respondents, 143 (71.1%) were female and 58 (28.9%) were male (p < .0001). medical students had a median score of 6 of 10 correct answers on (1), 4 of 10 on (2), and 10 of 20 on (3), whereas pharmacy students had median score of 7 of 10 correct answers on (1), 4 of 10 on (2), and 10 of 20 on (3). there were no significant differences in knowledge between two student groups. the results indicate an inadequate level of knowledge of ar in both groups, especially regarding the therapy approach. since general practitioners and community pharmacists have a major role in providing treatment to patients suffering from ar, it is important to develop advanced knowledge on this topic during medical and pharmacy degree courses. despite a relatively small study population, it would be advisable to introduce change by improving the core curriculum regarding ar with more emphasis on treatment, but additional research on this topic is necessary. tan r 1 ; cvetkovski b 1 ; kritikos v 1 ; price d 2 ; yan k 3 ; smith p 4 ; bosnic-anticevich s 5 1 woolcock institute of medical research; university of sydney, sydney, australia; 2 observational pragmatic research institute pte ltd, singapore, singapore; 3 royal prince alfred hospital, sydney, australia; 4 clinical medicine, southport, australia; 5 griffith university, sydney, australia background: people with allergic rhinitis symptoms frequently selfselect over-the-counter medications from community pharmacies without seeking advice from a health care professional. this increases the incidence of complications due to delayed diagnosis and suboptimal treatment. this study aims to (i) compare the demographics, clinical characteristics and medication selected, between pharmacy customers who choose to self-select and those who interacted with a pharmacist when purchasing medication for allergic rhinitis symptoms, and (ii) identify the key factors associated with allergic rhinitis patients' medication self-selection behaviour. a cross-sectional observational study was conducted in a convenience sample of community pharmacies from the sydney metropolitan area. data were collected using a researcher administered questionnaire that included: demographics, pattern of allergic rhinitis symptoms, their impact on quality of life, factors triggering allergic rhinitis symptoms and medication(s) selected. logistic regression was used to identify key factors associated with participants' medication self-selection behaviour. results: of the 296 recruited participants, 202 were identified with allergic rhinitis, of which 67.8% were female, 54.5% were aged more than 40 years old, 64.9% had a diagnosis of allergic rhinitis, and 69.3% self-selected medication(s). significant differences were noted in allergic rhinitis symptoms, impact of allergic rhinitis on quality of life and medication(s) selected between participants who chose to self-select and those who interacted with a pharmacist. participants who experienced moderate-severe wheeze were 4 times more likely to self-select allergic rhinitis medication(s), and those who had allergic rhinitis symptoms impacting on their quality of life were 0.4 times less likely to self-select allergic rhinitis medication(s). conclusion: there is a high incidence of self-selection of over-thecounter treatments for allergic rhinitis symptoms in community pharmacy, with the majority of allergic rhinitis sufferers failing to seek pharmacist advice. this research identified predictors of medication self-selection behaviour in community pharmacy among people with allergic rhinitis, which can inform the design of tools/strategies and targeted interventions, aimed at improving pharmacist engagement and future practice in optimising allergic rhinitis management. the weir family health clinic, cork, ireland; 2 university college, cork, ireland background: allergic rhinitis is a common condition that is predominantly managed in primary care. the incidence of allergic rhinitis is increasing. it is frequently under diagnosed, misdiagnosed and mistreated. it has a significant impact on patients' health related quality of life and represents a huge cost both to healthcare systems and society. the aim of this study was to implement appropriate guidelines regarding the management of allergic rhinitis in primary care and evaluate the effect on patients' health related quality of life. method: patients with a history of allergic rhinitis were selected from three general practice bases in west cork, ireland and quality of life of patients was assessed initially in year one and followed up one year later in a general practice setting using the standardised rhinoconjunctivitis quality of life questionnaire (rqlq). allergic rhinitis and its impact on asthma (aria) guidelines and appropriate prescribing were implemented during this year and patient education and structured follow up was arranged in the intervention group. this was compared with the control group who received usual care. results: 93 valid responses were received, 34 from the control group and 59 from the intervention group. the study demonstrated a statistically significant difference in quality of life in the intervention group. in the adult intervention group the quality of life score decreased between 2015 and 2016 representing an improvement in their quality of life, (t = 4.13; df=56; p < 0.01). the difference in the score between the control and intervention groups in 2016 was also statistically significant.(t = 6.11; df=54; p < 0.01). the numbers in the adolescent groups and paediatric group also demonstrated an improvement in quality of life but the sample size was too small to demonstrate a statistically significant difference. conclusion: as the majority of patients rely on their general practitioners for treatment and diagnosis of allergic rhinitis, primary care represents an important area to target in the management of allergic rhinitis to improve patients' quality of life. the implementation of guidelines has been shown to improve patients' quality of life. this study demonstrates this care can be delivered in a primary care setting with an improvement in patients quality of life but substantial investment in education and resources available to primary care physicians is needed. 0752 | the predictive value of allergy tests in the diagnosis of peanut allergy in adults rey-garcia h; gunawardana n; wheeler k; scadding g; durham s; skypala i royal brompton hospital, london, united kingdom background: adults presenting with either new-onset symptoms attributed to peanuts or with early-onset peanut allergy, often wish to know whether they should continue to avoid peanuts. clinical history and standard tests may be sufficient to provide an answer, but for many the tests are inconclusive and an oral food challenge is required. this review was undertaken to determine the most accurate tests. conclusion: these data suggests that peanut spt and ara h 2 provide the most accurate prediction of the outcome of oral food challenge in adults. should components not be available, then spt would be the test of choice being more accurate in all aspects than sige. combining spt and sige improves the sensitivity and negative predictive value of spt alone. however, the best combination is spt and ara h 2, which increases the overall accuracy to 87%. further studies are needed before it can be determined whether peanut diagnostic tests can replace the oral food challenge in adult patients. method: retrospective chart review was carried out in a community allergy clinic. patients with rap, bloating and altered stools who underwent bt were characterized by age, gender and atopic status. a separate study to assess patients' outcome post-dietary counselling was carried out to determine impact on symptom management. results: thirty-four patients were assessed for fi from january 2014 to december 2017. female gender predominated (31/34, 91%) with an average age of 31 years at presentation. results of fi were positive in 15/34 (44%), borderline in 2/34 (6%) and negative in 17/ 34 (50%). the average age of patients with a positive, borderline and negative tests were 30, 20 and 34, respectively. of the patients who tested positive for fi, 5 (33.3%) had comorbid inhalant allergies alone, 1 (6.7%) had comorbid (unrelated) food allergies alone, 2 (13.3%) had inhalant and food (unrelated) allergies, and 7 (46.7%) were non-atopic. of the patients who tested negative for fi, 7 (41.1%) had comorbid inhalant allergies alone, 0 (0%) had comorbid (unrelated) food allergies alone, 1 (5.9%) had inhalant and food (unrelated) allergies, and 9 (53.0%) were non-atopic. conclusion: patients investigated for carbohydrate intolerance with rap, bloating and altered stools were predominantly female (91%). fi was confirmed in half. atopic status did not help differentiate between the fi positive or negative groups. results of a fod-map elimination diet are separately reported. conclusion: post-bt, 88% of patients reported symptom improvement. patients who implemented fructose or fodmap avoidance reported symptom improvement. one patient who tested negative for fi reported symptom improvement with a low fodmap diet. patients suspected as being fructose intolerant may benefit from a fructose restriction or fodmap diet, while awaiting bt confirmation. this form of dietary intervention may assist and shorten the natural history of non-specific chronic gi symptoms. inappropriate referrals to a uk paediatric tertiary allergy clinic demonstrate lack of allergy education and knowledge in primary care marriage de bristol royal hospital for children, bristol, united kingdom background: up to 8% of children have a food allergy. allergy has become an explanation for all manner of nebulous symptoms and self-diagnosis is common. sham allergy tests are easily available giving incorrect results and resulting in unnecessary, potentially harmful abstracts | 423 parentally-imposed dietary exclusions. there are 100 million allergyrelated google searches per year. the rising prevalence of perceived allergic disease has led to an increase in health service utilisation, including increased referrals to secondary care. clinic waiting lists are long and children with severe food allergies have to wait longer than necessary to be seen method: uk paediatric tertiary allergy clinic referrals were prospectively reviewed over three months. five inappropriate referrals deemed most reflective of poor knowledge in primary care were selected as case summaries to highlight this gap in knowledge. results: 1: schoolchild referred for investigation of allergic cause for a red, watery eye after splashing juice in her eye whilst cutting a kiwi, despite having a co-existent dendritic ulcer. 2: schoolchild referred for peanut allergy testing after inhaling a peanut and developing wheeze, with all respiratory symptoms resolving following peanut removal. 3: young child referred for peanut allergy testing after developing a rash on leg following skin contact with faeces 24 hours after ingestion of peanut butter. 4: teenage boy referred for investigation of likely peanut allergy despite eating peanut butter and tree nuts almost every day. the family were concerned he was allergic to peanut butter. 5: toddler referred for milk allergy investigation after developing urticaria lasting 24 hours 15 minutes after drinking a bottle of milk. the child had consumed cow's milk formula since birth, and continued to consume milk daily for a further five months following the episode of urticaria. conclusion: provision of allergy services in the uk is poor and lack of investment in allergy services has led to suboptimal recognition and management of food allergy in primary care. allergy education provision for primary care practitioners is inadequate and fails to empower healthcare professionals to discern between allergy requiring full investigation and management, parentally-diagnosed allergy or symptoms which clearly have no association with allergy. progress to improve primary care training for allergy needs to be optimised to prevent further unnecessary referrals and lengthening clinic waiting lists. background: in case of allergic reactions to food or insect venom, quick and adequate treatment, based on clear instruction for use of emergency medication and calling for help, is necessary. however, daily practice shows that patients do not use the prescribed emergency medication because they are afraid to use the epinephrine auto-injector or they do not know how to use it. information and instruction offered by a reliable app could be a useful aid. we aim to develop an app for adult patients and children older than 12 years with allergy to food or insect venom, which offers a step-wise approach to support patients, their relatives or acquaintances in case of an allergic reaction. method: first, the content of the app, including a step-wise approach to treat the allergic reaction has been determined, based on literature, a survey about needs of patients and on consultations of healthcare professionals. subsequently, a web-based prototype has been developed with an adult profile and children profile. the content and flow of this prototype was tested by the project group, as well as by selected healthcare professionals and patients and improved according to the test results. next, the revised prototype was submitted to representatives of patient and professional organizations for final approval. currently the procedure for ce approval is ongoing. finally, the app will be built and offered to the market for ios and android. results: a web-based prototype of the allergy app is available with two profiles: adult and older children. the app is useful for patients with a doctor's diagnosed allergy to food or insect venom, who received emergency medication and instructions to use prescribed medication in case of an allergic reaction. based on severity of complaints, the user is informed about the steps to treat the allergic reaction. in case of a moderate to severe reaction, the patient is advised to use an epinephrine auto-injector, to call the emergency number and, if prescribed, to use medication such as antihistamines, prednisone or inhaler. besides that, the app provides links to websites of expertise centres and patient organisations and includes instructions how to use the epinephrine auto-injector. conclusion: the allergy app will help patients, their relatives or acquaintances to adequately treat an allergic reaction to food or insect venom. involving patients and professionals in the development of the app will contribute to its acceptability and usability. 0757 | electronic documentation of drug allergies in a tertiary hospital in singapore: are we relying too much on it? choo kjl; garuna murthee k; naing cs singapore general hospital, singapore, singapore background: singapore has 26 hospitals shared between public and private healthcare system. its healthcare system, ranked #6 in the world by who in 2010 serves a multi-racial population of 5.2 million of which 9% are above 65 years old. drug allergy alert cards (medik awas) were started in 1970s by singapore medical association to improve patient safety. work on computerisation of drug allergy and medical alerts started in the 80s, a precursor to today's critical medical information system (cmis). cmis serves as a platform across all public hospitals in singapore. it promotes uniform reporting of drug allergy and notification of adverse drug events to the health science authority. yet, we found that there is a lack of awareness of one's own drug allergies. method: all patients admitted to ward 73 (general medicine ward) at singapore general hospital from 17 july to 31 oct 2017 were screen for any previously documented drug allergies. consenting patients who had previously documented drug allergies on cmis were interviewed to document their demographics, education level, current medications, knowledge of their own drug allergies and possession of a drug medication alert card. the answers were then compared with their electronic documentation of drug allergies for accuracy. we interviewed 192 patients aged 20-94 with documented drug allergies during the recruitment period. 74% had secondary school education or higher. the majority (76%) spoke english and (58.5%) mandarin. almost half had medical problems and are on long term medications (mean 5.17 medications); hypertension and diabetes being the top two common diseases. 48% of the patients could accurately relay their drug allergies; antibiotics and analgesia being the most labelled. only 24% had a drug allergy alert card while the rest both rely on the hospital's electronic documentation and/or their caregivers to record and relay their allergies to future prescribers. about 21% received prescription from multiple healthcare sites in both the public and private healthcare system. we found patients' knowledge of their own drug allergies dismal. the cmis electronic documentation provided a false sense of security. unfortunately, the cmis platform is not available to all private hospitals, increasing the risk of mis-prescription due to the lack of information. unless this is made available nationally, patients with drug allergies should be given some written documentation, either a letter or medik awas. how frequent are they and how are they treated? method: for this cross-sectional study, participants were recruited in the waiting rooms of local doctors in the rural bavarian forest region of southern germany (q1/2017). a paper questionnaire was handed out to the participants, asking for allergies (pollen, animal hair, bee and wasp venom, drugs, food, house dust mites, contact allergies and other allergies) and how or rather by whom (e.g. general practitioner, specialist, self-treatment) these allergies are treated. results: 718 participants with a mean age of 50.61 years (sd=15.15) and 59% women were included in this study. 38.2% indicated to have at least one allergy, including pollen allergy most frequently (17.4%). women had significantly more often at least one allergy than men (rr= 1.552; ci [1.243;1.937] ) and for almost all examined allergies a significant higher risk of disease. younger age groups indicated more often to have at least one allergy (18[.506;1.151 ]) seemed to be affected less. participants indicated most frequently that their allergy was treated by a general practitioner (37.5%), except of the 18-29-yearold young adults who indicated "no treatment" most frequently (28.2%). conclusion: there is a high self-reported prevalence of allergies in the examined rural bavarian region, that increases with decreasing age and is significantly higher among women. moreover, the data on the absence of an appropriated treatment for allergies is alarming. therefore, medical care needs to be improved in rural regions to lower the burden of allergies. 0759 | the prevalence of the burnout syndrome among medical professionals involved in allergology education programmes astafieva n 1 ; kobzev d 2 ; gamova i 1 ; perfilova i 1 ; udovichenko e 1 ; skuchaeva l 1 ; michailova i 1 1 ≥10) and rpa (low ≥0-11, subscales were calculated and analyzed. results: on average students demonstrated: moderate/high ee scores (24-26); moderate/high dp scores (9-12) and moderate rpa scores (17); higher rpa scores were common (41.4%) among junior students, which is also linked with their levels of engagement, and lower (28%) among senior students. junior specialist (starting specialization) had very low scores in all 3 subscales and expressed a very high motivation in their course and new profession. clinical allergologists with significant experience demonstrated moderate / high ee scores (22-26); low dp (1) (2) (3) (4) (5) and rpa (below 10) scores. high ee scores associated with pressures of service were compensated by a substantial loyalty to their profession and positive assessment of the outcomes of their work. clinical academics demonstrated the highest level of ee scores (29 + among 70 + % of the group) with low to moderate dp and rpa scores, the latter being associated with a loyalty to their profession. it was also possible to identify a correlation between engagement in research activities and lower rpa scores. conclusion: burnout is a complex and multifaceted phenomena, which requires further investigation. however, this research identified that students and junior specialists involved in allergology and clinical immunology programmes with higher levels of engagement and motivation to acquire new specialist knowledge had lower levels of ee, while loyalty to the profession and positive assessment of the outcomes of clinical and research work allows to compensate high levels of ee among experienced practitioners and clinical academics and to reduce burnout effects overall. 0760 | appeal (allergy to peanuts impacting emotions and life): the first pan-european study to evaluate the psychosocial burden of living with peanut allergy deutscher allergie-und asthmabund (daab)/german allergy and asthma association, mönchengladbach, germany; 8 food allergy italia, padua, italy; 9 aepnaa asociación española de personas con alergia a alimentos y látex, madrid, spain; 10 afpral association pour la prevention des allergies, paris, france; 11 asthma-allergy denmark, roskilde, denmark; 12 anaphylaxis campaign ireland, cork, ireland; 13 brainsell ltd, london, united kingdom; 14 aimmune therapeutics, london, united kingdom background: peanut allergy, one of the most common and rapidly growing food allergies, is most frequently a lifelong condition. current management is limited to avoidance and symptomatic treatment of allergic reactions when accidental exposures occur. peanut allergy can affect the quality of life (qol) of individuals and also that of parents/caregivers and family members. appeal was designed to assess the impact of peanut allergy on qol in peanut-allergic individuals and their parents/caregivers and families. method: the first, quantitative part of appeal is described here and consisted of a pan-european, cross-sectional online survey of approximately 30 minutes in length. the study was conducted in the uk, republic of ireland, france, spain, germany, italy, the netherlands and denmark. over 1800 participants were recruited via patient advocacy groups or directly through a specialist survey recruitment panel. ethics committee approval was obtained and all participants provided their informed consent. eligible participants were: (1) parents or caregivers of a child/adult with peanut allergy; (2) parents or caregivers responding as a proxy for a child aged under 18; (3) adults. all allergic subjects had self-reported diagnosed peanut allergy. after several screening questions, eligible participants answered a set of clinical questions about their (or their child's) allergies and other conditions, details on the peanut allergy diagnosis, contact with healthcare professionals, worst allergic reaction to date and use of emergency medicine. depending on whether they were an allergic adult, a parent responding on behalf of the child, or a parent/caregiver recounting their own experience, they then answered specific questions on restrictions on life choices, coping strategies and the impact of peanut allergy on feelings and emotions of families, friends and other people. sociodemographic questions completed the questionnaire. the results of the survey are being summarized using descriptive statistics and the data are being analysed on a pan-european level, by country, and according to the participant's perspective (parent, caregiver or individual). conclusion: this comprehensive, pan-european online survey has been specifically designed to uncover the psychosocial burden and effect on qol of peanut allergy in terms of individuals' lives and those of their families. results: 246 pediatric patients were included in the study. 65.9% (n = 162) were male. the median age of onset of symptoms (interquartile range) was 4 months (2-6).the median age (interquartile range) of diagnosis was 6 months (4-7). initial reactions associated with cmpa were observed in 95.8% of patients before 12 months old. patients' diagnoses were atopic dermatitis (39%), urticariaangioedema (24%), anaphylaxis (12.2%), proctocolitis (10.2%), atopic dermatitis and urticaria (8.9%), food protein induced enterocolitis (4.9%) and eosinophilic esophagitis (0.4% method: the study involved 147 patients, who are two years old (and above), diagnosed with cow milk allergy and are observed for at least six months in our hospital. socio-demographic features of the patients, their symptoms, symptom-start ages, age of diagnosis, clinical findings at diagnosis and during observation were recorded in data collection questionnaires. results: the samples were 91 (61.9%) boys. the average symptomstart age was observed to be 5 months , average diagnosis age 6 months (1-54) and average age of final check 36 months . when symptoms at entry were observed, 85.7% of the patients had dermal system, 25.2% gastrointestinal system, respiratory system disorders, and 15% were detected to have developed anaphylaxis. among the patients diagnosed with cow milk allergy, 31.3% showed food reaction to nutrients with lge agents, 51.7% to mixed types, and 17% to nutrients with non-lge agents. it was also observed that, in the end of 30.4 ± 19.8-month observations, sensitivity to cow milk was observed to continue in 34 (23.1%) of our patients. when tolerance improvement rates among the patients were compared, anaphylaxis (p < 0.001) during entry were observed to be influential in continued allergic state. 5 (3.4%) patients were able to consume yoghurt, 10 (6.8%) patients could consume dairy products and 19 (12.9%) patients could not consume dairy products. conclusion: in the end of our investigation, it was observed that 57 (50.5%) of the 113 patients developed cow milk tolerance before the age of 2. when the factors enabling the continuation of sensitivity in cow milk allergy were investigated, anaphylaxis during entry, entry specific lge and pasteurized milk antigen as well as high skinprick test results were detected to be significant. 0765 | initial lower threshold was a risk factor of severe adverse reaction during oral immunotherapy for cow's milk anaphylaxis results: before oit, median age was 5.7 years old, median threshold to induce initial reaction was 2.1 ml, to induce anaphylaxis was 14.6 ml of cm and median milk specific ige was 56.4 ku/l. twentyseven subjects (24%) dropped out from the protocol, 69 subjects 0766 | investigation of heat and matrix effect on milk proteins' allergenicity and the development of hypoallergenic food products reduce some milk proteins' allergenicity (ß-lactoglobulin) . in this project we aimed to investigate the effect of heat and matrix on different milk protein fractions through maillard reaction and eventually develop hypoallergenic food products that have milk protein with low reaction risk. method: milk cake matrix is prepared in different flour/sugar (f/s) ratio (2f/1s, 1f/1s, 0.5f/1s) and baked 30 minutes at 180°c. proteins that cake contains are separated using sds page and stained with coomassie blue to check total protein. in parallel specific proteins are detected by western blotting using pooled sera from patients with milk specific ige>60ku/l for incubation results: in normal milk cake recipe (2f/1s) ß-lactoglobulin bands are disappeared but casein bands did not differ in size. in order to investigate the matrix effect f/s ratio is changed and it is found that when this ratio decreases, with the affect of heat and maillard reaction, milk casein bands' intensities also decrease in sds gel coomassie staining. in western blot experiments it is also shown that milk specific ige bound weakly to casein bands in low f/s ratio cake (0.5f/1s) whereas in cakes that have high f/s (2f/1s) ratio it bound significantly higher. and ß-lactoglobulin proteins' structure and lower the milk specific ige bindings to milk proteins in low f/s ratio cake through maillard reaction. 0767 | extensively hydrolyzed formulas for the management of cow's milk protein allergy in infants: is extensive hydrolysis sufficient to guarantee success? method: to better understand the range of ehfs, we aimed to analyse samples of commercially available ehfs from 11 countries and various manufacturers, with a focus on suitability for cmpa management. samples were de-identified and coded for the analyses. molecular weight (mw) distribution of hydrolysates and residual proteins and peptide profiling were assessed with sds-page gel and size exclusion-high-performance liquid chromatography (se-hplc), as they reflect both the design of the formula and the quality management applied during production. osmolarity, nitrogen fractions, lactose content, total and free amino acids, β-lactoglobulin, and casein content were quantified and β-lactoglobulin residual allergenicity was assessed. results: peptide mw distribution displayed significant variation, with the percentage of peptides with mw >1.2 kda varying from 1% to 36%. mw distribution was shown to be positively correlated with β-lactoglobulin specific in vitro degranulation. twenty % of samples had non-measurable β-lactoglobulin content (smaller than or at the limit of quantification (loq): 0.010 mg/kg); however, 80% of samples had β-lactoglobulin content greater than the loq, with high variability from 0.020 to 36 mg/kg. surprisingly, even in samples featuring a high degree of hydrolysis, significant levels of residual β-lactoglobulin were quantified. conclusion: lack of consensus over the definition of 'extensively hydrolysed' is reflected in the wide range of degree of hydrolysis in commercially available ehfs, and can result in products that are mislabelled as 'extensively hydrolysed' and may be high-risk or even unsuitable for the management of cmpa. results of these analyses also highlight that degree of hydrolysis alone is not sensitive enough to characterise ehfs, and that whilst a high degree of hydrolysis is desirable, further quality control measures are essential to ensure clinically safe and suitable products. actionable guidelines to better define hypoallergenic formulas based on extensively hydrolysed milk proteins are warranted. background: assessing the effect of baked milk products on accelerating unheated milk tolerance in patients with cow's milk allergy. method: a randomized clinical trial was done on 84 patients (6 months-3 years old) divided randomly to case and control groups matched for age and sex. baked milk in form of muffin for 6 months followed by baked cheese in form of pizza for next 6 months was given to the patients in case group. skin prick test and serum ige (sige) levels (immunocap) of milk, casein and betalactoglobulin were measured before and after the study. the ones having milk sige less than 3 ku/l and being asymptomatic during the study underwent oral food challenge test for evaluating unheated milk tolerance. chualalongkorn university, bangkok, thailand; 8 kk women's and children's hospital, singapore, singapore; 9 university of the philippines, philippine general hospital, manila, philippines background: problems in recognising cow's milk allergy (cma) and lactose intolerance (li) in infancy may lead to a delayed or incorrect diagnosis, as well as inappropriate dietary interventions. method: between january and november 2017, a survey was conducted online in china, india, singapore, thailand, mexico, kuwait, united kingdom, australia, and paper-based in the philippines. the survey consisted of 12 multiple-choice questions on cma and li in infants aged under 12 months, two case scenarios (non-ige cma and anaphylaxis) and 10 questions on educational needs (likert scale [1] [2] [3] [4] [5] . data on the type of medical practitioner and clinical setting were collected. responses were summarised as percentages and categorised by country. results: 1663 responses were received from general practitioners (22.2%), paediatricians (39.7%), paediatric allergists (6.9%), paediatric gastroenterologists (11.2%) and other specialities (20.0%). there were significant misconceptions about the clinical importance of primary li in infancy. while primary li rarely manifests before 3 years of age, 73.7% of participants felt it was a significant clinical problem in the first year of life. regarding secondary li, 44% of respondents recommended lactose restriction for viral gastroenteritis, and 36% for cow's milk protein-induced enteropathy. while the management of ige cma was relatively well understood, there were greater knowledge gaps for non-ige cma. 59% of practitioners appropriately identified extensively hydrolysed formula (ehf) as first-line treatment of cma in formula-fed infants. however, the distinction between lactose-free and lactose-containing ehf appeared to be an area of uncertainty. in india, 34.4% used soy-based formulas as firstresults: patch tests were positive in 62 (79.5%) and negative in others. positivity to milk was seen in 29 patients (37.2%), to soy in 41 (52.6%), to egg white in 7/72 (9.7%), to wheat in 12/66 (18%), to potatoes 6/48 (12.5%), to corn (maize) in 3/38 (7.9%), to rice in 1/2, and to peanut in 3/37 (8.1%). patients were requested to withdraw the suspected food(s) from their diets during a 4 months period. preliminary follow-up data show the improvement of one or more symptom in 19/20 patients (gastroesophageal reflux in 10, appetite in 5, stool consistency in 1, respiratory symptoms in 10, pain in 3, eczema in 1). conclusion: patch tests are informative, easy to use tools in order to identify potential causes of common lasting symptoms in children with negative or weak rast results and introduce beneficial changes in the daily diet. longer follow-up is necessary in order to refine and assess the benefit of such strategy. background: currently in the us, 1 in 13 children suffer from food allergies. at present, there is no cure and strict avoidance of the relevant foods is the only way to prevent allergic reactions. elimination diets put infants and children at risk for nutritional deficiencies and impaired growth. we examined the role of the registered dietitian (rd) in advising patients and families of food allergic children. method: a retrospective review of clinical notes was performed for the first 13 consecutive children who required a dietetic consultation in a dedicated food allergy clinic. we examined common questions from parents that were addressed by the dietician during the consultation. results: patients were aged 10 months -9 years (median: 16 months) and were diagnosed with the following food allergies: cow's milk: 69.2%, egg: 62%, tree nut: 54%, peanut: 39%, wheat: 31%, soy: 31%, fruit/vegetable: 15%, legume: 8%, fish: 8%, sesame: 8%. the most common questions for the dietitian included: ways to meet nutritional needs following a prescribed allergen-restricted diet (31%), meeting vitamin d and calcium requirements on a milk protein-free diet (23%), suitable oral supplements and recommended serving sizes (14%), appropriate order of solid foods introduction in food protein-induced enterocolitis syndrome (fpies) (14%), cautionary food ingredient statements (7%), baked milk protein introduction (7%), cross-reactivity risk of milk protein with soy (7%) and crossreactivity of nuts in retail bakeries (7%). conclusion: parents of children with food allergies have multiple questions with regards to nutrition. dietetic input in the food allergy clinic addresses important issues for children and families including successful avoidance of allergen-containing foods while ensuring optimal nutrition, decreased exposure to high-risk situations and avoidance of allergen cross-contamination. 0773 | multicenter prospective study of a stepwise single dose oral food challenge of egg background: oral food challenges (ofcs) are necessary for allergy management. we previously reported that a low-dose ofc can avoid complete elimination, even if patients react to higher doses of causative foods. nevertheless, this approach has only been validated in a retrospective single-center trial. we have previously reported that the median time for initial symptom onset is 50 minutes for egg ofc using a single exposure. therefore, this study aimed to confirm the safety and effectiveness of a stepwise single-dose ofc in a multicenter, prospective study. who showed a positive reaction to low-dose ofc, only 1 patient (2%) showed a severe reaction: barking cough immediately improved with adrenaline inhalation. among 8 patients with a positive reaction to medium-dose ofc, none had a severe reaction. the median times to symptom onset were 60 and 50 minutes following low-dose and medium-dose ofc, respectively. patients in the three groups, divided according to threshold doses, differed significantly in sige levels against egg white and ovomucoid. conclusion: this multicenter prospective study confirmed that stepwise single-dose ofc to egg will help to clarify the severity of egg allergy, and will contribute to improved food allergy managemethod: the study design was a retrospective cohort study extracting data from the electronic chart of children older than 4 years who visited our out-patient clinic for egg or milk allergy and who underwent an oral food challenge test (ofc) twice within 24 months between november 2013 and december 2017. the patients were divided into five groups according to their treatment schedule, which consisted of those who: a) started from 1/10 of the first ofc reaction threshold and maintained 1/10 till the end of oit; b) started from 1/100 of the threshold and maintained 1/10; c) started from 1/10 000 of the threshold and maintained 1/10, d); conventional slow oit (started from just below the first ofc reaction and increased 1.2-1.5 times every few weeks); or e) continued elimination. we determined the presence or absence of an increase in threshold reacted to the allergen, any adverse events during oit, and food-specific ige reduction. results: the number of participants was 217 and their median age was 6 years. the number of patients in groups a, b, c, d, and e was 17, 51, 33, 95, and 21, respectively. the percentage of patients in groups a, b and c showing an increase in reaction threshold to the allergen was higher than that in group e (p < 0.05), and that in group b was higher than that in group d (p < 0.001). the number (percentage) for group a, b, c, d, and e was 12 (70.6%), 43 (84.3%), 23 (69.7%), 54 (56.9%), and 5 (23.8%), respectively. there was a significant difference in the frequency of adverse events during oit between group a-c and d, which was as follows: 5 (29.4%), 9 (17.6%), 8 (24.2%), and 67 (70.5%), for the respective groups (p < 0.0001). there was no significant difference in the percentage of patients showing a decrease in food-specific ige in each group. conclusion: the regimen starting from 1/100 of the ofc reaction threshold and maintaining the dose at 1/10 was safer and more effective for increasing the threshold reacted to the allergen than the 'conventional slow oit' regimen. elimination continuation was not effective for increasing the threshold reacted to the allergen. legumes allergy was presented in different clinical features; urticaria and angioedema in 32 (50%) patients, anaphylaxis in 23 (35.9%) patients, atopic dermatitis in 5 (7.8%) patients, eosinophilic esophagitis in 3 (7.8%) patients and as food-related enterocolitis in 1 (1.5%) patient. thirteen (35.1%) of the patients had asthma, 9 (24.3%) had allergic rhinitis. fourteen (58.3%) of the 24 patients with single legume allergy showed improvement. the patients who developed tolerance, of these 7 (29.1%) had peanut allergy, 4 (16.6%) had lentil allergy and 3 (12.5%) had chickpea allergy. two of 13 patients with multiple legumes allergies, it developed tolerance to all the legumes they are allergic. conclusion: peanut and lentils were the most frequent legumes that displayed allergic reactions in our study. in these patients the rate of allergy to non-legumes food is high. in patients who were allergic to single legumes, the symptoms were ameliorated in 58.3%. conclusion: cashew nut is a potent allergen and can cause quite severe reactions. avoidance of pistachio nut and other related allergens should be advised to patients after allergologic investigation. in the majority of the patients, presence of atopic dermatitis with food allergy is noteworthy. therefore, it would be useful to investigate these patients for cashew and other tree nut allergy before they present with a serious clinical reaction. and jellyfish sting. serum allergen-specific ige test was negative; skin prick test was positive for natto and pork. we performed an oral food challenge with natto, pork, crustaceans, and wheat, and she developed a general itchy rash after 7 hours of eating natto. h1blocker was administered and she recovered soon. however, the general itchy rash relapsed after 4 hours. hence, we intramuscularly injected epinephrine, h1-blocker, and steroids; then, her symptoms did not relapse. based on these findings, we inferred that anaphylaxis caused by natto could be associated with a jellyfish sting. discussion: although association between japanese fermented soybeans (natto) allergy and jellyfish sting has been previously reported, its anaphylaxis is a rare event. in this case, we suggest that anaphylaxis was caused by natto allergy, which was perhaps related to jellyfish sting. hence, further investigation is essential to elucidate the association between fermented soybeans allergy and jellyfish sting. introduction: non-celiac gluten sensitivity (ncgs) is a syndrome characterized by intestinal and extra intestinal symptoms related to the ingestion of gluten-containing food, in subjects that are not affected by either celiac disease (cd) or wheat allergy (wa).once the gluten-containing foodstuff is removed from the diet, the patients will have relief of their symptoms. case: a 6-year-old girl was referred by his general practitioner with history of occasional constipation and abdominal pain (especially after main meals and defecation), short stature and low weight. the growth indices were proper for her age till she was 5. then after there was a stunting. she had short stature and low weight. despite different types of supplementation, there was no improvement in growth indices, so she was referred to a pediatric endocrinologist for gh therapy. primary investigations and anti-ttg, iga, anti-ema all were normal. after a consultation with a pediatric gastroenterologist, a genetic study of hladq2 and 8 were done because of the highly suspicion of celiac disease. the results were also negative. at last she was referred to immunology-allergy clinic for evaluation of probable food allergy. ige level was checked and a prick test was performed which they were not indicative of any suggestive food allergy. because of the history of the abdominal pain and constipation which was more prominent after meals, negative results of genetic study, spt to wheat, and serologic markers, a gluten free diet was suggested for her with the suspicious of non celiac gluten sensitivity. a significant improvement in her symptoms was noticed within 2 weeks of starting gluten free diet. she has 2kg of weight gain and height improved from 116 cm to 120 cm in 4 months. she continued to improve on a gfd and when seen in the follow-up clinic 6 months later reported complete resolution of symptoms and another 2 cm and 1 kg gain in her height and weight. conclusion: non-celiac gluten sensitivity syndrome is a diagnosis made by excluding celiac disease and wheat allergy. it should be taken into consideration especially in patients who have the suspicious symptoms of celiac without supporting lab data, and also negative spt to wheat. the young man in question along with his parents were keen to proceed, so with some hesitation we proceeded to a hazelnut oral provocation challenge, having very carefully explained the risks of undertaking such a challenge. he successfully completed the challenge and experienced no allergic symptoms and is now able to have hazelnuts in his everyday diet. discussion: this young man wanted to confirm if indeed he was allergic to hazelnuts. not being hazelnut allergic would mean that he would be no longer allergic to any nut and would not have to take precautions prior eating products. positive results to both cor a 9 and cor a 14, hazelnut storage proteins are associated with the patient possibly experiencing systemic reactions, at a higher risk of experiencing anaphylaxis it they were to ingest hazelnut. these facts in conjunction with his specific ige to hazelnut would have prevented us from proceeding to challenge was it not for this young man's persistence that he wanted to proceed to challenge despite the risks. conclusion: appearances are deceptive, as this case demonstrates; allergen-specific ige and component testing can only predict the probability of an allergic reaction, the final test in the diagnostic process is the oral provocation challenge. the patient and his family were happy for me to share the above with other health care professionals. method: we present the case of a female of 29 years old diagnosed of acu with poor control of the symptoms at maximum doses of antihistamines. we decided to associate omalizumab treatment. the patient had a good control of the symptoms with omalizumab at dose of 300 mg/4 weeks, but in the 6th month she presented an erythematous, raised and pruritic lesion in the area of injection together with localized abdominal edema at 12 hours of the administration, with two weeks of evolution without symptomatic treatment. we decided to discontinue omalizumab alter a second episode with half doses. results: we performed a skin biopsy of the lesion and epicutaneous tests with the drug. immediate hypersensitivity tests were not taking due to the impossibility of stopping antihistamines. skin biopsy showed a perivascular lymphocytic inflammation of the superficial and deep dermis with frequent presence of perivascular and interstitial eosinophils, suggestive of a hypersensitivity reaction. results: nine months before presentation at our clinic, the patient had been hospitalized and treated with imipenem and tmp/smx for pulmonary nocardiosis. once discharged, she had been prescribed oral tmp/smx alone, according to antimicrobial susceptibility. at our first evaluation, the patient presented with fever, macular erythematous non-pruritic (vasculitic-like) skin lesions on the upper limbs, polyarthralgia and bilateral ankle arthritis. tmp/smx was transiently stopped. after four days, there was a dramatic improvement, with resolution of all signs and symptoms. she was tentatively diagnosed with a viral infection and thus tmp/smx was started again. however, after three days, the symptoms (fever, arthritis and skin lesions) recurred. laboratory investigations showed increased levels of inflammatory markers. complete blood count with differential, serum creatinine, urinary sediment, liver enzymes, rheumatoid factor, antinuclear antibody, c3, c4, immune complexes, serology for rickettsia, borrelia and coxiella were all negative. hence, tmp/smx was stopped again and cutaneous lesions, fever and arthritis resolved spontaneously in five days. conclusion: given the clinical course and the resolution after the withdrawal of tmp/smx, we diagnosed a sslr due to sulfonamides. to the best of our knowledge, this is the first case of sslr occurring after a nine-month therapy with tmp/smx and allergists/immunologists should be aware of the possibility of such a reaction even after months. case report: * we received written informed consent for publication of these clinical details and/or clinical images included in my abstract was obtained from the patient. drug rash with eosinophilia and systemic symptoms (dress) syndrome is a severe adverse cutaneous reaction that usually appears 2-6 weeks after treatment with the causative drug. this syndrome is characterized by severe dermal rash, fever, eosinophilia, and internal organ involvement, and clinically, diffuse maculopapular eruption, exfoliative dermatitis, and facial edema are often observed. we performed blood tests and laryngeal fiberscopy for the diagnosis of the patient. intradermal test with delayed reading and patch test were performed 2 months after the end of treatment. a 53-year-old man had begun treatment with carbamazepine for epilepsy. after 4 weeks of treatment, he observed skin rash with pruritus on both lower extremities, and after 6 weeks, his skin lesions had begun to spread over his whole body, and he complained of several new symptoms, including hoarseness, dyspnea at rest, and dysphagia. an examination revealed maculopapular rash, facial edema, and bilateral cervical lymphadenopathy. laryngeal fiberscopy revealed both arytenoid and epiglottic swelling. laboratory studies revealed eosinophil counts of 2100 /μl and increase in alanine aminotransferase level to 65 u/l. a diagnosis of dress syndrome was definite according to the regiscar group criteria. carbamazepine, the suspected culprit drug, was withdrawn, and systemic corticosteroid was initiated. the patient experienced rapid improvements in hoarseness, dyspnea, and dysphagia. after 5 days of treatment, laryngeal fiberscopy revealed complete resolution of both arytenoid and epiglottic swelling. to the best of our knowledge, our case is the first reported case of dress syndrome to manifest with laryngeal edema. case report: bortezomib (velcade ⓡ ), a targeted therapy works by blocking the action of proteasomes in side cells, is commonly used to treat newly diagnosed as well as relapsed/refractory myeloma. bortezomib has been reported to have gastrointestinal symptoms, peripheral neuropathy, neuropathic pain and thrombocytopenia as its most common side-effects. although several cases of skin lesion caused by bortezomib have been reported, severe cutaneous adverse reaction (scar) such as stevens-johnson syndrome (sjs) is very rare. we here report a case of bortezomib induced sjs. a 71-year-old female patient, who was diagnosed with multiple myeloma, received bortezomib and melphalan /dexamethasone therapy. after the 4th dose of bortezomib, she presented with fever and maculopapular skin rashes spreading from face to the trunk. erosive lesions in the oral mucosa and corneal ulceration with conjuntival injection were observed. she was diagnosed as sjs. the symptoms of sjs improved after bortezomib was discontinued and systemic steroids and intravenous immunoglobulin were administered. drug patch test was performed, the result was positive in bortezomib. this is the first case report of bortezomib induced sjs in this country, which was diagnosed by a patch test. although the scar by bortezomib is generally considered very rare, we suggest that clinicians be aware of potential adverse reactions, including sjs. case report: we report the case of a healthy 46-year-old woman with history of red erythematous macules in both hands, one hour after taking a fluconazole (150 mg) tab for a vaginal candidiasis. it faded spontaneously. she didn't recall if she had ever taken that medicine, but denied known drug allergies. although fde is primarily a clinical diagnosis, we conducted an oral challenge test with fluconazole (150 mg). two hours after intake of the drug the patient started complaints of pain and erythema in both hands and the challenge was stopped. two days after the challenge, she developed red painful erythematous macules on the same sites of the first episode. due to the specificity of the challenge, local patch testing was not performed. introduction: the classic form of a fixed drug eruption is one or more anular or oval erythematous patches as a result of systemic exposure to a drug. these skin lesions normally resolve with hyperpigmentation and may recur in the same location with re-exposure to the drug. other types of fixed drug eruptions have been described, being fixed drug urticaria a rare form of presentation. (1, 2) case report: in the last 2 years, a 48 year old woman has developed more than 15 episodes of a wheal in the right supraciliary region 5 minutes after taking 600 mg of oral ibuprofen. the symptoms resolved in less than 6 hours without treatment and without leaving residual lesion. after the last episode, she refers good tolerance to 1 g of oral paracetamol. she denies local traumas. she also refers mild spring rhinoconjunctivitis well controlled with antihistamine, and sneezing with house dust. a 37-year-old-m patient had psoriasis vulgaris for 15 years, and had been using methotrexate at intervals of 4 years. despite the addition of phototherapy, he underwent a new treatment with biological agent (antitumor-necrosis-factor; anti-tnf), since the disease control was insufficient. before anti-tnf, preventive treatment against latent tuberculosis (tb) activation was indicated with positivity in tuberculin skin test (20 mm). he was given inh 300 mg/day, and at the 20th day of treatment, desquamation, erythema, and subsequent exfoliation developed in his hands and foots dorsum. inh was withdrawn. in order to distinguish the lesions from psoriasis attack, skin biopsy was performed and reported as erythema multiforme-like dermatitis with no relation to psoriasis. the lesions were completely improved at 3 weeks of topical steroids, and inh was re-initiated at the same dose. a week after the initiation of the drug, skin lesions similar to previous reoccurred with more severity and progression from distal to proximal extremities. cell counts, renal and hepatic function tests, and hepatitis markers in blood were in normal limits. skin lesions were retracted after 4 weeks of topical steroids, and withdrawal of inh. there was positivity in skin patch test with inh at 72 hours. finally, for tb prevention an alternative drug rifampicin (10 mg/kg/day) was given, and the patient successfully completed with no adverse event. his psoriasis lesions were improved with anti-tnf which was started after 1 month of tb prevention with rifampicin. in these days which the use of biologic agents is increasingly widespread, inh use will be more prevalent than the past. even tough, it is effective and safe in most of the patients, its adverse event dermatitis may be a reason to withdraw in patients with dermatological diseases. in this case, diagnostic drug allergy evaluation should be performed to optimize the second-line treatment of tb infection, in addition to early withdrawal of the culprit drugs. background: around 50% of cancer patients will receive radiotherapy (ionizing radiations) as a treatment, either as a single therapy or as an adjuvant to chemotherapy and surgery. several side effects have been described due to radiotherapy, of which we can mention erythema multiforme and stevens johnson syndrome, but in lower prevalence. erythema multiforme can be described as an acute skin condition and may be present within a wide spectrum of severity. erythema multiforme minor represents a localized eruption of the skin with minimal or no mucosal involvement. the papules evolve into pathognomonic target or iris lesions that appear within a 72-hour period and begin on the extremities (see the following image). lesions remain in a fixed location for at least 7 days and then begin to heal. it is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers precipitating factors and complex interactions may trigger the appearance of signs and symptoms. these include especially recurrent herpes simplex virus (hsv), epstein-barr virus (ebv), histoplasmosis, alcohol, systemic diseases and immunological factors. method: 69-year-old male diagnosed with prostate adenocarcinoma who underwent transurethral resection and was taking trinomia (ramipril, atorvastatin, acetyl-salicylic acid) after his 8th rte external radiotherapy session, he presented erythematous maculo-papular lesions in the suprapubic area with some vesicles. therefore, withdrawal of treatment was decided and the performance of a skin biopsy. 15 days later, regarding the improvement of the lesions, rte was continued, presenting incipient exacerbations of the lesions but it allowed us to end the cycle of treatment. results: skin biopsy results (anatomical pathology): basal keratinocytes, which blur the dermoepidermal interface, with lymphocyte exocytosis at this level, associated with isolated images of spongiosis. the dermis shows a superficial perivascular lymphocytic inflammatory infiltrate of moderate intensity. compatible with erythema multiforme. conclusion: radiotherapy is a technique of increasing use, so it is important to recognize the associated cutaneous lesions that appear less frequently and are sometimes underdiagnosed. diagnosis is both clinic and pathological and is usually late in most cases so it is vital to take into account this skin disease complication in order to be properly managed. including chinese herbal medicine is usually considered to be without any allergic and adverse reaction. method: visits were made to pharmacies in hong kong and luoyang, china and a martial art monastery/temple in dengfeng, china. some cam were found to have ingredients with potential allergic and adverse reaction. results: three cam, one from hong kong (1), one from shaolin martial art monastery/temple in dengfeng (2) and one from luoyang (3), china were found to contain chinese herbal medicine with potential allergic and adverse reaction. (1) cordyceps ling-zhi complex ingredients: cordyceps sinensis "caterpillar fungus", tremella fuciformis "snow fungus", ganoderma lucidum (ling-zhi) "reishi mushroom" and others 30 years old female patient who has ulcers in oral mucosa and purple, itchy lesions on her right hand palmar area, little finger, index finger, on her left hand palmar area, pollex finger. in her history, she has relapsing vaginal yeast and she hasn't any hypersensitivity reaction with fluconazole before 1 month ago she started to take fluconazole because of vaginal candidiasis. after using fluconazole she started to itch from described areas and dark redpurple eruptions appeared. she was prescribed oral methylprednisolone and topical pomade which included corticosteroid for four days but she didn't aware of fluconazole related drug reaction. lastly four days ago she took fluconazole and metronidazole for severe vaginal yeast. 12 hours later pruritus, same eruption appear on the same area, lip and tongue angioedema than she had dyspnea, dizziness, hypotension, arrhythmia and consciousness. she had admitted to the emergency department and performed adrenalin. after a day bullae and ulcers came into existence in her oral mucosa. in her blood analysis there was mild increase in white blood cell count (13.300 /mm 3 ), eosinophil count was normal (300 /mm 3 ), biochemistry parameters were in normal limits, crp and sedimentation rate were in normal limits, total ige was 439 iu/l. introduction: tuberculosis is a disease that most commonly affects the lungs, which is transmitted by the respiratory tract and drugs are the most important factor in the treatment. non-resistant tuberculosis infection is usually treated with hrze. in rare cases, a hypersensitivity reaction may develop against one or more of the drugs during treatment. case: a 37-year-old female patient was diagnosed with culturepositive pulmonary tuberculosis and hrez treatment was started by the related department. seven days later she referred to the policlinic with edema and itchy erythematous lesions which are common in her extremities, which developed after 6 hours of taking her medication. liver and kidney function tests and eosinophil count were normal. drug eruption was considered with current physical examination findings. the treatment was interrupted, short time systemic corticosteroids and antihistamine treatment started. desensitization planned. there was no feature in the prick and patch tests with drugs. desensitization was performed with isoniazid, no reaction was observed during the procedure. six hours after the procedure, the patient applied to the emergency department with painful edema and pruritic erythematous lesions in the extremities. desensitization procedures with rifampicin, ethambutol, pyrazinamide were performed without any problems after the lesions were regressed. isoniazid was withdrawn from the treatment protocol. outcome: we would like to present on this case that drug eruption may develop in the form of maculopapular rash after desensitization. this study aims to compare ethmoid mucosa and nasal polyp regarding density of tissue eosinophil and its sensitivity, specificity, and correlation with clinical characteristics for diagnosing ecrs. method: patients with crs with polyps scheduled for endoscopic sinus surgery were enrolled. specimens were collected from polyp apex, polyp pedicle and ethmoid mucosa. tissue eosinophil from these three sites in the same patient were compared. using eosinophilic mucin as a reference, sensitivity, and specificity of each site for diagnosing ecrs was assessed. correlations between tissue eosinophilia (defined as greater than 10/ hpf) and clinical characteristics of ecrs including asthma, serum eosinophilia, and eosinophilic mucin were analyzed using each site of specimens. results: thirty patients with crs with polyps were enrolled. polyp apex, polyp pedicle and ethmoid mucosa gave similar results regarding tissue eosinophilia in 16 patients (53.3%). eleven (36.7%) patients were ecrs (having tissue eosinophilia at all sites) and five (16.6%) were non ecrs (no tissue eosinophilia at any sites). median tissue eosinophil was significantly greater in polyp apex (84, and polyp pedicle (96, iqr: 80-320) than ethmoid mucosa (21, iqr: 10-220), p = 0.04. sensitivity of polyp apex, polyp pedicle and ethmoid mucosa for diagnosing ecrs were 100%, 60% and 80% respectively. specificity were 36%, 40% and 48% respectively. correlations between tissue eosinophilia and asthma were significant when assessing ethmoid mucosa (p = 0.04), and polyp pedicle (p = 0.05) but not polyp apex (p = 0.21). correlations with serum eosinophilia, and eosinophilic mucin were not significant (p > 0.05) when assessing any specimens. gov/pubmed/) was performed using the following key words: "obstructive sleep apnea syndrome"; "allergy rhinitis"; "hypoxia"; "intermittent hypoxia"; "fluctuating hypoxia"; "cyclic hypoxia"; and "hif-1α" results: osas may affect the prognosis of ar patients based on the following evidence: 1) ar is thought to be a cause of osas. 2) exposure to hypoxia could mediate immune activation in ar and affect the response to treatment. 3) hif-1α expression may be a risk factor for ar. 4) intermittent hypoxia can induce robust expression of hif-1α. conclusion: first, improvement of ventilation during sleep represents an efficient strategy for treating ar. therefore, continuous positive airway pressure or nasal surgery to resolve a nasal obstruction could be added to ar treatment. finally, medications that target hif-1α, such as digoxin, can be tested as adjuvant therapy. method: forty patients diagnosed with allergic rhinitis and olfactory dysfunction were recruited in current study in the group 1 and 2. patients of group 1 were administered with no treatment and patients administered with the traditional chinese acupuncture therapy were incorporated into the group 2. before the treatment, all of them underwent t&t olfactory testing, nasal sinus computer tomography scanning and visual analog scale (vas; 0-100), and repeated the assessment after four-week treatment. results: improved total t&t olfactory testing scoring averages and vas scoring averages was observed in eleven patients treated with traditional chinese acupuncture compared with four patients in the observation group. no side effect was found. no significant differences in olfaction recovery were found according to age, gender, or duration of disease between the two groups. the observation group underwent nasal endoscopic sinus surgery and the control group underwent external approach surgery, and the therapeutic effect of the two groups were investigated. results: the total effective rate was 94% in observation group and 74% in control group, the total effective rate of observation group is significantly higher than control group (p < 0.05). the recurrence rate was 3% in observation group and 24% in control group, the recurrence rate of observation group is significantly lower than control group (p < 0.05). complication occurrence rate of observation group was 6% which is significantly lower than control group 24% (p < 0.05). the therapeutic effects of endoscopic sinus surgery on chronic sinusitis in geriatric patients are better than conventional external approach surgery which is worth clinical application. results: (descriptive). the equick app is user-friendly even for vkc patients with sub-optimal reading ability. home use between clinic appointments allows responsive temporal data gathering of qol, symptoms, medication scores and impact of medical interventions. equick may be used in future as a research tool in gathering outcome data following interventions for vkc. ectoine, a substance deriving from halophilic micro-organisms, is a strong water structure forming solute exerting cell protective antiinflammatory and antiallergic properties. method: purpose of our study was to assess the efficacy of the preventive administration of 2% ectoine eye-drops (3 times a day for 6 months) to shorten the duration of vkc relapses (which begin, in our country, very early in spring and usually end in october), or to mitigate the attacks, which are only controlled by topical corticosteroids or cyclosporine resulting in an important burden of side-effects. in this retrospective study, we included 192 children of both sexes (148 males and 44 females), under the age of 10 years (mean age 7.8 years), affected by vkc from more than 3 years/seasons and treated for more than 4 months during a year, with cyclosporine eye-drops. these patients underwent, from february to september 2017, the additional-to-the-usual protocol treatment with 2% ectoine eyedrops. results: 8% of the included subjects astonishingly had no relapse of vkc, 38% needed topical cs or cyc treatment but it was started 2 months later compared to previous years, 29% needed the topical drugs 3 months later and 25% had a similar to previous years course (no ectoine efficacy). the treatment was well tolerated and only 1 child had to stop it because of local allergy to the eye-drops. the preventive administration of 2% ectoine eyedrops was able to stabilize and to delay vkc attacks in more than 50% of the selected patients showing the importance of anti-inflammatory and anti-allergic properties of this product. following international criteria we considered normal levels of vitamin d the levels between 50 nmol/l (20 ng/ml) and 125 nmol/l (50 ng/ml), a potential deficiency between 30 nmol/l and 50 nmol/l and a severe deficiency less than 30 nmol/l. results: 58.8% (30 children) of akc group patients presented vitamin d low levels, among them 18 children showed a potential deficiency and 12 a severe deficiency. 24.3% (18 subjects) of vkc patients suffered a deficiency in vitamin d which was mild in 13 and severe in 5 patients. 40.3% (25 children) of sac group showed a deficiency in vitamin d which was potential in 17 and severe in 8 subjects. conclusion: our study shows that in different forms of allergic conjunctivitis many children are suffering a vit. d deficiency and it can be supposed that a correlation between the severity of the allergic form and the level of vit. d deficiency exists. we recommend allergists and ophthalmologists to check vit. d levels in children suffering from allergic conjunctivitis because its deficiency is very common and many are unaware of it; in case of a vit. d insufficiency it is fundamental to give a vit. d suitable-to-the-case supplementation. method: 83 children (57 males and 26 females, mean age 7.3 ± 5 months) affected by vkc and allergic rhinitis from more than 2 years were treated with mometasone furoate nasal spray 1 spray bid × 2 weeks in a month, for 3 consecutive months as a co-seasonal treatment at the beginning of eye allergic symptoms. other systemic or topical treatments did not vary compared to the previous 2 years. results: a quick questionnaire administered to children and their care-givers showed that nasal symptoms regressed after a mean period of 9.2 days from their beginning but, impressively, in more than 30% of them, these patients did not show a vkc typical relapse along the 3 months of mometasone treatment, moreover the following summer period was milder in subjective ocular symptoms in more than 25% of the patients. our experience pointed out that incs adjunctive treatment was positively associated with a regression of eye and nose symptoms in children suffering from vkc, confirming previous literature data which concern milder forms (seasonal allergic conjunctivitis or allergic rhino-conjunctivitis) compared to the severe forms (like vkc) we analyzed in our work. one of the involved mechanisms of action can be the alleged effect on the reduction of substance p in tears; it is supposed to reflect the neuropeptides levels in ocular tissues. 0816 | patient response to mp-azeflu in an allergen exposure chamber onset of action (ooa) timing may impact treatment adherence. mp-azeflu, intranasal azelastine hydrochloride (aze) and fluticasone propionate (fp) in a single device, has proven to have greater efficacy and faster ooa than a combination of oral loratadine and intranasal fp (lora/infp), but the clinical relevance for patients is unclear. this single-center (ontario, canada), randomized, double-blind, double-dummy, three-period crossover trial examined by which extent mp-azeflu provides clinically relevant symptom improvements according to different efficacy parameters. method: ar symptoms were induced in asymptomatic, ragweedsensitive patients via ragweed pollen challenge in an environmental exposure chamber. patients received a single dose of mp-azeflu, lora/infp, or placebo and were monitored for 4 hours. symptoms were assessed using total nasal symptom score (tnss) and total ocular symptom score. responder analyses included the number of patients to achieve relevant response (rr) to therapy (30% or 50% reduction in tnss), time to rr (ie, first time point at which rr was reached), and minimal clinically important difference (mcid) in ooa. background: nasal allergen provocation test (napt) is a standardized diagnostic tool indicated in the diagnosis of allergic rhinitis, to design and monitoring allergen immunotherapy, and to study the pathophysiology of airway allergy. unfortunately, until now very few studies have evaluated its reproducibility and safety. in this study we wanted to analyse the safety and reproducibility of napt in a large group of rhinitis patients and healthy controls. unit until december 2017. a bilateral saline challenge followed by a bilateral napt were performed in symptoms-free individuals. the response was assessed by nasal-ocular symptoms and acoustic rhinometry. all subjects signed a written informed consent. the safety of napt was checked by the occurrence of extra-nasal/ ocular reactions (enor), severe adverse events (sae), and use of rescue medication (rm). enor was assessed by clinical symptoms, physical examination, cardiopulmonary auscultation, spirometry, and oxygen saturation. the reproducibility of napt was tested by comparison of the results in 2 or more sessions with≥1-month interval. background: nasal hyperreactivity (nhr) is self-reported by a majority of patients with allergic rhinitis (ar) and is likely mediated by neural-immune interactions. the combination of fluticasone propionate (fp) and azelastine (aze) hydrochloride administered in a single spray (mp-azeflu) has been shown to be superior to fp or aze alone in patients with seasonal ar (sar). we hypothesize mp-aze-flu may reduce neuro-immune mediators in ar with nhr. in a post hoc analysis of three pivotal studies of mp-azeflu, we analyzed the efficacy of mp-azeflu, fp, and aze in patients with ar with and without nonallergic triggers. method: in three randomized, double-blind, controlled trials, patients with sar were randomized 1:1:1:1 to mp-azeflu, fp, aze, or placebo (pbo). patients self-reported sensitivity to nonallergic triggers. change from baseline in total nasal symptom score (tnss) and treatment differences between active agents and pbo were calculated. results: across 3412 patients in three studies, mean age was 36.3 years and mean age at ar symptom onset was 15.6 years. overall, 89% reported ≥1 nonallergic trigger, which included sudden temperature/humidity change (72%), tobacco smoke (61%), perfumes/fragrances (57%), incense/candles (38%), and cleaning products (38%). change from baseline in tnss for patients with ar and nonallergic triggers was greater with mp-azeflu than with fp or aze (table) , and patients with nonallergic triggers improved slightly less than patients without nonallergic triggers in both the mp-azeflu and fp groups. background: in low-income countries (lics), assessment of phenotypes, prevalence and risk factors for allergy-related diseases (ards) using allergen-specific ige may be complicated by environmental exposures such as helminths. these exposures may also induce cross-reactive carbohydrate-specific ige profiles that could inhibit allergic effector responses. we sought to elucidate the molecular basis of ige sensitisation among individuals in uganda, using a component-resolved approach to ige measurement. we employed the isac ® allergen microarray to assess plasma ige reactivity to 112 purified natural and recombinant allergen components in participants of three studies: a trial of intensive versus standard anthelminthic treatment in the rural helminth-endemic lake victoria islands (n = 126), a parallel urban survey of allergy outcomes in a lower helminth exposure community (n = 60) and a study on asthma risk factors in children from the urban setting and from nearby rural schools (n = 100). data on sensitisation to crude allergen extracts were obtained by skin prick testing (spt) with cockroach and house dust mites (hdm), and by immunocap ige testing (cockroach, hdm, and peanut). results: the rural setting was characterised by high prevalence (≥34%) of sensitisation to crude extracts (immunocap ige>0.35 ku/ l) but low sensitisation to the major, established, allergenic components on the microarray (≤2%, ige>0.30 isu). however, sensitisation to cross-reactive carbohydrate determinant (ccd)-bearing components and venoms was more common in rural (up to 14%) versus urban (up to 8%) individuals, and was associated with helminth infection. urban individuals mounted higher responses to allergenic components of dust mites but responses to other components were similar between the two settings. sensitisation to allergenic components was higher among asthmatics and spt+ children but ccd sensitisation profiles were similar between asthmatics and nonasthmatics, and between spt+ and spt-school children. conclusion: we show that, in lics, ige to crude allergen extracts (detected in standard immunocap assays) reflects sensitisation to a myriad of environmental exposures (absent in more developed countries), such as ccds expressed by helminths, and may not accurately define ard phenotypes in this setting. however, our data does not seem to indicate that ccd-specific ige detected by isac ® microarray protects against ards. considered minor allergens. due to their sequence homology and conserved structure, they show a high cross-reactivity. the objectives were to study the ige/igg binding properties of polcalcin in relation to the calcium ions, and the ige cross-reactivity between purified polcalcin from olea europea (ole e 3) and two recombinant polcalcins (rphl p 7 and rbet v 4). method: ole e 3 was purified by immune-affinity chromatography using polyclonal antibodies anti-rche a 3. serum samples were obtained from 6 patients allergic to grasses recruited at hospital de guadalajara (spain), all of them positive to phl p 7 with sige values ranging from 12.1 to 92.6 ku/l. equal volumes of all sera were used to prepare a pool. calcium binding assay was performed either by addition or not, or depletion of ca 2+ . ole e 3 was incubated with 0.1 mm cacl 2 or with 1 mm egta ph 7.5 (ca 2+ chelator agent) at the same time as the antibody in immunoblot or elisa assays with the pool of sera or with anti-che a 3 polyclonal antibody. crossreactivity assay was performed by immunocap inhibition. aliquots of the pool of sera were previously incubated with amounts of ole e 3 ranging from 0.02 to 12.5 ng. the same dilution of the pool of sera without ole e 3 was used as a control. after 2 hours of incubation, sige (ku/l) binding to rbet v 4 or rphl p 7 was determined. results: a 9 kda protein was purified from the o. europea extract and identified by lc/ms-ms as ole e 3. in the calcium binding assay there were no differences between the samples with or without ca 2+ . however, the addition of egta to the reaction completely inhibited the binding of the polyclonal antibody by immunoblot and also produced a 32.3% reduction of ige binding by elisa. in the cross-reactivity assay, a 50% inhibition of ige binding was obtained with 2.8 ng of ole e 3 for rbet v 4 and 3.9 ng for rphl p 7. the maximum rate of achieved inhibition was 68.6% for rbet v 4 and 61.6% for rphl p 7. conclusion: native purified ole e 3 contains the ca 2+ necessary to bind to the specific antibodies and the depletion of ca 2+ inhibited this binding. high cross-reactivity of ole e 3 with rphl p 7 and rbet v 4 was demonstrated. 0826 | effect of glutathione-s-transferase pi on the cysteine protease activity of the house dust mite allergen der p 1 background: environmental proteases have been proposed to be involved in the pathogenesis of allergic disorders via different mechanisms, such as the disruption of epithelial tight junctions, the cleavage of surface proteins, the activation of damage and pathogen-associated molecular patterns receptors, and the alteration of redox status. der p 1 from house dust mite is one of the most clinically relevant indoor allergens worldwide, which exhibits cysteine protease activity and has been linked to allergenic rhinitis and asthma. however, it is unknown whether the host microenvironment could regulate der p 1 activity once it reaches the mucosal surface. glutathione-s-transferase pi (gstpi) is an anti-oxidant and detoxification enzyme. gstpi is the predominant gst in human lung epithelial cells, where it is expressed in high levels. polymorphic variants of gstpi have been associated to various inflammatory lung disorders such as allergic asthma. more recently, gstpi has been identified as a redox regulator through protein s-glutathionylation, a post-translational modification where glutathione (gsh) is conjugated to cysteine residues. method: this work aimed at determining if gstpi affects the cysteine-protease activity of der p 1, compared to gstmu -a different gst isoform-by using different in vitro approaches. results: we found that gstpi increased der p 1-activity, but not gstmu. our results suggested a potential role of gstpi in upregulating the protease activity of der p 1 allergen. however, the clinical implications of these findings in allergic airway diseases needs for further investigations. 0827 | cari p 1, a novel polygalacturonase allergen from papaya acting as respiratory and food sensitizer biswas sarkar m; sircar g; ghosh n; das ak; jana k; dasgupta a; gupta bhattacharya s bose institute, kolkata, india background: papaya was globally reported to elicit ige-mediated hypersensitivity. certain papaya sensitive patients with food allergic symptoms were found to experience recurrent respiratory distresses at peak flowering period of papaya even after quitting the consumption of papaya fruits. the immunoreactive protein present both in pollen and fruit proteome was detected by ige-serology and identified by mass spectrometry. one such allergen, designated as cari p 1 was cloned, and purified as recombinant protein. the ige-reactivity of rcari p 1 was examined by immunoblot using patient sera. the allergenic activity of rcari p 1 was evaluated by histamine release assay from ige-sensitized granulocytes. the aggregation and folding pattern of rcari p 1 was assessed by size exclusion chromatography and circular dichroism spectroscopy respectively. the presence of cari p 1 in papaya fruit was searched by igg-immunoblot using allergen-specific rabbit antisera. a mouse model of papaya allergy was established to study the role of rcari p 1in eliciting respiratory and food hypersensitivity. results: a 55 kda ige reactive protein commonly present in pollen and fruit proteome of papaya was identified as endopolygalacturonase. recombinant cari p 1 remained monomer and the cd-spectra revealed predominantly β-sheet characters. the melting curve of the allergen showed partial refolding from a fully denatured state indicating the possible presence of conformational ige-epitopes in addition to the linear ige-epitopes of food allergens. 7 out of 7 papaya allergic patients displayed ige reactivity to rcari p 1. rcari p 1 at 1 μg/ml, induced histamine release from challenged granulocytes within a range of 30% to 72% (i.e. 50 ± 9.2%; n = 4 patients). expression of cari p 1 was detected in the peel and pulp tissues of papaya fruits at two edible stages of fruit maturation. in mouse model, rcari p 1 exhibited a comparable level of eosinophil infiltration and goblet cell hyperplasia in lung and duodenum histology. conclusion: cari p 1 the first major allergen reported from papaya with a dual role in respiratory sensitization via pollen inhalation and sensitization of gut mucosa via fruit consumption. the recombinant allergen can be used as marker allergen for molecular diagnosis and immunotherapeutic management of papaya allergy. background: lipids can be potent stimulators of the immune system, and their role in allergy is highly investigated and debated. since many allergens bind lipids, one question that arises is the relative importance of the lipids versus the lipid-allergen complex in eliciting the immune response. also of interest is an evaluation of the importance of the allergen-lipid complex. in our characterization of the structure of the cockroach allergen bla g 1, we discovered that it could promiscuously bind a variety of lipids in a large central cavity. this suggested that bla g 1 could be used as a prototypical allergen and lipid delivery vehicle to test in various models of sensitization. method: cd spectroscopy. nmr spectroscopy. molecular modeling. we have developed an hplc procedure to strip the phospholipids derived from the e. coli-based expression system, and reconstitute the allergen with a variety of lipids. using cd spectroscopy and nmr, we have verified that the protein conformation is highly similar in the presence and absence of lipids. temperature dependent cd spectroscopy revealed that unloaded bla g 1 is the least stable, and the melting temperature increased with increasing fatty acid chain length up to c20. similar cd melting experiments revealed that bla g 1 could bind lipoteichoic acid (lta) from gram positive bacteria, but did not interact with lipopolysaccharide (lps) from gram negative bacteria. molecular modeling studies have suggested that the stoichiometry of phospholipid binding is likely 4 phospholipids per bla g 1 and give insight as to the different binding characteristics that would allow bla g 1 to bind lta but exclude conclusion: these biophysical studies will allow the design of bla g 1-lipid systems to test a variety of sensitization models. 0829 | sal k 7, a new allergen from salsola kali sola jp; pedreño y; fernández j; cerezo a; peñalver m probelte pharma, murcia, spain background: the polcalcin from salsola kali was identified and sequenced (genbank kt254655) and the recombinant protein was characterized as a minor allergen with a prevalence of 40% of patients with a spt positive to s. kali. the objective of this study was to purify the polcalcin from s. kali pollen and to include the allergen in the website for the systematic allergen nomenclature (www.allergen.org). method: the native polcalcin from s. kali (npsk) has been purified from pollen after a first step of protein extraction and then diverse chromatographic steps: a size exclusion chromatography to remove particles minor than 5 kda, an ionic exchange chromatography, a hydrophobic interaction chromatography and a final step of size exclusion chromatography to obtain the purified sample of polcalcin. the purity of the npsk has been determined by sds-page and the binding capacity to a specific polcalcin antibody from rabbit serum was tested by immunoblot. the specific antibody had previously been obtained by immunization with the recombinant polcalcin from s. kali. the allergenicity of the npsk has been assayed by immunoblot with a pool of sera of patients sensitized to s. kali. the identity of the purified npsk has been analyzed by peptide footprint in hplc-ms/ms after digestion with trypsin. all the information about the polcalcin from s. kali was sent to who/iuis allergen nomenclature sub-committee. the npsk showed a high purity in sds-page with a molecular weight of approximately 9 kda and this purified protein reacted with the specific polcalcin antibody from rabbit serum. the ige binding capacity of the npsk was confirmed by immunoblot using a pool of sera from patients sensitized to s. kali. the analysis of peptide footprint confirmed that the purified protein is a polcalcin. the who/iuis allergen nomenclature sub-committee included the polcalcin from s. kali in the website for the systematic allergen nomenclature as a new minor allergen named sal k 7. conclusion: the polcalcin from s. kali has been purified from pollen and tested for its ige binding. it is included in the website for the systematic allergen nomenclature as the new allergen sal k 7. background: alt a 1 protein is the major allergen from the fungus alternaria alternata and responsible for chronic asthma, yet little is known about its physiological role and immunological activity. our main purpose was to investigate the mechanism through which alt a 1 induces an allergic response in bronchial epithelium. method: although alt a 1 has a unique topology, we studied the structural relationship by in silico procedures consisting of three distinct structural alignment methods in order to understand its nature. the immunological properties of the allergen were investigated by using monocyte cell line thp1 and human peripheral blood mononuclear cells. results: its crystal structure has been recently reported and claimed to be exclusively in fungi without equivalent in the protein data bank. data obtained in silico show that this allergen shows some structural relationships with a number of other β-barrel proteins such as human lipocalin 2 (lcn2). besides, our experimental data demonstrate that alt a 1 is also able to interact with lcn2, human lipocalin. in this way, the results obtained from several immunological assays showed that alt a 1 is able to produce a response of the immune system through different immune innate receptor pathway inducing the th2 cytokines. background: increasing evidence of cross reactivity syndromes between pollen grains and fruits, with immediate or delayed reactions, has been reported. while some syndromes such as the birch pollen/apple syndrome are well documented, some other such as the cypress pollen/peach syndrome remain to be understood. for the latter, significant progress has recently been made with the discovery of a new allergen family, the gibberellin regulated proteins (grps), which has been shown to be responsible for the observed cross reactivity i.e. pru p 7 and bp14 (1, 2) for the peach and the cypress pollen respectively. grps are small cationic proteins with anti-microbial properties and have been shown to be over produced in response to a stress. herein, the case of a patient, born and raised in the south of france but currently living in paris, has been studied. this patient has been suffering since childhood from allergic rhinoconjunctivitis to cypress pollen and from some oral symptoms to peach and other fruits (including pomegranate). method: in addition to the clinical exploration and cutaneous tests, a very thorough biological characterization of the patient samples has been performed through various specific ige quantitation techniques, western blotting after one and two-dimensional gel electrophoresis and flow cytometry based basophil activation testing (bat). results: specific iges to cypress pollen, birch pollen, peach, orange and apple have been found. pr10 allergenic proteins are recognized by iges but no ltps. the presence of specific iges to cypress pollen bp14, peach peamaclein (pru p 7) and a cationic 14 kda protein from pomegranate has been shown through western blotting after gel electrophoresis separation of the protein extracts. the use of bat finally enabled to demonstrate that the basophils of this patient were, ex vivo, strongly activated with protein extracted from orange and cypress pollen and also with purified proteins such as bp14 and pru p 7. conclusion: these results unambiguously show that the cypress pollen grp, bp14, is clinically relevant, similarly to its homologous protein in peach, pru p 7. it can be proposed that these two allergens are at the basis of the observed cross-reactivity syndrome. the search for new cross-reactive allergenic grps in pollen, fruits or vegetables may enable to better understand other pollen/food associated syndromes that still remain unexplained. background: nine allergens of phleum pratense have been described until now (iuis database) and classified into groups based on their function and cross-reactivity. group 1 and 5 allergens are considered the most immunodominant, due both to their greater ige-binding capacity and the number of patients ige-reactive to them. previously published studies have estimated that group 1 is recognized by almost 95% of grass pollen-allergic patients, and group 5 by 80%. however, until now a comparative of the ability of these allergens to provoke an immune response has not been performed. the objective was to study the immunogenicity of the major allergens phl p 1 and phl p 5, by analyzing the ability of the recombinant forms (rphl p 1 and rphl p 5a) to induce a humoral immune response. method: five mice were immunized with the same amount of each recombinant protein: rphl p 1 and rphl p 5a (indoor biotechnologies) (60 μg plus two boosters of 30 μg). the specific igg antibodies produced by each mouse were tested against the recombinant proteins by direct elisa and the title of each of them was determined by optical density (o.d.). additionally, the recognition of both allergens in native and depigmented-polymerized (dpg-pol) extracts of p. pratense was studied by direct elisa using these generated antibodies. results: preimmune sera were negative. all mice produced antibodies against the corresponding recombinant protein. the immune response (sigg) was statistically significant higher in mice immunized with rphl p 5 than in those immunized with rphl p 1; it was needed 8 times more rphl p 1 serum than rphl p 5a serum to obtain the same o.d. values. the difference in responses was higher in the group of mice immunized with rphl p 1 than with rphl p 5a. differences in the recognition of phl p1 and phl p 5 in native and depigmented-polymerized extracts of phleum pratense was also observed. it was necessary 8 times more rphl p 1 serum to produce the same signal than rphl p 5a serum in native extract and it was necessary 4 times more rphl p 1 serum to produce the same signal than rphl p 5a serum in dpg-pol extract. conclusion: rphl p 5a is more immunogenic than rphl p 1, which was also probed with native and dpg-pol extracts. background: glioblastoma (gbm) is an incurable primary malignant brain tumour with a median life span of less than 15 months despite multimodal treatments. therefore, there is a serious need for the development of innovative medications. several epidemiological studies underlined an inverse correlation between pre-existing igemediated allergy and gbm risk, where having such an allergy decreased the odds of developing gbm by 20 to 40%. we aim to delineate the intrinsic immuno-biological and molecular mechanisms that can be responsible for these correlations, based on the hypothesis that allergies may promote a state of increased immuno-surveillance in the brain through the presence of immunological factors such as immunoglobulins, cytokines and cells involved in th2-driven allergic reactions. we consider that as the major immune cell type of the brain, microglia should be implicated in this beneficial association and may favour the elimination of the nascent tumour in brain parenchyma in an allergic context. we implemented a long term allergic airway inflammation by repeated nasal instillation of house dust mite (hdm) extract in a syngeneic orthotropic mouse model of gbm. we followed animal survival and the tumour growth by mri. in addition, we purified microglia from allergic vs non-allergic mice in order to assess their cytotoxic function against the gbm cell line ex vivo and their secretory capacities. finally, we investigated immunoglobulin reactivity against gbm antigens in the context of allergic reactions by reverse phase protein array (rppa). we demonstrated an increase of the animal survival that was correlated with a delayed tumour engraftment and a reduced tumour growth. these phenotypes were associated with functional modification of microglia from sensitized mice. indeed, these microglia showed a rise in the production of il-6 and tnf-a as well as an increase in cytotoxic functions against a gbm cell line ex vivo. in parallel, we observed an increase in serum igg1 reactivity against gbm antigens in mice sensitized with hdm compared to control mice. results: in 23 patients (48%) with cvid we recorded at least one temporary platelet count decrease below 150 × 10 9 /l compared to only 1 patient (10%) with xla (p = 0.024). more importantly in 18 patients (38%) with cvid this decrease was observed in a period longer than 6 months compared to 1 patient (10%) with xla (p = 0.077). in 10 patients (21%) with cvid we recorded at least one temporary platelet count decrease below 100 × 10 9 /l and only in 3 patients (6.5%) with cvid this decrease was observed in a period longer than 6 months. we did not record any platelet count decrease bellow 100 × 10 9 /l in patients with xla however the difference with cvid did not reach statistical significance. no thrombocyte count decrease bellow 50 × 10 9 /l was observed in either group. none of patients required immunosuppressive treatment for immune thrombocytopenia (itp). conclusion: although the statistical significance was documented only in temporary platelet count decrease below 150 × 10 9 /l it is obvious that numbers of thrombocytes commonly fluctuate in some patients with cvid. the mechanism leading to these temporary decreases is unclear. monitoring of complete blood count is a basic follow-up investigation in patients with cvid. introduction: wegener's granulomatosis (wg) is a systemic disease that may affect all organs, most frequently the ears, noses, throats, sinuses, lungs and kidneys. it is a rare autoimmune disease, also called granulomatosis with polyangiitis, and characterized by necrotizing granulomatous inflammation in small and medium sized blood vessels. anti-neutrophil cytoplasmic antibody against to proteinase 3(c-anca) is thought to be responsible for autoimmune inflammation. the coexistence of wg and common variable immunodeficiency (cvid) is extremely rare. in this report, we describe a patient with wg and cvid who was treated with immunosuppressive drugs and intravenous immunoglobin concomitantly. case report: a twenty-four-year-old male patient was referred to our clinic for immunological evaluation due to recurrent infections, fever of unknown origin and neutropenia. the patient had been diagnosed with wg and taking immunosuppressive therapy for three years. he had chronic renal failure due to wg and had also been on peritoneal dialysis for three years. serum igg, iga levels, peripheral blood cd19 + b cell percentage and absolute count of the patients were found to be low according to reference limits. he was diagnosed with cvid after excluding secondary reasons for hypogammaglobulinemia and he started to receive 600 mg/kg intravenous immunoglobulin (ivig) therapy once in a month. also, the treatment that consists of mycophenolate mofetil (mmf) and glucocorticoids was continued to decrease c-anca levels in serum. he has been accepted as a candidate for kidney transplantation, and prepare for this purpose. discussion: the management of the patient with cvid and wg may be complicated. it is considerably difficult and needs competency and courage. moreover, the cases similar to ours, are extremely rare. therefore, the authors should share their own experiences on cvid and discuss them by comparing the data obtained from other cases. background: leukocyte adhesion deficiencies (lads) are a group of three genetic disorders leading to defective leukocyte adhesion to the endothelium and as a consequence decreased leukocyte recruitment and immune defense. lad-i is caused by mutations in the gene encoding the ß2-integrin cd18 on chromosome 21.lad-iii is a rare primary immunodeficiency syndrome, characterized by homozygous mutations in the kindlin-3 gene (official symbol fermt3). we have aimed to evaluate our patients who were followed up with lad for the last 15 years, retrospectively. method: all data of the cases were obtained from the file records of age at diagnosis. results: seven patients from separate 6 families were included in the study. four patients were lad-iii and 3 patients were lad-i. the female to male rate was 2/5. the age of diagnosis is ranged from 16 days to 4 years. the median umbilical cord detachment was 21 days (7 -53 days groups: up to 6 times (6 people) and from 6 to 12 times (6 people). 10 healthy donors were examined as a control. flow cytofluorometry method was used to study peripheral blood and assess the parameters of innate and adaptive immunity results: it was found that at a frequency of edema up to 6 times a year there are changes in the t-system of adaptive immunity, which are shown by a decrease in the expression of late activation markers (cd3 + hladr+ 3.46 ± 0.60%, in control 8.04 ± 0.14%), an increase in the number of cd3 + cd8 + cytotoxic lymphocytes (0.60 ± 0.17x10 9 /l, in control 0.39 ± 0.01x10 9 /l) and as an increase in their functional activity (cd8 + gr+ 0.53 ± 0.02x10 9 /l, in control 0.16 ± 0.01x10 9 /l). the nature of disorders of cellular factors of the innate immunity is manifested by decrease in the adaptive resources of neutrophils (kstnbt 1.62 ± 0.13u.e., in control 2.15 ± 0.02u.e.). patients with hae with a frequency of edema up to 12 times a year, we observed the disorders of the humoral link of adaptive immunity, which consist in an increase in the number of circulating b lymphocytes (0.27 ± 0.11x10 9 /l, in control 0.11 ± 0.01x10 9 /l). in addition, with the strengthening of the hae clinic, changes in the system of innate immunity progressed very fast and consisted in increasing the amount (cd16 + 0.37 ± 0.05x10 9 /l, in control 0.21 ± 0.01x10 9 /l), and functional activity (cd16 + gr+ 0.32 ± 0.16x10 9 /l, in control 0.14 ± 0.0210 9 /l) of natural killer cells results: we included 261 children, mostly males (54%), aged between 1 month and 16 years. 37.5% of patients (n = 98/261) showed abnormal absolute results of lymphocyte count for age. we found more patients evaluated in the age group of 2 to 5 years (31.8%), followed by 5-10 years (24.5%), lymphopenia was found in 15.4% of patients. b lymphocyte deficiency was the most common pattern (37%) followed, in decreasing order, by low cd4, t cd3, tcd8 and nk. many patients have more than one affected population (12.6%) . some patients were affected in all three series (4.2%). the cd4 / cd8 ratio decreased in 28.7% of the patients. the majority of the children were males between the ages of 1 month and 16 years. 37.5% of patients showed abnormal absolute lymphocyte count for age. b-cell deficiency was the most common pattern followed, in decreasing order, by low cd4, t cd3, tcd8 and nk. many patients have more than one affected population. 0847 | indicators of the humoral immunity in the mechanical jaundice of benign genesis the aim of the investigation was to study the indices of humoral immunity in patients with benign mj, depending on the level of bilirubin. method: 62 patients with mj and 125 practically healthy volunteers were examined. patients with a level of bilirubin less than 60 μmol / l -9, with a bilirubin level of 60-200 μmol / l -37 and with a bilirubin level of more than 200 μmol / l -16 patients. the concentration of immunoglobulin classes a, m, e and g in serum was determined by enzyme immunoassay. the statistical significance of the differences was determined using the ranked mann-whitney test. the critical level of significance in checking statistical hypotheses was assumed to be p < 0.05. results: of the contacted dermatologists, 136 participated (53 women, 83 men; mean age 53.2 ± 8.5) which results in a response rate of 27.3%. the guideline compliant prescription rate of biologicals in patients with csu was 6.9%. the most prevalent barriers in the prescription were the high cost of the treatment (64.7%), low reimbursement for doctors (62.5%) and the fear of a recourse claim (52.9%). however, a lack of evidence or an insufficient efficiency were not concase report: eosinophil associated gastrointestinal disorders (egids) including eosinophilic colitis are commonly associated with atopy. aeroallergen sensitization may accompany food allergy in these patients. a case with eosinophilic colitis responsive to anti-ige monoclonal antibody (omalizumab) treatment is presented. an eleven-year-old boy had bloody diarrhea lasting nearly one month in autumn for last 3 years. this year diarrhea lasted more than 3 months. colonoscopic biopsy revealed lymphoplasmacytic inflammatory cells including eosinophils leading to a diagnosis of ulcerative colitis. corticosteroid and mesalazine treatment was started with a good clinical response. recurrence of diarrhea during corticosteroid dose reduction suggested corticosteroid dependent ulcerative colitis. eosinophilic/allergic colitis was an alternative diagnosis when seasonal recurrence, lack of weight loss, eosinophils in biopsy and high serum ige level were considered. colonoscopy done after cessation of therapy for one month, revealed exudative ulcerous lesions, lacerations, loss of haustration compatible with colitis (inflammatory/allergic?). presence of significant mucosa associated lymphoid tissue in biopsy supported any inflammatory, reactive process. he had recurrent bronchiolitis until age six and allergic rhinitis in spring for three years. total ige and mix aeroallergen specific ige were high (518 iu/ml, 56.1 kua/l), absolute eosinophil count was normal (210/mm3). food skin prick and patch tests were negative. he had positive skin reactions with dermatophagoides, grass and olea pollens (induration diameter: 9, 10, 6 mm, respectively). pulmonary function test was normal. he was considered as eosinophilic/allergic colitis and omalizumab was started according to manufacturer's dosing table (300 mg/ 2 weeks). rectal bleeding decreased after first dose and ceased after the second dose. early colonoscopy examination after 3rd month of therapy showed that exudations disappeared and haustrations became evident. microscopy revealed mild nonspecific colitis. few patients with eosinophilic colitis improved with omalizumab were reported before. ige-mediated processes are responsible from eosinophilic inflammation in egids, making anti-ige therapy as a promising treatment option. 0859 | design of liposomal carriers modified by glycoconjugates for liver cell delivery of nucleic acids used. the surface of liposomal nanoparticles can be modified to increase the selectivity of intracellular delivery. it is well known that asialoglycoprotein receptors of hepatocytes have a strong affinity to galactose carbohydrate. therefore, the aim of this study was to assess the effect of the modification of the liposome surface by glycoconjugates on the selectivity of intracellular transport of nucleic acids into the liver cells. method: liposomes based on ornornglu(c 16 ) 2 were chosen previously as the effective nucleic acid delivery system. we modified liposomes with novel lactose-based derivatives. every of four glycoconjugates was added to ornornglu(c 16 ) 2 in an amount of 5, 10 and 15%. as a result, 12 variants of modified liposomes were obtained. to determine the cytotoxicity, an mtt test was used. using luciferase test, the selectivity of penetration was evaluated on nonspecific 293t (human embryonic kidney) and specific hepg2 (human liver cells) cell lines. results: modified liposomal compositions ornornglu(c 16 ) 2 -4 + lacc 16 (5%) and ornornglu(c 16 ) 2 -4 + lacggg16 (15%) had the lowest cytotoxicity similar to that for unmodified ornornglu(c 16 ) 2 . the ic 50 , calculated based on the data of mtt test, was 0.14 and 0.26, vs. 0.16 mg/ml, respectively. ornornglu(c 16 ) 2 -4 + lacggg16 (15%) showed a 1.5-fold increase in transfection activity on the nonspecific 293t cells, compared to unmodified ornornglu(c 16 ) 2 , whereas the modification of ornornglu(c 16 ) 2 -4 + lacc16 (5%) resulted in a 6-fold decrease in transfection activity. however, the ability of these variants to penetrate the specific liver hepg2 cell was significantly higher by 15 and 25 times, respectively, than for unmodified ornornglu(c 16 ) 2 . results: the greatest inhibitory effect of sbfhd was observed in mdm infected with hiv-1 bal: 90% and 50% suppression of hiv replication was achieved at concentrations of 1.5 μg/ml and 0.4 μg/ ml, respectively. the activity in pbmc and dc was less pronounced (the respective ic90 values were 5.8 μg/ml and 19.7 μg/ml). studies in endometrial hec-1a cells demonstrated that sbfhd suppressed cd4-independent entry of hiv-1 (10 3 tcid 50 /ml) by 33%, 54%, and 98%, respectively, at 1, 10, and 100 μg/ml. the effect was also observed after increasing the dose of the virus. at 10 4 tcid 50 /ml, sbfhd suppressed hiv infection by 45% (10 μg/ml) and 97% (100 μg/ml). the cytotoxicity of sbfhd in this system was low. similar results were obtained with colorectal caco-2 cells. sbfhd exhibited no spermicidal activity at concentrations of up to 3 mg/ml. combining within a single microbicide two agents that target distinct steps of hiv life cycle will maximize its efficacy (via synergistic effects and/or interference with multiple stages of the transmission). we therefore explored the synergistic potential of combinations of sbfhd and azt, the classical nucleoside rt inhibitor. in these experiments, 50% suppression of hiv infection was reached at concentrations of sbfhd and azt, which were significantly lower than the respective ic50 values of each component (determined in parallel experiments). the synergistic effect was most pronounced for the combination of 0.1 μg/ml sbfhd (which is 60 times less than the ic50) and 0.16 nm azt (which is 45 times less than its ic50). cd80 expression was increased after the co-culture with reishi, shiitake and boletus mushrooms (c -5.6(1.4-9.2)%; pma -60.5 (27.2-70.9)%; )%; shiitake -9.6(4.3-15.5)%; boletus -16.6 (14.0-24.0)%). method: the study included 38 men (mean age 34 ± 5.9 years) before and immediately after staying in countries with a hot climate. results: the development of lymphopenia observed in the first week of observation. this was accompanied by a decrease in the number cd3 + lymphocytes expressing the markers of late activation (cd3 + hladr+ 4.8 ± 1.09x10 9 /л и 3.2 ± 2.04x10 9 /л). revealed significant decrease of cd4 + cd25 + foxp3 + regulatory cells in the first week after returning from the area of adverse climatic conditions, as well as a significant sustained decrease in the number cd3 + cd8 + hladr+(p < 0.05). change of the effector link of innate immunity was determined in significant reliable decrease in relative (cd16 + 13.2 ± 2% and 4.6 ± 2.1%, respectively, p < 0.05) and absolute (cd16 + 0.3 ± 0.02 x109/l and 0.1 ± 0.03%, respectively, p < 0.05) in the number of a population of natural killer cells in the first week of observation. in the context of acute stress marked a significant increase in relative and absolute numbers of b lymphocytes (8 ± 1.16% (0.15 ± 0.04 × 109/l) before a trip to countries with a hot climate and 19 ± 3.1% (0.4 ± 0.07 × 109/l) in the first week after returning, p < 0.05). the activity is the production of antibodies was not changed. (ast) which is the intramuscular injection of patients own serum, is a promising therapy with a substantial efficiency on ciu patients. in this study we aim to assess the efficacy of ast on chronic urticaria patients by dlqi questionnaire. method: this was a single-blind randomized clinical trial which evaluated the efficacy of autologous serum therapy compared to oral antihistamines in patients with ciu. 49 ciu patients received the ast. every session 5 cc of each patient's blood was centrifuged at the speed of 2000 rpm for 10 minutes and 2.5 cc of the serum was injected intramuscular into the patient's deltoid muscle weekly for 9 weeks. the control group consisted of 51 ciu patients took 10 mg of cetirizine daily for 9 weeks. patients answered the dlqi questionnaire at the first session of treatment as baseline and 7 weeks after the last session(week 16) as response to treatment. the mean baseline score of dlqi for ast group was conclusion: pharmacotherapeutic and inpatient costs for patients with prevalent ar and asthma were lower in those prescribed ait than in those not prescribed ait in all years, both with and without including the cost of ait itself. this indicates that treatment with ait is associated with lower cost burden for health services. background: immunotherapy with peptides rather than conventional whole allergens is being developed to improve the benefit/risk balance of subcutaneous immunotherapy (scit). lolium perenne peptides (lpp) demonstrated reduced allergenicity following ex-vivo analyses, allowing higher doses to be given over a shorter period to improve treatment adherence and compliance. such treatment resulted in significant reduction in symptoms and rescue medication intake during the grass pollen season. here we report the safety of lpp immunotherapy in adults. background: a new allergoid from alternaria alternata was characterized to determine its reduced allergenicity in vitro. the objective of this study was to determine the skin response to the allergoid and to evaluate the clinical tolerance of the immunotherapy with the allergoid product using a rush schedule. method: to assess the skin response (sr) two groups of patients were included: group 1 with patients sensitized to a. alternata and with respiratory disease caused by this mold; group 2 (control) with patients sensitized to others allergens and non-atopic patients. the sr was determined by spt using three concentrations of the allergoid: p1 (lowest concentration), p2 (four times higher than p1) and p3 (estimated to obtain a wheal area similar to histamine 10 mg/ml). in spt was also used a native extract of a. alternata (n) and histamine 10 mg/ml (h). all products were tested in duplicate in all patients and the sr was evaluated by comparing the median of the wheal area produced by different products. to evaluate the clinical tolerance to immunotherapy the patients of group 1 were treated with the allergoid product using a rush schedule consisting in a dose of 0.2 + 0.3 ml the first day and 0.5 ml after one month (maintenance dose). the clinical tolerance was determined as the percentage of adverse reactions (ar) to the treatment and the classification of ar was established according to eaaci. the number of patients included to evaluate the sr was 46 (group 1: 25; group 2: 21, 16 atopic and 5 non-atopic) with an average age of 34.8 (range . the spt data from group 1 were expressed as median and interquartile range of wheal area (mm 2 ): h: 19.58 (15.3-25.2); n: 22.71 (11.1-33.1); p1: 0.99 (0-5.7); p2: 6.44 (0-12.5); p3: 19.78 (12.0-30.4 ). it was determined that sr of allergoid was reduced in 87% respect to the native. the products n, p1, p2 and p3 did not produce any response in patients of group 2. to evaluate clinical tolerance, 21 patients of group 1 were treated with the allergoid product with a rush schedule and only two ar were registered (3.2% of doses). these were retarded local reactions with a wheal diameter higher than 5 cm. no systemic reactions were registered and all patients continued the treatment. the allergoid from a. alternata produces a significant reduced response to spt due to its reduced allergenicity. the treatment with an allergoid product in a rush schedule is safety and clinically well tolerated. background: in our study we aim to determine the more effective, the total cost of 3 years of patients using scit was 15665 tl per person whereas the total cost of 3 years of patients using slit was 15271 tl per person. when we compare the total cost data of both groups, we found that they are close to each other. while the greatest portion of the cost data of patients with scit treatment was direct costs associated with the treatment itself (72%); the remaining part of the total cost was indirect (16%) with non-medical expenses such as transportation (12%). in the slit group, direct costs including drug expenditures have a larger percentage (92%) and it was significantly more costly compared to the direct costs of the scit group (72%). transportation costs were found to be more costly in the scit group (12%) when compared to the slit group (4%). similarly loss of parent work days in the scit group(%16) was found to be significantly more expensive compared with slit group (4%). our study results show that slit is a similar treatment for clinically and laboratorially and has a similar efficacy to scit to reduce the patients' complaints and to the need for medication. for cost-effectiveness however medicines for treatment of scit are less costly; when long term total treatment costs are calculated slit and scit treatment are economically close treatments. the protein content of the new acd was 182.28 μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in acd, involved in glutaraldehyde modification, was reduced in 91.96% respect to ncd and it can be considered as the polymerization degree. regarding to the allergenic profile, through elisa inhibition was determined a reduction of 18 times in the capacity to bind ige of the proteins in acd respect to ncd, whilst the igg binding capacity was maintained. in immunoblot there was no reaction of acd proteins to specific ige from sera. the analysis by peptide footprint determined the presence of fel d 1 and others allergens in acd. the content of major allergen fel d 1 in acd was determined as 11.9 μg/mg. the new developed and characterized allergoid from cat dander has an excellent safety profile and will allow a safer immunotherapy to treat the allergy to felis domesticus. results: the protein content of the new aaa was 65.6 μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in aaa, involved in glutaraldehyde modification, was reduced more than 85% respect to naa and it can be considered as the polymerization degree. regarding to the allergenic profile, in immunoblot there was no reaction of aaa proteins to specific ige from sera and by elisa inhibition was determined a reduction of 91% in the capacity to bind ige of the proteins in aaa respect to naa. the igg binding capacity in aaa was maintained. the analysis by peptide footprint determined the presence of alt a 1 and others allergens in aaa. the content of major allergen alt a 1 in aaa was determined as 2.4 μg/mg. a. alternata shows an excellent safety profile and allows a safer immunotherapy to treat the allergy to this mold. she was an otherwise healthy woman: she took no drugs and she did not have any remarkable concomitant diseases. the distribution and appearance of the remaining body hair was normal and the hormonal level profiles (lh, fsh, estrogens, progesterone and testosterone) did not show any significant alteration according to her age. a 30 year old woman with allergic rhinitis underwent sq glutaraldehyde-modified ait to house dust mites (d pteronyssinus and g domesticus) without any incidences and complete tolerance to maintenance dose without local reactions during a 5 year period. two years after ait discontinuation, patient first experienced a local urticarial reaction with multiple hives at previous sq ait injection sites 40 minutes after 600 mg of ibuprofen intake. these symptoms recurred at least in seven occasions when patient was exposed to ibuprofen (in five) and metamizol (in two). results: case 1: dermatologist diagnoses localized hypertrichosis. case 2: a single blind, placebo controlled oral challenge (sbpcoc) with ibuprofen 600 mg was performed and elicited multiples hives in the circumscribed area in the arm where ait was conducted. subsequently, sbpcoc with aspirin was carried out showing the same reaction although a controlled challenge with celecoxib was negative. conclusion: local hypertrichosis is a very rare injection-disease associated with injected allergen vaccine treatment. we also firstly described a recall urticaria phenomenon after allergen immunotherapy which has been only elicited after different nsaids intake. results: there were included 47 patients, in five spanish hospitals. following aria 2010 guidelines, 95.7% of patients were diagnosed of persistent moderate/severe rhinitis. the mean age was 37.7 ± 11.8 years, being 59.6% female. moreover, 57.4% of the patients had concomitant mild/moderated asthma. the period between the diagnosis of rhino-conjunctivitis and the informed consent signing was 9.8 ± 7.5 years. according to international 2006 guidelines, eight systemic reactions were registered, representing 1.9% of the administered doses: five reactions grade 0, (described as nonspecific ocular pruritus, nasal herpes, general discomfort, localized non-specific pruritus plus nausea and non-specific pruritus in throat), a grade i reaction described as rhinoconjunctivitis and two reactions grade ii, registered as generalized urticaria and asthma. all reactions were classified of mild or moderate intensity and only two required symptomatic treatment. there were five clinically significant delayed local reactions, which were higher than 10 cm or involved modifications in next dose. regarding efficacy parameters, immunoglobulin titers between baseline and final visit according to specific igg and igg4 significantly increased. cutaneous reactivity also decreased significantly in the dose response skin prick test. results: 47 patients were included, 24 to accelerated and 23 to polymerized cluster group schedules. according to aria criteria, 89.4% of patients presented persistent moderate/severe rhinitis. the mean age was 31.1 ± 9.9 years, being 40.4% male. moreover, 61.7% had concomitant mild/moderated asthma. immunoglobulin titers method: the quantification of total proteins in the products was carried out by means of a colorimetric technique using the bradford reagent (sigma-aldrich™, us) in accordance with the manufacturer's instructions. the absorbances of each standard and samples were obtained in a scinco™ s-3100 spectrophotometer (seoul, korea) at 595 nm. all samples were analyzed in duplicate. the electrophoretic profile of the proteins in the tested allergens was obtained according to the procedure described by laemmli, under denaturing conditions in a polyacrylamide gel at 12.5% concentration and stained in silver. in each lane approximately 30 μg of total proteins were applied. commercial extracts of the main allergens marketed in mexico were obtained, rossel ® , alk ® , alerquin ® , alergomex ® , allerstan ® , ipi asac ® ; and they were assigned randomly with the numbers 1, 2, 3, 4, 5 and 6. results: the following protein concentrations were found in the various extracts analyzed: see table 1 conclusion: differences were found in the protein profiles anabackground: a new allergoid from cat dander was developed and characterized to determine its reduced allergenicity in a 95% and the maintenance of igg binding capacity. the objective of this study was to develop an immunogenicity assay in mice with the new allergoid and a native extract from cat dander. the study included 24 female balb/c mice separated in three groups of 8 mice each: group 1, immunized with a mold allergen extract (control); group 2, immunized with a native extract from cat dander with a fel d 1 content of 0.525 μg per dose; group 3, immunized with the new allergoid from cat dander with a fel d 1 content of 2.36 μg per dose. all mice were immunized four times by subcutaneous injections with a volume corresponding to 1/10 of the recommended human maintenance dose with an interval between injections of 2 weeks. one week after the last injection the mice were sacrificed and the serum was obtained. to determine the specific antibody title indirect elisa were performed using a cat dander extract as antigen, sera from mice as primary antibody and antimouse igg or igg1 as secondary antibody. elisa assays were performed using serial dilutions of sera or a simple dilution by duplicate to determine the specific antibody title as arbitrary units/ml (au/ml). the data were analyzed by one-way anova and tukey hsd test to compare the averages of specific antibodies in each group. results: the immunization with both the native extract and the allergoid from cat dander produces specific igg and igg1. regarding to igg, a higher title was observed in group 3 respect to group 2 in a curve obtained after elisa with serial dilutions of sera. the specific igg title obtained in terms of au/ml was 18.6 ± 2.6 in group 1, 105.0 ± 15.0 in group 2 and 139.9 ± 16.6 in group 3. concerning to igg1 the au/ml obtained was 5.7 ± 0.4 in group 1, 73.5 ± 16.8 in group 2 and 97.5 ± 18.8 in group 3. the increase of specific igg or igg1 in mice from group 3 respect to mice from group 2 and control group was statistically significant (p ˂ 0.01). the safety profile of the allergoid from cat dander allows a treatment with higher dose of allergens to produce a greater response to immunotherapy to induce formation of specific this was an open, multicenter clinical trial, in patients aged between 18 to 60 years with rhinoconjunctivitis with or without concomitant mild asthma sensitized to house dust mites (hdm). the aim was to evaluate the safety and tolerability of the vaccine. secondary endpoints included were: changes in immunoglobulin levels (specific ige, igg and igg4) versus d. pteronyssinus and d. farinae and changes in cutaneous reactivity. patients were under study treatment for 17 weeks: five for the induction phase (weekly injections) and 12 for the maintenance phase (monthly injections). results: 42 patients were included. there were 6 withdrawals from the trial; no one was related to treatment. the patients mean age was 33.6 years, being 50% female. 71.4% were diagnosed of persistent moderate/severe rhinitis according to aria guidelines and 31.0% presented concomitant mild asthma. regarding to safety results, 22 systemic adverse reactions were registered which corresponded to 7.9% from a total of 277 administered doses. the most of systemic reactions were grade i, (5.4%) described as rhinitis or urticaria, grade 0 or nonspecific (2.2%) and 1 reaction (0.3%), was grade ii. all of them were mild or moderate and only 4 needed treatment. among local reactions, 21 (7.6%) were clinically relevant late local reactions, meaning a wheal at injection site >10 cm and /or requiring a dose readjustment in the next administration; 6 (2.2%) were clinically relevant immediate local reactions meaning a wheal >5 cm. concerning the efficacy parameters, cutaneous reactivity at the final visit versus baseline was, in average, significantly decreased, and specific titers of igg and igg4 against tested hdm increased significantly at final visit. 162 patients completed the study. mean values in rqlq questionnaire (total score) decreased from 2.56 to 1.24 points (51.6% score reduction) in final visit, reflecting a statistically significant improvement (p < 0.01). annual episodes of rhinoconjunctivitis decreased from 13.7 to 9.7 (p < 0.01). 43.8% of patients improved from persistent to intermittent rhinoconjunctivitis (p < 0.01) and 46.9% from moderate/severe to mild intensity (aria) (p < 0.01). moreover, 16 .1% of asthmatic patients at baseline, did not have any bronchial symptoms after 1-year treatment (p < 0.01). mean value of treatment satisfaction was 7.2 (sd=1.8) and 7.2 (sd=1.7) for patients and physicians respectively. 0884 | evaluation of safety and tolerability of "allergovac poliplus" in polysensitized patients with allergic rhinitis-rhinoconjunctivitis with or without asthma: an observational prospective study (apolo) background: the objetive of this study was the safety and tolerance assessment of "allergovac poliplus" scit treatment, with 2 allergen combination-mixtures in polysensitized patients, as well as the evaluation of the clinical improvement and patients' satisfaction after treatment. method: this is a prospective observational clinical study. allergovac poliplus treatment is being administered in a "1-day" or in an abbreviated schedule. polysensitized patients (to pollens or mites), with rhinitis or rhinoconjunctivitis, with or without asthma, and between 5-60 years have been included. all adverse events are being recorded. visual analog scales (vass) are being used to evaluate clinical improvement, tolerance and satisfaction after treatment (10 months). results: a total of 147 patients have been included, with an averresults: in all groups prevailed severe forms of the disease and the phenotype of frequent exacerbations. groups were comparable in age composition and structure of severity. observations in the group of vaccinated pcv13 continue the dynamics of decreased dyspnea up to 1.66 (1.11;2.21) results: of a total of 631 pts under scait, 110 were excluded due to data unavailability, and 521 included (♀283 (54%), mean age 32 ± 13 years (minutes: 7 max 73 md30), age range [18-30] being most prevalent (40%). the most frequent diagnosis was rhinitis/rhinosinusitis (97%), followed by asthma (43%), diagnosis coexisting in abstracts | 479 214 pts (41%). other diagnosis such as conjunctivitis (24%), atopic eczema (15%) and food allergy (9%) were also found. mite sensitization occurred in 422 patients (81%) of which 199 (47%) were monosensitized. the pollen sensitization was verified in 288 (55%) with 88 monosensitized pts (31%). the double sensitization mitespollens was displayed in 189 (36%). sensitization to epithelia and fungi occurred respectively in 100 (19%) and 42 pts (8%). it was found that 20 pts (4%) presented sensitization to the 4 groups of allergens (mites, pollens, fungi, dander). an average of 58 ± 23 pts started this treatment per year. prescription included 10 laboratories with the following %: a-39.6; b-29.3; c-13.2; d-5.4; e-4.7; f-4.2; g-2.5; h-0.9; i-0.1; j-0.1. option for extract of physical modification (5%), physical-chemical (16%) and chemical (79%). table 1 shows the frequency of distribution of scait composition. conclusion: in this population sensitization to mites was predominant being the most prescribed scait followed thru sensitization to grasses with the respective scait. the majority of the population was polysensitized. however, in composition preference the choice of 1 group of allergens prevailed and only 5% had more than one sort of pollen and 4% pollen+mites. polysensitization is a reality, nonetheless the choice of ait composition should be guided thru scientific criteria and not through the availability of mixtures encouraged by laboratories. background: allergen immunotherapy (ait) has been proven to be an effective treatment of allergic diseases in numerous studies. however, its use in seniors remains limited and questionable, due to common comorbidities and limited evidence of efficacy and safety of ait in aging population. the aim of presented study was to assess the safety of ait in patients over 55 years of age undergoing subcutaneous immunotherapy (scit) and analyze the potential risk factors of adverse reactions in this population, compared to younger adults. we followed subcutaneous immunotherapy in a group of 1302 patients treated in the outpatient clinic of medical university of lodz, of whom 163 were aged 55 and older (118 between the age of 55-60, 31 aged 61-65 and 14 patients above the age of 65). we recorded detailed information of each administration and corresponding adverse reactions over the period of 2 years. we compiled results of our observations with patients' medical records to compile a database, which we then analyzed using statistical software. method: a total of 46 cases with seasonal allergic rhinitis undergoing pre-seasonal immunotherapy and 28 cases followed with conventional drug treatment were included in the study. immunotherapy and control groups were divided into monosensitized (only pollen) and polysensitized (at least 1 additional allergen except pollens) patient groups according to skin prick test reactivity. all patients were followed between march-september 2013 with symptom and medication scores, and visual analogue scale (vas). the quality of life was assessed using the mini-rqlq questionnaire. phleum pratense (phl p) specific ige and specific igg4 (uni-cap 100, phadia) measurements were performed before and after 7 weeks of immunotherapy in all patients. gramineae pollens were counted during the grass pollen seasons. results: mean age was 34.9 ± 10.6 and 34.2 ± 12 years, female/ male ratio was 29/17 and 17/11, the number of monosensitized/polysensitized patients were 37/9 and 20/8 in immunotherapy and control groups, respectively. in the immunotherapy group, june-july symptom scores, may-june-july-august vas scores and june combined symptom-medication scores were lower than the control group (p = 0.005). furthermore, improvements in activities-practical problems and other quality of life scores were significantly different between two groups (p < 0.05). in immunotherapy group, phl p specific ige and phl p specific igg4 levels measured after immunotherapy were significantly higher compared to those before immunotherapy (p < 0.001, p < 0.001, respectively). phl p specific igg4 levels measured after immunotherapy were also significantly higher in the immunotherapy group than in the control group (p < 0.001). there was no difference in terms of clinical and immunologic parameters in monosensitized and polysensitized patients (p > 0.05). conclusion: clinical improvement with pre-seasonal allergoid immunotherapy is accompanied by an important increase in specific igg4 blocking antibodies despite short-term injections. our findings show that pre-seasonal allergoid immunotherapy has similar clinical efficacy and b cell response in polysensitized subjects compared to monosensitized patients. 0891 | the safety trial of sequential sublingual immunotherapy with japanese cedar droplet and house dust mite tablet matsuoka t 1 ; kuroda y 1 ; igarashi s 1 ; fukano c 2 ; natsui k 2 ; ohashi-doi k 2 ; masuyama k 1 1 university of yamanashi, yamanashi, yamanashi, japan; 2 torii pharmaceutical co. ltd., tokyo, japan background: sublingual immunotherapy (slit) is recognized as the only treatment option with the potential to provide long-term posttreatment benefits. in japan, the prevalence of japanese cedar (jc) pollinosis is very high, about 30% of the population, of which the majority are co-sensitized to hdm. slit is now well established, safe and convenient treatment form for allergic disease, and recently, jc slit-droplet and hdm slit-tablet products were approved in japan for treatment of jc and hdm induced allergic rhinitis, respectively. however, the safety of sequential jc slit-droplet and hdm slittablet has not yet been investigated. therefore, we investigated the safety trial on slit combined with jc droplet and hdm tablet in allergic patients. method: eleven subjects with jc pollinosis and hdm rhinitis were enrolled. patients were treated once-daily with jc slit-drops for 4 weeks, followed by 24 weeks of sequential slit treatment where the jc slit-drops and the hdm slit-tablets were administered daily with a 5 minute interval (1st: jc-slit drops, 2nd: hdm slit-tablet). the primary endpoint was the frequency and severity of adverse events (aes) during sequential slit by common terminology criteria for adverse events (ctcae) v4.0 and slit grading system. serum antibodies were measured as the secondary endpoint. results: eleven patients were recruited. aes after jc slit-drops administration were found in 9 patients out of 11 cases (82%). aes after sequential slit were found in 8 patients out of 10 cases (80%). all aes were graded 1 or 2. no severe aes were observed during the study period. the levels of jc-and hdm-specific ige and igg4 in serum were increased during treatment. conclusion: sequential-administration of jc slit-drops and hdm slit-tablets was well tolerated by patients suffering from both jc pollinosis and hdm rhinitis. background: according to the ema guideline on the clinical development of products for specific immunotherapy products should be tested in phase ii at different doses in several study-arms to establish a dose-response relationship for clinical efficacy before confirmatory trials can be initiated. allergen exposure in an aec may be used as primary endpoint. the study was a single-center, randomized, double blind, placebo-controlled, phase ii trial, treatment duration 10 months. 168 grass pollen allergic patients (18-65 years of age) with seasonal rhinitis/rhinoconjunctivitis (arc) with (mild, gina i) or without concomitant asthma were randomized to three different dosages of a liquid phase iii study is in preparation. as part of an effort to prepare the analysis plan using the csms as primary endpoint, the grass pollen data of the european aeroallergen network (ean) was used to identify the window within the grass pollen season (gps) with optimal correlation between the grass pollen counts and the csms. method: ean currently includes information from more than 400 active and 300 historical pollen-monitoring stations in europe including 39 countries. the ean database used for analysis included grass pollen data collected during 2009-2016. the daily allergy symptoms and medication were recorded spontaneously using an app questionnaire on the subject's smart phone. the csms was re-calculated using the ean database, using the recorded symptom scores with estimation of the medication score using similar methods as recently published. the correlation between the daily grass pollen count and the daily csms was analyzed with a mixed effects model accounting for patient-specific correlations and symptom levels. conclusion: these results confirm a statistically significant correlation between grass pollen counts and the csms. importantly, these findings suggest that the optimal window to observe treatment effects after immunotherapy may be a short interval after start of the gps and during the peak gps, due to generally higher csms values. this provides sufficient basis to consider additional sensitivity analyses to evaluate the treatment effect of grass mata mpl scit on the primary csms endpoint during a shortened window after the start of the gps and to consider excluding the overlapping period between the bps and gps from the primary analysis. 0894 | combo-vas as a tool to assess efficacy of allergen immunotherapy ciprandi g 1 ; silvestri m 2 ; olcese r 2 ; tosca ma 2 1 ospedale policlinico san martino, genoa, italy; 2 istituto g. gaslini, genoa, italy background: allergen immunotherapy (ait) is at present the unique cure for respiratory and venom allergy. usually, ait lasts for some years, but its efficacy is longstanding. criteria for assessing ait efficacy are mainly based on symptom severity improvement and saving of symptomatic medications. in this regard, there are different score grading for both measuring symptom severity and drug use. visual analogue scale (vas) is a well-defined and validated method widely used in many diseases, including allergic disorders. vas is a psychometric tool measuring the patient's perception of symptoms, emotions, pain, drug use, etc. recently, it has been published an eaaci position paper concerning the recommendations for the standardization of clinical outcomes used in ait trials for allergic rhinoconjunctivitis, but it is complex. so we would propose a simpler way to measure ait efficacy by vas, in particular a combo-vas based on one vas for symptom and one for medications. results: globally 150 patients were retrospectively evaluated. all of them were treated with a 3-year ait course: 120 were defined as responders and 30 as non-responders. in responders group the combo-vas mean value was 14 (iqr 12-15) at baseline and 4 (iqr 3-6) after ait treatment. in non-responders group combo-vas mean value was 13 at baseline and 11 (iqr 9-12.5) at the end of ait. the difference was significant (p = 0.012). the d combo-vas was −66.67% in responder group and −10% in non-responders group (p < 0.0001). conclusion: combo-vas, i.e. the sum of vas for symptoms and medications, could be an easy and quick tool for assessing ait efficacy and reflects the patient's perception. therefore, it could be very fruitful in clinical practice. 0895 | rapid up-dosing in sublingual specific immunotherapy is safe, well-tolerated and effective in patients suffering from tree pollen allergic rhinitis background: an optimised up-dosing period of specific immunotherapy (sit) is desirable for better patient compliance because a long or complicated up-dosing scheme is sensitive to disruption. the aim of this study was to compare the safety, tolerability and effectiveness of an optimised up-dosing scheme with two preexisting schemes of sublingual sit (slit) in patients under standard medical care. method: this was a prospective, open, active controlled, multi-center non-interventional study in germany and austria to document the treatment of children and adults with allergic rhinoconjunctivitis and/or allergic asthma treated with a slit containing purified, aqueous extracts of birch, alder and hazel pollen. the investigators were free to select an up-dosing scheme for included patients: scheme a consisted of an up-dosing period of up to 12 days at the patient's home using three different solution strengths to reach the maximum dose; ultra-rush scheme b performed only with the highest solution strength at the physician's office within 2 hours, and the optimised scheme c which was initiated at the physician′s office and continued at home using exclusively the highest solution strength within 2 (long-term) or 4 (pre-seasonal) days. data on up-dosing and maintenance treatments were documented by physicians during 5 patient visits and by patient diaries. the study was approved by ethic committees, and all patients or parents gave their informed consent. results: in total, 164 patients aged 3-76 years were included into this study. scheme a was applied by 90 patients, 29 patients decided on regimen b, and 45 patients on the optimised scheme c. conclusion: one-day ur-scit conducted in an outpatient clinic was safe and well-tolerated in patients with ad sensitized to hdm. ur-scit can be a safe and useful option to start a subcutaneous allergen immunotherapy for ad. 0899 | factors affecting on adherence to allergen specific immunotherapy results: among 1162 enrolled patients, 228 (19.6%) patients failed to complete at least 3 years of ait, which were regarded to be nonadherent in this study. univariate analysis revealed that male, younger age group less than 40 years, cluster and ultra-rush schedules, atopic dermatitis, the absence of associated diseases, and follow up of other department were found to be associated with nonadherence to ait. in multivariate analysis, younger age group less than 40 years (or 2.31, 95% ci 1.55-3.45), cluster (2.37, 1.56-3.60) and ultra-rush schedules (6.03, 3.18-11.42) , and absence of follow up of other department (2.11, 1.31-3.40) were independently associated with non-adherence to ait. no association was found in gender, diagnosis of allergic diseases, kind of allergen extracts, and patients' distance from hospital. conclusion: various factors are related with ait non-adherence to interfere the effectiveness of immunotherapy. clinicians need to be aware of the factors associated with non-adherence to ait and consider them when choose to maximize ait adherence. 0900 | cost-effectiveness of allergen immunotherapy to grass in patients with allergic rhino-conjunctivitis and asthma background: allergen immunotherapy (ait) has been shown to reduce symptoms and medication use in subjects with rhino-conjunctivitis and asthma. however, long-term cost effectiveness of this therapy needs to be evaluated. our aim was to assess cost effective of ait, both subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit), vs. pharmacotherapy alone in subjects with rhino-conjunctivitis, with or without allergic asthma, to grass pollens. method: a markov cohort state-transition model with a time horizon of 9 years was used to assess the costs and effects of 3-year ait in adults. relative efficacy of the treatments expressed as standardized mean difference was estimated using an indirect comparison on symptom and medication score extracted from available meta-analyses. the rhinitis symptom utility index was used as a proxy to estimate utility values for symptom score. the societal perspective, through the human capital technique, was used to estimate indirect costs, to represent the scenario of a country with nationalized medicine. data on drug and other medical costs were derived from published sources as well as ait duration and asthma occurrence. additional sensitivity analyses were performed to test the robustness of our results. results: in the base case analysis, using italy clinical practice patients with moderate-to severe allergic rhino-conjunctivitis (ss ranging from 6 to 15 points) and a mean age at entry of 21 years, both scit and slit were associated with increased cost but superior efficacy compared to pharmacotherapy alone. the results were most sensitive to variation in efficacy estimates and ait persistence rates. conclusion: this analysis suggests that ait is cost effective relative to pharmacotherapy alone. scit, despite significantly higher indirect cost burden, seems to be the most cost effective option. the results should be interpreted in the context of the data input and modelling assumption used. 0901 | ielisa as a tool to measure ige binding towards single modified peanut allergens background: immunotherapy has shown to be a potential treatment for food allergies but needs further research to improve safety. modification of peanut allergens to reduce their allergenicity is a promising approach to develop a safe and effective immunotherapy as shown by the successful completion of a first-in-human safety and tolerability study using hal-mpe1 in adult patients with peanut allergy (eudract 2013-004238-13) . in order to assess the impact of modification on individual peanut allergens and to assess its impact on ige binding by individual patient sera, we have developed peanut allergen-specific inhibition elisas. with this methodology we are able to identify patients with residual ige binding to modified peanut allergens. method: ige inhibition elisas (ielisas) were developed and performed to test ige binding towards purified ara h2 and ara h6 and their reduced and alkylated (modified) versions, using the individual responses of single patient sera. results: ara h6-specific ielisas showed that modification of ara h6 results in >95% reduction in ige-binding for all individual sera tested. ara h2-specific ielisas showed that modification of ara h2 also results in >95% reduced ige-binding for most of the sera, but some sera were identified which showed residual, 10%-20% ige binding to mara h 2. in some of the latter sera, the presence of ige binding to a linear hydroxyproline-containing peptide could be confirmed as a possible source for the residual ige binding to mara h2. we have developed a methodology to assess residual ige binding to modified peanut allergens. the sensitivity of the allergen-specific ielisas allowed us to discriminate between patient sera in which ige binding to mara h2 and to mara h6 was virtually completely absent and sera in which 10-20% residual ige binding to ara h2 was observed. the clinical importance of these observations is yet unknown. future clinical studies will need to reveal whether the patient-specific ige binding profiles to individual modified peanut allergens do correlate with the adverse events profile of immunotherapy with modified peanut extract. 0902 | design of a phase ii allergen immunotherapy study to determine the optimally effective and safe dose of subcutaneously administered tyrosine adsorbed modified grass allergen+mpl (mpl) adjuvants for the treatment of allergic rhinoconjunctivitis (arc) due to grass pollen. there is increasing evidence that the effectiveness of allergy immunotherapy to control arc symptoms is related to the cumulative allergen (or allergoid) dose administered. previously, two clinical studies have been conducted using a conjunctival provocation test (cpt) as primary efficacy measure for a similar scit mata mpl product for birch allergy [eudract 2012-004336-28 and 2015-000984-15] . these studies showed a 5.5 fold increase in cumulative dose to achieve~50% increase in efficacy, with a relative reduction in total symptom score (tss) of 32.3% compared to placebo and no safety signals of concern. the shape of the dose response curve was curvilinear, where this high dose almost reached plateau. method: this is a multi-center (~47 clinical study centers across europe), randomized, double-blind, placebo-controlled, parallel-group study in~440 adult patients with moderate to severe seasonal arc with or without mild asthma. a positive cpt is to be achieved at screening and verified prior to randomization. the primary outcome is the post-treatment tss following cpt. a wide range of cumulative dose regimens is used (5100, 14400, 27600 and 35600 su) applied over 6 weekly injections to establish the shape of the dose response to support dose selection for phase iii. the design of the current phase ii grass allergoid scit study will be discussed, including the rational of using 4 cumulative dose regimens and placebo and the pre-selected shapes of the dose response curves. in addition, the number of patients screened and randomized will be presented by country, gender and/or age category and screen failures will be categorized. conclusion: this phase ii study was initiated to establish the dose response of a grass mata mpl scit product, using cpt to measure the effect of a wide range of cumulative dose regimens. the achievement of its aim will be an important milestone in the development of an efficacious and safe state-of-the-art grass scit. conclusion: we observed that the specific nasal challenge with house dust mite generates an inflammatory response within the first hours, but we did not demonstrate any correlation with the response to immunotherapy after six months. 0905 | tolerability of a two week rush updosing with modified allergens in pollen allergic subjects in the day-to-day practice background: in two phase iv studies the tolerability of a subcutaneous rush up-dosing, using three injections in two weeks, has been tested and proven to be save in adults. in the course of a non-interventional study (nis) now the tolerability of this treatment scheme was tested in the day-to-day practice. conclusion: over 97% of the patients could reach the highest dose of 0.5 ml. the overall tolerability is very good. the data from daily practice confirm the data that were previously obtained in two phase iv studies. siges from 40 patients, evaluated during the 1st semester of 2017 at an outpatient clinic. all patients presented persistent moderatesevere allergic rhinitis, in pollen season and had not been submitted to it. all patients had positive spt for grasses (grass) and olive (olea). sige-tot for phleum pratense and olea europaea and some sige-crd (rphl p 1, rphl p 5, rphl p 7, rphl p 12, role1 and nole7) were determined. physicians were divided into 2 groups (group 1 if <10 years of practice and group 2 if≥10 years of practice) and were asked to choose which it to prescribe for each patient (none, only grass, only olive or both grass and olive), according to spt and sige results. results: fifteen physicians (60% with ≥10 years of practice) participated in the survey. considering only the sige-tot results, the it choice (group 1/2) was: no vaccine in 10%/3%; grass vaccine 50%/ 58%; olive vaccine 5%/10% and both grass and olive vaccines in 35%/30% of the patients (p = 0.42), the intergroup agreement was 70% (kappa 0.612). according to the sige-crd results the physicians chose (group1/2): no vaccine at 10%/13%; grass vaccine in 63%/60%; olive vaccine in 10%/5% and both vaccines in 18%/23% of patients however, data on control of allergic rhinitis (ar) after discontinuation of therapy are insufficient. the aim of our study was to assess sustained control of ar in three consecutive years after grass-pollen slit discontinuation. method: a total number of 35 patients [24 (68.57%) males; mean age 32 years, age range 15-56] well-controlled after a three-year course of slit with grass pollen extract were prospectively evaluated in three consecutive years after discontinuation of therapy. conclusion: a three-year course of grass-pollen slit seemed to have a long-term effect on control of symptoms in patients with ar. the authors declare no conflict of interest. results: all patients showed a positive sensitization profile by skin prick test to either betula and/or alnus. in 40% of patients this profile was furtherly confirmed with serum specific ige levels to betv1, (mean 13.56 ku/l). allergic symptoms in patients with birch/alnus pollen allergy after ingestion of certain food can result from crossreactivity of bet-v1-specific ige to homologous pathogenesis-related proteins, particularly the pr-10 protein. conclusion: within the allergy history we emphasize on focusing on sao symptoms as many patients under-recognize them. among the sensitization profile of these patients it is quite important to highlight cross reactivity between bet v1 and alnus. the other patient suffered from anaphylaxis(grade ii) induced by minimum amount of lettuce consumption without co-factors. both patients suffered from oral allergy syndrome to peach and allergic rhinitis. spts to foods and pollens were performed with commercial extracts, prick-through-prick with fresh plant foods, while specific ige was determined accordingly. ltp syndrome was defined as a sensitization to pru p 3 and symptoms elicited by at least 2 unrelated plant foods. co-factors were also investigated. results: the first patient was sensitized to lettuce, peanut, hazelnut, sunflower's seed, peach and banana, and plane tree, olive tree, grasses, parietaria and mugwort. sige to lettuce was 2.04kua/l, to pru p 3 was 20.8kua/l and total ige was 703.4u/ml. co-factors, such as exercise, were involved. the second patient was sensitized to peanut, walnut, hazelnut, almond, sunflower's seed, cashew, lettuce and peach, and, plane tree, olive tree, grasses, parietaria, mugwort and willow. sige to lettuce was 27.6kua/l, to pru p 3 was 37 and total ige was 1705.9ku/l. no co-factors were identified. background: garlic (allium sativum) is a vegetable that belongs to amaryllidaceae's family. hypersensitivity to garlic is not very common. it has been mainly reported in occupational allergy but it also may cause contact dermatitis, rhinoconjunctivitis, asthma, urticaria, gastrointestinal symptoms and anaphylaxis after its ingestion. some studies have identified alliin lyase, a 56 kda protein, as a major garlic allergen and it seems to be a heat-sensitive allergen. we report on a 9-month-old infant who presented, 15 minutes after an accidental ingestion of garlic sauce, generalized erythema and cough. she was still breastfeeding and she had never abstracts | 491 eaten garlic before (although the mother usually consumed garlic). the patient had never tasted other vegetables belonging to amarylidaceae's family either but zucchini, with good tolerance. we performed skin tests and specific ige (sige) to different vegetables. a raw garlic extract was also carried out and analysed in the patient by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: prick by prick with garlic was positive (10 mm) and negative to onion, leek, asparagus, zucchini and saffron. skin prick tests to commercial extracts of mugwort, grass pollen, peach ltp and profilin were negative as well. specific ige to garlic was 3.15 ku/l (out from a total ige 32 ku/l) and 0 ku/l to onion and asparagus. sds-page immunoblotting assay with patient′s serum revealed ige reactivity with proteins of 6 kda and 8 kda. conclusion: we report a garlic ige-mediated anaphylaxis case in an infant with proteins of 6 and 8 kda as the relevant allergens. the mechanism of sensitization in the present case remains unclear. the authors hypothesized that breastfeeding, cutaneous contact or inhalation might be possible mechanisms involved. chong kw 1 ; saffari se 2 ; chan n 3 ; seah r 3 ; tan ch 3 ; goh sh 1 ; goh a 1 ; loh w 1 1 allergy service, department of paediatric medicine, kk women's and children's hospital, singapore, singapore; 2 centre for quantitative medicine, office of clinical sciences, duke-nus medical school, singapore, singapore; 3 yong loo lin school of medicine, national university of singapore, singapore, singapore background: the predictive decision points for both peanut skin prick test (spt) wheal size and serum ige concentrations, in peanutsensitized children, have not been evaluated in singapore. we aim to assess these for purposes of risk stratification and prediction of oral food challenge (ofc)s' outcomes by means of a retrospective chart review. results: the number of patients evaluated was 328, of which 269 had clinical diagnosis of peanut allergy based on recent immediate reaction to peanut (pa group) and 59 were tolerating peanuts regularly (pt group). the mean age of both groups were similar, 3.9 ± 3.2 and 3.7 ± 3.3 years in pa and pt groups respectively. there was a high prevalence of atopic diseases in both groups, with atopic dermatitis (75.8% in pa, 79.7% in pt), and other food allergies (55.4% in pa, 44.1% in pt). presence of rhinitis was statistically higher in the pa group compared to the pt group, with odds ratio of 2.52 (95% ci: 1.42-4.47) . a wheal size of ≥8 mm and a peanutspecific ige of ≥6 ku/l provided for a 95% positive predictive value. the larger the wheal size on spt, the higher the probability of a clinical reaction to peanuts. the results will help us in deriving preliminary cut-off values when conducting future prospective studies with ofcs in our peanut-sensitized cohort (whom had no prior peanut exposure), and to eventually reduce the need for expensive and potentially risky food challenges. 0913 | ginger: flavory, spicy …allergenic? a report of four patients with allergy to ginger background: ginger (zingiber officinale) belongs to the family zingiberoidae, along with cardamom and turmeric. the edible portion is the horizontal rhizome, and it is very appreciated for its aroma and spicy flavor. it also presents great interest for its therapeutic and culinary use. hypersensitivity to ginger is rare and has been scarcely reported. we report 4 cases (p1, p2, p3, p4) of adverse reactions to ginger after its ingestion and with good tolerance to cardamom and turmeric. method: skin prick tests (spt) to environmental allergens and prick-by-prick with ginger were carried out. total ige, and specific ige to ginger were also determined. a raw ginger extract was prepared. this extract was analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). background: food allergy is divided into 3 groups according to pathophysiology: ige-mediated, ige-and non-ige (mixed type), and non-ige (cellular type). however, in clinical practice, patients who fall under more than one group may be observed. method: patients who were diagnosed with food allergy at our clinic from january 2012 to december 2016 were included in the study. the medical files of patients were retrospectively evaluated, their symptoms and findings after consumption of foods were recorded, and they were categorized into 3 groups (ige-mediated type, non-ige type, and mixed type) according to their symptoms and findings. results: a total of 587 patients (63.5% male) with food allergies were included in the study. according to categorization via symptoms and findings, the distribution of patients was as follows: 140 (23.8%) ige-mediated type, 44 (7.5%) non-ige type, 195 (33.2%) mixed type. the remaining 208 (35%) patients were found to show various combinations of symptoms and findings that fit more than one group. in this study, we observed that food allergy symptoms and findings were distributed in a broad range which caused difficulties in the categorization of more than one-third of our patients. background: fish allergic patients suffer a lifetime of strict dietary restrictions. crocodile meat is a nutritious alternative choice in many countries around the world; however, it has recently been reported to also trigger severe allergic reactions. in these two case reports from 2017 pediatric patients were sensitised to the major fish allergen parvalbumin (pv), a potential cross-allergen. bony fish contain predominantly pvs of the β-lineage, which are the most common trigger of allergic reactions in fish allergic patients. in most other vertebrates, pvs of the α-lineage are most abundant, which have been reported as a causal allergen in frog, cartilaginous fish, and chicken allergies. we aimed to evaluate the allergenicity of crocodile meat in fish allergic children, with focus on pv. method: over 70 children with clinical history of ige-mediated fish allergy were identified, skin tested to commonly consumed fish species using commercial and in-house preparations, and serum samples were collected. a sub-cohort was skin tested to crocodile using heat-treated tail muscle tissue from saltwater crocodile (crocodylus porosus). extracted proteins and purified pvs were analysed by sds-page, immunoblotting, and mass spectrometry. serum from all fish allergic children was analysed for ige reactivity to the crocodile pv. this reactivity was compared to those of raw and heated crocodile protein extracts as well as protein extracts and purified pvs from frequently consumed fish species. results: more than 5 fish allergic children were positive on skin testing to crocodile (wheal size>3 mm), demonstrating its clinical reactivity. in vitro analyses revealed ige reactivity to crocodile pv in serum from more than half of all patients. two βand one α-crocodile-pv isoforms were identified. pvs constituted approximately 90% of total proteins in heated crocodile extracts, with β-pv (11 kda) being 10 times less abundant, but up to 500 times more ige-reactive than α-pv (13 kda). αand β-pvs from crocodilians, including alligators and crocodiles, share more than 96% and 74% of their amino acid sequence, respectively. conclusion: crocodile pv is a new allergen as per the iuis guidelines. fish allergic patients may be at risk of severe allergic reactions upon ingestion of crocodile meat due to strong ige cross-reactivity of β-pvs. this study suggests that fish allergic individuals and health professionals need to be aware of potential allergic reactions to meat from crocodilians, termed 'fish-crocodile syndrome'. background: we present a 39-year-old nonatopic woman that in december 2016 after eating a seafood paella with green pepper presented asthenia, nasal obstruction, incoercible vomiting and diarrhea. later she ate a grilled loin sandwich in a bar and she had the same symptoms (she asked the waiter at the bar and the chef had cooked her sandwich in the same pan where he had cooked green pepper just before). after that, she suffered from abdominal pain, nausea, abdominal distension without diarrhea two hours after she ate an omelet sandwich with certain flavor of green pepper. at present even the casual smell of pepper causes her nausea. the woman eats everything including spices and just avoids pepper. method: skin prick tests were performed using extracts from food (nuts, fish, mollusk, fruits, vegetables, legumes), aeroallergens (mites, abstracts | 493 pollens and epithelia) and purified proteins (pru p 3, profilin, polcalcin, alfalactoalbumin, betalactoglobuline, casein). we also performed prick by prick to raw and cooked green pepper. sds-page immunoblotting according to laemli under reducing conditions (with 2-mercaptoethanol) was performed to study the molecular mass of the ige-reactive proteins. extracts from green pepper and green pepper seed were used. the prick tests were all negative and the prick by prick test to raw and cooked green pepper was positive in both cases. blond was taken from all patients to specify the levels of allergenspecific ige against 112 allergen components of immunocap isac test, the result≥0.30 isu-e was assumed as positive. results: in the study group, in 12 patients (24%) specific antibodies against ltp were detected, the isu-e level range 0.3-34 average 5.26 isu-e on average, in patients with detected ltp ige was detected for 3.5 components belonging to the ltp, however the highest number 41% patients were detected ige only for 1 ltp. in 9 subjects (75% of respondents with detected ltp), ige was detected against art v 3 and this is the only ltp component whose occurrence was statistically significant (p = 0.044). in 6 patients ige was detected against pru p 3, jug r 3, pla a 3,; 5 patients ige to ara h 9; 4 patients cor a 8; 3 patients ole e 7, 2 patients tri a 14, and in 1 person para j 2. background: the birch pollen-associated oral allergy syndrome (oas), an ige-mediated local allergic reaction, is the most common manifestation of pollen-associated food allergies. its origin is explained by cross-reactions between birch pollen-and food-allergens belonging to the pathogenesis-related protein subfamily 10 (pr-10). [1] so far, there is no marker available for its detection and no standardized test established to evaluate objectively the subjective feelings experienced by oas. the diagnosis is based on a characteristic history and on detecting the sensitization to triggering allergens in skin prick test (spt) and laboratory examination. method: the aim of this study was to evaluate whether the food skin prick test could be a helpful marker in the diagnosis of a birch pollen-associated oas. for this exploratory study, data from 2016-2017 was collected retrospectively at the dermatological outpatient department of the ordensklinikum linz elisabethinen. patients with positive spt results for birch pollen were included. the variables age, gender, tree pollen-(birch, alder, hazel) and food-spt, laboratory tests (ige, bet v 1, bet v 2, gly m 4) and symptoms (oas, rhinoconjunctivitis allergica, atopic dermatitis, anaphylaxis) for statistical analysis. results: there was an association between food-spt and oas but also between the negative oas patients and food-spt (p = 0.9-0.1). all of the bet v 1 sensitized patients with positive gly m 4 results had also a positive food-spt result. conclusion: there was no evidence for a possible role of food-spt as helpful markers in the diagnosis of birch pollen associated oas. maybe gly m 4 could be a helpful marker, but more data are needed. bet v 1 seems to be the cause of birch-pollen associated oas, due to the dominant sensitization pattern to major allergens in austria. background: eggs are among the foods most frequently causing allergy. the most common one is hen egg, although we may consume other bird's eggs such as duck's, those of goose, quails and seagulls. clinical and serological crossreactivity between hen egg proteins and those of other birds eggs have been described. allergy to other species eggs are less frequent and are usually described in patients allergic to hen eggs. we report a case of food allergy after ingestion of duck egg in an adult patient without hen egg allergy. the patient was a 50 year-old man who had symptoms of generalized itching, swelling uvula, erythema neck and deglutition difficulty immediately after he ate eggs from duck and hen. he claimed to have eaten hen eggs almost daily without clinical symptoms and he had not previously ingested duck egg. he denied allergic reactions to any other food but did complain of seasonal allergic rhinoconjunctivitis in the spring. we performed skin prick test with extracts of egg and feathers, prick by prick test with cooked and fresh yolk and white from duck and hen egg and oral challenge with hen eggs. specific serum ige was measured to hen proteins and we carried out a western blot with the proteins of allergenic extracts from different eggs (white and yolk of quail, chicken, goose and duck) and an inhibition of western blot with ovalbumin as inhibitor allergen. results: skin test with extracts of eggs and feathers, cooked and fresh hen and duck eggs were positive. total serum ige was 29.2 ku/l. specific ige to hen's egg was class two for hen egg white, ovoalbumin and class one for yolk and ovomucoid. oral challenge with heated egg yolk negative and with egg white was positive. the patient's serum recognized mainly and intensely several proteins of white and egg yolk of quail and duck with a molecular mass around 45 to 50 kda respectively. on the other hand a protein around 45 and 50-52 kda was unique recognized in white eggs of hen and goose. the western blot inhibition revealed ovalbumin inhibited the protein recognized in the egg white but not egg yolk involved in. background: management of tree nut allergy is usually based on the avoidance of the suspected tree nut (tn), as well as peanuts and seeds, either because of the risk of cross-reactivity and/or contamination, or due to the clinical severity. objective: to assess the sensitization pattern and clinical reactivity patterns to different tn, peanut and sesame seeds (ss) in patients with a history of reaction to at least one of these foods. results: a total of 47 patients with confirmed nut allergy were included; 70% female, median age [interquartile range] of 28 years; 72% were atopic. the most frequently involved foods were walnuts (53%), hazelnuts (40%), almonds (32%) and peanuts (38%). anaphylaxis was the clinical presentation in 51% of the patients. in those with a history of reaction to only one nut (24), the most prevalent was peanut (42%). in the 23 patients that reacted to more than one nut, the most frequent combinations were walnut/hazelnut (15), walnut/almond (12) and almond/ hazelnut (10). of these patients, 5 tolerated other nuts. two had sesame seed allergy, one reacted only to ss. nine patients (19%) were sensitized to foods that they tolerated. fourteen (30%) patients were sensitized to ltp and 8 of them reacted to more than one nut. conclusion: these data concur with the existence of different sensitization profiles (primary, concomitant or cross-reactive), which may predict different clinical reactivity patterns and therefore, influence dietary recommendations. background: buckwheat (fagopyrum esculentum) is a polygonaceae weed, not a cereal, which is increasingly been consumed and used as an alternative food in the diet of celiac patients. despite its wide use, allergy to buckwheat has unfrequently been reported in our setting. method: two female patients, aged 37 and 58, suffered an immediate severe allergic reaction after eating a bread and a pancake containing buckwheat among its ingredients. the first patient presented generalized urticaria, palpebral angioedema and pharyngeal occupation. the second one showed those same symptoms, as well as abdominal pain, nausea, dyspnea, dizziness, hypotension and loss of consciousness. skin tests and specific ige determination to aeroallergens and food allergens were carried out, including prick-prick test with buckwheat and all other components contained in the food involved. buckwheat allergens were studied by sds-page and ige-immunoblotting of one of the patients. results: prick-prick tests yielded strongly positive results to the food itself and buckwheat, and negative to the remaining food components in both cases. cap was positive to buckwheat (11.30 ku/l and >100 ku/l, respectively). basal serum tryptase levels were normal. both patients were not sensitized to cereals, ltps, profilins or pr-10 proteins. for the first patient, the skin tests were negative for other foods, seeds and nuts. the cap was negative for ltps, profilins and storage proteins of peanut and other nuts. the second patient who had the most severe reaction, was also sensitized to hazelnut(cap 13.7 ku/l), pistachio (1.44ku/l), almond(0.66ku/l), walnut(29.7ku/l) and sesame(4.47ku/l), which were not included in the pancake. the buckwheat immunoblot of the first case, under non-denaturing conditions, revealed a ige-binding protein of 60-kda. ige-immunoblotting under reducing condition showed protein bands of 30, 20, 17 and 14 kda in the buckwheat extract. conclusion: two cases of anaphylaxis by buckwheat flour contained in two frequently consumed foods are presented. the absence of sensitization to ltps, together with the pattern of specific ige binding in the immunoblot in one of the cases suggests that the responsible allergen could correspond to a storage protein of buckwheat, without cross-reactivity with other seed and nut allergens. buckwheat must be taken into account as an unsuspected food allergen capable of causing severe allergic reactions. background: allergy to linseed (linum usitatissimum) has infrequently been reported despite of its wide use in bread and in a range of "health food" products. linseed contains potent allergens which have not yet been characterized. we studied three patients who presented allergic reaction after eating different foods which contain linseed. two of them (patient p1 and patient p2) had anaphylaxis and the third one (patient p3) had oral syndrome, abdominal pain and diarrhoea. p2 was also allergic to mustard and p3 to sesame seed. all of them tolerated the remaining seeds, nuts and food. baseline tryptase levels were in normal range in all patients. skin tests and specific ige determination to inhalants and food allergens were carried out. linseed allergens were studied by sds-page and ige-immunoblotting. skin tests: patient 1: prick tests were positive to pollens and linseed, and negative to ltp, profilin, nuts, seed and the remaining food; patient 2: prick tests were positive to linseed and mustard and negative to other food and inhalants; patient 3: prick tests were positive to linseed, pollens, sesame and nuts (peanut, hazelnut, almond, pistachio). we present three cases of severe allergic reactions to linseed. the pattern of specific ige binding in the immunoblot seems to lead to storage proteins as the responsible allergens. 0925 | pr-10 sensitization-looking it up in food allergy background: pr-10 protein group sensitization is found in patients with respiratory allergy, mainly in areas inhabited by trees of the betulacea or fagacea families. its role in food allergy is, however, more frequently described in the context of cross reactivity. our aim was to characterize the pattern of molecular sensitization of food allergic patients sensitized to pr-10 protein group with immu-nocap isac ® (isac). the remaining patients, with more severe reactions, were all co-sensitized to either ltp and/or storage proteins (sp). only 2 of the 7 patients without pfa were co-sensitized to ltp or sp versus 7 of 9 with pfa (p < 0.05). conclusion: pr-10 sensitization is rare in our population. approximately half of the patients had allergy to plant foods, but the majority were co-sensitized to ltp and/or sp. the few patients only sensitized to pr-10 had minor reactions. among the patients without plant food allergy, co-sensitization to ltp and sp was significantly less common. according to these results, in our population, pr-10 seems to be less relevant to food allergy, when compared to reported results from other european countries. gür çetinkaya p; uysal soyer ö; esenboga s; sahiner üm; sekerel be hacettepe medical school, ankara, turkey background: pistachio is a tree nut belonging to "anacardiacea" family, and constitutes 7% of tree nut allergies. this nut most often abstracts | 497 cross-reacts up to 95% with cashew which is located in the same family. pistachio allergy is mostly seen in iran, turkey, the united states, and china where this tree nut is frequently consumed. in this study, we analyzed age and cut-off values for development of tolerance to pistachio. method: children who had reported allergic reactions with pistachio, and who have not consumed pistachio, but had positive spt and/or specific ige levels were enrolled into the study. spt and specific ige levels were measured in all patients. oral provocation(op) tests with pistachio were performed by 82 patients, and 21 of them had positive test result. the median age of tolerance development was 60 months (iqr: 48.0-89.0 months). the most commonly involved systems during op tests were skin (90%, n = 19), gastrointestinal system (33%, n = 7), and lower respiratory tract (24%, n = 5). concomitant allergic diseases were atopic dermatitis (70%), asthma (40%) and allergic rhinitis (17%). there was a positive correlation between skin prick test diameter (spt) and specific ige levels (spige) (r = 0.331, p = 0.001). spt of≥8.25 mm to pistachio nut was found as highly predictive of clinical allergy (auc: 0.83, 95%ci: 0.73-0.94, p < 0.001). any relation was not determined between eosinophil, basophil counts, triptase levels, and op test positivity. conclusion: pistachio allergy is one of the frequently seen nut allergies in turkey which may cause serious allergic reactions including anaphylaxis. op test showed that tolerance was achieved by the median age of 60 months, and a cut-off level of 8.25 mm was best predictor for positive reaction. in an oral challenge test, the patient responded with generalized urticaria, swelling of the lips and difficulty breathing at a cumulative dose of 0.1 g peanut protein, however, without blood pressure drop. (grade 2, moderate symptoms). the patient was treated with anti-ige for 3 months (with 450 mg every 4 weeks sc). oral desensitization began with ingestion of 500 μg peanut, escalating to 500 mg, on the first day and escalating weekly doses of peanut from 500 mg to 4000 mg (8 peanuts). then anti-ige was discontinued while the patient ingested 8 peanuts every day. we have followed the patient's sensitivity to peanuts from before anti-ige treatment to after anti-ige washout with basophil testing. results: the patient completed desensitization without side effects, and continues to ingest 8 peanuts a day. basophil sensitivity was reduced 13-fold by anti-ige treatment, but returned to baseline levels after anti-ige washout. conclusion: anti-ige allows rapid desensitisation of peanut allergic subjects with peanut oral immunotherapy. in the majority of subjects, this desensitization is sustained after anti-ige is discontinued. additional studies will help clarify which patients would benefit most from this approach. the return of basophil response to pre-treatment levels suggests that the patient is desensitised, and depends on the daily ingestion of allergen. what do we (not) know? background: the use of biologic prosthesis is a well-established surgical procedure. acute and delayed complications may occur, but accurate epidemiologic data about allergic reaction to graft tissue is lacking. methods: a 9 years old boy referred to our unit for urticaria and gastrointestinal symptoms which developed a few years before. he received a biologic porcine vascular duct during a cardiovascular surgery at 20 days of life. at the age of 5 urticarial episodes occurred, and a diagnosis of beef allergy was made. after the exclusion of beef meat from the diet, most symptoms resolved, but the child began to complain about occasional episodes of vomit and diarrhoea. results: skin prick tests confirmed the beef meat sensitization and prick-prick test resulted positive against raw pork meat but not against cooked pork meat. in vitro tests demonstrated the presence of pork meat specific iges (14.1 kua/l). component-resolved diagnostic tests revealed allergy sensitization toward bos d 6 (bovine serum albumin, bsa; porcine serum albumin was not tested due to lack of a specific test). after accurate exclusion of pork meat from diet, a complete remission was achieved, and the diagnosis of pork meat allergy was confirmed. conclusion: bsa is a major beef allergen, responsible for the raw beef-cow milk cross-reactivity but with a scarce importance in milk allergy. it is highly homologous with human serum albumin and other mammalian serum albumins, including porcine albumin. porcine albumin is also highly homologous with cat serum albumin and therefore responsible for cross-reactivity in patients affected by cat-pork syndrome. we hypothesize that the implanted porcine tissue was the trigger for pork meat allergy in our patient, as this condition is exceptional in childhood and that our patient never owned a cat. few cases of pork allergy due to porcine tissue implantation have been reported so far. of interest, pig sensitization was recognized as a rare but possible cause of blood-culture negative endocarditis in patients with porcine bioprosthesis according with anamnesis, increased ige level against pork, tissue eosinophilia during autopsy. background: desensitization to foods is assuming a new paradigm in food allergy. this technique is becoming widespread especially for patients with egg and milk allergy, but the effect of desensitization on the consumption of similar but not identical foods is still uncertain. material and methods: we describe the case of a 16-year-old patient, with a history of chicken egg allergy, who had been successfully desensitized tolerating cooked and raw chicken eggs for a year. the patient came to the office after presenting an episode of anaphylaxis immediately after eating fried quail eggs. an immunological study was carried out. we performed skin prick test with chicken egg′s proteins (white, yolk, ovoalbumin and ovomucoid). an immunoblotting to detect specific ige to egg proteins was also performed. for this purpose, the following extracts were used: chicken egg white and yolk (commercial extract form alk) and quail egg white and yolk prepared following a similar procedure (extracted in 10% phosphate buffer (w/v)). conclusion: we present the case of a patient with specific allergy to quail egg white and yolk, probably through ovotransferin, but not to chicken egg. the desensitization against chicken eggs does not allow the consumption of eggs of other species of birds, such as quail eggs, and this indication must be made specifically to patients after a protocol of desensitization against chicken′s eggs. case report: seven years ago we presented the case of a 32year-old male, who suffered two acute episodes of oral pruritus, lip angioedema, epigastric pain, generalized urticaria and dizziness after ingesting lettuce. he previously tolerated salads (including lettuce). he was later diagnosed with non-ltp-dependent lettuce anaphylaxis and an aspartyl protease was identified as a new lettuce allergen with cross-reactivity with other members of the compositae family. since the diagnosis he has avoided lettuce and all the other compositae. we present the patient's curious outcome after 7 years of follow up. methods: total ige, basal tryptase, specific ige to lettuce by immu-nocap, prick-prick and oral challenge tests with lettuce and other compositae. sds-page, immunoblotting and molecular characterization of ige binding bands by mass spectrometry. skin prick tests and specific ige to lettuce were repeated on several occasions in the following years. after 7 years an oral challenge test with lettuce was carried out. results: prick-prick test was positive to fresh lettuce (11 × 15 mm) and to other compositae (raw endive, chicory, thistle, artichoke and chamomile). prick-prick test was negative with these boiled compositae. basal tryptase was 7.07 μg/l. total ige in serum was 189 ul/ml. specific ige by immunocap was positive to lettuce (7.35 ku/l) and negative to profilin, ltps and thaumatin. oral challenge test with endive was positive and negative with cooked compositae (artichokes and thistle). sds-page and immunoblotting detected an intensely binding ige band about 46 kda, common for endive and chicory, which was identified by mass spectrometry as an aspartyl protease. no bands were detected at ltp (9 kda) and profilin (16 kda) . in the first two years after the diagnosis, prick-prick test and specific ige to lettuce remained positive (cap 1.91 ku/l and 0.44 ku/l, respectively). after 7 years, prick-prick test and specific ige to lettuce became negative (cap 0.08 ku/l). with this findings a new oral challenge test with lettuce was carried out which result turned out negative. we report the first case of spontaneous tolerance to lettuce in a patient who previously presented lettuce anaphylaxis and identify an aspartyl protease as the causative allergen. introduction: eosinophilic esophagitis (eoe) is an emergent allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. recently, it has been seen that eoe develops in up to 2.7% of patients with ige-mediated food allergy undergoing oral immunotherapy (oit). ingestion of baked milk and egg was associated with increased development of tolerance to regular milk and immunologic changes have been reported in subjects ingesting baked milk and egg, similar to those seen in food oral immunotherapy studies. case description: we present the case of a 13-year-old girl, with history of ige mediated cow′s milk allergy and rhino conjunctival and bronchial asthma symptoms. prick test against milk proteins showed: milk 6 mm, alpha-lactalbumin 6 mm, casein 3 mm and to beta-lactoglobulin: negative. total ige: 469 ku/l. specific ige to milk: 3, 15 alpha-lactalbumin: 3, 16 ku/l; casein: 2 ku/l and beta-lactoglobulin: 0.10 ku/l. we performed an oral food challenge with baked milk which was well tolerated. then, we performed an oral food challenge with fresh milk and she presented facial urticaria and pharyngeal pruritus. after 3 months eating baked milk every day, she had symptoms of dysphagia and esophageal food impaction. for this reason, we performed an esophagogastroduodenoscopy (egd) and biopsies which showed white exudates and vertical furrows. the histological study showed eosinophil count>20 per high-power field. eosinophilic esophagitis was diagnosed and she started treatment with esomeprazole 20 mg. the egd was repeated 8 weeks later with similar results in the biopsy. she was treated with a comprehensive diet free of cow′s milk proteins. after 8 weeks she was asymptomatic and endoscopy and biopsy findings were normal. we report the case of a cow′s milk allergic patient who developed eoe after introduction baked cow′s milk which apparently was tolerated in her diet. the avoidance proved efficacy in inducing the remission of eoe. method: we examined 87 bottle-feeding infants with food allergy aged from 1 to 12 months. serum vitamin levels were measured by immunoassay methods (retinol binding protein (rbp), vitamin b6, 25hydroxy vitamin d), biochemistry methods (vitamin c, vitamin e) and microbiology methods (vitamin b1, vitamin b2). as criteria for complete sufficiency standards adopted in the russian federation were used (the lower limit of normal levels: rbp -0.52 μmol/l; b6-8 ng/ml; 25-hydroxy vitamin d-15 ng/ml; vitamin c -0.4 mg/dl, vitamin e -0.8 mg/dl; vitamin b1 -28 μg/ml; vitamin b2 -6 ng/ ml). results: complete sufficiency were observed in 21 infants (25.9% cases), one vitamin deficiency in 33 infants (40.7%), two vitamins deficiency in 23 infants (28.4%), three and more vitamins deficiency in 6 infants (7.4%). should be used after vitamin status asses, mainly using monovitamin medication. results: patients were followed with the diagnoses of cma and asthma. age at the beginning of symptoms and start of oit were in the range of 3-6 months and 4-19 years, respectively. they had high total ige (139-843 iu/ml), milk spige (2.9-418 kua/l), casein spige background: food allergies may affect up to 6% of school-aged children. it has been shown that approximately 20% of all anaphylactic reactions caused by food allergy are firstly presented at (pre) school. therefore, it is of high importance that (pre)schools have a policy on food allergy management and the use of an epinephrine auto-injector (eai). to our knowledge, limited is known on the policies of food allergy management at (pre)schools. the aim of this study was to investigate the policy on food allergy management in preschools and primary schools in the northern part of the netherlands. results: we included 87 preschools and 110 primary schools in this study. we showed that 80.5% of the preschools and 73.6% of the primary schools had a child(ren) with food allergy. only 13.8% of the participating preschools and 27.2% of the primary schools had a policy on allergen avoidance and only 35.6% of the preschools and 35.8% of the primary schools had a policy for the use of an eai. the majority of the pre-and primary schools in the northern part of the netherlands have children with food allergy. however, only a limited number of (pre)schools do have written guidelines for food allergy management in (pre)schools. additionally, there is limited experience how to use an eai at (pre)schools. therefore, an evidence-based policy on food allergy management in (pre) schools is needed. background: food allergies are the most common cause of anaphylaxis in childhood. here we present 3 cases had anaphylaxis due to cow 's milk allergy, and treated with specific oral tolerance induction (soti̇) to cow' s milk. method: soti protocol was administered according to previously published by longo et al. skin prick test were performed according to standard methods with allergens. cow's milk specific ige was investigated with immunocap system. in all cases, the wheal size of the cow's milk in skin prick tests or the specific ige levels was higher than level of positive predictive value of 95%. results: case 1: a 7 years old male patient who had 3 anaphylaxis after milk consumption. soti treatment was started one year ago. there was no complications during the dose increasing phase. however, he had two episodes of anaphylaxis during the maintenance phase. in the final visit, we observed that he could drink 200 ml milk and could consume dairy products. case 2: eight-year-old male patient has an intensive care-of-hospitalization story due to anaphylaxis three times after milk consumption. his accordance to strict diet was bad, and had frequent asthma attack. anaphylaxis developed 2 times during the dose increasing phase in soti protocol. after soti treatment, he could consume 200 ml cow's milk and dairy products without problems. case 3: a 7-year-old male patient followed-up for asthma and cow's milk allergy. it was learned that anaphylaxis developed 2 times after milk consumption. he was fed in accordance with the milk-free diet. he has used fluticasone nebules, montelukast, mometasone nasal spray, and cetirizine. anaphylaxis developed 4 times during the dose increase phase of soti administration. there were many mild to moderate anaphylactic episodes during the maintaining phase. after the soti treatment, he could consume 150 ml milk and dairy products. background: cow's milk protein allergy (cmpa) is one of the most common food allergies in early childhood. small dietetic group sessions for parents of infant with non-ige mediated cmpa were held to meet increasing demands and reduce waiting times. parents were given information on cmpa, advice on weaning and milk reintroduction using a locally designed milk ladder. parents were also advised to contact the dietitians via telephone if they had further questions. we aim to evaluate the sustained effectiveness and patient satisfaction of the group sessions. method: parents and carers who attended the group dietetic sessions held between november 2015 and july 2016 were included in the survey. feedback were obtained via a self-designed questionnaire using a likert-type scale, rating several questions from 1 (least satisfied) to 5 (most satisfied). initial feedback was obtained directly after the session. we followed these patients up a year after the initial session via telephone and postal questionnaire. results: overall attendance rate of the 9 group sessions held was 58% (n = 40). during the initial survey, participants found the group session useful (mean score 4.7 out of 5) and felt more confident in managing cmpa (mean score 4.8). we successfully obtained follow up feedback from 13 participants. majority agreed that the group sessions have been informative (mean score 4.8). they also said they felt confident weaning their child on milk-free diet (mean score 4.8), and in reintroduction of cow's milk in diet (mean score 4.3). 30% (n = 4) said that they would have preferred an individual session. 38% (n = 5) have contacted the dieticians via telephone after the initial session, and 15% (n = 2) had requested individual consultations. 69% (n = 9) have attempted reintroduction of cow's milk in their child's diet using our local milk reintroduction guide. the mean age at first challenge was 14 months (age range 6 to 26 months), with average of two attempts. 31% (n = 4) have been successfully challenged and are managing well on a normal diet. we recognised the limitation in obtaining feedback via telephone and postal questionnaire, which resulted in the poor follow-up response rate. overall, parents felt more confident in managing cmpa and the positive responses were sustained a year on, highlighting the success of these group sessions. follow up opt-in sessions could be offered to provide additional support and allay parental anxiety in challenging their child with cow's milk at an appropriate age. results: goats and rabbits were immunized with specific allergoids, the allergoid-specific igg titer determined and sera pools produced. the allergoid reference material was comprehensively characterized. while ige reactivity of the allergoids was not detectable anymore, igg reactivity was maintained. allergoid-specific assay parameters as serum dilution, reference dilution and sample dilution factor to obtain at least six data points within the pseudo-linear range of the inhibition curve were determined. with these set parameters the evaluation of the analytical method was performed. the assay showed very good results in terms of linearity, accuracy, precision, reproducibility and robustness for all investigated allergoids as well as aluminum-adsorbed allergoid-preparations. conclusion: with the developed immunological inhibition assay, it is possible to determine the specific igg reactivity of allergoids in different preparations. the performance of the analytical method met all pre-defined acceptance criteria, which will be confirmed in the next step by a validation procedure according to ich-guidelines. case report: we present the case of a 32-year-old patient, diagnosed with rhinitis and asthma due to sensitization to pollens, as well as dyshidrosis and allergic contact dermatitis to cobalt. the patient presented a cutaneous pattern consisting of erythematous papules, some scaly, very pruritic, of initial appearance in the upper limbs 2-3 days after initiation of administration of specific immunotherapy extract (depigoid forte grasses, leti ® ). subsequently generalize lower limbs and neck. she presented them repeatedly and late after 2-3 days of the first 3 doses administered. she referred partial control of pruritus with oral antihistamines, without total resolution of lesions for weeks. immunotherapy was suspended persisting the skin lesions for 3 more weeks. according to the personal history of sensitization to metals, and the clinic presented in a temporal relationship with the use of an extract of immunotherapy with aluminum hydroxide, a study was requested with epicutaneous tests with aluminum hydroxide as well as with epicutaneous tests with immunotherapy extract. aluminium hydroxide and depìgoid forte grasses extract epicutaneous test were negative. in subsequent visits the patient reported that coinciding with the start of immunotherapy, presented at home and mainly in her bedroom a plague of cimex lectularius, popularly known as bedbugs, proving that they had been the cause of bites on their skin, and later skin reaction. patient reported that with the elimination of said pest the skin lesions disappeared. the administration of its immunotherapy extract was tolerated. cimex lectularius, commonly known as bed bugs, is a hemiptera insect of the family cimicidae. the clinical picture usually corresponds to multiple pruriginous lesions from the prurigo type, to multiple erythematous plaques, some infiltrated and others with a urticarial appearance, or even bullous. the lesions last for 3 to 6 weeks without treatment, and while the older ones heal, new ones may appear. in our patient it was not considered as an initial diagnosis, having considered immunotherapy as an etiological factor, but we must not forget that although in our country it is not a reason for frequent consultation, either due to underdiagnosis, because of the transitory nature of the pathology or because of scarce number of causative agents, it is important to consider insect bites in the differential diagnosis of dermatosis. di cara g; salvatori c; testa i; pacitto a; bizzarri i; isidori c; tarsia m; esposito s università degli studi di perugia-dipartimento di scienze chirurgiche e biomediche, perugia, italy background: house dust mites (hdm) are one of the most important allergens involved in childhood respiratory diseases, and the most frequently prescribed extract for sublingual immunotherapy in children (slit). despite the improvement of standardization methods for the production of slit, the differences in cultivation and purification processes used to produce raw materials for specific immunotherapy extracts may still impact on the final composition of mite allergen extracts. our study investigated the total protein and main allergen content of five commercial hdm sublingual immunotherapy extracts using sds-page and immunoblotting. recombinant allergens of group 1 and group 2 major allergens were used to test the immunogenicity of such extracts. method: hdm slit extracts were purchased from five italian suppliers (alk-abellò, allergy therapeutics, anallergo, lofarma, stallergenes). the protein composition of extracts was evaluated analysing equal volumes (15 ml/lane) by sds-page (12% separating gel) and subsequent immunoblotting. for identification of allergens in the extracts, western blot analyses were performed with rabbit monoclonal antibodies (raybiotech) against der p 1 and der p2. the total protein content in the five tested commercial extracts showed a relevant variability. the protein contents ranged from 32.9 to 44.2 μg/mg for what concerns der p1, while der p2 showed a greater variability, ranging from 4.2 to 14.6 μg/mg. sds-page showed a similar pattern of distribution in 3 of the tested extracts, which showed protein bands of comparable intensity, while 2 extracts showed a lower total protein count. extract 2 showed a higher intensity band corresponding to the molecular weight of tropomyosin. western-blotting showed a similar concentration of der p 1 in most extracts, while der p2 was more variable. conclusion: our analysis of five commercial extracts commonly used for sublingual specific immunotherapy against hdm showed important variations in term of total protein content. a less evident but still relevant difference was also evidenced when testing the major allergen content, with up to 25% variation in der p1 and up to a 3-fold variation in der p2 concentration. this differences, likely related to the different production and extraction methods, could still be responsible of a different immunological response in children who underwent slit. method: we evaluated 29 children who had completed their immunotherapy treatment. along with demographic data we were able to record skin prick test (spt) results and mrqlq at start and end of treatment. we only included patients who had completed pre and post treatment questionnaires in the study to allow a comparison. the scores were evaluated using a student t test. results: patients' starting age ranged from 6 to 17 years (mean 11 years). 29 of the 48 children had completed pre and post treatment questionnaires. all 29 had grass pollen allergy confirmed on spt at the start of treatment. 10 patients (34%) had isolated grass pollen allergy on spt and 19 (66%) had multiple allergies. mean start treatment score for all patients was 37 on mrqlq. mean score at end of treatment was 24, indicating a 35% reduction in total mrqlq score (p value <0.05). for those with multiple allergies the mean total mrqlq scores were 33 at start of treatment and 25 at end of treatment, indicating a 27% reduction (p value 0.16). for those with isolated grass pollen allergy scores were 44 at start of treatment and 23 at end of treatment indicating a 50% reduction (p value <0.05). conclusion: for children with uncontrolled symptoms of allergic rhinoconjunctivitis, grass pollen immunotherapy is associated with statistically significant improvement in quality of life. this improvement is most beneficial for patients with isolated grass-pollen sensitivity on spt. those with multiple aeroallergen sensitivities on spt did show an improvement (not statistically significant) post-treatment. grass-pollen immunotherapy is an effective treatment for rhinoconjunctivitis to offer patients in a rural dgh setting. background: allergic asthma is a common clinical refractory disease, most patients with asthma are accompanied by varying degrees of allergy. in clinical practice, treatment of this disease using specific immunotherapy has proven effective. in the current study, we examined the effectiveness of specific immunotherapy in a total of 99 patients admitted to our hospital from 2015 to 2016. method: to investigate the clinical efficacy of allergic asthma-specific immunotherapy. 99 patients were selected, of which 49 were males, aged 22 to 61 years, 50 females, aged between 23 to 64 years old, all patients were clinically diagnosed only as allergic asthma. the 99 patients were randomly divided into two groups, including the observation group containing 50 cases, the control group of 49 cases. all patients were first treated with conventional basic treatment. the observation group was subsequently treated with specific immunotherapy. both groups were followed-up and the treatment efficiency were analyzed. results: after treatment, both two groups of patients showed improvement, in the observation group, the effective rate was 93%, while for the control group, the effective rate was 75%. observation group showed significantly better outcomes than the control group. conclusion: in allergic asthma treatment, adding specific immunotherapy on the basis of routine treatment is beneficial and could be widely used in clinic. case report: atopic dermatitis(ad)is the most common itchy dermatosis that affects millions of children and adults. during recent years, diagnosis and treatment based on component resolved diagnostics (crd)is recommended. we report a 9-year-old boy with severe atopic dermatitis. he had positive family history of atopy. the atopic dermatitis was developed since infancy. he was referred to our clinic when he was 5 years old. he had generalized xerosis with ulcerative eczematous lesions on his neck, popliteal and antecubital areas. he had mild eosinophilia and his serum total ige level was 590 iu/ml. daily bleach bath, moisturizing agents, topical steroids and systemic antibiotics in addition to antihistamine were prescribed. he had multiple food and aeroallergen sensitization in skin prick test (spt). he started to eliminate some foods according to the spt results. he was suffering from recurrent relapse even after strict food avoidance; so treatment with cyclosporine was initiated for him, with partial response. crd showed sensitization to alternaria alternata (alt a1 specific ige:10.97 ku/l). allergen immunotherapy by alternaria alternata was started. after accomplishment of buildup phase, he had significant improvement and we were successful to taper and finally discontinue cyclosporine. now he is on maintenance phase of immunotherapy, his skin is in optimal condition only by hydration and moisturization. result: a 15-year-old thai girl is a known case of severe asthma since one year old. her asthma was uncontrolled asthma even treatment with high dose combination of inhaled corticosteroid and long acting beta agonist (ics/laba), montelukast and omalizumab. spirometry revealed the force expiratory volume in one second (fev1): 34% predicted, fev1/forced vital capacity (fvc): 48% predicted and 14% improvement of fev1 after salbutamol 400 ug inhalation. allergic sensitization showed specific ige to cat: 2.04 kua/l. slit with cat allergen started at the dose of 450 au per month and increased to 1500 au per month (scit dose is 1000 au per month) for three-year-and-six-month course. after slit, her asthma symptom improved significantly. she can exercise without exacerbation and plays sport at school. her last episode of asthma exacerbation was 1.5 year ago. her fev1 (% predicted) was improved from 34% predicted to 48% and the fev1 bronchodilator response decreased from 14% to 6%. conclusion: an improvement of pulmonary function and asthmatic symptoms of the presenting case would support the efficacy of slit of cat allergen in a patient with severe asthma. ra developed during pollen scit in this case might be related with immunomodulation effect of immunotherapy. background: we report a case of 20-year-old woman with allergic rhinoconjunctivitis and mild persistent asthma due to sensitisation to seasonal pollens and molds with bad clinical evolution and not response to conventional drug therapy. we decided to start subcutaneous allergen specific immunotherapy with alternaria extract in our immunotherapy unit in accordance with the guidelines of the european academy of allergology and clinical immunology (eaaci) and we used a cluster regimen. the immunotherapy was not well tolerated: the patient had two grade 2 systemic reactions with the first dose in two attempts. method: sensitisation was diagnosed through skin prick test with aeroallergens standard panel and serum specific ige by elisa. due to the bad tolerance to immunotherapy, molds molecular diagnosis by immunocap, study of the molecular weight to specific ige binding proteins by sds-page ige immunoblotting, and cross-reactivity study by means of immunoblotting-inhibition assay were performed. a. fumigatus extract was able to produce a total ige binding inhibition on the 38 kda band of a. alternata extract when ige immunoblotting assay was performed. conclusion: respiratory allergic disease due to alternaria is difficult to control, the use of subcutaneous specific immunotherapy could be of significant benefit. most of the allergic patients to a. alternata are sensitized to alt a1, major allergen from a. alternata. however, our patient is sensitized to a 38 kda alternaria protein due to cross-reactivity with a. fumigatus allergens, this sensitization could explain the bad tolerance to the alternaria immunotherapy. background: the association between natural pollen exposure, clinical symptoms as well as allergen-specific immune responses has not been investigated at a molecular level. our aim was to monitor the effect of seasonal birch and grass pollen exposure on clinical symptoms as well as specific b cell and t cell responses to defined allergen molecules in sensitized subjects during two consecutive years. method: grass pollen sensitized (n = 10) and birch pollen sensitized (n = 13) subjects were included in this study and were followed for two consecutive years (2013) (2014) . subjects were taking part in a clinical trial for the recombinant grass pollen vaccine (bm32) but did not receive immunotherapy for the allergen they were sensitized to. before, during and after the respective seasons ige and igg levels as well as t cell responses to the major birch pollen allergen bet v 1 and the major grass pollen allergens phl p 1, 2, 5 and 6 were measured. pollen counts were recorded throughout the year and patients kept a daily diary including symptom medication score (sms) and visual analogue scale (vas). results: we noted that ige levels specific for bet v 1 and the grass pollen allergens increased most in the seasons in which patients experienced the highest peak symptoms according to vas and sms but not depending on cumulative pollen counts. increases in allergen-specific t cell responses were observed in the pollen seasons as compared to shortly before the pollen seasons in the grass pollenallergic patients also in association with vas and sms but not in the birch pollen allergic subjects. no relevant changes of allergen-specific igg levels were observed during the two years observation in grass and birch pollen allergic patients. we found an association of increases of allergen-specific ige increases shortly after the pollen season with clinical symptoms in the pollen season as reflected by vas and sms which was not necessarily reflected by cumulative pollen counts in the season. these results may be important for the analysis of allergen-specific immunotherapy trials. background: the morbidity and mortality of severe asthma is much higher than that of mild to moderate asthma. this study was performed to understand the clinical characteristics of severe asthma in korea. results: data from the questionnaire showed that bronchial asthma was diagnosed before pregnancy only in 193 women (4.83%). 43 patients (1.1%) were diagnosed with chronic bronchitis at the pregestation stage. asthma attacks were experienced repeatedly during a lifetime in 4.2% of patients, 12.7% of patients noted long periods of dry cough at night, among them 8.1% had wheezing. the cold did not precede the wheezing breathing in 5.1% of patients. difficulty in breathing on waking was noted in 2.6% of patients, at night-4.3%. after examination, the diagnosis of asthma was confirmed in 14.65% of the respondents (586 people). symptoms of rhinitis are noted in 58% of women surveyed, 18% of rhinitis was allergic. before examination, the diagnosis of ar was only in 3.5% of patients. the incidence of symptoms of asthma and ar in pregnant women is significantly higher than the reported cases of these diseases, which leads to untimely initiation of treatment. method: a total of 117 nonsmoker asthmatic patients without concomitant pulmonary pathology are recruited to our study. all patients underwent spirometry tests, measurement of fraction of exhaled nitric oxide and sputum induction to asses sputum cell counts, demographic features and current medications were recorded. using the variables of age at onset, bmi, allergy status, fev1%, fev1/fvc, asthma severity and induced sputum cytology cluster analysis is performed. results: 4 clusters are identified. cluster1: (n = 43) early onset atopic asthma, consists of mild asthmatics with a good asthma control and lower bmi. cluster 2: (n = 14) severe atopic asthma, consists of lowest spirometry measurements with a least act scores. induced sputum cytology shows a neutrophilic character, while having also the highest percentage of eosinophils. cluster 3 (n = 27) late onset obese asthma, nonatopic asthmatics having high spirometry measurements, with a lower act scores. cluster4 (n = 33) nonatopic mild asthma, consists of patients with the best respiratory functions and least inflammation in means of lowest total ige, feno, sputum cell counts. conclusion: identification of asthma phenotypes in different countries will improve our understanding on the heterogeneity of the disease among the different geographies. results: results and discussion. in the course of analysis, obesity was more common in children with bronchial asthma −25% than in the comparison group-in 9.3%. obesity of the 1st degree was diagnosed in 10 patients of the main group, ii degree-in 8, and iii degree-5 and iv degree-in 2 patients e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesitymore than +2.0 (i degree: sds bmi 2.0-2.5, ii degree: sds bmi 2.6-3.0, iii degree: sds bmi 3.1-3.9, iv degree: sds bmi ≥4.0). conclusion: thus, the results obtained indicate a high prevalence of constitutional-exogenous obesity in children with bronchial asthma and precedes the formation of the underlying disease e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesity-more than +2.0 (i degree: sds bmi 2.0-2.5, ii degree: sds bmi 2.6-3.0, iii degree: sds bmi 3.1-3.9, iv degree: method: postal questionnaires were distributed to an unselected group of asthma patients (n = 190). healthy non-asthmatic volunteers were recruited amongst university and hospital co-workers (n = 53). the presence of self-reported nhr, the type of triggers evoking nasal symptoms, asthma phenotype, medication use and environmental factors were evaluated. results: 114 patients and 53 controls completed the questionnaire (responder rate of 60% and 100% respectively). nhr was reported in 71% of asthma patients and 22% in non-asthmatic controls (p < 0.0001), with changes in temperature being the most important inducer of nasal symptoms (74% of asthmatics), followed by strong odours (62%) and cigarette smoke (61%). interestingly, nhr was more prevalent in patients with severe (79%) compared to mild (50%) asthma symptoms (p = 0.015), and more prevalent in atopic (77%) compared to non-atopic (55%) asthmatics (p = 0.028). most asthma patients reported more than one trigger evoking nasal symptoms, with 44% of patients reporting 3 or more triggers evoking nasal symptoms. results: the mean score of cbcl questionnaire in case group with 28.12 ± 2.06 was significantly higher than in comparison with a control group with 17.33 ± 9.7 (p = 0.01). the mean scores of the subscales of social isolation (the case group: 5.83 vs control: 1.18, p = 0.006), anxiety-depression (4.99 vs 2, p = 0.22), intellectual problems (4.8 vs 2.3, p = 0.000), and aggressive behaviors (5.1 vs 2.3, p = 0.003) were significantly higher in children with asthma than in healthy children. the study showed a significant correlation between the mean duration of asthma and a general score of cbcl (p = 0.012, cc=0.8). moreover, there was also a significant correlation between asthma severity and cbcl scoring (p = 0/001, cc=0.03). conclusion: behavioral disorders in children with asthma are significantly more than healthy children. the duration of asthma and the severity of asthma, are related to and can predict behavioral disorders in children with asthma. background: assessment of asthma control is an integral part of the management of asthma. whilst asthma control test (act) is a commonly used questionnaire to assess symptom control, its utility in predicting long term risk of exacerbation has not been well studied. aim: to analyze the factors associated with uncontrolled asthma symptoms using act and its impact on predicting future exacerbation. method: severe asthma patients on at least step 4 background: most of the asthma-scoring tools detect the asthma severity from patients' symptoms but there is no scoring tool using parameters to define risk of asthma exacerbation. thus, this study use factor analysis to evaluate the relationship of parameters in childhood asthma. method: the descriptive study using factor analysis in asthmatic children aged less than 15 years old, who attended thammasat university, the center of excellence for allergy, asthma and pulmonary diseases, thailand. the participants or caregivers were inter the factors which have the major impact on asthma control are changing bed sheets less than once per month and using dust mite-proof bed sheets. this study is supporting non-pharmacological strategies but further studies are needed to create a more efficient asthmatic symptom checker. were not different between the controlled and uncontrolled group. the act score in the controlled group was significantly higher than the uncontrolled group (p < 0.001). the study showed that cigarette smoke is one of the significant factors that can trigger asthma exacerbation (p < 0.001) and mosquito repellent coil smoke is also significantly associated with asthma exacerbation (p < 0.03 background: experimental studies have demonstrated that tumor necrosis factor family member 14 (tnfsf14/light) plays an important role in airway remodeling. there is little data available concerning in vivo regulation of tnfsf14/light expression in humans. the aim of this study was to evaluate serum concentration of tnfsf14/ light in different subsets of asthmatic patients. the study was performed on 36 nonsmoking asthmatic patients (a), including 24 mild-moderate-severe asthmatics controlled on inhaled corticosteroids (aics) and 12 asthmatics evaluated twice during asthma exacerbation (aex) and during subsequent remission (arem). in addition age and sex matched 24 nonsmoking healthy controls were included (hc). serum tnfsf14/light concentration was evaluated using elisa method. in asthmatic patients lung function tests, exhaled nitric oxide concentration (feno), serum total ige concentration (t-ige), allergen-specific ige concentration (s-ige) and peripheral blood eosinophilia were evaluated. (250 + /-134 pg/ml) was significantly greater than that in hc (72 + / -32 pg/ml; p < 0.001). among all asthmatic patients studied the greatest tnfsf14/light serum concentration was demonstrated in aex (357 + /-79 pg/ml), which was significantly greater than that in aics (194 + /-123 pg/ml p < 0.001). during resolution of asthma exacerbation a significant decrease in serum tnfsf14/light concentration (118 + /-70 pg/ml; p < 0.001) was demonstrated. in arem the mean serum tnfsf14/light concentration was comparable to that seen in aics (p = 0.06) but was still significantly greater than in hc (p < 0.01). no significant correlation could be demonstrated between serum tnfsf14/light concentration and baseline lung function parameters, exhaled nitric oxide concentration, serum t-ige or s-ige concentration or peripheral blood eosinophilia. conclusion: enhanced production of tnfsf14/light seen in asthmatic patients, which is further upregulated during asthma exacerbations may play an important role in asthma pathogenesis. method: two models of aspergillus fumigatus-induced allergic airway inflammation were used in the study: long terms (4 weeks) and short terms (2 weeks background: chalcone 4 is identified as an inhibitor of the interaction between cxcr4 or cxcr7 and their ligand cxcl12. therefore it is called a neutraligand. the chemokine cxcl12, interacting with the cxc-receptor4 (cxcr4) can play a role in the progression and development of bronchial asthma. asthma is defined as a chronic disease characterized by episodes of obstructive events which affects about 300 million people over the world. the aim of this study is to approach the mechanism of the anti-inflammatory effect of the cxcl12 neutraligand chalcone 4 and also to assess its impact on the migration of dendritic cells in a murine model of allergic airway inflammation. method: chalcone 4 is administered intranasally to balb/c ovalbumin (ova) asthma mice and control groups as well. our results indicate that the cxcl12 neutraligand chalcone 4 can modify the inflammatory reaction in an airway allergic hypereosinophilia model. furthermore, found out that cxcl12 neutraligand chalcone 4 prevents dc migration to the airways and airway jnc ganglia during allergic airway inflammation. the detection of the cxcr4-cxcl12 pathway and its role in the pathophysiological actions of asthma offers a promising target for allergic diseases treatments. method: four groups of balb/c mice were defined: control and asthmatic, with and without treatment. asthmatic groups were sensioverexpression of ptgdr in pulmonary cells associated to a generalized increase of cytokine expression. conclusion: in a mouse model we confirmed the involvement of ptgdr in allergic asthma by the increase of its expression levels after ovalbumin sensitization. we also identified a reduction of ptgdr levels in response to dexamethasone treatment. the in vitro model suggests that ptgdr induces an inflammatory response, increasing the cytokines levels. 0979 | immune imbalance between transcription factor t-bet/gata3 and allergic asthma results: t-bet mrna expression of peripheral blood lymphocytes in patients with allergic asthma was lower than that of the normal control group, and the expression level of gata-3 mrna was higher than that of the normal control group (p < 0.05). the th1 percentage of peripheral blood lymphocyte subsets was lower than that of the normal control group (p < 0.05), the percentage of th2 cells was significantly higher than that of the normal control group (p < 0.05), and the changes in t-bet/gata3 expression and th1/th2 ratio was highly correlated. our objectives were to assess the changes of bmp4 and bmp7 serum levels in the response to allergen and methacholine challenge tests and the correlation between bmp4 and bmp7 serum levels and fev1 before and after allergen and methacholine challenge tests. method: study group consisted of 59 patients with asthma and 48 healthy volunteers. spirometry, skin prick tests, allergen and methacholine challenge tests were performed in compliance with eaaci, ers and ats guidelines. personalized clinic surveys including act ™ were performed. venous blood was collected before and after 1 hour, and 24 hours afterwards the provocation to edta-ke-filled test tubes. evaluation of bmp4 and bmp7 serum protein levels was performed using specific elisa immunoassay kits according to the manufacturer's protocol. results: the increase in bmp4 and bmp7 serum level 24 hours after provocation test correlates significantly with the concentration methacholine during provocation time (p < 0.05). bmp7 serum level before the provocation, 1 hour and 24 hours after provocation, correlates negatively with fev1 change (p < 0.05). the median bmp7 level 24 hours after provocation was significantly lower in patients with negative methacholine challenge test compared to the control group (p = 0.03). the median bmp4 level 24 hours after provocation was higher in patients with positive allergen provocation test than in patients with negative test results (p = 0.03). the bmp7 serum level 24 hours after positive methacholine test is lower and correlates inversely with fev1 change in every time point, which could indicate that serum level of bmp7 is a predictive factor of fev1 change. the higher bmp7 serum level, the lower fev1 change was observed. this could suggest the protective influence of bmp7 in patients with obstructive pulmonary disease, i.e. asthma. the higher bmp4 serum level 24 hours after positive allergen provocation test result shows that the bmp4 could be an indicator of the response to a specific trigger. background: inflammation and coagulation are closely linked events. thrombin is the key enzyme in coagulation system. besides its well-known functions in hemostasis, thrombin plays a role in inflammation. the aim of our study was to evaluate thrombin generation in children with mild asthma and demonstrate associations between thrombin levels and control of asthma. method: forty-two children with mild asthma and forty-nine healthy children included in the study. asthmatic children had no asthma exacerbation during the last 6 months. patients (n = 27) who had mild persistent asthma, were using either inhaled steroid or montelukast. all patients performed spirometry. thrombin levels were measured by thrombin generation test. thrombin peak levels, endogenous thrombin potential, thrombin lag time, time to thrombin peak and thrombin tail time were recorded. results: thrombin lag time was significantly longer in children with asthma (3.98 ± 1.2) compared to those in control group (3.29 ± 0.6) (p < 0.01). children with asthma also had longer thrombin tail time compared to control group (19.5 ± 8.9 vs 16.7 ± 2.9, p = 0.02). thrombin peak was inversely correlated with fef 25-75 (-0.41, p < 0.01). thrombin lag time was inversely correlated with fef 25-75 (-0.39, p < 0.01). thrombin generation parameters did not show difference according to asthma control treatment, asthma control scores and having atopy. conclusion: coagulation/anticoagulation balance is disturbed in mild asthma but this disturbance may not be as strong as to increase thrombin levels. factors increasing inflammation may cause an increase in lag time, and increase in inflammation and excessive fibrin deposition may contribute to airway narrowing. background: cytokines represent key mediators in the onset and persistence of inflammatory process, in both asthma and copd. il-31, which belongs to il-6 family, it might act in a similar way with il-6 at the beginning of the inflammatory process. its role in atopic skin diseases has already been demonstrated, but there are conflicting results related to its role in respiratory allergic diseases. the aim of the study was the evaluation of il-31 plasmatic level in patients with asthma and copd and the its correlation with clinical and lung function parameters. method: fifty consecutive patients with bronchoobstructive diseases were included in the study. thirty-two patients presented asthma and 18 patients had copd. the evaluation included: number of exacerbation in the last year, disease's severity, spirometry. plasmatic levels of il-31 and il-10 were determined in all patients. results: the mean age was higher in patients with copd dermatophagoides pteronyssinus [house duste mite (hdm), 100ug/ mouse] were administered oro-tracheally on days 0, 7, 14, 21, 28, 35, 42 and 49 . at was performed in a treadmill during 4 weeks in moderate intensity, from day 24 until day 52. results: at inhibited hdm-induced total cells (p < 0.001), eosinophils (p < 0.01), neutrophils (p < 0.01) and lymphocytes (p < 0.01) in bronchoalveolar lavage (bal), and eosinophils (p < 0.01), neutrophils (p < 0.01) and lymphocytes (p < 0.01) in peribronchial space. at also reduced bal levels of il-4 (p < 0.001), il-5 (p < 0.001), il-13 (p < 0.001), cxcl1 (p < 0.01), il-17 (p < 0.01), il-23 (p < 0.05), il-33 (p < 0.05), while increased il-10 (p < 0.05). airway collagen fibers (p < 0.01), elastic fibers p < 0.01) and mucin (p < 0.01) were also reduced by at. at also inhibited hdm-induced airway hyperresponsiveness (ahr) to methacholine 6.25 mg/ml (p < 0.01), 12.5 mg/ml (p < 0.01), 25 mg/ml (p < 0.01) and 50 mg/ml (p < 0.01). mechanistically, at reduced the expression of stat6 (p < 0.05), stat3 (p < 0.001), stat5 (p < 0.01) and jak2 (p < 0.001), similarly by peribronchial leukocytes and by airway epithelial cells. socs1 expression (p < 0.001) was upregulated in leukocytes and in airway epithelial cells, socs2 (p < 0.01) was upregulated in leukocytes and socs3 down-regulated in leukocytes (p < 0.05) and in airway epithelial cells (p < 0.001). conclusion: at reduces asthma phenotype which is followed by positive modulation of socs-jak-stat signaling in peribronchial leukocytes and in airway epithelial cells. rodolfo a 1 ; paciência i 2 ; rama t 1 ; leão l 1 ; silva d 3 ; rufo j 2 ; mendes f 4 ; padrão p 5 ; oliveira fernandes e 6 ; moreira p 7 ; delgado l 8 ; moreira a 9 porto, portugal; potentially irritating chemicals that may have a cutaneous drying side effect. this study aimed to evaluate if skin barrier function, as measured by transepidermal water loss (tewl), is affected by a training session in swimmers compared with football players. environment impact on the human respiratory health (clinicaltrials.gov identifier: nct03017976) and football players were invited to participate. due to the lack of prior information no sample size calculation was possible and all athletes that provided informed consent were included in the analysis (n = 58, 29 females, aged 12 to 21 years). tewl was measured using the tewameter ® tm 300 before, immediately after, and 30 minutes after a 2 hours training session. the probe was held on the dorsum of hand, the volar forearm and the antecubital flexure for 60 s. the average of two consecutive measurements was recorded. non-parametric statistic was used were appropriate. ethical approval was obtained from the university clinical research ethics committee and informed consent provided. results: mann-whitney u test showed significantly higher baseline median tewl level on football players hand's dorsum compared with swimmers, median (p25-p75) respectively 17.1 (14.7 to 21.7) and 13.7 (11.9 to 16.2); p = .001. friedman test revealed a significant effect of swimming on tewl on the hand's dorsum, volar forearm and antecubital flexure (p < .001) while football training affected only the hand's dorsum (p = .008). differences in changes after swimming and football training were significant only for tewl in volar forearm (p = .028). in conclusion, our exploratory findings do not provide support for a specific deleterious effect of swimming, compared with football training, on the training induced changes in tewl. background: exercise-induced bronchoconstriction (eib) is defined as transient, reversible airway narrowing occurring during or after exercise, is common among elite athletes and associated with epithelial damage. however, little is known about the existence of eib in young athletes. the goal of this study is to investigate the presence and to evaluate potential (bio)markers of eib in young high-school elite athletes in different sport disciplines versus age-matched control subjects. method: high-school selected elite athletes (12-13 years) from different sport disciplines: basketball (n = 26), football (n = 44) and swimming (n = 47) performing at least 12 hours of sport per week (median=13 h) and 17 control subjects (performing less than 6 hours of sport per week) were recruited. the eucapnic voluntary hyperventilation (evh) test was performed according to ats guidelines and adapted for this age group. lung function was measured before, immediately after and 5, 10, 15 minutes after the evh test. the test was considered positive if a maximal fall in fev1 of 10% was measured on at least one time point and exhaustion was excluded. a blood sample was obtained at baseline. sputum induction and skin prick test for the most common allergens were performed after the evh test. results: fifteen swimmers had a positive evh test (33.3%), which is higher than in basketball players (18.2%), football players (17.95%) and controls (17.65%). 40.4% of the swimmers were atopic which is also higher than in basketball players (23.1%), football players (31.8%) and controls (23.5%). serum clara cell secretory protein (cc16) levels are significantly higher in swimmers (7.6 ± 2.5 ng/ml) compared to indoor athletes (5.1 ± 2.2 ng/ml) and controls (5.2 ± 1.2 ng/ml). a significant positive correlation was found between the magnitude of maximal fall in conclusion: young elite swimmers have a higher prevalence of eib compared to basketball and football players. atopy and/or chlorine is a risk factor for the development of eib in young elite athletes. cc16 levels and sputum uric acid levels are increased in athletes compared to control subjects suggesting the presence of epithelial damage already at young age. this is especially observed in young elite swimmers, pointing to a probable role of exposure to chlorineby-products in combination with intensive exercise. results: data from 237 subjects (134 females, 56.5%) were analyzed. frast was positive in 97 (40.9%) patients (55 females, median age of 14 years (iqr 11-18)). in this group, 55 (56.7%) had a previous diagnosis of asthma, 27 (27.8%) practiced federated sports, 18 (18.6%) had smoke cigarette exposition and 3 (3.1%) had a bmi >30 kg/m 2 . 82.5% of patients showed a δfev1% >10% in the first 5 minutes after finishing the challenge. median fev1 reduction was 13.4% ) and 390 ml . frast was more frequently positive in patients with previous diagnosis of asthma (p < 0.01). there were no differences related to conclusion: frast is an important tool to diagnose exerciseinduced bronchospasm without asthma (eib wa ), as well as to diagnose asthma. in our study, frast was fundamental to access eib wa in 28% of patients with rsee, and confirmed asthma diagnosis in 53% of cases with previous asthma diagnosis and negative sbt. there was no difference in the prevalence of atopy between patients with positive and negative frast. patients older than 9 years-old presented higher δfev1% compared to younger patients (p = 0.04). higher levels of feno were observed in patients with positive frast (p = 0.032, p = 0.045), both in patients with and without previous diagnosis of asthma. a positive correlation was observed between feno levels and δfev1% in the whole sample (r = 027, p = 0.009); when these data were analyzed considering a previous diagnosis of asthma, only patients with this condition showed a positive correlation of feno and δfev1% (r = 0.29, p = 0.031). conclusion: our results evidenced that higher feno was associated with atopy and a positive frast, both in patients with and without previous diagnosis of asthma. higher feno seems to correlate with δfev1% in patients with previous diagnosis of asthma. background: specific immunotherapy is the casual treatment for allergic rhinitis. a 28 year old professional footballer suffer from severe allergic rhinitis since two years. during may, june and july his level of playing, concentration and durability decreased about 20%. patient was complaining of runny nose, nasal blockage, each eyes, sneezing, tearing. method: we did skin prick tests -which showed greatest allergy to grass pollen. we confirmed the allergy by specific ige and nasal provocation tests. spirometry was done-fev1 116%. the patient was qualified to undergo specific immunotherapy. however, because of his profession, it was hard to find a day without trainings to get the vaccine. after long discussion, patient decided to start specific immunotherapy-scit. results: the patient start the immunotherapy. he was attuning very irregularly, because of matches, injuries, trips, trainings, and lack of time. several times we had to call the patient to remind him about the immunotherapy. after one year of scit the patient felt big improvement. during grass pollen season he suffered from mild allergic symptoms, and just for few days. after next year of immunotherapy, the patient had no symptoms of allergic rhinitis during the grass pollen season. however, it was the reason for him, to stop sit, before 3rd year of immunotherapy. conclusion: such a treatment-specific immunotherapy-is a burdensome method for both, for professional athletes and doctors. such a patients need to be on special observation, and cooperation with trainers must be obtained, if we want to see results. to improve compliance we have to keep in touch with patients, to remind them about next visit. gherasim a 1 ; choual i 1 ; radu c 2 ; khayath n 2 ; beck n 1 ; jacob a 1 ; schoettel f 1 ; domis n 1 ; de blay f 2 1 alyatec, strasbourg, france; 2 hôpitaux universitaires de strasbourg, strasbourg, france background: late allergic response (lar) is a good asthma model. it has been shown, in individual challenge tests that mite allergen induces more frequently late allergic responses (lar) than cat allergen. the aim of this study is to compare the frequency of lar in asthmatic subjects allergic to mite with asthmatic subjects allergic to cat. method: 24 asthmatic subjects allergic to mite were compared to 21 subjects allergic to cat (gina 1 or 2). the subjects had prick tests≥5 mm compared to the negative controls and specific ige ≥ 0.70 ku/l. the dose selected for the mite and cat allergen was the airborne allergen concentration inducing the most frequently early asthmatic response (ear) (a 20% drop in fev1) and lar (a 15% drop in fev1). results: the frequency of lar with mite allergens was 66.6% and 20% with cat allergens (p = 0.007). the frequency of ear for mites was 78.2%; of 91.3% for ear or lar, and 50% for ear and lar. in contrast, with cat allergens, 55% of patients had an ear, 60% had ear or lar and 25% had an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. the frequency of lar in asthmatic subjects allergic to dust mite exposed in alyatec ® eec was higher than in asthmatics sensitized to cats. our results confirmed previous results with individual bronchial challenge. therefore, it appears that the mite model is more interesting in the study of asthma. exposure chamber in strasbourg (alyatec ® ) in asthmatic patients allergic to cat allergens gherasim a 1 ; choual i 1 ; radu c 2 ; khayath n 2 ; beck n 1 ; jacob a 1 ; schoettel f 1 ; domis n 1 ; de blay f 1 1 alyatec, strasbourg, france; 2 hôpitaux universitaires de strasbourg, strasbourg, france background: as recommended by the task force on environmental exposure chamber (eec), allergenic and non-allergenic exposure must be better controlled in eec. it is the aim of alyatec's eec. the aim of the study is to validate alyatec's eec by determining the concentration of fel d1 inducing 50% of early asthmatic response (ear) and/or late phase asthmatic response (lar) in subjects sensitized to cat. method: it was a randomized, double blind, cross-over study including group a:20 asthmatic subjects allergic to cat and group b:10 asthmatic subjects allergic to another allergen. all subjects were first exposed to placebo. group a was exposed to 2 fel d1 concentrations. the number and size of particles were recorded online during the exposure. group b was exposed to the concentration of fel d1 which fulfills the objective of the study. the mean age of subjects was 29 years (±8). for the 2 concentrations of fel d1, we obtained more than 50% ear and/or lar. the mean time necessary to obtain an ear was: 59.7 ± 8 minutes and 138.6 ± 90 minutes for the lar. the mean fall in fev1 during ear and lar was −29.22% and −17.64% respectively. we didn't observe any severe reaction. no subjects in group b experienced any symptoms during exposure. we have validated alyatec's eec in asthmatic subjects allergic to cat allergens. we also demonstrated its specificity. background: the best test and strategy for diagnosing asthma especially in those patients with negative bronchodilator reversibility tests still remains unclear. in this study we aimed to investigate the diagnostic yield of peak expiratory flow (pef) variability for the patients with symptoms suggesting asthma but negative bronchodilator reversibility tests. method: subjects referred to our outpatient clinic with suspicion of asthma were enrolled in this study. demographics and referral symptoms were recorded, asthma control test (act) scores and health related quality-of-life scores (aqlq, sf36) were calculated. monitoring of pef variability during 2-weeks and bronchial challenge test with methacholine (bpt) were analyzed. asthma was diagnosed by having pef variability ≥20% and/or positive bpt. results: thirty out of 50 enrolled patients were diagnosed as having asthma. when we compare asthmatic patients with nonspecific respiratory symptomatic subjects there were statistically-significant differences regarding to wheezing (p = 0.020), activity limitation (p = 0.058), total symptom score (p = 0.028) and basal fef (p = 0.050) in the favor of asthma cases. multiple logistic regression analysis revealed that lower basal fef 25-75 was an independent predictive factor of asthma diagnosis (p = 0.05). when the bpt positivity was assessed as gold standard for the diagnosis of asthma, the sensitivity and specificity of pef variability for different cut-offvalues (≥20%, >15% and >%10) were 61.5-83.3%, 88.5-62.5% ve 100-16.7%, respectively. conclusion: fef 25-75 is an important diagnostic parameter for asthma. although current guidelines recommend pef variability of 10% for the diagnosis of asthma in general, this cut off level may not be appropriate for this defined group of subjects. our results suggest to use a cutoff level of >15% while excluding asthma and ≥20% while confirming the diagnosis of asthma for patients with asthma suspicion but without shown reversibility. de barayazarra s background: in recent years obesity has been considered as a factor that contributes to the development of asthma, increases exacerbations and leads to poor control of it due to resistance to drugs to control this pathology. it is known that obesity produces chronic systemic inflammation; one of the markers that are affected is the levels of c-reactive protein (crp), which are increased. objective: evaluate, lung function, the use of medications to control asthma and systemic inflammation, after bariatric surgery. results: 15 obese asthmatic patients with surgery, 15 non-asthmatic obese patients with surgery, 16 obese asthmatic patients without surgery. a significant difference was found between the severity of obesity and forced expiratory volume in patients with asthma and without asthma of 1 second (fev1) before surgery with an average of 87.9% at the beginning of the study and 105.5% at 12 months (p:0.0004). in the non-operated group, fev 1 at the beginning was 69% and 83.04% at 12 months (p: 0.0018). the crp, before surgery in all operated patients had crp: 9, at 12 months after surgery they became negative, crp: 0 (p: 0.004). in obese asthmatics with surgery at the beginning, 100% used medication, and at 12 months only 20% in obese asthmatic patients without surgery, 93.75% used the medication at the beginning, at 12 months 62.5% (p:0.0006). method: 20 patients with asthma aged 18 to 80 and a predetermined positive methacholine pc20 were recruited and underwent a single challenge to cause bronchoconstriction of~20% comparing the outcome of the device with spirometry. the subjects were monitored at baseline, after a~20% fall in fev 1 and after bronchodilation back to baseline. the study protocol allowed for an interim analysis of the initial 8 subjects at which point the sensor was calibrated to optimise sensitivity. a further 12 subjects were studied using the optimised sensor. results: all 20 subjects successfully completed the study. the device was found to be straightforward to use by both operator and subject with no concerns regarding safety. the initial sensitivity of the device was found to be suboptimal in the first eight patients to reliably detect changes in lung function. after adjustment to the device the tests results of the remaining 12 subjects were analysed. 66.6% of subjects were female. the mean age of all subjects was 45.8 years. an average baseline fev 1 value of 2.575 (s.d. 0.881) was observed. changes in lung function were detected in 100% of subjects. a baseline value, drop in lung function and reversal were measured in 66% of subjects. the mean percentage drop observed in 66% of subjects using the investigational device was 13.04 %. the mean percentage increase observed using the investigational from drop to reversal was 25.36 %. the device (using ebc 1 ) was able to detect changes in lung function tracked using fev 1 . this provided proof of concept that the device could potentially be used to monitor lung function more effectively in the home than peak flow and supports further development to optimise the device and demonstrate functionality in clinical asthma. method: ninety four patients under 18 years of age seen in the allergy department due to common asthma symptoms (wheezing, dyspnea, cough, chest tightness) with normal spirometry and negative bronchodilator response, underwent mct during 2016 and 2017. the variables studied were: sex, age, body mass index (bmi), asthma symptoms, exercise symptoms, rhinoconjunctivitis, family history of atopy, sensitization to respiratory allergens, spirometric data and fractional exhaled nitric oxide (feno). results: of the total sample, half were women (51.06%) and the other half were males (48.94%). mean age was 11.8 years. bmi was normal in most of them (with an average of 19.55 kg/m 2 ). the most common symptom among the patients with positive mct was cough (79.8%), followed by dyspnea (62.76%), wheezing (34%) and chest tightness (11.7%). 43.6% had symptoms of asthma with exercise and 70.2% had rhinoconjunctivitis. 37.23% had a family history of atopy. 74.4% were sensitized to aeroallergens, mainly to pollens (grass and olive tree). 75.5% of the mct′s were positives, with a mean pc 20 of 1.89 mg/ml. 62.7% had a moderate-severe result (pc 20 ≤4 mg/ml), 7.4% mild (pc 20 4-6 mg/ml) and 5.3% bordering (pc 20 6-8 mg/ml). the mean feno was 19.62 ppb. conclusion: in our series, the completion of a test of hrb was decisive to confirm the diagnosis of asthma in most patients of a pediatric population with symptoms of suspicion (cough, mainly), normal spirometry and negative bronchodilator response (with normal feno in most of them). therefore, we consider it important to include in the routine clinical practice hrb tests in the pediatric population with suggestive symptoms of asthma, despite normal functional and/or inflammation tests. 1000 | cut-points of the ′control of allergic rhinitis and asthma test′ (carat) asthma subscale based on an international survey patients with asthma) in kashan, iran. the data collection tool was a questionnaire with 38 questions, designed to gather information on demographic asthma patients, the current use of mobile functionalities, and the willingness to use these functionalities to receive selfmanagement services, which was distributed among patients with informed consent. the collected data were analyzed by descriptive statistics method using spss software. results: the most use of patients from mobile phone functionalities was to receive information about asthma symptoms and allergens and irritants via mobile internet (42.1%). patients were most likely to use social networking (31.7%) in comparison with other mobile phone functionalities, to receive reminders about appointments and medication. the respondents were most likely to use social networks through mobile phone functionalities, to receive asthma self-management information (53.1%), to communicate with other patients (55.9%), to receive reminders about medication use, and to perform a peak flow meter test (52.4%) and to get an alert when the asthma is not controlled (53.1%). the findings show that asthma patients are currently using the internet search for educational information and they have a tendency to use social networks to receive asthma-related services. patients believe that mobile health is an appropriate intervention for providing educational information, reminders, and alerts and communication with other patients. 1002 | concordance between the determination of asthma control through the gina 2015 guidelines and the act questionnaire-results of the efimera study background: the exacerbation of asthma, progressive worsening of acute episodes, is one of the most frequent attending reasons at hospital emergency unit 1 . several factors causing poor control of asthma, such as inadequate therapy, have been described. in the present study, estimations of asthma severity by researchers were assessed by comparing the concordance between the assessment of asthma control through the gina 2015 guidelines and the act questionnaire method: cross-sectional observational study on the evaluation of factors related to treatment that influence the poor control of asthma was assessed through the gina guidelines and the act questionnaire. patients referred to a pneumologist or allergist by a primary care for the first time were evaluated. two variables were collected for the assessment of asthma control: one derived from the gina 2015 guidelines and another derived from the act questionnaire. regarding the gina assessment, researchers' evaluations guidelines were compared with the scoring calculated from the variables registered in the crd. both measures were compared in terms of sensitivity-specificity to determine their ability to classify patients. the patients included in this study (n = 1682) had a mean age of 45 ± 17 years, with a 64% of women and an average disease evolution of 14.9 ± 14.1. the control of asthma according to "gina results: pts were reasonably representative of those in sls asthma (at sls baseline: 43.8% male; mean age 48.4 yrs; mean asthma control test [act] score 16.5) . the most frequently reported symptoms during sls asthma for these pts were cough/ breathlessness, followed by wheeze, phlegm and chest tightness; breathlessness and wheeze were perceived as the biggest impactors on pts' lives. the aspects of daily life most impacted by asthma were reported as walking at a hurried pace, strenuous physical activity, and asthma-related frustration. since sls began, 50% of pts in this subset reported improvements in overall asthma (44% no change; 6% worsening). perceived changes in symptoms are shown (table) . most pts (66.0%) reported avoiding places with dust, smoke or fumes. most pts (57.5%) perceived no change in overall qol; 36.3% reported improvement. being an act responder during sls (total act score ≥20 or ≥3 change at end of sls) was associated with reported improvements in overall asthma symptoms, lower impact of asthma on qol, and higher perceived confidence/control in managing asthma. more pts (65.8%) in the ff/vi arm reported an overall improvement in asthma vs uc (34.3%); the most evident differences between treatment groups were for breathlessness, wheezing and chest tightness. improvements in confidence/control in managing asthma were reported by 53.8%/49.3% of pts (ff/vi) vs 31.3%/25.3% (uc). conclusion: breathlessness and wheezing were key symptoms in sls asthma and had the biggest impact on pts' daily lives. this patient-centred study enriches the findings of sls asthma. funding: gsk (study 204500) 1004 | asthma and copd treatment adherence and breach using tai questionnaire suarez-vergara m; fuentes-soltero f; garcia-nunez i; ignacio-garcia j background: adherence is defined as medication (inhalator) intake following the dosage and schedule prescribed. adherence mistakes are a public healthy problem according to the big morbi-mortality presented in patients with an incorrect intake. our aim is to evaluate the adherence level and fulfillment in patients with asthma or copd using tai (inhalators adherence test) questionnaire. method: patients with a diagnosis of persistent asthma or copd were selected. we used to size adherence and breach type the tai questionnaire. adherence is defined as good when patient′s test reaches 50 points, medium (46-49 points) and bad (less than 45 points). breach type is defined as erratic when points between questions 1 to 5 are less than 25, deliberate when questions 6 to 10 are less than 25, and unconscious when questions 11 and 12 are less than 4 points. a correct fulfillment is defined when questionnaire reaches 50 points plus 4 points of conscious fulfillment. results: fifty-five patients more than 14 years old (mean age 50.61 years and 50.9% males) were selected. a 67.27% of them were asthmatics, 30.9% copd and 1.81% a mix phenotype. a 21.81% presented a correct fulfillment with conscious fulfillment, and the other 78.18% presented good, medium or bad adherence with a breach type. according to adherence level, a medium adherence was defined in 16 patients (29.09%), with an erratic mistake in 8 patients (50%). bad adherence was seen in 21 patients (38.14%) , with the three breach types in 9 patients (40%). good adherence with unconscious breach type was defined in 6 patients (10.9%). conclusion: tai questionnaire confirms a good adherence and fulfillment in less than 30% patients. an erratic mistake is the most frequent breach type defined in our patients. educational protocols should be applied to improve adherence and fulfillment. 1005 | what is adhesion to treatment of asthmatic patients like in argentina according to the tai questionnaire? background: asthma is a chronic inflammatory disease of the airways, which requires an adequate treatment and control. the adhesion of a patient to an asthma treatment is a critical factor in order to achieve and maintain control. this adherence arises from a consensual agreement of the doctor-patient relationship; it is a complex multifactorial variable in which the variability in human behaviour in relation to its environment influences. background: the association between ambient pollen and asthma has been studied intensively with inconsistent results, attributed to differences in study population, geographic factors (geoclimatic features), data sources, measurement of pollen (different types of traps), and different outcome occurrence (hospitalizations or emergency department visits). we investigated the associations between daily sales of short-acting β2-agonists (saba) and outdoor pollen concentrations in the central france area. the relationship between daily changes in pollen concentrations and daily saba sales obtained from the social security database was analysed with generalized additive models, taking into account confounding factors such as air pollution, weather conditions, and day of the week. results: the daily saba sales (mean, sd) rose from 46. 5 (23.6) conclusion: this study indicates that outdoor pollens contribute to asthma morbidity in the general population. it confirms the highly allergenic role of fraxinus, betula and quercus pollens, but also shows a relatively unknown association between treated asthma and carpinus and platanus pollens, despite their counts being less than 1% of overall pollen concentration. results: of 15 437 asthma patients (mean age 47.8 years, female 62.6%), regular ocs use was identified for 223 patients (1.4%), periodic ocs use for 3054 patients (19.7%), and no ocs use for 12 160 patients (78.7%) 1-year post-index. regular ocs users had a greater mean age, were more often male, and had greater eosinophil counts, lower lung function, and greater prevalence of comorbidities than did the periodic and no ocs users (p < 0.001). total yearly cost was greatest for the regular ocs users (€ 5509), followed by periodic ocs users (€ 2892) and no ocs users (€ 2042) (p < 0.001). among regular ocs users, hospital admissions were the main cost driver (41.5% of total cost), while gp consultations were driving the total cost in periodic and no ocs users (48.0% and 52.9% of total cost, respectively). conclusion: in this sample of patients with asthma in sweden, the total yearly cost of health care resource utilization for a regular ocs user is twice as high as for a patient with no ocs use, demonstrating substantial economic and clinical burden in asthma patients on regular oral steroid treatment. method: children with physician-diagnosed asthma who attended to an outpatient pediatric allergy and asthma center were enrolled in the study along with control subjects. asthma severity and control status of the patients were evaluated according to recent gina guidelines. laboratory investigations including skin prick tests, complete blood counts with differential, total ige levels, serum periostin levels and pulmonary function tests were performed. results: a total of 158 children (125 with asthma and 33 age and sex-matched control subjects) with a median age of 10.2 years (range 5.9-17.0) were enrolled. asthma severity was mild in 41 (32.8%), moderate in 63 (50.4%) and severe in 21 (16.8%) children. children with asthma had significantly higher periostin levels than controls (53.1 ± 13.1 vs 43.0 ± 11.2 ng/ml; p < 0.001). the mean serum periostin levels of children with severe asthma (63.8 ± 10.8) were significantly higher than in children with moderate asthma (53.3 ± 12.7) and mild asthma (47.4 ± 11.1) (p < 0.001). serum periostin levels were found to be significantly correlated with asthma severity (spearman's rho [r]=.41, p < 0.001). analysis using roc curves identified the role of periostin levels in determining children with severe asthma (auc: 0.77, 95% ci: 0.67-0.87, p < 0.001]. conclusion: serum levels of periostin, a novel asthma biomarker, were higher in asthmatic children, and were associated with asthma severity. adam i 1 ; selevestru r 1 ; rogut v 2 ; sciuca s 1 background: nowadays, data from several epidemiological studies confirm the important role of fungi in respiratory disease in the indoor as well as in the outdoor environment. in general, exposure to fungi occurs via inhalation, skin contact, or ingestion. alternaria alternata is one of the most common fungi associated with presence asthma and persistence and severity of asthma. although exposure to a. alternata is also may represent a risk factor for development of asthma. in ukraine has been an increase in the number of the mold sensitized children for the last few years. at the same time we can see increasing frequency ba at the children of pre-school age. method: thirty five children aged 3-7 years with allergic rhinitis and high level of asthma predictive index (api) sensitized to a. alternata were included in a 2-year cohort study of the efficacy and safety of slit (diater laboratories, spain) using standardized sublingual extracts containing molds (alternaria alternata). treatment efficacy was analyzed using the score of symptoms such as difficulty in nasal breathing, rhinorrhea, sneezing, itching of the nasal mucosa (upper palate) and discharge from the nose and recurring wheezing. we also have analyzed the level api during the period investigation. symptoms were measured before starting treatment, and at 4, 12 and 24 months after starting immunotherapy. results: slit significantly reduced both symptoms and medication score: nasal symptoms (38% vs. control group) and the use of rescue medications (38% vs. control group), and improved fev1 (in children aged≥5 years). in the slit group, api decreased by 15% for the first year, by 31% for the second year. no patient had a systemic reaction during therapy. our results have shown that slit is an effective treatment in pediatric patients suffering from allergic rhinitis and high api with significantly improved clinical outcomes (less symptoms and less medication intake) in comparison with children treated with symptomatic drugs only. in this study, large and statistically significant differences in symptom and medication scores were demonstrated in patients receiving slit compared to control group. sublingual immunotherapy is effective for allergic rhinitis in children especially early age and is generally advantageous because of the convenient administration and safety profile and ensure prevention of developed ba. bednarek a background: the classification of asthma based on the severity of its clinical course has been recommended by gina since 2008. this division is useful for the patient's initial assessment when asthma is being diagnosed and essential decisions concerning an appropriate therapy are made. the objective of the work is to evaluate the influence of a clinical form of asthma on vaccine immunity in preschoolers following three years after the programme of mandatory vaccination has been realised. the study encompassed 172 preschool children (mean age of 5.22 ± 0.34 years old) with asthma being newly diagnosed, including 140 patients with mild asthma and 32 ones with moderate asthma, whose vaccine immunity (igg specific antibody titer) was assessed after the mandatory early childhood vaccines had been administered. monovalent vaccines (hbv+ipv+hib) along with a three-component combined vaccine (dtwp) were given to 86 children while a six-component vaccine (dtap+ipv+hib+hbv) was given to the remaining 86 children. the vaccine doses were consistent with the polish immunisation programme and manufacturers' recommendations. the elisa immunoenzymatic method was applied to assess titer of specific antibodies to diphtheria, tetanus, pertussis, poliomyelitis and h. influenza type b. the level of hbv antibodies was measured chemiluminescently. the immunity class for particular vaccinations was assessed according to the test manufacturers' instructions. results: children suffering from mild asthma had considerably more frequently vaccinations on time (p < 0.001) and the type of vaccines (monovalent, highly-combined) administered to them did not have a significant influence on a clinical form of asthma in the children examined (p > 0.6951). apart from the vaccines against hepatitis b and rubella where considerably more frequently a high antibody titer occurred in children with mild asthma, the titers of antibodies to other vaccines, namely diphtheria, tetanus, pertussis, hib and mumps, were not associated with a clinical form of asthma. the protective antibody titers in the children with asthma were found in 100% after vaccinating them against poliomyelitis (≥12u/ ml) and measles (≥300 ml u/ml). significantly higher current weight was solely found in the children with mild asthma (m = 20.80, sd=3.77; p < 0.05). conclusion: there are some clinical and cultural differences among the four southern chinese cities within the canton province. this study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and qol for healthcare interventions. having a smoker in the family is independently associated with poor asthma control and qol. were classified into two groups (levocetirizine group (l) and montelukast group (m)) and we treated each group for another 10 week. to evaluate the therapeutic effectiveness, we used symptom score (ss) and ebc leukotriene e4 (lte4). ebc samples were collected with rtube. each parameter was checked at 0, 2, 12 week therapeutic period. results: most ar patient showed clinically improvement with 2 and 12 week fluticasone therapy (0 wk ss=6.6, 2 wk ss=3.2, 12 wk ss=1.9 p < 0.01 in l group; 0 wk ss=6.8, 2 wk ss=3.6, 12 wk ss=2.0 p < 0.01 in m group). lte4 levels of ar were higher than control (0 wk 77 vs. 12 pg/ml), and were reduced after 2 week flutimic were: md allergic rhinitis, wheezing apart from colds, eosinophilia ≥4%. outcome was defined as md asthma and at least 1 episode of asthma during the previous year or more than 3 episodes of wheezing during the 12 months regardless of asthma diagnosis. results: from a total of 144 of parents approached, 86 (58%) agreed to participate in a phone interview. 18 (21%) children were diagnosed with asthma. the age at the time of admission (mean, abstracts | 533 (sd)) was 27.0 (9.9), at the time of phone survey 77.6 (10.9) months, respectively. positive loose api at 2-3 years of age had sensitivity of 77.8%, specificity 75%, positive predictive value (ppv) 45.2%, negative predictive value (npv) 92.7%. positive stringent api at 2-3 years of age had sensitivity of 50%, specificity 91%, ppv 64.3%, npv 85%. background: asthma is the most common chronic airway disease in childhood, with a high unmet need for new treatments due to insufficient symptom control in a relevant percentage of patients. ethics and resource factors limit the feasibility of large, long pediatric trials required to assess outcomes such as exacerbations and symptoms. for diseases like asthma, where the disease process is largely similar in children and adults, with the same expected therapy outcome, the international council for harmonisation advise extrapolating adult data to those of a younger age, reducing unnecessary pediatric trials. here we assess the partial extrapolation used in the clinical development of tiotropium. phase 3 trials in adults (aged 18-75), adolescents (aged 12-17) and children (aged 6-11) with symptomatic severe (primotina-/pensie-tina-/vivatina-asthma) or moderate asthma (mezzotina-/rubatina-/ canotina-asthma), respectively. trials lasted 12-48 weeks, all with tiotropium respimat 5 μg add-on vs placebo as two puffs once daily. results: in adult trials, lung function, symptoms and exacerbation endpoints were evaluated in a confirmatory manner: tiotropium significantly improves lung function and asthma control, and reduces risk of exacerbation, vs placebo ( conclusion: based on similarities in disease profile and magnitude of treatment responses between age groups, it is reasonable to expect tiotropium add-on to produce clinically meaningful improvements in exacerbation and symptom endpoints in children and adolescents, as in adults. the robust tiotropium clinical program supports using a partial extrapolation to avoid overly long and large trials in pediatrics. 1019 | clinical state of treatment and examination during last 3 years before remission about asthmatic children in long-term remission cases method: remission cases (no symptom and no therapy) for 3 years of asthmatic children were studied. clinical background and treatment (drugs) was studied during last 3 years before remission annually. acetylcholine inhalation test by standard method was performed, and respiratory threshold of acetylcholine (rt-ach) was obtained. fev1%, and serum ige also examined. these data were compared before remission with 3 years after remission. results: mean age of 25 cases at 3 year before remission was 9.2 years old. male to female ratio was 1.3. severity of asthma was all mild type, and number of attack was 2 to 8 times in a year. there was no admitted case during this study. the long-term therapeutic drugs were leukotriene receptor antagonist (anti lt) in 20 cases, and/or inhaled corticosteroids (ics) in 12 cases, but 5 cases had no treatment for the control. geometric mean of rt-ach (after then: 3 years before and after remission) was 2900 μg/ml and 5800 μg/ml. the mean fev1% was 83% and 90%. geometric mean of serum ige level was 360 iu/l and 410 iu/l. complicated cases of atopic dermatitis decreased after remission, but the incidence of allergic rhinitis increased slightly. conclusion: characteristics of asthmatic children during last 3 years before remission were mild type, had several times of attack in a year, and the treatment was mainly anti lt and/or ics. fev1% was within normal range, and serum ige level was not changed after remission. rt-ach had the tendency to improve during 3 years before and after remission. these data is supposed that airway hyperresponsiveness is one of the indicators for quitting treatment. 1020 | clinical aspects of polyvalent mechanic bacterial lysate (pmbl) treatment in children with uncontrolled asthma our results indicate that long-term treatment with omalizumab in children can help to achieve better asthma control and reduce the amount doses of basic therapy. method: allergic rhinitis (ar) and allergic rhinoconjunctivitis (arc) diagnosed-patients' demographic information, accompanying-asthma, the allergic history of the family, the onset of symptoms, types of aeroallergens sensitivity were noted from patients' files in our hospital's pediatric allergy clinic. results: in this study, 675 patients were evaluated. the mean age of the patients were 11.65 ± 3.85 years and 61% (n = 412) were male. 452 (67%) patients had ar and 223 (33%) patients had arc. background: allergic rhinitis (ar) is a disease characterized by symptoms of nasal discharge/congestion, sneezing, and pruritus, and is caused by an ige-mediated immunological response to inhaled allergens. we aimed to evaluate pollen season and out of pollen season pulmonary function tests (sft) of patients with ar in our study. method: in our study, the demographic characteristics and aeroallergens were recorded from patients' files with ar diagnosed. in addition, pollen season and out of pollen season sfts were evaluated and compared. conclusion: in patients with ar, fev1 and fvc values are seen to be lower during the season even though there is no lower respiratory symptom. therefore, sfts of patients with ar should be evaluated during pollen season. results: among the clinical manifestations, the most common combination of allergic rhinitis (ar) and conjunctivitis (ac) is noted in 83.80% of adults and 55.11% of children, but in children aged 3-7, the combination of ar and ac is observed only in 48.40%, among 8-12 years old-51.25%, while in the remaining age groups it is encountered in more than 80%. higher percentage of isolated ar is also observed among young children-17.55%, and those of the results: allergic rhinitis was a main symptom in 69.8% of children with pollen-food sensitization. in all of them concomitant allergic disorders were noticed: bronchial asthma (77.7%), atopic dermatitis (77.8%). only in 26.7% temporal association between ingestion of pollen-related foods and nasal symptoms was observed (mainly apple and peanuts); occurring also outside the pollen period. the simultaneously sensitization to animal origin food allergens was stated in 63.3% of children with sar, but only in two of them milk and white egg proteins were an additional exacerbation factor of nasal symptoms. in 18.5% anaphylactic reactions to food allergens were registered. 36.7% of children were asymptomatic despite pollen-food sensitization. the statistically significant differences were noticed in comparison to the control group. conclusion: 1. allergic rhinitis in children, similar to adults, is a common manifestation of pollen-food syndrome and this type of sensitization should be taken into account regardless to age. 2. children with pollen-related food allergy have the predisposition to multiorgan clinical manifestation. 3. the lack of association of symptoms with plant-origin foods in the majority of cases and the asymptomatic course of food sensitization in more than one third of patients indicate the need for follow-up. 1026 | clinical benefit of the screening of suspected food allergen using multiple allergen simultaneous test in the patient with pollen-food allergy syndrome (pfas) background: the quantitative fluoresce enzyme immunoassay immunocap (ic) system has been widely used for detection of allergen-specific ige for the diagnosis of allergy. however, the system can only detect ige against a single allergen, the multiple antigen simultaneous tests has been developed such as the fluorescence enzyme immunoassay view allergy 39 (va) or chemiluminescent enzyme assay mast iv (ma) and both assay detect more than 39 allergen-specific ige. in this study we examined the diagnostic capability of these two systems for screening test in the patient with pfas. method: total number of participants are 37 (male/female: 20/17), aged 12.0 ± 3.9 (range 3~20) years old. all the patients showed oral allergy syndrome (oas) to rosaceae family plants (apple, peach) and/ or kiwi and/or banana, also showed tree pollen allergy. specific ige assay were performed using ic, ma or va. results of greater than class 1 were to be regarded as positive, and the concordance rates between the assays were assessed. results: the correlation of sensitivity between pr-10 (rbet v1, rmal d1, rpru p1, measured by ic) and specific ige to apple (measured by va), specific ige to peach (measured by ma) in 27 oas patients to rosaceae family plants were assessed. rbet v1, rmal d1, rpru p1 were found to be 96.0%, 96.3%, 92.6% positive measured by ic while the specific ige to apple (supposed to be including pr-10) were found to be 100% positive measured by va. on the other hand, the specific ige to peach (supposed to be including pr-10) were found to be only 33.3% positive measured by ma, this detection rate was lower than that of va (p < 0.0001). also, the correlation of sensitivity between pr-10 (ract d8, measured by ic) and specific ige to kiwi in 17 patients with oas to kiwi were assessed. ract d8 were found to be 76.5% positive measured by ic while the specific ige to kiwi (supposed to be including pr-10) were found to be 64.7% and 17.6% measured by va and ma, respectively (p < 0.005). additionally, all the 3 oas patients to banana found to be positive for the specific ige to banana measured by va, but only 1 patient was detected as positive measured by ma. conclusion: in this study, we found that va showed better agreement of sensitivity and specificity with ic compared to ma in the oas patients to rosaceae family plants, kiwi, or banana. therefore, it may be clinically useful for screening of allergen specific background: the hygiene hypothesis for autoimmune and allergic diseases, which exists nowadays, shows that human immune system is dependent on various environment factors. we consider the effects of humic substances (hs) to be important in understanding the hygiene hypothesis. due to urbanization, the amount of human interaction with hs found in soil has significantly dropped. the goal of our work was to study allergenic potential and antimicrobial activconclusion: hs appear to be exogenous immunocorrectors, and also to have an ability of suppressing propagation of allergic reactions and sensibilization, which leads to conclusion that they seem to play a major role in hygiene hypothesis. moreover, hs selectively interact with bacterial cell wall, and this effect could be used in order to create antimicrobial drugs based on hs. background: peach tree pollen has been identified as having relevant allergens (the third most prevalent after olive tree and grass pollen) in areas of high cultivars (murcia, east-spain). when analyzing molecular components in sensitized patients, along with pru p 3, we have identified other relevant inhalant allergens one of which was named pru p x. because pollen of different species share allergens and with plantderived food, we have also studied peach tree pollen sensitization in a non-exposed population (madrid, central-spain). the aim was to study the association between peach tree pollen and several panallergens, as well as the relevance of pru p x in our area (madrid). method: a total of 328 patients who came to our allergy unit in those patients with positive spt to at least one pollen we also performed peach tree pollen spt. if positive, we tested pru p 3, pho d 2, pho d 3 and pru p x. to study the clinical relevance of these findings, we also performed nasal provocation test (npt) with peach tree pollen and pru p x. results: a total of 57 patients were sensitized to peach tree pollen. from these, 33% had also positive spt to pru p 3 and none of them to pru p x. positive spt to polcalcin were found in the 33% of the cases and to profilin in the 13%. in 7 patients sensitized to peach tree pollen npt was performed being 4 cases positive to peach tree pollen and none to pru p x. conclusion: peach tree pollen sensitization in non-exposed patients with allergy to other pollens is high although primary sensitization is unlikely. these patients present clinical response when exposed to that pollen that needs further evaluation. in our study, one third of the patients were also sensitized to polcalcin and pru p 3 and none to pru p x. we have not found clinical response to this new inhalant allergen identified in highly exposed peach tree pollen population. results: the bet v 1 elisa 2.0-ep complete kit format (including pre-coated plates and all buffers and reagents) allowed for the consistent measurement of bet v 1 in birch pollen extracts within the same lab (intralab cv=5.5%) and between different labs (interlab cv=13.5%). the average recovery from matrix spiked samples (crs in birch pollen extracts) ranged from 75-112%, with an average recovery of 91% (n = 10). assay time was reduced from several days to two hours compared to the original method. the performance of the bet v 1 elisa 2.0-ep kit was comparable to that of the stallergenes greer candidate standard method and has been successfully cross-validated. this will enable allergen manufacturers and regulatory authorities to adopt a standard method for bet v 1 determination, which, ultimately, may be included in the european pharmacopoeia. the development of a certified elisa represents a major step forward in the standardization and quality control of allergen products. 1031 | an isoform of the ole e 7 allergen assembled by proteomics could explain the cross-reactivity with pollen and food nsltps results: a total of 457 peptides were obtained by de novo sequencing. ten of them allowed the completion of the full-length amino acid sequence of the allergen. after purification, role e 7 was obtained with a yield of 1.5 mg/l of cell culture. immunological assays confirmed that the recombinant isoform of ole e 7 shared most of the allergenic and antigenic properties of the natural allergen. moreover, we observed its implication in cross-reactivity with pollen extracts, and plant-derived food extracts. conclusion: these results suggest that the presence of this isoform in the olive pollen could explain the co-sensitization observed in some allergic patients between ole e 7 and nsltps from foodderived extracts and might be used for a more effective clinical diagnosis of olive pollen sensitized patients. background: penicillium oxalicum, one of the prevalent airborne fungi in india, was selected to detect its spores as potential source of allergens and also to identify and characterise its major ige-reactive component. the airborne spores of penicillium oxalicum was detected by andersen 2-stage air sampler at different parts of west bengal. the allergenic potency of p.oxalicum was tested by spt, elisa and immunoblotting. total protein was resolved in 1-d and 2-d gel electrophoresis and allergens were identified by 1-d and 2-d immunoblots. identification of major ige-reactive protein spots was made by mass spectrometry based maldi-tof-tof. major allergen was partially purified by ion exchange chromatography. results: aerobiological investigation clearly indicated the predominance of p. oxalicum spores (56 cfu m −3 ) in the air of west bengal, india. sensitivity of patients to spore antigens was highly correlated with rhinitis. in sds-page, 80 bands were detected with molecular weight range of 16-180 kda. the allergenic potency of spores was confirmed by skin-prick test, elisa and dot-blotting. eleven ige-reactive proteins were detected as allergens by 1-d and 2-d immunoblots, of which 43% patients were sensitized to 22 kda allergen. this 22 kda protein was found to be the major allergen which was further characterized by mass spectrometry based maldi-tof-tof. this major allergen (pi 6.08) was partially purified by ion exchange chromatography. the eleven allergens were identified from spore of penicillium oxalicum fungi for the first time from india. immuno-proteomic identification of major ige-reactive protein (22 kda background: airway epithelium (ae) is one of the largest cellular surfaces exposed to the environment. ae constitutes a physical barrier due to the presence of intercellular apical junctional complexes between neighboring cells. in the past years evidence indicates an association between epithelial airway dysfunctionality and allergic asthma. it is still unclear if an impaired epithelial barrier could be the cause of allergy development as opposed to the consequence. one of the most common comorbidities of asthma is house dust mite (hdm) allergy. it has been shown that hdm allergen der p 1 can disrupt the epithelial airway due to its protease action against cellular apical junction complexes damaging the epithelial monolayer. in the last decade, metabolomics has been successfully employed as a new approach to describe metabolic changes in biological systems. metabolomics focuses on describing and identifying small molecules to explain complex biological processes. we theorized that metabolomics could be used as a new tool to detect damage of epithelial barrier in vitro after der p 1 exposure. method: human cell line calu-3 cultured at air-liquid interphase (ali) was used as an in vitro model of bronchial epithelium. ali culture system allows establishing 2 different compartments, mimicking the conditions found in the human airways: a basolateral compartment in which basolateral surface of the cells is in contact with the culture medium, and an apical compartment where the apical cellsurface is exposed to air. after 7 days in ali, the cells were exposed to either der p 1 or pbs as a control in the apical side for 24 hours. then, apical and basolateral media were collected and processed for metabolomics analyses. results: metabolic profiles from samples were obtained, these were composed by 248 and 397 features for apical and basolateral media, respectively. of these, using mann-whitney unpaired test as statistical analysis, 108 and 15 features were found changed within the apical and basolateral compartments, respectively. specifically, in the apical compartment there were 104 signals significantly increased and 4 decreased after der p 1 exposure; whereas for the basolateral compartment, 11 signals were found to be significantly decreased and 4 increased after exposure. background: mites are one of the major causes of allergies. it is known that allergen concentration varies depending on the species of mites and the degree of allergy induction is different, but the difference in microbiota according to mite species is not known. in addition to allergen, endotoxin or bacterial dna, adjuvants of allergen derived from the microbiota in the mites, are also present in the feces. bacterial endotoxin is found in gram-negative bacteria, acting on tlr4 and acting as an adjuvant to allergies. method: three species of mites (d. farinae, d. pteronyssinus, and t. putrescentiae), known to cause allergies, are cultured in same condition(autoclaved media, 80%rh, 25°c)and analyzed for microbiota of each species. using the next generation sequencing that complements the existing sanger sequencing, we analyze the difference of microbiome according to the dust mite species and measure the level of endotoxin. method: six hundred and thirty five patients (51.8% males and 48.2% females, mean age 30.2 years old, range 3 to 82 years old) were included. all of them referred respiratory symptoms (rhinitis, conjunctivitis or bronchial asthma) and had skin prick tests positive with any pollen. patients were skin prick tested with a battery of common pollens in our area, including three species of chenopodiaceae: chenopodium album, salsola kali and salsola oppositifolia. results: three hundred and forty tree (54%) patients were sensitised to pollen of any chenopidaceae species: 255 (40.2%) to chenopodium album, 245 (38.6%) to salsola kali and 220 (34.6%) to salsola oppositifolia. the prevalence of skin sensitisation to pollen of salsola oppositifolia was 34.6% in the population studied and 64.1% in patients sensiresults: in patients aged 1-60 years of age in 80.5% of the cases ige reactivity was at least to one allergen tested. the majority of patients (more than 2/3) had a complex sensitization profile and reacted on average to more than 5 allergens. the highest frequency of sensitization in ukraine among patients who turned to the clinic among adults was found phl p1 (34.1%), amb a1(33.3%), fel d1 (33.3%), bet v1 (30.2%) and children (29.2%, 34.6%, 38.5%, 36.9%), respectively. when analyzing the results of tests for the source of the allergen, most often among house dust mites (hdm) allergens in adults and children is sensitization to fel d1 (35.9%), as well as to hdm: in adults (der f2-15.1% der p2 −15.1%, der f1-12.7%, der p1-11.9%) and in children (12.3%, 13.1%, 9.2%, 10 .8%), respectively. among fungal allergens the most common is sensitization to alt a1 and varies from 2.4% in adults to 26.9% in children. among pollen allergens in adults is sensitization to phl p1 (34.1%), amb a1 (33.3%), bet v1 (30.2%), cynd1 (23.8%), art v1 (22.2%), bet v2 (11.1%) and in children (29.2%, 34.6%, 36.9%, 19.2%, 16.9%, 21.5%), respectively. tests for food allergens in adults and children are more common on pr-10 proteins. in children, sensitization to milk and egg proteins is more common than in adults. conclusion: most patients who came to the clinic have a complex ige reactivity profile in which pollen sensitization predominates. among hdm allergens, more than 1/3 of the examined have sensitization to the cat's proteins. sensitization to mold alternaria alternata in children occurs 10 times more often than in adults. results: total 130 children were examined, aged 1-16 years (median 5 years). 72% children were sensible to two and more components 57.7%to 5 and more components. the frequency of sensitization to inhalation components was 65.4%, to food abstracts | 545 components-33.1%. among the most frequent inhalation components were feld 1-39%, betv1-37%, amba1-35%, phlp1-29%, alta1-27%, the sensitization to house dust mites (hdm) was most often observed to der p2-13%. however, the analysis of these protein by the level of isu showed that the highest levels were for der f1median 19 (iqr 9.4-47.0), whereas for fel d1-6.9 (iqr 2.6-15.0). among food allergens, sensitization was most commonly observed to pr-10 proteins -42%. children sensitized to pr-10 proteins were in most cases sensitized to -mal d1(28%), cor a1.0401(27%), pru p1 (22%).this co-sensitization was accompanied by a high correlation of isu levels among these components. sensitization to celery and kiwi was less common, the level of these proteins was also low. the frequency of sensitization to storage proteins was 38%, among which the highest level of isu was in ara h6 median 13 . sensitization to ltp proteins was detected in 22% of children, among which the most commonly detected pru p3 protein was 9.2%. the sensitization to profilins, which was evaluated at the level of bet v2, was found in 21% of children, but the levels of these proteins were not high. among the food products of animal origin, the most frequent was sensitization to egg component gal d2 −13.1%, however, isu levels were the highest to milk component bos d4 −9.8 (iqr 1.2-21.0). the most frequent causative inhalation allergens were epidermal allergens and weed pollen, however, the highest level of isu was to hdm and mould. among food allergens, the most commonly observed sensitization was to pr-10 proteins. hypereosinophilia of peripheral blood was observed in 87 children under study, which was 50% (4.7%). as a result of testing patients with a wide panel of allergens, 98% of the patients had diagnostic levels of antibodies to allergens siged1, 91.2%to allergens siged2. in 50% of cases, a significant level of antibodies to plantain allergens sige w8 was detected, 30.8% to dandelion allergens sige w9, 35.7% to evergreen trees sige t23, to maple sige t11 to 33.3%, to allergens of olive tree sige t9 -40%, to the banana allergens sige f92 -63.6%, to the egg protein sige f1 in 24.5%, in 34% to the milk allergens sige f2, to the food mixture sige f x5 -37.7%, to allergens of mold fungi mx2 −17.8%. among the leading household allergens were registered in the 1st group and in the 2nd group of the investigated children -d pteronyssinus (80.3%, 97.8%), and d. farinae results: the prevalence results are expressed in the table 1 . we have not observed any significant association in allergic rhinitis patients group with any ltp or pr-10 molecules. for atopic dermatitis only rara h 9 (or with 95% ci -10.2 (1.9-54.6) and njug r 3 (or with 95% ci -6.7 (1.6-29.5)) were associated significantly. for asthma, the most important molecules were rbet v 1, raln g 1, rcor a 1.0101, rcor a 1.0401, rmal d 1, rpru p 1 and rapi g 1 (p-values for or less than 0.05). conclusion: future studies focusing on the evaluation the association of cross-reactive molecules with allergy phenotype should be done. background: the fuzzy/green kiwifruit (actinidia deliciosa), widely grown commercially, contains various pulp allergenic molecules, including the major allergen cysteine protease actinidin. methods. this case report is about a 40-year-old male patient with house dust mite allergic persistent rhinitis and intermittent asthma, presenting a convincing history of anaphylaxis immediately after eating a kiwifruit on empty stomach, followed, a few months later, by a severe oral allergy syndrome after licking a slice of raw kiwi. previously, the patient ate kiwi without any problems and had no manifestations of pollen or latex allergy. skin prick testing was done with commercial allergen extracts, while prick-prick testing was performed with raw kiwifruit, avocado and banana. molecular approach consisted in assessment of serum specific ige to native extracts and molecular allergen components using patient-friendly allergen nanobead array multiplex test and singleplex capsule-enclosed activated cellulose solid phase fluorescence enzyme immunoassay. results. regarding kiwifruit allergy, the patient presented positive prick-prick tests with raw edible kiwifruit components: outer pericarp and inner pericarp (each 15 mm wheal) and columella/core (19 mm wheal) and negative with kiwifruit whole seeds, avocado and banana, and pollen extracts. serum specific ige to kiwifruit were detected (0.5 ku/l), but specific ige values were negative (≤0.01 fiu/ml) for actinidin act d 1, thaumatin act d 2, kiwellin act d 5, nsltp type 1 act d 10, bet v 1-like major latex/ripening-related protein act c 11, act c chitinase_iv, act d 9 cross-reactive profilins bet v 2 (birch pollen profilin) and hev b 8 (latex profilin), and also negative (<0.1 ku/ l) for pr-10 ract d 8. moreover, specific ige to avocado were nor found (≤0,01 fiu/ml). although ige against seed proteins cupin/11s globulin act d 12 and 2s albumin act d 13 were not determined, this was not considered of great importance since allergic symptoms were also induced by licking kiwi pulp, in which abundantly expressed actinidin enzymatically degrades seed storage proteins, and prick-prick test was negative to kiwifruit seeds. conclusion: in a patient with anaphylaxis to kiwifruit, positive skin tests to its pulp and detectable serum specific ige to actinidia deliciosa, a detailed molecular allergy diagnosis is necessary, including assessment for act d 3 glycoallergen or other molecules, not performed in this patient. 1049 | is pr-10 sensitization a portuguese phenomenon as well? background: bet v 1, a major allergen found in birch pollen, belongs to the pr-10 protein group. in our practice, some bet v 1 sensitized patients have been identified, residing in areas without this tree genus in its flora. our aim was to characterize a portuguese patient population with pr10 sensitization. method: a group of patients in whom immunocap isac ® (isac) study was performed, between january 2009 and june 2017, were analyzed. all subjects with one or more pr-10 sensitizations were selected, and their clinical records reviewed. a sequential sample of the last subjects (n = 80) who underwent isac study, was then used for comparison. results: out of 234 isac studies performed, only 16 were positive for pr-10 protein group. median age was 18.3 years, 68% (n = 11) were male. pr-10 sensitized individuals were more likely to live in portalegre district compared to the control group (7/16 vs 1/80; p < 0.001). 15 patients were positive for pr-10 family pollens (93.7%), frequently bet v 1 (n = 13), followed by aln g 1 (n = 10) and cor a 1 (n = 8). 14 out of the 16 patients were sensitized to pr-10 foods, mostly cor a 1.0401 (n = 13) and mal d 1 (n = 12). skin prick tests revealed birch as the main sensitizing pollen as well (14/ 16). moreover, only four patients were skin prick tested for fagaceae trees which were positive for oak (4), chestnut tree (3) and cork tree (1) . all patients were co-sensitized to other pollens, namely grass and all had respiratory allergy. nine patients were food allergic, although seven of them were co-sensitized to other cross reactive (ltp/profilin) or species specific proteins. conclusion: although pr-10 sensitization is known to be rare in our population, mostly alto alentejo inhabitants showed sensitization to this protein family in our sample, either by in vitro and/or in vivo methods. this phenomenon is consistent with the native plant species of this region, which should be taken into account when studying the allergic profile of these patients. in our sample, all pr-10 sensitized patients had respiratory allergy while this protein didn't seem to be relevant when it comes to food allergy. further studies are needed to characterize which plant species belonging to this protein family are more significant for our country's aerobiology context and to determine its clinical relevance. included. allergic asthma, rhinitis, conjunctivitis and eczema allergic symptoms were diagnosed. all patients were tested by immunocap with mugwort pollen extract and the natural components nart v 1, nart ar 2, nart v 3, and nart an 7. results: the positive frequency and sige levels of the four components in the artemisia allergic patients from southwestern china were significantly lower than that from the north. art v 1 and art an 7 were the highest recognized allergens, followed by art v 3 and art ar 2. patients from northern china were more likely to have abstracts | 549 asthma (50%) than patients from southwestern china (3%), and being sensitized to more than two allergens increased the risk of asthma. sensitization to art v 1, art v 3 and art an 7 played a significant role in the development of asthma. artemisia pollen allergic patients is helpful to assess the potential risk of asthma. conclusion: a small but significant part of the population react to ragweed pollen extract and are not identified as disease-positive by standard sige tests. there is a need for targeted tests towards a larger spectrum of allergen molecules. in ragweed allergic individuals, this allergy can be the main cause of overall sige levels and also of in vivo reactions (tested by spt). 1052 | molecular profile of pollen sensitization of tashkent residents with respiratory allergy background: in paediatric cohorts, a correlation between specific ige (sige) levels to house dust mite extract or allergen components and the occurrence of asthma has been shown. higher levels of sige to mite extract were associated with a higher risk of wheezing. moreover, asthmatic children recognized more allergens and had higher sige levels to nder p 1 as well as rder p 2, 5 and 23. we sought to investigate potential differences in sige levels or sensitization patterns between asthmatic and non-asthmatic patients in a mixed paediatric and adult house dust mite allergic cohort. method: total ige and specific ige against house dust mite extracts (dermatophagoides pteronyssinus and farinae) and allergen components (rder p 1, 2, 10, and 23) were determined in 190 house dust mite allergic patients. 35 patients had diagnosed asthma ("asthmatic", 54% females, mean age 27 ± 15 years, 31% younger than 18 years), whereas 155 had rhinitis (and conjunctivitis) without respiratory symptoms ("non-asthmatic", 54% females, mean age 28 ± 15 years, 29% younger than 18 years). results: total ige levels were markedly higher in asthmatic compared to non-asthmatic patients (315 vs. 144 ku/l, p = 0.022). positivity to rder p 1 (71 vs. 52%, p = 0.039) as well as rder p 10 (9 vs. 1%, p = 0.044) differed between both groups. specific ige levels to house dust mite extracts and allergen components (rder p 1, 2, 10, and 23) and positivity to rder p 2 and 23 did not differ between both groups. conclusion: in contrast to previously published data, sige levels to house dust mite extracts or allergen components were not statistically different between asthmatic and non-asthmatic patients in our mixed paediatric and adult house dust mite allergic cohort. only higher total ige levels and a higher reactivity to rder p 1 and 10 were found in asthmatic patients. however, larger studies are needed to confirm clinical relevance of these findings. results: prior treatments reported at baseline (bsl) included: 17.3% of pts were receiving 1 or more second-generation h 1 -ah at approved dose (recommended first-line), 23.9% were receiving them at increased dose (second-line); 8.5% were receiving omalizumab (third-line); 29.9% had no treatment. the majority of pts (78.2%) had uncontrolled csu (uct<12) at bsl (table) . treatment changes were most evident at the bsl visit, with an increase in pts receiving omalizumab (21.4%) and a decrease in those receiving no treatment (12.8%) vs. prior therapy. these changes were associated with improvements in rates of hives and/or angioedema, uct and qol scores at month 3, but only modest improvements thereafter (table) . a sub-analysis of 528 pts with uct<12 and who were receiving the approved (36.9%) or increased dose h 1 -ah (63.1%), revealed that few pts had recommended escalation from the approved to increased dose h 1 -ah (0.0-6.7%) or from increased dose h 1 -ah to omalizumab (0.0-11.1%) (table) . conclusion: poor physician adherence to guidelines was evident throughout aware. initial improvements in disease activity and qol plateaued after month 3, possibly owing to fewer changes to recommended therapies. greater physician adherence to guidelines is needed for better symptom control in pts with uncontrolled csu. results: we revealed that in russians urticaria is associated with rs20541*arg/gln genotype of the il13 gene (p = 0.02) and rs5743794*cc genotype of tlr6 (p = 0.0011) gene polymorphism. in tatars the association with disease development was shown for rs5743571*tt genotype of tlr1 gene snp (p = 0.0054). the rs5743794*c allele of tlr6 gene polymorphism is associated with acute and chronic forms of urticaria (p = 0.0209 and p = 0.0063, respectively) and rs2243250*c allele of il4 gene polymorphismwith acute urticaria (p = 0.0247). method: 100 csu patients from the urtica cohort (clinicalttrials.gov number: nct01940393) participated in the study. a questionnaire was carried out evaluating the triggers identified by the patients, the comorbidities and the treatments received. patients with a self-report of skin exacerbation by foods, nonsteroidal antiinflammatory drug (nsaid) or physical triggers were subjected to a controlled provocation test with the suspect food, medication or physical stimuli report by the patient. the levels of anti-tpo ige were measured during a period of clinical control and during two exacerbations in all patients. results: 30% of the patients had at less one inducible urticaria demonstrated by provocation tests (24% dermographism, 10% cold, 8% pressure). self-reported exacerbation for a food (60%) or medication (30%) were high, but positive provocation tests were low (1% and 14% respectively). 30 patients had (+) anti-tpo ige during the baseline period. among them, 60% presented a significant elevation of anti-tpo ige during at less one of the two exacerbations. 18.5% of patients (n = 13) with (−) anti-tpo ige, presented elevation of anti-tpo ige one of the two exacerbations. conclusion: foods, drugs and physical triggers must be verified by challenge tests to avoid unnecessary lifestyle restrictions in patients with csu, nevertheless self-report is usually greater than positive provocation tests. increase concentrations of anti-tpo ige seems to be implicated in urticaria exacerbations in some patients with csu. brzoza z 1 ; adamczyk k 2 ; wcislo-dziadecka d 3 ; zbiciak-nylec m 2 ; brzezinska-wcislo l 2 adipokines. the aim of the study was to evaluate the possible contribution of leptin to chronic spontaneous urticaria pathophysiology. the study included 48 chronic spontaneous urticaria patients and 41 healthy subjects. the leptin level in both examined groups was measured. results: no statistically significant difference in leptin level was determined between the studied subgroups. we are among the first to present the effects of exploration aimed at assessment of the possible role of adipokines in chronic spontaneous urticaria pathogenesis. in this study we did not prove any difference in leptin level. in our opinion it is valuable to perform further studies in this area. the microorganisms were inactivated with phenol, and the concentration was adjusted to 1 000 000 microbial cells/ml (labeled as a 1/ 1). dilutions 1/2 and 1/4 were made from the product labeled 1/1. the dot blot technique was used to detect the presence of specific ige to the different microbial antigens and controls (anti ige 1/1 and 2 fold dilution ½ and ¼). the dot blot images were processed with a documentation system (gel doc ez, bio-rad), and the different microbial antigens in different dilutions were compared with the positive anti-ige controls. results: all patients have specific anti ige to microbial antigens (see table below). the presence of microorganism-specific ige could explain, the relationship between the infections and / or microorganisms in ciu, as well, the urticaria control by omalizumab, even when it has not been detected ige sensitizations to common allergens. finally, these findings, showed that the bacterial allergy could be one line of research to understand the unresolved etiology of urticaria. background: dermographism is the most common form of inducible urticaria. it shows itself as hives made by scratching or rubbing on the surface where it has been produced and with the same morphology. the pathogenesis has not been clarified nor has it been associated until now with the sensitization to allergens. we have studied the relationship between the presence of dermographism and domestic mites sensitization. we have selected 95 patients older than 14 years old. all of them had symptoms compatible with dermographism at the moment of medical evaluation. at least one third of patients additionally showed rhinitis and/or asthma symptoms. we performed:: -skin prick tests with our basic neumoalergens (mites d. pteronyssinus y lepidoglyphus destructor, pollen, molds, dog, cat and horse dander, latex and anisakis simplex). -determination of specific ige levels for dermatophagoides pteronyssinus, lepidoglyphus destructor, and anisakis were measured in serum by using the immunocap (thermo fisher scientific). -blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram. results: blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram were normal. we divided patient in different groups. background: urticaria results from the appearance of pruritic papules and/or erythematous plaques caused by substances from mastocytes present in the skin, notably histamine. chronic urticaria is defined as flare-ups that occur at least two or three days per week over a six-week period. in addition, affected subjects are often prone to an atopic or auto-immune profile that promotes urticaria [1] . the association of polyphenols (ambora, green tea) and the soothing active ingredients slow down the itching biological process from the outset by reducing the release of pruritic mediators (e.g. histamine, cytokines, etc.) of immune cells such as mastocytes and lymphocytes, involved in urticaria. in this context, the purpose of the study was to evaluate the efficacy and the tolerance of an anti-pruritic spray containing the polyphenols and the soothing ingredient. the tested product aims to quickly calm the itching in subjects with chronic urticaria. results: on average, the product was applied 2.3 times per day with a significant decrease of 5d-pruritus scale (-35%) and sensations of itching (-58%) between d0 and d21. in terms of quality of life, a significant decrease of the skindex score was observed (-48%). the product soothed the pruritus within 60 seconds for all subjects and the anti-pruritic effect lasts at least 2 hours for 80% of subjects. the product also showed very good cosmetic properties and was well tolerated; no intolerance case was reported. showed near complete remission. in the week before omalizumab and for a few days after, her urticaria flared but on 3 of 4 weeks she was largely asymptomatic (uas7 0-5). after 3 years of successful treatment she reported an increase in csu activity. no trigger factors could be identified. add-on treatment with cyclosporine was refused, montelukast showed no, and prednisolone only transient benefit. over a period of 2 months wheals occurred almost daily and a maximal score of 42 was achieved on uas7. we replaced omalizumab with cyclosporine but this was subsequently discontinued due to side effects. 3 months later the patients' csu remained poorly controlled with up to 100 wheals occurring almost daily despite rupatadine 40 mg/d. due to the good initial response to omalizumab and lack of good treatment alternatives, a trial of re-treatment was considered. results: within 1 week of re-commencing omalizumab she once again achieved near complete remission of csu with uas7 ≤ 3 on 3 of 4 weeks. the mechanism of action of omalizumab and the development of resistance to it in csu, are incompletely understood. our case shows that some csu patients developing resistance to omalizumab may benefit from a subsequent trial of re-treatment, particularly if treatment alternatives are poorly tolerated. manipulate and store data by electronic means. this includes e-mail, sms text messaging, video chat and online social media as well as all the different computing devices that perform a wide range of communication and information functions. a rapid increase in the use icts in recent decades is an enormous contributing factor in the development of a number of novel clinical and public health intervention strategies. the aim of the present study is to assess the level of ict use and to examine patterns of preferences among patients with chronic urticaria (cu). method: we will conduct an anonymous multicentre cross-sectional study, starting from january 2018, to investigate the use of icts in patients with cu, using a questionnaire as a survey method. this questionnaire will assess the frequency of use of social media and icts in patients, and their preferences for receiving and asking disease-related information. the survey will consist of 20 items, evaluating demographical information, time with disease, medication currently used, and additional aspects of social network use. results: we will use a chi-squared test to assess the association between internet access or owning a cell or smartphone, and age, gender, type of urticaria, educational level and number of years since diagnosis. we will employ the same test to assess the association between the independent variables previously introduced and the frequency of use of each ict type (short messaging service [sms], facebook, twitter, youtube, email, internet, linkedin and skype) as well as agreement in receiving and seeking information (i.e. asking questions to the practitioner) through such icts. we will perform adjusted regression analyses between categories of age, gender, educational level, type of urticaria, years since diagnosis and the use and level of interest shown in communicating through icts. our aim is to report on remarkable findings from a registry of a large sample of patients, potentially providing clues for its approach and results: 285 patients with a median length of 14 months suffering from urticaria were registered, being 71% women; mean age 35.9 years. in 72% of patients no causal agent was identified. parasites were found in 9.3% and thyroid peroxidase antibodies in 8.9%, while autologous serum skin test was positive in 47% and igg to mycoplasma in 42% of evaluations. two thirds of patients reported wheals on uas7, with just 1/4 having concomitant angioedema. almost 2/3 reported significant affection on quality of life because of itch by cu-q2ol. just 14% of patients achieved total control on first anti-histamines provided, and less than half had good control of urticaria. cetirizine was the first choice in 44%, followed by fexofenadine (15%) and first generation anti-histamines (16%). method: cases at 18-65 years of age which were being followedup in our clinic with diagnosis of chronic urticaria and were not receiving any antihistaminic medication for last one month were included in the study. cu-q2ol, uas-7, psqi and psg results of the patients were evaluated. correlation of data with each other in regard to sleep disturbances was evaluated. results: 21 patients were included in the study. patients' mean total score in cu-q2ol was 36.25 ± 13.23. patients' mean uas-7 value was 16.71 ± 9.41. mean total psqi was 9.75 ± 3.92, the ratio of total scores ≥5 and those with poor quality of sleep was 87.5%. mean epworth sleepiness scale (ess) score was 9.71 ± 2.05, with total score ≥10 in 52.4%. in psg, mean apnea-hypopnea index (ahi) was 11.93 ± 12.6, with 44.4% of the patients having ahi ≥5. when patients having ahi<5 were compared with patients having ahi ≥5, no significant difference was determined in regard to total cu-q2ol score, mean score for questions concerning status of sleep, uas-7 and psqi. when correlation analysis was performed between cu-q2ol and total score for questions concerning status of sleep, a positive correlation was determined with psqi (p = 0.037). conclusion: it was demonstrated in our study that patients with chronic urticaria had poor quality of sleep and this disturbance was independent from ahi. omalizumab was discontinued due to absence of improvement in csu symptoms after three consecutive doses. the plasmapheresis without intravenous immunoglobulin replacement was initiated. results: the symptoms were relieved during the first procedure and the disease improved shortly thereafter. the following weeks the symptoms still occurred but with lower intensity and severity. (angioedema was gone). the second attempt with omalizumab was successful after this course (5 procedures of plasmapheresis). case report: rosacea is a chronic skin disorder associated with flushing, erythema, dryness, burning and stinging, and inflammatory papules and pustules. new treatments available or in development target the inflammatory and erythematous components of the disease. these agents include the selective alpha-2 receptor agonist brimonidine. allergic contact dermatitis to brimonidine is an unusual condition. in addition to this, urticarias due to brimonidine are rarely reported. we report on a 35-year-old woman who, immediately after apply a thin layer of brimonidine gel as preparation for a rosacea treatment on her face developed facial urticaria, which reverted in approximately four hours with systemic steroids. she had previously tolerated this product without any problems, but has not use it again ever since. skin prick-tests with brimonidine (0.03 mg/ml) and latex were realized in the patient. skin prick-tests with brimonidine were realized in eleven healthy control subjects. results: skin prick-tests with latex was negative in the patient. skin prick-tests with brimonidine were positive in the patient (9x5 mm). the prick-test with brimonidine was negative in teen healthy control subjects. we report on a case of immediate urticaria due to brimonidine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. we highlight this case because it is the only case described in the literature with a positive prick-test. method: the study was in accordance with the helsinki declaration and was previously approved by the national comity of ethics. this was a one dose study conducted on 16 fasting young healthy volunteers, of which 11 were females and five males. the mean age was 21 ± 1 years old and the body weight 61. 13 + 9.44 background: cetirizine is a potent h1-receptor antagonist indicated in the treatment of allergic rhinitis and urticaria. cetirizine is widely used due to its potent antihistaminic effects in yielding strong and fast relief of itchy sensation, sneezy and rhinorrhea and its unlikely probability to manifest anticholinergic side effects in therapeutic doses. histamine flare and wheal inhibition by anti-h1 are widely used as a standard to test and compare the effect intensity and duration. our study aimed to test these effects of cetirizine in young healthy adults. method: this was a double-blind, single dose study in healthy young adults, previously approved by the national comity of ethics. eleven females and five males with a mean age 21 ± 1 years participated in this study. histamine skin pricks were tested before and after they received a tablet of 10 mg cetirizine as previously scheduled. twenty minutes after each test flare and wheal were drawn in a transparent paper which was then scanned and measured with a software. wilcoxon signed ranks test two-sided with significance at 5% level was used to analyze the differences. claims that the preparation relieves itch within 60 seconds of its application. we performed a simple study to verify this claim. we used irp in 20 consecutive subjects, 15 males, median age 12, range 6-49 years, whose workup implied ast. their preliminary diagnoses were "asthma" (6 subjects), "allergic rhinitis" (10 subjects), "atopic dermatitis" (2 subjects) and "food allergy" (2 subjects). all of them had refrained from systemic antihistamines for at least one week. standard skin prick tests (spt) were applied as appropriate, including histamine controls to assess the level of their skin sensitivity. subjects were asked to mark their sense of itch in the area of the skin to be tested on 100 mm visual-analogue scales (vas) starting from "0"-"no itch" to "100"-"unbearable itch". vas assessments were repeated 20 minutes after ast was done; then irp was applied according to the manufacturer's instructions, and the vas assessments were repeated after 60 seconds and 20 minutes. results: there vas assessments are shown in table format: table 1 irp did not affect the wheal and flare of the histamine control, nor did it abolish positive spt. no differences were outlined between subjects with different diagnoses. the commercially available itch relieving preparation not containing defined pharmacological antihistamine is effecting in relieving itch associated with allergen skin testing. before ast (1) 4.9 ± 2.6 vs (2) p < 0. represent the first-line treatment for osteoporosis-related mastocytosis. we report a case of sm with bone pain and with an area of osteolysis in the femur as first sign and symptom. we had to consider the risk of adverse reaction when we decided to treat the patient with bp, but the patient was under antihistaminic treatment and also we made a premedication to reduce the risk. the pk/pd model available was informed by data from 12 clinical trials. the pd endpoint data was available from two studies and used to characterize the effect of bilastine on wheal and flare. moreover, food effect had been characterized in 2 pk studies and the data was used to model the effect of food in the pk of bilastine. the pk parameters relative to the fed state were then used to simulate the temporal evolution of the wheal effect using the pk/ pd model. all analyses were conducted by nonlinear mixed effect modeling (nonmem v 7.2). using the pk model developed (food effect model) and the pk/pd model already available, monte-carlo simulations for plasma concentrations and pd over time were performed for both the fed and the fasting states. results: . a reduced bioavailability (f) and a slow absorption constant characterized the pk of bilastine when administered concomitantly with food (f = 77% relative to the fasting state and ka = 0.51 hour −1 , a 3-fold reduction compared to fasting conditions). the rest of the pk parameters remained unchanged. onset of action was 1 hour for bilastine both in fed and fasted conditions. maximum wheal inhibition occurred at 3.5 hours (fasted 78% and fed 77%). from 2 to 12 hours, the percentage reduction with bilastine for both fasted and fed was between 75% and 86% after the third day of treatment. a 50% inhibition in wheal effect was maintained during 23 hours for both conditions after the third day. the results of the simulations show that even if the pk is altered with food, the pd is maintained unchanged. conclusion: even if a significant food effect was described for bilastine at a pk level, the difference is not translated directly into the pd. therefore, the antihistaminic effect of bilastine remains unaffected by the concomitant administration with food. the results of these simulations will be further confirmed in a dedicated clinical trial. results: we also found no correlation between the different tgt parameters and other clinical and analytical parameters associated with uc (table 1) results: both cetirizine products have no differences in respect to the pharmacodynamic and pharmacokinetic parameters analyzed. the 95% confidence interval of the mean ratios of the auc 0-24 , auc 0-inf , cmax, auce 0-24 , and e max , between the test and the reference, were within the bioequivalence ranges (80%-125%) in both cases. no statistical difference was revealed when comparing the respective t max and te max too. the two cetirizine products tested were bioequivalent. the bioequivalence was evident even when tested with the pharmacodynamic parameters. there is strong evidence that supports the use of histamine skin prick test for the bioequivalence evaluation of different cetirizine products. 1089 | bradykinin-mediated angioedema associated with combination of angiotensinconverting enzyme and dipeptidyl peptidase iv inhibitors: a disproportionality analysis from the who database method: we performed a disproportionality analysis using data from the who pharmacovigilance database by a case-noncase study, until the 14/12/2017. we extracted all individual cases safety reports (icsrs) included in the high level term "angioedemas", according to the medical dictionary for regulatory activities classification. given the absence of term "bma", we selected only the icsrs of angioedema without associated symptoms evoking another underlying mechanism, such as histamine angioedema (e.g. pruritus, urticaria, rash, etc.). drug class exposure was "acei" and "dpp4i", considered suspect or concomitant, using the atc classification. we results: there was no correlation between mother's disorders such as periodontitis, rhinitis, diabetes etc. and the onset of ar (p > 0.05). a multivariate analysis showed, neonatal jaundice (p < 0.001), respiratory system infection (p < 0.001), diarrhea (p < 0.001), eczema (p < 0.001) in the first 6 months of life and home environmental factors (house decoration (p < 0.001), mold environment (p < 0.001), keeping flowers (p < 0.001), passive smoking (p < 0.001)) increased the risk of ar. besides, there was no significant difference in current height and birth weight of the participants between ar and control group. however, ar group had significantly lower current weight (p = 0.003) and age (p < 0.001) compared with the control group. paternal age and maternal age in the ar group were significantly higher than the control group (p < 0.01). conclusion: diseases in the first 6 months of life and home environmental factors increased the risk of sequential ar. the older parents increased the possibility of ar in the offspring. the data of general characteristics of participants were statistic analysis by z text analysis. *significance at p < 0.05. results: anosmia was more frequent in crs than in rhinitis (28.1% vs 3.9%, p < 0.001) and in crswnp than in crssnp (40.6% vs 13.4%, p < 0.001). lms was higher in crs than in rhinitis (8 [4-15] vs 0 [0-0], p < 0.001) and in crswnp than in crssnp (10 [6-18] vs 5 [1] [2] [3] [4] [5] [6] [7] , p < 0.001). in addition, lms was associated with loss of smell in patients with hyposmia (or = 2.66 [1.27, 5.53 clinics. patients were submitted to confirmatory exams including oral provocation test with aspirin. nasal polyps were removed by functional endoscopic sinus surgery and eosinophils in this tissue were quantitated. eosinophil counts in peripheral blood was obtained. serum periostin was measured by elisa and total ige was determined using immunocap. as control groups, 12 (9f/3m) patients with par and 23 healthy subjects (14f/9m) were selected. samples of nasal tissue and blood were collected from these subjects during elective surgery for correction of anatomical variations, and compared with the patients with aerd. results: ar symptoms were significantly improved in the treatment group compared with the control group (76.6% (36/47) vs 21.7% (10/46); p < 0.05). furthermore, the mean total vas score for patients in the treatment group was reduced from 6.21 ± 1.83 before treatment to 1.36 ± 1.51 after treatment (p < 0.05). moreover, the reduction in free ige levels was greater in the treatment group than in the control group. the results of this study suggest that the chinese herbal medicine ber may be effective for improving the symptoms of ar. a multicenter clinical trial is needed to confirm this finding. results: in patients with "eosinophilic" polypoid rhinosinusitis, mucociliary transport was 35.2 ± 0.80 minutes, ph 7.4 ± 0.01, suction-88.6 ± 6.5 minutes, excretory-57.9 ± 0.9 mlg and in patients with "neutrophilic" polypous rhinosinusitis, mucociliary transport was 34.5 ± 0.65 minutes, ph 7.3 ± 0.01, suction-76.2 ± 5.0 minutes, excretory-54.9 ± 0.8 ml. the study showed that disruption of the transport function, changing the concentration of hydrogen ions method: this prospective controlled study was carried out on crs patients underwent ess. patients participating in the study were divided into two groups-group 1: partial middle turbinectomy (n = 22) and group 2: partial middle turbinectomy and middle turbinate fenestration (n = 23). objective assessment of olfactory function using the university of pennsylvania smell identification test (upsit) and subjective assessment of symptom using visual analogue score (vas) were performed before and 3 months after surgery. results: there were significant improvement comparing postoperative and preoperative upsit in both group 1 (35.23 ± 2.96 vs 32.23 ± 2.54, p = 0.000) and group 2 (36.09 ± 2.35 vs 32.04 ± 2.64, p = 0.000). the vas were also significantly improved postoperatively compared to preoperatively in both group 1 (5.77 ± 0.75 vs 6.73 ± 1.08, p = 0.000) and group 2 (5.13 ± 0.81 vs 6.78 ± 1.28, p = 0.000). patients undergoing partial middle turbinectomy and middle turbinate fenestration were more likely to show improvements in upsit (4.00 ± 1.20 vs 3.00 ± 1.11, p = 0.014) and vas (1.59 ± 0.21 vs 0.95 ± 0.15, p = 0.000) compared to those with only partial middle turbinectomy. conclusion: partial middle turbinectomy and middle turbinate fenestration during ess is an effective method for improving postoperative olfactory function. 1109 | nasal irrigation for the alleviation of nasal symptoms in pregnant women with allergic rhinitis we sought to determine specific ige responses to bacterial pathogens in sera from cystic fibrosis patients and analyze their kinetic during disease course. genes, respectively. in contrast, most of healthy donors had normal homozygous genotype with tt-60.0 ± 8.9%(n = 18) and cc-56.6 ± 9.0%(n = 17) with low frequency of mutations; gg-16.6 ± 6.8%(n = 5) and tt-23.3 ± 7.7%(n = 7) and heterozygous genotype tg-23.3 ± 7.7%(n = 7) and ct-20.0 ± 7.3%(n = 6) for il-2 and il-4 genes, respectively. following a 2 month treatment, there was a significant reduction of cytokine levels in the il2-29.5 ± 0.5 and increased in the il4-16.6 ± 0.4, when compared to the beginning of therapy and after 2 months (p < 0.001) results: at baseline the 1st group had serum levels of il-2 (43.6 ± 0.8) pg/l; il-10 (34.8 ± 0.8) pg/l and ifn-γ (108.2 ± 1.1) pg/ l; 2nd group had il-2 (39.6 ± 1.5) pg/l; il-10 (38.6 ± 1.2) pg/l and ifn-γ (103.3 ± 1.4) pg/l vs il-2 (21.6 ± 0.8) pg/l; il-10 (50.2 ± 1.2) pg/l; ifn-γ (63.8 ± 2.2) pg/l in the control group. after 2 months, there was a significant decrease in pro-inflammatory cytokine levels in the 1st (il-2: 35 ± 0.9; ifn-γ: 75.6 ± 1.9) pg/l and 2nd group (il-2: 28.6 ± 1.3; ifn-γ: 66.7 ± 3) pg/l, respectively. conversely, il-10 increased in 1st and 2nd groups to 41.9 ± 0.9 pg/l and 46.0 ± 1.7 pg/l (p < 0.05). conclusion: prior to the study initiation patients with tuberculosis had higher il-2, ifn-γ and lower il-10 content than healthy controls. two-month chemotherapy produced significant reduction in proinflammatory cytokines and increase in anti-inflammatory il-10, with levels approaching those of healthy controls. thus, tuberculosis drugs appear to have the anti-inflammatory effect in tuberculosis patients, which was predictive of positive clinical outcome. 1114 | antibiotic resistance: ligands of innate immunity take the challenge in this work, we aimed to perform an ex vivo hrsv infection in precision-cut lung slices (pcls) from human, rhesus, and cynomolgus macaques, comparing whenever possible the response with the viral surrogate poly i:c. method: pcls containing airways were prepared from lung sections of human, rhesus, and cynomolgus macaques. the slices were inoculated with hrsv-a2 10 6 iu/ml, uv-inactivated hrsv, or vehicle control for 48 hours. macaque slices were also incubated with poly i:c 100 μg/ml with and without the immunosuppressive dexamethasone 50 μg/ml. viral replication, tissue viability, and immune response assays were assessed in supernatants, lysates, or slices. the inoculum infectivity of 10 6 iu/ml as well the uv-inactivation were confirmed by plaque-assay on hep-2 cells. immunofluorescence staining using a fitc-labeled anti-rsv showed the presence of infected macrophages in pcls, but not in mock infected samples. hrsv stimulation slightly decreased tissue viability, as seen by live/dead staining and ldh assay. the viral infection increased ip-10 production in pcls of human, rhesus, and cynomolgus macaques, reaching respectively 13.3, 3.4, and 1.7 fold-increase in comparison to the vehicle controls. poly i:c stimulation caused ip-10 response comparable to hrsv in rhesus and cynomolgus pcls. the ip-10 production ratio comparing hrsv/poly i:c was 1.1 in rhesus and 0.9 in cynomolgus pcls. conclusion: hrsv infects ex vivo pcls of human and non-human primates, inducing the release of the pro-inflammatory chemokine ip-10. this response is comparable to the viral surrogate poly i:c. in the future, these systems can be used to further investigate host response to hrsv, especially in the context of asthma development. however, a relatively small number of reports are related to the association of ebv with allergic diseases, in particular atopic ones. we found that among patients with activated ebv infection, polysensitization was found to be 2.2 times more frequent, chest syndrome was 1.32 times more common and hyper-ige syndrome occurred 1.5 times more frequently. in most of these patients, atopy was not detected in medical history. method: we evaluated the laboratory test results of five boys (45.4%) and six girls (54.6%), 11 children (6 with hbov and 5 with cov). their average age at the study time was 59.2 ± 45 months. nasal swab specimens were taken from these patients who admitted to our hospital with respiratory symptoms between 2015-2016. patients are recalled after an average of 21 ± 2.5 months. isaac questionnaire and skin prick test to common inhalated allergens were performed. results: only one patient had family history of atopy. forty percent of the patients with cov and 50% of the patients with hbov developed rhinitis. one patient with cov and one patient with hbov developed recurrent wheezing. one patient with cov developed atopic dermatitis. all skin prick tests were negative. it was noteworthy that 72.7% of the patients were passive smokers. conclusion: hbov and cov may be associated with rhinitis but there is a need for more patient groups for a clear result. rna_lig (ccg-agg-aug-cga-ggc-uug-uu) . to study chemotaxis in vitro, a boyden96 chamber was used -wellfiltrationplatemultiscreentm -mic with a pore size of 8 μm (millipore, usa). chemotaxis was studied in dynamics after 10, 60 minutes and a day using the above ligands. as control, rpmi-1640 medium without glutamine was used (paneco, russia). the statistical analysis was carried out using the computer statistical program biostat2009 conclusion: with all the data provided, a drug induced hypersensitivity was diagnosed. we present a case of immediate allergic reaction with eosinophilia due to carbapenems, with tolerance to other beta-lactams antibiotics. written informed consent of patient has been obtained in the two cases. discussion: the first case shows cutaneous immediate hypersensitivity response to infbeta1a. literature reports a few cases of urticaria and anaphylaxis but this is the first for the pegylated formulation. polyethylene glycol (peg) confers to a drug modified pharmacokinetics, solubility and immunogenicity. immediate reaction to peg (macrogol) have been described when combinated in vaccines or drug pils. dmf is a known cause of contact dermatitis related to footwear, wallets and furniture. flushig is a reported side effect of dms in ms managed with dose reduction. this case shows the possibility to immediate sensitization to dmf. as the armamentarium to treat ms now combines immunomodulatory and biologic drugs, the avaliability of diagnostic and desensitization protocols for hypersensitivity reactions must be keeped in mind. case report: drug rash with eosinophilia and systemic symptoms (dress) syndrome is an uncommon but serious hypersensitivity drug reaction, manifested with rash, fever, lymphadenopathy and visceral organ involvement. table) . drug withdrawal and prednisolone treatment leaded to attenuating of mentioned skin symptoms within 2 days, associated by occurrence of a exfoliative dermatitis. one week after admission, the patient developed fever that lasted for 4 days with enlarged lymph nodes on submandibular, paracervical, axillar and inguinal regions. a preventive antibiotic therapy is started and 2 weeks later, the lymph nodes were not palpable and the skin got the normal appearance. corticoid therapy is reduced gradually according to symptoms resolvement. case 2: a 56-year old woman presented to our department with a 6-day history of pruritic, macular rash, periorbital swelling, cheilitis and fever. she had started some weeks ago the allopurinol for asymptomatic hyperuricemia, had longer history for treatment of arterial hypertension and type-2 diabetes mellitus (olmersartan, nitrendipine, methyldopa, furosemide, regular and glargine insulin), and experienced nephrectomy and cholecystectomy. the patient was febrile, while blood tests revealed eosinophilia, increased seric creatinine/urea levels (due to nefrectomy), and severely-altered liver parameters (see table) . the allopurinol withdrawal, topical and systemic corticoid therapy, and the liver protectors attenuated serologic transaminases levels and patient's skin lesions within few days, followed by substantial improvement of laboratory findings one week after therapy start. the treatment dosage was gradually tapered and finally stopped within a period of 2 months in accordance with attenuating and complete resolvement of the clinical and laboratory abnormalities. our case demonstrated that dress syndrome is a severe drug reaction, but the immediate introduction of treatment and supportive measures can improve disease's outcome even after a temporary exacerbation or severe affection of internal organs. case report: a 40-years-old woman, diagnosed of ischemic cardiopathy, developed an anaphylactic shock 5 minutes after the administration of 2 ml sulphur hexafluoride intravenous during an echocardiogram. she was treated in emergency room with a total recovery. 2 months earlier, she had developed an extensive erythematous-maculopapular rash converging in plaques in relation with adhesive dressings which had been placed during a hospitalization due to thoracic pain. an allergic contact dermatitis was suspected and recommendations thereon were given. interestingly, an arteriogram with iodixanol (icm) was carried out one week before skin reaction with good immediate tolerance. methods: blood test: blood count and serum chemistry were done during both reactions to contrast media. serum tryptase level was not measured during the anaphylaxis, but its baseline level was quantified later. conclusions: we present a patient with a double sensitization to parenteral contrast media: an anaphylactic shock due to sulphur hexafluoride and an atypical delayed exanthema related to iodixanol, and diagnose was obtained with st in both cases. this is the first documented case with a positive immediate st to sulphur hexafluoride. with the culprit drugs mixed with 10% and 30% petrolatum resulted negative. patient was suspected to have behcet's disease, and consulted to rheumatology department. oral colchicum dispert twice a day was prescribed. afterwards, patient achieved to take oral amoxicillin-clavulanate for a week without any hypersensitivity; and has been following by oral colchicum dispert maintenance therapy since then. the reported patient had one anaphylactic perioperative reaction to morphine and another anaphylactic reaction to tramadol during her diagnostic investigation. remain the question if this patient had two allergic anaphylactic reactions with cross-reaction between morphine and tramadol, or two non-allergic anaphylaxis due to "hypersensitive" mast cells. case presentation: a 61-year-old female was diagnosed with rectal adenocarcinoma. one year after radical surgery, progression with pulmonary metastasis was shown. in first line of systemic therapy she received premedication with pantoprazole, metoclopramide, clemastine and dexamethasone, followed by cetuximab infusion. during first minutes of infusion, grade 4 anaphylactic reaction occurred. a reaction started with generalized pruritus, urticaria, rhinitis, followed by hypotension, bradycardia and loss of consciousness. she was treated with fluids, clemastine and methylprednisolone. next day she received same premedication followed by panitumumab. during first 30 minutes she had grade 1 reaction with generalized urticaria. the third day she had generalized urticaria 10 minutes after metoclopramide application. skin prick tests with cetuximab (5 mg/ml) were negative, but intradermal test were posibat response was highly positive for both cetuximab and alpha-gal, with comparable values and dose response curves. thus, we showed 70%, 63%, 58%, 35% and 4% of cd63 positive basophils for stimulation with cetuximab (500-0.1 μg/ml), and 67%, 40%, 17%, and 1% for stimulation with alpha-gal (33.3-0.033 ng/ml). bat response to panitumumab was negative (<5%; 500-0.1 μg/ml). drug provocation with panitumumab was negative and patient received treatment with panitumumab. in the operating theatre, the skin is disinfected using povidoneiodine and pupil dilation is carried out with tropicamide (showing no immediate reaction in the surgery). method: as we are dealing with a late cutaneous reaction, the study of the medicine involved is carried out by means of epicutaneous medicine testing. in order to do the study of aflibercept, we wore gowns, two sets of gloves, a mask, eye protection and in a containment hood in the outpatients hospital. the patient diagnosed himself with dermatitis when in contact with povidone-iodine and despite the fact that the cutaneous provocation was negative, it is known that when there is surgery involved, there needs to be moistness and occlusion for it to show up clinically. the application of this antiseptic seems to lose its irritation and allergic properties when it dries on the skin and therefore tends to give a negative result in these patients, but this does not mean that they are not allergic to this antiseptic. we report the case of a 60 year old man who experienced erythema and pruritus immediately after an intravenous injection of ranitidine and hyoscine butylbromide given for gastric pain treatment. results: spt and idt were performed for ranitidine (10 mg/ml and 0.01 mg/ml respectively) and hyoscine butylbromide (0.5 mg/ml and 0.005 mg/ml respectively) being exclusively positive for ranitidine at idt dose with a 15 × 25 mm papule (histamine control 23 × 35 mm). oral provocation test for hyoscine butylbromide was negative. bat for ranitidine and famotidine were carried out, being negative for both drugs. conclusion: skin tests for h2ra are the best option when studying a suspected reaction to h2ra and are also useful for assessing cross-reactivity between other h2ra. the sensitivity for bat in diagnosis of drug allergy is about 50%, and the specificity up to 93%, although these percentages make reference to the common drugs studied (beta-lactams, quinolones, pyrazolones, etc). specific studies for h2ra are still to be done. in our case we had a negative result for the bat test, although we proved ranitidine was responsible for the reaction. conclusion: gentamicin is an aminoglycoside antibiotic used systemically for septicemia and as prophylaxis during surgery. immediate type allergy (type i) to gentamicin is rarely reported. since 2016, approximately only five cases have been reported in literature. in our case, initial theories were pointed towards cefazolin as beta-lactams report a higher rate of allergic reactions. after an exhaustive allergological study, results disproved our initial theory indicating gentamicin as the responsible drug. giangrande n 1 ; bobadilla-gonzález p 1 ; garcía-menaya jm 1 ; cámara-hijón c 2 1 allergy department, infanta cristina university hospital, badajoz, spain; 2 clinical immunology department, san pedro de alcántara hospital, cáceres, spain background: polyethylene glycol (otherwise known as macrogol or peg) is a polymer with a wide application as an excipient, solvent and dispersing agent in food, cosmetic and pharmaceutical industry. it presents distinct length polymer chains with a molecular weight from 200 to 10 000 000 g/mol conferring them specific properties. macroglol with a molecular mass between 3500 and 4000 g/mol is commonly used as osmotic laxative previously to colon endoscopy and radiologic examinations. after the introduction, anaphylactic reactions to macroglol are rarely reported, considering it safe and well tolerated. we report on a 56-year-old man who, immediately after of the topical application of benzindamine in left inferior limb developed acute urticaria in this limb, which reverted in approximately 2 hours with systemic steroids. she had previously tolerated this product without any problems. skin prick-tests with benzindamine (0.06 mg/ml) and latex were realized in the patient. skin prick-tests with benzindamine were realized in eleven healthy control subjects. results: skin prick-test with latex was negative in the patient. skin prick-test with benzindamine was positive in the patient (6 × 5 mm). the prick-tests with benzindamine were negative in eleven healthy control subjects. we report on a case of contact urticaria due to benzindamine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. some of the drug used in daily clinical practice can cause allergic contact urticaria and should therefore be borne in mind. background: the use of new oral anticoagulants which act as direct inhibitors of activated factor x is constantly increasing, due to lower rates of serious and fatal bleeding events than warfarin/acenocoumarol. rivaroxaban, the first commercialized drug in this group, is the most used for prevention of thromboembolic events. however, <10 cases of hypersensitivity reactions have been described so far, most of them delayed and severe. to present a case of delayed hypersensitivity to rivaroxaban, diagnosed by a positive ltt (lymphoblastic transformation test). a 79 year old woman with hypertension and chronic atrial fibrillation (af) was referred to our clinic for suspected drug allergy. she reported that 2 months before, for af she was started on oral amiodarone and rivaroxaban, presenting on the seventh day with both of them generalized erythema, pruritus, micropapular rash and facial angioedema. no oral or other mucosal were observed, neither pustules, vesicles or blisters. blood eosinophilia, enlarged lymph nodes, renal and hepatic injury were discarded in emergency, where the new drugs were discontinued and replaced by acenocoumarol. the rash subsided one week later, with oral antihistamines. before and after the episode the patient also has been taking losartan and hydrosalurethyl, with good tolerance. she denied other adverse reactions. in allergy department we performed skin prick tests and intradermal tests with amiodarone (0.05 mg/ml and 0.5 mg/ml) and rivaroxaban (0.1 mg/ml and 1 mg/ml), and a ltt with both drugs, 3 months after the reaction. background: patients with history of beta lactam allergy, often self-reported, are commonly encountered in the hospital setting. this frequently leads to increase use of broad spectrum and more expensive antibiotics that may be unnecessary or even less efficacious at times due to fear and concerns about potential disastrous outcomes. nonetheless, with increasing awareness, many patients are now being referred to allergy service for formal evaluation. we aim to look at patients who underwent evaluation for beta-lactam hypersensitivity and determine the number of patients that were successfully de-labelled. method: a retrospective analysis was conducted with patients referred for evaluation of questionable beta-lactam allergy to the allergy service in our institution from the years 2016-2017. initial evaluation process included a thorough history to determine the type of hypersensitivity reaction and suitability for further testing. patients underwent skin prick test (spt) and intradermal (idt) with either (a) both major and minor determinants of penicillin, benzyl penicillin, amoxicillin and ampicillin, and/or (b) the culprit drug itself. if skin testing was negative, oral or intravenous (iv) drug challenge was then performed after informed consent. clinical details and reactions were documented. patients were also contacted post challenge to ensure no delayed reaction had occurred. results: a total of 130 patients were evaluated for beta-lactam allergy in the 2 year period, of these 80 were females and 50 were males. 107 of the referred patients had presumed penicillin group allergy and 29 had cephalosporin group allergy (3 patients had both penicillin group+cephalosporin allergy). 95 cases (73%) were successfully de-labelled. beta-lactam allergy was confirmed in 26 patients (20%); identified by positive spt in two patients, positive idt in six patients and positive drug challenge in 18 patients (15 patients developed rash/urticaria, 1 had respiratory symptom and 2 patients developed anaphylaxis). 14 patients were referred before any drug allergy labelling was done, out of which 10 were confirmed not to have beta-lactam allergy. conclusion: in our study, 80% of patients were confirmed not to have true beta-lactam allergy. we were able to successfully remove beta-lactam allergy label from the electronic record for 73% of the patients. results: a total of 66% referred amoxicillin-clavulanic acid (ax-clv) as trigger for the hypersensitivity reactions (hrs), followed by ax (21%), penicillin (6%) and cephalosporins (5%). almost 80% of hrs were immediate (<60 minutes). positivity of skin tests was observed in 65% subjects, of bat in 61% and of rast in 68%. in conclusion: the label of penicillin allergy is quite often erroneous. this involves using of more expensive and less effective therapeutic alternatives, which also facilitate the emergence of multi-resistant micro-organisms. hence the importance of confirming the diagnosis of allergy. finally, we did not find differences in the study of penicillin allergy in patients older than 60 years compared with the general population. background: severe cutaneous delayed drug reactions (toxic epidermal necrolysis -ten-, stevens-johnson syndrome -sjs-, acute generalized exanthematous pustulosis -agepand drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome -dress/dihs-) among others, are a rare but potentially fatal complications of drug treatment. although its epidemiology has been described in different latitudes, it is unknown in latin america. our aim was to describe the epidemiological characteristics of severe cutaneous reactions to drugs in countries of latin america. method: an online questionnaire was designed to report new and old cases (since 2013). it was a modified and adapted version of enda questionnaire for drug allergy interesting group. sociodemographic data, type of reaction (ten, sjs, dress-dihs, agep), culprit drug (s), treatment, complications, mortality and sequelae, were described. three centers from colombia, one from argentina, one from brazil and one from paraguay were included. an excel database was created, in which cases were recorded and analyzed. results: thirty seven cases were reported. 24 (65%) were women. the median age was 47 years. 19 (51%) had dress/dihs, 6 (16%) ten, 3 (8%) sjs, 3 (8%) agep, 3 (8%) other not classified scars, and 1 (2.7%) overlapping ten/sjs. the main culprit drugs were aromatic anticonvulsants in 17 cases (46%), beta lactam antibiotics in 6 (16%), non-beta lactam antibiotics in 3 (8%) and allopurinol in 2 (5.4%). in 100% of the patients the suspect drug was withdrawn. thirty one patients (83.7%) received systemic corticosteroids. complications occurred in 17 cases (49%) and death in one patient (2.7%). seven patients (19%) had some type of sequelae. countries, dress/dihs was the most frequently reported clinical entity, and the anticonvulsants were the main triggers. complications were frequent, but mortality was low. 1155 | drug-induced cough: analysis of nationwide spontaneous reports in korea over ten years using who-adverse reaction terminology (who-art) indicative of cough. results: from 856 524 cases of spontaneously reported adverse drug event cases, a total of 9003 cases (4.5%) were identified as drug-induced cough. most cases occurred in adults (93.4% of the subjects) and females were more common than males (54.9% vs 45.1%). regarding severity, only 629 cases (7.0%) were classified as serious based on who criteria. the most common causative drug category was antineoplastic and immunomodulating agents (24.8%), followed by cardiovascular drugs (24.2%). the most common causative drugs were ace inhibitors including perindopril and ramipril. conclusion: in the nationwide spontaneous reports of adverse drug events, many cases of drug-induced cough have been reported so far. much attention is needed to find new causative drugs of cough in the future. background: allergological assessment to determine the mechanism of the perioperative reaction and to identify the agent responsible and recommendation of a range of drugs or agents likely for future surgery is essential, but it often poses a significant challenge. in this study, we analyze our experience in the investigation of adverse reactions during anesthesia in the last 4 years. method: a total of 15 patients who attended our allergy unit with suspected perioperative reactions between january 2014 and december 2017 were reviewed retrospectively. the severity of the perioperative allergic reactions was graded according to ring and messmer system. results: grade iii, ii and i reactions were observed in 9, 1 and 3 patients, respectively. in 2 patient we didn't know the reaction suffered. tryptase measurements were available for 11 patients. of those, 3 and 4 patients had elevated and normal levels respectively and suffered grade 3 reaction. ige mediated reactions was diagnosed in 9 patients (60%): 3 for ßlactam antibiotics (33.3%), 2 for patent blue (22.2%), 1 for neuromuscular blocking agents-nmbas (11.1%), 1 for latex (11.1%), 1 for colloids (11.1%) and 1 for ranitidine (11.1%) . cefazolin was the ß-lactam antibiotics causing the largest number of reactions. non-ige-mediated reactions was diagnosed in 6 patients (40%). the allergy tests were negative and tryptase levels were normal. conclusion: in our series, among the 9 patients who suffered allergy reactions during anaesthesia and the cause was subsequently identified, ß-lactam antibiotics were the most common causative agent (33.3%), followed by patent blue (22.2%), nmbas, latex, colloids and ranitidine (11.1% each agent). in contrast, data from other authors indicated that nmbas were the most common cause of anaphylaxis, followed by latex, hypnotics, antibiotics, plasma substitutes and opioids. these differences might be due to the small size of our study, which was limited to our centre over the last 4 years and thus may not be representative. diagnostic evaluation. all patients signed an informed consent. we made a retrospective analysis of their clinical records and excluded 11 patients whose records were missing or incomplete. it was analyzed each patient's medical history (focusing allergic disease) and clinical reaction to the suspect drugs. signals/symptoms at pcc were characterized. we also studied the variation of the dpt's results when it was performed after a pcc. aim: to define and quantify the ongoing pharmacy needs in sustaining a large drug allergy assessment program. method: a retrospective review of pharmacy files was used to identify and quantify the drugs and dosages most frequently used and to determine prescription trends within the allergy testing program over the last 3 years. results: initially, this reaction was thought to be a result of a drug allergy, but upon further review and the onset of fever, we determined that it met the diagnostic criteria of jhr. his twin brother was diagnosed with penicillin and betalactamic allergy. neutrophilia 83% was to be underlined in the blood test. after this, drug oral challenge with penicillin was performed, ruling out penicillin allergy. conclusion: it is not uncommon to confuse drug allergy with jhr. jhr should be an anticipated reaction to early doses of antibiotic treatment for treponemal diseases, such as syphilis. antibiotic treatment should be continued; it is not a warrant to stop treatment. clinicians should be aware and anticipate jhr as a potential complication to early doses of antibiotic for spirochetal diseases such as syphilis or lyme, leptospirosis. the patient was unresponsive in oral drug provocation tests with amoxicillin-clavulanic acid, clarithromycin and trimethoprim sulfamethoxazole for 6 months. the patient could use these drugs. results: chronic abacterial inflammation of the prostate gland was accompanied by a significant increase in concentration of slpi, il-8, tnf-α, il-17 in the seminal plasma and serum concentration, and a decrease in the concentration of il-6 and tgf-β1 compared to healthy men (p < 0.05). there was no statistically significant difference between slpi, il-8, tnf-α, il-23, il-17, and tgf-β1 in the ejaculate of patients with inflammatory and non-inflammatory forms of cap (p < 0.05). the concentration of il-6 in ejaculate of patients with inflammatory forms of cap was significantly greater than in patients with non-inflammatory form of cap (p = 0.01). the inflammatory and non-inflammatory forms of cap are pathologically similar with changes in the concentration of the studied cytokines except for il-6 in both forms with signs of inflammation. the terms "leukocytic" vs "non-leukocytic" chronic abacterial prostatitis are more correct than "inflammatory" and "non-inflammatory" when describing chronic abacterial prostatitis. results: the status of all patients after dc immunotherapy was evaluated as satisfactory. heart rate, blood pressure in patients remained within the age norm. skin had normal color without rash or peripheral edema. there were no local or systemic allergic reactions. the body temperature after the injection did not exceed 37°c. conclusion: these results show, for the first time, that among mastocytosis patients, besides the already known periodontal disease risk factors that include diabetes, age, osteoporosis and alcohol consumption, the bone marrow mast cell burden is also associated with increased periodontal disease severity. results: metformin at relatively low doses (1-10 μm) was shown to mildly suppress ige-mediated responses, including degranulation (34% reduction, p = 0.0135), tnf-α (23% reduction, p = 0.0139) and il-13 (38% reduction, p = 0.0015) secretions in bmmcs. importantly, metformin at the same doses potently inhibited mast cell responses in all parameters (100% reduction, p < 0.0001 for degranulation; 87% reduction, p < 0.0001 for tnf-α; 90% reduction, p < 0.0001 for il-13) in mast cells treated with an ahr ligand, 5,11-dihydroindolo[3,2-b]carbazole-6-carbaldehyde (ficz). mechanistically, its inhibitory effect was mediated through the suppression of ficz-induced mapk activation, intracellular calcium release and ros generation. metformin also blocked ahr-mediated pca in vivo (90% reduction, p < 0.0001). conclusion: metformin, a common anti-diabetic agent, was shown to exert inhibitory effect on ahr-mediated mast cell activation in vitro and in vivo, suggesting its potential utility as a newer form of therapy for asthma and allergic diseases; this is particularly relevant when considering the adverse effect of the exposure to environmental polycyclic aromatic hydrocarbons. gasser p 1 ; brigger d 1 ; zbären n 1 ; jardetzky t 2 ; pennington l 2 ; eggel a 1 results: in one of affected family members, we were able to identify the c.9886a>g mutation in the plasminogen (plg) gene that was recently described to be associated with hereditary angioedema. this mutation leads to a missense mutation with an amino acid exchange p.lys330glu in the 3rd kringle domain of plasminogen. there is no direct relationship between the earlier described cases with this mutation and the family we report here. in all affected members of the family, the symptoms manifested in early adulthood, with swelling of the face, the tongue and the larynx. the frequency of attacks was variable, between once in a year to once in a month. in one of the three family members, we found a slightly decreased level of coagulation factor xii and of plasminogen. icatibant proved to be very effective for the treatment of acute attacks in the affected family. the occurrence of the same c.9886a>g (p.lys330glu) mutation in the plg gene in many families with no or only unknown distant relationship suggests that the disease might have been inherited through the generations without being purged from the population. the mutated amino acid exchange appears to be significant for the function of plasmin or plasminogen. we found a decrease in plasma levels of coagulation factor xii and plasminogen, which may be beneficial markers for diagnosis and monitoring of this disease. several biomarkers are useful in the diagnosis (fibrin degradation products (fdps), d dimer (dd), and fragments of prothrombin 1 + 2). also, a correlation between the levels of biomarkers and activity phases of the disease has been detected. alterations in coagulation parameters have an etiopathogenic role in the ae attack, but have not been considered as biomarkers of activity phases. tgt is a global coagulation test which quantifies in vitro the ability of plasma to generate thrombin and estimates alterations in coagulation parameters. the objective is to assess the usefulness of the thrombin generation test (tgt) to characterize patients with hereditary angioedema (hae). method: seventeen hae patients from hospital la fe were recruited to obtain blood samples in remission and during ae attacks. none of them experienced thromboembolic events. plasma was collected in citrate tubes to obtain platelet rich plasma. hemostatic parameters were analyzed:. tgt was conducted using a calibrated automated thrombogram (cat) method and a fluoroskan ascent as a reader. results were analyzed via thrombinoscope v5. citrated plasma was incubated with calcium, tissue factor, phospholipids and a fluorogenic substrate. a thrombin generation curve is generated, obtaining parameters: latency time (lagtime), thrombin generation maximum speed (vo), maximum peak of thrombin generated (peak), time to generate the maximum peak of thrombin (ttpeak), total quantity of generated thrombin (etp), and the end time of thrombin generation (starttail). tgt parameters from 322 healthy donors were used as controls. results: thirty-eight samples were collected from seventeen hae patients (58.8% female). fifteen (39.5%) samples were collected during ae attacks. tgt parameters and fdps were significantly higher in hae patients compared with controls (p < 0.0001), although no significant differences were found in tgt between acute attacks and remission. a decrease trend in tgt is observed in ae attacks. fdps were increased during ae attacks, but normalized at remission periods. these results support the involvement of coagulation in the pathophysiology of hae, although no increase in prevalence of thrombosis is observed during acute attacks. method: the repeated measures design study included 108 patients in two groups: the slit group, 63 patients-67 follow-ups per allergen (p), and the vit group, 45 patients-54 p. the slit group had patients treated for hdm (41 p), and patients on pre-coseasonal pollen ait (grass 11 p, ragweed 10 p, birch 5 p). the vit group had 28 patients on rush protocol (18 for bee and 9 for wasp) and 18 patients on conventional protocol (9 bee, 2 wasp, and 7 for both). the ige and igg4 levels were measured by the immunocap method. the friedman test was used to compare data. results: when compared to placebo group, slit+vitamin d group therapy was more effective in the reduction of nasal symptoms (p = 0.04), asthma symptoms (p = 0.001) and combined symptommedication score (p = 0.001); there was no significant difference between groups in medication and ocular scores. we observed a significant improvement of fev1 (vitamin d group p = 0.014, placebo group p = 0.015) and fev1%vc levels (vitamin d group p = 0.004, placebo group p < 0.001), within both groups, between visits. feno results did not differentiate statistically significantly the study participants in terms of receiving slit along with vitamin d or placebo. significant increase in the percentage of cd4 + cd25 + foxp3 + and in tlr positive cells in children receiving slit+ vitamin d was observed compared to placebo group. increase in cd4 + cd25 + fox-p3 + induction, and in tlr positive cells recruitment were independently associated with better clinical effect of slit in children. conclusion: overall, ait with a high-polymerized ash pollen extract was well tolerated. as ash pollen are supposed to be an important allergen during spring time, it is recommended to include spt and npt with ash pollen in the test panel for allergological diagnostic. additionally, determination of ash pollen specific ige could be applied. furthermore, appropriate ait should be considered for ash pollen allergic patients. 1194a | impact of sublingual immunotherapy with a five-grass pollen tablet on grass pollen allergic rhinitis and asthma: a real-life, long-term analysis in france background: data on the fulfilment of prescriptions of symptomatic medications in patients with grass pollen allergy were analysed to evaluate the long-term effectiveness of sublingual immunotherapy (slit) on allergic rhinitis (ar) and asthma. method: by using data in the lifelink ™ treatment dynamics database (iqvia, paris, france), we compared two cohorts of patients with ar: a group treated with oralair® (stallergenes greer, antony, france) slit tablets (n = 617), and a matched control group having received symptomatic medications only (n = 10 990). oralair®'s effectiveness was assessed as the change in symptomatic medication fulfilments between the pre-index period (before the initiation of slit) and the follow-up period (after slit), and as the onset of asthma or the progression of pre-existing asthma (based on fulfilments of prescriptions for asthma medication). the number of fulfilments per year was calculated for each patient and each period. results: in line with prescribing guidelines, the mean duration of treatment with oralair® was 6.3 months per season for either 2 seasons or 3 seasons. the mean number of symptomatic medications for ar fulfilled per patient and per year in the pre-index period was 6.7 ± 5.9 in the slit tablet group and 9.6 ± 7.7 in the control group. in the follow-up period, this value fell for the slit tablet group (to 2.6 ± 4.2) but did not change significantly in the control group (8.6 ± 8.1). when considering individuals not taking any asthma medications in the pre-index period, asthma onset during the treatment period was observed in 12.1% of those in the slit tablet group and in 15.8% of those in the control group. the corresponding values for the follow-up period were 1.2% in the slit tablet group and 5.8% in the control group. when considering individuals already taking asthma medications in the pre-index period, the mean ± sd number of asthma medication fulfilments in the pre-index period was lower in the slit tablet group (4.7 ± 4.6) than in the control group (8.1 ± 7.9). the corresponding values for the treatment period were 4.1 ± 5.4 and 10.2 ± 9.5, respectively. in the follow-up period, the number of asthma medication fulfilments fell more in the slit tablet group (to 2.3 ± 4.1) than in the control group (7.2 ± 9.0). oralair® tablets have long-term effectiveness by relieving allergic rhinitis and slowing a progression to asthma. 1194b | a real-life, retrospective analysis evidencing slower long-term progression of asthma in grass pollen allergy patients treated with sublingual immunotherapy tablets 1195 | an examination of the reasons for treatment discontinuation and non-compliance to allergen immunotherapy background: allergic rhinitis (ar) patients treated with subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) may be non-compliant or discontinue treatment too early, which can negatively impact efficacy. therefore, understanding the reasons for non-compliance and treatment discontinuation is vital to help improve compliance, persistence and thus outcomes. this study reported reasons for treatment discontinuation to scit and slit and non-compliance to slit in patients with ar in published real-world studies. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit (1998-2017) using key search terms for allergic rhinitis, scit, slit, non-compliance and non-persistence. across all studies,~20% of patients were non-compliant, and 1-year drop-out rates ranged from 23% to 74%. reasons for noncompliance and treatment discontinuation in this subset of patients were stratified according to the who dimensions for adherence (patient-related, treatment-related, or socio-economic). results: from the 428 publications identified, six studies reported reasons for non-compliance to slit (n = 3) or treatment discontinuation (n = 3) to scit or slit, and the results were grouped for analysis. the majority of patients cited treatment-related factors as the primary reason for discontinuation (66% for slit, 50% for scit). common reasons were a length of treatment for slit and frequency of injections for scit. 45% of patients discontinued scit due to patient-related factors such as travel to doctors and waiting time for administration. only 24% of slit patients discontinued due to patient-related factors. socio-economic reasons for discontinuation were low for both therapies (10% slit and 5% scit). conversely, for non-compliance to slit, socio-economic factors were the most frequently cited reasons (50%), and included taking time off work and financial concerns. conclusion: of patients who discontinued therapy, treatmentrelated factors were the most cited reasons for scit and slit, reflecting concerns with administration and treatment length. noncompliant slit patients cited socio-economic factors as common reasons for non-compliance, suggesting financial concerns over a long treatment course. differences in reasons for non-compliance and treatment discontinuation may be due to patients assigning differing importance for compliance (a day-to-day decision) compared to the long-term decision to discontinue treatment. results: 53% of patients had monosensitization to rbet v1 component. the rest 47% had combinations ige to rbet v1 and ige to one, two or even three minor allergens (35%, 10%, 2% accordingly). after 2 courses of slit by standardized pollen extracts symptoms of arc and pfas decreased in 90% and 63% patients accordingly. in group 54 patients with monosensitization to rbet v1: 49 patients had a reduction of arc (85% had 3-4 degree by ado); 41 patients had reduction of pfas. 3 patients hadn't finished treatment due to allergic reactions. among 26 patients with sensitization to rbet v1/v6: 24 patients had a reduction of arc (75% -3 to 4 degree by ado); 17 had reduction of pfas. 1 patient hadn't finished treatment due to allergic reactions. in 9 patients with sensitization to rbet v1/v2: 7 patients had a reduction of arc (57% -3 to 4 degree by ado); 3 had reduction of pfas. 10 patients with sensitization to rbet v1/v2/v6 showed the similar results: 10 patients had a reduction of arc (57% -3 to 4 degree by ado); 3 had reduction of pfas. 2 patients had sensitization to all cra, and only 1 patient who also received slit with grass allergens had reduction of arc only (2 degree by ado). as the result of the study it was identified that beneficial effect of slit is highest in patients with monosensitization to rbet v1. the increase of sige sensitization profiles to minor birch allergens caused less efficacy of slit treatment. dermatophagoides pteronyssinus immunotherapy is independent of sensitization to blomia tropicalis among children with allergic rhinitis and asthma method: 95 children (5-17 years old) with allergic rhinitis and asthma sensitised to both dp and bt received 3 years dp-scit. clinical symptom and medication scores, serum specific ige and specific igg 4 were evaluated during dp-scit. in order to investigate whether the treatment outcome was dependent on the sensitisation pattern between dp and bt, patients were further grouped into dp and bt co-sensitisation and cross-reaction, according to positive or negative ige against bt major allergen (btma) blo t 5 and blo t 21. btma+ group, with specific ige to either blo t 5 or blo t 21, was defined as the co-sensitized group; btma-group, with no detectable ige to both blo t 5 and blo t 21, was defined as the cross-reactive group in this study. results: all the recruited 95 patients completed 1 year of dp-scit, 74 (78%) patients completed 3 years of treatment. after 3 years of dp-scit, compared to baseline, all patients had significant reduction in symptom and medication scores. lung function (fev 1 ) was significantly improved as well. 65% of the patients were free of medication use and asthma symptoms, 3% of them were free of rhinitis symptom, and the fev 1 % in all patients were higher than 95% of predicted. dp-scit induced significant increases in dp and bt specific igg 4 . in 50% of patients, dp specific igg 4 increased more than 67 fold and bt specific igg 4 increased more than 2.5 fold. further investigation in btma groups showed moderate correlation (spearman r = 0.48, p = 0.004) between specific ige against dp and bt in the btma-group (n = 34), indicating specific ige cross-reactivity. no specific ige correlation (spearman r = 0.03, p = 0.82) was found in the btma+ group (n = 61) indicating co-sensitisation to both dp and bt. the two groups showed almost identical change in clinical responses. dp and bt specific igg4 significantly increased during dp-scit, no difference was found between the two btma groups. conclusion: dp-scit can induce specific igg4 cross-reacting with bt allergens. patients with specific ige sensitisations to both dp and bt may have clinical benefit from dp-scit treatment. moreover, the clinical benefit of scit was independent of ige cross-reactivity or co-sensitisation to dp and bt. method: we investigated 16 allergic rhinitis children who were basically sensitized to house dust mite and received house dust mite slit for 1 year and 6 months. among 16 patients, 9 patients were mono-sensitized to house dust mite (group 1) and 7 patients were poly-sensitized aside from house dust mite (group 2). we also assigned another 7 allergic rhinitis children who were only treated by medication as control group. nasal symptoms (rhinorrhea, sneezing, nasal obstruction, nasal itching, sleep disturbance) and anti-allergic medications use were assessed at every 6-month visit. results: the symptoms of allergic rhinitis started to improve after 6 months of slit and significantly improved after a year and a half in group 1 and group 2 compared with control group. there was no significant difference between group 1 and group 2. anti-allergic medication use in group 1 and group 2 significantly decreased after a year and a half compared with control group and there was no significant difference between group 1 and group 2. conclusion: house dust mite slit was more effective than treatment only by medication. the effect of house dust mite slit was similar between mono-sensitized and poly-sensitized allergic rhinitis children. house dust mite slit could also be recommended to polysensitized allergic rhinitis children. method: a prospective, randomized, double-blind, controlled, multicenter phase ii study was conducted with four different concentrations of cluster allergoid clustoid wiesenlieschgras (group 1: 2000 tu/ml; group 2: 10 000 tu/ml; group 2: 30 000 tu/ml; group 4: 50 000 tu/ml). out of 103 patients screened, 83 grass pollen allergic patients (18-59 years) were randomized. the cluster build-up phase was followed by four monthly maintenance injections of 0.5 ml. the efficacy was evaluated by the change of the threshold concentration step needed to induce a positive reaction in a titrated nasal provocation test (tnpt) before start and after end of the study (pre-post analysis). the safety profile was assessed for each treatment group by analyzing treatment-related adverse events. background: allergen immunotherapy relies on the consistent administration of allergen extract, therefore compliance to these treatments (subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) tablets and drops) is vital for efficacy. as scit is administered as an injection by a healthcare professional, and slit is self-administered, compliance to scit may be perceived as superior. therefore, a review of real-world studies investigating compliance to scit, slit-tablets or slit-drops was conducted. real-world studies, instead of clinical trials, were included in this review as they are more likely to reflect actual clinical practice and patient compliance. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit (1998-2017) using key search terms for ar, scit, slit-tablets and slit-drops, and real-world compliance. compliance was reported according to ispor medication compliance and persistence work group definitions. results: from the 428 publications identified, eight studies (seven slit [one slit-tablets, two slit-drops, four unspecified], one both scit+slit-tablets) reported compliance rates and were included in the analysis. real-world compliance rates ranged from 80% to 81% for slit administration and 83% for scit administration. only one study compared compliance of slit to scit, with similar rates reported over three years (81% and 83% respectively). three studies reported "good" compliance (physician-reported or patients consuming >60% of allergen extract) to slit-drops or slit-tablets. the good compliance rates were higher for slit-drops (90%-99%) compared to slit-tablets (77%-80%). observed compliance to slit-drops or slittablets did not vary by country or geographical region. the percentage of patients defined as having "good" compliance to slit-tablets or slit-drops did not vary by study length or patient population. conclusion: whilst compliance to scit may be perceived as superior to slit-tablets and slit-drops, comparable compliance rates between scit, slit-tables and slit-drops were identified across real-world studies. differences between perception and real-world results may be explained by a lack of direct comparisons between scit and slit administration. limitations included discrepancies in definitions of compliance, as well as methodology between studies. however, these are common to reviews analysing compliance, regardless of therapy area. conclusion: in the allergic rhinitis patients, successful compliance for 3-year slit compared with control was approximately 52%. method: igg inhibition elisa: rabbit igg antibodies specific for grass allergen allergoids are pre-incubated with different concentrations of alum-adsorbed grass pollen allergoid. the mix is added to an allergoid coated microtiter plate. unbound igg will bind to the allergoid coat and is subsequently incubated with anti-igg hrp labeled conjugate and stained with tmb. results are expressed as percentage inhibition relative to the uninhibited value. the concentration of alum-adsorbed allergoid that is required to inhibit 50% igg is used as read-out. circular dichroism: far-uv cd spectra (190-260 nm) were recorded on a j-815 spectropolarimeter. a cuvette with a stirring compartment was used to keep the suspension homogeneous during measurement. results: the igg inhibition elisa assay is specific for grass pollen allergoids (not for other allergen allergoids), has a good inter-and intra-assay precision and is robust for assay variation. thermally stressed alum-adsorbed grass pollen allergoids were used to show that the igg inhibition assay can be used as a stability indicating method. severe thermal stressing resulted in a higher 50% inhibition value, indicating a loss of igg epitopes. furthermore, far-uv cd analyses showed that there is a close relation between the decreasing igg binding capacity (50% inhibition values) and the loss secondary protein structures by unfolding (cd-ratio 207/222 nm values). the igg inhibition assay was demonstrated to be a valuable method to determine the stability of alum-adsorbed grass pollen allergoid preparations. in addition, a relation was shown between the igg binding capacity and the change in secondary protein structures. 1205 | design of a pivotal phase iii trial of allergen specific immunotherapy (ait) using a high-dose house dust mite (hdm) allergoid in patients with allergic bronchial asthma method: 1038 male and female outpatients (age 12-65 years) asthmatics allergic to hdm are enrolled. during the baseline phase, the patient's minimal dose of ics required to achieve asthma control will be assessed. after the baseline period, approx. 446 patients will receive double-blind placebo-controlled treatment for approx. 8 months, followed by a 2nd period of 16 weeks to assess the minimal ics dose and further 2 months of observation for the assessment of asthma exacerbation. based on the results of the dose finding study regarding the efficacy endpoints and the safety profile, the optimal allergoid dose is considered to be 5400 pnu. results: competent authorities and ethic committees in all participating 12 eu countries, serbia, russia and ukraine approved the study design. the primary endpoint of the trial is the change in predefined dose steps of the minimal daily ics dose required to achieve asthma control after approximately 8 months of subcutaneous ait. all efficacy data will be determined using daily questionnaires and the acq6 by e-diary for 4 months from october to january. the aim of this clinical trial is to demonstrate efficacy and to evaluate safety of ait with an allergoid preparation of major allergens of dermatophagoides pteronyssinus in patients suffering from allergic bronchial asthma caused by house dust mites. asthma increases the burden of allergic disease and health care costs, especially when uncontrolled. with the development of a high-dose preparation we intend to treat asthmatic patients highly efficiently. romantowski j; jassem e; lata j; wasilewska e; chelminska m; specjalski k; niedoszytko m background: specific immunotherapy (sit) is the only causal treatment in patients allergic to airborne allergens. it has been proven to be widely effective in allergic populations, but individual patients vary in terms of response to the therapy. the aim of the study was to assess the factors that might affect the efficacy of sit. method: patients treated with sit for grass pollen or house dust mites were included. the efficacy of sit was assessed with the use of allergy control score (acs), performed before and at least after one year of sit. the following variables were assessed as potential risk factors for a poorer response to sit: age, gender, type of allergy, type of allergen, type of vaccine, type of sit and smoking history. background: specific immunotherapy (sit) is a suitable treatment option for asthma and allergic rhinitis (ar), but it is not commonly used in korea. in the achievement of the treatment, it is important that immunotherapy is applied with ideal dose and regular intervals and it is essential for the patient compliance. the aim of this study is to investigate evaluate compliance with immunotherapy protocols of patients who were treated with sit in clinic and their satisfaction of the treatment. we performed a multicenter, cross-sectional survey using a specially designed questionnaire that was given to allergy specialists and patient in korea. a member of the trained research group conducted face-to-face questionnaire interviews with each respondent. conclusion: this study shows that most patients are ar with asthma. in our study sit compliance and satisfy are found to be high in both groups. aim: to identify the frequency of regress claims in a dermatological setting and to assess its impact on general prescription behaviour and immunotherapy. method: all physicians of the psoriasis-praxisnetz süd-west e.v. (n = 222) were invited to participate in a web based questionnaire study on the topics of dermatology and medical law. the survey was separated into two sub-polls which were carried out after a first poll deciding whether the topic of medical law is of any interest for the dermatological practice. the topic of interest was located in the second poll. results: overall, 66 dermatologists participated in this study. most participants were form bavaria, baden-wuerttemberg or rhineland-palatinate and had more than 10 years of experience as a dermatologist. out of the 66 participating physicians 28.8% (n = 19) already experienced a previous regress claim. of these, 73.7% (n = 14) stated, that the experienced regress claim changed their prescription behaviour. half of these participants (n = 8) further stated, that the fear of a possible recourse affects their prescription behaviour, whereas only 4 out of the 47 other participants declared a possible influence. missing values excluded, this leads to a substantial hesitation in physicians who experienced a prior recourse (50.0% vs 16.7%). nevertheless, this seems not to affect the usage of allergen immunotherapy, as all 19 physicians who already experienced a regress claim, stated to use allergen immunotherapy. the fear of a possible regress can change physicians' prescription behaviour but does not seem to have an effect on the prescription of allergen immunotherapy. therefore, the topic should be addressed from another perspective such as providing trainings on relevant regulations for physicians who experienced a prior recourse claim. this approach could also improve patient centred care related to modern treatments. results: the sds were significantly reduced in patients subjected to slit (p < 0.01) 1 year after the onset it. vas also was significantly reduced (p < 0.05) with satisfied control of sar and the same time with translation from moderate-severe to mild-moderate sar, after slit. nbh was also significantly reduced (p < 0.05) 1 year after the onset slit. in patients receiving pht only, sds, vas and severity of sar did not change and significantly higher (p < 0.01) from the value obtained in the experimental group. nbh also remained unchanged and significantly higher (p < 0.05) then in experimental group. precoseasonal slit added to pht shows short-term beneficial clinical effects in polysensitized patients with sar and scuad phenotype. results: ten studies (248 children, 99 adults; median sample size, 28) met the inclusion criteria. the risk of bias was moderate to high in all but one studies. low strength evidence supports the assumption that ait is effective in reducing symptoms and medication use, with only 5 out of 10 studies reporting higher benefit in the ait group vs comparator group. subgroup analyses of studies sharing similar characteristics did not explain inconsistency. safety does not appear was not major concern for alternaria ait. conclusion: this is not enough strength of evidence to suggest that mold ait is efficacious for the treatment of respiratory allergies. high-quality studies with an adequate sample size are needed. abstracts | 627 1213 | tolerability of a two week rush updosing with modified trees, modified grasses or modified grasses/trees mixture in pollen allergic subjects in the day-to-day practice table) severe systemic reactions (grade iii and iv) did not occur. conclusion: rush immunotherapy is an effective therapeutic method for patients with allergic rhinitis. it seems that in cases requiring faster response to treatment, this immunotherapy can be considered as a substitute for conventional immunotherapy. 1217 | design of a pivotal phase iii allergen immunotherapy study to assess the efficacy and safety of subcutaneously administered tyrosine adsorbed modified birch allergen+mpl results: the design of this study, including sample size and primary and secondary endpoints, will be discussed based on prior experience gained in two dose finding studies. in addition, the number of patients screened and randomized will be presented by country, gender and/or age and screen failures will be categorized. results: the primary analysis showed an absolute difference in tcs between placebo and 12 du of 3.02 (40%, p < 0.0001). the odds of experiencing a severe day during the bps were approximately doubled in the placebo group compared to the 12 du group (or = 2.12, p < 0.0001) and the odds of experiencing a mild day were halved (or = 0.52, p < 0.0001). similar results were seen for the tree pollen season (tps), covering both alder, hazel and birch pollen seasons. the total rqlq score was improved for 12 du compared to placebo during the bps and tps (p < 0.05, except for the last week of the tps), with the most pronounced effects during week 2-5 of the bps (absolute difference: 0.47-0.58, p < 0.0001). treatment was well tolerated. the most frequent adverse reactions were mild or moderate local reactions related to the sublingual administration. no deaths were reported and no serious adverse events were assessed as related to the sq tree slit-tablet. conclusion: treatment with the sq tree slit-tablet improved arc symptoms and need for symptomatic treatment. the 12 du group had less "severe days" and more "mild days" during the pollen seasons. the quality of life was similarly improved. these findings substantiate the clinical relevance of the sq tree slit-tablet for patients with arc induced by pollen from the birch homologous group. nagaraju k 1 ; nagaraju k 2 ; katare s 3 ; kapatkar v 3 ; shah a 3 ; rathod r 3 results: total n = 57 subjects (mean age 4.6 ± 2.09 years, 61.4% males) completed entire study. the mean incidence of artis reduced from 7.7 ± 2.34 episodes at baseline to 1.4 ± 1.23 (p < 0.001), with 31.6% subjects not suffering from any episode. the mean duration of episodes reduced from 8.2 ± 3.58 to 2.5 ± 1.23 days (p < 0.001). 64% of episodes (vs 95% at baseline, p < 0.05) required antibiotics for mean duration of 2.3 ± 0.98 days (vs. 6.6 ± 1.76 days, p < 0.001). none of arti episodes in follow-up period required hospitalization as against 22.8% episodes, (mean duration 5 ± 2.06 days; p < 0.05) before pidotimod therapy. the number of school days lost & work days lost showed reduction of 3.6 ± 5.34 days(p < 0.001) & 0.1 ± 4.07 days(p = 0.871) respectively. the average expenses incurred in treatment of artis shows significant reduction of rs. 13 193 ± 1541 (p < 0.001). 11 adverse events were reported in 8 (14%) subjects, which were mild in nature. a statistically significant increase in absolute counts of t-& nk cells was seen in explorative assessment of immune markers. the study shows pidotimod to be well-tolerated effective therapy in reducing the incidence and severity of recurrent artis, thereby providing additional benefit of reduction in discomfort & healthcare cost due to recurrent artis. thus, pidotimod can be considered as potential therapeutic option for treatment of recurrent artis in children. martignago i 1 ; ridolo e 1 ; incorvaia c 2 1 department of medicine and surgery, university of parma, parma, italy; 2 cardiac/pulmonary rehabilitation, asst pini/cto, milan, italy background: two registered sublingual immunotherapy (slit) products are available to treat grass-pollen induced rhinoconjunctivitis, consisting of the 1-grass (phleum pratense) and the 5-grass pollen tablets. no study of direct comparison of the efficacy of the two products was performed. we report the case of a patient who was treated in different years with the 5-grass or the 1-grass tablets with contrasting efficacy. the patient was a 18-year old woman suffering from 3 years of grass pollen induced rhinoconjunctivitis. in 2015 slit was started with the 5-grass pollen tablets, but in 2016, due to unavailability of the product, slit was performed by the 1-grass pollen tablets. in the third year of treatment slit with the 5-grass pollen tablets was resumed. for the 5-grass tablets slit was initiated before the pollen season and stopped after 7 months of treatment, while for the 1-grass tablets the treated was prescribed to be continuous. the efficacy of slit was evaluated by symptom-medication scores as reported in diary cards by the patient during the month of may, when the grass pollen usually reach the higher concentration in the atmosphere in lombardy, where the patient lives. results: the mean symptom-medication score in the first year of treatment (5-grass tablets) was 4.35, compared with a mean score of 7.2 in the second year (1-grass tablets). the patient was unsatisfied of the symptoms control and asked to resume for the last year of slit the 5-grass tablets. the mean symptom-medication score in such year was 0.77. no clinically relevant adverse event was reported with any slit product. conclusion: based on the momentary unavailability of the 5-grass pollen tablet, it was possible to assess in a same patient the clinical outcome associated to either of the two registered slit products. a significantly different efficacy of slit with the 5-grass tablets compared with the 1-grass tablets was observed. 1222 | fusion proteins consisting of bet v 1 and phl p 5 form ige-reactive aggregates with reduced allergenic activity najafi n 1 ; hofer g 2 ; gattinger p 1 ; smiljkovic d 3 ; blatt k 3 ; selb r 4 ; stoecklinger a 5 ; keller w 2 ; valent p 3 ; niederberger v 4 ; thalhamer j 5 ; valenta r 6 ; flicker s 6 background: bet v 1 and phl p 5 representing major allergens in birch and grass pollen, occur as monomeric proteins with high allergenic activity as assessed by clinical provocation testing in patients. she did not suffer more hymenoptera stings after the last reaction. one bee sting several years before bst resulted in no reaction. she has no symptoms with honey, vegetable or other food ingestion. methods: total ige and specific ige were determined using inmu-nocap system (thermofisher, scientific inc). apis, vespula and polistes (hørsholm, denmark) were also performed. prick tests showed negative results for all extracts tested. intradermal skin tests were positive for apis at 1 μg/ml, but negative for vespula and polistes. our patient was diagnosed of anaphylaxis due to apis venom, thus bst was contraindicated and an epinephrine autoinjector was prescribed. she rejected hymenoptera venom immunotherapy. conclusion: to our knowledge, this is the first case of anaphylactic reaction after bee sting therapy. bee sting therapy should be considered a risk factor for anaphylaxis. patient reported good control of their disease, improved their quality of life, tolerating contact and exposure to numerous horses as well as contact with clothes of people who had been exposed. although ita is absolute contraindication on uncontrolled asthma with a degree of evidence ia, our case had only "transitory" con and immunocap among wasp allergen components-i3, i209, i211 were 88%; 0.5, 90%; 0.6 and 68%; 0.4 respectively and honey bee allergen components-i1, i208, i217 were 95%; 0.9, 93%; 0.7 and 97%; 0.9 respectively. agreement between polycheck and immuno-cap i1 and i3 allergen components were 85%; 0.7 and 66%; 0.3 respectively. agreement between polycheck and euroline i1 and i3 allergen component were 86%; 0.7 and 61%; 0.2 respectively. based on wasp and bee components in all three systems, sensitization pattern was analyzed. similar test results were found between euroline and immunocap systems. the comparative studies carried out showed a markedly higher compliance of results with the euroline tests compared to polycheck with the immunocap system. percent agreement was extremely high and kappa value was substantial or almost perfect in the case of bee venom allergy between euroline results: a total of 113 patients were included; 80 (71%) males, with a mean age of 38 (±15) years; 23 (21%) beekeepers, 25 (23%) were atopic, 4 (4%) had asthma, 14 (13%) rhinitis and 18 (16%) cardiovascular disease, and 14 of these patients were on ace/beta blockers. vit with honeybee was proposed in 73 (64%), wasp 38 (34%) and polistes 2 (2%). the mean duration of vit was 45 (±16) months. however, 23 completed less than 36 months. of the total, 28 patients (25%) were not treated with vit. eighty-eight patients (78%) participated in the telephone interview: 49 completed vit (56%), 15 were still on vit (17%) and 24 did not undergo vit (27%). of those who completed vit, 14 (29%) were restung and 3 went to the emergency department (er). twenty-four patients (36%) were stung while still on vit. of those never on vit, 12 (50%) were re-stung and 9 went to er. the severity of the reactions according to mueller of the patients who completed vit (mean follow-up time was 45 months (1-110 months)) and were stung again was: local reaction in 11 (79%), grade i in 1 (7%); grade iii in 1 (7%). one had a toxic reaction after multiple stings. in those who were stung during vit, 20 (87%) had local reactions, 1 (4%) grade i and 2 (9%) grade iii. of those who were not treated and were re-stung: 3 (25%) had grade i, 4 (33%) grade iii and 5 (42%) grade iv. in this series, the patients who did not undergo vit presented a greater number of systemic reactions when re-stung as well as more severe reactions (p < 0.01). conclusion: in this group with indication for vit, the reactions of the re-stings were less severe in the patients who had completed or who were on venom immunotherapy, as expected. three quarters of those who did not undergo treatment had severe anaphylactic reactions when they were stung again. this study reinforces the importance and the efficacy of immunotherapy in the treatment of hymenoptera venom allergy. method: this is a retrospective, descriptive study of cases diagmethod: data were issued from the reference centre in mastocytosis of toulouse university hospital. ms diagnosis was determined using world health organization diagnostic criteria. hymenoptera venom immunotherapy was performed with an ultra-rush protocol (table) . results: seven patients were included (4 women, 3 men), median age 47 years old. during the anaphylactic reaction, cutaneous signs missed in all cases. the reaction was most often severe: grade 2 (n = 1), grade 3 (n = 5), grade 4 (n = 1). three patients suffered from digestive symptoms and one from respiratory manifestations. basal tryptase in serum reached 10.1-41.7 μg/l. hymenoptera venom specific ige were low (0.11-1.51 kui/l) except for one patient (35.6 kui/l). ait was initiated with vespula venom in 3 patients, polistis in 1 patient, apis mellifera and vespula in 1 patient, vespula and polistis in 2 patients. no reaction was observed during ait. four restringing accidents led to increase the cumulative dose to 150 μg and 200 μg in 2 patients. in these patients, the diagnosis of mastocytosis was made due to the resting. conclusion: hymenoptera venom ait using ultra-rush protocol seems well tolerated in patients with systemic mastocytosis. specific studies are necessary to determine the real tolerance profile of this protocol. collaboration with reference centres for mastocytosis should be considered for all patients with mastocytosis associated to hymenoptera venom allergy. dose (μg/ml) results: see table. conclusion: there is a shift or immunomodulation in terms of sige to vespids. even in patients double sensitised who were receiving venom of only one of the vespids. albanesi m background: slit has been suggested as an alternative route for allergen-specific immunotherapy. aim of this study was to investigate allergen-specific antibody responses in birch pollen allergic children who had received slit for two years using recombinant allergens. method: children (n = 28; 5-12 y o) with respiratory symptoms of birch pollen and oral allergic syndromes (oas) were studied. ten children received slit with staloral, 10 were treated by slit with microgen, and 8 children received only symptomatic therapy (control group). sige and sigg levels to rbet v 1, rbet v 2, rbet v 4 were measured twice (before therapy started and after two years) using quantitative immunocap and a panel of more than 170 microarrayed allergens using immunocap isac technology. clinical efficacy of slit was evaluated by recording symptoms upon allergen contact and need of rescue medication. results: all 28 children were sensitized to the major birch pollen allergen, bet v 1 and one patient from each of the groups showed to bet v 2, no patient had sige to bet v 4. after two years of slit clinical improvement was observed in the slit patients. in the staloral group there were no respiratory symptoms in 3 patients and a decrease of symptom severity in the other 7 cases as well as a partial or complete tolerance to pr10 allergen-containing food in the 10 patients. microgen treatment had no influence on oas symptoms but decreased of pollinosis severity in 8 children. however, there were no statistically significant differences of bet v 1-specific levels measured before and after treatment in the slit and control groups (mann-whitney, p > 0.05). in this real-life study we found that birch allergic children who had been treated with slit showed a reduction of clinical symptoms but we did not find a significant induction of allergen-specific igg levels in the slit-treated group when compared with children who had only symptomatic treatment. conclusion: our study confirms the scarcity of food additives allergy. it also suggests that even when the diagnostic of allergy was excluded with a negative oral food challenge, families remain suspicious about industrials feeding products containing food additives. these results should reassure health professionals and parents who incriminate too frequently food dyes and conservators when a manifestation which mimics allergic reactions occurs. background: autumn/winter birth has been reported to be a risk factor of food allergy (fa) development. a putative mechanism is that dry/cold weather causes and exacerbates infant atopic dermatitis (ad), which is a major risk factor for food sensitization through inflamed/damaged skin. we investigated prevalence of fa among infants under well skin care in relation with seasons of birth (sob). we recruited full-term newborn infants without perinatal diseases at an obstetric/pediatric clinic. participants were followed up for skin status and food allergy symptoms until 12 months of age. sob were defined as spring (march-may), summer (june-august), autumn (september-november) and winter (december-february). ad was diagnosed based on the united kingdom working party's criteria. use of moisturizer (mo) and topical corticosteroids (tcs) was recorded. primary outcome was fa based on apparent immediate allergic reaction after ingestion of causative food. we classified infants who avoided any food because of sensitization or mother's anxiety as suspected fa. results: six hundred and thirty-one infants were screened for 12 month-period and 531 infants were enrolled in this study. of them, 277 infants were born in spring-summer (s-born) and 254 infants were born in autumn-winter (w-born). fa developed in 24 (4.5%) infants and 31 (5.8%) infants had suspected fa. there was no difference (p = 0.68) in prevalence of fa and suspected fa between s-born and w-born. multivariate analysis revealed ad at 2 and 7 months of age was a significant risk factor for fa with or=2.6 (95%: 1.1-6.0) and or=3.5 (95% ci: 1.4-8.9), respectively. prevalence of ad at 2 months of age was higher in w-born than s-born but prevalence promptly decreased thereafter and stayed low with early use of mo and tcs. prevalence of ad was rather higher at 7 months in s-born than w-born. results: 160 cases and 126 controls were included. the median age was 44 years, (q1-q3 33-53). men and women were almost equally represented (50.35% males). alcohol consumption associated with the intake of mammalian meat or innards as the trigger factor. the overall prevalence of a positive result of sige to α-gal was abstracts | 645 15.7% ic95% (11.5, 20 .0); cases _26.3% ic95% (19.4, 33.1) controls _2.4% ic95% (0.0, 5.1)_. among cases sige anti α-gal positivity rate ranged from 55.8% (rural), to 35.7% (half-urban) and 12.6% (urban). the rates of positivity were 69.5%, (northern) 1.4% (center) and 0% (mediterranean). a positive result of sige to α-gal was more frequently observed among men (24.31%) than women (7.04%) and associated with history of tick bites, practice of outdoor activities, pet's ownership and the antecedent of having eaten mammalian meats or innards previously to the development of symptoms background: a special challenge in the 21st century for allergists is allergy to food, which is considered "the second wave" of epidemics of allergic diseases. panallergens occur in unrelated organisms and perform a similar function in them. in their structure, they have highly conserved amino acid sequence regions and a similar three-dimensional structure, and thus meet the requirements for cross-recognition by ige. results: in 46 patients (92%) isac test has been shown to have specific ige for panallergen components. mostly, the presence of ige for pr-10 proteins has been shown in 41 patients. in 12 patients ige to ltp; 11 patients ige to ccd; 6 patients to profilin; 5 patients to tropomyosin; 4 patients to serum albumin, 1 person to tlp. an important aspect is undoubtedly the occurrence of simultaneous sensitization to several panallergens. analysis of data from the study group showed that isolated sensitization to one panallergen concerned only pr10 proteins (24 patients), tropomyosin (2 patients) and profilin (1 patient). in the remaining 19 patients, the analysis of the isac test results showed that two or more panallergens were allergic. in the study group, asige for the component responsible for the occurrence of real food allergy was detected in 13 (26%) patients. mostly, the presence of ige for jug r 2 has been shown in 9 patients. in the study group, panallergens were more likely to be responsible for food intolerance than specific food allergens. results: of 43 children, 14 children had peanut allergy only, 14 children had tree nut allergy only, and 15 children had both. the mean age was 3.3 ± 1.9 years in peanut allergy, 5.0 ± 3.6 years in tree nut allergy, and 4.2 ± 3.0 years in both. male to female ratio was significantly higher in tree nut allergy (78.6%) than peanut allergy (42.9%). among tree nut allergens identified, walnut (75.9%) was most frequent, followed by almond (55.2%), hazelnut (34.5%), pine nut (20.7%), chestnut (13.8%), cashew (6.9%), pistachio (3.4%), and macadamia (3.4%). mean serum total ige level was 888 kua/l in tree nut allergy and 1440 kua/l in peanut allergy. mean serum specific ige level to peanut, walnut, almond, hazelnut, and pine nut was 30.0, 21.9, 14.2, 22.4, 5.6, and 6 .3 kua/l, respectively. children with peanut allergy had higher rate of co-sensitization with soybean and higher soybean-specific ige levels than children with tree nut allergy. however, there was no difference in co-sensitization rate with tree pollen between peanut and tree nut allergy. children with peanut allergy showed significantly increased co-sensitization rate with egg white and wheat compared to children with tree nut allergy. a 42.8% of the children with peanut allergy and 28.6% of tree nut allergy showed co-sensitization with aeroallergens. a total of 75% of the children with peanut allergy showed decreased specific ige levels within 1-5 years. conclusion: prevalence of peanut and tree nut allergy is similar. tree nut allergy develops later than peanut allergy and more common in male. children with peanut allergy showed higher co-sensitization rate with soybean, egg white and wheat compared to children with tree nut allergy. 1257 | natural history of egg allergy in a large cohort of infants with food allergy shows its high prevalence but also its transient nature in a 36 months of follow-up background: the cohort of 80 infants (55 boys,25 girls,3-36 months) with the food allergy has been followed for 36 months. as more than 70% of infants manifested atopic dermatitis (ad), a condition closely linked to egg sensitisation, we focused our attention on egg allergy, following its natural history as well as a development of atopic march. method: the diagnosis of food allergy was based on a personal history, clinical examination, skin prick tests and/or atopy patch tests with native foods. laboratory tests were performed within 1 year of age the latest. the specific ige levels against food allergens were measured using immunocap or immulite. patients with ad were scored according to scorad system. the oral food challenges (ofcs) with cooked/baked egg were done in children at the age of 12 months except for children at risk of anaphylaxis. results: within the whole cohort the allergy to cow milk proteins was confirmed in 70 pts (87.5%), to egg in 35 pts (43.7%), to wheat in 8 pts(10%), to lentil in 3 pts (3.75%) to banana in 3 pts (3.75%), to soya in 2 pts (2.5%) and to potatoes in 1 pt (1.25%). in a cohort of 35 egg allergy patients we found out that: 83% of pts presented the early onset of allergy-up to 3 months of age, 80% of pts presented severe ad (scorad >50), 46% of pts showed cosensitisation to peanuts, 34% of pts had early sensitisation to inhaled allergens, and majority 54% of pts presented with early onset allergic rhinitis and/or asthma. we proved that egg allergy is closely linked with the early onset of allergy symptoms, with severe forms of ad, co-sensitization to peanuts, early sensitisation to inhaled allergens and an early onset of allergic rhinitis and/or asthma. we also proved that the egg allergy in infancy is transient. the tolerance to baked/cooked egg was achieved in about 75% of pts at the age of 3 years, unlike previously published results claiming the reach of tolerance in 75% of pts at the age of 7 years. in these patients we studied: sex, personal history, type of reaction they presented, time of onset of symptoms and food involved. results: out of a total of 1479 patients over 60 years of age (from 60 to 99 years old) who have been attended the consultation for the first time during these period, 70 patients (4.7%) ask about possible allergic food allergies. of these patients who came for possible allergic pathology, 28 patients (40%) presented positive results. these are the other item we have studied: 1. sex of patients: 55% of the patients are women. these patients because of that, it is important to remember that food allergy can also appear in old people. the food that is mainly involved in our population is fish and seafood. a much higher percentage than in other populations, probably due to the mediterranean diet of spain. the symptoms mainly involved are itching and skin lesion, which is the characteristic symptom of a mild allergic reaction. in our population, there was 3 patients with a anaphylactic shock, a much higher percentage than in other studies. the experience with this group of patients is still limited. more studies are needed to know better this patient profile. background: cow's milk allergy (cma) is the first atopic disease in children. diagnosis suspicion in the emergency room (er) is increasingly frequent, however, further assessment by an allergist is often difficult to schedule. therefore, screening for cma through a blood test (specific ige) while the infant is still in the er has gained momentum in recent years. we set out to analyse (a) symptoms which had led the emergency physician to prescribe specific ige, (b) the prevalence of confirmed cma among infants screened in the er, and (c) the long-term outcome of the screened infants. method: a retrospective study of medical records and laboratory results was performed. patients were infants under 6 months, without a previous diagnosis of cma, attending one of the two pediatric er of the university hospitals of marseille, france. allergy blood tests were specific ige to cow's milk extract (immuno-cap, thermofisher, sweden). in infants with specific ige to cow's milk extract of 0.12 kua/l or higher, ige directed to the main three individual proteins (casein, alpha lactalbumin et beta lactoglobulin) were also measured. results: 482 infants were included from december 2011 to june 2016. the sex ratio was 1.45. 40% of infants were atopic et 48% were currently or had been breastfed. the most prevalent symptoms were vomiting and reflux. one third of infants were hospitalized after the er visit. following the er visit, 25% of infants attended a specialized consultation with an allergist. 15% of infants with a follow-up visit were diagnosed with an ige mediated cma. 18 infants with cma developed further food allergies (egg, nuts, cashew…). it is difficult to diagnose it. the emergency pediatrician are increasingly confronted to infant with symptoms evoking cma. thus they prescribe sige and extensively hydrolysed proteins because they know that ige-positive infants can be ige-negative during the interval between the er visit and the follow-up one. after bad results interpretation of blood assay after er visit, cma was probably over diagnosed without prick test for ige positive allergy and no eviction/ reintroduction test for non ige. the lack of allergist is probably leading to over prescription of blood assay in er to diagnose cma and prolonged eviction of milk. results: a total of 96 patients were included (59% female) aged from 18 to 82yo with an average 33.9 ± 15 years. 77% of patients had history of atopic disease: 60% rhinitis, 30% asthma, 9% prior food allergy, 8% eczema, 6% drug allergy, 5% eosinophilic esophagitis (ee) and 3% chronic urticaria. mean serum total ige was 441.9 ui/ml. sensitization to aeroallergens was present in 63% of patients, the most common were dust mites (22.9%), pollen (15.6%) or both (25%). in 69(72%) patients, first symptoms of fa appeared ≥18 yo, with an average age of 35 ± 15.4 yo. in this group, 4 were diagnosed with ee, 1 with eosinophilic colitis and 2 with eosinophilic gastritis. from the remaining 62 patients, 20 had history of reaction with more than 1 food group (fg). cutaneous reactions were referred in 60% of patients followed by anaphylaxis (20%) and gastrointestinal symptoms (10%). the fg most commonly implied were: fresh fruits (n = 26), seafood (n = 19) and tree nuts (n = 6). fa diagnosis was confirmed in 66% of patients, the remaining had negative ofc. in 27(28%) patients, their symptoms started under 18 yo, with an average age of 11.5 ± 5yo. from this group, 10(44%) were diagnosed ee. from the remaining 17 patients, cutaneous complaints were the most frequent (47%) followed by gastrointestinal (35%) and respiratory symptoms (17%). the most common fg implied were: fresh fruits(n = 9), seafood(n = 4) and tree nuts(n = 3). only one anaphylaxis was referred. fa was confirmed in 82%, the remaining had negative ofc. in patients with history of anaphylaxis 13 of 14 had positive st and/ or sige; one had negative sp and sige, with ofc positive. the 401 blood donors were classified based on their clinical symptoms related to possible as contact via fish intake: allergic to as (1%), chronic urticaria (0.5%), unspecific dyspepsia (2.8%) and asymptomatic (95.5%). the prevalence of sensitization (anti-as ige >0.35 kua/l) were 12.7% (ic: 9.6-16.4%; mean 0.69 kua/l; median 0.03 kua/l) with a maximum value of 40.70 kua/l. raw fish consumption was the only variable associated with statistical significance (p < 0.05) to as sensitization (20.4% vs 9.5%, respectively). albacore and codfish were the most consumed species associated to seropositive results (15%), followed by hake (10%). coastal population (13.6% vs 9.3%), non-previously frozen fish consumption (13.7% vs 9.2%) and >3 times per week fish consumption (51.2%) were other seropositive associated factors. background: oral allergy syndrome (oas) is an ige-mediated allergy caused by raw fruits and vegetables in patients with pollen allergy, which is known as the most common food allergy in adults. however, there has been no nation-wide study on oral allergy syndrome in korea. the aim of this study is to investigate the prevalence and clinical manifestations of oas in korea. method: twenty two investigators from 19 hospitals and 2 private clinics participated in this study. the patients with allergic rhinoconjunctivitis and/or bronchial asthma with pollen allergy were enrolled to the survey. the questionnaires include demographics, a list of fruits and vegetables, and clinical manifestations of food allergy. pollen allergies were diagnosed by positive results of one or more pollen allergens including birch, alder, hazel, beech, oak, willow, poplar, bermuda, meadow, orchard, rye, timothy, mugwort, ragweed, hop japanese on allergy skin prick tests (allergen/histamine ratio ≥3+) and/or serum specific ige levels using multiple allergen simultaneous tests (mast ≥2+) or immunocap (≥0.35 ku/l). conclusion: this is the first nation-wide study for oas in korea. the prevalence of oas in korea was 41.7%, in which substantial proportion had anaphylaxis. these results will provide useful information for clinicians to apply in clinical practice. we conducted a self-administered, questionnaire-based survey in 2013-15 during the 18-month checkup. children were considered to have food allergies if they were diagnosed by a physician or if they had been instructed to avoid a causative food after medical examination by interview. we divided the year into three periods. the months of march-june were considered spring, july-october as summer/fall, and november-february as winter. while the season of onset for the 4095 boys occurred in 8.2%, 12.7%, and 15.3% in spring, summer/fall, and winter, respectively, it was 6.9%, 10.5%, and 12.2%, respectively, for the 3922 girls. thus, the onset rate was the highest in winter for both genders. in boys whose mothers did not consume folic acid (fol − ), the food allergy onset rate was significantly higher for boys whose mothers ate no eggs and for boys whose mothers ate 2-5 eggs per week than for those whose mothers ate eggs daily according to the dunnet multiple comparison test. however, no relationship was observed with egg intake if the mother had consumed folic acid (fol + ). on the basis of seasons, fol − and egg intake by mothers affected only children born in winter, with a significant difference in the dunnet multiple comparison. among mothers who did not eat eggs, fol + was 15.2% and fol − was 28.2%; for mothers who ate 2-5 eggs per week, fol + was 16.5% and fol − was 12.9%; and for mothers who ate eggs every day, fol + was 17.9% and folwas 4.9%. thus, consumption of folic acid seemingly annulated the effects of eating eggs. however, for girls, neither folic acid nor eating eggs had any effect on the onset rate. conclusion: since this effect varied according to the birth season, consumption of folic acid, a methyl group donor, appeared to affect the allergy onset in children. results: skin prick test with commercial extracts of tuna (7 mm), cod (5 mm), rooster (8 mm), hake (6 mm), salmon (4 mm), trout (7 mm) and anisakis (7 mm ige to shrimp, lobster, crab and mixed seafood were all undetectable. dermatophagoides pteronyssinus 10, to assess for tropomyosins was negative. outcome: the patient continues to react to both hdm and shrimp, despite undetectable ige levels to tropomyosin associated components. this is the only testing available in south africa currently and hence we are unable to look at other proteins. the relationship between tropomyosins in shellfish allergy and mite allergy has been well documented and investigated, but other allergens are now also being implicated in cross-reactions. we also established the level of ige specific to allergen components using the immunocap isac method. allergen-specific ige was not elevated to any shrimp allergens available in immunocap isac: n pen m1 (tropomyosin), n pen m2 (arginine kinase) and n pen m4 (calcium binding sarcoplasmic protein). the patient was diagnosed with a shrimp allergy. the molecular diagnostics used did not explain which allergen component is the patient allergic to. it is possible that the patient is allergic to hemocyanin, which can also cross-react with house dust mite allergens, but confirmation of this diagnosis requires further investiresults: the groups were identical in terms of the age and sex (table 1) . ara h 2 ige correlated (spearman test) with the cumulative protein dose (threshold dose) r = −0.439 (p = 0.023) but not with reaction severity r = 0.091 (p = 0.348), or the use of adrenaline r = 0.300 (p = 0.093). patients with ara h ige < 10 ku/l had higher threshold doses (644 vs 71 mg) than children whose ara h 2 ige was ≥10 ku/l (p = 0.016). there were no significant differences in severity of the reaction or in use of adrenaline (table 1) . the level of ara h 2 ige is relevant in predicting the threshold dose at peanut exposure. a low reaction threshold dose increases the risk of reaction at an accidental exposure leading potentially to a severe reaction. flaxseed allergy is uncommon and most of the cases reported involved anaphylaxis. cross reactivity has been described with other seeds. case report: a 9-year-old atopic girl diagnosed with egg allergy and rhinoconjunctivitis and asthma due to pollens. when she was eight, she presented two reactions consisting of conjunctival, periorbicular, malar erythema and abdominal pain after eating egg free french toasts cooked with flaxseed. she was treated with oral antihistamines. the allergic workup included prick-by-prick test with flaxseed which was positive and skin prick tests with mites, molds, cockroach, cat, dog, profilin, ltp and pollens with positive results for olive and grass pollens. the serum total immunoglobulin (ig) e was 476 u/l, and specific ige to flaxseed was 7.23 kua/l. the flaxseed extract was resolved with sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) and an ige immunoblotting was performed under nonreducing conditions. the patient's serum showed specific recognition of a 18-kda band in the immunoblot. proteins were identified using mass spectrometry (maldi-tof) that showed results highly consistent with conlinin, a 2s storage protein of flaxseed. we described for the first time a patient with allergy to flaxseed due to conlinin, a 2s storage protein of flaxseed. background: cyperus esculentus is an herbaceous plant that has edible tubers called tiger nuts. in spain, they are used mainly in the elaboration of the well-known "horchata" or tiger nut milk, which is obtained by macerating tiger nuts with water and sugar. tiger nut allergy has rarely been reported, despite of its widespread consumption. case report: we present the case of a 19-year-old male with a history of oral syndrome allergy with several fruits (peach, melon, banana, kiwi, apple, pear and plum) and seasonal allergic rhinoconjunctivitis due to grass pollen. he reported oral pruritus, vomiting and cutaneous itching in both arms and hands immediately after drinking tiger nut milk. he became asymptomatic without treatment after 3-4 hours. the allergic workup included skin prick tests with profilin, ltp, latex and fruits that were positive to melon and watermelon and negative to profilin, ltp, latex and the rest of the fruits. prick-by-prick tests with melon, banana, kiwi, apple, pear, tiger nut and tiger nut milk were positive. the serum total immunoglobulin (ig) e was 68.7 μg/l, and specific ige was negative to profilin, ltp, bet v1 and all the tested fruits. background: specific blood ige tests for food allergens are mainly used to confirm a suspect food allergy than to diagnose such an allergy. this is due to the low positive predictive value and the high negative predictive value they have. nevertheless, they are very helpful when they are interpreted in the context of medical history by an experienced allergist. we analyzed the prevalence of sige in children with suspected food allergies. we retrospectively analyzed the all the consecutive laboratory tests of sige for food allergens during the two-year period (2015) (2016) (2017) . tests were of children diagnosed or suspected to have food allergies. a quantitative immunoblot assay was used to measure the circulated 30 different sige. t-test, wilcoxon signed rank test, and chi-square were used to make comparisons. results: fifty-six (55.4%) men and 45 (44.6%) females, 3.4 + 3.2 years old with a maximum of 16 years and a minimum of 2 months old were part of 101 children whose tests were analyzed. one-third of the tests (30.7%) reveals more than one sige present and 55.4% of the tests resulted negative for the sige for the 30 allergens tested (table) . only 3 (3.0%) children have very high concentrations (>100 iu/ml) of egg whites sige, and 2 (2.0%) have egg yolk sige. concentrations of 79.27% of sige positive cases were 0.35-3.5 iu/ml. in our study more than half of the children suspected of food allergies resulted negative for sige for 30 most common food allergens. seventy-nine percent of the positive cases had relatively low sige. only a few positive cases have higher sige than 100 iu/ml. our data support the recommendation that sige couldn't be decisive in food allergic diagnosis, but they may help if they are interpreted cautiously. method: seven patients with a mean age of 61.4 years and female to male ratio of: 3:4, with a background history of hypertension treated with an acei presented with oro-pharyngeal irritation (itch, tingling), face and tongue angioedema and laryngeal constriction, on ingesting fresh fruits (cherries, apples, plums, peaches, apricots, strawberries, grapes), vegetables (parsnips) and/or nuts (peanuts, hazelnuts). two patients required admission to emergency department and three received adrenaline auto-injector. six out of seven patients underwent skin prick testing to common aeroallergens and the index foods. in five cases, immunocap/isac testing was undertaken. in one case the diagnosis was based on the history and in one other case it was based on history and skin prick tests. results: a diagnosis of pfas was confirmed in all patients through the clinical history, spt and/or specific ige serology to the offending food confirming predominant sensitisation pr-10 allergens. primary food allergy and spontaneous angioedema was excluded in all patients. in the cohort studied, the pfas symptoms were unusually severe. we therefore postulate that this was secondary to concurrent use of acei. the management of these patients to sensitization to a β-casein with high homology between only the first 3 milks. more precisely, the allergen candidate could be γcasein, which is derived from β-casein by proteolysis, whose abundance increases during cheese production from fresh milk, and which is absent in cow's milk. a lactoglobulin specific to buffalo's milk may also be responsible. in case of ewe's and goat's milk allergy without cow's milk allergy, sensitization to buffalo's milk should systemically be seeked out. we recommend inclusion of all mammalian milks in the list of the 14 mandatory allergens for declaration on food products. method: prick tests with fruit battery, ltp and profilin was made. analytical with blood count, immunoglobulins, triptasa, total ige and specific ige to banana, apple and orange. finally, open oral provocation with fruits was performed. the diagnostic key was given by the mother of the patient who attended consultations because the infant had erythema in the temporary zone after drinking sea water on the beach. associated with salivation, the patient presented erythema in the malar area lasting a few seconds many times. the prick tests with fruits, ltp and profilin were negative. hemogram: 100 eosinophils/μl, total ig e: 4.9 iu/ml, specific ige to fruits were negative. triptase: 5.1 μg/l. method: here we describe a variety of cases of nsltp allergy presenting to a tertiary allergy centre in the north west of england. results: nsltps have been found to be major allergens in various foods and they are likely to produce severe and systemic allergic reactions. this is reflected in the cases we present here. these proteins are highly cross-reactive due to extensive sequence homology and are panallergens. nsltps are remarkably heat stable and retains its allergenicity in processed foods. it is assumed that nsltps may sensitise both by inhalation and ingestion. an intriguing aspect in nsltp hypersensitivity is the extreme variability of its clinical expression. co-factors are often needed for the clinical expression of nsltp hypersensitivity. conclusion: patients regardless of where they are from, presenting with multiple severe/systemic food allergies need to be investigated for nsltp allergy. these patients require specific dietary advice on foods to avoid and a tailored management plan on how to deal with their allergic reactions. cow's milk as well as cow's milk products are tolerated. material and methods: skin prick tests with different sorts of milk, cheese and milk proteins were performed, specific ige antibodies were measured, a basophil activation test with cow's and goat's milk was performed and an oral provocation test (opt) with cow's milk, cow's milk cheese, raw milk and raw milk cheese was conducted. results: skin prick tests were positive for sheep's milk, goat's milk, goat's milk casein, feta, pecorino and parmesan cheese. elevated specific ige against goat's milk (12.7 ku/l) and sheep's milk (11.7 ku/ l) were detected. activation of basophil granulocytes after incubation of the patient's blood with cow's milk and goat's milk was measurable but also in the non-incubated control blood. all cow's milk products were tolerated in the opt. conclusion: despite consistent homologies between whey and casein proteins of mammals and high cross-reactivity between cow's, goat's and sheep's milk an isolated goat's and sheep's milk allergy with tolerance of cow's milk is possible. skin testing and specific ige help to distinguish from allergy against cow's milk proteins. diet counseling is possible after opt. introduction: salmon roe's allergy, without concomitant fish allergy, is rarely described in western countries. there are few studies on its allergenicity. objective: to report of a case of salmon roe allergy without concomitant fish allergy in a western country. case report: a 26-year-old male with house dust mite allergic rhinitis and asthma, describes for the 1st time, in 2015, an acute episode of dyspnoea, rhinorrhoea, ocular pruritus, epigastric pain and nausea, a few minutes after the ingestion of a sushi meal with rice, salmon, salmon roe, wasabi, soy and ginger. these complaints motivated observation in the emergency room, where it was still documented uvular oedema. he was prescribed intramuscular adrenaline, intravenous steroids and anti-histamines with complete symptoms resolution. the patient declares not had eaten other foods, taken any drugs including nsaid, been infected or practised exercise. skin prick tests with food extracts (salmon and other fish, shellfish, soy, rice, egg total, egg white, egg yolk, ovalbumin and ovomucoid) were negative. skin prick-prick tests were positive for salmon roe (17 × 10 mm) and negative for egg (white and yolk), ginger, salmon, flying fish roe (tobiko), sturgeon roe (caviar) and black scabbard fish roe. specific-ige (sige) to salmon roe extract was 0.28 kua/l (immu-nocap-phadia) and negative against extracts from salmon fish and other fish (<0.1 kua/l). sds-page immunoblotting with salmon roes extract showed a 20 kda-ige binding band, that may correspond to a lipovitelin. after the allergic reaction the patient have tolerated abstracts | 659 salmon fish and other fish roes (tobiko, caviar and black scabbard fish). no oral provocation test with salmon roes was performed given the severity of the reaction. conclusion: this report is an example of a severe allergic reaction to salmon roe without concomitant fish allergy, where the clinical history and the in vivo and in vitro tests were important to an accurate diagnosis. the authors believe this is the first report of a salmon roe anaphylaxis in our country and highlight the importance of this allergen in the western countries, given the increase of sushi consumption in these countries. case report: the prevalence of food allergy is increasing worldwide and consumer habits are changing. pomegranate (punica granatum) was commonly consumed in the mediterranean area but in the last few years became also popular in the different parts of europe. a 5-year-old boy was admitted to our emergency department suffering from allergic reaction within 10 minutes after consumption of pomegranate. he presented with skin pruritus, generalized urticaria and eyelid edema. symptoms resolved within an hour after oral intake of cetirizine. prick-to-prick test with pomegranate was positive (wheal diameter 13 × 7 mm). he had a history of anaphylaxis with egg (urticaria and wheezing) at the age of 9 month, meanwhile consumption of egg is well tolerated. an episode of anaphylaxis with unknown origin appeared at the age of 4 years (urticaria, wheezing and abdominal pain). skin prick tests with aeroallergens revealed birch pollen allergy and he was diagnosed with allergic rhinoconjunctivitis. dietary elimination of pomegranate was suggested and adrenaline auto-injector was provided. we have analyzed omalizumab effectiveness and safety in patients with csu from our database. clinical response was categorized as: no response, partial or complete response by using the urticaria activity score 7 (uas 7). furthermore, the dosage, administration frequency and any side effects were recorded. results: effectiveness: 23 out of 25 patients (92%) achieved complete response. 15 (65.2%) after a single dose of 300 mg (8 patients) or 150 mg (7); 5 patients (21.7%) after two doses of 300 mg (4 patients) or 150 mg (1) results: multi-ethnic adolescents accounted for approximately 1.2% of the total sample of adolescents. prevalence of asthma was significantly higher in multi-ethnic group than non multi-ethnic group. we examined if maternal or paternal foreign born status had a differential effect: in multi-ethnic family with foreign-born father, prevalence of asthma was significantly higher. parental region of country at birth had a significant influence on the prevalence of asthma. adjusted logistic regression analysis was used to determine risk factors for occurrence of allergic disease. residential area, perceived household economic status, parental region of country at birth, and body mass index (bmi) had a significant effect on prevalence of asthma. conclusion: population admixing appears to have significant effect on the prevalence of asthma. further study will be needed to clarify the effect of population admixing on prevalence of allergic disease. several studies have aimed to explore the possibility of mirs as biomarkers for various diseases. in our study we examined six different mirs, previously shown to be involved in eosinophil development and other immune responses, in serum from non-allergic and allergic asthmatics and healthy control subjects in order to determine their potential ability to be used as biomarkers for varying forms of asthma. method: serum from healthy individuals as well as age matched non-allergic asthmatics (naa) and allergic asthmatics (aa) were utilized. additionally, the naas and aas subjects had high eosinophila (≥0.4 × 10 9 cells/l) compared to healthy controls (≤0.1 × 10 9 cells/l) and eosinophil cationic protein (ecp) in serum was measured. asthmatic subjects were included irrespective of inhaled corticosteroid usage. rna was extracted from serum, reverse transcribed and subjected to qpcr analysis. expression changes in six candidate mirs, mir-126, -145, -146a, -155, -223, and -374, were investigated. results: two mirnas, mir-155 and mir-146a, were significantly upregulated in aas as compared to naa or healthy subjects. additionally, mir-223 was upregulated in naa, but not aa or healthy subjects. furthermore, the expression change observed in the aa mirs appeared to correlate with the use of inhaled corticosteroids, but not in the naa mirs. finally, mir-223 and mir-374 expression levels were altered based on the number of eosinophils, which correlated to ecp levels, in naa subjects. conclusion: using six mirs found in the literature to be involved in eosinophila or immune responses, we were able to detect expression changes in the serum of healthy and asthmatic individuals. moreover, were able to distinguish between healthy individuals, aas, and naas on inhaled corticosteroids or with differing eosinophil levels, leading to the possibility that these mirs may be valuable future biomarkers for asthma. background: some studies report that certain sensitization profiles may increase the risk of a more serious allergic respiratory disease. the aim of this study was to describe the sensitization patterns to major allergens of dust mites in our area and investigate the association of these patterns with a specific clinical picture. method: multicenter study performed in 3 hospitals for 4 months. we recruited 133 patients older than 5 years with rhinitis and/or bronchial asthma, with a history of allergy to dust mites and both skin test and specific ige to d. pteronyssinus, d. farinae or l. destructor positive. der p1 and der p2 were determined to all of them. we analyzed 133 patients with an average age of 28.25 years, 60.9% women, 9.7% smokers, 69.9% rhinitis and asthma, 17.3% only rhinitis and 12.8% only asthma. 94% of patients presented sensitization to d. pteronyssinus, 83.5% to d. farinae and 63.2% to l. destructor. the detected sensitization patterns were: both der p1/der p2 positive 73.9%; der p1 positive 8.4%, der p2 positive 11.8% and both der p1/der p2 negative 5.9%. it was observed that patients with higher specific ige levels had more severe forms of respiratory disease, with isolated asthma or associated with rhinitis. for d. pteronyssinus, d. farinae, der p1 and der p2 > 50ku/l there is a greater number of cases of asthma associated with rhinitis, while for l. destructor >3.5ku/l greater number of cases of asthma. no relationship was observed between a specific sensitization pattern and an increased risk of asthma. conclusion: 1. specific ige values greater than 50 ku/l for d. pteronyssinus, d. farinae, der p 1 and der p 2, were significantly associated with a higher probability of asthma and this association was significant for l. destructor>3.5 ku/l (class 3). 2. there are four well-defined sensitization patterns in our population that are influenced by geographic location, being the double sensitization to der p 1 and der p 2 the most prevalent and allowing the correct characterization of 94% of the cases. none of them increased the risk of asthma. kobori t 1 ; nagao m 1 ; ekenkrantz t 2 ; borres m 2 ; sjölander a 2 ; fujisawa t 1 1 national mie hospital, tsu-city, japan; 2 thermo fisher scientific, uppsala, sweden background: reliable biomarkers for diagnosis and management of asthma in young children are needed since pulmonary function test and exhaled no measurement, good biomarkers for asthma in older children and adults, are difficult to perform in young age. we have developed a sensitive and stable assay system to measure eosinophil-derived neurotoxin (edn), an eosinophil granule protein, that is released upon activation, and that may serve as a marker for eosinophilic inflammation also in young children. method: volunteer children from 0-6 years old were recruited and an isaac-based questionnaire was filled out by their caregivers. venous blood was obtained to measure serum and plasma edn and eosinophil count. edn was measured with a research assay developed on the immunocap ® platform. conclusion: blood edn may be a reliable biomarker for diagnosis of asthma in preschool children. conclusion: feno measurement as an add-on option in asthma management to identify asthma patients with th2 driven airway inflammation is less costly than the use of standard diagnostic methods. new biologics may have an additional impact on overall asthma treatment costs. our model demonstrates that incorporating feno measurement may help to optimize asthma medication and reduction in physician visits as well hospitalizations due to severe exacerbations. 1294 | peripheral airway inflammation assessed by fractional measurement of the exhaled breath temperature is a leading feature of asthma background: airway inflammation is considered to be a hallmark of asthma. the potential clinical benefits of assessing it non-invasively has led us to develop a method and device for measuring the temperature of the exhaled breath (ebt=exhaled breath temperature) reflecting the thermal state of the airway mucosa. studies have demonstrated that ebt is increased in asthma, proportionately to the level of control of the disease. in an attempt to further increase the usefulness of this approach, we have further developed a device to allow the assessment of the relative contribution of the central and peripheral airways (caw and paw). now we present the frebt data gathered from patients with suboptimal control of their asthma and from healthy subjects. method: in this cross-sectional study we included 120 volunteers: 71 patients with suboptimally controlled asthma of mild to moderate severity (median age 44, range 18-68 years, 31 men) and 49 nonsmoking subjects without respiratory disease (median age 49, range 18-70 years, 17 men). we measured the fractions corresponding to caw and paw sampled with a fast reacting inflatable balloon valve system operated by a computer during a single breathing cycle. it allows steering of the expired airflow through channels with sensitive temperature sensors. during an initial deep inhalation, the inspired volume is measured and the sequence of valve openings is adjusted so as to yield volumes of air characteristic of caw or paw during expiration. the ratios between [pawebt-cawebt] over the total ebt [%] measured during the same manoeuvre (fractional ebt, frebt) were calculated and compared between asthmatics and controls. results: there was high statistically significant difference between the frebt ratios of asthmatics and controls: 16.25 ± 0.51 (mean ± sem) vs 12.66 ± 0.28, p < 0.001. as the magnitude of the ratio depends on the difference between pawebt and cawebt, higher values of the frebt ratio point to bigger contribution of the peripheral lung tissues, presumably indicative of peripheral inflammation. multiple regression analysis with frebt ratio as dependent variable identified only asthma diagnosis as significant predictor (p < 0.001) and excluded all other anthropometric indices. conclusion: peripheral airway inflammation assessed by frebt measurement appears to be a leading characteristic in asthmatics compared to healthy subjects. method: we examined 142 outpatients (30% male, aged 18-82 year, mean age 54.7 years) with severe asthma according to ers/ ats (2014) definition treated with high dose of ics/laba± tiotropium, antileukotrienes and omalizumab. some patients (n = 21) had orally steroid-dependent asthma. they referred to our secondary care center by gps. pulmonary function tests were measured by dry spirometer (2120, vitalograph ltd., uk). skin prick tests or serum specific ige to common inhalant allergens (house dust mite, animal dander, pollen) were used to assess atopic status. results: seventy five percent (n = 107) of patients with severe asthma had fao in 50% of those was diagnosed concomitant copd. duration of asthma was 14.6 years in patient with reversible airway obstruction (rao) and 14.5 years in those with iao (p > 0.05). early (before age 12 years) onset of asthma was established in 13% of patients with rao and in 9% of patients with fao (p > 0.05). prevalence of atopy did not differ between both groups (81% vs 81%, p > 0.05) but total ige level in serum was higher in severe asthmatics with rao than fao (924 me/ml vs 330 me/ml respectively, p < 0.01). most of atopic patients with severe asthma both with fao (91%) and roa (83%, p > 0.05) were sensitized to house dust mites (d. pteronyssinus and d. farinae). hypersensitivity to pollen was diagnosed in 36% patients with foa and in 17% with rao (p > 0.05), to cat and dog dander in 49% and 25% respectively (p < 0.05). the majority (75%) of patients with severe asthma had fao. hypersensitivity to house dust mites was most common in severe atopic asthmatics with foa and roa where as sensitization to animal danger was associated with presence of foa. 1296 | loss of smell as a clinical marker of severe asthma and its association with upper airway inflammatory diseases background: asthma is frequently associated with rhinitis and chronic rhinosinusitis (crs) while severe asthma is more associated with crs with (crswnp) than without (crssnp) nasal polyps. loss of smell (los) is associated with crs, mainly with crswnp. we aimed to assess loss of smell as a clinical marker to discriminate crs from rhinitis and severe from non-severe asthma. method: in a cross-sectional multicentric study, asthmatic patients (n = 383) were evaluated by pulmonologists and ent specialists using gina, aria, and epos definitions. los was evaluated by severity [vas scale, 0-100 mm, median (iqr,inter-quartil range)] and by prevalence of anosmia (hyposmia vas >0-70 mm, anosmia vas>70 mm). results: los was present in 55.4% of asthmatics (hyposmia 41.5%, anosmia 14.9%). los was more severe [22 mm (0-75), p < 0.001] and anosmia more frequent (26.4%, p < 0.001) in severe persistent asthma than in moderate [10 mm (0-50); 11.4%] mild [0 mm (0-28); 10.7%], or intermittent [0 mm (0-45); 8.6%] asthma. in addition, los was more severe [38 mm (2-76) vs 0 mm (0-20), p < 0.001] and anosmia more frequent [28.1% vs 3.9%, p < 0.001] in crs than in rhinitis patients. in those asthmatic patients with crs, los was even more severe [50 mm vs 20 mm (0-56) p < 0.001] and anosmia more frequent (40.6% vs 13.4%, p < 0.001) in crswnp than in crssnp. conclusion: loss of smell and specially anosmia may clearly discriminate severe from non-severe asthma and crs (specially with np) from rhinitis alone in asthma patients. thus, los may be considered a significant clinical marker of severe asthma and its association with upper airway inflammatory diseases. 1297 | last station in the eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis march: eosinophilic asthma with radiological findings associated with blood eosinophilia yilmaz i 1 ; nazik bahçecioglu s 2 ; türk m 3 ; tutar n 1 ; oymak fs 2 ; gülmez i 3 1 erciyes university school of medicine, kayseri, turkey; 2 department of chest diseases, kayseri, turkey; 3 division of immunology and allergy, kayseri, turkey background: eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis (eacrs/np) is a subphenotype of adult-onset eosinophilic asthma. blood eosinophil levels are shown to be highly elevated in patients with ea-crs/np and have potential for tissue infiltration. we aimed to demonstrate the clinical features of the patients who have a blood eosinophil level above 10% and have thorax computed tomography findings due to blood eosinophilia. results: we identified 36 patients who met the above criteria. we defined this group as "eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis with radiological findings related to blood eosinophilia" (earr). the mean age was 44.9 ± 11 years and 64% was female. nasal polyps, aspirin exacerbated respiratory disease and atopy was present in 81%, 47% and 25% of the patients, abstracts | 665 respectively. the mean blood eosinophil count was 1828.6 cells/mm 3 (19%). the majority of earr patients had upper lobe dominant ground-glass opacities. the mean follow-up period was 3.2 ± 2.5 years. earr patients did not evolve into eosinophilic granulomatous polyangiitis in the follow-up. method: we aimed to identify features more probably associated with asthma in a unselected group of patients with diagnostic criteria for aco. we consecutively selected the first 10 consecutive patients with diagnostic criteria for aco. all patients were evaluated by accurate clinical history interview, assessment of asthma control test (act) and copd activity test (cat), lung function and exhaled nitric oxide (fe no ) measurements, sputum cytology, blood eosinophil count, serum total ige and periostin levels, methacholine and adenosine-mono-phosphate (amp) bronchial challenges. all these measures were repeated after an oral corticosteroid (ocs) trial of methylprednisolone 32 mg/day for 14 days. we defined 9 parameters that we expected improved after the ocs trial, and therefore considerable as markers of asthma: fev 1 , fef 25-75 , fev 1 /fvc, fe no , act, sputum and blood eosinophilia, methacholine and amp challenges. patients with improvement of at least 4 of these parameters after ocs trials were defined as "responders" to the treatment, and therefore more likely to be asthmatic than copd or aco. results: five (50%) patients were classified as responders and they were characterized by having basal higher fe no values (102.8 ± 34.2 vs 13.6 ± 3.5 ppb, p = 0.032), greater bronchial reversibility basal values of serum periostin and total ige, and blood eosinophils were higher in responders but without reaching the statistical significance. conclusion: fe no and the degree of bronchial reversibility (and possibly also the degree of response to an amp challenge) are reliable biomarkers to distinguish asthmatics among those with suspect aco. method: the preliminary case-control study included 52 obese persons with asthma who were matched for age and sex and 48 nonobese asthma subjects. non fasting serum levels of adiponectin, and leptin were measured by commercially available immune assay kits, and routine biochemical parameters were analyzed in both the study groups. the results show statistically significant lower levels of serum adiponectin and higher serum leptin levels in obese asthma subjects with respect to non-obese asthma patients (p < 0.001). moreover, an inverse correlation was also observed between serum adiponectin and serum leptin in obese asthma subjects (p < 0.05). our results indicate the association of these hormones might act as a significant predictor in the progression of asthma. moreover, the role of serum adipokines is promising and might potentially act as a meaningful drug target in the pathogenesis of asthma. background: overweight/obesity is known to be a possible factor for poor asthma control. the aim of the study is to determine the serum concentrations of leptin in atopic asthmatic patients and its relationship with body mass index (bmi), asthma severity defined by medical treatment and asthma control defined by the asthma control test (act). method: we randomly selected 33 adult patients previously diagnosed with allergic asthma based on gina (global initiative for asthma) guidelines, returning for follow-up to an outpatient allergy/ immunology clinic during november 2017. following an informed consent, the patients were asked to fill act, their bmi was recorded, and elisa blood assays for leptin were drawn. exploratory data analysis, spearman's correlation (95% ci by bootstrapping), and partial correlations were performed. results: female/male ratio was 24/9, mean bmi was 27.2 ± 4. conclusion: leptin was significantly associated with overweight/ obesity in asthmatic subjects, and showed higher values for women. leptin inverse correlation with act did not reach statistical significance, likely owing to underpowered estimates, in a small sample characterized by an elevated mean bmi and severe allergic asthma. background: immunoglobulin lowering may be associated with recurrent wheezing symptoms and clinic by increasing the tendency to viral respiratory tract infections. in this study, it was aimed to investigate the frequency of immunoglobulinemia in preschoolers with wheezing. the study was conducted between 01.01.2013 and 01.01.2016 between. university of health sciences, ankara child hospital, the children allergy and immunology clinic included patients who had been followed up and treated for at least one year with recurrent wheezing attacks within younger than 48 months. the immunoglobulin (g, a, m) values of the patients were retrospectively analyzed. immunoglobulin levels were determined to be normal and low according to age limits. the study included 585 patients (65.6% male, 34.4% female) under the age of 6 years with a mean age of 26.9 months. the mean follow-up period of the patients is 2.2 years. in 33.7% of these patients, at least one immunoglobulin was found to be low. none of these patients had any signs or symptoms of immunodeficiency. immunoglobulin a was low in 21% of the patients, immunoglobulin g in 18%, and immunoglobulin m in 7.5% of all patients. conclusion: immunoglobulin was found to be low in these patients when there was no immunodeficiency and preschool wheeze was diagnosed. this should be etiologically investigated as to whether if this is a special group in preschoolers with recurrent wheezing and hypogammaglobulinemia combination. method: asthma severe unit is formed by allergists, pneumologists, pediatricians and otorhinolaryngologists. hematologists and immunologists make specific collaborations. we present the partial results of our data collection, which include 75 patients with severe asthma according to ers/ats task force, selected by peripheral eosinophils >220 according to wagener et al. we followed them up to assess control for 1 year. we obtained cellularity in sputum using induced sputum technique. values of il of th2, th1, th17 pathway, periostin and ilc were not yet available. results: median age was 36 ± 24, feno 45 ± 34, exacerbations previous year 1.8 ± 2.4, act 17.7 ± 5, fev1 75% ± 21 and dose of inhaled corticoids (budesonide equivalent) 1235ug ± 618. most of the patients were sensitized (78%) and 15.9% were polysensitized. the most frequent sensitization was dust mites (81%). 27% had received immunotherapy of whom 35.3% with lack of response. not sensitized patients were older. sputum cell analysis of 54 patients was performed, 37% had sputum eosinophils>3%, mean sputum eosinophil value was 4.1 ± 4.7 and peripherally 518 ± 384. correlation among sputum and peripheral eosinophilia was 0.097 (p = 0.485). the peripherally eosinophil value >220 had a sensitivity of 80% and a specificity of 54% for the detection of sputum eosinophils >3%. no differences were observed in sputum cell count depending on allergic sensitization. 64% had an uncontrolled asthma. presence of polysensitization, rhinitis or polyposis were not statistically related with the control. different patterns were observed in function of cause of poor control: patients with obstructive pattern (fev1 < 80%) were older and received more inhaled treatment. patients with high rate of exacerbations had more sputum eosinophilia and neutrophilia. both groups had worse act and received more oral steroids. patients who received oral steroids were more often sensitized to fungi in some follow-up visits. not significant differences were observed in control according to the act. asthma had more sputum neutrophilia, were older, received higher inhaled steroids dose and had adult onset asthma. the only control variable related with sputum eosinophilia was exacerbation. fungi sensitization was more frequent among patients with oral steroids. method: a randomized, double blind, placebo controlled study with 80 patients from the de la salle university medical center with a mean age of 44 with partly or uncontrolled asthma. they were assigned to either cm glucan or placebo group for two months. act score and %fev1 postbronchodilator were assessed at the 1st visit, 4th week follow up, and 8th week follow up visits. an independent and paired t-test were used to determine mean changes in act scores and %fev1 between the groups. results: in the two treatment groups, those in the cm glucan group had a greater % fev1 mean change of −6.95 compared to placebo which had only −14.1, a mean difference of −7.15, and a trend toward significance with a t-test p value of 0.061. in terms of changes in act score, those in the cm glucan group had a mean change of 10.12 and 9.75 for placebo, a mean difference of 0.37 and was not significant at t test p value of 0.718. the result of the emanuel trial showed a trend of improvement among patients on both groups in terms of act score and %fev1 postbronchodilator. however, it was not statistically significant. 1306 | lung function improvements with tiotropium in patients across all ages: impact of episodes of asthma worsening during phase 3 trials vogelberg c 1 ; casale tb 2 ; bleecker er 3 ; goldstein s 4 ; szefler s 5 ; engel m 6 ; el azzi g 6 ; dewberry h 7 ; hamelmann e 8 method: post hoc analyses involved 6 phase iii, randomized, double-blind, placebo-controlled trials: 4 in patients aged 6-17 years (rubatina-/canotina-/vivatina-/pensietina-asthma) who received tiotropium (5 or 2.5 μg) or placebo, as two puffs once-daily via the respimat, as add-on to ics ± other controllers; and 2 in adults (pri-motina-asthma replicate trials) who received once-daily tiotropium 5 μg or placebo, as add-on to ics/laba ± other controllers. we analyzed change from baseline for peak fev 1(0-3h) and trough fev 1 at week 12 in vivatina-and pensietina-asthma, and week 24 in pri-motina-/rubatina-/canotina-asthma, comparing patients with and without episodes of asthma worsening during the trials. asthma worsening was defined as an episode of progressive increase in dayto-day asthma symptoms (recorded by patients and confirmed by the investigator) or a decrease of patient's best morning pef ≥30% from mean for ≥2 consecutive days. as a post hoc analysis, p values are nominal. results: there were no differences in baseline disease characteristics between those who experienced episodes of asthma worsening and those who did not, within specified age and asthma severity groups. placebo-adjusted lung function improvements were observed with tiotropium 5 μg in patients who experienced episodes of asthma worsening and those who did not during the trials (table 1) . there was some variability in subgroups with low numbers of patients. conclusion: once-daily tiotropium add-on had a similar efficacy in adult and pediatric patients with symptomatic asthma, irrespective of whether they experienced episodes of asthma worsening or not during the trials. these data support the broad efficacy of tiotropium and show largely consistent improvements in lung function even in patients who experience episodes of disease worsening. 1307 | cochrane review of the use of antibiotics for acute exacerbations of asthma method: we searched the cochrane airways trials register, trial registries and reference lists of primary studies. we extracted outcome data and assessed risk of bias in duplicate and used current cochrane methodology throughout. our primary outcomes were intensive care unit (itu) admission, duration of symptoms/exacerbation and adverse events. we included six studies, including a total of 681 adults and children. trials were of varied methodological quality and we were able to perform only limited meta-analysis. one study reported a single itu admission but no other studies reported admissions to itu. two studies investigating macrolides reported diary card symptom score and showed antibiotics improved symptoms (md −0.34, 95% ci −0.60 to −0.08). one study including 40 participants reported more symptom-free days in the macrolide group than usual care. one study of a penicillin including 69 participants reported asthma symptoms at hospital discharge; the between group difference was reported as non-significant. serious adverse events were rare; 10 events were reported across the three trials (n = 502). the pooled effect estimate for all adverse events from three studies was imprecise (or 0.99, 95% ci 0.69-1.43). no deaths were reported. conclusion: our results confirmed that omalizumab significantly improves disease control and is a safe add-on therapy. also in appropriate patients with controlled disease over time, efforts to stepdown other asthma medications will be appropriate. (45) aerd: aspirin exacerbated respiratory disease; sd: standard deviation. data are n (%), mean ± sd or n/n (%). c-act: asthma control test for children, fev1: forced expiratory volume in one second; fev1/fvc: the ratio of forced expiratory volume in one second to forced vital capacity, pef: peak expiratory flow; feno: fractional exhaled nitric oxide, vas: visual analogue scale *these included allergic rhinitis, asthma, eczema, atopic dermatitis, food allergy, etc. **there were 11, 13 and 18 missing data in treatment a, b, and c, respectively. this study examines the potential treatment effects of sq ® hdm slit-tablet on qol measured by sf-36v2 in people with aa and ar. the analyses are based on data from the mt-04 trial (eudract no. 2010-018621-19) and utilize data from the 12 sq-hdm treatment group (282 subjects) and the placebo group (277 subjects). throughout the trial, qol was measured at each of visit 3-13 via sf-36v2. this yielded psychometrically-based physical and mental health summary measures, as well as a sf-36v2 total score. according to trial design, the use of inhaled corticosteroid (ics) was reduced by 50% for a three months period (visit 10 and 11) and completely withdrawn for the last three months of the trial (visit 12 and 13). results: by estimating a simple regression on differences in sf-36v2 total score from baseline measurements (visit 3), a positive and statistically significant treatment effect on the overall qol of the 12 sq-hdm treatment compared to the placebo group in visit 9 and 10 was found. further analyses show that the qol improvements are mainly driven by increases in the general mental health score, which are carried through to visit 12. in particular, the mental health and role emotional domains show statistically significant improvements. the results show that the sq ® hdm slit-tablet improves qol measured by sf-36v2 in patients with hdm induced aa and that this effect is driven by improvements in the mental health domains. 1315 | impact of treatment prescription, adherence to treatment and use of inhalers in asthma control-results of the efimera study method: cross-sectional multicenter observational study conducted with patients who use any type of medication with inhaler devices. patients referred from primary care and seen by a pneumologist or allergist for the first time were evaluated. the following data was collected in a single visit: adequate prescription according to gina2015 guidelines (gina); specific and general treatment adherence using morisky-green questionnaire (mg) and inhaler adherence test (tai); disease control with asthma control test (act) and assessment of inhaler use technique were measured with the extended tai. results: patients included in this study (n = 1682) had a mean age of 45 ± 17 years, an average disease evolution of 14.9 ± 14.1 years, 64% of which were women. according to gina recommendations, 35.9% of patients have insufficient or inadequate prescription. when measured by the mg test the 68.5% of patients showed bad adherence, meanwhile measured by the tai test adherence was 76.8% measurements of inhaler use technique resulted in 17% of patients having one or more mistakes regardless of whether the device was a mdi or dpi. several factors showed to be related with bad asthma control: inadequate prescription (or: 8.05 [5.74-11.27 background: it is well known that the constant and prolonged tobacco smoking affects the natural history of asthma. vaping is the act of inhaling and exhaling the vapor produced by an electronic device called e-cigarette (e-cig), whose basic structure includes a power source and an atomizer. two types of vaping are the most popular ("mtl" and "cloud chasing"). we have created a web-survey with questions concerning epidemiological data, quality of life and symptoms worsening in asthmatic vapers. the survey has been advertised through various social networks and local press. 2403 people responded, including 437 asthmatics (18%). the asthmatics were: males 88%, under 18 3%, 18-25 years 36%, 26-30 years 19%, 31-65 years 42% and over 65 0%. 70% used ecig-only, 30% smoked and vaped together, 0%. those who preferred mtl-type of vape were 43% and "cloud chasing" were 57%. results: to the question: "has vaping ever worsened asthma symptoms?" 90% answered no, 10% yes. to the question: "as asthmatic, would you suggest to an asthmatic smoker to start vaping instead of smoking?" 1.3% answered no, 98.7% yes. to the question: "how much nicotine do your vaping liquids have?" 15% answered 0 mg/ml, 4% 1.5 mg/ml, 62% 3 mg/ml, 11% 6 mg/ ml, 6% 9 mg/ml, 1% 12 mg/ml and 0% 18 mg/ml. to the question: "do you take medications for your asthma?" 57% declared to use a drug as needed, 0% used a single drug daily, 16% used more than one drug daily and 27% declared "i don't take any asthma medication". we related (χ2 test) the worsening of asthma symptoms with the nicotine content (p = 0.313), the type of vaping (p = 0.305), the current therapy (p = 0.123) and we did not find a statistically significant correlation. vaping has undoubtedly shown an advantage in terms of improvement of symptoms compared to cigarette smoking (p = 0.016), in particular 82.5% subjects who smoke and vape did not have a worsening of symptoms, while 17.6% of them had a worsening. the vaper-only users who never worsened were 271 (90.6%) and 28 (9.4%) had a worsening. conclusion: despite the limits related to the online survey as a data source, e-cigs seem to be a useful tool in the pathway to quit smoking. in fact, 98% of the asthmatics who smoked traditional cigarettes would recommend switching to e-cig and 90% did not worse their asthma symptoms. background: despite the success of pharmacotherapy, more than half of patients with persistent bronchial asthma (ba) do not achieve disease control. in recent years, the issue of approaches to treatment based on the identification of phenotypes of the disease has been increasingly discussed. this approach becomes the key to optimizing therapy for asthma, allowing the personification of treatment. anti-ige-therapy using omalizumab is one of the most researched variants of phenotype-specific treatment. method: aim of our study was to investigate of the causes of uncontrolled predominantly atopic asthma, the frequency and effectiveness of the personalized therapy in real clinical practice. 54 patients with uncontrolled severe atopic asthma were examined in outpatient department of the city hospital during 2017. all patients underwent physical examination, pulmonary function testing, and total serum ige evaluation. results: 35% of patients had uncontrolled asthma due to inadequate basic therapy of the disease. the change in therapy allowed them to achieve control of the disease. obstructive sleep apnea syndrome (osas) was revealed in 11.1% of patients. these patients underwent cpap (continuous positive airway pressure) therapy. 13% of patients had gastroesophageal reflux disease (gerd). 25% of patients had an elevated level of serum ige level and needed anti-ige therapy. in 7.4% of cases, the initial serum ige level was more than 1500 iu/ml which was a contraindication to therapy of omalizumab. 8 patients received omalizumab therapy. this therapy led to relief of symptoms and decreased frequency of asthma exacerbations. results: it was found that the prevalence of obesity among the 367 patients with asthma and being treated in inpatient conditions in 2013-2015 was 44.9% of patients, which is comparable to the prevalence of obesity among the population in general. the data of the patients suffering from asthma and obesity treated both in inpatient and outpatient conditions, was analyzed and it is set that obesity does not affect the severity of the clinical course of asthma. it is shown that obesity does not affect the control of symptoms of asthma. thus, the control of asthma symptoms depends on timeliness of diagnosis, the adequacy and terms of appointment of basic asthma therapy, the presence, severity and adequate treatment of concomitant diseases, psychoemotional background of patients, their compliance and adherence to therapy. results: the causes of smoking in asthmatics were not significantly different from the control (p > 0.05). patients most often used smoking as "support for emotional stability". the motivation to smoking cessation was higher in the asthmatics group (58%) than in the control group. the main reason for smoking cessation was a deterioration in health -60%. the majority of smokers -85%, performed attempts for smoking cessation. low level of br was revealed in 90% asthmatics (27% non-smoking asthma patients and 18.5% of cases in the control group, p < 0.001), cf had low values and was lower in asthmatics group in compare to the control group (p < 0.05). the pac values correlated with the level of br: a low level was determined in 100% in smoking asthmatics, in 50% in nonsmokers with asthma and 7.4% in smokers of the control group obstructive sleep apnea (osa). all of the patients were on regular treatment with low dose inhaled corticosteroids for at 12 months and start treatment with continuous positive airway pressure (cpap) .to assess quality of life, we used asthma symptom control tools (asthma control test) .patients performed daily peak flow meter and spirometry (once a week) during period of 4 weeks after start using cpap. results: during the study, 47 of the followed patients had no exacerbation of asthma. four of patients during this period had exacerbation, due to upper airway infection so they were excluded from study. results of following showed that there was improvement in quality of life in all 47 patients included in study but there no statistically significant improvement in pulmonary function tests fpt. huang y 1 ; yao t 1 ; huang y 1 ; chiu c 1 ; tsai z 1 ; kao p 1 ; lu k 1 ; fang h 1 ; lin c 1 ; gau c 1 ; lee w 1 ; tsai h 2 results: the rate of preterm birth among the study subjects was 18.2%. the prevalence of physician-diagnosed rhinitis was 50.6%. there was no significant association between preterm birth and physician-diagnosed rhinitis (p = 0.43). when stratifying by atopy status, we found that preterm birth was associated with physiciandiagnosed rhinitis among children without atopy (adjusted or [aor] = 0.33, 95% ci = 0.12-0.93, p = 0.04), but not among children with atopy (p = 0.77). when further classifying by gender, greater protective effect of preterm birth on rhinitis was only found in boys without atopy (aor = 0.12, 95% ci = 0.03-0.56, p = 0.007). the results suggest that preterm birth may have a protective effect against the development of childhood rhinitis in our study population. the protective effect is only observed in boys without atopy. further investigations will be merited to confirm these findings and to investigate underlying mechanisms. background: folic acid supplementation (fas) during pregnancy has been suggested due to its protective effect against neural tube defects. at present the effect of fas during pregnancy on childhood rhinitis has remained unclear. we aimed to investigate the relationship between fas during pregnancy and childhood rhinitis. logistic regression analysis with covariate adjustment was performed. adjusted covariates included sex, age, number of older siblings, breast feeding duration, maternal smoking during pregnancy, maternal allergy, maternal education level, maternal age and socioeconomic status results: the prevalence of physician-diagnosed rhinitis was 55.3%. there is a significant association between fas and physician-diagnosed rhinitis (adjusted odds ratio [aor] = 2.07; 95% confidence interval [ci] = 1.25-3.43 for fas ≥3 months) compared to the group of never use. in the stratified analysis by atopy status, maternal fas during pregnancy was significantly associated with physician-diagnosed rhinitis in the atopic group (aor = 1.91, 95% ci = 1.07-3.40 for fas <3 months; and aor = 2.34, 95% ci = 1.19-4.58 for fas ≥3 months), but not in the non-atopic group. when further stratified by gender, significant association between maternal fas during pregnancy and physician-diagnosed rhinitis was only found in boys with atopy (aor = 3.23, 95% ci = 1.39-7.50 for fas <3 months; and aor = 4.02, 95% ci = 1.51-10.72 for fas ≥3 months). the results demonstrate that maternal folic acid supplementation during pregnancy might increase the risk of childhood rhinitis, especially among boys with atopy. further investigation will be needed to validate our findings and to understand potential underlying mechanisms. according to sequence data 13 from 16 detected adv (in all groups of patients) belongs to species f 41 type and 3 samples to species c 1 type (rei group). bv type 1 was identified in 3 strongly positive (ct ≤ 25) swab samples in ari group. conclusion: simultaneous testing of respiratory and stool samples together shown that at least 6.6%/7.9% of 151 study subjects had dual/mixed infections, respectively, including 11%/9.5% of 63 respiratory disease patients, 3.6%/7% of 56 gastroenteritis patients and 3.1%/6.2% of 32 patients with combined respiratory/enteric infections. we found no virus combination specific for different groups of patients. 1327 | neonatal respiratory supports and future asthma-like presentation in prematurity with bronchopulmonary dysplasia results: of all the tests analyzed 54.4% were males and 45.6% females with a mean age 5.7 ± 4.8 years old. half of the tests (49.2%) reveals positive specific-ige to more than one allergen and 38.6% (66) have no serum specific-ige for the tested allergens (table 1) . sixteen patients (9.4%) have very high concentrations (>100 iu/ml) of derm. pteronyssinus specific ige, 13 (7.6%) of derm. farina, 7 (4.1%) of rey pollen and 6 (3.5%) of oak and timothy grass pollen. further studies are needed in order to elucidate the effect of these cytokines on allergy development and protection. shinohara m 1 ; matsumoto k 2 1 department of pediatrics, ehime university hospital, toon, japan; 2 department of allergy and clinical immunology, national research institute for child health and development, tokyo, japan background: probiotics consumption during perinatal and postnatal periods reportedly reduces the risk of atopic dermatitis in the offspring, whereas such probiotics consumption did not affect ige levels or the risks of other allergic diseases; the precise mechanism how probiotics consumption reduces the risk of atopic dermatitis remains unknown. we hypothesized that probiotics consumption may reduce skin hypersensitivity to histamine. to test this hypothesis, we investigated whether perinatal/postnatal consumption of yogurt associates with skin hypersensitivity to histamine or not. method: this was a cross-sectional study enrolled 256 motherinfant (≥6-months-old) pairs. physician-diagnosed allergic diseases and food consumption, such as milk, fermented drinks, and yogurt, by mothers during the third trimester of pregnancy and by infants during the first 6 months of life were assessed using self-questionnaires. skin prick tests (spts) to saline and 1 mg/ml histamine were performed using bifurcated needles, and wheal sizes were measured 15 minutes after the puncture. the spt wheal sizes in infants with eczema/atopic dermatitis (n = 44) were significantly larger than those in infants without eczema/atopic dermatitis (n = 156; 4.6 ± 1.9 mm vs 3.8 ± 1.8 mm, respectively, p = 0.015), and thus these infants were excluded from the further analyses. the spt wheal sizes to histamine in infants with daily yogurt consumption during the first the aim of this study was to evaluate the prevalence and clinical relevance of sensitization to profilins in atopic patients with food allergy. the study was performed on a group of 43 children age 2-14 years with sensitization to at least one plant-derived food allergen (ige > 0.7 ku/l). the included patients had never been treated with allergen immunotherapy before the study. the presence of ige to recombinant (r) rbet v 2, rart v 4 and ramb a 8 in serum was evaluated using elisa method as previously described (jbc 2016; 291:15447) . in addition serum level of igg4 to rbet v 2, rart v 4 and ramb a 8 was also evaluated. results: sensitization to profilins was found in 8 out of 43 (18.6%) patients (p+). sensitization to all 3 studied profilins was demonstrated in each p+ patient. the remaining 35 children, with pollenfood sensitization, were not sensitized to any of the studied profilins and they served as a comparator group (p−). analysis of the clinical status revealed that asymptomatic patients in regard to plant-derived food hypersensitivity were found more frequently among p+ (75%) than p− (37.1; p < 0.01) patients. sensitization to profilin was associated with positive ige to the same food allergens as in the control group. clinical manifestation of pollen-food sensitization expressed as allergic rhinitis, bronchial asthma and atopic dermatitis was comparable between groups, except of oral allergy syndrome, which was not seen among p+ children. similarly, history of anaphylaxis to plant-derived foods was registered only among p− (11.4%) patients. interestingly, all patients with sensitization to profilins had also elevated level of serum igg4 against rbet v 2, rart v 4 and ramb a 8. results: no significant difference of physician-diagnosed eczema (p = 0.88) or current eczema (p = 0.82) was observed between children born full-term and preterm. after stratifying by atopy status, we found that children born preterm had a more than three-fold higher risk of having physician-diagnosed eczema (adjusted or (aor) = 3.92; 95% ci = 1.25-12.29; p = 0.02) and current eczema (aor = 3.16; 95% ci = 1.06-9.41, p = 0.04) than their counterpart in the non-atopic group. no statistical significance was observed for the association between preterm birth and eczema in the atopic group. no association between preterm birth and eczema was found when stratifying by gender. our results reveal that non-atopic children born preterm have a higher risk of developing eczema. the results suggest potential modifiable effect of atopy on the association between preterm birth and eczema. further studies with a larger sample size are needed to validate the findings in this study. background: there is a need for more knowledge about factors of importance for a successful transition from childhood to adulthood among adolescents with allergic disease and especially those with severe allergy. therefore the aim of this study was to describe experiences of living with severe allergy from the adolescents and their parent's perspective and thereby identify factors of importance for transition from pediatric to adult care. method: a qualitative study was performed based on six focus groups interviews, two with adolescents and four with their parents. in total 11 adolescents (age 10-16 years old) and 21 parents participated. the interview guide contained questions about experiences of living with severe allergy. the transcribed data was analysed using systematic text condensation. results: in total four themes were presented, two themes occurred in both the adolescent and the parent's focus groups, to be special and to be prepared. for two themes there was a difference between the adolescents and their parents. the theme, the importance of the parents, only occurred in data from the adolescents and the theme the meetings with health care only occurred in the parent's data. the adolescents felt that they had low priority in the class and several stated they were teased at school and their parents felt that focus on their child often was in a negative way. the adolescents described that they took responsibility for their diseases while their parents expressed a need to protect. the adolescents stated that one of the parents were always present or had been during the years, the reason being safety and security. only the parents mentioned experiences from healthcare. parents who described that they had continuity in healthcare meetings and where met by high competence and with a professional approach were more satisfied with the support from the health care. one factor that was felt to be important was whether the doctor involved the youth in the conversation or not. the teenagers in this study relied on their parents while also taking responsibility for their illness at the same time. parents, on the other hand, showed a tendency to overprotect their adolescents. for healthcare professionals it is important to involve the adolescents in the care to facilitate the transition. results: 50.9% of the children used antibiotics currently and 21.0% out of them used antibiotics ≥3 times yearly. current wheeze (w) was established in 6.5%, sleep-disturbing w in 3.6%, exerciseinduced w in 1.7%, dry night cough apart from a cold in 12.2%, and asthma in 2.3%. current antibiotics use ≥3 times yearly was positively associated with current w (aor: 13.37; 6.14-29.11; p < 0.001), sleep-disturbing w (aor: 7.87; 3.34-18.57; p < 0.001), exercise-induced w (aor: 5.44; 1.89-15.61; p = 0.002), dry night cough (aor: 3.80; 2.29-6.29; p < 0.001), and diagnosed asthma (aor: 5.68; 1.96-16.50; p = 0.001) while antibiotics use <3 times yearly was positively associated only with current w (p = 0.003) and dry night cough (p = 0.011). the results suggest an aggravating role of antibiotics use on asthma in school age thus further supporting the recommended restriction of antibiotics exposure. results: after questioning 31.6% 95% ci, 23.2-40.9 were suffering from respiratory diseases, having symptoms of chronic disease: cough-86.1%, wheezing-41.66%, tightness in the chest-27.7%. the risk factors (passive smoking, open fire house warming and no air conditioning) were commonly met in major cases at ill children rather than healthy ones (68.4% 95% ci, 59.1-76.8). as a result of studies made of the equal to 17.5 ± 0.3, comparative the end of lessons equal 19.2 ± 0.2 (p ≤ 0.05); air relative humidity varies during lessons equal with 62.9 ± 1.4 (norma toilet 30%-60%); co2 concentration exceeds allowable limits −0.3 ± 0.02 (mac −0.1%). conclusion: respiratory morbidity in high school examined has a tendency to increase. we noticed deviations from the hygienic norms: the indoor temperature and relative humidity was lower and the co 2 level was twice higher than the normal one. the "asthma ever" outcome was reported in 32 cohorts. 28 cohorts defined this as parental reported asthma (with or without specifying that it was doctor-diagnosed), 2 cohorts used gp records as the only source of diagnosis, and 2 used parental report or gp records. the "current asthma" outcome was reported in 40 cohorts. there was little consistency with how current asthma was defined or worded, with 23 different definitions used. the most common definition of current asthma, reported 16 times, was "asthma ever and either asthma symptoms in the last 12 months or asthma medication in the last 12 months". other criteria included in asthma definitions were bronchial hyper-responsiveness, reversible airway obstruction, positive exercise test, and asthma symptoms reported at a previous questionnaire. only one "current asthma" definition was based exclusively on prescription data: "dispensed two asthma medication during the past year". nine cohorts reported asthma outcomes without specifying how it was defined, and were categorized as "asthma unspecified". conclusion: "asthma ever" and "current asthma" are two main asthma outcomes used to define asthma in child cohort studies. definitions of asthma vary substantially across cohorts. case report: thereby we present two case reports of two children with impairment verbal communication as part of asd and allergic diseases. the first patient was a 3 year old boy with sneezing, rhinorrhea night cough and eye redness. he had been suffering for almost 2 years from the above mentioned symptoms. he had family history for atopic diseases and was for 7 month breastfed. specific ige revealed sensitization to birch, alder, hazel, oak, mugwort pollen and dog epithelia and dermatophagoides farinae. specific ige resulted positive for nuts and rye flour. the second patient was almost 3 year of age in the tame that he presented in our hospital. he cried and screamed all the time because of severe atopic dermatitis and typical symptoms such as itching all over the body and his impairment of verbal communication. specific sensitization showed sensibilization to egg white and egg yolk, to nuts, rye and wheat flour. the food specific ige leaded to positive results to alder, birch, hazel and oak pollen, but also to grasses, ragweed and mugwort. prick by prick test showed positivity to egg white and egg yolk. atopy patch test to pollens resulted negative. results: the first patient symptoms were well controlled after treatment with antileukotrienes. his verbal communication was also improved after a year or more. the second three year old patient after required a combination of specific treatment with antihistamines, corticosteroids, immunosuppressive drugs and diet recommendation. afterwards he had a reduced level of itching and anxiety but compared to other children he had a severe eczema. erythema multiforme (em) is an acute, immune-mediated, mucocutaneous condition that is most commonly caused by infection and drugs. it is characterized by targetoid lesions, sometimes accompanied by oral, genital or ocular mucosal erosions. there was no pediatric patient that had previously been reported in the literature with development of type 4 reaction after omalizumab treatment. we presented a case who developed em to omalizumab therapy. an 16 year-old female patient was admitted to pediatric allergy clinic with complaints of fever and rash. she had been diagnosed with chronic spontaneous urticaria (csu) 8 years ago and she was planned to treat with omalizumab (75 mg, subcutaneously every 2 week) because of the inadequate response of antihistamines at a medical center. her complete blood counts, liver, renal, thyroid function tests and serum c3,c4,c1 esterase inhibitor protein levels introduction: celiac disease is an autoimmune disease triggered by exposure to gluten in genetically predisposed individuals and characterized by chronic inflammation of the small intestine. chronic urticaria is a skin disease, characterized by the appearance of pruritic wheals with or without angioedema, whose underlying mechanism cannot be identified. objective: to report a sporadic case of an 11-year-old boy with chronic urticaria associated with celiac disease. methods: an 11-year-old boy(weight 31 kg, 3rd-10th percentiles) was admitted to our clinic with a 6-year history of chronic urticaria. during the first three years, he was under antihistamine treatment(of incremental doses)and occasionally received preparations of cortisone according to the eaaci guidelines. he was asymptomatic for 2 years until treatment was discontinued. eight months earlier, after a viral infection, a recurrence of urticaria, involving the trunk and extremities without angioedema was noted. subsequently, he was under antihistamine treatment with cetirizine but had an uas-7 score of 11. total laboratory investigations were performed. results: laboratory control was negative except for positive antibodies to celiac disease(anti-transglutaminase >200 u/ml, anti-endomysial, gliadin antibodies).further control with colonoscopy and biopsies (from duodenum and stomach) were obtained. the histopathological findings along with the clinical findings indicate celiac disease, type 3b marsch-oberhuber and grade b1 corazza-villanacci. in the past, similar cases have been reported. efforts have been made to associate chronic urticaria with celiac disease, although the mechanism remains unclarified. evidence suggests that the duration of gluten exposure, among otherwise asymptomatic patients with celiac disease, is related to the development of other autoimmune mechanisms. this can be explained by resolution of urticaria manifestations after the onset of gluten-free diet. in our case, three months after gluten-free diet, an improvement of urticaria with decreased uas-7 score of 5 was observed. conclusion: he specific case of subclinical diagnosis of celiac disease in a child with chronic resistant urticaria further reinforces the suggestion that screening for celiac disease should be included in the diagnostic approach of chronic urticaria. 1350 | allergy to gingival balm in an infant with cow's milk protein allergy we report a case of an infant with a diagnosis of cmpa with an allergic reaction to a gingival balm caused by the presence of cmp in its constitution. furthermore, it is important to reinforce that milk proteins were labeled in an unusual form which might increase the risk of misunderstanding. these findings illustrate the difficulty in implementing total avoidance of common food allergens as well as the need to improve their labeling, particularly in non-food products. bakiri ah results: after specific treatment with corticosteroids, antihistamines, emollient creams, disinfectants and antileukotriens he was feeling better, he was smiling again and wished to have the chance to play with his classmates again. conclusion: this case report shows an association between level of stress and risk for atopic dermatitis. as previously showed children with low educational level parents and boys with higher stress have increased risk of having severe atopic dermatitis as compared to "no stress" boys. so early treatment and diagnoses are key important factors improving the children`s social life. results: the data cover 69 immigrants (mean age 39.0, range 8-62) and 232 locals (mean age 40.8, range 9-80). a slight difference in male prevalence (30.4% vs 47%, p = 0.01), and pet possession (20.2% vs 41.8%, p = 0.01) were found between immigrants and locals, respectively. no differences were find in term of age and symptoms at presentation. the pattern of sensitization to the different allergens showed no statistically significant differences between migrants and controls. the rate of monosensitization resulted slightly higher in migrants (27.5%) than controls (21.1%). pollen-only sensitization was statistically higher among migrants than control (39.1% vs 22.4%, p < 0.01). monosensitization was more frequent among patients who have been living in italy for less than 4 years (52.6% vs 20%, p = 0.05). the opposite phenomena can be seen among polysensitized patients. conclusion: migrants are more frequently monosensitized than locals and tends to cluster towards either a pollen or dust mite sensitization. sensitization to house dust mite tends to appear early (< 4 years of stay). pollen or mixed sensitization is more frequent the longer the residence time. 1353 | allergenonline.org: update of comprehensive allergen and celiac protein searchable databases for risk assessment of novel food proteins goodman re 1 ; baumert jl 1 ; taylor sl 1 ; ebisawa m 2 ; ferreira f 3 ; bohle b 4 ; van ree r 5 ; kleine-tebbe j 6 ; abdelmoteleb m 1 ; koning f 7 ; amnuaycheewa p 8 conclusion: allergen and cd databases have been updated following a described review process. they can be used to identify proteins that might represent risks of food allergy or cd for affected consumers. han dh 1 ; lee jw 1 ; yim hj 1 ; ko yk 1 ; kim d 1 ; rhee c 2 1 seoul national university hospital, seoul, south korea; 2 seoul national university bundang hospital, seoul, south korea background: stress can change the immune response and aggravate various allergic diseases. we already demonstrated in previous allergic rhinitis cohort (arco) kids study that stress might be a risk factor for pediatric allergic rhinitis (ar). the aim of this arco study is to investigate relationship between stress intensity, symptoms severity and quality of life as well as allergic markers in adult ar patients. results: as stress intensity increased, the proportion of moderatesevere ar patients was significantly increased. ar patients in high stress group was likely to belong to moderate-severe group (or, 1.60; 95% ci, 1.01-2.50). global vas of ar symptom was 7.0 ± 1.9 in high stress group and 6.7 ± 2.0 in low stress group, respectively. the each 7 rqlq domain score was significantly higher in high stress group than in low stress group. total rqlq scores were 75.3 ± 35.5 in high stress group and 57.4 ± 36.0 in low stress group, respectively. however, as the level of stress increased, there were no significant changes in serum levels of allergic markers. our results suggest that stress may affect ar symptom severity and quality of life in ar patients. 1355 | skincare and synbiotics for the prevention of atopic dermatitis or food allergy in newborn infants: a 2 × 2 factorial randomized non-treatment controlled trial dissanayake e 1 ; tani y 2 ; sahara m 2 ; mitsuishi c 2 ; nagai k 3 ; sato y 4 ; suzuki y 5 ; nakano t 1 ; yamaide f 1 ; shimojo n 1 (n = 118). the skin care group was advised to apply an emollient 2-3 times/day especially on cheeks and peri-oral area. the synbiotics group consumed a mixture of fos (1 g) and bifidobacterium bifidu-mol6378 (7 × 10 9 )/day. the last group received both. emollient application was not prohibited in the no-intervention group. interventions were carried out from birth to 6 months of age. the development of ad was assessed at 1 month, 6 months and 9 months by a pediatrician and at 1 year by a questionnaire. ad was diagnosed using guidelines of the japanese society of dermatology. sensitization to food allergens was assessed by allergen-specific ige levels at 9 months of age. results: skin care and synbiotics, alone or in combination, did not prevent the development of ad at 1 year of age or the sensitization to food allergens at 9 months of age. conclusion: our data suggest that skin barrier protection using emollients may be insufficient to prevent the development of ad as other factors affecting skin barrier integrity and trans-epidermal water loss such as the method of skin washing may have an additional effect. the probiotic bacterial species used may also affect the outcome as lactobacilli have been shown to be more beneficial. more studies are required to confirm the effects of skin care and synbiotics on ad. results: in the population number of girls exceeded the one of boys (p < 0.001), especially within the age group from 4 to 15 years. questioning, for 12 months, symptoms of allergic rhinitis (rhinorrhea, sneezing, nose itch, nasal obstruction and eyes' itch) were identified in 19.5 (p < 0.05); symptoms of bronchial asthma (wheezing (14%), episodes of cough at night (8.3%), intolerance to physical load (2.5%), indoor and outdoor (13.6%), coughing and rales in response to stimulus (7.2%)) in 9.8% of the population; atopic dermatitis (dermatitis, itch, revelation in early age, involvement of large areas in early age, damage of extremities bending and stretching surfaces in adults)-5.7% (p < 0.01); food allergy-3.7% (p < 0.001) etc. at the second stage of clinical studies, on the basis of prick-testing, average ige, in our case, was 3-5 times greater than normal level. results of study of allergens showed sensibilization to domestic dust (d.f. and d.p.) (64, 43%) (p < 0.05). in 25.46% of cases there was stated sensibilization conditioned by cat and dog epidermal allergens results: among the 2624 women with available serum, 39.3% were sensitized of whom 12.5% were monosensitised, and 25.3% polysensitised (to two or more allergens). sensitisation to inhalant allergens dominated (38.9%), with grass being most common (25.5%). only 4.0% were sensitized to food allergens, most often to peanuts (2.6%), while among the 11.4% who reported ddfa, ige reactivity to foods were identified in 17.5%. compared to women with no asthma, women with dda (14.9%) were in a significantly higher background: regular exercise has been known as beneficial that it reduces the risk of chronic diseases including allergic diseases. however, little has known regarding the relationship between exercise and allergic diseases in korean adolescents. we analyzed the national data whether exercise is related to the prevalence of allergic diseases in the population of korean adolescents method: data from sixth korean national health and nutrition examination survey (2013-2014) that included 1272 adolescents from 12 to 18 years old was analyzed. we defined regular exercise according to physical activity guidelines for americans. multivariate regression analysis was performed to find whether lack of exercise could be a risk factor for allergic diseases. results: the prevalence of asthma, allergic rhinitis (ar) and atopic dermatitis (ad) were 1.3%, 9.3% and 5.2% in korean adolescents, respectively. after adjusting for factors, lack of exercise was not associated with asthma and ar, but was significantly related to ad in korean adolescents (adjusted odd ratio 3.254, 1.202-8.810 , results: it was found that over 43% of ch up to 14 y.o. having the ad within allergic disease (ads). the most significant symptom was a long-lasting itchy rash lasting for 6 month in 12.42 ± 0.56% of 1g and 9.23 ± 0.49% of 2g. the first morbidity of ad was noticed at the age of up to 2 y.o. among 56.29 ± 1.27%. at the age of ch 2-4 y.o. and older than 5 y.o. the skin ads onset was noticed for 31.12 ± 1.11% and 12.58 ± 0.57% accordingly. the ad sl was determined as follows: 52%moderate (mo), 12%severity (s), 36% were 13 ± 10 kua/l, 344 ± 132 iu/l respectively. skin prick tests were positive in 43.4% of the patients (61.7% multiple allergens). grass pollens (53%) and dermatophagoides (45.2%) were the most common allergens. average vitamin a and d levels were 469.8 ± 108 μg/l (257-832), 54.8 ± 21.3 (13-187) respectively. thirty percent of the patients vitamin d levels were mildly low, 8.6 percent was low. in control group 20% was mildly low, vitamin a levels was low in 6.7% of the patients. none of the children in control group had low vitamin a levels. we didn't find any statistical significant difference for both vitamin levels between patient and control groups. vitamin a deficiency was mostly found in asthma patients whereas vitamin d deficiency was mostly in allergic rhinitis and asthma groups. passive smoking and vitamin d deficiency was significantly related (p = 0.09). there wasn't any relation between asthma attacks and vitamin levels. conclusion: in conclusion vitamin a and d levels weren't found significantly related with allergic diseases but was found lower than control group. patients having chronic diseases are one of the population groups that are chronically exposed to drugs. this study aims at evaluate the impact of this factors in developing drug allergies in the medical staff. method: this was a cross-sectional study that included 639 nurses from the uhc "mother theresa" of tirana. they were asked to fill up a questionnaire where questions about chronic diseases and drug allergies were included. 92.18% were females and the mean age was 43.28 (+10.71) years old. relative risks with 95% ci were calculated for different groups. results: 40.69% (260) nurses reported to have at least a chronic disease. the most common non-atopic disease was hta followed by the groups of autoimmune and thyroid diseases. nurses who had one chronic disease have a rr of 1.82 (95% ci = 1.03-3.21, p < 0.05) to develop a drug disease higher than those who didn't had any chronic disease, and those who have more than one chronic disease have a rr of , p < 0.05) to develop a drug disease. the presence of chronic diseases can be a risk factor to develop a drug allergy probably through the increased risk to drug exposure. these patients may be exposed to drugs not only through therapy but also through hospitalizations and other forms of health care. lapeere h 1 ; oosterlinck p 2 ; vermeir p 3 ; vermeire i 2 ; coppens m 3 ; gevaert p 3 1 ghent university hospital/ghent university, ghent, belgium; 2 ghent university hospital, ghent, belgium; 3 ghent university hospital/ghent university, ghent, belgium background: the key to managing latex allergies in healthcare professionals and patients lies in correct recognition and appropriate action. 7.7 million people are employed in the health care sector. while there are no overall statistics on the prevalence of latex allergy in that work force, studies do indicate that 8%-12% of health care workers regularly exposed are sensitized, compared with 1%-6% of the general population. latex allergy is defined as an immune mediated reaction to latex products (e.g. balloons, contact dermatitis for gloves, condoms, surgical catheters); these encompass immediate and delayed hypersensitivity reactions. method: based on the experience of the belgian dutch pathway network, a 7-phase method to develop, implement, evaluate and continuously follow up a care pathway for latex allergy was designed and implemented. the purpose of the study was to develop and implementation of latex allergy clinical care pathways to provide all staff at ghent university hospital with appropriate knowledge and skills to identify and manage patients who have a known latex allergy or those at risk of developing latex allergy. results: care pathways, also known as clinical pathways, are used all over the world to implement and monitor patient-centered care processes in a transparent way. care pathways are defined as a complex intervention. 7 -phase method consists of: 1) screening phase; 2) project management phase; 3) diagnostic-and objectification phase; 4) development phase; 5) implementation phase; 6) evaluation phase and 7) continuous follow-up phase. this phased approach is based on the deming cycle, better known as the "plando-study-act" (pdsa)-cycle. conclusion: this method can offer support to multidisciplinary teams (re)designing and implementing safe, efficient, effective, person-centered, timely, equitable, continuous and integrated care processes. however, the method is no guarantee to success. the key to success is the collaboration and critical attitude of the entire multidisciplinary team when implementing pathways. background: cord blood ige (cb-ige) were considered to be a useful predictive tool for allergic symptoms especially in early childhood. there is only sparse knowledge about their importance for health in later life. the aim of our work was to determine the importance of cb-ige for allergic symptoms in young adults. we also studied the possible modifying factors for cb-ige concentration. results: resutls shown as daily mean, pollen grains/m³: table 1 . the daily means of pollen concentrations of cupressus arizonica, platanus acerifolia and plantago lanceolata in our area differs from other sites in madrid city. although cupressus arizonica and platanus acerifolia counting were lower, plantago lanceolata counts were higher, representing a relevant pollen in our area. the clinical relevance of these findings is under evaluation by our group. method: grass pollen counts were performed since 1979-2016 using a burkard 7 days spore trap located in our allergy center in madrid. the beginning of the algid period of pollination was considered the first of three consecutive days with more than 10 grains/m 3 and the end, the last day of three consecutive days with more than 10 grains/m 3 . madrid, barajas meteorological station data, was used. skin prick tests (pt) to grass pollen was also studied in comparison conclusion: total grass pollen concentration did not suffer any increase or decrease in its counts despite the dramatic increase of the temperature. an advance at the beginning and the end of the season was seen. these changes significantly correlate with the temperature increase during may and july. discrete decrease in the sensitization prevalence. since several years, the reference method to monitor the biological particles concentrations has been the hirst method: a volumetric pollen trap, located on the roof of building for background measurements, sucks continuously 10 l of air per minute, particles depositing by impaction on a coated tape. the tape is then analyzed by optical microscopy. the hirst method produces accurate but past data. nowadays, many researches are focused on the development on new devices to get real time information. method: rapid-e from plair sa is a device using red laser beam to determine the size and the shape of sucked particles and an ultraviolet ray to measure the fluorescence of these particles. the results: the correlation coefficients got between rapid-e and hirst trap are higher than 70% for most of calibrated pollens, this correlation reaching 86% for all pollen taxa: • plane 99% • pine 99% • birch 96% • oak 82% • plantain 75% • dactylus 73% • urticaceae 55% conclusion: new calibrations are planned for 2018 and a real time information will be set up. results: the quinquennial media concentrations since 1979-2016 were 3.866; 4.903; 6.610; 13.454; 9.501; 7.248;11.027 and 19.406 grains/m 3 . the quinquennial media temperatures were 14.2; 13.8; 14.3; 14.9; 14.2; 14.7; 14.9 and 15.8°c. increase of 1.4°c (r s = 0.9 p < 0.05). the beginning and the end of the actual season advanced 5 days respectively in regard to the period from 1979 to 1983. the annual prevalence of positive pt to platanus in 1979 was 2% an 52% in 1994. the quinquennial media from 1999 to 2016 was 50, 38, 26 and 29%. conclusion: platanus pollen counts had a dramatic increase that meaningfully correlates with the dramatic increase of the temperature. a discreet advance at the beginning and the end of the season was seen. these changes did not influence in a longer duration of the season. we observed a significant increase in platanus pollen sensitization prevalence whiting madrid pollinosis patients. results: the quinquennial media concentrations since 1979-2016 were 1963, 4813, 5455, 6948, 6985, 5976, 6727 and 9298 grains/m 3 . the quinquennial media temperatures were 14.2; 13.8; 14.3; 14.9; 14.2; 14.7; 14.9 and 15.8°c. increase of 1.4°c (r s = 0.9 p < 0.05). the actual season beginning advanced in 51 days and the end has results: over 60% of house dust samples collected between april and may from central european countries were found to contain bet v 1 allergen at levels well above the limit of detection of 0.0039 μg/g for elisa 2.0 ep kit and 0.001 μg/g on maria. samples were found to have much higher levels of bet v 1 allergen from midto-late april, particularly those that were collected in germany, belgium and hungary. samples taken from outside of the pollination season were tested and found to be negative for bet v 1. in conclusion, we found that bet v 1 allergen can be detected and quantified in house dust samples. these data suggest that household dust is a source of pollen allergen and could therefore be contributing to asthma and allergic rhinitis symptoms in individuals affected by pollen allergy. household dust may also be considered as a source of bet v 1 allergen which could contribute to allergic sensitization. 1383 | cupressaceae pollen in the atmosphere of alentejo: disruption of pollen grain during air transport spring, depending on the temperature. despite being considered moderately allergenic, it might be responsible for winter allergic outbreaks. as ornamental trees, they are found scattered throughout the territory but are more abundant in pockets of wild forest, outside alentejo. despite being more common in mountain, this pollen type is captured in considerable amounts in alentejo, portugal, where its aerobiological features and allergenic impacts are poorly characterized. the aim of this work is to characterize the aerobiology of cupressaceae pollen, to evaluate the effect the meteorological conditions and the source of this allergenic pollen type in the atmosphere of evora, alentejo. method: pollen were collected using a hirst type 7-day pollen trap and pollen was identified following standard methodology. background: allergic rhinitis caused by pollen is one of the most common allergic diseases. the presence of pollen in the air is currently centrally monitored at roof top levels, and not in the direct living environment of sensitized subjects. in the current project we aimed to develop a handheld pollen sampler, called pollensniffer, that can collect pollen in the living environment of the allergic subjects. as a first step this device was validated against the standard burkard pollen sampler and used to monitor local pollen concentrations at street level in the city of leiden. method: rooftop level pollen were monitored routinely by a hirst type pollen sampler (burkard, uk). the pollensniffer ( 1385 | does the allergy risk due to pollen exposure information is useful for the allergy sufferers? sindt c; oliver g; thibaudon m background: in france the information for the allergy sufferers is not made with pollen counts, which have not a real signification, but with the allergy risk due to pollen exposure. method: since more than 20 years, rnsa (réseau national de surveillance aérobiologique), the french aerobiology network, has measured the pollen exposure in the main cities of france, using background: the effect of environmental factors on allergic sensitizations is still unclear. rural areas vs cities have different exposure levels to pollutants and aeroallergens. these differences could give clues on the causes of higher allergic sensitization rates in children exposed to city air. method: two studies with children aged 5 years old were initialized to analyse the airborne drives of allergic sensitization: seal (günzburg, 350 children) and ae2r kids (munich, 200 children). capillary blood was collected and the parents filled in a questionary. sensitization rates were quantified using the immunocap ® isac sige array. pollen data were measured at both locations. results: in günzburg more children were sensitized to aeroallergens, however munich children showed significant higher sensitization to phl p 1 (p < 0.05), despite the lower concentration of pollen. in günzburg 66% children had no sensitization at all compared to 58% in munich. 80% of the children in munich spend at least 1 hour per day outside and 91% of the total have no animals at home. 23% felt symptoms of hay fever in the last 12 months, the majority between march and june, which correlated with the pollen flight. results: the total rate of atopy in crd patients was 36.1%, and asthma patients was the highest (45.9%). the positive rate of phadiatop in urban asthma patients (56.0%) was significantly higher than that in rural areas (25.0%, p < 0.05) and the phadiatop positive rate of office staff (62.5%) was significantly higher than that of outdoor workers (37.5%, p < 0.05). the total rate of atopy in copd patients was 32.7%, and in patients with acute exacerbation was 42.9%. beside, atopy is a risk factor for dyspnea (or = 1.22, p < 0.05), and the fvc levels in copd patients with atopy were significantly lower than those without (2.06 l vs 2.63 l, p < 0.05). optimal scaling analysis show that, there were a correlation between the tige and smoking coefficient (cronbach's alpha = 91.1%). in addition, the correlation between the level of tige and phadiatop sige was so strong in the patients with mild to moderate asthma (r s = 0.709, p < 0.001), but it was weak in severe asthma patients (r s = 0.486, p < 0.001), and up to 35.0% of the gold iii iv patients with low phadiatop level (≤10 ku/l) had a high level of tige (≥1000 ku/l) compared gold i ii (5.5%). conclusion: the rate of atopy in patients with crd is high, and atopy is an important factor affecting the process of crd. the patients with severe copd or asthma is likely to has high serum tige level but the level of common allergen sige is low, so the allergy screening strategy should be adjusted and we should pay attention to those patients, therefore, it is necessary to screen the sensitization situation of crd patients at first, and the results can guide the treatment, management and prevention of crd. background: due to a limited amount of epidemiological data [1] it has been thought that many severe allergic asthmatics in germany remain unidentified and are therefore not adequately treated. a pilot project demonstrated that more than 50% of patients, having been mean total ige (sd) was 366.4 (692.2) ku/l. 26.5% of the patients had no sensitization towards any of the specific iges tested, whereas 24% were positively tested on 5-10 allergens and further 23.5% showed sensitizations towards >10 allergens. conclusion: approximately 75% of 392 online recruited (severe) asthmatics had a total ige level of >30 ku/l and ≥1 sensitization (allergen-specific ige) towards atopic allergens. this further supports the high prevalence of atopy in asthma. results: 875 patients (mean age: 26 ± 11.9 years, range 2-64 years, m/f ratio: 0.89) who suffered from allergic rhinitis or allergic rhinoconjunctivitis enrolled in this study. highest rate of skin sensitivity was for weeds/grasses pollen including salsola kali, amaranthus retroflexus, chenopodium album and compositae family (74.3%, 62.5%, 50.9% and 39.3% respectively). among tree's pollen; ash (49%), walnut (46.9%) and mesquite (29.3%) were the most common. less than 20% of patients showed skin reactivity to indoor allergens and storage mites, mix of cockroaches and house dust were the most common (17.6%, 17.3% and 9.8% respectively). the results of current study confirmed the importance of weed/grass and trees pollen as the major source of allergic sensitization in our area. interestingly the rate of sensitization to indoor allergens was low which can be explained by geo-climatic situation. background: there are few studies of cutaneous sensitivity to gramineae in our region. mostly of them use allergens of foreign species. the study aims to estimate the prevalence of skin sensitivity to widespread grasses in our region. method: this is a retrospective observational study of 894 patients with seasonal allergic rhinitis. patients were studied using skin tests with pollens extracts from pooideae, chloridoideae and panicoideae grass species. results: the prevalence of positive reaction to pollen from pooideae subfamily was 86.8% (ic: 84.4%-88.9%). in turn, prevalence of allergy to panicoideae subfamily pollens was 69.6% (ic: 66.5%-72.5%) and positive reaction to chloridoideae subfamily reach 48.1% (ic: 44.8%-54.1%). cochran test suggests that prevalence in those three groups is different (χ2 = 319.11, p < 0.01). when comparing just the groups of allergens from pooideae and panicoideae differences are also significant (χ2 = 71.43, p < 0.01). in particular, 52.5% (ic: 49.2%-55.7%) of patients were allergic to paspalum notatum. regarding cross-reactivity between subfamilies, we find a no crosscorrelation between pooideae and panicoideae (χ2 = 2.197, p = 0.138). conclusion: in bahia blanca, patients with seasonal rhinitis are sensitive to pooideae, chloridoideae and panicoideae. paspalum notatum, belonging to panicoideae, has a significant prevalence, high reactivity and low cross-reactivity within the group of species studied. this last species is relevant because it is a native grass from the northwest region of our country, paraguay and the south of brazil. prevalence of grass positive skin tests in patients with seasonal rhinitis by species. allergen frequency percentage 95% ci results: correlation analyzes were performed between sige and spt and area results. the concentration with the highest correlation by diameter and area for blo t was 30 μg/ml and for der f of 400 μg/ml. in the case of der p the concentration with the highest correlation for the diameter was 30 μg/ml and for the area of 3 μg/ml. when evaluating the reproducibility of the results according to the area and the greater diameter of the spt, a strong agreement was observed for blo t in the concentrations of 3 μg/ml and 0.3 μg/ml. results: among the 94 patients, the majority of allergens-positive was t20, accounting for 60.6%, followed by f14 (59.6%), f13 (58.5%), ds1(57.4%) and ccd (56.4%). the prevalence of plant-related allergens (t20, w1, f14, f13, w6 and u80) in ccd-positive patients were significantly higher than those in ccd-negative patients (all results: with our new point-of-care methods using a selected recombinant protein e other markers, we were able to detect the disease early as 10 days post-infection and more than 95% of positive cases from chronic and low endemicity areas (which are characterized by hard to detect patients with extremely low parasite load, <10 eggs per gram of feces) were obtained. plus, chromatography poc-cca ® test was improved by our group with a urine concentration step that turned its sensibility from 6% to 56%. conclusion: monoclonal antibody and recombinant protein technologies allowed superior detection methods when comparing it to the conventional ones. in conclusion, data showed 100% of sensitivity of chronic patients and 98% of acute patients. marton c county hospital, oradea, romania background: allergic rhinitis is a disease that affects about a quarter of the population, a disease with an important negative impact on daily activities, both on learning and working ability, as well as spending leisure time or sleeping. in the western part of romania, the most popular and blamed allergen is ambrosia, in the late summer months. it is a plant of the compositae/asteraceae family, along with goldenrod, sunflower, dandelion, cocklebur, chamomile, wormwood, daisy, etc. allergen identification is important for applying prophylactic measures, but especially for determining the allergen to be desensitized. considering the possible cross-reactivity within the compositae plant family, as well as the possibility of co-sensitization, as well as the number of patients sensitized to these pollens, which is steadily increasing, i considered is necessary a broad screening for a more precise identification of the allergen and increase chances for a successful desensitization. method: the observational study includes 37 patients who presented on october for testing with standardized allergen extracts, as recommended. criteria for inclusion: patients with specific symptoms of rhinoconjunctivitis in august and september, with or without asthma symptoms, who returned for allergic prick test after the end of treatment. criteria for exclusion: patients who disagreed with cutaneous testing, who did not discontinue antihistamine treatment or who had been treated for other diseases with drugs that influence skin testing. background: in recent years, cationic liposomes are thought to be the most effective and non-toxical nucleic acids`transport system, so most of gene therapy drugs are developed on their base. however, lipoplexes are quickly captured by reticuloendothelial system cells after the injection and taken out of a blood stream. there are many modification methods of liposomal surface for liposomes with prolonged pharmacokinetic properties production. addition of hydrophilic polymers (peg) is seemed to be the most promising approach, that is able not only to create steric barrier on the particle`s surface and prevent the interaction with blood plasma lipoproteins, but also inhibits the protein adsorption, opsonisation and subsequent degradation in human body. the aim of this study is the evaluation of liposomal surface modification by hydrophilic polymers influence on nucleic acids`lipoplexes conjugation and on their physico-chemical and biological properties. method: liposomes preparation (including peg-modified liposomes), size determination by photon-correlation spectroscopy, examination of transfection efficacy by luciferase assay. (c16h33)2) were obtained. also the modified liposomes were produced by addition of 5% of peg (by mass) during thin lipid layer preparation step. the size distribution was analysed by photon-correlation spectroscopy. it was shown that peg addition does not increase the parconclusion: it can be noted that addition of peg can change the lipoplex formation but the cationic liposomes still remain an effective rna delivery system. and peg modification will be able to impart prolonged properties for the vehicle in bloodstream. foundation (grant № 17-74-10111). ory c4 may cause a cross reaction with fel d4 (cat), can f6 (dog), equ c1 (horse), mus m1 (mouse) and rat n1 (rat). february 2017 eight patients that were treated at our institution were diagnosed with rabbit allergy. results: all eight patients with the diagnosis of rabbit allergy presented with signs of upper respiratory involvement. two patients had itching teary eyes, watery nasal discharge and sneezing while feeding farm rabbits. one of those also presented with dyspnea. four patients developed problems whenever in contact with domestic rabbits. one patient developed allergic rhinoconjunctivitis whenever she was home-her parents own a rabbit, but while away in her college room she had no problems. another patient had dyspnea whenever visiting his girlfriend's house. she owned a rabbit. two patients developed asthma-like symptoms, one also presented with angioedema. the other two had developed allergic rhinoconjunctivitis. two patients have problems in contact with cats, one of them also with cows, however skin prick tests were also positive to rabbit. three out of eight patients developed allergic asthma with a positive methacholine test. six patients had a positive house dust mite prick test. all patients were diagnosed with a positive prick tests to rabbit allergens. all were treated with a nasal steroid and antihistaminesic. they were also advised to avoid contact with the animal. conclusion: domestic rabbit-induced asthma and/or allergic rhinoconjunctivitis is possible, however it is still rare in our environment. it is very important to always ask the patient about their pets in general, not just focusing on cats or dogs. only with a thorough examination and history we can find the true cause of the patient's allergy where pets play an important role. korea. changes of protein and major allergen concentration were measured over one year by bradford assay, two-site elsia, and sds-page after reconstitution of the lyophilized allergen extracts in various buffer (normal saline, 0.3% phenol saline, and 10 or 50% glycerol with saline) and stored at room temperature (rt, (18) (19) (20) (21) (22) (23) (24) (25) (26) or refrigerated (4°c). results: more than 90% of the initial protein concentration in all four extracts examined was detected over one year when 50% glycerol was added and refrigerated, whereas 57.9%-94.5% remained in the extracts at rt. the addition of 50% glycerol to the storage buffer was found to prevent protein degradation at rt. all four extracts were found to be stable when reconstituted in 50% glycerol. amb a 1, a major allergen of ragweed, was almost completely degraded in 9 weeks at rt when reconstituted in a buffer without 50% glycerol. however, 55.6%-92.8% of amb a 1 content was detected after one year of incubation at 4°c in all buffer conditions except 0.3% phenol. conclusion: addition of 50% glycerol as well as refrigeration was found to be the important to increase the shelf-life of allergen extracts from pollens of allergenic importance. results: this is the first genetic study of the bulgarian hae patients. genetic defects were identified in 10 hae families are: 3 nonsense, 2 splice-site defects, 2 frameshift mutations, 1 indel non frameshift, 1 missense, and 1 large deletion of exon 4. novel mutations, not previously reported in human gene mutation databases were discovered, and were predicted to be deleterious due to the expected effect on dna transcript and protein. descriptive statistics were used to summarize the eq-5d-y descriptive system responses and vas scores by treatment and visit. results: twelve patients with hae type i and a median (range) age of 10.0 (7) (8) (9) (10) (11) years were enrolled, 7 (58.3%) of whom were female. during bop, treatment with 500u c1 inh, and 1000u c1-inh, ≤33.3%, ≤22.2%, and none of the patients, respectively, reported having problems with mobility, self-care, doing usual activities, pain or discomfort, and feeling worried, sad or unhappy. the mean [sd] eq-5d vas scores increased from 78.3 (13. results: overall, the model-derived median exposure and peak concentration across all weight ranges in paediatric patients is predicted to be higher with 5 wb vs weight-based dosing (table) . the effect was most pronounced in patients aged 2-5 years, where the 5wb dosing achieved approximately 30% higher values than weight-based dosing for median auc 0-6 (1251 ng hour/ml vs 853 ng hour/ml, respectively) and c max values (777 ng/ml vs 529 ng/ml, respectively). the 5wb levels are closer to those in adults receiving 30 mg icatibant (median auc 0-6 2975 ng hour/ml; median c max 1254 ng/ ml) but never exceed them. results: samples from 124 patients were analysed. lanadelumab concentrations in plasma increased with higher doses and dosing frequencies. steady state was reached around week 10 (range week 8 to week 14 as evaluated by predose concentrations). at baseline, mean (sd) chmwk levels were 49. 9% (28.8), 47.7% (27.1), 53.7% (24.5) and 48.4% (30.0) for patients in the placebo and lanadelumab 150 mg q4 wks, 300 mg q4 wks and 300 mg q2 wks treatment arms, respectively. by week 14, mean (sd) chmwk levels decreased to 24.0% (13. 3), 28.7% (17.2), and 22.4% (11.5) following treatment with lanadelumab 150 mg q4 wks, 300 mg q4 wks, and 300 mg q2 wks, respectively, and remained reduced throughout the treatment period. conversely, chmwk levels remained elevated at 52.3% (28.1) at week 14 in patients who received placebo. patients in the placebo group had the highest attack rates over the 26-week treatment period (mean 2.46 attacks/month), whereas the rates were markedly lower in patients treated with lanadelumab 150 mg q4 wks (0.48 attacks/month), 300 mg q4 wks (0.60 attacks/month) and 300 mg q2 wks (0.31 attacks/month). dose-and frequency-dependent manner. exposure to lanadelumab was associated with decreased chmwk levels (indicating inhibition of plasma kallikrein activity) and lower hae attack rates, corroborating the efficacy findings and utility of chmwk as a bioactivity marker in the help study. with cyklokapron (tranexamic acid) since she was 9 years old and took the medication very irregularly due to lack of efficacy. one year before presentation at our clinic, she married and moved to vienna. we started a treatment with the bradykinin-2 receptorantagonist icatibant sc at the beginning of the menses and if needed a second time at the time of ovulation. she responded well until she got pregnant. during pregnancy, she developed weekly attacks with increasing severity. therefore, a weekly treatment with humanplasma-derived, pasteurized, nanofiltered c1-inhibitor (inh)-concentrate, 1000 units iv once a week was started and had to be increased to twice per week after one month of therapy due to increasing number and severity of attacks. results: with this treatment attack frequency and severity attenuated. in january 2016 she had a normal delivery at term and gave birth to an otherwise healthy son. treatment had to be continued during 1 year of lactation period and also thereafter due to persistent attack severity. conclusion: there are only limited data for the use of humanplasma-derived, pasteurized, nanofiltered c1-inh concentrate during pregnancy and lactation period. this case confirms the safety and efficacy of the named drug during these periods. wheals are yet classified. the best characterized stem from hereditary or acquired c1 inhibitor deficiency (c1-inh-hae and c1-inh-aae) . last year, the french angioedema network (creak) joined the registry of angioedema without wheals (cloud-r hae). here we present the contribution of the grenoble alpes university hospital (chuga) to this disease registry. the study population is composed of patients with a proved diagnosis of c1-inh-hae/aae. the following items are collected: patients' personal-demographic data, clinical/laboratory/genetic characteristics, major comorbidities, treatments (prophylaxis/acute attacks). data from existing registries at chuga are merged into cloud-r hae and missing data obtained at follow-up visits. as from cloud-r hae structure, patients can directly provide information on angioedema attacks and their treatment through a dedicated electronic app, web connection or paper support, which is then transferred into the registry at chuga. method: in a retrospective study, we included a total number of 48 patients, suffering from a chronic skin disease, whose lesions did not improve or even worsened under immunosuppressive treatment (18 chronic ulcers/pyoderma gangrenosum, 21 bullous autoimmune diseases, 9 skin lymphomas). ffpe tissue was examined for the presence of cmv dna by pcr. next, within the framework of a small prospective study (n = 29) we analyzed the seroprevalence of cmv as well as the presence of cmv dna in lesional skin in patients that had been diagnosed with a chronic skin disease and in whom longterm immunosuppressive therapy had been initiated. results: in the retrospective study cmv dna could only be detected in 1/18 chronic ulcers/pyoderma gangrenosum (5.6%), but not in bullous autoimmune diseases and skin lymphomas. 21/29 patients (72.4%) of the prospective study group were seropositive for anti-cmv-igg, as compared to 55/87 patients (63.2%) in an ageand sex-matched control group. anti-cmv-igm could be detected in method: in this study, we aimed at testing the diagnostic potential of skin function measurements in ss. sixteen patients with conformed diagnosis ss were enrolled in the study. skin fibrosis was assessed by conventional rss and involvement of inner organs and serum inflammation parameters were determined. four objective criteria, namely transepidermal water loss (tewl), corneometry, ph and elasticity, were assessed at nine predefined sites of the body. results were compared to patients with atopic dermatitis (n = 19) and acne vulgaris (n = 22). method: a multicenter prospective observational study was conducted to investigate the clinical significance of serum scca2 in children as a biomarker for ad. patients with ad younger than 16 years old and age-matched healthy children without any allergic disease were enrolled in this study. the severity of ad was evaluated using the objective scorad (o-scorad). the serum levels of scca2, tarc and total ige were also measured. results: in total, 176 patients with ad and 159 non-allergic healthy children were recruited. the serum levels of scca2 had the strongest significant correlation with o-scorad, compared with tarc and ige (r = 0.622, 0491 and 0.407, respectively). after standard treatment with topical steroids and emollients resulting in an improvement of symptoms, the serum levels of scca2 and tarc decreased significantly. the area under the curve (auc) for the roc curve was higher for scca2 (0.929) than for tarc (0.871) or ige (0.820). the difference in aucs between a single cut-off value and age-dependent cut-off values was not significant for scca2, compared with that for tarc (0.042 and 0.064, respectively). conclusion: scca2 is a more reliable biomarker than tarc for the diagnosis of ad and for determining the clinical severity of ad in children. challenges in predicting severity of atopic eczema patients results: before modeling, we checked for significant differences between patients and controls. these were detected for the levels of ccl17, ccl22, cxcl10, ige and ldh. next, we assessed whether single serum proteins already explain disease severity by calculating correlations. twelve of the proteins, namely gcsf, il-5, il-13, il-22, ccl22, il-1ra, cxcl8, ifng, ccl3, il-1ß, ccl17, and il-6, significantly correlate with severity (r 2 range: 0.3-0.45). finally, we built a model for the severity of ae based on all measured serum proteins. ten of the proteins are included in the best-fit model (adjusted r 2 =0.47). the overall correlation between original and predicted severity scores is high (r 2 =0.759) nevertheless the cross validation prediction error is substantial with 19%. conclusion: applied in daily practice, a prediction error of 19% translates to a possible miscalculation of 19 scorad points in both directions and therefore the model is of no practical use. aside from using model-based quality measures like cross validation prediction errors to infer the usefulness of predictive models, testing them in independent cohorts could validate these models. collaborations among scientists working on similar approaches would lead to an increase in statistical power and ideally to more robust models. only robust and validated models are going to have the chance to take the step forward from being a result of computational modeling to being applied in the clinical practice of assessing disease severity in patients. jargosch m 1 ; lauffer f 1 ; pätzold k 1 ; krause l 2 ; garzorz-stark n 1 ; schmidt-weber c 3 ; eyerich s 3 ; eyerich k 1 preclinical studies in cell cultures, mice, guinea pigs and rabbits, comprising sterility, cytotoxicity, systemic toxicity, skin irritation, delay contact sensitization and phototoxicity tests, demonstrated safety of this therapeutic agent. we next conducted a single-blinded, intra-individually controlled, 2phased clinical trial on patients with keloids. the aim was to determine the effects of 1-month therapy on keloid volume and symptoms of pain and itch. two similar keloids on each subject were selectedone was treated with once-daily, self-administered application of triamcinolone-loaded (0.015 mg/patch) microneedles for 4 weeks, while the other served as control with no intervention. outcome measures were (a) keloid volume using a 3-dimensional high-resolution (0.1 mm) scanner and (b) pain and itch scores on 0-10 numerical rating scales. evaluations were performed at baseline, 4 and 8 weeks. in phase 2 of the trial, the whole process was repeated using microneedles loaded with a higher dose of triamcinolone (0.1 mg/patch). case report: a 15-year-old girl was admitted to our department with a single round-shaped lesion in the popliteal fossa which spread to extremities, trunk and face and persisted for several weeks and then faded slowly to residual hyperpigmented patches. courses of antihistamines, antibiotics, cyclosporine a, fluconazole, hydroxychloroquine, prednisolone and topical steroids were ineffective. also patient has had history of itchy urticarial rash and angioedema since 5-year-old, suffered from the flares triggered by physical exertion, stress, cold air and water, spicy food, which resolved within 3-4 hours. the patient's father and 7-year-old brother also had chronic urticaria induced by the same stimuli. the physical examination revealed multiple pink-to-red non-scaly, non-pruritic papules coalescing into annular, arcuate, polycyclic plaques (4-5 cm) with central clearing, centrifugal spread, indu1448 | the role of humoral immunity in the pathogenesis of psoriasis results: we found significantly increased levels of iga in the serum of treatment-naïve psoriasis patients correlating with disease score. however, iga was only observed in dermal vessels of skin sections. we next performed in-depth analysis of peripheral b cell subsets using flow cytometry. among all investigated subsets, we only found a moderate positive correlation of cd138 + plasma cells with iga levels and disease score in untreated psoriasis patients. however, in the group of treated psoriasis patients, neither did iga levels drop nor did plasma cells correlate with iga levels and disease score, rather hinting at an epiphenomenal finding. confirming our hypothesis that psoriasis can develop in the absence of proper humoral immunity, we present a patient who suffered concomitantly from both psoriasis and a hereditary common variable immune defect (cvid). conclusion: here, we provide new insights in the immunology of psoriasis, demonstrating the clear dominance of t cells over shifts in b cell subsets. conclusion: allergic diseases show an increasing incidence in geriatric age. this is partly due to the growing emphasis on a more accurate and careful diagnosis of the aging population. we must also take into consideration the influence of other factors, besides comorbidities and therapeutic regimens in elderly that might affects the immune response, such as environmental pollution as well as food contamination and changing dietary habits of elderly such as easy access to exotic food. one of the challenges in the decades to come is recognizing and fulfilling the need for accurate and timely diagnostics of allergic manifestations in elderly patients, as important part of achieving the best possible quality of life for this growing age group. method: sixty-eight patients with various forms of psoriasis and 30 healthy subjects (healthy control group) were assessed after informed consent was obtained. all subjects were asked to complete a questionnaire including age, gender, duration of psoriasis, concomitant diseases and medications. in the group of patients psoriasis was with only skin involvement with skin plus joints involvement ranging from moderate to severe. psoriaticplaques were evaluated by a specialized medical team using the psoriasis area and severity index (pasi). all patients were seen by a dermatologist and clinical immunologist, who collected data considering the demographic, health status and any other relevant details. blood samples included serum levels of 25-hydroxycholecalciferol and tnf-α using an elisa kit (germany). method: 30% ethanolic extract of sp (sp etoh ) and its five major chemical constituents are prepared. to elucidate whether human orai1 modulated by sp etoh and its chemical constituents, conventional whole-cell patch clamp performed in horai1-overexpressing hek293t cell. we also assessed whether sp etoh and its constituents could inhibit mast cell degranulation and t cell activation. results: in jurkat t lymphocytes, we found that 3 mg/ml sp etoh inhibited orai1 current (i orai1 ) by 81.0 ± 11.1%, while one of its constituents (compound v (com v ); 100 μm) inhibited i oria1 by 48.9 ± 8.71%. investigation of human primary t cell proliferation induced by co-stimulation with antibodies to cluster of differentiation 3 and 28, and of rbl-2h3 mast cell degranulation following ige-antigen complex stimulation, revealed that 100 μm com v inhibited both t cell proliferation (by 34.8 ± 6.08%) and mast cell degranulation (by 36.7 ± 0.07%); these effects were concentrationdependent, and no cytotoxicity was observed. conclusion: considering that most regional plants have not been investigated chemically or pharmaceutically, they remain as untapped potential sources of topical agents for drugs and other application. our findings suggest that com v , which derived from sp etoh , represents a promising candidate compound for the development of therapeutic agents for the prevention and treatment of allergic diseases. results: the cohort consists of 14 caucasian patients. eight of them (57%) are women. the mean age (and range) at the clinical presentation of disease was 33 years (4-51 years). the mean age at diagnosis for men was 23 years and 48 years for women. all patients have a positive history of recurrent and/or persistent lip swelling, 3 of them (21%) report oral ulceration, 5 cases (36%) have history of previous or current facial palsy and 4 patients (28%) present tongue fissuring. concurrent cd has been diagnosed in one patient. biopsy reports were available for 10 patients (71%); in 6 cases (60%) non-caseating granulomas were seen. various therapeutic approaches have been described: intralesional corticosteroids had a good response in 6 patients, infliximab was partially effective in 3 cases; oral corticosteroids and/or methotrexate seem to cause a partial symptoms improvement. conclusion: this is the first attempt, in our knowledge, to (a) centralize all data of patients with ofg in a national registry with the aim of carrying out epidemiological data and (b) develop italian guidelines including a diagnostic-therapeutic flow chart, shared by the participating centers. the registry will guide the clinicians in the identification and management of the ofg patients, reducing the diagnostic delay and hopefully improving quality of life. case report: a 10-year-old girl without personal history of atopy, got a temporary tattoo with henna. after three days, she developed a local exudative, erythematous eruption with painful blisters lesions that followed the contours of the tattoo. she had neither fever nor other lesions. she was treated with topic methylprednisolone-gentamicin showing an important improvement 10 days after. as a liquenoid scar remained in tattoo area, trofolastin ® (centella asiatica, αtocopherol, hydrolysed collagen, elastin) patch was prescribed to be placed on the scar. forty-eight hours later, the patch was removed and was newly observed an exudative, erythematous and painful wound that required oral treatment with amoxicillin-clavulanic. after three days, the girl developed on a maculopapular, generalized and itching rash. she was treated with dexchlorpheniramine and methylprednisolone with a complete resolution in 4 days and she was referred to our allergy unit to be studied because of a suspicion of drug allergy to amoxicillin-clavulanic acid. an allergy workup was performed after obtaining an informed consent. case report: it may be sometimes difficult to find the causing allergen in allergic contact dermatitis. face is a region on which various materials contact. in this manuscript a woman case is presented who shows patch test positivity to her husband's shaving product. a 35 years old woman applied because of allergic contact dermatitis on her face. it is learnt that lesions have been continuing for a long time, occasionally getting well with corticosteroid creams; but continuing again. patch test was performed with european standard series and cosmetic products she was using. negative result was observed. following, patch test was performed for the products her husband was using. 2 positive results were obtained for the shaving cream of her husband was using. in detailed anamnesis, it is learnt that the lesions developed approximately 1 month after her husband started to use this cream. it is advised not to use this product to her husband. the disease did not repeat again. it should not be forgotten that cases with allergic contact dermatitis could get in touch with allergenic materials via individuals in close contact. gül ü akdeniz university faculty of medicine, department of dermatology, antalya, turkey case report: tnf-alpha plays role in etiopathogenesis of allergic contact dermatitis (acd). in mice which lack tnf-alpha, the response of late type hypersensitivity is spoiled. in addition, tnfalpha blocker are also used in some cases with acd. in this poster the results of european standard patch test is given in which acd is observed and tnf-alpha blocker are used without dermatological indication. 3 cases who use tnf-alpha blocker applied because of acd: there was lesion in one case on face, in other case on face and hand, and in the last case only on hand. european standard patch test was performed to patients who were continuing to use tnf-alpha blocker. in one case no positive response was observed, while in two cases positive response to more than one allergen were obtained. in conclusion, tnf-alpha blockages cannot suppress the response of delayed type hypersensitivity. 1459 | case of allergy to nickel on the background of its intake in food peredelskaya m case report: nickel is one of the most commonly used metals; it is used for the manufacture of jewelry, plates and dishes, and medical products. a patient n, 32 years old, female, complains of pruritic rash on the body skin with the itch intensity up to 8-9 points and the number of lesions more than 50. allergic background: for quite some time now the patient noted occasional eruptions on her skin after a contact with jewelry made of non-precious metals. previously patch skin tests with nickel showed a positive reaction. the patient sought emergency medical care with complaints of a number of itchy lesions erupted on her whole body during the last 24 hours. on admittance: state of moderate severity, the patient was emotionally labile, focused on her body sensations, tearful. on the skin of face, upper and lower extremities and torso a punctuate purpura with lesions up to 0.5 cm diameter, prone to confluent. a physical status was within normal limits. in order to control the itching, as well as to sedate the patient, antihistamines of the first generation were administrated parenterally; but the eruptions kept to progress and to intensify; lesions were spread throughout the whole body, merged in gigantic areas. system glucocorticosteroids therapy was administrated, with 120 mg of prednisolone, but then new lesions kept appearing in a large number, including after-meal rash. water, tea, bakery products, thin yoghurts did not impact the skin condition, whereas the intake of pasta, cereals, and similar products provoked intensifying of eruptions. the patient observation revealed a sharp increase in the rash after such manipulations as intravenous injections or blood sampling from the vein, the process spreading from the injection site to the entire arm. a detailed anamnesis of the disease: on the eve of the start of hives, the patient purchased a coffee machine (with metal nickel-plated parts) and started to use it. diagnosis: a systemic contact dermatitis. an allergy to nickel. the injection treatment was discontinued and a therapy with per oral gcs and antihistamines of the second generation was administrated. a recommendation was given to cook and to eat food using ceramic or wooden utensils. three days later marked positive dynamics of the skin process has been noted. the episode of systemic contact dermatitis has developed due to exposure to nickel from ingestion in food, as well as during the parenteral treatment. background: anaphylaxis reactions during anesthesia can have a mortality of 3%-6%. 2/3 of the anaphylaxis in the operating room are due to the use of neuromuscular blockers. rocuronium is frequently involved because is oftenly used. we present a case of a 41 years old man with an anaphylaxis shock due to the administration of rocuronium. method: 41 years old man with no personal history of interest that is going to undergo vertebral surgery. minutes after anesthetic induction with fentanyl, propofol and rocuronium he started with lowering of oxygen saturation. orotracheal intubation is performed and, with the suspicion of anaphylaxis shock, adrenaline, antihistamines and corticoids were administered. after 20 minutes without improvement, 500 mg of sugammadex was administered, given the possibility that the condition was secondary to the use of rocuronium. tryptasa level was 63. results: skin test to fentanyl, propofol, látex and rocuronium were done 6 weeks after and only rocuronium test was positive. conclusion: in summary, the occurrence of anaphylactic shock after neuromuscular blockers is widely described in medical literature. there are conflicting data about the use of sugammadex as coadjutant treatment in case of anaphylaxis due to the use of rocuronium. we believe is a good option when conventional treatment is not useful. case report: a 31-year-old woman with past history of allergic rhinitis and hypertension was admitted to the obstetrics service in labor of first child in april 2016. epidural anesthesia with ropivacain and sufentanil was administered. as there was no labor progression, eighteen hours later she was admitted to undergo cesarean section and epidural anesthesia was re-administered. metoclopramide, ampicilin and ranitidine were given intravenously. during ranitidine perfusion, the patient presented general cutaneous erythema and pruritus, tongue, lips and eyelids angioedema and dyspnea. perfusion was suspended and hydrocortisone and supplementary oxygen administered. she denied any type of previous adverse reaction to drugs and any symptoms with use of latex-containing material. allergic evaluation revealed negative latex skin prick test (spt) and negative penicillin, amoxicillin and ampicillin specific ige assay. skin prick and intradermal tests with sufentanil, ppl, mdm, amoxicillin and ampicilin were negative. oral amoxicilin and metoclopramide provocation challenge were negative. spt and subcutaneous provocation challenge with ropivacain were negative. spt with ranitidine was negative but skin intradermal test proved to be positive. the patient was taught to avoid histamine h2 receptor antagonists and use as a safe alternative proton pump inhibitors. conclusion: anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. the identification of responsible drugs is a complex task. we report a case in which a commonly used and generally safe drug caused a severe reaction, which demonstrated that even the least obvious culprit should not be disregarded. epidemiologic data suggest that the number of cases of chx allergy appears to be increasing. background: chlorhexidine is a synthetic chemical with excellent antiseptic and disinfectant quality frequently used in everyday products and medical devices. the prevalence of allergic reactions towards chlorhexidine is rare, though there is increasing evidence for its allergenic potential. in this case we report about a patient with serious perioperative anaphylaxis. next to multiple potential allergens that he was exposed to, a chlorhexidine containing lubrication gel has been used for urinary catheterisation. within minutes post-exposure, the patient developed generalized urticaria, bronchospasm, tachycardia and hypotension. material and methods: we performed skin prick tests and intradermal tests with all substances documented in the anaesthesia chart, further we analysed specific immunoglobulin e (sige) antibodies and performed oral provocation challenges for exclusion. results: in the skin tests all substances except for chlorhexidine (spt: 7 mm wheal diameter/31 mm erythema) were negative. a sensitization for chlorhexidine was further corroborated by chlorhexidine-specific ige antibody (4.08 ku/l) in the patient's serum. in addition, the challenges for the drugs without sensitization (cefuroxime, lidocaine) were tolerated. considering all potentially relevant allergens that the patient was exposed to and the proof of specific sensitization, we diagnosed an immediate-type allergy towards chlorhexidine. conclusion: with the ubiquitous use of chlorhexidine an increase in hypersensitivity reactions including immediate-type allergic reactions is observed. anaphylactic reactions are rare, but potentially life-threatening, the diagnosis is crucial. as a warning declaration in medical devices is missing, the diagnosis of chlorhexidine allergy might be easily under-recognized or misdiagnosed. unfortunately, until now validated provocation tests are not existent, but the evaluation of combined skin tests and sige is sensitive and specific. 1464 | an approach to incidence of death due to anaphylaxis in spain (1998 spain ( -2011 background: reports about death due to anaphylaxis are still scarce because of its rarity and limited information to few countries. also, data source analysis is usually not included. we report incidence of death due to anaphylaxis in spain using two databases. method: we used a hospital series of anaphylaxis deaths from the spanish hospital system and a series from the national institute of toxicology and forensic sciences (intcf) predominantly formed by extra-hospital deaths. deaths from the spanish hospital system were extracted using codes from icd-9-cm, related to anaphylaxis among all deaths occured in the 1998-2011 period. for extracting deaths due to anaphylaxis at the intcf in the same period, two allergist researchers identified these deaths among cases with suspicion of anaphylaxis cause. a regression logistic was run to discriminate the probability of anaphylaxis death belonging to each database. incidence rates were calculated for the different groups (age, sex) using the spanish population as the denominator. temporal trends were calculated from the hospital database using poisson regression models with the number of cases of anaphylaxis detected each year as the dependent variable, and age and sex as covariates. results: there were four positive predictors of fatal anaphylaxis after the logistic model (usual allergen, positive specific ige, suggestive symptoms and previous reaction to the same allergen case report: we were informed that a girl was admitted to the pediatric endocrinology department due to early breast development. she had been diagnosed as central precocious puberty (pp). later, triptorelin acetate (ta) therapy had been started monthly. within 20 minutes after first sc injection of ta at home, she had developed shortness of breath, decreased air entry, and coughing for ten minutes and lastly she had developed vomiting for 15 minutes. her symptoms were accompanied by a pruritic blanchable maculopapular rash on her ears, cheeks, lips, and eyelids approximately for two hours. although they had applied emergency department of the local hospital. based on the diagnosis of anaphylaxis she was immediately treated with adrenalin. she was subsequently hospitalized for possible recurrence and discharged next day without any further events. treatment with another preparation, leuprolide aseptate(la-lucrin), as an alternative treatment was started with premedication against anaphylaxis risk only at first time and the patient did not develop any reactions. the patient is still on this treatment with no complications. anaphylaxis is diagnosed in the presence of a detectable allergen accompanied by symptoms of two systems. our patient had symptoms of the three systems as described above, that is, dyspnea with coughing, hives, nausea, and vomiting. main treatment of anaphylaxis is the epinephrine use. early usage maximizes the likelihood of survival. diagnostic tests with culprit drug were not performed in our hospital if the patient had the anaphylactic drug reaction and grouped as "physician diagnosed anaphylaxis". there has been only one report regarding anaphylaxis to ta treatment in cpp in turkey. in the literature, anaphylactic reactions against ta have been reported only in few pediatric cases. gnrh analogues are important to ensure the physiological growth in precocious puberty. because anaphylaxis can be lethal, and gnrh analogues are similar structure; the present case suggests that one should bear in mind the possibility of anaphylaxis in all patients who receive gonadotropin-releasing hormone and anologs and monitor such patients carefully as needed. furthermore, we must provide sufficient information of adverse reactions, including anaphylaxis, to patients. hence, managements against anaphylactic shocks should be recognized and treatment should be given immediately. 1467 | an anaphylactic shock induced by the rocuronium anesthesia: a case report cabrera v; barrios j; callero a; gonzález ce; pérez e; martínez ja hospital universitario nuestra sra de la candelaria, santa cruz, spain background: the anesthetic act is a unique pharmacological situation, where the patient is exposed to a multitude of substances.among them, neuromuscular blocking agents are the leading cause of preanesthetic anaphylaxis, with a frequency of between 50%-70%.followed by latex in second place and antibiotics in third place. among the neuromuscular relaxants, most reactions are due to suxamethonium or succinyl-choline in 60.6%, followed by atracurium, rocuronium and verocuronium.the one that produces the least reactions is cisatracurium. method: a 61-year-old woman presented a type iii anaphylaxis of the brown classification during the anesthetic induction in a surgery scheduled for laparoscopic cholecystectomy. for which adrenaline, dexchlorpheniramine, hydrocortisone, ranitidine and sugammadex was administered and was transferred with orotracheal intubation to the anesthetic resuscitation room. due to good evolution of the patient, she was extubated within three hours. the drugs involved in the reaction were: rocuronium, amoxicillin-clavulanic, fentanyl, propofol, midazolam, lidocaine and atropine. there was a high suspicion by the anesthesiology and resuscitation service that the abstracts reaction could have been due to the neuromuscular relaxant used, in this case rocuronium, since the reaction was reversed with sugammadex. the patient had undergone surgeries under general anesthesia previously without incidents. a specific allergy study was performed with laboratory tests with tryptase, skin tests with drugs and basophil activation test for rocuronium, sugammadex-rocuronium mixture and cisatracurium. • serial measurement of serum tryptase: 12.9 u/l, 10.9 u/l y 3.42 u/l there is no activation of basophils for sugammadex-rocuronium mixture and cisatracurium. the patient is diagnosed with rocuronium allergy. sugammadex not only acts as an antidote to reverse the neuromuscular block against rocuronium, but also has antiallergic properties by inhibiting mast cells. as an alternative for future interventions, the patient can use cisatracurium, as the skin tests and the basophil activation test are negative. unal d yedikule chest disease, istanbul, turkey case report: tetracycline hydrochloride may rarely cause hypersensitivity reactions. (hrs). immediate type reactions are at the level of case presentations and anaphylaxis is reported. we report a patient with late onset anaphylaxis caused by tetracycline. a 47-year-old woman referred to our allergy outpatient clinic because of urticaria due to an antibiotic that she does not remember the name of. the patient reported that many years before she had presented urticaria on her arms and legs one hour after taking the drug. to confirm drug allergy invivo and invitro testing have to performed. for many drugs there was no validated skin test. for all that invitro tests are often less sensitive and more expensive. therefore single blind placebo controlled drug provocation tests (sbpcdpt) is the gold standard in the diagnosis of drug hypersensitivity reactions. we did not know which group of antibiotics were allergy to the patient. because the patient had history of asthma and atypical pneumonia we were performed the allergy tests with clarithromycin and she had tolerated. it was necessary to use tetracycline because of patient had vaginal infection. skin tests have not yet been validated for tetracyclines. for skin prick tests of tetracycline that is only available as tablet, not in a soluble form. therefore, the tablet was smashed and diluted with 0.9% nacl. it was also tested. 10 healthy controls to exclude irritation. because of skin prick tests with tetracycline negative. sbpcdpt was planned. sbpcdpt was performed by progressively increasing four divided doses at 30 minute intervals. two hours after last dose the patient experienced dyspnea, palpitations, and hypotension. as the reaction was considered to be anaphylaxis, she was given 0.5 mg of intramuscular epinephrine, intravenous 45 mg of pheniramine, and 40 mg of methylprednisolone. the reaction resolved within 3 hours. blood tryptase level was 14.9 ug/l taken at the 2nd hour of the reaction approximately 2 months after the anaphylaxis, serum tryptase level was 1.59 ug/l the serum tryptase level and the patient's clinic confirmed anaphylaxis due to tetracycline. we had proved late onset anaphylaxis due to tetracycline with the patient's clinic and serum tryptase level. anaphylaxis due to tetracycline is limited to case reports and small series but to our knowledge, there is no previous report of late onset tetracycline anaphylaxis. 1469 | case series of ige mediated anaphylactic shock due to polysorbate case 2: an 86-year-old male patient with hypertension, hypothyroidism and episodes of sustained monomorphic ventricular tachycardia (smvt), developed an anaphylactic shock after the administration of injectable amiodarone due to smvt. serum tryptase levels reached 34.8 μg/l during the reaction (baseline 6.59 μg/ l). skin tests were positive to injectable amiodarone (prick 50 mg/ ml, intradermal 0.5 mg/ml) and polysorbate 80 and 20 (prick-prick). skin prick-prick to amiodarone and dronedarone tablets were negative. the patient tolerated oral amiodarone. we report an anaphylactic reaction during the first intravenous administration of amiodarone in a female patient being treated for supraventricular tachycardia. bat was positive, suggesting a direct effect on basophil activation, as the patient was not previously exposed to the drug. 1472 | anaphylaxis during labor: don't forget to think of an amniotic fluid embolism case report: a 32-year old primigravida (40 weeks of gestational age) was admitted with signs of pre-eclampsia and labor was induced. benzylpenicillin and ropivacaine (epidural anesthesia) was administered >3 hours before the event. eighteen minutes after starting an infusion with oxytocin (15 ml/h) and a vaginal toucher, the patient developed a decreased level of consciousness, generalized edema/erythema and thoracic pain, followed within 3 minutes by fetal bradycardia and maternal collapse. after resuscitation, an urgent sectio was performed, and a baby girl was born. patient was extubated the same day. serum tryptase, 1 hours after the event, was 11.2 μg/l (basal tryptase level 3.4 μg/l). allergy workup demonstrated negative specific ige and skin tests for latex and chlorhexidine, negative skin and provocation testing for ropivacain. however, skin testing was hampered by dermographism: intradermal (idr) testing of benzylpenicillin (10 000 iu/ml, 1/1000-1/1) and oxytocin (10 ie/ml, 1/10 000-1/100) showed extensive erythema. idr testing of oxytocin in healthy volunteers showed pallor around the injection site (n = 3). intravenous provocation with benzylpenicillin was uneventful. a basophil activation test with oxytocin (patient and control) was negative. an additional bone marrow evaluation showed no evidence for mastocytosis. although clinical criteria for anaphylaxis were fulfilled, a diagnosis of an amniotic fluid embolism (afe) was concluded. no drugs were prohibited. patient gave consent for publication. conclusions: afe is one of the most devastating conditions in obstetrics, occurring typically during labor and delivery or immediately postpartum. the pathogenesis remains incompletely understood, however, it has been suggested that afe involves an anaphylactic reaction to fetal tissue exposure associated with breaches of the maternal-fetal physiological barrier, supported by transiently increased serum tryptase levels. the diagnosis is primarily clinical, and generally one of exclusion. no specific antemortem diagnostic tests are available to confirm afe. postmortem identification of fetal squames in the maternal pulmonary circulation gives final diagnosis. differential diagnosis includes drug-induced anaphylaxis or mastocytosis, which were ruled out in our case. method: the patient presented after hymenoptera stings dyspnoea, generalized erythema with pruritus, edema of the face that required emergency therapy in 3 episodes. results: an angio-ct was performed at the inferior limbs with optiray and 5 minutes after the end of the investigation, the patient presented an anaphylactic shock requiring admission to the icu for 4 days. conclusion: the patient's progression was slowly favorable. results: thirty seven cases were reported. 24 (65%) were women. the median age was 47 years. 19 (51%) had dress/dihs, 6 (16%) ten, 3 (8%) sjs, 3 (8%) agep, 3 (8%) other not classified scars, and 1 (2.7%) overlapping ten/sjs. in 100% of the patients the suspect drug was withdrawn. thirty one patients (83%) received systemic anti-inflammatory treatment. twenty six patients (70%) received intravenous (iv) corticosteroids alone, 3 (8%) iv corticosteroids plus ivig, 1 (2.7%) iv corticosteroids plus ivig, infliximab and colchicine, and 1 (2.7%) iv corticosteroids plus infliximab and cyclosporin. there were complications in 17 cases (49%), and death occurred in the patient with overlapping ten/sjs who had received corticosteroids plus immunoglobulin. in this study, our aim was to evaluate severe ihr to icm. method: we retrospectively analysed patient who consulted to our allergy unit between july 2011 and july 2016 reporting symptoms within 1 hour after icm administration. from a total of 109 patients, we selected eight that had suffered an anaphylactic reaction. a written informed consent had been obtained for diagnostic procedures. introduction: immediate type hypersensitivity reactions to pemetrexed have been reported as very rare case reports. as limited availability of alternative therapies in chemotherapeutic allergy, desensitization plays an important role in ensuring reuse of the culprit drug. we report a case of pemetrexed anaphylaxis and successful desensitization. case: 43 years old female patient with lung adenocarcinoma had been treated with cisplatin-pemetrexed as second-line therapy. during the 5th cycle within 5 minutes after the end of pemetrexed infusion she had chest pain, shortness of breath, cough, swallowing difficulty, erythema on face and body, nausea and vomiting. she was diagnosed as anaphylaxis and adrenaline was administered besides antihistamine and methylprednisolone. symptoms and findings of the patient were improved within 15 minutes. oncologists decelerated no suitable alternative therapy for the patient. although skin tests (prick test with 1/1 concentration, intradermal test with 1/10 000-1/10 concentration) were negative with pemetrexed, taking into account the severity of the reaction, pemetrexed desensitization was applied with the consent of the patient. no reaction was observed during the procedure result: desensitization is a successful and safe method of reusing the culprit drug. successful desensitization of pemetrexed with immediate type hypersensitivity reaction is described. the 28 years old man was admitted emergency department with fever, rash (maculo-papular) and pain in joints. it was the 9th day of taking of amoxicillin. the hematological abnormalities were revealed -eosinophilia, increased erythrocytes sedimentation rate. the level of serum ecp was 183 μg/l. the liver functional tests were increased too. hepatomegaly and cervical lymphadenopathy were observed. the patient was treated as a dress syndrome (infusion therapy, systemic steroids) and discharged after 2 weeks with improvement. all hematologic parameters were in normal limits. lymphadenopathies were resolved. the level of ecp was retaken -84 μg/l. patient was prescribed oral steroids till normalization of limits of ecp. it lasted 2 weeks after discharging. the serum level of ecp can play key role in the management of dress syndrome and in the making of diagnostic processes. until now, allergic or anaphylactic reactions to peg have been rarely reported. although patient with hypersensitivity to peg should avoid peg-containing drugs or products, patient who needs colonoscopy has few alternative bowel cleansing methods. no successful desensitization to peg has been reported to date. we report a case of successful desensitization and subsequent safe colonoscopic examination in patient with allergic reaction to peg. method: a 50-year-old woman developed generalized urticaria, pruritus, throat swelling, and shortness of breath immediately after taking a bowel preparation solution for colonoscopy. she had the first symptoms 3 years ago, and has had 2 more experiences so far. the symptoms appeared within 20-30 minutes of taking cleansing solution, and the endoscopy was no longer possible. seven years ago, she underwent endoscopy with no specific symptom. when the last symptom occurred a year ago, she was treated at emergency room because of severe dyspnea and dizziness. the patient came to our clinic for the proper diagnosis of allergy reaction and possible colonoscopic evaluation. objectives: to describe a successful desensitization to vedolizumab in one patient diagnosed with ulcerative colitis, refractory to infliximab and intolerant to azathioprine and sulfasalazine. methods: our patient was a 38 year old woman receiving treatment with intravenous vedolizumab (300 mg/cycle). cycles 1 and 2 were well tolerated, but in cycles 3, 4 and 6 she experienced hypotension and dyspnea, in spite of premedication with oral dexamethasone and metoclopramide. during cycle 6, she also showed facial angioedema, systemic urticarial reaction and oropharyngeal pruritus treated with methylprednisolone and ebastine. the results of prick (vedolizumab concentration 60 mg/ml) and intradermal skin tests (1:10 and 1:100) with vedolizumab were negative in our patient and in ten healthy controls. total ige level was 26.4 ui/ml and specific ige against dermatophagoides were positive, being negative for hamster epithelium and latex. since vedolizumab was the only therapeutic alternative, the patient was planned to undergo vedolizumab desensitization according to an 8-step protocol. patient informed consent was obtained previously. premedication consisting of ebastine, acetylsalicylic acid, montelukast and methylprednisolone one hour before desensitization was administered. desensitization protocol was performed with a total duration of 4 hours and 35 minutes and a total dose of 293 745 mg. dose steps were 0.015, 0.03, 0.3, 0.6, 1.2, 9, 18 and 264.6 mg. conclusions: our 8-step protocol desensitization to vedolizumab resulted safe and effective in our patient and it has allowed the continuation of treatment with vedolizumab for her ulcerative colitis. montelukast, anti h1 and h2 blockers were used for the pretreatment of desensitization. all procedures (skin and blood tests, desensitization) were carried out with the informed consent of the patient. we present an exceptional, non-immediate case of fever after cisplatin and etoposide infusion with positive skin test. case report: a 63-year-old man, recently diagnostic of lung cancer stadium iv, in first line of treatment with cisplatin and etoposide, started 2 hours after finishing the 2nd infusion: facial erythema that becomes generalized after 4-5 hours from infusion. twelve hours later, developed warmth sensation, shivering and fever (39°c) that persisted despite the use of several oral antipyretics treatment. infectious disease was discarded, so he was referred to our department in order to assess further administration of cisplatin and etoposide. methodology: skin testing was performed 30 days after the last reaction to minimize false-negative results, as follows (a) cisplatin prick test (1 mg/ml) and intradermal tests (0.1 mg/ml); (b) etoposide prick test (20 mg/ml) and intradermal tests (2 mg/ml); with histamine as the positive control and nacl-diluent as the negative control. the results of skin test were negative for immediate reading. but two hours later, intradermal test for cisplatin turned into red and itchy and 12 hours later, still associated a wheal. the patient was classified as high-risk (lung diseases, forced expiratory volume in 1 second <1 l) and underwent programmed inpatient desensitization according to the standardized birmingham women's hospital protocol. desensitization was performed in the medical intensive care unit. the patient received only standard oncology premedication. he tolerated the final dose of cisplatin with no breakthrough reactions followed by etoposide standard infusion. two additional desensitization procedures were performed, with no breakthrough reactions. therapy ended when the disease worsened. the importance of this case, lies in the fact that fever has not been described as a clinical hypersensitivity reaction for cisplatin but for oxaliplatin. although a non-immediate reaction at the 2nd infusion of cisplatin could scarcely suggest a hypersensitivity reaction, the positive skin test and successful desensitization with this drug, could suggest it. introduction: propylthiouracil is commonly used as the first treatment option in patients with hyperthyroidism. although it is generally a well-tolerated drug, it may lead to some side effects including liver damage, leucopenia and skin rash. among skin rash findings, urticaria is considerably common. nevertheless, in cases that developed urticaria, a rapid desensitization protocol specific to propylthiouracil has not been encountered. we represented a case in which we applied successful oral desensitization via a scheme in accordance with general desensitization principles in a case that developed propylthiouracil-induced urticaria. case report: propylthiouracil at a dose of 50 mg/day was initiated for a 36 year-old female patient with diagnosis of hyperthyroidism in internal diseases clinic. the patient developed widespread itching and swelling in the body 5-6 hours after she took the first dose of the drug. she had experienced a similar reaction with use of propylthiouracil in 2012. the patient who was breastfeeding a baby and did not have any treatment option other than propylthiouracil was referred to us with pre-diagnosis of drug allergy. the patient was thought to have propylthiouracil-induced hypersensitivity reaction and desensitization was planned. we prepared a desensitization scheme in accordance with general desensitization principles (table 1 ). in accordance with this prepared scheme, we successfully applied the desensitization protocol with propylthiouracil for the patient. the patient gave informed consent before testing and desensitization. results: spt was negative, but idt reaction was positive at 1:1000 method: we present a desensitization protocol to intravenous etoposide used in a 35-year-old male for non-hodgkin's lymphoma who was referred to the department of allergy at sotiria general hospital of athens. within 5 minutes after receiving the first dose of the drug, the patient complained for flushing, retrosternal pain, difficulty in breathing and weakness. the infusion was ceased immediately and the patient received proper treatment with gradual recovery of the symptoms. the next day, skin prick test (spt) and intradermal test (id) were performed with etoposide at dilution 1:10 (2 mg/ml). both of the tests, spt and id, were negative. histamine and nacl 0.9% were also used as positive and negative controls, respectively. a desensitization protocol of three-day cycle with intravenous etoposide was conducted. premedication for 3 days was administered including methylprednisolone, cetirizine, ranitidine, paracetamol and montelukast. results: the desensitization protocol of the first day consisted of 11 steps of rapid pulses administered at increasing infusion rates every 15 minutes, and 1 step of drip infusion at a final rate of 60 ml/hour (372 mg/232.5 ml) until completion of the infusion. the following 2 days, the patient received a modified rapid protocol consisting of the administration of the calculated dose of 400 mg in only one step of infusion rate of 60 ml/hour completing in only 4 hours and 15 minutes. the same protocol was applied in another three-day cycle with no adverse reactions. conclusions: hsrs to etoposide are rarely described in the literature. we propose a three-day modified rapid desensitization protocol to intravenous etoposide that could be particularly useful compared to other time-consuming desensitization protocols. case report: imatinib, a tyrosine kinase inhibitor, sometimes causes cutaneous reactions that can be of various severity. we present a case of a patient who was started on imatinib 400 mg daily and after 3 months developed diffuse mildly pruritic rash with some desquamation of palms of the hands. the dose of imatinib was reduced to 300 mg daily and therapy with prednisone 30 mg was started. after resolution of rash, the dose of prednisone was tapered to 10 mg daily, but the rash reappeared, although milder in intensity. the dose of prednisone was increased and levocetirizine added and rash resolved. prednisone was slowly discontinued and rash did not appear. in the case of reactions to imatinib the dose of drug can be reduced and short course of oral corticosteroid given. milder reactions can be treated with antihistamine or topical corticosteroid. therefore, when adverse skin reaction to imatinib occurs, induction of tolerance to this important drug should be attempted. method: the exosomes were collected from in vitro primary human sinonasal epithelia cell, which derived from three different groups (normal control, chronic rhinosinusitis and chronic rhinosinusitis with asthma). generation of exosomes in epithelia was confirmed by nanosight, tem and western blot. the proteins of exosomes were identified by proteomics analysis. the cellular proliferation and ciliogenesis were analyzed by cck8 and qpcr.the ciliary beat frequency was detected by sava system. we found that epithelial cellular exosomes from chronic rhinosinusitis and chronic rhinosinusitis with asthma could reduce the multiplication rate of normal epithelial cell at a certain concentration (≥10 μg/ml).we found that exosomes from chronic rhinosinusitis with or without asthma could interrupt the cellular ciliogenesis and ciliary beat frequency. using mass spectrometric analysis we demonstrated that the epithelial exosomes contained different proteins in different disease states. conclusion: our findings first identified that exosomes could be secreted by nasal epithelial cells. we also demonstrated exosomes from chronic rhinosinusitis with or without asthma could be a pathogenic factor in the remodeling of sinonasal mucosa. it could be considered as a significant biomarker for detecting the progress of chronic rhinosinusitis and a alternative therapy target. background: mucociliary transport (mct) is a major respiratory tract host defense mechanism and chronic exposure to allergen can deteriorate the these defense mechanism. the aim of this study was to investigate the effects common allergen (dp/df) on human nasal mucociliary transport in allergic rhinitis patients, and to determine the pathophysiology of ciliary beat frequency (cbf) during allergeninduced change method: allergic nasal mucosa cells of allergic rhinitis patients were exposed to common allergen (dp/df), and cbf was analyzed using an optical flow technique with the peak detection method results: the allergen(dp/df) exposed group showed a decreased cbf when compared to the control group. in the cytotoxicity assay, difference in survival rates was not found between the two groups. in the allergen(df/df)-exposed group, protein kinase c (pkc) activity was increased during a pkc activity assay. the broad pkc inhibitor, calphostin c abolished the allergen(dp/df)-induced decrease of cbf. the allergen-induced decrease of cbf was abolished by gf 109203x, a novel pkc (npkc) isoform inhibitor, whereas the decrease was not attenuated by g€o-6976, a specific inhibitor of conventional pkc (cpkc) isoform. conclusion: allergen may inhibit cbf via an npkc-dependent mechanism. therefore, we have confirmed that chronic exposure to allergen could decrease cbf by increasing pkc activity. method: ova-alum allergic rhinitis mouse model (ar model) and poly(i:c) induced il-17 dominant mouse model (neutrophil dominant model) were used. both mouse models were exposed to tio2 particles for 2 hours twice daily for 7 days, while the controls (n = 5) were not. sirius red staining for eosinophil infiltration, immunohistochemistry for neutrophil and il-17a, serum immunoglobulin (ig) g and e were assayed by using enzyme-linked immunosorbent assay. in addition, the expression of interleukin (il)-4, il-17, and interferon (ifn)-γ in the nasal mucosa and cervical lymph nodes was measured by immunohistochemistry, and real-time reverse transcription-polymerase chain reaction (rt-pcr), il-17 monoclonal antibody (secukinumab) was administered in vivo to evaluate il-17a dependency. results: tio2 exposure did not influence eosinophil infiltration in both ar and neutrophil dominant model. however, tio2 exposure increased neutrophil infiltration in both models and neutrophil infiltration was correlated with il-17 expression in the nasal mucosa. serum igg and ige levels were changed significantly in the tio2exposed group. th2 cytokines (il-4, il-5) and th1 cytokine, ifn-γ were not changed significantly in both models after tio2 exposure, however, il-17 were increased in tio2 exposure group. and these increased type 17 pathway and neutrophil infiltration were reversed after il-17 monoclonal antibody administration. conclusion: exposure to airborne tio2 induced neutrophil infiltration in the nasal mucosa. the type 17 response seems to play a dominant role in the nasal immune response following airborne tio2 exposure. 1501 | toll-like receptor 9 ligands increase type i interferon induced b-cell activating factor expression in chronic rhinosinusitis with nasal polyposis results: first: paf-r mrna expression was very low in fibroblasts from nm and np (data not shown). paf-r mrna expression was detected in whole sinonasal tissue, submerged and ali epithelial cell cultures from both controls nm and np. paf-r mrna was also detected in peripheral blood eosinophils. although no differences were found between nm and np tissues and cultures, paf-r mrna expression was significantly higher (p < 0.001) in eosinophils than in upper airway tissues and cells. second: protein paf-r was found expressed in whole tissue (predominantly in the epithelium and submucosal glands), submerged and ali epithelial cell cultures from both nm and np. peripheral blood eosinophils also showed paf-r protein expression. conclusion: both paf-r mrna and protein expression was found in sinonasal nm and np tissues (epithelium and submucosal glands) and in peripheral blood eosinophils. these findings suggest the paf/ paf-r system could play a pathophysiological role in crswnp through the modulation of structural and inflammatory cell functions. "this study was funded with a research grant from uriach group". background: allergic rhinitis (ar) is an increasingly more common nasal inflammatory disease in which an antigen such as pollen or dust mites triggers symptoms such as itching, sneezing, and rhinorrhea, which can lead to nasal obstruction. ar is mediated by thelper type 2 cells together with mast cells, eosinophils, and several inflammatory cytokines and chemokines. for example, recent abstracts | 757 research indicates that hypoxia-inducible factor 1α (hif-1α) is involved in the mechanism of ar development. the anti-heart failure drug digoxin has a specific inhibitory effect on hif-1α, and thus, the aim of the present research was to explore the anti-hypertensive effect and mechanism of digoxin in ar. method: an animal model of ovalbumin-induced ar was established in guinea pigs. the experimental group was treated with digoxin through the tail vein. for the comparison of symptoms between the experimental and control groups, the incidence of sneezing was recorded, and the eosinophilic interleukin il-4 and il-5 levels in nasal secretions were measured by enzyme-linked immunosorbent assays. western blotting and reverse transcription polymerase chain reaction analyses were conducted to evaluated hif-1α expression in guinea pig nasal mucosa. results: the ar symptoms of guinea pigs in the experimental group were significantly improved after administration of digoxin. specifically, the experimental group exhibited a significantly lower numbers of sneezing times(average 36.0 ± 1.10 vs 7.4 ± 0.78, p < 0.05) and lower il-4 and il-5 secretion levels (p < 0.01) compared with the control group. moreover, guinea pigs of the experimental group showed less severe nasal mucosa edema, lower hif-1α production, and reduced eosinophil infiltration in nasal mucosa compared with the control group. conclusion: the anti-heart failure drug digoxin may ameliorate the symptoms of ar by inhibiting hif-1α production. campo p 1 ; eguiluz i 1 ; bogas g 1 ; gomez f 1 ; ariza a 2 ; espino t 1 ; torres mj 1 ; rondon c 1 1 allergy unit-regional hospital of malaga-ibima, malaga, spain; 2 allergy laboratory_regional hospital of malaga-ibima, malaga, spain background: similarly to what has been described in allergic rhinitis, there is an important association of local allergic rhinitis (lar) with lower airway symptoms suggestive of asthma, being selfreported in 24.4% of lar patients after five years of follow-up, and increasing to 30.7% after 10 years. however, clinical suspicion alone it is not enough for asthma diagnosis and could overstate its real prevalence. the aim was to evaluate the real prevalence of asthma in lar patients based on validated objective methods. method: seventy-five patients (29 with lar, 20 with non-allergic rhinitis (nar), 18 with allergic rhinitis (ar)), and 8 healthy controls (hc) were included. all patients had perennial history of rhinitis and bronchial symptoms suggestive of mild-moderate asthma for at least two years. non-specific airways hyperresponsiveness (methacholine challenge test, using tidal breath method following ats guidelines) was performed in all subjects. results: subjects were mostly young females, non-smokers. median μg/day of inhaled corticosteroids (budesonide/equivalent dose) was similar in all groups. median fev1% in ar group (75.5%) was significantly lower compared to lar (90%, p = 0.002), nar (85%, p = 0.007) and hc (88%, p = 0.005). in the lar group, 15/29 (51.7%) had a positive methacholine, 12/20 (60%) in the nar, 15/18 (83.3%) in ar group and 0/8 (0%) in hc. patients with lar had a significant lower percentage of confirmed asthma than ar (p = 0.031) and similar to nar (p = 0.771). no differences were detected between ar vs nar (p = 0.155). conclusion: presence of objectively demonstrated asthma was lower in lar compared to ar, and with better lung function. conclusion: ambient air pollution influenced the hospital visit of patients with rhinitis, even, the level of pollutants, below the national standard. so2, o3, no2, and pm10 could increase an incidence of rhinitis and/or induce an aggravation of rhinitis symptoms. health care provider might expect upraising patients with rhinitis in the clinic with increase of air pollutants, even under the standard levels. results: during relapse of erosive oral lichen planus mononuclear cells obtained from peripheral blood of patients showed increased number of nk-cells cd3 + cd56 + in acute (15.5 ± 4.5%) and chronic (14.9 ± 6.3%) disease periods, and cd16 + grb cells in acute (18.1 ± 1.5%) and chronic (14.5 ± 2.5%) disease periods, p < 0.05. in patients with the non-erosive forms of olp there were cd3 + cd56 + and cd16 + grb cells in acute (8.9 ± 2.5%) and (7.3 ± 1.3%) and chronic disease (9.5 ± 2.2%) and (8.2 ± 3.1%), p < 0.05. the number of cd3 + cd56 + and cd16 + grb cells in the controls were (9.8 ± 2.1%) and (6.2 ± 5.4%), p < 0.05. conclusion: acute relapse of erosive oral lichen planus, unlike nonerosive forms, is characterized by increases in the number of cd3 + cd56 + and cd16 + grb cells. chronic disease in patients with erosive oral lichen planus showed a steady increase in the number of cd3 + cd56 + killer cells and cd16grb lymphocytes. bite", were observed in 6 patients (85%). typical hyper-and hypopigmentation were observed in six patients mainly on the fingers and the cheekbones. fibrosis of the skin of the fingers often leads to flexion contractions, which we observed in 6 patients. we were watching two-sided swelling of the fingers, but it was very pronounced in 5 patients (71%). 86% of our patients have impaired motility of the esophagus. accelerated esr and c-reactive protein were found in 5 patients as follows-2 intensively accelerated and 3 moderate. in our patients with positive ana, we observed 4 patients -at low titer 1:40 at 2 and titration 1:80 in 2 patients. the spectrum of ana found by us in raynaud's syndrome patients is closer to scleroderma than to lupus. we underline the importance of ana (57%) and anti-cc antibodies (27%) for the early diagnosis of raynaud's syndrome and scleroderma, which is also seen in our patients. anti-scl-70 antibodies were observed in 3 patients coinciding with other publications describing about 40% of the patients. low levels of complement were observed in 2 patients. low hemoglobin levels were observed in 1 patient, with no iron deficiency. conclusion: 1. we observed a typical fibrinoid necrosis and polymorphonuclear infiltration, and collagen accumulation in the walls of small and medium-sized blood vessels. results: statistically significant increase of il4 level (3.23 pg/ml [2.18; 5.02]; 3.42 pg/ml [2.8; 4.18] respectively) was determined in patients with uc both in acute stage and remission compared to controls (1.87 pg/ml [1.4; 3.2] , (p = 0.002; 0.009 respectively). statistically significant increase of il17a level (15 pg/ml [12.11; 23.38] ); 14.68 pg/ml [11.29; 17.19 ] respectively) was also observed in patients both in acute stage and remission compared to controls (7.36 pg/ml [5.18; 8 .06], p = 0.00007, p = 0.00029 respectively). besides statistically significant increase of ifnγ both in acute stage (176.15 pg/ml [65.15; 359.84] ) and remission (42. 6 pg/ml [29.4; 64.45 ]) compared to controls (16.5 pg/ml [12.3; 23 .2], p = 0.00107; 0.0118 respectively) was revealed. background: the presence of antinuclear antibodies (ana) is commonly associated with a broad spectrum of connective tissue diseases. low titres might be detected rarely also in healthy individuals, especially in higher age. an indirect immunofluorescence (iif) detection of ana antibodies on hep-2 cells is the most frequently used laboratory method in this respect. the method is quite reliable regarding sensitivity, however the specificity of this test is lower. we would appreciate a biomarker for clinical discrimination of anaother autoantibodies were tested in relation to basic diagnosis. results: a cohort of patients was divided into 6 groups according to main diagnosis: immunodeficiency, connective tissue diseases, bronchial asthma and allergic rhinitis, recurrent infectious diseases, gastrointestinal diseases, endocrinopathy and others and the last group was generated from healthy subjects. the presence of anti dfs70 antibodies was highest in the group of recurrent infections, mostly in females. in these subjects homogenous pattern of ana antibodies by iif was also detected quite often, probably induced by non-specific activation of immune system. on the other hand, in a group of connective tissue diseases, we have not found any anti dfs70 positive patient. the clinical impact of anti-dfs70 antibodies is not yet finally confirmed, but their low frequency in connective tissue diseases and presence in 5%-10% of healthy subject suggests their potential role as a new biomarker to be used as a negative predictive factor in non aard. confirmation of presence or absence of anti-dfs70 antibodies seems to be helpful to exclude potential diagnostic errors in iif ana positive patients. background: multiple sclerosis is a debilitating autoimmune and degenerative condition of the central nervous system, that predominantly affects young adults. both genetic and environmental factors are associated with increased risk for this disease. we propose that the effect of environmental factors, particularly latitude of childhood, is mediated through epigenetic mechanisms. specifically, we propose that unfavourable gene methylation predisposes individuals to multiple sclerosis, that this is set in childhood and adolescence, and transmitted from haematopoietic stem cells to progeny. method: cd34 + , cd14 + and cd56 + cell subsets were isolated from peripheral blood of healthy controls. libraries enriched for cpg islands and promoter regions were generated using modified reduced representation bisulfite sequencing and subjected to next generation sequencing. site specific methylation profiling of genome wide cpg islands, including ms susceptibility genes was conducted using methpipe software. results: genomic coverage was consistent with other published methylomes using modified reduced representation bisulfite sequencing. the methylation signature of peripheral blood derived subsets showed greater differences in methylation compared to buccal cells than with each other. individuals displayed differences in cd34 + methylomes, and these were recapitulated in the progeny cd56 + and cd14 + cells for those individuals. methylation of specific genes regions (e.g. prf1), were consistent with the known biological function of these genes and their potential contribution to ms risk. the vast majority of cpg islands interrogated show recapitulation of their methylation signature from cd34 + to progeny. however, individual differences and cell subset differences identified, likely reflect the known biological function of these genes in progeny cells. our preliminary results are consistent with the hypothesis that the epigenetic signature (that predisposes to ms risk) is set in childhood and adolescence. the physiological basis underlying the setting of this epigenetic signature is still to be elucidated, but may involve uv light and/or vitamin d, and may provide novel therapeutic targets, especially at a personalised level, for treatment of ms. background: auto-inflammatory diseases are rare disorders characterized by recurrent episodes of fever/inflammation affecting serosal surfaces, joints, eyes and skin without autoantibody production or an underlying infection. innate immunity is implicated in their pathogenesis and the underlying genetic defect has been identified in a fraction of the syndromes. during last years, the increased knowledge about auto-inflammatory diseases and the difficulty in their characterization aroused great interest to better understand these pathologies. the acidic soluble fraction of salivary proteome of patients and controls (hc) were analyzed by rp-hplc-esi-ms. 60 known salivary proteins (salivary acidic proline-rich phosphoproteins (aprps), histatins (hst), salivary cystatins s, sn and sa, statherin, p-b peptide, α-defensins 1-4, cystatins b, c, thymosin β-4, s100a7, s100a8, s100a9, and s100a12 proteins) and several derivatives (acetylated, glutathionylated, phosphorylated, and oxidized forms) were searched in the chromatographic profiles by xic (extracted ion current) procedure. 21 adult patients (mean age ± sd: 34.4 ± 10.1; 15 f, 6m) were enrolled and compared with 27 sex/age matched healthy controls (mean age ± sd: 33.4 ± 9.6; 18 f, 9m). patients are classified on the base of clinical manifestations as follows: 6 patients with fmf (mean age ± sd: 33 ± 7.9; 5 f, 1m), and 15 with unclassified fever syndrome (uc) (mean age ± sd: 34.9 ± 11.1; 10 f, 5m). results: fmf patients showed low levels of α-defensins 2, 3 and 4, this last was absent, with respect hc, and high levels of the glutathionylated proteoforms of cystatin b, and s100a9, and of antileukoproteinase (slpi). similar results were obtained on saliva of unclassified patients, which showed also levels of cystatin c higher than controls. interestingly, proteins and peptides typically secreted by salivary glands (cystatin c, histatins, statherin, aprps) were found more abundant in uc patients than in controls, and in some cases also than fmf patients (see table) . an evaluation of relative abundance of phosphorylation of phosphorylated proteins/peptides highlighted a significant hypophosphorylation of hst-1, prp-1 and prp-3 in uc patients with respect to controls, probably due to a less active fam20c kinase responsible for their phosphorylation conclusion: we show by a top-down proteomics approach a wide salivary modification, highlighting dysregulation in neutrophil-derived proteins and significant differences between fmm and uc patients. the control group consisted of 10 healthy donors aged 40-50 years. immunological methods of investigation included determination of membrane antigens b cells: cd3 − cd19 + cd45 + , cd19 + cd5 + cd45 + , cd19 + cd23 + cd45, cd19 + cd25 + cd45 + , cd19 + cd40 + cd45 + , cd19 + cd86 + cd45 + , cd3 + cd4 + cd40l + cd45 + , cd19 + cd45ra + cd27 + cd45 + , by flow cytometry. results: in the study subpopulation composition of lymphocytes in seropositive variant form of ra visceral a statistically significant increase in relative amount as b1-cells with immunophenotype cd19 + cd5 + cd45 + (0.6 ± 0.01% 0.12 ± 0.03%) and b2 lymphocytes with the phenotype cd19 + cd5 − cd3 − cd45 + (16.4 ± 1.2% and 7.9 ± 0.5%). in the analysis of the processes of maturation and differentiation of b2 cells detected statistically reliable increase of the relative number of mature cd19 + cd3 − cd45 + naïve b2 cells cd19 + cd45ra + cd27 number of mature cd19 + cd3 − cd45 + naïve b2 cells cd19 + cd45ra + cd27 − cd45 + (11.8 ± 0.9% and 5.7 ± 0.5%) compared to the control group. in the study of surface markers b2 lymphocytes revealed an increase of expression of costimulatory cd19 + cd40 + (19 ± 1.3% and 7.0 ± 0.42%) molecules and increasing the relative amount of cd40l 0.9 ± 0.2% (0.3 ± 0.05%) ligand on cd3 + cd4 + cd45 + subpopulation of t-lymphocytes. analysis of surface antigenic receptor b2 cells in the visceral form of ra showed an increased expression of early markers of cd19 + cd23 + cd45 + (2.9 ± 0.08% and 0.91 ± 0.1%), cd19 + cd25 + cd45 + (1.6 ± 0.4% 0.05 ± 0.01%) activation in comparison with the control group. case: a 44 year-old male patient who works as a dental technician with a history of lung silicosis and recurrent sinusitis applied to an orthopedics clinic for left hip pain and difficulty in walking. he has a history of keeping a dog during childhood. hip mri revealed a 5 × 3 cm sized mass on left iliac wing extended to gluteus muscle and subcutaneous tissue. incisional biopsy was reported as chronic granulomatous osteomyelitis. the lesion was considered as tuberculous abscess. despite anti-tuberculous (fourdrug regimen) treatment for one year, the lesion showed no regression. excisional biopsy was carried out by the same orthopedics clinic. chronic inflammatory reaction and fibrosis was considered to be due to cyst hydatid in the detailed evaluation. antiechinococcus igg and igm was performed with elisa and found positive. no other lesion was detected in lungs and liver. albendazole 400 mg twice a day was initiated and substantial regression observed after three months. atypical and sustained infections made us think of primary immunodeficiency disorders. immunoglobulin subgroups were as follows: iga: <1 mg/dl (70case description: 31 year-old male was firstly admitted to gastroenterologist due to intermittent diarrhea, abdominal pain and reactive lymphadenopathy. celiac disease was suspected as genetic test showed hla dq8 (hla-dqa1*03 and hla-dqb1*0302), histological evaluation of duodenum biopsy provided picture of lymphoid hyperplasia and marsh iiia variant. however, laboratory testing for celiac disease showed very low amount of antibodies against transglutaminase. gluten free diet for almost one year was ineffective as patient had a continuous problem of gaining weight due to chronic diarrhea. additional questioning revealed recurrent respiratory tract infections with a need of antibiotics more than two times/year during last decade. lymphocyte phenotyping by flow cytometry showed that cd3, cd4, cd8, cd19 are in normal ranges, but amounts of all immunoglobulins are low: igm <0.22 g/l, igg 2.53 g/l and iga 0.09 g/l. based on clinical symptoms and immunological evaluation diagnosis of cvid was confirmed, and replacement therapy with subcutaneous immunoglobulin (400 mg/kg/month) was initiated. after six months of treatment patient affirmed reduction of gastrointestinal symptoms; he gained 12 kg of weight, has no more infections and stable sufficient level of igg (7.9 g/l). conclusions: this clinical case shows the importance of immune testing for primary immunodeficiency in all subjects (despite age) with unusual symptoms of autoimmune and/or infectious disorders. cvid may have manifestation of various symptoms, which can lead to misdiagnosis, as well as inadequate treatment. results: in our sample, all patients who progressed to hypogammaglobulinemia were receiving lymphomas. there is no immunoglobulin dosage record prior to treatment. of the 9 cases, mean age was 52 years (4 men and 5 women), 2 lost follow-up, and 1 of them also presented neutropenia. seventeen patients who continued in followup required ivig replacement, due to infectious exacerbations, mainly pneumonia and sinusitis. the mean serum igg dosage at the time of onset of ivig replacement was 491 g/dl. the mean time between the first dose of rtm and the need for ivig replacement ranged from 2 to 8 years, with an average of 5 years. the iga dosage was used as a parameter for the recovery of hypogammaglobulinemia, and it was observed that only 1 of the 7 patients presented recovery of the condition up to the moment. conclusion: given the data, we considered the immunoglobulin dosage to be important before initiating rtm treatment and periodically, in order to indicate the replacement of ivig or igsc in a timely manner avoiding complications such as potentially serious infections. background: steinert's disease, also known as type 1 myotonic dystrophy (md1), is the most common dystrophy of the adult. it is inherited with an autosomal dominant mechanism. it causes myotonia, progressive muscles atrophy, muscular weakness, and problems at the heart's conduction tissue and at the respiratory muscles. in patients with myotonic dystrophy, hypogammaglobulinemia is frequently described. the associations and the pathogenesis between those affections are not totally clear, but it is recognized an increased catabolism of the immunoglobulin in these patients. in most of the cases, hypogammaglobulinemia affects only the igg class and does not become clinically manifest. however, replacement treatment is not always successful in these patients. we report the case of a patient with myotonic dystrophy and hypogammaglobulinemia. case report: a 44-years-old man with md 1 came to our attention for a history of recurrent infections of the upper respiratory tract and persistent infection by helicobacter pylori. at the laboratory tests, we documented low serum igg levels (449 mg/dl), normal igm and iga levels and protective antibodies against tetanus consisting with the diagnosis of hypogammaglobulinemia. due to the recurrent infections, he started replacement therapy with ivig (0.4 g/kg/ months), switched one year ago to facilitated subcutaneous ig (fscig) with achievement of protective serum igg levels (>600 mg/dl) and significantly reduction of infectious episodes. conclusion: hypogammaglobulinemia is frequently reported in patients with md1. in literature most of the cases described does not become clinically manifest, but in our case, the patient was symptomatic with recurrent infections. the replacement therapy with fscig showed both clinical effectiveness and safety. 1532 | real-world experience of a novel, highly purified 10% liquid iv human immunoglobulin for the treatment of antibody deficiencies guidelines for immunoglobulin use (july 2011). a highly purified 10% liquid iv human immunoglobulin (ig), with low levels of iga, anti-a and anti-b haemagglutinins, factors xia, xiia, kallikrein and aggregates (i10e) was recently approved for use in the uk. here i report our centre's experience in using this novel 10% i10e in three patients with antibody deficiencies. case presentations: a patient who presented in clinic with a first diagnosis of pid, was initiated on 10% i10e at 30 g infused every four weeks. after starting i10e, they experienced a decrease in the rate and frequency of infections, in line with expectations for igrt. a young patient on home therapy with a 20% subcutaneous ig for pid presented in clinic with low trough igg levels. non-compliance was identified as the cause of these low trough levels and therapy was switched to 10% i10e at 40 g infused every four weeks in a clinical setting. both the rate and severity of infections reduced and trough igg levels normalised. an older patient on igrt for sad was reviewed in clinic due to discontinuation of their current igrt product. they were switched to 10% i10e at 20 g infused every four weeks. the efficacy and tolerability of i10e was comparable to their previous therapy. a detailed analysis of patient, clinical and safety parameters associated with the initiation of 10% i10e will be presented, including infection rates, white cell counts, c-reactive protein levels, tolerability and infusion-related adverse events. conclusion: these cases highlight the real-world use of 10% i10e in two patients with pid and one patient with sad. they show that i10e was well-tolerated and efficacious in one treatment-naïve, and two previously-treated patients. method: prospective study of families with one or more members with c1-inh-hae followed in 7 hospitals in the northern area of spain. a cohort of 105 patients from 28 families with c1-inh-hae was evaluated for familiar diagnosis of c1-inh-hae one or several patients from the same family were chosen and were given a questionnaire to identify the total family members from the family branch affected by c1-inh-hae that had been already studied (members with diagnosis of c1-inh-hae and healthy members) and those that had not been previously studied. we also register the difficulties for obtaining these data. family members not previously studied and that consent to be contacted were asked for study of c1-inh-hae. for c1-inh-hae screening we use c4 blood levels results: we have studied 28 families with c1-inh-hae, 24 (87%) type 1 and 2 (7%) type ii; 13 families had all their known members already studied for c1-inh-hae (50%): 12 families have all their members studied (42.8%), 18 families have 90% or their known members studied (64.2%) and 10 families had less than 50% of their total known members studied. we have identified 85 members from 11 unrelated families that had not been previously studied for hae, 10 healthy, 4 had low c4 levels and had presented symptoms of hae; 1 had not presented symptoms of angioedema, had normal c4 levels, and low antigenic and functional c1-inh levels. difficulties for a complete family testing study have been: family dispersion, scarce or no family relationship, do not wish to know their possible pathology conclusion: it is crucial to insist on the study of the relatives of patients with hae. we propose to include a questionnaire to identify all patient's relatives at medical reviews of hae patients. case: a-4 year old boy was admitted to our clinic with the history of recurrent respiratory tract infections. his all immunoglobulins were low (igg <154 mg/dl, iga <25.4 mg/dl, igm <17.8 mg/dl) associated with the absence of b cells. his aunt cousin also had xlaa missense point mutation, c562c>t in exon 17 of the btk gene was identified in both affected cousins. the patient was commenced on regular ivig treatment every 3 weeks. at the age of 8, he suffered from intermittent fever attacks, abdominal pain and weight loss. tests for giardia lamblia, clostridium difficile and cryptosporidium, noro virus or parasites were negative. mr-enterography revealed intra-abdominal fluid and thickened walls of his jejunum and cecum. histopathological examination of the biopsy material obtained from terminal ileum, colon and cecum showed crohn disease. initially, he was treated with prednisolone and infliximab. because of the lack of response, infliximab treatment was switched to adalimumab. terminal ileum was resected to relieve obstruction complication. although he had been treated with adalimumab for 1 year, a significant improvement was not observed. vedolizumab (entyvio ™ ), is a humanized monoclonal antibody α4β7 integrin-receptor antagonist, was commenced. induction dosing was 300 mg infusions at 0, 2, and 6 weeks followed by a maintenance phase at 8week intervals. at the 6 month of the treatment, fever and abdominal pain attacks reduced, while his weight and oral intake increased. no side effects were observed. discussion: vedolizumab is effective for inducing and maintaining remission in adults with inflammatory bowel disease (ibd); however, there is limited pediatric data. this is the first immunocompromised child treated with vedolizumab. the symptoms of the patient receded and no side effect observed during 6 months of the treatment. results: louis-bar syndrome is a multisystem progressive disease with polymorphic manifestations which varies by age. the locomotor disability of these children is determined by neurological disorders, the exitus being caused by respiratory infectious and malignancies. the children involved in the study, had frequent episodes of respiratory infectious (bronchitis, pneumonia, atelectasis, empyema, lung abscess), ent infections (otitis, mastoiditis, sinusitis), chronic pulmonary disease (pulmonary fibrosis, bronchiectasis). index of death in this group is high (66.7%). in one of the boy, the pulmonary ct showed lymphadenopathy, later was confirmed non-hodgkin lymphoma, with subsequent death. another child died from pulmonary and systemic infectious complications. results: in this paper we present the clinical and morphological analysis of children with nezelof syndrome diagnosed post-mortem. clinically were predominantly the generalized intrauterine infections or their development in the postnatal period. at macroscopic examination all patients had thymic hypoplasia. later on the microscopic study of the thymus specimens determined dysplastic changes, defined by the presence of concentrically arranged epithelial cells. in all patients, was determined the total lack of hassall corpuscles and its predecessors. besides the above-mentioned modifications in all specimens, there was no cortico-medullary segregation. thymic parenchyma outside pseudorrhagia was made up of a reticular stroma with total lymphocyte depletion. conclusion: nezelof syndrome is a severe primary immunodeficiency associated with thymic dysplasia and alymphocytosis, which is manifested early with generalized infections and major risk of death in neonatal and infant. background: the study was aimed to evaluate the cytokine profile in nasal secretion and blood serum in patients with seasonal (sar) and perennial allergic rhinitis (par) with a potential for additional sensitization with microbial allergens. method: the inclusion criteria for ar were as follows: a diagnosis of ar for more than 2 years, the absence of nonallergic disorders of the nasopharynx, age of patients from 4 years to 60 years.control group: healthy volunteers at the age of 3-43 years without any allergic disorders at examination.in order to evaluate the innate and adaptive immunity, the cytokine profile of blood serum (il-4, il-10, and tgf-β) and nasal secretion (tslp, il-1β, tnf-α, and gm-csf) was determined. to determine tslp, tgf-β, il-10, and gm-csf concentrations, enzyme-linked immunosorbent assay kits were used (ebioscience, bender medsystems, r&d systems, mn, usa). we have noticed a significant correlation (r = 0 46, p = 0 014) between the tslp concentration in nasal secretion and as-ige level to staphilococcus aureus enterotoxin (allergen component m80) in patients with par. there was a significant correlation conclusion: staphylococcal superantigens might be one of the stimuli of local tslp hyperproduction by the epithelium. there was a significant correlation between gm-csf concentrations in nasal secretion and the intensity of sensitization to a staphylococcal enterotoxin (seb) in the patients with ar. seb is one of the polyclonal t cells activators, which may account for increased concentrations of cytokines such as gm-csf locally within the system of mucosal immunity. the patients with ar and additional high sensitization to ses demonstrated a higher tnf-α production profile due to macrophage and tcell activation by these toxins. 1547 | evaluation of circulating osteopontin level as potential biomarker of allergic asthma in patients with caucasian and south-east asian ethnicity background: osteopontin (opn) is a pleomorphic cytokine known to influence a wide range of immune cells; allergic asthma was previously associated with high circulating opn levels. in the present study, we aimed to verify if opn may qualify as biomarker of activated immune response in allergic patients belonging to two different ethnic groups: caucasians and south-east asians. method: serum opn levels were measured by elisa test (human osteopontin duoset, r&d systems) in a series of 121 italian adult patients affected by extrinsic asthma, allergic rhinitis, hymenoptera venom allergy, food allergy, allergic contact dermatitis and ige mediated hypersensitivity to beta lactams. 116 healthy subjects served as controls. 576 ethnic chinese subjects were recruited at the national university of singapore (nus) as cross-sectional cohort of an ongoing epidemiological study on the national prevalence of allergic diseases, and opn levels were detected by luminex (milliplex map, merck) and elisa assays (r&d systems). results: in the italian cohort, opn levels were significantly higher in cases compared to controls (p = 0.0010 by the mann-whitney test). statistically higher opn levels were found in asthma (p = 0.0269) and food allergy (p = 0.046) groups in comparison to controls. no significant differences were found (p = 0.597) between singaporeans with lifetime asthma and healthy controls, only the highest opn levels were heterogeneously found to correlate with asthma. however, a strong gender effect was shown, in both cases (p < 0.0001) and controls (p < 0.0001), with males presenting higher opn levels in comparison to females. consequently, we checked the mrna expression levels of opn gene (spp1) with illumina chips in whole blood of males and females, and no difference was found (p < 0.05). several experiments with western blots and different gel types were performed to verify if possible post-transcriptional/posttranslational modifications of opn could explain these findings. conclusion: opn seems to be a promising biomarker for current, active allergic asthma in caucasians even though technical difficulties, due to opn intrinsically disordered structure, the complex enzymatic metabolism, and the low circulating levels, significantly affect the experiments. further studies are needed to confirm these data. 1548 | mortality, intubation, and healthcare cost in patients with allergic bronchopulmonary aspergillosis in a hospital setting: a nationwide study fan x; luo y; yue b background: abpa is a complex hypersensitivity reaction to aspergillus fumigatus that colonize in airways, it is almost exclusively seen in patients with asthma or cystic fibrosis(cf). this study is to estimate hospitalization outcomes and healthcare cost of hospitalized patients with abpa. method: we conducted the study using data from national inpatient sample(nis) from 2010 to 2014. diagnosis were identified using icd-9-cm codes. hospitalization with a primary diagnosis of abpa and hospitalization with a primary diagnosis of acute respiratory failure/acute and chronic respiratory failure/respiratory distress/ asthma/cf and a secondary diagnosis of abpa were included. the study population was divided into groups including abpa with asthma, and abpa with cf. mortality and intubation rate were the primary outcomes; length of stay and total hospitalization cost(adjusted to cost in 2014 based on medical care cpi) were secondary outcomes. student t-test and chi-square were used for univariable analysis, linear and logistic regression were used for multivariable analysis. results: a total of 6308 hospitalizations with abpa were included, with 2896 hospitalizations with abpa and asthma, and 2793 hospitalizations with abpa and cf. the overall mortality rate was 0.82% (95% ci: 0.44%-1.50%), the mortality for abpa with asthma was 0.69% (95% ci: 0.26%-1.83%) and for abpa with cf was 0.56% (95% ci: 0.19%-1.63%). the overall intubation rate was 4.83% (95% ci: 3.77%-6.18%); the intubation rate for abpa with asthma was 5.51% (95% ci: 3.91%-7.72%) and 84.0% were early intubation (<3 days); the intubation rate for abpa with cf was 1.95% (95% ci: 1.13%-3.35%) and 36.6% were early intubation. the overall mean length of stay(los) was 8.7 (95% ci: 8.0-9.3) days, while the los for abpa with asthma was 5.6(95% ci: 5.2-6.1) days and the los for abpa with cf was 12.1 (95% ci: 11.1-13.0) days. the overall total cost was 147 million usd, the total cost for abpa with asthma was 33.4 million usd with a mean of 12 069, while the total cost for abpa with cf was 101 million usd with a mean of 38 005. conclusion: mortality among hospitalized patients with abpa is low<1%. intubation rate is relatively low, intubation, especially early intubation (<3 days), is more common in patients with asthma. although abpa is not a common disease in inpatient population, it does have a high health care cost and despite lower intubation rate, patients with abpa and cf generally have a longer hospital stay with a higher hospitalization cost. 1549 | frequent exacerbations of bronchitis with wheezing in adults: is it possible to predict and prevent asthma? case report: frequent episodes of bronchitis, accompanied by wheezing and dry with a prolonged duration in adults, the clinical course may be similar to bronchial asthma. the aim is to assess the risk of asthma in adult patients with 2 or more episodes of acute bronchitis per year, had a prolonged duration and accompanied by a dry wheezing. for 5 years in two regional clinical pulmonology centers were observed in 46 patients (19 men and 27 women) with average age 34 ± 6.8 years. each had at least 2 episodes of acute bronchitis per year, which was accompanied by prolonged cough and presence of wheezes. average number of acute episodes per year was 3.2 ± 0.8. in the course of the observation the patients were divided into 2 equal groups. the first group consisted of 23 persons treated in acute episodes of the disease symptomatic therapy, including inhaled β2-agonists short-acting short course. in the second group to the corresponding treatment added montelukast 10 mg per day lasting for 1 month. in all cases of exacerbation had a viral nature. held in the period of remission of allergic sensitization, the survey revealed. starting from the first year of follow-up all patients were vaccinated against influenza annually. by the end of the fifth year of observation in the first group in 5 cases was diagnosed of bronchial asthma-4 cases easy persistent asthma and 1 case moderate. the diagnosis was exhibited in accordance with the gina criteria. in the second group, the diagnosis of bronchial asthma were exposed to 1 patient (hazard ratio of 0.18). prospective observation suggests that the use of anti-inflammatory potential antileukotriene medicines in complex therapy of recurrent acute episodes of bronchitis accompanied by a dry wheezing in adults may be a factor preventing the development of asthma. for more conclusive results require more extensive research. background: chemokine receptors play an important role in regulating the migration of t lymphocytes, monocytes and neutrophils from the peripheral blood into inflamed tissue, such as lung. however, little is known about their expression on natural killer (nk) and natural killer t (nkt) cells in patients with chronic obstructive pulmonary disease (copd). therefore the aim of the study was to determine the chemokine receptor profile of peripheral blood nk and nkt cells of copd patients. method: for analysis of lymphocytes subtypes the flow cytometry method was used. the study population consisted of 57 smokers with copd, 12 healthy smokers and 12 healthy non-smokers. results: we observed an increase in blood nk cells expressing cxcr3 receptors in smokers with copd compared to healthy smokers (p = 0.003) and healthy non-smokers (p < 0.001). the percentage of nkt cells containing cxcr3 receptors was also significantly higher in blood of smokers with copd compared to healthy smokers (p = 0.021) and healthy non-smokers (p < 0.001). copd smokers had significantly higher proportion of ccr5 + nk cells than smokers without copd (p = 0.002) and healthy non-smokers (p < 0.001). increased proportion of blood nkt cells expressing ccr5 on their surface was observed in smoking copd patients compared to healthy smokers (p = 0.002) and healthy non-smokers (p < 0.001). there were no significant changes in the percentage of cxcr3 + and ccr5 + nk and nkt cells between healthy smokers and non-smokers. in addition, no differences were seen in the proportion of nk and nkt cells expressing cxcr4, cxcr6, ccr6 and ccr7 among all studied groups. method: 58 patients with copd in stable condition (gold stage 2) aged 40-70 years old, smoking history of ≥10 pack-years, were studied. bmi of patients were divided into 2 groups: obese (n = 31) (bmi-30.0-39.9 kg/m 2 ) and non-obese (n = 17) (bmi-18.5-24.9 kg/ m 2 ). ten subjects with normal lung function and bmi were the control group. the level of il-26 assessed in induced sputum (pg/ml) was measured using an elisa (raybiotech ® ). serum levels of crp were measured using the "vector-best" (russia federation). spirometry was performed according to american thoracic society and the european respiratory society (ats/ers) guidelines. results: obese copd patients had significantly increased concentrations of il-26 compared with healthy subjects and non-obese copd patients by 2.6 fold (139.0 ± 85.4 pg/ml vs 53.15 ± 18.5 pg/ ml) (p < 0.008) and 1.15 fold, (139.0 ± 85.4 pg/ml vs 120.6 ± 60.15 pg/ml)(p < 0.04), respectively. non-obese copd patients had higher levels of il-26 by 2.3 fold compared with healthy subjects (120.6 ± 60.15 pg/ml vs 53.15 ± 18.5 pg/ml) (p < 0.008). results: among these three groups, the level of cer in lung cancer patients (0.35 ± 0.10 g/l) was significantly higher than that in ild patients (0.31 ± 0.25 g/l) and healthy individuals (0.25 ± 0.04 g/l) (p < 0.05). meanwhile, the levels of c3 and c4 in healthy individuals, which are 1.70 ± 0.29 g/l and 0.27 ± 0.34 g/l respectively, were both significantly higher than that in lung cancer patients (c3: 1.04 ± 0.26 g/l, c4: 0.24 ± 0.09 g/l) and ild patients (c3: 0.97 ± 0.25 g/l, c4: 0.21 ± 0.09 g/l), (c3: p < 0.05, c4: p < 0.05). results from optimal scaling demonstrated that lung cancer was closely associated with immune factors including crp, cer, c3 and c4 (cronbach's alpha = 84.7%). conclusion: for ild patients, when the level of crp and cer is increased and the level of c3 and c4 is decreased simultaneously, the risk of the development of lung cancer should be considered for these patients. results: among pbmc subpopulations, endurance exercises impacted the number of nkt and activated t cells with nkt cell numbers greater in male bobsledders vs bullet shooting and biathlon (42.4% and 44.3%, respectively). the number of activated t cells (cd25 + ) was greater in bullet shooting and bobsleigh athletes vs the biathlon group (34.9% and 22.7%, respectively). in female athletes the number of cd25 + cells in the shooting and bobsled groups was greater by 46.1% and 25.5%, respectively vs the biathlon group (p < 0.05). increased il-10 occurred in bobsleds in comparison to bullet shooting and biathlon: 32% and 80% in male and 70.5% and 83% in female, respectively (p < 0.05). the concentration of il-18 in male bobsledders and biathlon was 30% and 34% greater, respectively, compared with bullet shooting (p < 0.05). serum concentrations of ifnγ in male as well as female athletes showed an increase of 41.6% and 39.5%, respectively vs biathletes (p < 0.05). increased il-4 occurred in the male biathlon group by 39.7% and 13%, respectively, vs the bullet shooting and bobsleigh athletes (p < 0.05). il-6 was increased in the male biathlon group, compared to bullet shooting and bobsledders by 76.7% and 70.3%, respectively (p < 0.05). conclusion: prolonged endurance exercises impacts secretion of pro-and anti-inflammatory cytokines in athletes of different sport specializations. concentrations of studied cytokines did not exceed reference values perhaps due to specialized sport nutrition, which may restore immune function during endurance exercises. background: oral immunotherapy (oit) is a promising therapeutic approach to treat food allergic patients. recently, we have shown that the use of a mixture of short-chain-and long-chain fructo-oligosaccharides (scfos/lcfos) improves the efficacy of oit in cow's milk and peanut allergic mice. however, concerns with regard to safety and long-term efficacy of oit remain and there is a need to identify novel biomarkers (panels) that predict, monitor and/or evaluate the effects of oit. here we present a method for the selection of candidate biomarkers by using the computational approaches bayesian networks (bn) and topological data analysis (tda). method: data were used from scfos/lcfos diet-supported oit studies performed in 2 independent cow's milk allergy (cma) and 2 independent peanut allergy (pna) experiments in mice. first, a subset of the data was used for learning the data structure and their interactions in terms of a bn. this bn was used to compare the key parameters in both experimental food allergy models. finally, the relations within the dataset in combination with the bn were explored to identify and rank candidate biomarkers for the effect of oit by applying tda. the bn was able to predict the efficacy of oit in the cma and in the pna model with 82% and 80% accuracy respectively, thereby identifying a set of 5 parameters (allergen-specific ige and igg1, body temperature, mmcp-1, earswelling) being key in the mechanisms involved in both scfos/lcfos-aided oit food allergy models. the tda zoomed in on the full set of 67 previously analyzed parameters and identified clusters of biomarkers closely linked to biologically relevant clinical symptoms but also unrelated and redundant parameters within the network. taken together, this enables the prioritization of candidate biomarkers. moreover, the tda indicated differences between pna and cma models in how the data are related to each other. here we provide promising bioinformatics methods to compare mechanistic features between two different food allergies and to determine the biological relevance of biomarker (panels) of oit for food allergy. we have shown that the key drivers that influence pna and cma are similar, but that these phenotypically similar diseases show mechanistic differences in their subnetworks. these new insights provide excellent starting points to generate new hypotheses to explain why cma has a different disease pattern than pna and to select biomarkers that are useful in future clinical studies. 1562 | functional and immunoreactive levels of igg4 correlate with clinical responses during the maintenance phase of house dust mite immunotherapy basophils were identified as ssc low cd193 high , and cd63 was used as an activation marker. reactivity was confirmed by anti-ige as a positive control. results: in 4 patients, basophil reactivity and sensitivity was comparable for grass pollen extract and recombinant phl p5, while phl p1 only caused a lower basophil activation. in one patient, recombinant phl p5 did not cause any basophil activation, while phl p1 elicited an even higher sensitivity and reactivity than grass pollen extract. conclusion: in 4 patients, basophil reactivity was comparable for grass pollen extract and recombinant phl p5, while phl p1 only caused a minor basophil activation. in one patient, recombinant phl p5 did not cause any basophil activation, while phl p1 elicited an even higher sensitivity and reactivity than grass pollen extract. reactivity of extract and the main sensitizing components correlated, while sensitivity did not. 1564 | in vitro assessment of hypersensitivity to allergen before and after allergen immunotherapy with whole blood basophil histamine release assay wbbhr assay in these patients was performed 7-10 days before and 7-10 days after ait. heparinized whole blood samples (8 ml) of each patient after substitution of plasma with pipes buffer were incubated one hour at 37°c with different concentrations of birch pollen extract (t3) in u-shape 96-well micro-titer plates. after incubation plates were centrifuged and supernatants from each well of the plate were directly analyzed for histamine content by reversedphase high performance liquid chromatography with electro-spray ionization mass-spectrometry (rp-hplc-esi-ms). results were expressed as ng/ml released histamine. sensitivity (limit of quantification) was 5-7 ng/ml. to compare results of histamine release in patients before and after ait data were calculated as area under the curve (auc) values. results: in contrast to pre-immunotherapy activity of blood basophils there were significant decreases in hr induced by t3 extract after ait. according to auc values all patients demonstrated decrease in hr after ait in compare to hr before ait in a range of 25%-65% demonstrating a decrease of hypersensitivity to birch allergens. analysis of basophil hr in patients received s.c. or s.l. the asthma and rhinoconjunctivitis symptom scores during and after pollination season decreased significantly and showed correlation with histamine release by t3. 1565 | immunotherapy with the recombinant b cell epitope-based grass pollen allergy vaccine bm32 induces a biphasic allergen-specific igg1 and igg4 response background: immunotherapy with the recombinant b cell epitopebased grass pollen allergy vaccine has been shown to reduce symptoms of grass pollen allergy in a multicenter, double-blind, placebocontrolled study. aim of this study was to investigate the levels and kinetics allergen-specific igg responses in a double-blind, placebocontrolled phase iib combined field and exposure chamber trial studying the effects of three, four and five pre-seasonal injections of bm32 as compared to placebo. method: a quantitative elisa assay based on purified human monoclonal allergen-specific igg 1 as well as igg 4 antibodies as standards was developed to measure allergen-specific igg 1 and igg 4 concentrations induced by ait with bm32. results: we found rises in levels of both tested allergen-specific igg subclasses in the actively but not placebo-treated patients. phl p 1-and phl p 5-specific igg 1 levels up to 83 μg/ml and 784 μg/ml, respectively and phl p 1-and phl p 5-specific igg 4 levels of up to 468 μg/ml and 1423 μg/ml, respectively were measured in bm32treated patients. five pre-seasonal injections induced the highest allergen-specific igg levels. interestingly, allergen-specific igg 1 and igg 4 antibodies showed a biphasic response with early rises of allergen-specific igg1 which declined quickly after the pollen season and a delayed but very sustained allergen-specific igg4 response. conclusion: treatment with bm32 induces a biphasic allergen-specific igg response consisting of an early igg1 and a sustained allergen-specific igg4 response which may be responsible for early and sustained protection against allergic symptoms. 1566 | t reg cd4 + cd25 high in peripheral blood in patient with grass pollen allergy during sublingual specific immunotherapy slit the aim of this study was to evaluate t reg cd4 + cd25 high in peripheral blood in patients with grass pollen allergy during sublingual immunotherapy slit. method: we examined 27 adult patients, aged 20-41, 13 female and 14 male. patients were qualified to slit after confirmation of allergy-by skin prick tests, specific ige and nasal provocation tests. we determined t reg cd4 + cd25 high from blood sampling of those patients (by flow cytometry method), before the slit, after reaching the maintenance dose, before the grass pollen season, during the grass pollen season, and after one year of slit. results: during slit the percentage of t reg cd4 + cd25 high increase after reaching the maintenance dose, then it decreased before and during the grass pollen season, and again increase after one year os slit. we observed, that in the group with significant improvement of symptoms, t regcd4 + cd25 high decreased during grass pollen season, comparing to group without clinical improvement. conclusion: slit as a method of immunotherapy influence on levels of t reg cd4 + cd25 high cells. the observed decreased levels of these cells during the grass pollen season might be consider as a prognosing marker of clinical improvement. 1567 | t reg cd4 + cd25 high from peripheral blood during subcutaneous specific immunotherapy (scit) for grass pollen hofman a; hofman j; hofman t centrum alergologii, poznan, poland background: specific immunotherapy is the only causal method for grass pollen allergic rhinitis. however, we don't observe in every patients satisfying clinical effects. because the treatment of allergic rhinitis takes 3-5 years, and is quite expensive, everyone is constantly looking for a perfect parameter, which may prognose the effectiveness of specific immunotherapy (sit). the aim of this study was to evaluate t reg cd4 + cd25 high lymphocytes from peripheral blood in patients during subcutaneous specific immunotherapy (scit) for grass pollen . method: we examined 99 adult patients (36 female, 63 male), age 18-60, who undergo scit for grass pollen allergy. we have done skin prick tests and specific ige in those patients. additionally, we confirmed the allergy by nasal provocation tests. we have determined lymphocytes t reg cd4 + cd25 high from blood sampling from those patients, with flow cytometry method: before immunotherapy, after reaching the maintenance dose of scit, before and during the grass pollen season, and after one year of scit. our control group was represented by 12 adult healthy volunteers. after one year of scit we divided patients into two groups-with and without clinical improvement. results: in allergic patients we have observed decreased levels of t reg cd4 + cd25 high compared to control group before the start for scit. during immunotherapy, the percentage of t reg cd4 + cd25 high increased after reaching the maintenance dose, however it did not reached the level of healthy volunteers. again, levels of t reg cd4 + cd25 high decreased before and during the grass pollen season, and increased after one year of scit. we compared also patient with significant improvement of clinical symptoms, and without. and we observed that the level of t regs cd4 + cd25 high decreased during pollen season in improved group, and increased in the group without clinical improvement. conclusion: in patients with grass pollen allergy, during the grass pollen season, decrease of t reg cd4 + cd25 high cells might be conresults: in the group of patients treated with sit gene expression analysis revealed significant change in ifng expression (p = 0.03) (comparison between sample a and b). comparison between samples a and c showed significantly different expression in genes: afap1l1 (p = 0.006), commd8 (p = 0.001), pik3cd (p = 0.027), and twist2 (p = 0.0003). duncan's multiple range test confirmed difference between sample a and c for commd8 (p = 0.004) and also revealed new significant difference in tbx21 in samples a and b (p = 0.035; in wilcoxon's test p = 0.08). k nearest neighbors algorithm was built based on ifng, pik3cd, commd8 expression. the results of the study indicate, that there is a significant change in the expression of a few genes during the build-up phase of sit. it may be suspected, that this change contribute to the mechanisms involved in the building tolerance to allergen. k nearest neighbors algorithm may be useful for sit efficacy prediction. 1569 | regulation of cytokine thymic stromal lymphopoietin (tslp) in modulating tgf-ß1induced interstitial inflammation and cellular fibrosis background: thymic stromal lymphopoietin (tslp) has previously been linked to allergic inflammatory diseases, tissue fibrosis and organ dysfunction. it remains unclear, however, whether tslp plays any role in the occurrence of renal fibrosis, so this study investigated that underlying mechanism. method: an in vitro fibrosis model was established by treating normal rat kidney fibroblast (nrk-49f) cells with transforming growth factor-β1 (tgf-β1), after which the levels of various fibrogenic markers (e.g., fibronectin) and downstream fibrogenic signal proteins (e.g., smad 7) were investigated. also, tslp shrna was used to silence the effects of tslp, while an elisa was conducted to evaluate the fibronectin secretions. results: the level of fibronectin in the nrk-49f cells was doseand time-dependently increased by the administration of exogenous tslp (p < 0.05). tslp also significantly increased the level of fibrosis signaling, in addition to inducing a marked decrease in the down-regulation of smad7. interestingly, the application of tslp shrna caused a dramatic reversal of the tgf-β1-induced cellular fibrosis while simultaneously leading to the suppression of fibronectin and fibrogenic signal proteins. conclusion: taken together, these observations provide insights into how extracellular matrices develop and could lead to potential therapeutic interventions for the suppression of renal inflammation and fibrosis. abstracts | 779 1571 | effects of two years treatment with the recombinant b cell epitope-based grass pollen allergy vaccine bm32 on allergen-specific b and t cell responses background: bm32 contains recombinant fusion proteins of nonallergenic peptides from ige-binding sites of the four major timothy grass pollen allergens phl p 1, 2, 5 and 6 and pres protein from the hepatitis b virus as a carrier. in a multicentre, double-blind, placebocontrolled trial, 181 grass pollen allergic subjects were treated for two years either with bm32 or placebo. here we investigated in detail the effect of immunization with bm32 on allergen-specific t and b cell responses. during the study from 35 subjects treated in the vienna centre (bm32: n = 25, placebo: n = 10) were investigated regarding proliferation using 3 h thymidine incorporation and cytokine production in response to various recombinant allergens at 9 different time points. grass pollen allergen-specific ige, igg 1 and igg 4 levels were determined by immunocap and elisa. results: a significant increase of allergen-specific igg 1 and igg 4 levels was found in the bm32-but not in the placebo group in both years (year1 > year2) after treatment. there was no difference regarding t cell proliferation in response to phl p 1 and phl p 5 after first grass pollen season between actively and placebo-treated patients whereas proliferation in particular of phl p 1-specific responses seemed to be blunted in the active group in the second year. no significant differences regarding allergen-specific th1, th2 and tolerogenic (i.e., il-10) cytokines were observed between bm32and placebo-treated patients. the findings indicate that the bm32 induces high levels of allergen-specific blocking antibodies which may reduce allergen-specific t cell proliferation but does not induce significant increases of regulatory cytokines in t cells. this study was supported by grants f4605, f4613 and dk 1248-b13 of the austrian science fund (fwf). 1 hospital universitario ramón y cajal, madrid, spain; 2 department of immunology iis-fundación jiménez díaz, uam, madrid, spain background: shiitake mushroom (sm) (lentula edodes) is an edible fungi native to east asia. it is traditionally cultivated and used in many asian countries and its consumption is increasing worldwide. direct skin exposure to sm can cause cutaneous reactions, including allergic contact dermatitis and urticaria, while its oral intake may prompt "shiitake flagellate dermatitis" (sfd), which is a distinctive itching linear erythematous eruption. sfd is usually considered a toxic reaction to lentinan, a thermolabile polysaccharide that increases interleukin-1. we report 3 cases (p1, p2, p3) of shiitake flagellate dermatitis studied in our centre. method: skin prick tests (spt) to environmental allergens-including moulds -, prick-by-prick and patch test with raw and cooked sm were carried out. total ige and specific ige to mushroom, white mushroom and environmental moulds were also determined. a raw and cooked shittake mushroom extracts were prepared. both extracts were analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: skin prick tests, prick-by-prick, patch tests and specific ige were all negative except for p1, who had positive prick-by-prick to raw shiitake mushroom. sds-page ige immunoblotting assays with the patient's sera revealed ige-reactivity with proteins ranging from 16 kda to 32 kda for p1, p2 and p3. we report 3 cases of shiitake flagellate dermatitis with demonstrated ige-sensitization. physicians should take into account that some cutaneous reactions considered as toxic might be allergic reactions. vorozhko i 1 ; sokolnikov a 1 ; sentsova t 2 ; donnikov a 3 ; ilyenko l 2 ; denisova s 2 background: allergic diseases such as asthma, rhinitis and food allergy have increased in recent decades in tropical countries. the tropics has climatic, environmental and ecological peculiarities that allow us to emit several hypotheses that could explain this phenomenon. in one of them, it is postulated that the increase of the sensitization to food, is due to the presence of lower serum levels of vitamin d, product of the adoption of a western lifestyle, with lower sun exposure, which in its turn diminishes the immunomodulatory action of this vitamin at intestinal level, favoring the sensitization against food antigens. we evaluate differences between the titers of serum antibodies against food antigens between two populations with african ancestry but different environment (rural vs urban) and investigate the influence of vitamin d levels. method: an observational, cross-sectional and descriptive study was carried out on 200 afro-descendant children living in san basilio de palenque (rural) or in the city of cartagena, bolivar (urban). the sensitization was determined by a positive skin prick test to allergen extracts, including foods, and, specific ige, iga and igg4 to egg, milk and peanut extract, as well vitamin d, were measured by elisa. antibody and vitamin d titers were correlated by spearman's test and comparisons between groups were done using the wilcoxon rank sum test. a p < 0.05 was considered significant. results: atopy was more prevalent in the urban population (24% vs 7%, p < 0.001). however, none participant tested was positive for food allergens. regarding vitamin d levels, these were found to be higher in the rural population compared to the urban group (p < 0.001). among the antibodies analyzed, only ige against peanut showed differences, which were higher in rural population (p < 0.001) as well as those of iga to peanut, which were higher in the urban population (p < 0.001). we observed only a significant correlation between peanut specific ige (rho 0.2127259, p < 0.005) and iga (rho -0.342434, p < 0.001) response and vitamin d. conclusion: in our study, we found differences between the peanut specific ige and iga response in urban and rural populations. the correlation between the levels of specific ige and iga to peanut and vitamin d, suggest that this vitamin may influence peanut sensitization in this population, besides other components like diet and genetic and environmental factors. 1580 | evaluation of inhaled allergen sensitivity in patients with food allergies younger than two years of age kulhas celik i 1 ; aldemir es 2 ; buyuktiryaki b 1 ; ginis t 1 ; toyran m 1 ; dibek misirlioglu e 1 ; kocabas cn 3 ; civelek e 1 carbohydrates and pyruvate was observed in the severe group compared to the rest of allergic groups. in addition, an increment in lactate was noticed. these metabolites were closely associated with the energy metabolism. other metabolic changes included increased levels of fatty acids such as myristate, palmitate and laureate. these fatty acids might be precursors of arachidonic acid, a key molecule in inflammation. finally, alterations in some amino acids and adenosine were found method: to evaluate these critical processes, 22 five-week old germ-free c3h/hen mice were split into two groups; 12 were intraperitoneally sensitized to the peanut allergen ara h 2 and 10 remained ns. upon reaching 8 weeks of age, mice were intragastrically challenged with purified ara h 2. mice were harvested in two groups: 30-minutes and 60-minutes post-gavage. upon harvest, the left lobe of the liver was collected and sera were removed. sera and livers were evaluated for drp-ara h 2 using an in-house quantitative sandwich enzyme-linked immunosorbent assay (elisa). a sample of the proximal small intestine was monitored for drp-ara h 2 using immunohistochemistry (ihc) and for mast cell degranulation using toluidine blue stain. results: sensitization does not have a large effect on the concentration of allergen present in the sera or liver. however, s mice allowed to digest ara h 2 for 60-minutes were more likely to display tissues positive for detection of drp-ara h 2 than ns mice at the same time point. conclusion: there is drastic biological variation among mice in their capacity to absorb and transport allergens. the elisa used in these analyses proved effective in the quantitative detection of drp-ara h 2 in both liver and sera samples, while ihc provided inconsistent results for the detection of drp-ara h 2 in tissues. however, in positive ihc samples, staining was indicative of paracellular transport across the epithelial barrier. 1583 | eczema induces a high ovalbuminspecific ige/igg1 ratio and affinity maturation during the lactation period irahara m; kido h; shinahara w inst. for enz. res., tokushima university, tokyo, japan background: recent articles have revealed that ingestion of foods induces oral tolerance and cutaneous sensitization induces food allergy. relationships with levels of immunoglobulin subclasses, affinity of allergen-specific ige, and development of food allergy have also been indicated. however, relationships with levels and affinity of specific immunoglobulins and eczema during early infancy remain poorly understood. therefore, the present study aimed to elucidate these relationships. method: this study enrolled women who visited naruto hospital (tokushima prefecture, japan) in late pregnancy and their children. blood samples and information on skin condition were taken every 2 months from neonate to 6 months old. egg white and milk allergen-specific immunoglobulin subclasses and affinity of ovalbumin (ova)-specific ige levels were measured using the densely carboxylated protein (dcp) microarray with 20 μl of serum. results: this study included 84 infants whose parents agreed to join this study. of these, 42 infants (50%) were diagnosed with eczema by 6 months old. egg white (ew) and milk-specific igg4 were detected in a few subjects at 6 months old. however, these specific ige and igg1 were detected in some subjects at that time ew-and ova-specific ige levels and ige/igg1 ratios were significantly higher in participants with eczema than in those without eczema at 6 months old. moreover, subjects with high ova-specific ige/igg1 ratios showed higher affinity ova-specific ige antibodies than subjects with low ova-specific ige/igg1 ratios. these results were not reflected in milk-specific ige levels. the milk-specific ige level differed between breast feeding and formula-fed infants, with no difference in the ige/igg1 ratio. conclusion: eczema contributed to high ew-and ova-specific ige levels and ige/igg1 ratios. high ova-specific ige/igg1 ratios involved high affinity ova-specific ige antibodies. however, the milk source during early infancy had no effect on the specific ige/igg1 ratio with eczema. these results suggest different sensitization routes provoke different results in levels and affinity of immunoglobulins. 1584 | purification and characterization of naturally occurring post-translationally cleaved ara h 6, an allergen that contributes substantially to the peanut allergome background: the 2s albumin ara h 6 is one of the most important peanut allergens. a post-translationally cleaved ara h 6 isoform has been described in the past but had not been characterized in detail, nor had its relevance for peanut allergy been investigated. method: post-translationally cleaved ara h 6 (para h 6) and intact ara h 6 (intact ara h 6) were purified from virginia type peanuts and the cleavage site was mapped using high-resolution mass spectrometry. biochemical characteristics were determined by sds-page, uv absorbance spectroscopy, far uv cd spectroscopy, and immunochemical reactivity of both forms of ara h 6 was compared by igg immunoblotting and ige-elisa using sera from individuals sensitized to peanut. reversed-phase liquid chromatography was applied to study the occurrence and abundance of para h 6 in various peanut types. results: compared to intact ara h 6, para h 6 lacks a 5-amino acid stretch, resembling amino acids 43-47 (uniprot accession number q647g9) in the non-structured loop. consequently, para h 6 consists of 2 chains; a n-terminal chain of approximately 5 kda, and a c-terminal chain of approximately 9 kda, held together by disulfide bonds. intermediate post-translationally cleaved products, in which this stretch is cleaved but not removed, are also present. the secondary structure and ige-binding of para h 6 resembles that of intact ara h 6, indicating that the loss of the non-structured loop is not critical for maintaining conformational ige-epitopes. both forms of ara h 6 were reactive with several commercially available igg antibodies. the peanut cultivars runner, virginia, valencia, and spanish contained para h 6 at equivalent levels, suggesting para h 6 is a consistent and important constituent of the peanut proteome. conclusion: a post-translationally cleaved form of ara h 6 is abundant in the main peanut market types, and has ige-binding comparable to intact ara h 6. this should be taken into account when ara h 6 is investigated in peanut-containing products. 1585 | release of major peanut allergens from their matrix at various ph and at saliva conditions; ara h 2 and ara h 6 are quickly bioaccessible background: the oral mucosa is the first immune organ that encounters allergens upon ingestion of food. peanut is often consumed in solid form, and it is not known if peanut allergens are released from the food already in the mouth. we set out to investigate the solubility of individual peanut allergens at conditions that mimic the first exposure site, i.e. the mouth. method: light roast peanut flour was suspended in buffers of various ph mimicking saliva. protein concentration was measured in supernatant, and release of major allergens ara h 1, ara h 2, ara h 3, and ara h 6 was assessed by sds-page. also, the allergen profile of un-dissolved material was assessed. results: peanut protein solubility is poor in the ph range 3-6, while at low ph (1.5) and at moderately high ph (>8), the solubility is higher. at all conditions tested, there was a substantial amount of un-dissolved protein. this indicates that the ph range of saliva, between 6.5 and 8.5 in healthy individuals, may be critical for the release of peanut protein from its matrix. in this ph range from 6.5 to 8.5, ara h 2 and ara h 6 are readily released, while ara h 1 and ara h 3 are poorly released. increasing the ph from 6.5 to 8.5 slightly increased the release of ara h 1 and ara h 3, but still the recovery was low (approximately 20% for both ara h 1 and ara h 3) compared to that of ara h 2 and ara h 6 (approximately 100% and 65%, respectively). this remarkable difference in extraction kinetics suggests that ara h 2 and ara h 6 are the first allergens an individual is exposed to upon ingestion of peanut-containing food. conclusion: based on our observations, we conclude that the peanut allergens ara h 2 and ara h 6 are quickly bio-accessible in the mouth upon ingestion of peanut. this new insight may contribute to the understanding of the extraordinary allergenicity of ara h 2 and ara h 6 compared to other peanut allergens. background: in proven cases of non-ige mediated cow's milk allergy clinical response can be partial even when treated with amino acid formulae e.g pain in infants. residual intestinal symptoms can be related to ongoing nerve hypersensitivity, changes in microbiome or motility disturbance. mast cells are thought to play crucial role in non-ige mediated food allergy. ketotifen is a first generation h1 antihistamine which has mast cell stabilising properties with pain blocking and anti tnf-a effect. hence ketotifen could have important role in symptom resolution where diet elimination has not been successful. we aim to find out effectiveness of ketotifen to unresponsive/partially responsive symptoms such as pain in non-ige mediated cow's milk allergy infants. method: children who presented to single specialist centre over 11 years had their case notes reviewed retrospectively. inclusion criteria were those children with confirmed non-ige mediated cow's milk allergy by elimination of cow's milk with improvement of symptoms and worsening of symptoms on reintroduction of dairy. where symptoms partially responded e.g pain, ketotifen was used at 0.5-1 mg once at night for 4 weeks and symptoms were reassessed. statistical analysis was performed using r v3.3.3 with significance was set at p = 0.05. results: 1031 patients were identified with 675 patients excluded due to unconfirmed non-ige mediated allergy. of the 358 case (206 males, age 3-50 months), atopic co-morbidities were found in 62% children. common symptoms were abdominal pain (51%), vomiting (47%), back arching (37%), constipation (35%), bloating (33%), food aversion (29%) and diarrhoea (26%). we compared the children who had symptom improvement on ketotifen and cow's milk elimination against children who improved on cow's milk elimination alone. significant difference of symptom improvement was found with abdominal pain; 69% using ketotifen compared to 53% who did not use results: a total of 3548 analysis for ttgiga have been performed for a total of 2965 patients during the study period (2010, 2012, 2014, 2016) . 128 patients showed at least once a positive ttgiga. among these, 11 had a negative result at first testing, and were positive at the second (n = 10) or third testing (n = 1). despite an increasing number of ttgiga requests, the number of positive results decreased. wige were rarely requested but were positive in about 45% of tested sera (table 1a and 1b). the amount of laboratory requests for ttgiga has increased, while those for wige remains stable and is rare. wheat allergy seems to be rarely investigated in our center and may deserve more attention. case report: eosinophil-associated gastrointestinal disorders (egids), including eosinophilic gastroenteritis (eog), are a inflammatory diseases, characterized by gastrointestinal symptoms and eosinophilic infiltration. patients with eoe have an increased incidence of allergy, with increased ige mediated food and inhalant sensitivities. use of either a targeted food allergen avoidance approach (based on allergy testing) or untargeted approach (based on food allergen avoidance) results in the resolution of eosinophilia in the gastrointestinal tract of 50%-70% of adult. we describe a case of a 27-year-old patient diagnosed with eosinophilic enteritis, associated to protein-losing enteropathy. the patient experienced severe diarrhea, nausea, vomiting and weight loss, that caused a severe dysproteinaemia and electrolytes abnormalities. an upper and lower endoscopy was performed, showing an ulcerative ileitis. the histological pattern was characterized by eosinophilic infiltration of ileum and duodenum>40 hpf. she presented also high levels of total ige (800 k/ui), high serum tryptase (20 μg/l, n.v. ≤9.0) and sensitization to the lipid transfer protein (ltp) of peach. the patient was prescribed to a six-food elimination diet (sfed) and underwent high doses of oral and intravenously corticosteroids, but a satisfactory therapeutic response was not achieved. we hypothesized that ige has a role in the mechanism of aeg and that blocking ige would have improved disease symptoms and reduced allergic inflammation, as measured by a decrease in intestinal tissue eosinophilia. we started off-label administration of omalizumab 300 mg/month subcutaneously, the same dosage schedule used in allergic asthma and, by other authors, in eosinophilic gastrointestinal disease after achieving informed consent by patient. except for an exacerbation of symptoms occurred 9 months after starting the therapy, when a further endoscopy, showing a gastrointestinal eosinophilic infiltration>50 hpf, was performed, a significant improvement of both gastrointestinal and cutaneous symptoms was observed during therapy, together with a normalization of laboratory parameters. after 30 months a clinical remission of disease was obtained and administration was stopped. although a histological remission during the first few months of treatment was not obtained, in a subset of aeg patients, ige plays a role in the pathophysiology of the disease and that anti-ige therapy with omalizumab may result in disease remission. 1590 | fullerene c60 reduces the allergic inflammation in food allergy mouse model background: a food allergy (fa) is an abnormal immune response to food. the signs and symptoms may range from mild to severe. they may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. food allergy is becoming increasingly common. fullerene c60 has the unique electronic properties making it an attractive candidate for allergic diseases therapy. the main purpose of our research was to assess therapeutic effect of fullerene c60 in a mouse model of fa. method: new efficient method for producing a water-soluble fullerene c60 has been developed. fa experimental model was induced in balb/c mice by the intragastrical (ig) ova administration after subcutaneous (sc) sensitization. fullerene c60 was administrated ig once a week, or twice a week, or daily. ova-specific antibodies were assessed by elisa. splenocytes cytokine production upon ova in vitro stimulation was detected by elisa. samples of jejunum of the small intestine were removed for histological examination immediately after the last ig allergen administration. results: it was shown that ova-specific ige and il-5 level were significant decreased in groups treated with water-soluble fullerene c60. the greatest effect was observed in mice receiving fullerene c60 daily. the ifn-gamma level was significantly higher in ig c60treated groups. the histologic analysis of jejunum of the small intestine samples showed that c60-therapy improved the histologic picture. the greatest effect was observed in mice receiving fullerene c60 daily too. conclusion: taken together, these results demonstrate that the water-soluble fullerene c60 exhibits a significant anti-inflammatory effect in a mouse model of fa, and possesses a high therapeutic potential. background: a 47-year-old male reported eight episodes of anaphylaxis after exercise. all the ingested food eight hours before each episode was analyzed. before each episode, he had always eaten chicken or turkey meat, and he tolerated these foods without exercising. in one of the episodes the patient had taken a tablet of dexketoprofen a few hours before. since several years, he referred chest tightness after eating some fish (emperor, salmon and whiff), however he tolerated others. the patient denied having eaten fish before any of the episodes of anaphylaxis. method: commercial skin prick tests (spts) and prick by prick tests (pp) with all food ingested and fishes were performed. tryptase, total serum ige (ige) and specific ige (sige) (immunocap. thermo-fisher scientific, uppsala, sweden) to the foods involved were determined. a controlled oral provocation test (opt) with dexketoprofen was performed. results: spt was positive to tuna extract (3 mm) and negative (0 mm) for the rest of fish extracts. it was also negative for chicken meat extract and other foods tested. pps were positive for raw and cooked turkey meat (3 mm), raw and cooked tuna (6 and 8 mm), raw emperor (11 mm), raw and cooked whiff (9 and 8 mm) and raw hake (18 mm). pps were negative to raw and cooked chicken meat. ige was 700ui/ml and tryptase 2.95 ng/l. sige was slightly positive to hake, cod and chicken meat. dexketoprofen opt was negative. at that moment, we recommended the patient to avoid chicken and turkey, as well as the fishes which he had symptoms with. since then, he has not suffered any new episode of anaphylaxis despite exercising daily. protein extracts from turkey meat, tuna, emperor, salmon, hake and whiff were prepared and analyzed by sds-page. conclusion: recently, triosephosphate-isomerase (28 kda) has been identified as a new chicken meat allergen. this allergen could be responsible for the cross-reactivity between bird and fish meat and the episodes of anaphylaxis after exercise in our patient. the triosephosphate-isomerase has not been implicated previously as a cross-reactive allergen involved in the fish-chicken syndrome. results: twenty-three patients were included, 61% male, median age 30 years (iqr 12.5), 48% atopic, 30% asthmatic. non-specific lipid transfer proteins (nsltp) were implicated in 70% (n = 16) and ω-5-gliadin in 30% (n = 7). eighteen (78%) patients referred anaphylaxis in the reaction with co-factor, 7(22%) urticaria/angioedema, 2 had both depending on the co-factor. all patients in which ω-5-gliadin was the allergen involved had anaphylaxis in the presence of co-factor, with tolerance to wheat without it. in patients in which nsltp was the allergen involved, 12 (75%) had anaphylaxis in the presence of co-factor. reaction with co-factor was more severe than without in 13 (81%) patients; 4 patients had no previous history of reaction and subsequently tolerated the culprit food. only 1 patient had anaphylaxis in the absence of co-factor; the remaining presented oral allergy syndrome and/or urticaria. exercise was the main co-factor, present in 22 patients. nonsteroidal anti-inflammatory drugs (nsaids) were the only co-factor in 6 patients; all of them had anaphylaxis, 4 with allergy to ω-5-gliadin, 2 to nsltps. all subsequently tolerated the nsaids involved. conclusion: nsltps and ω-5-gliadin were the most frequently involved allergens in cefa, with exercise being the most frequent co-factor. nsaids were relevant co-factors, even when ω-5-gliadin was the allergen involved. several patients subsequently tolerated culprit foods and nsaids, difficulting the diagnosis and further emphasizing the importance of a correct cofactor evaluation. molecular allergens had an important role in the diagnosis, avoiding unnecessary ofc. information about co-factors must be included in all patients with allergy to nsltps and ω5-gliadin. 1594 | allergy to wheat-dependent exerciseinduced anaphylaxis (wdeia) proteins, without? 5-gliadins as responsible ferreira a 1 ; castillo m 2 ; martins s 1 ; pineda f 2 1 unidade de imunoalergologia hospital das forças armadas., lisbon, portugal; 2 departamento de aplicaciones. diater laboratorios, madrid, spain background: the second well-characterized form of allergy to wheat proteins is wheat-dependent exercise-induced anaphylaxis (wdeia), with the ω5-gliadins (part of the gluten protein fraction) being the major group of proteins which are responsible, but other forms of food allergy have also been reported, with the proteins responsible including gluten proteins, cm proteins and non-specific lipid transfer proteins. the patient was a 38-year-old man who visited the hospital with acute urticaria just eat bread before run (30 minutes). according the components of bread. it was formed by a mixture of wheat, rye and barley. with a history (for several years) of episodes of severe urticaria after intake a mixture of cereals and/or different kinds of beer. results: prick test and specific ige with wheat, rye and barley were negative and the proteins from allergenic extract from these cereals, and also the gliadins and glutenins fractions were transferred onto a pvdf membrane to carried out a western blot technique with the patient's serum. the patient's serum recognized several proteins from wheat and millet gliadins not compatible in molecular mass with a ω5-gliadins. the association of w5 gliadin as responsible for the symptoms produced after the intake of products containing wheat and exercise is well referenced but in the case of this patient could have other proteins involved as triggers of their symptoms. suksawat y phramongkutklao hospital, bangkok, thailand background: food-dependent, exercise induced anaphylaxis (fdeia) is an anaphylactic condition that develops in patients who ingest specific food followed by exercise. a variety of foods have been described to be the cause including shellfish, wheat and vegetables. the mechanisms of fdeia is believed that exercise increases allergen absorption or decreases threshold of mast cell. the investigations such as skin prick test or specific ige for food are useful because food sensitization is demonstrated. however, a challenge test including ingestion of suspected food followed by exercise is the only method to diagnose this disease. we report a case of fdeia in a 17-year-old adolescent male. result: he presented with generalized urticaria and hypotension after eating a barbecue buffet which was one hour followed by playing taekwondo. after treatment with intramuscular adrenaline, antihistamine and systemic steroid, his condition was improved. the barbecue buffet consists of many kinds of food including shrimp, squid, salmon and pork meat which were previously tolerated. he had no past history of anaphylaxis or drug allergy. he was referred to our allergy unit for investigation. we performed skin prick test with food allergens and many kinds of fresh foods that he ate on that day and the result was positive to shrimp (6 mm. in diameter). three-day challenge protocol was set up a month after recovery and we used aspirin as a cofactor. on the first day, open challenge for 500 gram of shrimp was administered and the result was negative. on the second day, exercise challenge test based on the american thoracic society guideline was also negative. however, on the last day, he developed generalized urticaria five minutes after the same exercise challenge test which was 1 hour preceded by aspirin intake and 500 gram of shrimp ingestion. but his vital signs appeared to be stable. the patient was administered intramuscular adrenaline and antihistamine with full recovery. he was strongly advised to avoid shrimp for 4-6 hours before exercise and carry an adrenaline autoinjector. the-three day challenge protocol is a definite tool to confirm the diagnosis of fdeia. a correct diagnosis is important to avoid unnecessary restricted diet. 1596 | food dependent exercise induced anaphylaxis in peach allergic patient-case report consumption of different types of food (pancakes with cream cheese and fruit, peach, chinese dish, sandwiches-all eaten on other occasions without symptoms) and co-occurring physical exercise (dancing, shopping, walking). during diagnosis we performed spt with inhaled and food allergens (allergopharma), prick by prick tests with peach, banana, apple, pear and bread. we established the concentration of allergen specific ige (peach, wheat flour, peanuts, hazelnuts) and the level of ige specific to allergen components (immunocap isac). we performed exercise provocation test and open food challenge with peach. results: spt were negative with all tested food and inhaled allergens (inc.egg; milk; cocoa; tomato; carp; apple; banana; strawberry; rye flour; wheat flour; peanuts; hazelnut; citrus, d. farinae; d. pteronyssinus; grass; weeds; clad. herbarium; alt. tenuis; dog; cat; poplar; hazel; alder; birch; mugwort). prick by prick tests were positive with fresh peach. concentration of peach specific ige was 0.55 ku/l. in immunocap isac we found elevated levels of ige specific to ltps from different allergen sources (jug r 3 -1.3; pru p 3 -0.8; pla a 3 -0.6; tri a 14 -0.5 [isu-e]). open food challenge with a medium size peach was negative. exercise provocation test without allergen exposition was negative. exercise provocation test after eating a medium size peach concluded with severe lip and eyelids edema, followed by whizzing, dyspnea and urticarial. patient received adrenaline 0.5 mg im, steroids and antihistamines with good clinical effect. conclusion: patient was diagnosed with food dependent exercise induced anaphylaxis (fdeia) due to ltp allergy. she was advised to eat peeled fruit and vegetables, avoid cofactors of allergic diseases and carry rescue set (adrenaline, steroids and antihistamines). cases reports: we report 1case of fdeia and 3 cases of wdeia. case 1:24-year-old woman with intermittent severe allergic rhinitis and food allergies since childhood. in the last 7 years she registered weekly episodes of fdeia (urticaria, angioedema, wheeze, drop of bp) especially when during effort and after alcohol intake. prick tests were positive for grass pollen, mugworth, ragweed, dust mites, celery, soy, sesame, pistachio, mango, honey and shellfish. she followed 3 years of subcutaneous immunotherapy for grasses pollen. the fdeia episodes frequency and severity diminished during it. provocation test for celery and mango were positive, for alcohol, soy, sesame, pistachio, honey and shellfish were negative. case 2:23-year old man with a 7-year history of acute gluten induced urticaria, recently developed 2 episodes of wdeia (flushing, severe urticaria and angioedema, wheeze) when he went for gym. skin test was highly positive for wheat flour and dust mites, in vitro tests for 5 omega gliadin and wheat-specific ige were positive. food challenge for wheat was positive. he followed oral immunotherapy for wheat. the wdeia episodes were rare and mild. case 3:30-years old female with mild allergic rhinitis and controlled asthma, with wdeia (urticaria, angioedema, wheeze, drop of bp) in the last 3 years. skin tests showed positive results for wheat flour, dust mites and dog hair. omega-5 gliadin and wheat specific ige were high, but the provocation test for wheat was negative meanwhile combined wheat and effort provocation test was positive. 25-year-old female athlete, otherwise healthy, experienced three episodes of fdeia following running sessions. two reactions were preceded by intake of salad containing lettuce, tomato and sunflower seeds and the third one occurred after eating celery salad. the patient denied occurrence of any symptoms with physical exertion or food ingestion alone. physical examination and blood testing did not reveal any abnormalities. the differential diagnosis was performed. in skin prick test and specific serum ige antibodies sensitization to house dust mite, grass and mugwort were found. the spt and specific ige assay to culprit and most common food allergens were negative. the molecular diagnostic has been applied (faber, caam, rome, italy). the test scored positive for art v, blo t, der f, der p, eur m, lol p, phl p. no positive results for available food molecules including celery, tomato, sunflower seeds and lettuce were found. the detection of culprit food in fdeia is of crucial meaning as the syndrome can be life-threatening. the molecular diagnostic has been applied already in diagnosis of wheat-dependent exercise-induced anaphylaxis (wdeia) proving ω-5-gliadin sensitization in the majority of the cases. as the presented case did not reveal sensitization to culprit food in traditional allergy tests the molecular diagnostic was performed. this test did not show sensitization to culprit food either. however, not all of the molecules are available in molecular assays yet. cross-reactivity reaction to mugwort and grass has to be considered. the pathophysiological components of physical exertion has to be taken into consideration as well. this could contribute to the assessment of reasonability of molecular approach in diagnostic work-up for fdeia and to the establishment of standardized protocols for diagnosis and management of that syndrome. case report: food allergy to wheat is rare in adults, often reported in exercise-induced anaphylaxis. food-dependent exercise-induced anaphylaxis (fdeia) is a form of food allergy induced by exercise. fdeia symptoms can include urticaria/angioedema, respiratory and gastrointestinal manifestations and hypotension/shock. a 61-year-old male patient presented to the emergency department, was admitted after an episode of hives, hypotension and loss of consciousness. his consciousness was restored after treatment with epinephrine, glucocorticoids as well as fluids, and thereafter, the patient reported that the anaphylactic episode occurred when he started rapidly walking 1 hour after eating a slice of pizza. he mentioned that the offended food was tolerated always when it was not followed by a physical exercise. review of his past medical history and family one were non-contributory with respect to this episode. the allergy skin prick testing for common foods revealed a positive response only to wheat, while and other laboratory test values were within normal ranges. the patient is discharged after instructions on the use of epinephrine auto-injector. he was also advised to avoid wheat containing products up to 6 hours prior to physical exercise. our case demonstrated that fdeia can be characterized by the onset of anaphylaxis soon after physical exercise, when preceded by the ingestion of the responsible food. avoidance of the combination of the exposure to respective allergen and exercise is the most efficient precautive measure toward subsequent fdeia episodes. 1600 | residual exercise-induced allergic reactions after successful rush oral immunotherapies for milk and wheat method: we conducted roit for 55 children (median 8.7 years old) with milk allergy and 46 children (median 6.8 years old) with wheat allergy during 2010-2015. after 5-12 days of the rush phase in the hospital and a slow-increasing phase at home, patients consumed the maintenance dose (6.5 g milk protein or 5 g wheat protein). after at least three months of the maintenance phase without allergic symptoms, we conducted an exercise provocation test (ept) after eating the target food. if the ept was positive, we repeated it after a couple of years to check for remission. the presence or absence of eiars was based primarily on the results of epts but also on the clinical history in some cases. results: as of december 2017, 44 milk-and 41 wheat-allergic patients were able to continue ingesting the maintenance dose (desensitization). in these patients, 38 milk-and 38 wheat-allergic patients underwent the first ept at a median of 635 (228-2538) days after roit, and the result was positive in 19 (50.0%) and 19 (50.0%) patients, respectively. among these ept-positive patients, 10 milk-and 9 wheat-allergic patients conducted a second ept at a median of 504 (119-1120) days after the first ept. the result of the second ept was positive in 7 milk-and 7 wheat-allergic patients. in addition, clinical histories of eiars were subsequently observed in 4 milk-and 4 wheat-allergic patients after negative results on an ept. altogether, 19 (43.2%) milk-and 21 (51.2%) wheat-allergic patients still had eiars even after getting desensitization as of december conclusion: patients with persistent milk and wheat allergy often have residual eairs even after three to five years of desensitization due to the administration of successful roit. abstracts | 791 1601 | anaphylaxis caused by omega-5-gliadin initially diagnosed as idiopathic anaphylaxis: a case report tziotou m 1 ; syrigos k 2 ; syrigou e 1 ; sinaniotis a 1 1 department of allergy,, athens, greece; 2 gpp,, athens, greece case report: we report the case of a 59-year-old man who experienced two episodes of wheat dependent exercise induced anaphylaxis, initially diagnosed as idiopathic anaphylaxis. first episode: the patient woke up in the morning and drove to his resort. while driving, he ate a piece of cheese and ham pie. when he arrived, he walked some meters to the garden and started feeling pruritus and dizziness. he lost consciousness and recovered by himself. he was carried to hospital where his vital signs were normal. the patient has a history of atrial fibrillation and has been on flecainide bid and aspirin at noon for the last four years. a month after the first episode he visited an allergist. skin prick tests to aeroallergens and prick to prick tests to the ingredients of the pie were negative. tryptase levels were within normal limits and skin biopsy was negative for mastocytosis. an endocrinology workup was also negative. the patient was prescribed an epinephrine autoinjector and was asymptomatic for eight months. second episode: that morning he had a cup of milk and two slices of toast for breakfast and started working in the garden. two hours later he experienced pruritus and urticaria and fell unconscious. his wife had to administer two epinephrine autoinjectors before he regained consciousness. after the second episode it was decided to start treatment with omalizumab. two months later he experienced an episode of urticaria while working in the garden. he could not recall what he had eaten before. based on history, we thought that a cofactor might contribute to the occurrence of anaphylaxis. we performed skin prick tests with peach (ltp) and gliadin, allergens associated with food dependent exercise induced anaphylaxis in our region. the test to gliadin was positive. specific ige in serum to omega-5-gliadin was also positive, while specific iges to all ltps tested were negative. the patient was advised to avoid wheat and has been asymptomatic ever since. cases diagnosed with idiopathic anaphylaxis may actually be cases in which the culprit allergen has not been identified. detailed history and extensive workup may contribute to the successful management of these patients. written informed consent has been obtained from the patient. 1602 | wheat-dependent exercise-induced anaphylaxis (wdeia) and nsaids: clinical history is crucial conclusions :we present a case clinically compatible with wdeia with nsaids intake as augmenting factor. this case emphasizes that a carefully and thoroughly taken medical history is of crucial importance, otherwise wdeia can easily be unrecognized. as a result, non-allergic hyperreactivity to nsaids could be excluded and the diagnose of selective allergy to arylpropionic acids was made. exercise challenge test could not be performed in our case. case report: kounis syndrome (ks) has been defined as an acute coronary syndrome that manifests as unstable vasospastic or non-vasospastic angina, and even as acute myocardial infarction. it is triggered by the release of inflammatory mediators following an allergic insult. a 77-year-old woman with type ii diabetes and hypertension, and unstable angina pectoris as cardiovascular risk factors, has consumed chamomile tea. thirty minutes later, she developed generalized itching, skin rash, swelling of the face and the throat, chest tightness, dyspnea and syncope. the patient was transferred immediately to the emergency department, and sodium chloride, 50 mg prednisolone, 8 mg dexamethasone, 80 mg methylprednisolone, 5000ui heparin, 75 mg voltaren were intravenously administered along the subsequent 60 minutes under simultaneous treatment with oxygen therapy. an ekg examination is performed based on the patient disease's history, showing a 2.5-3 mm st-depression on d1-d3 leads, 1 mm on v3, and 3.5 mm on the v4-v6 ones. in addition, 2.5 mm st-elevation on the avr and 1 mm on the v1 derivation was observed, associated by a negative t-wave on the v1, v2, and avr leads. blood tests revealed a normal troponin i level (of 0.07 ng/ml). five hours later in the ekg was noticed: isolined st-segments, and negative t waves on the d3, avr, and v1 leads. ultrasound examination revealed normal heart kinetics and function. following the heart changes, the patient was administered sol. heparin 5000ui twice i.v., nebivolol 5 mg, plavix 75 mg, atorvastatin 80 mg, abstracts | 793 monocinque 20 mg, ordinary insulin 10ui s.c., glargine insulin 20ui s.c., and sol. furosemide 20 mg i.v. the patient progressed favorably, and four days after the anaphylactic episode the ekg revealed a 0.5 mm st-depression on leads v4, and v5, negative t-wave on avl lead, and normalized one on the v3 one. this case emphasizes the role of serious allergic reactions as cause of acute coronary syndrome in patients with altered coronary arteries and food intake as cause of kounis syndrome. 1605 | recall urticaria in two young patients with alpha-gal-syndrome after tick bites case report: patient a (m, age 25) had suffered from 7-8 anaphylactic reactions (hives, nausea, dyspnea and dizziness) within the past 15 months. all episodes occurred 3-5 hours after ingestion of red meat, once with alcohol as a co-factor. all episodes started with a wheal measuring about 0.5 cm in exact the same spot where he had been bitten by a tick one year before. specific ige to galactose-alpha-1,3-galactose (alpha-gal) was positive (2.55 ku/l). skin prick testing using raw pork kidney suspension and intradermal testing with gelafundin ® 4% diluted 1:10 also showed positive reactions. we performed an oral challenge with cooked pork kidney under careful monitoring being able to reproduce the recall urticaria as described above with a cumulative dose of 8 g pork kidney. we stopped the challenge and treated the patient with antihistamines and corticosteroids. patient b (m, age 22) reported on several anaphylactic reactions within the past 4 years with symptoms including abdominal pain, diarrhea, as well as dyspnea and loss of consciousness in one of the episodes. all episodes occurred several hours after ingesting food. furthermore the patient remembered a tick bite about 2 years before the first anaphylactic reaction, which repeatedly became inflamed and only healed completely over months. every episode started with pruritus and a wheal in the area of the former tick bite (in loco). specific ige to galactose-alpha-1,3-galactose was positive (4.37 ku/l) as well as the skin prick testing with cooked pork kidney and intradermal testing with gelafundin ® 4% diluted 1:10. this patient refused performance of oral challenge tests. an elimination diet of red meat for 12 months resulted in the absence of the symptoms as described. the diagnosis of alpha-gal-syndrome with recall urticaria in loco was made in both cases. this symptom may also be useful in evaluating results of oral challenge tests as well as an important clinical sign in medical history. pali-schöll i 1 ; meinlschmidt p 2 ; purschke b 2 ; hofstetter g 1 ; einhorn l 3 ; mothes-luksch n 3 ; jensen-jarolim e 3 ; jäger h 2 background: insects have gained interest as alternative nutrient source for humans and animals. however, being a "novel food" in the industrialized part of the world, several safety aspects, like allergenicity, need to be thoroughly addressed. in the present work we evaluated the cross-recognition of ige from patients allergic to crustaceans, house dust mite or stable flies, using house cricket acheta domesticus (ad), desert locust schistocerca gregaria (sg) and mealworm tenebrio molitor (tm). we further investigated changes of immune-recognition in terms of ige-binding in differently processed insect extracts. method: migratory locust locusta migratoria (lm) was subjected to different extraction methods, enzymatic hydrolysis or thermal processing, whereas tm larvae (tml) were evaluated after different centrifugation modes and ph levels. results: we revealed that ige from patients with crustacean allergy shows cross-recognition of acheta domesticus, schistocerca gregaria and stable flies. ige from house dust mite allergic individuals binds to acheta domesticus and schistocerca gregaria. importantly, the cross-reactivity to lm can be deleted by enzymatic hydrolysis with different enzymes or heat treatment (cooking, autoclaving), but not by different extraction methods. changes of ph and varying centrifugation steps are not sufficient to reduce ige-binding to tml. our results show that patients allergic to crustaceans, house dust mite or stable flies-allergic patients cross-recognize desert locust and house cricket proteins, and crustacean-allergic patients also flies proteins. furthermore, we confirm that the appropriate food processing method of insect proteins can reduce the risk of cross-reactivity for crustaceans-and house dust mite-allergic patients. the study was supported by the austrian science fund fwf (grant sfb f4606-b28 to ejj). results: the mean age at diagnosis was 10 years in children and 34 years in adults, more frequent in males (3:1). in the pediatric group, three had first-degree relatives with eoe and three had celiac disease. two children had performed milk oral immunotherapy and five adults aeroallergens subcutaneous immunotherapy. most of them were atopics with sensitization to aeroallergens (77.5% of children and 82.5% of adults) and food allergens (75% of children and 82.5% of adults), without statistically significant differences. the most frequent foods were fruits and nuts in both groups. we found significant statistical differences in fruits (35% of children abstracts | 795 and 57.5% of adults; p = 0.007) and cereals sensitization (5% of children and 47.5% of adults; p < 0.001). in the clinical presentation we observed significant statistical differences in impaction (22.5% of children and 82.5% of adults; p < 0.001), dysphagia (42.5% of children and 77.5% of adults; p < 0.001) and abdominal pain (25% of children and 7.5% of adults; p = 0.034). in the endoscopic findings children had more frequently exudates (92.5%; p < 0.001) and adults had esophageal trachealization (50%; p < 0.001). significant statistical differences were found in the treatment with topical corticosteroids (30% of children and 77.5% of adults; p < 0.001) obtaining a variable positive response. 77.5% of patients in both groups received food elimination diet, 45% with four or more foods. conclusion: eoe presents differences in the sensitization profile, clinical manifestations and endoscopic findings according to the age of presentation. the response to pharmacological treatment is variable and a high percentage of patients receive food elimination diets. it is a pathology difficult to control, therefore new non-invasive techniques would be useful in order to facilitate its management. 1610 | modulation of gut microbiota in patients with nickel allergy and ibs after diet and probiotics supplementation mb 1 ; garcía-figueroa be 2 department of allergy1 department of allergy fang l 12 united states 1431 | bcx7353 improves health-related quality of life in hereditary angioedema with c1-inhibitor deficiency bygum a 4 fang l 16 former yugoslav republic of; 6 division of clinical immunology huissoon a 2 bygum a 3 ; panovska vg 4 united states callejas fdb 1 alobid i 1 ; muñoz-cano r 1 izquierdo i 2 icahn school of medicine at mount sinai method: the case report form was developed by experienced allergists, and the web-based registry was established in cooperation with a professional medical software team. twenty-two departments from 16 hospitals took part during the first year 8%), whereas in adults, drugs (54.5%) were more common than foods (31.4%). the most common food triggers were eggs (27.1%), milk (15.8%), and walnut (7.9%) in children, and shrimps (21.1%), wheat (15.8%), and crab (7.9%) in adults. among drug triggers in adults, antibiotics (50.0%) were the most common cause followed by nsaids (16.7%), and h2-blockers (13.6%). the onset time was≤10 minutes in 48.6%. in children, home was the place of occurrence in more than half of the cases, whereas adults experienced anaphylaxis in out-of-home settings more often than children. cofactors were present in 19%. among the 289 cases registered via the emergency department of participating hospitals, epinephrine was administered in 66.8% (62.5% in adults, 69.8% in children) and the route of administration was im in 90.8%, iv in 6.3%, both im and iv in 2.1%, and subcutaneous in 0.7%. the number of epinephrine administration was single in 83% conclusion: this multicenter prospective registry would provide a better understanding of anaphylaxis, and provide visionary modalities to improve the management and prevention of anaphylaxis in future a case of kounis syndrome after chamomile tea consumption characterized by symptoms related to esophageal dysfunction and esophageal mucosal infiltration by eosinophils objective: characterize patients (pts) with eoe diagnosis and analyze the differences between pts with diagnosis at pediatric (ch, <18 years old) and adult age epicutaneous tests(epict)], serum total ige and eos, findings in upper digestive endoscopy (ude) and biopsies. the correlation between food sensitization, clinical severity (visits to er services or hospitalization due to complications of eoe, sclin) or severe histology results: 74 pts (81% male, average age 27 ± 17 years) ad 31 and 34, respectively. 96% ch and 67% ad were atopics. the most frequent symptoms of eoe were dysphagia (73%) and gastroesophageal reflux(46%) in ch; impaction(85%) and dysphagia(46%) in ad. 92% ch and 71% ad had aeroallergens sensitization. 77% ch and 69% ad had food sensitization. the most frequent positive tests were for ch: spt to milk(25%) and shellfish(19%), epict to shellfish(50%) and meat(19%); for ad: spt to milk(21%), fresh fruits and nuts both 18%), epict to shellfish(35%) and meat(13%). ude showed: 65% striation and white plaques in 50% ch shist (46%) was associated with sclin (35%), p = 0.001 in ch; but this was not observed in ad group there was no correlation between food sensitization and sclin or shist in both groups(p > 0.01). the average values of serum total ige (kua/l) were 653 in ch and 458 in ad; eos were 679 and 413, respectively in ch and ad allergy unit-fondazione policlinico universitario a. gemelli, università cattolica del sacro cuore conclusion: ltp with a fixed dose (2000 iu in 4 ml) of ready-touse shp616 led to fewer severe attacks, a higher proportion of attack-free patients, and a clinically meaningful and statistically significant reduction in cumulative attack severity and daily severity in hae patients relative to placebo. background: c1-inh-hae is a rare, potentially life-threatening disease characterized by episodes of subcutaneous and/or submucosal swelling. apex-1 was a phase 2, double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx7353, a once daily oral kallikrein inhibitor, in patients with c1-inh-hae.method: patients with c1-inh-hae with a history of at least 2 hae attacks per month were randomized to receive four different doses of bcx7353 (350 mg, 250 mg, 125 mg, 62.5 mg) or placebo for 28 days. blood samples for bcx7353 concentrations and kallikrein inhibition were obtained from patients before dosing and for 24 hours post-dose on day 14. pk analyses and pk-pd modeling were done in phoenix winnonlin v 8.0 and sas v 9.3. the pk population included 16, 14, 14, and 7 subjects in the 350 mg, 250 mg, 125 mg, and 62.5 mg groups respectively.after daily dosing achieved steady state, c max was reached at a median of 3-4 hours after dosing. there was a greater than dose proportional increase in exposure (auc tau and c max ) over the 62.5-mg to 350-mg dose range, with an approximate 14-fold increase in exposure with a 5.6-fold increase in dose. at doses ≥125 mg, which showed statistically significant and clinically meaningful reductions in hae attack rates, geometric mean plasma trough concentrations (c tau ) were maintained at or above the minimum target concentration (4-fold ec 50 ) estimated to be required for adequate plasma kallikrein inhibition. percentages of study subjects at steady-state with bcx7353 plasma concentrations>4-fold ec 50 were 0%, 57%, 100% and 100% in the 62.5, 125, 250, and 350 mg dose groups, respectively. a 125-mg dose provided a mean c tau of slightly above 4.0fold ec 50 , with a corresponding reduction in hae attack rate of 69% (p < 0.001) compared with placebo. consistent with the exposure data, a dose dependent inhibition of kallikrein was observed with bcx7353 treatment over the dose range. the drug effect on kallikrein inhibition was highly correlated with exposure (r = 0.867). in patients with c1-inh-hae, bcx7353 treatment at doses ≥125 mg resulted in clinically meaningful reductions in the mean weekly hae attack rate. concentrations of bcx7353 at doses ≥125 mg were maintained at or above a c tau of 4-fold the kallikrein inhibition ec 50 in most patients, and kallikrein inhibition was highly correlated with bcx7353 plasma concentrations.background: c1-inh-hae is a rare, life-threatening disease characterized by recurrent episodes of subcutaneous and/or submucosal swelling that lead to considerable morbidity and a poor quality of life (qol). apex-1 was a phase 2, double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx7353, a once daily oral kallikrein inhibitor, in patients with c1-inh-hae.method: patients with c1-inh-hae with at least 2 hae attacks per month were randomized to four different bcx7353 doses (350 mg, 250 mg, 125 mg, 62.5 mg) or placebo. subject-reported qol assessments were conducted at the start and end of treatment using the disease specific angioedema quality of life (ae-qol) questionnaire that measures 4 domains (function, fatigue, nutrition, fear/ shame) and has minimal clinically important difference (mcid) of 6 points. the changes from baseline in total and domain scores was compared between the treatment and placebo groups. modified angioedema activity score (aas) values across 4 domains (daily activities, appearance, physical discomfort, overall severity) were calculated for each attack and a total score was derived for each subject by summing scores from each attack. total scores were compared to placebo using an ancova model with adjustment for qualifying attack rate. reduction of attacks was statistically significant for all 3 top doses and there was a dose related increase in adverse events.results: in the 125 mg dose group, qol assessed by ae-qol was significantly improved after 4 weeks of treatment compared to placebo for ae-qol total score (-26.0, p < 0.001) as well as across all 4 domains (function: -28.2, p = 0.002; fatigue: -12.7, p = 0.05; fears/shame: -36.5, p < 0.001; nutrition: -23.4, p = 0.012). all other treatment groups showed a trend towards improvement. qol improved the most in the125 mg group, and 92% of subjects in the 125 mg group showed ae-qol reduction of more than 6 points. disease activity as assessed by the aas was significantly reduced in the 350 mg, 250 mg and 125 mg dose groups as compared to placebo, whereas there was no significant reduction in the 62.5 mg dose group. results: there were no marked differences in the age, sex, total ige titer, comorbidity of bronchial asthma and atopic dermatitis or the starting dose of rush oit among the groups. all patients in the low-bmfi group achieved ≥100% of the target dose, whereas 28.6% of the middle-bmfi group and 50% of the high-bmfi group failed to achieve the target dose (p < 0.05). results: a total of 473 infants were diagnosed with food allergy (ige-mediated and mixed type) at our center during the study period, 305 of these patients underwent prick test for inhalant sensitivity, and 220 (64.9% male) of these were younger than 2 years of age. conclusion: sensitivity to inhaled allergen were found in 14 of 292 (4.9%) patients with food allergy. therefore, we believe that inhalant sensitivity should be evaluated in these patients. there is also a requirement for further studies to identify the influence of inhaled antigens on the disease activity of patients with allergic conditions. method: in this study, we aimed to perform the metabolic profiling of severe profilin mediated food allergic patients looking for biomarkers that might both, predict the prognosis of the disease and understand the molecular mechanisms of inflammation underneath. other allergic patients (mild and moderate) and non-allergic were recruited in the study as comparative groups. the allergic patients class was predicted using a mathematical algorithm from non-allergic vs severe model results: plasma samples from non-allergic subjects, mild, moderate and severe allergic patients were measured using gas chromatography coupled to mass spectrometry (gc-ms). the samples were from 4 different hospitals in spain covering the areas with the highest pollen exposure. the metabolic profile was composed of 95 metabolites for each sample. results after the statistical analysis showed differences between the groups. firstly, a clear reduction of several abstracts conclusion: we found, as expected, a predominance of males with eoe diagnosis. ch were more frequently atopic and had aeroallergen and food sensitization. impaction and esophageal stenosis were more frequent in ad than ch. shist was associated with sclin only in ch. method: three children with ee, boys aged 1.5-11 years, were assessed over 6 months to 3 years. results: 2 cases developed in infancy. one had dyspepsia and low weight gain in infancy soon after feeding began. another had symptoms in infancy but not diagnosed until age 6 with dysphagia and esophageal stricture.. the third case was diagnosed at 11 years old after 2 episodes of food impaction in the esophagus beginning at age 9. all cases had allergic comorbid diseases including atopic dermatitis in all 3 and allergic rhinitis in 2. skin prick tests were positive to several food allergens (cow's milk, egg protein) in 2, to dust mite in 2 and to pollens in 1. serum total ige levels ranged from 490 to 1039 iu/ml. eosinophils in peripheral blood were elevated in all 3, reaching 10%-13%. treatment included restricted diet and topical budesonide 1-2 mg daily depending with periodic endoscopic biopsy.in all cases clinical improvement occurred by one month of treatment, with endoscopic confirmation. morphological improvement folthe study aimed to evaluate the effects of probiotic supplementation, in addition to diet, in ibs and snas patients, in terms of modulation of faecal microbiota population, reduction of gi and cutaneous symptoms, increase of patient's quality of life and modification of gut dysbiosis.method: forty patients aged between 18 and 65 years, affected by ibs, ni sensitization and ltp sensitization were enrolled to evaluate gut dysbiosis. dna extraction method (next generation sequencing) with commercial kit (microbiopassport ® ) was performed on stool samples. ibs patients were divided in two groups, according a gluten free diet prescription or a low fodmaps diet prescription for three months. similarly, (suspected) snas patients (confirmed by 5% ni sulfate in petrolatum patch test) were prescribed a low ni diet (100 μg/kg nickel content during the first four weeks and then up to 200 μg/kg up to three months). two ltp (lipid transfer protein) sensitized patients underwent a ltp free diet.gut dysbiosis was re-assessed after a fixed probiotic supplementation. a sex-age matched group of individuals without history of ibs, snas or any gastrointestinal disease was considered as control.gastrointestinal symptoms were evaluated using the visual analogue scale before and after treatment. conclusion: our preliminary findings suggest that probiotic implementation could be useful in patients with snas on a low-ni diet to increase population diversity, which could contribute to restore the intestinal homoeostatic conditions.