Impact of allergic rhinitis treatment on quality of life

Air Pollution Affecting Pollen Concentrations through Radiative Feedback in the Atmosphere

Episodes with high air pollution and large amounts of aeroallergens expose sensitive individuals to a health damaging cocktail of atmospheric particles. Particulate matter (PM) affects the radiative balance and atmospheric dynamics, hence affecting concentrations of pollutants. The aim of the study is to estimate feedback between meteorology and particles on concentrations of aeroallergens using an extended version of the atmospheric model WRF-Chem. The extension, originally designed for PM and dust, concerns common aeroallergens. We study a birch pollen episode coinciding with an air pollution event containing Saharan dust (late March to early April 2014), using the model results, pollen records from Southern UK and vertical profiles of meteorological observations. During the episode, increased concentrations of birch pollen were calculated over the European continent, causing plumes transported towards the UK. The arrival of these plumes matched well with observations. The lowest parts of the atmospheric boundary layer demonstrate a vertical profile that favours long distance transport, while the pollen record shows pollen types that typically flower at another time. The model calculations show that feedback between meteorology and particles changes pollen concentrations by ±30% and in some cases up to 100%. The atmospheric conditions favoured meteorological feedback mechanisms that changed long distance transport of air pollution and aeroallergens.

Changes in ambient temperature increase hospital outpatient visits for allergic rhinitis in Xinxiang, China

BACKGROUND

The effect of ambient temperature on allergic rhinitis (AR) remains unclear. Accordingly, this study aimed to explore the relationship between ambient temperature and the risk of AR outpatients in Xinxiang, China.

METHOD

Daily data of outpatients for AR, meteorological conditions, and ambient air pollution in Xinxiang, China were collected from 2015 to 2018. The lag-exposure-response relationship between daily mean temperature and the number of hospital outpatient visits for AR was analyzed by distributed lag non-linear model (DLNM). Humidity, long-time trends, day of the week, public holidays, and air pollutants including sulfur dioxide (SO2), and nitrogen dioxide (NO2) were controlled as covariates simultaneously.

RESULTS

A total of 14,965 AR outpatient records were collected. The relationship between ambient temperature and AR outpatients was generally M-shaped. There was a higher risk of AR outpatient when the temperature was 1.6-9.3 °C, at a lag of 0-7 days. Additionally, the positive association became significant when the temperature rose to 23.5-28.5 °C, at lag 0-3 days. The effects were strongest at the 25th (7 °C) percentile, at lag of 0-7 days (RR: 1.32, 95% confidence intervals (CI): 1.05-1.67), and at the 75th (25 °C) percentile at a lag of 0-3 days (RR: 1.15, 95% CI: 1.02-1.29), respectively. Furthermore, men were more sensitive to temperature changes than women, and the younger groups appeared to be more influenced.

CONCLUSIONS

Both mild cold and mild hot temperatures may significantly increase the risk of AR outpatients in Xinxiang, China. These findings could have important public health implications for the occurrence and prevention of AR.

Different Development Forms of Local Allergic Rhinitis towards Birch

Background

Efficacy of allergen immunotherapy (AIT) in local allergic rhinitis (LAR) is a new subject of research. The presence of asthmatic symptoms in patients with LAR in the context of AIT is unexplored.

Objective

The efficacy and safety of AIT in patients with LAR towards birch pollen were investigated. The possibility of concomitant local allergic asthma in studied patients and the impact of AIT on it were examined.

Methods

36 patients with LAR towards birch were included in three years of AIT in a double-blind, placebo-control study. Primary outcome measurement was the mean changes in the combined symptom and medication scores (CSMSs) after AIT, and the second is the changes in the quality of life (QoL). Skin prick tests, serum, nasal allergen-specific IgE to birch, nasal and bronchial provocation challenge tests with birch allergen, methacholine tests, and spirometry were carried out at baseline and after AIT.

Results

Mean CSMSs of three years of AIT were significantly decreased in the active group from 5.88 (range: 4.11-9.01) to 1.98 (range: 1.22-4.51; p < 0.05). After three years of AIT, there was a significant increase of toleration for birch allergen from the mean concentration of 6250 ± 1200 SQ-U/ml up to 45000 ± 2500 SQ-U/ml (p = 0.02) during repeated nasal challenges. 16 patients with LAR had the positive results of methacholine tests, and 11 of them had a positive bronchial challenge to birch allergen. After AIT, the significant decrease of bronchial responsiveness to birch allergen in 5 from 7 patients was confirmed (p = 0.03). QoL assessed by the use of the RQLQ score was improved after AIT from 1.84 (95% CI: 1.53-1.97) to 1.45 (95% CI: 1.32-1.62) score in the active group after three years of AIT therapy (p = 0.03).

Conclusion

AIT to birch can be useful and safe in a patient with local allergic rhinitis and also with concomitant asthmatic symptoms. Further studies are needed.

The effects of particulate matters on allergic rhinitis in Nanjing, China

Particulate matter pollution is a serious environmental problem. Individuals exposed to particulate matters have an increased prevalence to diseases. In the present study, we performed an epidemiological study to investigate the effects of particulate matter less than 10 μm in aerodynamic diameter (PM₁₀) and particulate matter less than 2.5 μm in aerodynamic diameter (PM_2.5) on allergic rhinitis in Nanjing, China. Daily numbers of allergic rhinitis patients (33,063 patients), PM₁₀, PM_2.5, and weather data were collected from January 2014 to December 2016 in Nanjing, China. Generalized additive models (GAM) were used to evaluate the effects of PM₁₀ and PM_2.5 on allergic rhinitis. We found that the interquartile range (IQR) increases in PM₁₀ (difference of estimates, 5.86%; 95% CI, 3.00-8.81%; P = 4.72 × 10^-5) and PM_2.5 (difference of estimates, 5.39%; 95% CI, 2.73-8.12%; P = 5.67 × 10^-5) concentrations were associated with the higher increased numbers of allergic rhinitis patients with 3-day cumulative effects in single-pollutant model. In addition, we found that the IQR increase in PM₁₀ (age ≥ 18 years: 7.37%, 3.91-10.96%, 2.14 × 10^-5; 0-17 years: 0.83%, - 4.00-5.91%, 0.740) and PM_2.5 (age ≥ 18 years: 7.00%, 3.78-10.32%, 1.40 × 10^-5; 0-17 years: 0.40%, - 4.10-5.10%, 0.866) increased the number of allergic rhinitis patients in adults, but not in children. In summary, our findings suggested that exposure to PM₁₀ and PM_2.5 was associated with the risk of allergic rhinitis.

Efficacy and safety of birch pollen immunotherapy for local allergic rhinitis

BACKGROUND

Local allergic rhinitis (LAR) is a relatively new disease.

OBJECTIVE

To ascertain the effects of allergen-specific immunotherapy in LAR.

METHODS

A randomized, double-blind, placebo-controlled trial of birch subcutaneous allergen immunotherapy (AIT) for LAR was performed in 28 patients. The therapy was performed for 24 months in 15 patients with AIT and 13 patients given placebo. The primary end point was decrease in symptom medication score (SMS). In addition, we monitored serum-specific immunoglobulin E (IgE), serum-specific immunoglobulin G4, nasal-specific IgE to Bet v 1, and safety and quality-of-life parameters.

RESULTS

After 24 months of treatment, there was a significant decrease in the median area under the curve for SMS of the active group vs the placebo group: 2.14 (range, 1.22-4.51) vs 6.21 (range, 5.12-7.89), at the P < .05 level. During AIT, the active group showed a significant decrease in SMS of up to 65% vs baseline. A significant increase in immunoglobulin G4 and decrease in nasal-specific IgE were observed in the active group during AIT compared with the placebo group. AIT was well-tolerated and without systemic reactions.

CONCLUSION

This study demonstrates that AIT for birch pollen in patients with LAR was clinically effective and exhibited good tolerance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03157505.

Insights on Allergic Rhinitis Management from a Northern Cyprus Perspective and Evaluation of the Impact of Pharmacist-Led Educational Intervention on Patients' Outcomes

BACKGROUND AND OBJECTIVE

the global prevalence of allergic rhinitis (AR) is rising and yet there is scarce information concerning the diagnosis, management and treatment patterns of AR in Northern Cyprus (NC). This study aims to provide a unique perspective on AR management as well as assessing the effectiveness of the pharmacist-led educational intervention for improving care of AR patients.

METHODS

across-sectional survey was carried out with community pharmacists (n = 70), patients (n = 138) and ear, nose and throat (ENT) specialists (n = 12) in NC. For a controlled interventional trial, trained pharmacists provided a brief education on management of AR and nasal spray technique for patients while other pharmacists provided the usual care. Quality of life (QoL) and other outcome measures on the perceived symptom severity of the two groups were compared after a 6-week period.

RESULTS

only 33.3% of the ear, nose and throat (ENT) specialists and 15.7% of the community pharmacists are aware of the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. The majority of patients (63%) self-managed with over-the-counter medications. Nasal congestion (96.4%) is the most bothersome symptom and oral antihistamines are the most commonly purchased medications (51.4%), indicating a pattern of suboptimal management. The pharmacists-led educational intervention has resulted in statistically more significant improvement in regards to nasal congestion and QoL for the intervention group patients (p < 0.05).

CONCLUSION

the current management of AR has not been in accordance with the ARIA guidelines in NC. An educational intervention of the pharmacists can enhance the symptom management and improve the QoL in patients with AR.

Prolonged effect of allergen sublingual immunotherapy to grass pollen

Background: The prolonged effect of allergen immunotherapy is unknown, especially in older patients. Objective: The three-year effect of sublingual allergen-specific immunotherapy (AIT) to grass pollen on elderly patients with allergic rhinitis was analyzed. Methods: Thirty-eight elderly patients (63.18 ± 3.12 yrs.) underwent AIT to grass pollen, were monitored for three years and were compared to a placebo group. AIT was performed with the use of an oral Staloral 300 SR grass extract (Stallergens Greer, London, UK) or a placebo. Symptoms and medication scores, represented by the average adjusted symptom score (AAdSS), the serum level of IgG4 to Phl p5 and the quality of life were assessed immediately after AIT and three years later. Results: After AIT, the AAdSS was significantly decreased and remained lower than in the placebo group during the three years after AIT. Serum-specific IgG4 against Phl p5 increased during the AIT trial in the study group. For the three years of observation after AIT, there were no significant changes in specific IgG4 levels against the analyzed allergens in comparison to the results immediately after AIT. The quality of life, based on the Rhinoconjunctivitis Quality of Life Questionnaire, was significantly decreased in patients who received AIT, from 1.83 (95%CI: 1.45-1.96) to 0.74 (95%CI: 0.39-1.92) (p < 0.05) to 0.82 (95%CI: 0.45- 1.04) three years after AIT. Conclusion: A prolonged positive effect after AIT to grass pollen was observed in elderly patients with allergic rhinitis. Further trials are needed to confirm this effect.

Evidence of the efficacy and safety of house dust mite subcutaneous immunotherapy in elderly allergic rhinitis patients: a randomized, double-blind placebo-controlled trial

Background

Allergen specific immunotherapy (AIT) in elderly patients is controversial, and there is still little evidence supporting the safety and efficacy of this treatment in this population. The study objective was to evaluate the safety and efficacy of AIT for house dust mite allergens in patients over 65 years of age with allergic rhinitis (AR) and a documented allergy to house dust mites. The primary endpoint was the change from baseline in the mean average adjusted symptom score (AAdSS) and the total combined rhinitis score (TCRS) difference in the least square means for the label compared to placebo.

Methods

Fifty-eight AR elderly patients who were monosensitized to house dust mites were individually randomized in comparable numbers to one of two parallel groups with the following interventions: 2 years of perennial AIT using PURETHAL Mites or placebo. The symptoms and medication scores were presented as the AAdSS and TCRS. Quality of life, based on the rhinoconjunctivitis quality of life questionnaire (RQLQ), nasal allergen provocation responsiveness, serum allergen-specific IgG4 to D. pteronyssinus and D. farinae and Der p1 and Der p2 were monitored. The intent-to-treat population was analysed.

Results

After 24 months of AIT, AAdSS significantly decreased from 4.27 ± 1.58 to 1.82 ± 0.71 (p < 0.05). The TCRS was significantly decreased after 2 years of AIT. Serum-specific IgG4 against D. pteronyssinus, D. farinae, Der p1, and Der p2 increased during the AIT trial in the study group. The RQLQ score was significantly improved in patients who received AIT, from 1.86 (95% CI 1.51–1.78) to 1.26 (95% CI 1.09–1.55). Two mild systemic anaphylactic reactions (degree I) were reported after injections in the active group during the AIT therapy.

Conclusion

The DBPC trial showed AIT for house dust mite allergens was effective and safe in elderly patients with allergic rhinitis.

Trial registration

This randomized, double-blinded placebo-controlled (DBPC) trial was conducted at one centre (ClinicalTrials.gov no. NCT03209245)

Satisfaction and quality of life of allergic patients following sublingual five-grass pollen tablet immunotherapy in Spain

BACKGROUND

Five-grass pollen tablet is an effective and well-tolerated therapy for patients with allergic rhinoconjunctivitis (ARC). This trial sought to determine the satisfaction and health-related quality of life (HRQoL) of patients undergoing this treatment.

METHODS

This was a cross-sectional, multicentre, observational, naturalistic study, following a discontinuous pre- and co-seasonal five-grass pollen regimen over two seasons in Spain (2012, 2013). The HRQoL of the patients was measured with the specific Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) for adults, adolescent (AdolRQLQ), or paediatric (PRQLQ) patients. Treatment satisfaction was assessed by the Satisfaction Scale for Patients Receiving Allergen Immunotherapy (ESPIA) questionnaire. Patients/investigators were surveyed on beliefs and attitudes towards the five-grass pollen tablet. ARC evolution according to allergic rhinitis and its impact on asthma (ARIA) criteria and treatment adherence were evaluated.

RESULTS

Among the 591 ARC patients included, the mean (SD) HRQoL scores were 1.40 (1.1) in adults, 1.33 (1.1) in adolescents, and 1.15 (1.1) in children, indicating low levels of impairment (scale 0-6). ESPIA answers showed high levels of satisfaction, with an average score of 69.2 (scale 0-100). According to ARIA criteria, 88.2% of patients reported improvement of ARC. Moreover, this was accompanied by a reduced use of symptomatic medication. Adherence to treatment was estimated at 96.8%. In general, both patients and specialists exhibited a positive attitude towards five-grass pollen tablet treatment.

CONCLUSION

ARC patients treated with five-grass pollen tablet showed favourable levels of HRQoL and treatment satisfaction, with concomitant improvements in ARC and symptomatic medication use, which translated into high levels of treatment adherence and a positive attitude towards five-grass pollen tablet.

Prolonged effect of allergen sublingual immunotherapy for house dust mites in elderly patients

BACKGROUND

The prolonged effect of allergen immunotherapy is unknown, especially in older patients.

OBJECTIVE

To analyze the 3-year effect of sublingual allergen-specific immunotherapy (SLIT) to house dust mites in elderly patients with allergic rhinitis.

METHODS

Forty-seven elderly patients (65.78 ± 4.89 years old) underwent SLIT to house dust mites and were monitored for 3 years and compared with a placebo group. SLIT was performed with the use of oral Staloral 300 SR Der p and Der f 50/50% extract (Stallergens Greer, London, United Kingdom) or placebo. Symptoms and medication score, represented by the average adjusted symptom score (AAdSS), serum level of immunoglobulin (Ig) G4 to Dermatophagoides pteronyssinus, Dermatophagoides farinae, Der p 1, and Der p 2, and quality of life, were assessed immediately after SLIT and 3 years later.

RESULTS

The AAdSS was significantly decreased after SLIT, and the level remained low during the 3 years after SLIT compared with placebo. Serum-specific IgG4 against D pteronyssinus, D farinae, Der p 1, and Der p 2 increased during the SLIT trial in the study group. For the 3 years of observation after SLIT, there were no significant changes of specific IgG4 levels against the analyzed allergens compared with results just after SLIT. Quality of life based on the Rhinoconjunctivitis Quality of Life Questionnaire score was significantly decreased in patients who received SLIT, from 1.48 (95% confidence interval 1.33-1.79) to 0.98 (95% confidence interval 0.67-1.07; P < .05) compared with 0.94 (95% confidence interval 0.55-1.04) 3 years after SLIT.

CONCLUSION

The prolonged positive effect after SLIT to house dust mites was observed in elderly patients with allergic rhinitis. Further trials are needed to confirm this effect.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01605760.

Reduced work/academic performance and quality of life in patients with allergic rhinitis and impact of allergen immunotherapy

Background

Allergic rhinitis (AR) is characterised by burdensome nasal and/or ocular symptoms. This inflammatory disease can be debilitating and thus result in considerable health-related and economic consequences.

Methods

In a cross-sectional study, adult subjects with AR (N = 683) completed three allergy-specific questionnaires that assessed the impact of AR on the work/academic performance, daily activities, health-related quality of life (HRQOL), and satisfaction with allergen immunotherapy (AIT). Regression analyses were used to examine the associations between several clinical variables and the patient-reported outcomes.

Results

Total loss of productivity was 21.0 and 21.2 % for employed and student patients, respectively, whereas the impairment of daily activities was 22.0 %. The mean overall HRQOL score was 1.94 ± 1.29 (on the scale of 0–6 points). Global score for satisfaction with AIT was 65.5 ± 24.8 (on a 0–100 scale). Simple regression analysis found statistically significant associations between loss of work and academic productivity, impairment of daily activities and the type and severity of AR. AIT was a protective factor. The persistent and more severe types of AR and lack of AIT contributed to the worsening of HRQOL.

Conclusions

AR (the persistent and more severe form of the disease) has an impact on functional characteristics of adult patients in Spain. AIT might reduce the effect of this disease on the work/academic performance and HRQOL.

Trial registration Retrospectively registered

Pre-seasonal, subcutaneous immunotherapy: a double-blinded, placebo-controlled study in elderly patients with an allergy to grass

BACKGROUND

There is limited evidence indicating that specific immunotherapy in elderly patients is safe and effective.

OBJECTIVE

To evaluate the safety and efficacy of pre-seasonal specific subcutaneous immunotherapy (SCIT) against grass pollen allergens in patients older than 65 years with seasonal allergic rhinitis and to measure the prime outcome of area under the curve for the combined symptoms and medication score during grass pollen season after 3 years of SCIT in a double-blinded, placebo-controlled trial.

METHODS

This study included 60 65- to 75-year-old patients with seasonal allergic rhinitis and grass pollen allergy. Patients were individually randomized to the active or placebo group. Thirty-three subjects in the SCIT group and 27 subjects in the placebo group were monitored for 3 years. Patients were required to record each use of anti-allergy medication.

RESULTS

Thirty-one patients completed 3 years of pre-seasonal SCIT and 24 subjects finished placebo treatment. The median area under the curve for the combined symptoms and medication score after the third grass pollen season after SCIT was significantly decreased from 7.85 (range 3.67-8.98) to 4.63 (range 3.56-7.80) in the active group and did not significantly change in the placebo group. In the active group, the combined symptoms and medication score was decreased by 41%, the symptoms score was decreased by 55%, and the medication score was decreased by 64% after 3 years of immunotherapy.

CONCLUSION

Pre-seasonal SCIT in the elderly is safe and efficacious and elicits an immune response comparable to what is found in studies of younger patients.

The relationship between hypertension and health-related quality of life: adjusted by chronic pain, chronic diseases, and life habits in the general middle-aged population in Japan

OBJECTIVES

The aim of this study was to examine the relationship between hypertension and health-related quality of life (HRQoL) adjusted by chronic pain, other chronic diseases, and life habits in the general middle-aged population in Japan.

METHODS

This study is a population-based cross-sectional study. In this study, 1117 participants aged 40-65 years and living in Shika Town completed a self-administered questionnaire including Short Form-36 (SF-36). The scores of SF-36 among hypertensives were compared with those of normotensives. The independent association of hypertension with each SF-36 subscale was analyzed using a multiple linear regression model adjusted by age, BMI, chronic pain, chronic diseases, sleep, exercise, and occupational status. We analyzed two groups; Group 1 which contained 846 participants completed the questionnaire without coronary heart disease and cerebral vascular disease, Group 2 which contained 686 participants without coronary heart disease, cerebral vascular disease, or diseases accompanied by chronic pain (gastroduodenal ulcer, fracture, osteoarthritis, osteoporosis, rheumatoid arthritis, and disc herniation).

RESULTS

In Group 2, hypertensive women had a lower general health perception than normotensive women [unstandardized coefficients; B = -8.84, 95 % confidence interval (95 % CI) = -13.3 to -4.34, standardized coefficients; β = -0.200, p < 0.001], whereas hypertensive men had higher social functioning than normotensive men (B = 5.66, 95 % CI = 1.30-10.0, β = 0.149, p < 0.05) after adjusting by chronic pain and life habits.

CONCLUSIONS

These results may be due to the sex difference in the light of the perception for health.

Does the duration and time of sleep increase the risk of allergic rhinitis? Results of the 6-year nationwide Korea youth risk behavior web-based survey

Allergic rhinitis (AR) is the most common chronic disorder in the pediatric population. Although several studies have investigated the correlation between AR and sleep-related issues, the association between the duration and time of sleep and AR has not been analyzed in long-term national data. This study investigated the relationship between sleep time and duration and AR risk in middle- and high-school students (adolescents aged 12–18). We analyzed national data from the Korea Youth Risk Behavior Web-based Survey by the Korea Centers for Disease Control and Prevention from 2007–2012. The sample size was 274,480, with an average response rate of 96.2%. Multivariate logistic regression analyses were conducted to determine the relationship between sleep and AR risk. Furthermore, to determine the best-fitted model among independent variables such as sleep duration, sleep time, and the combination of sleep duration and sleep time, we used Akaike Information Criteria (AIC) to compare models. A total of 43,337 boys and 41,665 girls reported a diagnosis of AR at baseline. The odds ratio increased with age and with higher education and economic status of the parents. Further, students in mid-sized and large cities had stronger relationships to AR than those in small cities. In both genders, AR was associated with depression and suicidal ideation. In the analysis of sleep duration and sleep time, the odds ratio increased in both genders when sleep duration was <7 hours, and when the time of sleep was later than 24∶00 hours. Our results indicate an association between sleep time and duration and AR. This study is the first to focus on the relationship between sleep duration and time and AR in national survey data collected over 6 years.

Nasal allergies in the Asian-Pacific population: results from the Allergies in Asia-Pacific Survey

BACKGROUND

The Allergies in Asia-Pacific Survey describes the symptoms, impact, and treatment of allergic rhinitis (AR) across Australia, China, Hong Kong, Malaysia, Singapore, Taiwan, Vietnam, and the Philippines. The Allergies in Asia-Pacific Survey was undertaken to further clarify the prevalence of physician-diagnosed nasal allergies (NAs), impact on quality-of-life (QOL), existing treatment paradigms and gaps, and NA medications currently used in treatment.

METHODS

Thirty-three thousand three hundred seventy-eight households were screened for individuals, ≥ 4 years old, with a physician diagnosis of AR or NA and either symptoms or treatment in the past 12 months. Standardized questionnaires were used to make comparisons across regions. A total of 1043 adults and 192 children were included in the survey.

RESULTS

Nine percent of participants were diagnosed with AR with two of three responding that their NAs were seasonal in nature. Nasal congestion was the most common and bothersome symptom of AR. Most participants reported that AR impacted their QOL with nearly one-half citing impairments in school/work performance/productivity. Sleep disturbances, secondary to AR, were also shown to be appreciable. Two-thirds of patients took medication for their AR. Less than one-quarter of survey respondents reported taking an intranasal corticosteroid and the satisfaction rate was similar to that of over-the-counter medications. The most common reasons cited for dissatisfaction were related to inadequate efficacy and bothersome side effects.

CONCLUSION

AR appears to be extremely common across Asia-Pacific nations. Many individuals with AR suffer from symptoms that reduce QOL and treatment gaps exist with current therapies. Through identification of disease impact and highlighting treatment gaps, clinicians may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.

Clinical utility and patient adherence with ebastine for allergic rhinitis

Allergic rhinitis (AR) is a high prevalence disease, affecting 10%-20% of the general population. AR is sustained by an IgE-mediated reaction, and by a complex inflammatory network of cells, mediators, and cytokines, becoming chronic when exposure to allergen persists. A Th2-biased immune response is the basis for the allergic inflammation. Histamine plays a relevant role in symptom occurrence. Therefore, antihistamine use represents a cornerstone in AR management. Ebastine, a novel antihistamine, is effective overall in controlling symptoms, and its safety profile is good. Recently, a new formulation has been developed, ie, a fast-dissolving tablet. Several studies have demonstrated its favorable characteristics. In conclusion, ebastine is an effective and well tolerated antihistamine that may be prescribed for the treatment of AR. The fast-dissolving tablet formulation provides a new option which may be particularly convenient for the patient.

Epidemiology and burden of nasal congestion

Nasal congestion, which may be described as fullness, obstruction, reduced airflow, or being "stuffed up," is a commonly encountered symptom in clinical practice. Systematic study of congestion has largely considered it as a component of a disease state. Conditions associated with congestion include nasal polyposis, obstructive sleep apnea, and anatomic variation; however, most information on the burden of congestion comes from studies of allergic rhinitis and rhinosinusitis, diseases of which congestion is the major symptom. Congestion can be caused by other rhinologic conditions, such as non-allergic rhinitis, viral or bacterial rhinitis, and vasomotor rhinitis. Allergic rhinitis affects as much as one quarter of the population worldwide and imposes a significant economic burden. Additionally, allergic rhinitis significantly impairs quality of life; congestion causes allergic rhinitis sufferers decreased daytime productivity at work or school and reduces night-time sleep time and quality. Annually, rhinosinusitis affects tens of millions of Americans and leads to approximately $6 billion in overall health care expenditures; it has been found to be one of the most costly physical conditions for US employers. Given the high prevalence and significant social and economic burden of nasal congestion, this symptom should be a key consideration in treating patients with rhinologic disease, and there continues to be a significant unmet medical need for effective treatment options for this condition.

Intranasal Mometasone Furoate for Treatment of Allergic Rhinitis

Allergic rhinitis (AR) is a chronic nasal disease that affects the upper respiratory tract. This disorder is characterized by inflammation of the mucous membranes and it manifests with several nasal symptoms accompanied sometimes by non-nasal symptoms. Best therapy aims to prevent and improve the AR-clinical picture. Steroids have an important role in the treatment of AR. The development of steroids administrated directly on nasal mucosa has much reduced the systemic adverse affects associated with oral steroids therapy. Mometasone furoate aqueous nasal spray is a synthetic steroid assessed for intranasal use in the therapy of adults and children affected by AR. Such topical nasal steroid is an effective molecule improving clinical picture of AR and it is also approved as prophylactic therapy. In this article, apart from a careful description of its successful clinical use the authors review pharmacokinetic/pharmacodynamic profile, mechanism of action, safety, and efficacy of such steroid molecule.

Montelukast: Pharmacology, Safety, Tolerability and Efficacy

Allergic rhinitis and asthma are common disorders effecting large percentages of the population of Western countries. There are multiple treatment options available for allergic rhinitis and asthma and stepwise approaches to therapy have been recommended. Montelukast is a cysteinyl leukotriene receptor antagonist that has been found to be effective both in the treatment of allergic rhinitis and asthma. This paper will describe the pharmacology, safety, efficacy and tolerability of montelukast. It will examine the comparative efficacy of montelukast to other medications for the treatment of allergic rhinitis and asthma, as well as discuss the recent studies of combination therapy.

Are the birch trees in Southern England a source of Betula pollen for North London?

Birch pollen is highly allergenic. Knowledge of daily variations, atmospheric transport and source areas of birch pollen is important for exposure studies and for warnings to the public, especially for large cities such as London. Our results show that broad-leaved forests with high birch tree densities are located to the south and west of London. Bi-hourly Betula pollen concentrations for all the days included in the study, and for all available days with high birch pollen counts (daily average birch pollen counts>80 grains/m3), show that, on average, there is a peak between 1400 hours and 1600 hours. Back-trajectory analysis showed that, on days with high birch pollen counts (n=60), 80% of air masses arriving at the time of peak diurnal birch pollen count approached North London from the south in a 180 degree arc from due east to due west. Detailed investigations of three Betula pollen episodes, with distinctly different diurnal patterns compared to the mean daily cycle, were used to illustrate how night-time maxima (2200-0400 hours) in Betula pollen counts could be the result of transport from distant sources or long transport times caused by slow moving air masses. We conclude that the Betula pollen recorded in North London could originate from sources found to the west and south of the city and not just trees within London itself. Possible sources outside the city include Continental Europe and the Betula trees within the broad-leaved forests of Southern England.

Pharmacoeconomics of levocetirizine in allergic rhinitis and chronic idiopathic urticaria: considerations for the USA

BACKGROUND

Levocetirizine, a recent, second-generation oral antihistamine, was approved by the US FDA in May 2007 to treat symptoms of allergic rhinitis and chronic idiopathic urticaria.

OBJECTIVE

To review the economic literature for levocetirizine.

METHODS

Two reviewers conducted a systematic review of the literature to identify abstracts that met the inclusion criteria. Abstracts that were considered acceptable were retrieved with full text for further assessment.

RESULTS

A total of 82 potential studies were identified. After reviewing abstracts, 11 articles were preselected for potential inclusion. Of the 11 full-text articles, three articles met the inclusion criteria.

CONCLUSION

The pharmacoeconomic literature for levocetirizine was limited. The findings were consistent across the literature, suggesting levocetirizine improved outcomes, leading to incremental cost savings and cost-effectiveness. Since many of the available levocetirizine data come from European studies, differences in practice patterns and medical resources should be considered when extrapolating data to a US clinical setting.

Allergic rhinitis in women

Allergic rhinitis is a high-prevalence disease that significantly impairs the quality of life. Its pathogenesis is quite well understood, and involves numerous cells, cytokines and mediators, which result in an inflammatory process. The triggering IgE-mediated reaction does not differ between men and women, but in females some aspects, related mainly to the hormonal frame, must be taken into account. In fact, cyclic hormonal changes can affect the severity of rhinitis, as can pregnancy, which may result in a particular form of 'pregnancy rhinitis'. The most important and challenging aspect is the management of allergic rhinitis in pregnancy, which require a careful evaluation of the risk:benefit ratio. This review will examine the aforementioned aspects, with particular regard to the pharmacotherapy of rhinitis in pregnancy.

The long-range transport of birch (Betula) pollen from Poland and Germany causes significant pre-season concentrations in Denmark

BACKGROUND

Birch pollen is highly allergic and has the potential for episodically long-range transport. Such episodes will in general occur out of the main pollen season. During this time, allergy patients are unprotected and high pollen concentrations will therefore have a full allergenic impact.

OBJECTIVE

To show that Denmark obtains significant quantities of birch pollen from Poland or Germany before the local trees start to flower.

METHODS

Simultaneous observations of pollen concentrations and phenology in the potential source area in Poland as well as in Denmark were performed in 2006. The Danish pollen records from 2000 to 2006 were analysed for possible long-range transport episodes and analysed with trajectories in combination with a birch tree source map.

RESULTS

In 2006, high pollen concentrations were observed in Denmark with bi-hourly concentrations above 500 grains/m(3) before the local trees began to flower. Poland was identified as a source region. The analysis of the historical pollen record from Copenhagen shows significant pre-seasonal pollen episodes almost every year from 2000 to 2006. In all episodes, trajectory analysis identified Germany or Poland as source regions.

CONCLUSION

Denmark obtains significant pre-seasonal quantities of birch pollen from either Poland or Germany almost every year. Forecasting of birch pollen quantities relevant to allergy patients must therefore, take into account long-range transport. This cannot be based on measured concentrations in Denmark. The most effective way to improve the current Danish pollen forecasts is to extend the current forecasts with atmospheric transport models that take into account pollen emission and transport from countries such as Germany and Poland. Unless long-range transport is taken into account, pre-seasonal pollen episodes will have a full allergic impact, as the allergy patients in general will be unprotected during that time.

Treatment Options for the Management of Perennial Allergic Rhinitis, with a Focus on Intranasal Corticosteroids

Perennial allergic rhinitis (PAR) can have a significant impact on a patient's quality of life. While allergen avoidance is the first line of management for PAR, complete avoidance is difficult. Therapeutic options available for PAR include intranasal corticosteroids (INS), H1-antihistamines, decongestants and local chromones, as well as immunotherapy. For mild symptoms, INS and antihistamines are the standard of care, whereas for moderate-to-severe PAR, INS are the preferred therapy due to their proven efficacy. Patient quality of life and therapy preference play a role in maintaining adherence to treatment.

Pharmacokinetics and Safety of Ebastine in Healthy Subjects and Patients with Renal Impairment

OBJECTIVE

To assess the differences in the pharmacokinetics and cardiac safety of ebastine and its active metabolite, carebastine, in patients with normal and impaired renal function.

METHODS

Twenty-four patients with varying degrees of renal impairment (mild, moderate or severe: n = 8 per group) and 12 healthy subjects participated in an open-label, parallel-group, multicentre study. Ebastine 20mg was administered orally once daily for 5 days. Plasma concentrations of ebastine and carebastine were determined for 24 hours on day 1 and for 72 hours on day 5 by using a validated sensitive liquid chromatography-tandem mass spectrometry assay with a minimum quantifiable limit of 0.05 ng/mL for ebastine and 1.00 ng/mL for carebastine. Renal function was assessed by measuring 24-hour creatinine clearance (CL(CR)) at baseline. Cardiac and general safety parameters were also monitored.

RESULTS

The pharmacokinetics of ebastine were not modified by renal impairment. No correlation between ebastine pharmacokinetics and renal function, as expressed by CL(CR) assessed 2 days prior to dosing, was observed. Comparison of the plasma exposure and the elimination half-life of ebastine and carebastine between groups showed no significant differences. Therefore, no apparent accumulation of ebastine and carebastine occurred, and steady-state concentrations of ebastine and carebastine were predictable from single-dose pharmacokinetics for both healthy subjects and patients with renal impairment, even though the variability between the groups was large. In addition, no differences were observed in the safety of ebastine between patients with renal impairment and healthy subjects when assessing adverse events, vital signs, laboratory parameters or ECGs.

CONCLUSION

Ebastine was generally well tolerated in subjects with impaired renal function. No clinically important pharmacokinetic or safety differences were observed between patients with renal impairment and healthy subjects with normal renal function.

Novel therapeutic interventions for allergic rhinitis

Allergic rhinitis is a high-prevalence disease, affecting 10 - 20% of the general population. Allergic rhinitis is sustained by an IgE-mediated reaction and by a complex inflammatory network of cells, mediators and cytokines that becomes chronic when exposure to allergen persists. A T(H)2-biased immune response is the background of the allergic inflammation. The current therapeutic strategy is mainly based on drugs (antihistamines, nasal corticosteroids, cromones and decongestants) and allergen immunotherapy. Drugs are (overall) effective in controlling symptoms but do not modify the immune background that leads to allergic inflammation and safety concerns may be present, especially for prolonged treatments. Immunotherapy can modify the allergic response but there is still room for improvement. Nowadays, several approaches are under investigation to optimise the management of allergic rhinitis. On one hand, new drugs and antimediators are being developed. On the other hand, attempts are being made to selectively block relevant signal pathways of allergic reaction. Finally, one of the major goals is to modify the T(H)2-biased immune response by improving the characteristics and modes of action of allergen immunotherapy.

Levocetirizine: a review of its use in the management of allergic rhinitis and skin allergies

Levocetirizine (Xyzal) is a selective, potent, oral histamine H(1) receptor antagonist of the latest generation that is licensed for the symptomatic treatment of allergic rhinitis (including persistent allergic rhinitis [PER]) and chronic idiopathic urticaria (CIU). Large, well designed trials indicate that levocetirizine is effective and generally well tolerated in the treatment of allergic rhinitis and CIU. Its pharmacological profile offers many positive aspects: a rapid onset and long duration of antihistaminic effect; rapid absorption and high bioavailability; a low potential for drug interactions; a low volume of distribution; and a lack of effect on cognition, psychomotor function and the cardiovascular system. Allergen challenge chamber studies suggest that levocetirizine has better efficacy than desloratadine, loratadine or fexofenadine. Well controlled, long-term studies with other later-generation H(1) receptor antagonists are required to fully define its clinical profile relative to other agents in this class. Overall, levocetirizine is a valuable addition to the oral H(1) receptor antagonists available for the treatment of allergic rhinitis and as first-line therapy in patients with CIU.

Is outdoor air pollution associated with physician visits for allergic rhinitis among the elderly in Toronto, Canada?

BACKGROUND

While a number of studies suggest that air pollution is associated with allergic rhinitis in children, findings among adults have been equivocal. The aim of this study was to examine the relationship between outdoor air pollution and physician visits for allergic rhinitis among individuals>or=65 years of age in Toronto, Canada.

METHODS

Physician visits were identified by using data from the Ontario provincial health insurance plan that is made available to all residents. Our analyses are based on 52,691 physician visits for allergic rhinitis among individuals>or=65 years of age in the Toronto metropolitan area between 1995 and 2000. Generalized linear models were used to regress daily counts of physician visits against daily measures of gaseous and particulate components of air pollution after controlling for seasonality, potential confounders (temperature, relative humidity, aeroallergens), overdispersion and serial correlation.

RESULTS

A large number of comparisons were undertaken, with most showing no statistically significant associations between daily levels of air pollution and the number of physician visits for rhinitis. In contrast, an interquartile increase in the 10-day average of ragweed particles increased the mean number of daily rhinitis consultations by 6.4% (95% CI=0.7-12.4%).

CONCLUSIONS

Our findings suggest that outdoor air pollution is a poor predictor of physician visits for allergic rhinitis among the elderly.

Effects of adjuvant therapy with 0.1% olopatadine hydrochloride ophthalmic solution on quality of life in patients with allergic rhinitis using systemic or nasal therapy

BACKGROUND

Allergic rhinoconjunctivitis patients are often treated with nasal or systemic allergy therapy, forgoing therapy for ocular symptoms. This treatment regimen leaves important aspects of the allergic reaction untreated and affects quality of life (QoL). The Rhinoconjunctivitis Quality of Life Questionnaire and the Allergic Conjunctivitis Quality of Life Questionnaire quantify separate aspects of QoL.

OBJECTIVE

To determine the benefit gained in QoL, measured by these questionnaires, when antiallergy eyedrops (olopatadine) were added to patients' preexisting regimens of nasal or systemic allergic rhinitis treatment.

METHODS

This was a 4-week prospective, multicenter, open-label, crossover, environmental QoL study. Visit 1 randomized patients to treatment group A or B and included baseline examinations and questionnaires. Group A instilled olopatadine twice daily and concomitantly with previously prescribed nasal or systemic antiallergy medication for 2 weeks. Group B received no ocular therapy and used only previously prescribed antiallergy medication for 2 weeks. Treatment group crossover occurred at visit 2. Patients again completed the questionnaires at visits 2 and 3.

RESULTS

Two hundred patients completed the study, 97 in group A and 103 in group B. Groups A and B experienced ocular allergic symptoms for 3.88 and 3.96 days, respectively, during the week before baseline. At visits 2 and 3, questionnaire scores were significantly improved for each group when olopatadine was added compared with the nontreatment periods. By visit 2, olopatadine improved QoL by 49% compared with 5% in the nontreated group (P < .001).

CONCLUSIONS

In this study, 90.5% of patients with allergic rhinitis treated nasally or systemically also had ocular allergic symptoms. Adding olopatadine to these patients' medication regimens significantly improved ocular allergic symptoms and overall QoL.

Sexual dysfunction in patients with allergic rhinoconjunctivitis

BACKGROUND

Sexual dysfunction in chronic diseases has recently attracted attention owing to its impact on quality of life (QoL). Allergic rhinoconjunctivitis (ARC) affects QoL, causing limitations in many areas. However, there has not been research on changes in sexual function in patients with ARC.

OBJECTIVE

To report the effect of ARC and its treatment on sexual function in men and women.

METHODS

Forty-three sexually active patients with seasonal ARC aged 22 to 49 years were included in the study. The control group was composed of 40 healthy individuals aged 22 to 46 years. Conjunctival symptom scores (CSSs) and nasal symptom scores (NSSs) of patients with symptomatic ARC were determined, as were sexual function scores (SFSs) using the Female Sexual Function Index and the International Index of Erectile Function during allergen exposure in the pollination period and after treatment with oral desloratadine, 5 mg/d, for 30 days. The SFSs were evaluated in the control group.

RESULTS

The CSSs and NSSs significantly improved in treated ARC (P < .001). In women, Female Sexual Function Index results in symptomatic ARC were significantly lower than in treated ARC and controls (P = .003). In men, International Index of Erectile Function results in treated ARC (P = .001) and controls (P < .001) were significantly higher than in symptomatic ARC. Furthermore, correlation between improvement in CSSs and NSSs and that of SFSs was determined (P = .007 for women; P = .001 for men).

CONCLUSION

Improvement in sexual function as a variable of QoL may accompany the treatment of symptoms in patients with ARC.

A preference evaluation study comparing the sensory attributes of mometasone furoate and fluticasone propionate nasal sprays by patients with allergic rhinitis

OBJECTIVE

Data on intranasal corticosteroids suggest that individual product attributes may influence patient preference for therapy in allergic rhinitis. The study objective was to compare product sensory attributes and their impact upon patient preference for scent-free mometasone furoate nasal spray (MFNS) versus fluticasone propionate nasal spray (FPNS) in patients with symptomatic allergic rhinitis.

METHODS

In a double-blind, crossover study, 100 patients were randomized to MFNS microg followed by FPNS 200 microg, or vice versa. Patients rated the study drugs by completing an individual product sensory attributes questionnaire at the end of each period of drug administration. An overall sensory preference questionnaire was completed following crossover.

RESULTS

A significantly greater number of patients preferred MFNS to FPNS (p < 0.05). MFNS was superior for a number of individual sensory attributes based on mean patient ratings: significantly fewer patients perceived scent/odor (immediately and 2 minutes after drug administration; p < 0.001), taste (immediately after drug administration; p = 0.002), and after-taste (2 minutes after drug administration; p = 0.007) with MFNS compared with FPNS. Similarly, product sensory attribute preference data demonstrated that twice the number of patients preferred MFNS to FPNS for scent/odor (p = 0.0005), immediate taste (p = 0.005), and after-taste (p = 0.005). Fifty-four percent of patients said they would choose a prescription for MFNS compared with 33% for FPNS (p = 0.03). In addition, 47% of patients would be more likely to comply (use daily as directed) with MFNS compared with 25% with FPNS (p = 0.03).

CONCLUSION

Several individual sensory attributes of MFNS were rated significantly superior to FPNS. Overall, based on the tested sensory attributes, patients preferred MFNS to FPNS therapy for the treatment of allergic rhinitis.

Emerging anti-inflammatory agents for allergic rhinitis

Allergic rhinitis (AR) is a high-prevalence disease, affecting 10-15% of the general population. AR is sustained by an IgE-mediated reaction, and by a complex inflammatory network of cells, mediators and cytokines that becomes chronic when exposure to allergen persists. A T helper 2 (TH2)-biased immune response is the basis for the allergic inflammation. The current therapeutic strategy is mainly based on drugs (antihistamines, nasal corticosteroids, cromones, decongestants) and allergen immunotherapy. Drugs are overall effective in controlling symptoms, but do not modify the immune background that leads to allergic inflammation, and safety concerns may be present especially for prolonged treatments. Immunotherapy can modify the allergic response, but there is still space for improvement. Nowadays, several approaches are under investigation to optimise the management of AR. On one hand, new drugs and antimediators are being developed; on the other hand, attempts are made to selectively block relevant signal pathways of allergic reaction. Finally, one of the major goals is to modify the TH2-biased immune response by improving the characteristics and modes of action of allergen immunotherapy.

Immunotherapy with depigmented glutaraldehyde-polymerized extracts: changes in quality of life

BACKGROUND

Immunotherapy (IT) with modified allergens reduces allergic rhinitis (AR) symptoms and medications requirements. Improvement of quality of life (QOL) is a key point in the treatment of AR. The aim of this study was to provide evidence of changes related to the patient's QOL (well-being) induced by a modified (depigmented glutaraldehyde-polymerized) therapeutic vaccine and of its safety.

MATERIAL AND METHODS

Fifty-three patients with a well-documented clinical history of seasonal AR sensitized to Dactylis glomerata and Olea europaea pollens were included in a randomized clinical trial. Twenty-five patients (Group-A) received a mixture of D. glomerata and O. europaea pollen extracts and 28 patients received placebo (group-C). Any adverse event was recorded and graded in accordance with EAACI guidelines. RQLQ was recorded before the treatment (pollen season 2000) and after 1 year of treatment (pollen season 2001). Dose-response skin prick test with each allergen extract was conducted at baseline and at the end of the study.

RESULTS

Each patient received 17 injections during this period. All patients completed the trial and no systemic adverse reactions were recorded. Symptom scores (P<0.001) and medication requirements (P<0.001) were significantly reduced in the IT group during the pollen season. This patient group also experienced greater and statistically significant improvement in overall RQLQ score and in five of the seven domains, all of them surpassing the threshold of 'minimal important difference' of 0.5 points.

CONCLUSIONS

Results of this study provided evidence that IT with depigmented, glutaraldehyde-modified allergen extracts was well-tolerated and added beneficial effects to AR treatment in pollen allergic patients eliciting an improvement in QOL enough to justify a change in the patient's treatment.

Nasal allergies and beyond: a clinical review of the pharmacology, efficacy, and safety of mometasone furoate

Mometasone furoate nasal spray (MFNS; Nasonex, Schering-Plough Corporation, Kenilworth, NJ, USA) is an effective and well-tolerated intranasal corticosteroid approved for the prophylactic treatment of seasonal allergic rhinitis, and the treatment of perennial allergic rhinitis. MFNS is a potent molecule with a rapid onset of action and excellent safety and efficacy profiles. Having recently received approval for the treatment of nasal polyposis, data indicate that MFNS may also be effective in rhinosinusitis.

Quality of life scales in allergic rhinitis

PURPOSE OF REVIEW

The recent literature on types, development, validation, indications, and limitations of quality of life scales in allergic rhinitis is reviewed. This review does not report clinical trials that included quality of life as an outcome.

RECENT FINDINGS

Today, quality of life measurement is standard in allergic rhinitis. Different disease-specific and generic questionnaires are very well validated and established. Recent research concerns the development or adaptation of questionnaires for specific purposes or populations. Other research focuses on the registration of concomitant illnesses, especially of asthma, taking the model of rhinitis and asthma as 'one airway disease' into account. Recently, the first questionnaire for rhinitis and asthma was presented. Furthermore, attempts have been made to improve the registration of other local or systemic concomitant illnesses, the sensitivity to rapid changes in the patient's condition, and the objectivity of quality of life scales.

SUMMARY

Allergic rhinitis is associated with significant impairments of quality of life. Disease-specific quality of life scales offer a better registration of changes in disease-related problems, whereas generic scales allow for a comparison between different disorders and patient populations. Different versions of quality of life scales have been validated for different purposes. Careful selection of quality of life scales is becoming more and more important. The registration of comorbid conditions and of psychological factors influencing quality of life measurement remains a central problem. For research, the combination of disease-specific and generic quality of life scales may offer new perspectives; for clinical use, patient-friendly scales should be used.

The nose and sleep-disordered breathing: what we know and what we do not know

The relationship between sleep-disordered breathing (SDB) and nasal obstruction is unclear. In order to better understand, we performed an extensive computer-assisted review and analysis of the medical literature on this topic. Data were grouped into reports of normal control subjects, patients with isolated nasal obstruction, and those with SDB. We conclude that SDB can both result from and be worsened by nasal obstruction. Nasal breathing increases ventilatory drive and nasal occlusion decreases pharyngeal patency in normal subjects. Nasal congestion from any cause predisposes to SDB. Although increased nasal resistance does not always correlate with symptoms of congestion, nasal congestion typically results in a switch to oronasal breathing that compromises the airway. Moreover, oral breathing in children may lead to the development of facial structural abnormalities associated with SDB. We postulate that the switch to oronasal breathing that occurs with chronic nasal conditions is a final common pathway for SDB.

Intranasal corticosteroids for allergic rhinitis

Intranasal corticosteroids are accepted as safe and effective first-line therapy for allergic rhinitis. Several intranasal corticosteroids are available: beclomethasone dipropionate, budesonide, flunisolide, fluticasone propionate, mometasone furoate, and triamcinolone acetonide. All are efficacious in treating seasonal allergic rhinitis and as prophylaxis for perennial allergic rhinitis. In general, they relieve nasal congestion and itching, rhinorrhea, and sneezing that occur in the early and late phases of allergic response, with studies showing almost complete prevention of late-phase symptoms. The rationale for topical intranasal corticosteroids in the treatment of allergic rhinitis is that adequate drug concentrations can be achieved at receptor sites in the nasal mucosa. This leads to symptom control and reduces the risk of systemic adverse effects. Adverse reactions usually are limited to the nasal mucosa, such as dryness, burning and stinging, and sneezing, together with headache and epistaxis in 5-10% of patients regardless of formulation or compound. Differences among agents are limited to potency, patient preference, dosing regimens, and delivery, device and vehicle.