Rhinitis and Asthma

Nasal lavage technique reveals regular inhalation exposure of microplastics, not associated from face mask use

During the COVID-19 pandemic, the use of face masks has been a worldwide primary protection measure to contain the spread of the virus. However, very little information is known about the possible inhalation of microplastics (MP) from wearing masks. This pilot study evaluates the presence of MP accumulated in nasal cavities through the nasal lavages technique. Six different commercial face masks were tested in 18 participants during five working days (8 h use/day). Eight different polymers (polystyrene, polyamide, poly(ethylene - propylene) diene monomer, polyester, polyethylene, polyvinylidene fluoride, polypropylene, and polyvinyl chloride) predominantly within the 20-300 µm size were detected in nasal lavages, with an average concentration of 28.3 ± 15.6 MP/5 mL nasal solution. Results demonstrate that MP in the nasal cavity are not associated to face mask use but rather to general exposure to airborne MP. We highlight the use of nasal lavages to evaluate human inhalation of MP and associate it to potential sources and risks.

Overview on the occurrence of microplastics in air and implications from the use of face masks during the COVID-19 pandemic

Environmental pollution from microplastics (MPs) in air is a matter of growing concern because of human health implications. Airborne MPs can be directly and continuously inhaled in air environments. Especially high MPs contributions can be found in indoor air due to the erosion and breakage of consumer, domestic and construction products, although there is little information available on their sources and concentrations and the risks they might pose. This is in part due to the fact that sampling and analysis of airborne MPs is a complex and multistep procedure where techniques used are not yet standardized. In this study, we provide an overview on the presence of MPs in indoor air, potential health impacts, the available methods for their sampling and detection and implications from the use of face masks during the COVID-19 pandemic.

Chronic facial pain: different comorbidities and characteristics between neuropathic and nonneuropathic conditions

OBJECTIVE

The aim of this study was to investigate the association between comorbidities and chronic diseases and neuropathic and nonneuropathic orofacial pain diagnoses to suggest subclassifications of disease.

STUDY DESIGN

This was a cross-sectional, retrospective, case-control study. We evaluated 174 patients with orofacial pain and 132 controls by using a systematic protocol that consisted of medical history and demographic, pain, and orofacial characteristics. Patients were grouped according to their diagnosis-neuropathic or non-neuropathic pain; medical comorbidities; and exclusion criteria. Analyses included Z-score normalization, χ² test, Fisher's exact test, 1-way analysis of variance (ANOVA), Student t test, Pearson's correlation coefficient, 2-step clustering, and logistic regression at 95% confidence level.

RESULTS

Functional chronic diseases were prevalent and correlated with pain and orofacial features. Three groups were identified in the cluster analysis: neuropathic facial pain, other orofacial pain syndromes, and fibromyalgia/temporomandibular disorders (TMDs). Logistic regression showed that hypothyroidism and gastritis were predictors for nonneuropathic orofacial conditions. Psychiatric diseases and gastritis were more prevalent among patients with generalized pain syndromes and TMDs and less prevalent among patients with neuropathic pain.

CONCLUSIONS

Functional comorbidities were associated with orofacial and dental features and may correspond to multimorbidity states in patients with chronic orofacial pain. The findings support the hypothesis that nonneuropathic orofacial pain syndromes could be functional disorders.

ICON: Diagnosis and management of allergic conjunctivitis

Ocular allergy (OA), interchangeably known as allergic conjunctivitis, is a common immunological hypersensitivity disorder affecting up to 40% of the population. Ocular allergy has been increasing in frequency, with symptoms of itching, redness, and swelling that significantly impacts an individual's quality of life (QOL). Ocular allergy is an often underdiagnosed and undertreated health problem, because only 10% of patients with OA symptoms seek medical attention, whereas most patients manage with over-the-counter medications and complementary nonpharmacological remedies. The clinical course, duration, severity, and co-morbidities are varied and depend, in part, on the specific ocular tissues that are affected and on immunologic mechanism(s) involved, both local and systemic. It is frequently associated with allergic rhinitis (commonly recognized as allergic rhino conjunctivitis), and with other allergic comorbidities. The predominance of self-management increases the risk of suboptimal therapy that leads to recurrent exacerbations and the potential for development of more chronic conditions that can lead to corneal complications and interference with the visual axis. Multiple, often co-existing causes are seen, and a broad differential diagnosis for OA, increasing the difficulty of arriving at the correct diagnosis(es). Ocular allergy commonly overlaps with other anterior ocular disease disorders, including infectious disorders and dry eye syndromes. Therefore, successful management includes overcoming the challenges of underdiagnosis and even misdiagnosis by a better understanding of the subtleties of an in-depth patient history, ophthalmologic examination techniques, and diagnostic procedures, which are of paramount importance in making an accurate diagnosis of OA. Appropriate cross-referral between specialists (allergists and eyecare specialists) would maximize patient care and outcomes. This would significantly improve OA management and overcome the unmet needs in global health.

The use of omalizumab in allergen immunotherapy

Although omalizumab (anti-IgE) is currently only approved for the treatment of asthma and chronic idiopathic urticaria, it has also been studied as an off-label treatment for numerous allergic conditions, including use as an adjunct to allergen immunotherapy in the treatment of allergic rhinitis, asthma, venom hypersensitivity and food allergy. We conducted a review of publications involving the use of omalizumab with allergen immunotherapy, by searching PubMed with key search terms of "omalizumab" and "immunotherapy." Omalizumab has been used in combination with inhalant allergen immunotherapy for the treatment of seasonal allergic rhinitis and comorbid asthma. While there have been no randomized controlled trials evaluating the addition of omalizumab to venom IT, several case reports and small patient series have been published on the use of omalizumab with venom IT. Omalizumab has been used in conjunction with oral immunotherapy for the treatment of milk, peanut and egg, as well as other foods in multi-allergen protocols. In conclusion, omalizumab used in conjunction with immunotherapy has shown promising results, especially in the reduction of adverse reactions. At this stage, larger, randomized, placebo-controlled trials are needed to better identify those patients who would benefit the most from the addition of omalizumab to immunotherapy, as well as optimal dosing strategies and duration of treatment.

Diagnosing obstructive lung disease

Preview There is considerable overlap in features and treatment of chronic obstructive pulmonary disease and asthma. Why, then, is it necessary to distinguish between the two? As the authors explain, the two diseases have different causes, risk factors, and clinical courses. Correct diagnosis, described in this article, allows physicians to take measures that reduce exacerbations and to accurately assess progress.

Maintenance therapy for obstructive lung disease

Preview In all cases of obstructive lung disease, smoking cessation, proper use of metered-dose inhalers, up-to-date immunizations, adequate nutrition, and general physical conditioning are important components of treatment. Dr Jacobs summarizes these components as well as stepwise pharmacologic approaches to controlling the inflammation of asthma, the bronchospasm of chronic bronchitis and emphysema, and the symptoms of secondary or coexisting conditions.

Management of Allergic Rhinitisand Sinusitis

Allergic rhinitis and sinusitis are chronic conditions of the airway and cause significant morbidity. Both can require pharmacotherapy with nonprescription products to relieve symptoms or with prescription products to treat the underlying pathophysiology. Because these diseases are prevalent conditions, the pharmacist is in the unique position of being the first health professional contact for many patients. The pharmacist can assist the patient in selection of nonprescription antihistamines, decongestants, and nasal saline sprays as well as provide instruction on the use of steam therapy, aromatic vapors, and warm compresses for the relief of symptoms. Equally important, the pharmacist can encourage patients to seek care from a physician when treatment with intranasal corticosteroids, antibiotics, and nonsedating antihistamines are needed.

Do asthma patients in general practice profit from a structured allergy evaluation and skin testing? A pilot study

BACKGROUND

Although allergy is central to the pathophysiology of asthma, little is known about the benefits of a structured approach to allergen diagnosis and management in primary care asthma patients.

OBJECTIVES

We studied effects of a structured allergen evaluation and allergen avoidance advice combined with or without additional allergy skin testing on health status, illness perception, and lung function of asthma patients treated in general practice.

METHOD

Fifty-four asthma patients were randomly assigned to three groups: (i) Standard asthma care with information on the stepwise treatment approach, a written action plan, and inhaler technique training; (ii) Additional structured allergen evaluation and avoidance advice; (iii) Additional structured allergen evaluation and avoidance advice based on skin prick test results. Patients were seen for one initial appointment at a primary care asthma clinic and a follow-up examination 3 months later. On both occasions, questionnaire measures of symptoms, illness perception, and the perceived control of asthma were administered. Lung function was measured by spirometry (PEF, FEV1). Perceived allergic asthma triggers, the trigger impact, and the trigger control were assessed in both intervention groups.

RESULTS

Following intervention, a decrease in beta-adrenergic inhaler use, an increase in the perceived control of asthma, and a decrease in the bothering from asthma symptoms were observed for all three groups. Intervention groups showed a higher awareness of animal-allergic triggers, and the perceived control of asthma triggers was increased in the group receiving no skin tests. FEV1 showed an improvement in both intervention groups.

CONCLUSION

Structured allergy evaluation and avoidance advice can improve lung function and the control of asthma in primary care. Further research is needed on the additional benefits of allergy skin testing.

Some immunological aspects of patients with rhinitis in Lebanon

BACKGROUND

Hitherto immunological determinates in Lebanese patients with rhinitis have not been investigated.

OBJECTIVE

To identify causative allergens in Lebanese patients with allergic rhinitis and determine possible correlation's among serum allergen specific antibody, polyclonal IgE, IL-4, IL-5 and peripheral eosinophil levels.

METHODS

One hundred and thirteen patients with a long lasting history of nasal obstruction, rhinorrhea, sneezing and nasal itching were investigated. Serum allergen specific antibodies using a panel of 10 potential allergens, IL-4 and IL-5 levels were determined by enzyme immunoassays. Polyclonal IgE levels were estimated by an immunochromatographic assay and eosinophil counts by a Coulter STKS counter.

RESULTS

Based on the presence of serum allergen-specific IgE antibodies, 74 patients were considered to have an allergic etiology. Polyclonal IgE levels were elevated in 41 of the 74 allergic rhinitis patients while the other 33 patients had normal serum levels. In the remaining 39 specific IgE antibody-negative patients, 32 had normal, and 7 had elevated, polyclonal IgE levels. IgE specific antibodies to more than one allergen were detected in 59 of 74 patients. The most common causative allergens were mite, Dermatophagoides pteronyssinus, Dpt (83.8%) and Dermatophagoides farinae, Df (78.4%). Analysis of the data indicated that elevated polyclonal IgE levels correlated with the concentration of serum specific IgE antibodies and the number of the detected causative allergens per patient. Fifty-nine of 74 allergic rhinitis patients had elevated IL-4 levels and 44 had elevated IL-5 levels. The number of allergic patients with both elevated IL-4 and IL-5 levels was 24. Finally, only 9 allergic rhinitis patients had peripheral eosinophilia.

CONCLUSION

Mite Dpt and Df were the most common causative agents of allergic rhinitis in the Lebanese group studied. A prerequisite for Specific Immunotherapy is the identification of the causative allergen. Determinations of polyclonal IgE level and peripheral eosinophil count alone, as an aid to diagnosis are insufficient and may be misleading. On the other hand, determination of all the parameters studied in conjunction appears to be of diagnostic value.

Allergen-induced inflammation and the role of immunoglobulin E (IgE)

The prevalence of common allergic disorders such as asthma, allergic rhinitis, and atopic dermatitis has increased significantly in the past 30 years. The impact of these atopic diseases on the patient and the health care system is considerable: Allergic disorders are associated with a high degree of morbidity, which can profoundly impact patient quality of life and health care resource use. Existing strategies to treat allergic disorders beyond simple allergen avoidance focus on diminishing or eliminating the recurrent and/or persistent signs and symptoms that characterize the allergic response. A new strategy has been developed that uses antibodies directed against immunoglobulin E (IgE) to prevent it from binding to cells bearing its receptors and thus neutralizing the allergic response before it begins. These new agents reduce allergic responses in atopic individuals and improve their symptoms while reducing rescue medication and corticosteroid use in patients with allergic asthma or seasonal allergic rhinitis. Thus, anti-IgE antibodies represent proof that IgE plays a central role in allergic reactions and that anti-IgE therapy is a potentially effective treatment for allergic disease.

Down-Regulation of Human Basophil IgE and FCεRIα Surface Densities and Mediator Release by Anti-IgE-Infusions Is Reversible In Vitro and In Vivo

Previously, infusions of an anti-IgE mAb (rhumAb-E25) in subjects decreased serum IgE levels, basophil IgE and FcεRIα surface density, and polyclonal anti-IgE and Ag-induced basophil histamine release responses. We hypothesized that these effects would be reversed in vivo by discontinuation of infusions and in vitro by exposing basophils to IgE. Subjects received rhumAb-E25 biweekly for 46 wk. Blood samples taken 0–52 wk after rhumAb-E25 were analyzed for serum IgE and basophil expression of IgE, FcεRIα, and CD32. Basophil numbers were unaffected by infusions. Eight weeks after infusions, free IgE levels rose in vivo but did not reach baseline. Basophil IgE and FcεRIα rose in parallel with free IgE while CD32 was stable. FcεRI densities, measured by acid elution, returned to 80% of baseline, whereas histamine release responses returned to baseline. Basophils cultured with or without IgE or IgG were analyzed for expression of IgE, FcεRIα, and CD32. By 7 days with IgE, expression of IgE and FcεRIα rose significantly, whereas cultures without IgE declined. IgE culture did not effect CD32. IgG culture did not effect expression of any marker. The present results strongly suggest that free IgE levels regulate FcεRIα expression on basophils.

Direct expenditures for the treatment of allergic rhinoconjunctivitis in 1996, including the contributions of related airway illnesses

BACKGROUND

Previous estimates of the national economic burden of allergic rhinoconjunctivitis (AR/AC) have relied on data analyses in which AR/AC was the primary International Classification of Diseases-ninth revision-Clinical Modification (ICD-9-CM)-coded diagnosis. These studies ignore the costs when AR/AC was a secondary diagnosis to other disorders such as asthma and sinusitis.

OBJECTIVE

We sought to determine the national direct cost of illness for AR/AC.

METHODS

An expert panel used the Delphi technique to estimate the proportion of visits coded by other primary ICD-9-CM diagnoses in which AR/AC was a significant secondary comorbid condition. The costs of this proportion were deemed to be "attributable" to AR/AC and were added to the costs when allergic rhinitis and allergic conjunctivitis were the primary diagnoses.

RESULTS

The cost when AR/AC was the primary diagnosis was $1.9 billion (in 1996 dollars). The cost when AR/AC was a secondary diagnosis was estimated at $4.0 billion, giving an estimate of $5.9 billion for the overall direct medical expenditures attributable to AR/AC. Outpatient services (63%, $3.7 billion), medications (25%, $1.5 billion), and inpatient services (12%, $0.7 billion) accounted for the expenditures. Children 12 years and younger accounted for $2.3 billion (38.0%).

CONCLUSION

Upper airway allergy is an expensive disease process because of its readily apparent manifestations as AR/AC and its contribution to other airway disorders.

Allergic rhinitis. Outcomes of immunotherapy on symptom control

Recent scientific studies have demonstrated the efficacy of various forms of immunotherapy for the treatment of allergic diseases. Traditional subcutaneous immunotherapy, sublingual, oral, and intranasal immunotherapy have been shown to significantly reduce symptoms and favorably modulate the immune response. Outcome studies that use patient response data from standardized surveys represent the next challenge to all practicing allergists.

Recurrent sinusitis: examining medical treatment options

Recurrent sinusitis is an increasingly important disease in its own right and is an often overlooked underlying trigger for chronic asthma and/or bronchitis. The complications of unresolved recurrent sinusitis may include intracranial conditions with significant clinical implications. Patients failing conventional therapy require more aggressive therapy to avoid the necessity for invasive measures, and extensive patient education may help increase compliance with the regimen. Invasive measures (surgery) for the treatment of recurrent sinusitis carry a serious complication rate of 0.5% in 200,000 cases/ year. For this reason, aggressive medical management of these patients is an essential effort. This article explores recurrent sinusitis and its pathophysiology, and suggests a medical treatment regimen using nasally inhaled corticosteroids together with antimicrobial and supportive therapy.

Increase in epithelial mast cell numbers in the nasal mucosa of patients with perennial allergic rhinitis

The aim of the study was to compare the numbers and distribution of mast cells in the nasal mucosa of perennial allergic rhinitis (PAR) patients and controls, as demonstrated by different staining methods for light microscopy. Biopsies of inferior turbinate mucosa were taken from 10 patients with PAR and 10 patients undergoing septoplasty or septorhinoplasty (control group). Sections for light microscopy were stained with azure A. chloroacetate esterase and an ABC immunohistochemical technique using antibody to tryptase. Three times more mast cells were found in the epithelium of PAR patients compared to controls using the immunohistochemical technique (p = 0.0074). This method demonstrated considerably more mast cells than the other stains. The increase in epithelial mast cells is consistent with the migration of mast cells seen in seasonal allergic rhinitis, and this may be important in the phenomenon of nasal priming seen after repeated antigen exposure.

Nasal smear eosinophilia for the diagnosis of allergic rhinitis and eosinophilic non-allergic rhinitis

OBJECTIVE

To evaluate nasal smear eosinophilia for the diagnosis of allergic rhinitis and eosinophilic non-allergic rhinitis in general practice.

DESIGN

Nasal smear eosinophilia was assessed and compared with 'consensus diagnoses' made by three experts in a modified Delphi method.

SETTING

Nineteen general practices in The Netherlands.

SUBJECTS

363 consecutive patients aged 12 years or over who visited their general practitioner because of chronic or recurrent nasal symptoms between 1 March 1990 and 1 March 1991.

MAIN OUTCOME MEASURES

The predictive value of nasal smear eosinophilia for allergic rhinitis; the prevalence of eosinophilic non-allergic rhinitis.

RESULTS

The positive predictive value of nasal smear eosinophilia (> or = 10% eosinophils) for allergic rhinitis was 30/37 = 81% (95% confidence interval (CI): 65-92%), the negative predictive value 172/312 = 55% (95% CI: 50-61%). Addition of the result of nasal smear eosinophilia to the information that was already obtained from the medical history resulted in a significant but very small improvement in the discrimination between patients with and without allergic rhinitis. The prevalence of eosinophilic non-allergic rhinitis was 7/349 = 2.0% (95% CI: 0.8-4.1%).

CONCLUSION

Nasal smear eosinophilia contributes significantly to the diagnosis of allergic rhinitis; however, this contribution is very small and considered clinically irrelevant. Eosinophilic non-allergic rhinitis has a low prevalence; identifying this disorder is of minor importance. In conclusion, nasal smear eosinophilia is not recommended for use in general practice.

Implicating adhesion molecules in nasal allergic inflammation

Allergic rhinitis is now considered an inflammatory disorder where many leukocyte types, including eosinophils and T-lymphocytes, accumulate in increased numbers. Along with mast cells and other cells, they release a wide variety of mediators, cytokines, and granule constituents that can directly cause inflammation or activate the local vascular endothelium to further enhance the recruitment of leukocytes through the expression and function of adhesion molecules. While the understanding of the importance of leukocyte and endothelial adhesion molecules is still at a very early stage, recent evidence has already begun to implicate these cell surface molecules in the pathogenesis of allergic diseases such as rhinitis and asthma. Additional studies, including the use of adhesion molecule antagonists when available, will clarify the importance of these structures in the pathophysiology of these disorders.

Immunology in the pediatrician's office

The development of antibody-mediated immunity is reflected in the maturation of B lymphocytes, in the changing levels of total immunoglobulins, and in the development of specific antibodies first to proteins and then sequentially to different types of polysaccharides. The measurement of anti-pneumococcal antibodies allows us to recognize specific antibody deficiencies, which need to be differentiated from normal developmental phases in the maturation of antibody-mediated immunity. The recognition of the late phase of IgE mediated allergic reactions is important to understanding the chronic manifestations of allergy. Chronic manifestations of allergy are frequently missed because they do not appear to be clearly related to acute triggers of allergic reactions. These conditions can be appropriately diagnosed, prevented, and treated, however, when the mechanisms of the late manifestations of allergy are understood. The integration of knowledge about the development of immunity and of allergic diseases enhances the pediatrician's ability to care for patients with immunologic abnormalities.