Adaptation and validation of the Spanish version of the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL)

OBJECTIVES

The aim of this study was to develop a Spanish version of the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) and to test its acceptability, reliability, validity, and sensitivity to change.

METHODS

Forward and back translation by bilingual translators followed by pilot testing in patients with urticaria was used to adapt the questionnaire. The Spanish version of the CU-Q2oL was self-administered alongside the Skindex-29 in an observational, longitudinal, multicenter study. Feasibility was assessed by analyzing missing responses and ceiling and floor effects. Reliability was tested by examining internal consistency (Cronbach alpha). Construct validity was analyzed by examining convergent and discriminant validity with the Skindex-29 and by evaluating the ability of the CU-Q2oL to discriminate between patients according to a clinical classification of severity. Sensitivity to change was analyzed in a subgroup of patients who completed a second visit 4 weeks after baseline.

RESULTS

A total of 695 patients were included in the analysis. Mean (SD) age was 42.4 (15.0) years and 62.1% of the sample was female. All of the items on the CU-Q2oL were answered by 91.9% of the sample. Over 15% of patients scored at the floor (best possible health) on 5 of the 6 dimensions. Cronbach alpha coefficients were > 0.80 for all dimensions of the CU-Q2oL, and 0.86 for the overall score. Construct validity was supported by correlations between the CU-Q2oL and the Skindex-29, which generally fulfilled hypotheses, and by the questionnaire's ability to discriminate between groups with different severities of urticaria.The questionnaire was sensitive to change, with an effect size of 1.0 for the overall score in patients reporting an improvement on the health transition scale.

CONCLUSIONS

The Spanish version of the CU-Q2oL has shown satisfactory reliability, validity, and sensitivity to change. It is suitable for use as an outcome measure for chronic urticaria patients in clinical and research settings.

[Immunotherapy in Latin America. From the past to the future]

In Latin America, allergic diseases have a very high prevalence, comparable to that of many other countries of the world, and that prevalence is constantly increasing. Within the region, the number of allergy specialists is quite high, although allergy is not recognized as a full specialty in all countries. Specific immunotherapy is the only available allergen-oriented immunomodulator, capable of improving symptoms and modifying the natural course of the disease, and therefore it represents a powerful therapeutic tool for specialists. During the last 20 years, the practice of immunotherapy in Latin America has much improved, especially because of the intensive educational effort, the widespread divulgation of the international guidelines and the adoption of the paradigm of the evidence-based medicine. In this regard, indications, contraindications, and limits of immunotherapy, are currently well acknowledged. In Latin America, immunotherapy is properly prescribed for inhalant allergens and hymenoptera venom by allergy specialists, although some non-evidence based forms of immunotherapy (e.g. bacterial extracts, treatment of atopic dermatitis) are still occasionally practiced. Sublingual immunotherapy is now accepted as a viable alternative to the traditional subcutaneous administration, and it begins to be proposed and studied also in some Latin American countries. Some debate remains on the use of immunotherapy for one or few versus multiple allergens, and also the availability of standardized extracts is not uniform. Finally, this therapeutic modality is not always given for free to low income patients such is the case in some countries and the different modalities of reimbursement among countries often represent a limit to the use of this treatment. Much has been done in improving the use of immunotherapy in Latin America. The main challenges and objectives for the near future are greater diffusion of the evidence-based medicine, a better standardization of extracts and procedures, and the achievement of the availability of immunotherapy for a greater number of subjects.

Rhinitis, rhinosinusitis and quality of life in children

Quality of life (QoL) or, rather, health-related QoL, is currently regarded as a crucial aspect of the general well-being of patients and, in consequence, of the effects of a disease and its treatment. This is particularly true for respiratory allergy (asthma and rhinitis), which are chronic diseases and also for sinusitis (rhinosinusitis). A number of questionnaires (instruments), either generic or specific, have been developed and validated to assess the QoL in adults and children, for asthma and rhinitis, whereas there are few specific instruments for chronic rhinosinusitis. The literature provides strong evidence of the effects of allergic rhinitis, asthma and their treatments on QoL in paediatric patients, as well as in adults, whereas the number of experimental data on rhinosinusitis is limited, especially in children. Clinical trials evidenced some controversial points, mainly the weak correlation existing between QoL and traditional objective parameters. It has become clear that the QoL questionnaires measure the aspects of the disease that partially differ from the routinely evaluated parameters and that QoL should integrate, not replace, the objective measurements.

Allergic rhinitis and asthma ad hoc survey: clinical and psychological perspectives

BACKGROUND

Several studies have provided evidence of a strong association between asthma and rhinitis, with consequences in terms of therapy and disease management.

OBJECTIVES

The aims of our study were to evaluate physicians' knowledge about rhinitis/asthma comorbidity, to note the patients' management behaviour and to assess the patients' experience about symptoms and expectations, and to investigate the clinical and psychological meaning of general practitioners' and patients' awareness.

METHODS

One hundred and one general practitioners and 504 asthmatic patients participated in the study. General practitioners and patients filled in two different multiple choice questionnaires concerning asthma-rhinitis link and impact.

RESULTS

34.7% of general practitioners are aware of the link between asthma and rhinitis, and 43.6% of them hypothesize the comorbidity on the basis of their clinical experience. 21.8% of physicians make the diagnosis autonomously. 27.8% of asthmatic patients experience three or less rhinitic symptoms, 41% from four to six symptoms and 31.2 more than six symptoms. These symptoms deeply interfere with daily life, causing sleep problems (87.3%), lack of concentration (78.9%), difficulties in spare time (71.8%) and sport (71.7%). Rhinitis symptoms are responsible for the worsening of asthma, with an increase in dyspnoea (86.3%), cough (73.9%), and wheezing (59%). Ninety-three percent of patients expressed an interest in a combination therapy approach.

CONCLUSIONS

Asthma and rhinitis interact in the development of clinical burden and impact on quality of life. The survey results showed different perspectives when evaluated from clinical and psychological points of view.

Cost-effectiveness of GRAZAX for prevention of grass pollen induced rhinoconjunctivitis in Southern Europe

BACKGROUND

Allergic rhinoconjunctivitis is a global health problem. Around 14 million people in Spain, France, Italy, and Austria suffer from grass pollen induced allergic rhinitis. Standard care only provides symptoms relief, while allergen specific immunotherapy (SIT) treats the underlying cause of the disease. Grazax from ALK-Abelló is a new, tablet-based, effective route of SIT for home treatment. The objective was to assess the cost-effectiveness of Grazax in four Southern European countries.

METHODS

A prospective pharmacoeconomic analyses was carried out alongside a multinational, clinical trial measuring the efficacy of Grazax. Pooled data on resource use and health outcomes were collected. A societal perspective was adopted, and the analysis had a nine-year time horizon. The primary outcome measure was quality adjusted life years (QALYs).

RESULTS

Grazax was superior to standard care for all efficacy endpoints, including QALYs gained, and resulted in significantly less use of rescue medication and fewer hours missed from work. Grazax was cost-effective for all countries for an annual price in the range of 1500 euros - 1900 euros. The result was improved by inclusion of future costs of asthma and exclusion of Spanish trial centers which experienced an exceptionally low pollen season.

CONCLUSION

The analysis illustrates that allergen SIT with Grazax for grass pollen induced rhinoconjunctivitis is a cost-effective intervention in Southern Europe.

Asthma treatment: 'magic bullets which seek their own targets'

The most fascinating options of the new asthma treatments are probably represented by monoclonal antibodies. In fact, these molecules are virtually able to interact with whatever specific antigen. Anyway, it is mandatory to understand the limits of this group of molecules, in terms of both efficacy and safety. In this review, we have analyzed different ways of interfering along the course of the cascade of the allergic reaction, targeting different molecules (CD4, TNF-alpha, IL-4, IL-5, IL-10, IL-12, endothelial adhesion molecules, IgE), showing the efficacy and the risks of each kind of treatment. In the end, we focused our attention on omalizumab, the monoclonal antibody targeting IgE. Although with some restrictions, represented by the high costs and the limitation of its use only to a specific subset of patients affected by allergic asthma, at present anti-IgE appear to be the only 'magic bullet' for the treatment of allergic asthma. In fact, it proved to reduce exacerbations and symptom scores, and to improve quality of life, with a very good safety profile.

Unmet needs in asthma: Global Asthma Physician and Patient (GAPP) Survey: global adult findings

BACKGROUND

The Global Asthma Physician and Patient (GAPP) Survey is the first global quantitative survey designed to uncover asthma attitudes and treatment practices among separate groups of physicians and patients, with the goal of identifying barriers to optimal management.

METHOD

A total of 5582 physician and patient interviews were conducted globally online, by telephone and face-to-face. This paper highlights key global findings from the adult arm (3559 interviews) conducted in 16 countries.

RESULTS

Physician and patient responses were found to differ when respondents were asked the same set of questions. Perceptions of time spent on asthma education, the quality of physician-patient communications, awareness and experience of side effects and understanding and knowledge of treatment noncompliance were found to differ between these two sets of respondents.

CONCLUSIONS

The GAPP Survey not only defines an unmet need in asthma treatment, but also reveals that there is a direct relationship between the quality of physician-patient communication, the level of treatment side effects and the extent of patient compliance. These survey findings highlight a clear need for improved patient-focused care in asthma.

New perspectives in the treatment of allergic rhinitis and asthma in children

PURPOSE OF REVIEW

Allergic rhinitis and asthma are some of the most prevalent chronic diseases in children. Meticulous evaluations of the therapeutic options and interventions are needed to control this burden. The central pathogenic mechanism is an immediate hypersensitivity reaction, followed by interventions in the allergic cascade. Once inflammation is established, potent anti-inflammatory agents or mediator antagonists could help control the phenomenon and reduce the characteristic symptoms related to severity.

RECENT FINDINGS

Monoclonal antibody against IgE has demonstrated its efficacy in reducing the symptoms of asthma and rhinitis. In difficult-to-treat asthma patients it allows a reduction in the dose of inhaled steroids, the number of exacerbations, emergency visits and hospitalizations. Its broad implementation is limited by its high cost because adverse events are not a concern. Specific sublingual immunotherapy gave promising results in clinical trials, while modifying immunoglobulins and cytokine profiles, also inducing T-cell tolerance. Safety issues of subcutaneous immunotherapy have been surpassed by the sublingual route, with equivalent efficacy. The new inhaled steroid ciclesonide is effective in established inflammation, is activated only in the respiratory system, and has negligible systemic effects.

SUMMARY

Robust evidence on the efficacy and safety of several novel therapies in rhinitis and asthma is available.

Lower airway inflammation before and after house dust mite nasal challenge: an age and allergen exposure-related phenomenon

BACKGROUND

Upper and lower airways allergic disease is currently considered unitarily. Allergic inflammation in one site can extend to other sites of the respiratory tract.

OBJECTIVE

To evaluate bronchial inflammation before and after allergen-specific nasal challenge (ASNC) in rhinitic and asthmatic children, considering the different levels of allergen exposure, i.e. summer (low) and winter (high).

METHODS

Fourteen children with rhinitis and 15 with rhinitis and asthma, all monosensitized to mites and 10 healthy controls were studied. Nasal IgE were measured before ASNC in summer and in winter season. Nasal clinical score, eosinophil cationic protein (ECP), nasal tryptase, bronchial clinical score, FEV(1), PEF, sputum ECP, sputum tryptase and exhaled nitric oxide (eNO) were evaluated before and after ASNC in summer and winter season.

RESULTS

Nasal scores significantly increased after ASNC in rhinitic and asthmatic children in both seasons. Nasal IgE were significantly higher in summer compared to winter. Bronchial symptoms, FEV(1) and PEF showed no mean differences in rhinitic and asthmatic children after ASNC, with an increase of bronchial symptoms and a decrease of FEV(1) and PEF occurring in 3/15 asthmatic children. In both groups nasal tryptase and ECP after ASNC significantly increased in summer and winter, while sputum tryptase was undetectable before or after ASNC in both groups. Sputum ECP and eNO at baseline were significantly higher in patients than in controls (summer P=0.002, winter P=0.001). Sputum ECP significantly increased after ASNC in 3/15 asthmatics in summer and in 11/15 in winter, as well as in 3/14 rhinitics in summer and in 4/14 in winter. eNO significantly increased after ASNC in 3/15 asthmatics in summer and in 10/15 in winter, and in 1/14 rhinitics in summer and in 4/14 in winter. A significant median increase of sputum ECP (P=0.0007) and eNO (P=0.0012) after ASNC in asthmatic and of eNO (P=0.013) in rhinitic children was also found in winter.

CONCLUSIONS

Basal sputum ECP and eNO values, significantly higher before ASNC in rhinitic patients compared to control subjects, confirm the inflammatory link of upper and lower airways. The more frequent detection of inflammatory changes induced by ASNC in winter suggests that allergen exposure favours the transfer of nasal inflammation to lower airways.

Effectiveness of vacuum-cleaning in removing Fel d 1 allergen from cotton fabrics exposed to cats

BACKGROUND

The major cat allergen, Fel d 1, is ubiquitous, and clothes of cat owners are important vehicles for its distribution and dispersal in cat-free environments.

OBJECTIVE

We assessed the efficiency of a standard vacuum-cleaning in removing the cat allergen from cotton fabrics, experimentally contaminated by a prolonged contact with cats.

METHODS

Fifteen rectangles (80 x 100 cm) of a widely used cotton material were kept in baskets of male cats for 1 week. Afterwards, the squares were cut in half. One half was immediately sampled for cat allergen, and the other half was vacuum-cleaned for 15 minutes by a commercially available device before sampling. Five identical cotton rectangles not exposed to cats served as controls. Samples were collected with a high-volume vacuum air-sampler. Particulate material was harvested onto filters with 25-mm diameter and 2 microm pore size, extracted in phosphate buffer with BSA and then assayed for the Fel d 1 allergen with an ELISA method. The results were expressed as micrograms of allergen per filter.

RESULTS

After vacuum-cleaning the amounts of Fel d 1 extracted from cat-exposed fabrics were not significantly reduced ( t = 3.118; P > 0.005), with respect to the non vacuum-cleaned tissues. No Fel d 1 was found in control fabrics.

CONCLUSIONS

Our study suggest that vacuum-cleaning by using a commercially available device is not able to remove significant amounts of cat allergen from cotton fabrics exposed to cats.

Mechanisms of virus-induced asthma exacerbations: state-of-the-art. A GA2LEN and InterAirways document

Viral infections of the respiratory tract are the most common precipitants of acute asthma exacerbations. Exacerbations are only poorly responsive to current asthma therapies and new approaches to therapy are needed. Viruses, most frequently human rhinoviruses (RV), infect the airway epithelium, generate local and systemic immune responses, as well as neural responses, inducing inflammation and airway hyperresponsiveness. Using in vitro and in vivo experimental models the role of various proinflammatory or anti‐inflammatory mediators, antiviral responses and molecular pathways that lead from infection to symptoms has been partly unravelled. In particular, mechanisms of susceptibility to viral infection have been identified and the bronchial epithelium appeared to be a key player. Nevertheless, additional understanding of the integration between the diverse elements of the antiviral response, especially in the context of allergic airway inflammation, as well as the interactions between viral infections and other stimuli that affect airway inflammation and responsiveness may lead to novel strategies in treating and/or preventing asthma exacerbations. This review presents the current knowledge and highlights areas in need of further research.

Efficacy of desloratadine in the treatment of allergic rhinitis: a meta-analysis of randomized, double-blind, controlled trials

The objective of the study is to assess the efficacy of the nonsedating antihistamine, desloratadine, in the treatment of allergic rhinitis (AR). A search of MEDLINE, EMBASE, LILACS, and CINAHL databases was undertaken from January, 1966 to May, 2006. Double-blind, randomized, controlled studies of desloratadine in the treatment of AR in adult patients were carried out. The measured outcomes included the total symptoms score, the total nasal symptoms score, nasal airflow, and inflammatory markers (nasal eosinophils, nasal interleukin-4). The analysis included the calculation of standardized mean difference (SMD). A total of 57 studies were analyzed, and 13 randomized, double-blind, controlled trials were included in the meta-analysis. The trials included 3108 subjects who had completed studies involving desloratadine. There was significant heterogeneity among the study results, because of differing study methodologies. Desloratadine was associated with significant reductions in total symptoms scores (SMD -1.63; 95% CI -2.75 to -0.51; P = 0.004) and total nasal symptoms score (SMD -0.66; 95% CI -0.91 to -0.42; P < 0.001), when compared with placebo. Analysis of objective data on nasal blockage demonstrated a significant improvement in nasal airflow with desloratadine, when compared with placebo (SMD 0.32; 95% CI 0.10 to 0.55; P = 0.005). A benefit favoring desloratadine over placebo in terms of nasal eosinophil levels was also noted in the analysis. This meta-analysis confirms the reduction of AR symptoms and improvement in nasal airflow seen in individual studies of desloratadine. Objective improvements in nasal airflow, total symptoms, and total nasal symptoms seen with desloratadine are supported by Ia evidence.

Recommendations for standardization of clinical trials with Allergen Specific Immunotherapy for respiratory allergy. A statement of a World Allergy Organization (WAO) taskforce

Specific Immunotherapy for respiratory allergy is used since about one century and there is now solid documentation of its efficacy. Nevertheless, the methods and experimental designs used in clinical trials are quite heterogeneous and there is no unanimously accepted methodological standard. Many studies are planned with study designs that may not confirm the clinical value of SIT as an effective treatment to reduce disease severity. To ensure that patients are treated based on sound scientific evidence and to minimize the risk of misusing limited financial resources for scientific studies, the World Allergy Organization (WAO) convened a group of experts to provide guidelines for the methodology of future immunotherapy studies. This document summarizes the recommendations for study design, patients' selection, appropriate outcomes and statistical treatment to be used in planning and performing clinical trials with specific immunotherapy.

Sublingual immunotherapy in the treatment of adult allergic rhinitis patients

Sublingual immunotherapy (SLIT) was accepted for clinical use by the medical community only 15 years after the first controlled trial published. The acceptance of SLIT has been driven by the evidence base of a large number of clinical trials confirming the efficacy and a recent meta-analysis study. Although SLIT is self-managed by the patient, this does not generate problems with compliance. The safety profile, assessed in clinical trials and postmarketing surveillance studies, is satisfactory with no reports of systemic adverse reactions. New data are available on the persisting, long-lasting effect of SLIT and on the association with the prevention of asthma in paediatric patients. However, there is only indirect evidence for such persistence and duration of effect in adult patients. Key priorities for further investigation are the mechanisms of action, the efficacy in asthma, the cost/effectiveness and the identification of those patients who will achieve the maximum benefit with SLIT.

Sleep disturbances in allergic diseases

Sleep is fundamental for physical and mental health as well as daytime performance and represents a crucial aspect in the personal representations of well-being. Sleep disturbances in patients with chronic disorders constitute a factor that contributes to exacerbate symptoms, complicate management, and affect mood and quality of life (QoL). Allergic diseases are a global health problem of increasing prevalence that affects up to 15% of the population in Western countries. Sleep problems associated with allergic diseases may play a role in worsening the burden of illness, contributing to impairment of the QoL. The aim of this review was to describe the most common causes leading to sleep disturbance in allergic patients and their consequences on the QoL. The possible negative effects of treatment on sleep parameters has been also considered.

Tissue remodelling in upper airways: where is the link with lower airway remodelling?

Tissue remodelling reported in upper airways include epithelial hyperplasia, increased matrix deposition in the nasal or paranasal lining, matrix degradation and accumulation of plasma proteins. Genetic influences, foetal exposures and early life events may contribute to structural changes such as subepithelial fibrosis from an early age. Other structural alterations are related to duration of the disease and long-term uncontrolled inflammation. Structural changes may increase alteration of the protective functions of the upper airways namely by affecting mucociliary clearance and conditioning of inspired air. The sequences of tissue changes during wound repair of upper airway mucosa after surgery are illustrative of the complexicity of tissue modelling and remodelling and could be considered as an important source of information for a better understanding of the complex relationship between inflammatory reaction, of the subsequent tissue damages and fibroblast metabolism of upper airways.

The type of sensitizing allergen can affect the evolution of respiratory allergy

BACKGROUND

Numerous factors affect the evolution of respiratory allergy, in children, but little is known in adults. We assessed in a prospective study the influence of the type of allergen on the progression of disease.

METHODS

Outpatients, with respiratory allergy underwent skin tests and pulmonary function/methacholine challenge at baseline and after 3 years. Patients were subdivided in pure rhinitis or rhinitis + bronchial hyperreactivity (BHR). In polysensitized subjects a single relevant allergen (mites, grasses, birch, Parietaria) was identified based on symptom distribution and when needed on nasal challenge.

RESULTS

6750 patients (age range 12-46) were studied. Of them, 17.8% were monosensitized but this percentage decreased to 10.4% after 3 years (P < 0.05). Subjects with pure rhinitis were 81% at the beginning and 48% at the end. After 3 years, the patients with bronchial responsiveness increased from 18% to 58% for mites, 22% to 49% for birch, 18% to 44% for grasses, 17% to 32% for Parietaria, with a significant difference among allergens (P < 0.05). Almost the same was seen in monosensitized subjects, being mites most likely to cause a worsening. All patients with BHR at baseline received immunotherapy. In these patients the onset of new sensitizations was significantly lower than in the group (pure rhinitis) receiving drugs only and lower airways symptoms disappeared more frequently.

CONCLUSION

The different type of allergen influences the course of the disease, as well as the use of immunotherapy.

Levocetirizine improves health-related quality of life and health status in persistent allergic rhinitis

BACKGROUND

Allergic rhinitis is a chronic respiratory disorder with a detrimental impact on health-related quality of life (HRQOL) and health status. Enhancement and maintenance of patient function and well-being are therefore considered as essential.

OBJECTIVE

To determine whether long-term treatment with levocetirizine 5mg improves HRQOL and health status in persistent allergic rhinitis (PER) patients assessed with RQLQ and SF-36 scales over a 6-month period.

METHODS

The Xyzal in PER Trial (XPERT) was a multi-center, double-blind, parallel-group study. A total of 551 patients were randomized to receive levocetirizine 5mg or placebo once daily for 6 months and assessed for symptoms, HRQOL (Rhinoconjunctivitis Quality of Life Questionnaire: RQLQ) and health status (SF-36). Sensitivity of the RQLQ and SF-36 to disease severity was tested to ensure their suitability for use in PER patients. Treatment effect was assessed by means of repeated measures analyses.

RESULTS

Over the 6-month treatment period, levocetirizine showed statistically significant improvements over placebo in HRQOL (P < 0.001 for all RQLQ domains and overall scores) and health status (P < or = 0.004 for SF-36 physical and mental summary scores; P < 0.05 for all SF-36 scales). The relative improvement of levocetirizine over placebo exceeded the predefined clinically meaningful threshold of 30% for all RQLQ scores and the improvement from baseline was 3 times the established MID for RQLQ.

CONCLUSION

The RQLQ and SF-36 could be used to measure HRQOL and health status in PER patients. Long-term treatment with levocetirizine provides sustained improvement of HRQOL and reduces disease burden in PER patients.

Treating asthma as an inflammatory disease

Asthma is a chronic inflammatory disease involving many different cell types and cellular elements. Evidence suggests that, in the long term, this inflammation leads to remodeling of the airways, airflow obstruction, and the bronchial hyperreactivity symptoms of asthma, and is present even in patients with intermittent disease. Patients with allergic asthma and those with seasonal allergic rhinitis are believed to have minimal persistent inflammation, and the two diseases often occur together. Early intervention with inhaled corticosteroids (ICS) is believed to modify the disease process and may limit long-term remodeling. ICS remain the cornerstone and "gold standard" of treatment for asthma.

Pharmacologic and anti-IgE treatment of allergic rhinitis ARIA update (in collaboration with GA2LEN)

The pharmacologic treatment of allergic rhinitis proposed by ARIA is an evidence-based and step-wise approach based on the classification of the symptoms. The ARIA workshop, held in December 1999, published a report in 2001 and new information has subsequently been published. The initial ARIA document lacked some important information on several issues. This document updates the ARIA sections on the pharmacologic and anti-IgE treatments of allergic rhinitis. Literature published between January 2000 and December 2004 has been included. Only a few studies assessing nasal and non-nasal symptoms are presented as these will be discussed in a separate document.