Heterogeneity of sensitization profiles and clinical phenotypes among patients with seasonal allergic rhinitis in Southern European countries-The @IT.2020 multicenter study

BACKGROUND

Pollen allergy poses a significant health and economic burden in Europe. Disease patterns are relatively homogeneous within Central and Northern European countries. However, no study broadly assessed the features of seasonal allergic rhinitis (SAR) across different Southern European countries with a standardized approach.

OBJECTIVE

To describe sensitization profiles and clinical phenotypes of pollen allergic patients in nine Southern European cities with a uniform methodological approach.

METHODS

Within the @IT.2020 multicenter observational study, pediatric and adult patients suffering from SAR were recruited in nine urban study centers located in seven countries. Clinical questionnaires, skin prick tests (SPT) and specific IgE (sIgE) tests with a customized multiplex assay (Euroimmun Labordiagnostika, Lübeck, Germany) were performed.

RESULTS

Three hundred forty-eight children (mean age 13.1 years, SD: 2.4 years) and 467 adults (mean age 35.7 years SD: 10.0 years) with a predominantly moderate to severe, persistent phenotype of SAR were recruited. Grass pollen major allergenic molecules (Phl p 1 and/or Phl p 5) ranged among the top three sensitizers in all study centers. Sensitization profiles were very heterogeneous, considering that patients in Rome were highly poly-sensitized (sIgE to 3.8 major allergenic molecules per patient), while mono-sensitization was prominent and heterogeneous in other cities, such as Marseille (sIgE to Cup a 1: n = 55/80, 68.8%) and Messina (sIgE to Par j 2: n = 47/82, 57.3%). Co-sensitization to perennial allergens, as well as allergic comorbidities also broadly varied between study centers.

CONCLUSIONS

In Southern European countries, pollen allergy is heterogeneous in terms of sensitization profiles and clinical manifestations. Despite the complexity, a unique molecular, multiplex, and customized in-vitro IgE test detected relevant sensitization in all study centers. Nevertheless, this geographical diversity in pollen allergic patients imposes localized clinical guidelines and study protocols for clinical trials of SAR in this climatically complex region.

From MASK-air and SILAM to CATALYSE (Climate Action To Advance HeaLthY Societies in Europe)

Plant species vary under different climatic conditions and the distribution of pollen in the air. Trends in pollen distribution can be used to assess the impact of climate change on public health. In 2015, the Mobile Airways Sentinel networK for rhinitis and asthma (MASK-air®) was launched as a project of the European Innovation Partnership on Active and Healthy Ageing (EIP-on-AHA, DG Santé and DG CONNECT). This project aimed to develop a warning system to inform patients about the onset of the pollen season, namely, the System for Integrated modeLling of Atmospheric coMposition (SILAM). A global-to-meso-scale dispersion model was developed by the Finnish Meteorological Institute (FMI). It provides quantitative information on atmospheric pollution of anthropogenic and natural origins, particularly on allergenic pollens. Impact of Air Pollution on Asthma and Rhinitis (POLLAR, EIT Health) has combined MASK-air clinical data with SILAM forecasts. A new Horizon Europe grant (Climate Action to Advance HeaLthY Societies in Europe [CATALYSE]; grant agreement number 101057131), which came into force in September 2022, aims to improve our understanding of climate change and help us find ways to counteractit. One objective of this project is to develop early warning systems and predictive models to improve the effectiveness of strategies for adapting to climate change. One of the warning systems is focused on allergic rhinitis (CATALYSE Task 3.2), with a collaboration between the FMI (Finland), Porto University (Portugal), MASK-air SAS (France), ISGlobal (Spain), Hertie School (Germany), and the University of Zurich (Switzerland). It is to be implemented with the support of the European Academy of Allergy and Clinical Immunology. This paper reports the planning of CATALYSE Task 3.2.

Adherence to inhaled corticosteroids and long-acting β2-agonists in asthma: A MASK-air study

INTRODUCTION

Adherence to controller medication is a major problem in asthma management, being difficult to assess and tackle. mHealth apps can be used to assess adherence. We aimed to assess the adherence to inhaled corticosteroids+long-acting β2-agonists (ICS+LABA) in users of the MASK-air® app, comparing the adherence to ICS+formoterol (ICS+F) with that to ICS+other LABA.

MATERIALS AND METHODS

We analysed complete weeks of MASK-air® data (2015-2022; 27 countries) from patients with self-reported asthma and ICS+LABA use. We compared patients reporting ICS+F versus ICS+other LABA on adherence levels, symptoms and symptom-medication scores. We built regression models to assess whether adherence to ICS+LABA was associated with asthma control or short-acting beta-agonist (SABA) use. Sensitivity analyses were performed considering the weeks with no more than one missing day.

RESULTS

In 2598 ICS+LABA users, 621 (23.9%) reported 4824 complete weeks and 866 (33.3%) reported weeks with at most one missing day. Higher adherence (use of medication ≥80% of weekly days) was observed for ICS+other LABA (75.1%) when compared to ICS+F (59.3%), despite both groups displaying similar asthma control and work productivity. The ICS+other LABA group was associated with more days of SABA use than the ICS+F group (median=71.4% versus 57.1% days). Each additional weekly day of ICS+F use was associated with a 4.1% less risk in weekly SABA use (95%CI=-6.5;-1.6%;p=0.001). For ICS+other LABA, the percentage was 8.2 (95%CI=-11.6;-5.0%;p<0.001).

CONCLUSIONS

In asthma patients adherent to the MASK-air app, adherence to ICS+LABA was high. ICS+F users reported lower adherence but also a lower SABA use and a similar level of control.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

ConectAR: Collaborative network of patients with asthma and carers actively involved in health research. A protocol for patient and public involvement

Summary

Patients and Public Involvement in every stage of the patient-centred health research cycle is the key to the development of innovative solutions with an impact on patients' care. This protocol describes the development of ConectAR, a network to promote the involvement of patients with asthma and their carers in the health research cycle. This protocol comprehends 4 tasks: 1) define the mission, vision, governance and activities of the network through focus groups; 2) establish the communication strategy and tools; 3) test the feasibility of the network in a Delphi study on the research priorities for asthma in Portugal; and 4) coordination and dissemination activities. This network will improve research by ensuring that patients and carers have an active role in the co-creation of impactful solutions for asthma.

Self-reported adverse reactions to subcutaneous airborne allergen immunotherapy: a real-life, single center study

Summary

Objective. To estimate the prevalence of self-reported adverse reactions (AdR) to subcutaneous airborne allergen immunotherapy (SCIT) and to describe factors associated with its occurrence. Methods. Real-life, observational, descriptive study of all patients treated with SCIT at a Portuguese allergy unit between 03/2017 and 06/2019, and who answered ≥1 time to a pre-SCIT evaluation questionnaire assessing the occurrence of local and/or systemic AdR in the previous administration. Results. 939 questionnaires from 231 patients (42% female, 35% with asthma) were included. Most (60%) SCIT preparations had multiple allergens with concentration adjusted to prevent dilution (MA-NoDil), 26% were single allergen with standard concentration (SA-SC), 10% single allergen with higher than standard concentration (SA-HC), and 4% mixtures without concentration adjustment (MA-Dil). SCIT-related AdR were self-reported in 313 (33%) administrations, 97% at the injection site and 11% grade 1 systemic symptoms. In a multivariable model, being a female and having asthma were associated with higher risk of AdR. MA-NoDil SCIT presented a lower risk of AdR compared to SA-SC SCIT. Conclusions. SCIT-related AdR were self-reported in 1/3 of the administrations, most at the injection site. The risk of AdR was higher in females and in patients with asthma. The lower risk of adverse reactions observed in SCIT preparations with multiple allergens with no dilutional effect should be further explored in future, targeted studies.

Prescribing patterns of medication for respiratory diseases - cluster analysis of the Portuguese electronic prescription database

Summary

We aimed to describe, for the first time, the prescribing patterns among patients on persistent respiratory treatment, from the Portuguese electronic prescription and dispensing database. This was a one-year retrospective population-based analysis of prescriptions (n = 39810) for medication for respiratory disease and exacerbations. Cluster analysis was applied based on medication and prescribers' specialty. Prescribing patterns were grouped and labelled as: possible medication for asthma and allergic rhinitis (General Practitioners-GPs and allergists to younger patients); COPD (GPs and pulmonologists to older patients); asthma or Asthma-COPD Overlap (GPs and pulmonologists); exacerbation, infection and relievers. This analysis was an important first step to understand the Portuguese reality on the treatment of respiratory diseases.

The use of remote care during the coronavirus disease 2019 pandemic - a perspective of Portuguese and Spanish physicians

Summary

This study aimed to characterise how the follow-up of outpatients was done during the first months of COVID-19 pandemic by a multidisciplinary group of physicians involved in an asthma mHealth project. A cross-sectional study based on a web survey was conducted. The survey was sent to 123 physicians working at secondary care centres of Portugal and Spain, that participate in the INSPIRERS project. A total of 65 physicians completed the survey (53% response rate). They had a mean of 18 (11) years of clinical practice and 14% were residents. More than half were allergists (58%), 22% pulmonologists and 20% paediatricians. Most were working in Portugal (89%) and in public hospitals (88%). All were conducting consultations: 71% presential (median [p 25 ,75] duration 30 [20, 30] min), 91% telephonic (15 [10, 20] min) and 20% video consultations (20[10, 28]min). The median duration of presential consultations was significantly higher than pre-COVID-19 (20 [20, 30]min; p = 0.021). From the physicians conducting video consultations, 92% were allergists and only 54% considered that their institution provided adequate conditions. The physicians of the INSPIRERS group used telephonic consultations as the main alternative to presential ones and 1/5 used video consultations. These results suggest the need to rethink clinical follow-up services for outpatients in the near future increasing the use of telemedicine, especially video consultations.

Treatment of allergic rhinitis during and outside the pollen season using mobile technology. A MASK study

Background

The analysis of mobile health (mHealth) data has generated innovative insights into improving allergic rhinitis control, but additive information is needed. A cross-sectional real-world observational study was undertaken in 17 European countries during and outside the estimated pollen season. The aim was to collect novel information including the phenotypic characteristics of the users.

Methods

The Allergy Diary–MASK-air–mobile phone app, freely available via Google Play and App, was used to collect the data of daily visual analogue scales (VASs) for overall allergic symptoms and medication use. Fluticasone Furoate (FF), Mometasone Furoate (MF), Azelastine Fluticasone Proprionate combination (MPAzeFlu) and eight oral H1-antihistamines were studied. Phenotypic characteristics were recorded at entry. The ARIA severity score was derived from entry data. This was an a priori planned analysis.

Results

9037 users filled in 70,286 days of VAS in 2016, 2017 and 2018. The ARIA severity score was lower outside than during the pollen season. Severity was similar for all treatment groups during the pollen season, and lower in the MPAzeFlu group outside the pollen season. Days with MPAzeFlu had lower VAS levels and a higher frequency of monotherapy than the other treatments during the season. Outside the season, days with MPAzeFlu also had a higher frequency of monotherapy. The number of reported days was significantly higher with MPAzeFlu during and outside the season than with MF, FF or oral H1-antihistamines.

Conclusions

This study shows that the overall efficacy of treatments is similar during and outside the pollen season and indicates that medications are similarly effective during the year.

Opinions of patients with persistent asthma regarding the use of mobile applications for disease monitoring

Summary

Background. We assessed adherence to treatment and management needs of adults with persistent asthma and their interest in using apps for asthma management. Secondarily, we explored opinions of patients about an app to assess and improve adherence to treatment. Methods. A cross-sectional study was conducted with 40 adults with persistent asthma (49.9 ± 15.8 years) recruited at outpatient clinics from a district hospital. Participants answered a survey on sociodemographic, asthma control, treatment adherence and use of mobile devices, social networks and apps. Four patients participated in a prospective extension of the study, in which they were invited to use the InspirerMundi app. Results. 48 percent of the participants had at least greater-equal than 1 exacerbation in the previous year and 85 percent had uncontrolled asthma. Self-reported adherence to treatment showed that one in four participants had low adherence. At least daily, 55 percent of participants navigated on the internet with their smartphone-tablet, 35 percent used apps and 93 percent social networks. Nine (22 percent) participants had previously used health-fitness apps and 65 percent would like to use apps to improve inhaler adherence. Conclusions. Most participants had uncontrolled asthma, reported high adherence to treatment and were daily users of social networks and the internet. Only 1/4 used apps but 2/3 would like to use apps to support asthma management.

Cost of asthma in Portuguese adults: A population-based, cost-of-illness study

INTRODUCTION

Asthma is one of the most frequent chronic diseases, putting a considerable economic burden on societies and individuals. We aimed to estimate the total cost of adult asthma in Portugal, as well as the extent to which direct and indirect costs are influenced by the level of asthma control.

METHODS

A nationwide, prevalence-based, cost-of-illness study using a bottom-up approach to calculate direct and indirect costs of asthma was conducted, using participant data from the Portuguese National Asthma Survey (INAsma). Direct (healthcare service usage, diagnostic tests and treatment) and indirect (absenteeism and transportation) costs were measured. Decision analytic modelling was used to perform multivariate deterministic sensitivity analysis.

RESULTS

On average, each adult costs 708.16€ (95%CI: 594.62-839.30) a year, with direct costs representing 93% (658.46€; 95%CI: 548.99-791.29) and indirect costs representing 7% (49.70€; 95%CI: 32.08-71.56). This amounts to a grand total of 386,197,211.25€ (95%CI: 324,279,674.31-457,716,500.18), with direct costs being 359,093,559.82€ (95%CI: 299,391,930.03-431,533,081.07). Asthma direct costs are 2.04% of the total Portuguese healthcare expense in 2010. The major cost domains were acute care usage (30.7%) and treatment (37.4%). Asthma control was significantly associated with higher costs throughout several domains, most notably in acute medical care.

CONCLUSIONS

Asthma in adults poses a significant economic burden on the Portuguese healthcare system, accounting for over 2% of the total healthcare expenditure in Portugal in 2010. It is important to note that a considerable portion of this burden might be eased by improving asthma control in patients, as uncontrolled patients' costs are more than double those of controlled asthma patients.

Use of the Control of Allergic Rhinitis and Asthma Test (CARATkids) in children and adolescents: Validation in Dutch

BACKGROUND

Allergic rhinitis and asthma are common and closely related diseases. Recently, a Portuguese questionnaire has been developed 'The Control of Allergic Rhinitis and Asthma Test' (CARATkids) that measures disease control of both diseases in children. This study aims to validate the CARATkids in Dutch children and for the first time in adolescents and, in addition, to calculate the minimal clinically important difference (MCID).

METHODS

A prospective observational study was conducted in an outpatient clinic. After translation of the CARATkids from Portuguese to Dutch, patients (6-18 years) with asthma or asthma and allergic rhinitis completed the CARATkids, Asthma Control Test, and visual analog scale questionnaire three times. Baseline characteristics, mean scores, internal consistency, test-retest reliability, cross-sectional and longitudinal validity, discriminative properties, responsiveness, and MCID of the CARATkids were assessed.

RESULTS

A total of 111 patients were included. In total, 86% and 79%, respectively, completed the questionnaires at the second and third visits. All children had asthma, and 85% had concomitant allergic rhinitis. The internal consistency was good with all expected a priori correlations met. CARATkids scores were higher in patients with uncontrolled asthma and patients with moderate-severe rhinitis compared to better controlled subjects. Patients with a variable asthma control had significantly higher scores during periods of uncontrolled asthma. Also the Guyatt's responsiveness index was good. The MCID was 2.8.

CONCLUSIONS

The CARATkids questionnaire is a reliable and valid tool to assess allergic rhinitis and asthma control among Dutch children. The tool can be used in adolescents.

Assessment of asthma control using CARAT in patients with and without Allergic Rhinitis: A pilot study in primary care

BACKGROUND

Asthma and Allergic Rhinitis (AR) are two chronic inflammatory diseases that are often concomitant. The Control of Allergic Rhinitis and Asthma Test (CARAT) was developed to evaluate the control of these diseases from the patients' perspective. Its performance in asthma patients without AR has not been previously studied.

AIM

To test the hypothesis that CARAT can be used to assess asthma control in patients with asthma and without AR.

METHODS

A cross-sectional study was conducted in 3 primary healthcare centres in Northern Portugal. Adult patients identified in the Electronic Patient Record with a diagnosis of asthma were invited to participate. CARAT was used to assess asthma control and Asthma Control Test (ACT) as a comparator. The associations between asthma patients without AR (AsAR) and with AR (AwAR) were analyzed with Spearman correlation. Additionally, Receiver Operating Characteristic (ROC) curve analysis, summarized by Area Under the Curve (AUC), was used to assess performance of CARAT for screening asthma that was not well-controlled.

RESULTS

A total of 103 asthma patients completed the study, 64 (62%) had AwAR and in 87 (85%) asthma was not well-controlled. We observed a strong correlation between CARAT and ACT scores (r=0.734) in all asthma patients and in both groups: AsAR (r=0.737) and AwAR (r=0.843). ROC curve demonstrated CARAT as having a good discriminative power for both AsAR and AwAR groups (AUC=0.894 and 0.946, respectively).

CONCLUSION

These initial results suggest that CARAT has a good discriminative performance, similar to other asthma control assessment tools, for asthma patients with and without AR.

Asthma control and exacerbations in patients with severe asthma treated with omalizumab in Portugal

The analysis of outcomes from patients with severe asthma treated with omalizumab, using real-life prospective data, should contribute to future informed decisions about this treatment in Portugal. The aim of this study was to assess the clinical effect of omalizumab in Portuguese patients with severe persistent allergic asthma, considering specifically asthma control and exacerbations. This was an observational, prospective, multicentre study. Data were collected at routine care over a 12-month period. Disease control was defined by Control of Allergic Rhinitis and Asthma Test (CARAT) global score >24. All asthma patients already under treatment with omalizumab in 7 departments from 6 Portuguese hospitals were included (n=48). Most (77%) patients were female and the mean (SD) age was 51.9 (10.2) years old. During the study period, asthma was controlled in 34% of the visits and the 12-month exacerbation rate was 1.7 per patient (0.6 with unscheduled medical care). One-third of the patients needed unscheduled medical care because of asthma and 29% had to start or increase oral corticosteroid. There was still a 41% reduction in the total sum of oral corticosteroids usage from the first to the last trimester of the study. During routine treatment with omalizumab, Portuguese patients with severe asthma achieved asthma control in 1/3 of the visits and only 1/3 needed unscheduled or Emergency Room care because of asthma exacerbations. These outcomes support the maintenance of the clinical effect during treatment with omalizumab in routine care in Portugal.

Asthma control in the Portuguese National Asthma Survey

INTRODUCTION

We aimed (1) to measure asthma control using a structure-questionnaire and patient self-perception of asthma-control in the Portuguese National Asthma Survey (INAsma) and (2) to study the relationship between asthma control and asthma-related quality of life.

METHODS

We analyze data of asthma patients from a cross-sectional, nationwide telephone interview study - INAsma. Controlled asthma was defined as CARAT global score >24 or CARAT lower airways score ≥16. Mini-AQLQ was used to measure quality of life.

RESULTS

Two hundred and seven (56.9% [95%CI: 51.8-62.0]) of the 364 patients had controlled asthma. Most patients with non-controlled asthma (88%) perceived their disease as controlled. Patients with controlled asthma presented higher mini-AQLQ scores (median, P25-P75; 6.6, 6.0-6.9) than those with non-controlled asthma (4.9, 3.7-5.7) (p<0.001) and a significant positive correlation between CARAT and mini-AQLQ scores was observed (r=0.706; p<0.001).

CONCLUSION

More than half of the Portuguese patients presented controlled asthma and showed significantly better asthma-related quality of life. Almost 9 out of 10 patients with non-controlled disease have poor perception of their asthma control, which may hinder them from seeking better asthma control.

Prevalence of asthma and its association with rhinitis in the elderly

BACKGROUND

Asthma and rhinitis are frequent respiratory diseases in children and adults. Despite the increase in the aging population, there are few epidemiologic data on both diseases in the elderly. So far, no population-based study has analyzed the association between asthma and rhinitis symptoms and severity in this age group. This study aimed to estimate the prevalence of physician-diagnosed asthma in the population aged ≥65 years in mainland Portugal and to evaluate its association with the presence and classification of rhinitis according to ARIA recommendations, in this age group.

METHODS

A cross-sectional, nationwide, population-based survey of individuals aged ≥65 years, living in mainland Portugal was performed.

RESULTS

Data were obtained from 3678 respondents. The prevalence of physician-diagnosed asthma was 10.9% (95% confidence interval (95%CI) 9.9-11.9). The frequency of asthma diagnosis increased with the number of nasal symptoms (p < 0.001). A strong association between asthma and rhinitis was found (odds ratio (OR) 13.86 (95%CI 10.66-18.02)). The strength of this association increased with the persistence and severity of rhinitis, being particularly high in elderly subjects with moderate-severe persistent rhinitis (OR 39.9 (95%CI 27.5-58.0)).

CONCLUSIONS

Asthma is common in the elderly and strongly associated with rhinitis. The OR for asthma is especially high in persistent and severe ARIA classification rhinitis types. This study strengthens the need for an integrated assessment of asthma together with rhinitis in the elderly.

Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with asthma

BACKGROUND AND AIM

The Control of Allergic Rhinitis and Asthma Test (CARAT) was developed to be used in the concurrent management of these diseases, as recommended by the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. However, it was necessary to statistically identify and remove redundant questions and to evaluate the new version's factor structure, internal consistency and concurrent validity.

METHODS

In this cross-sectional study 193 adults with allergic rhinitis and asthma from 15 outpatient clinics in Portugal were included. The CARAT questionnaire was reduced using descriptive analysis, exploratory factor analysis and internal consistency. Spearman's correlations were used to compare the CARAT scores with a medical evaluation and other measures of control, including the Asthma Control Questionnaire and symptoms' visual analogue scales. The performance against physician rating of control was summarized using the area under the curve (AUC) from receiver operating characteristic analysis. In addition, CARAT was compared with the physician's decision to reduce, maintain or increase treatment.

RESULTS

The reduced version has 10 questions and 2 factors (CARAT10). The Cronbach's alpha was 0.85. All correlation coefficients of CARAT10 and factors with the different measures of control met the a priori predictions, ranging from 0.58 to 0.79. The AUC was 0.82. For the physician's decision groups of reduce, maintain or increase treatment, the mean (IC95%) scores of CARAT10 were 24 (21.4;26.6), 21 (19.4;21.9) and 15 (13.6;16.5), respectively.

CONCLUSION

CARAT10 has high internal consistency and good concurrent validity, making it useful to compare groups in clinical studies.

CD4+CD25+Foxp3+ indirect alloreactive T cells from renal transplant patients suppress both the direct and indirect pathways of allorecognition

Alloreactive T cells recognize donor antigens by two routes: direct and indirect pathways of allorecognition. Although the direct pathway is reported to be dominant in allograft rejection, indirect allorecognition also plays an important role. Indirect alloreactivity is also observed in renal transplant patients irrespective of rejection. Previously we showed a predominance of interleukin (IL)-10 induced by indirect allorecognition of donor human leucocyte antigen (HLA)-DR peptides, suggesting the existence of indirect alloreactive T cells displaying regulatory activity. In the present work, our objective was to characterize these regulatory T cells. We detected indirect alloproliferation of peripheral blood mononuclear cells (PBMC) from renal transplant patients, induced by donor HLA-DR peptides, dependent on IL-4 or IL-10, suggesting regulatory activity as part of the alloreactive T-cell repertoire. PBMC-derived indirect alloreactive T-cell lines were established and produced both inflammatory and regulatory cytokines. We showed that two of these T-cell lines which were able to inhibit both direct and indirect alloproliferation of another T-cell line from the same patient presented a CD4(+)CD25(+)Foxp3(+) T-cell population. These data support the idea that indirect alloreactive T cells may also have regulatory activity and may contribute to the maintenance of the human renal allograft.

Cellular autoreactivity against heat shock protein 60 in renal transplant patients: peripheral and graft-infiltrating responses

Autoreactivity to heat shock protein 60 (Hsp60) has been implicated in the pathogenesis and regulation of chronic inflammation, especially in autoimmune diseases. In transplantation, there is a lack of information regarding the cytokine profile and specificity of cells that recognize self-Hsp60 as well as the kinetics of autoreactivity following transplantation. We studied the cellular reactivity of peripheral and graft-infiltrating lymphocytes against Hsp60 in renal transplant patients. Cytokine production induced by this protein in peripheral blood mononuclear cells indicated a predominance of interleukin (IL)-10 during the late post-transplantation period, mainly in response to intermediate and C-terminal peptides. Patients with chronic rejection presented reactivity to Hsp60 with a higher IL-10/interferon (IFN)-gamma ratio compared to long-term clinically stable patients. Graft-infiltrating T cell lines, cocultured with antigen-presenting cells, preferentially produced IL-10 after Hsp60 stimulation. These results suggest that, besides its proinflammatory activity, autoreactivity to Hsp60 in transplantation may also have a regulatory role.

Identifying cyclosporine blood levels associated with the prevention of renal transplant rejection: a single-center, randomized prospective study

Multiple-drug therapy may allow reduced individual drug doses with fewer side effects. Blood levels of cyclosporine (CsA) necessary to avoid rejection may vary with different drug combinations. Fifty-eight kidney transplant patients were randomized into two groups: 25 subjects were assigned to the 4-hour area under the curve (AUC(0-4)) Cohort-the "high arm" (4500 to 5500 ng . h/mL)--1 and 33 to the AUC(0-4) "low arm" (2400 to 3400 ng . h/mL). After CsA introduction, AUC(0-4) was drawn on days 4, 7, 14, 21, 28, 42, 56, 70, 84, 90. We compared the proportion of rejection versus rejection-free patients, according to the CsA exposure. Logistic regression analysis showed that an AUC(0-4) of > or =4000 ng . h/mL or a 2-hour cyclosporine level (C(2)) of > or =1450 ng/mL predicted a rejection-free course among patients not receiving induction therapy. When either basiliximab or thymoglobulin was administered, a C(2) and AUC(0-4) of 1043 +/- 151 ng/mL or 3146 +/- 262 ng . h/mL, respectively, were associated with a rejection-free course. Our findings confirm the need for different CsA levels to prevent rejection according to induction therapy. Induction with either basiliximab or thymoglobulin allows reduced CsA levels during the first 3 months after renal transplantation.

Evaluation of the Asthma Life Quality test for the screening and severity assessment of asthma

BACKGROUND

Asthma Life Quality (ALQ) test, a 20-question questionnaire developed by the American College of Allergy, Asthma and Immunology, has been shown to be useful for asthma diagnosis. We aimed to determine the relation between ALQ scores and (a) diagnosis of asthma; (b) physician's classification of asthma severity according to National Institutes of Health/Global Initiative for Asthma (GINA).

METHODS

Standard translation and cultural adaptation to Portuguese was performed. Patients self-administered the ALQ in the waiting room; the attending allergist classified them, blindly for the test. The scores of nonasthmatics were compared with those of asthma patients. Asthma patients were analyzed in two severity groups: intermittent and mild persistent asthma (IMPA), and moderate and severe persistent asthma (MSPA); sensitivity, specificity, positive and negative predictive values were calculated and receiver operating characteristic curve plotted. Logistic regression analysis models were computed.

RESULTS

From 283 patients, 237 tests were analyzed. Non-asthmatic patients ALQ scores (mean +/- SD) were 6 +/- 4 and, for asthmatics, 10 +/- 5 [mean difference 4.6 (95%CI 3.3-5.9)]. The odds of positive diagnosis increased 1.27 times (95%CI 1.17-1.38) for each one-unit increase in the test. For asthma severity ALQ scores were 9 +/- 4 for IMPA, 15 +/- 3 for MSPA [difference 6.0 (95%CI 4.8-7.1)]; with a sensitivity of 88% and specificity of 74% for a score of 12. The odds of MSPA increased 1.49 times (95%CI 1.28-1.74) per unit increase in ALQ.

CONCLUSIONS

ALQ can help both to identify patients with asthma and to differentiate those more likely to have moderate/severe asthma. These are relevant characteristics for the possible use of this simple, self-administered questionnaire in the assessment of asthma patients needing additional medical management.

T-Cell response to self HSP60 peptides in renal transplant recipients: a regulatory role?

T-cell responses to heat shock proteins (Hsp) have been suggested to play a role not only in inflammatory conditions, but also in various human autoimmune diseases and in the allograft response. Previous data from our group suggested that during the early posttransplantation (post-Tx) period (<6 months post-Tx), the anti-Hsp60 T-cell repertoires in renal transplant recipients were predominantly proinflammatory. In the later period, they were predominantly regulatory. In agreement with our results, diversification of the T-cell responses toward the carboxy-terminal determinants of Hsp60, related to the resolution of the inflammatory process, was shown in an experimental model of adjuvant arthritis. It has not been clarified whether this diversification is also present in transplantation. In this context, our objective was to analyze cytokine production against autologous Hsp60 peptides from different regions of the protein, using peripheral blood mononuclear cells of 9 renal transplant recipients at 2 timepoints after transplantation: early (<6 months) and late (>1 year). IFN gamma production induced by Hsp60 peptides was observed in 71% and 75% of the patients in the early and late post-Tx periods, respectively. Interleukin (IL)-10 production induced by Hsp60 peptides was observed in 28% of the patients in the early period and in 62% in the late period. Interestingly, the production of IL-10 was induced mainly by peptides of the intermediate and the C-terminal regions. This suggests a predominance of autoreactive regulatory anti-Hsp T-cell repertoire in the late post-Tx period, which predominantly recognize peptides from the intermediate and C-terminal regions of the protein.

Predominant IL-10 production in indirect alloreactivity is not associated with rejection

In a prospective study of indirect alloresponse in renal transplantation, we detected proliferation and cytokine production to donor and third-party HLA-DR peptides unrelated to rejection. Twenty of 28 patients (71%) presented proliferation, 29% before and 71% after transplantation. Half of the patients also presented proliferation to third-party peptides. Indirect alloresponse was also detected in 75% of healthy individuals (HI). Variability of response was observed in patients and HI for both proliferation and cytokine production. IL-10 predominance was observed in indirect alloresponses to donor peptides pre- and post-Tx, in contrast with more IFN-gamma and TGF-beta being detected in HI. IL-10 production was frequently detected without proliferation, in contrast with more frequent proliferation being found with IFN-gamma and TGF-beta production. The lack of association of either cytokine or proliferation with rejection, together with the predominance of IL-10 unrelated to proliferation, suggests that regulatory cells may be part of the T cell repertoire involved in indirect alloreactivity.

Renal transplant patients show variations in their self-reactive repertoires: a serial study

We addressed the question of whether allo-transplantation (Tx) induces breakdown of tolerance to self-antigens or alteration of the autoreactive T cell repertoire in humans. The serial variation of T cell autoreactivity was studied in the peripheral blood of 12 renal transplant patients, by autologous limiting dilution assay and autologous mixed lymphocyte reaction. Ten of 12 patients presented a positive response in autologous peripheral blood mononuclear cells in the post-Tx period, in contrast to four of 12 patients before Tx (P = 0.038). Multi-hit kinetics was found in 57% of the assays analyzed, indicating frequent regulatory control of the autologous response. Quantitative analysis performed in eight patients showed an increase in precursor frequency at >1 year post-Tx in five patients. These data indicate that autoreactivity increases or develops following Tx, in humans. Post-Tx events such as alloreactivity, infections or immunosuppression could interfere with the balance of autoreactive and regulatory cells, leading to changes in the T cell repertoires to self-antigens and eventually breakdown of self-tolerance. Further investigation is needed to elucidate whether post-Tx autoreactivity contributes to rejection, plays a regulatory role over alloreactivity or both, at separate times.

Evidence of indirect allorecognition in long-term human renal transplantation

The purpose of this study was to investigate indirect alloreactivity in the peripheral blood of long-term renal transplanted patients. We evaluated the T cell proliferative response to a whole pool of donor cell-derived allopeptides, processed and presented by host antigen-presenting cells (APC), rather than to synthetic peptides. For the indirect pathway, proliferation assays were performed using APC-depleted donor cells. Indirect alloreactivity was detected in 57% (8/14) of the patients, 6 of whom presented no evidence of rejection, but 2 patients had a diagnosis of chronic rejection. In 4 of 8 positive cases (50%), proliferation was detected with 5 days of culture, and sometimes indirect alloresponse was the dominant route. We present evidence that the indirect alloproliferative response to a pool of naturally processed donor peptides is present in the peripheral blood of long-term renal transplanted patients irrespective of rejection.

[The influence of socio-economic conditions in renal posttransplant infection]

Two hundred and four patients who underwent renal transplantation were followed up as outpatients with a minimum of four years. They were divided into two socio-economic levels: group I - 104 patients who underwent transplantation in a private hospital and 120 patients (group II) with a lower socio-economic standard, treated in a public hospital. In both groups urinary infections and hepatitis were excluded. The incidence of infection in group I was 24% and in group II, 50% (p = 0.0002). There was no difference in relation to viral infection in either groups. However, bacterial infection and infection by opportunistic agents were significantly higher in group II (p = 0.0001 and p = 0.0282). The number of hospitalizations and the number of infections of patients were higher in group II. There was a tendency for an increase in mortality owing to infection in group II. There was no difference in the two groups as the parameters of: age, sex, type of donor, primary disease, number of rejections crises, level of serum creatinine and number of patients with ciclosporine. On the other hand, the dose of azathioprine and prednisone was mildly higher in those patients of group II. Low level of socio-economic conditions is a risk factor in renal transplant patients.

[Cyclosporin A: experience of the Renal Transplant Unit of the Clinical Hospital of the Medical College of the University of Sao Paulo]

The authors report their experience using cyclosporine-A (CsA) in renal transplant patients. When compared with azathioprine/prednisone, CsA contributed significantly to a better graft and patient survival, either if used associated with prednisone of with azathioprine plus prednisone. CsA was also used in substitution to azathioprine in patients with hepatopathy attributed to azathioprine toxicity. The initial results are promising. The association of CsA and azathioprine with corticosteroids withdrawal was used as an attempt to allow normal growth in children. This seems to be the best choice of treatment for children. Careful monitoring of CsA blood levels avoids, or at least, minimizes nephrotoxicity. To achieve therapeutic CsA levels, patients with liver damage need lower, while children need higher oral CsA doses. To summarise: when CsA in carefully used, it is an excellent immunosuppressive drug.

The natural history of diabetic nephropathy in type I diabetes and the role of metabolic control in its prevention, reversibility and clinical course

The authors present a contemporary picture of the pathogenesis and clinical course of diabetic nephropathy in type I diabetics describing the stages of the disease and the possible evidence for reversibility of the kidney damage with tight metabolic control. During the so-called latency period, which is clinically non-detectable, the predominant functional abnormalities (increase in GFR with sub-clinical glomerular proteinuria) can be corrected by strict control although there is no evidence for the regression of the associated anatomical changes such as the enlarged filtration area. As for the described increase in thickness of the glomerular basement membrane, from experimental data and pancreatic transplants in man, delay in its development and to some extent regression of the glomerular lesions can be expected. The problem of how the renal lesions in experimental diabetes mirror the changes in the human kidney is discussed. During the symptomatic period, with intermittent and subsequently constant proteinuria and progressive decline in renal function, which are observed in only about 30% of type I diabetics, the role of arterial hypertension and its effective control is emphasized. Finally, the renal failure period is indicative of irreversible damage to the kidneys. The progression from its early to its late stages is variable between different patients but each individual patient shows a constant rate of deterioration. The evidence for the efficacy of medical treatment in slowing down its progression is very limited at present but much can be done to improve the quality of life by dietary measures, treatment of fluid overload and hypertension. When the end-stage diabetic kidney disease is reached, with serum creatinine above 8 mg/dl, renal transplantation from a living donor offers a good chance for a relatively acceptable quality of life for years. In conclusion, it is stressed that the morbidity of diabetic nephropathy could eventually be reduced through effective control of the metabolic abnormalities of diabetes with the methods presently available.