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.

Abstract PR05: A genetic variant at 6q25 associated with estrogen receptor-negative breast cancer subtypes in Peruvian breast cancer patients

Background: We have previously identified a genetic variant, rs140068132, which has a strong protective effect on breast cancer risk. This variant is located near the estrogen receptor 1 gene (ESR1) on chromosome 6q25, a locus which has been repeatedly implicated in breast cancer risk. Women who carry two copies of the protective variant (GG) have 60-70% reduction in risk of developing breast cancer compared to women with none. The G variant has relatively high frequency in Latin American women (up to 23% in the 1000 Genomes Project Peruvians); it is only common in people of Indigenous American ancestry and almost absent in all other populations. We investigated whether the rs140068132-A/G polymorphism is associated with a specific breast cancer subtype among Peruvian women with breast cancer.

Methods: Blood samples and clinical data were collected from 441 women with breast cancer at the Instituto Nacional de Enfermedades Neoplasicas in Lima, Peru. Genotypic profiles were generated using the Affymetrix Precision Medicine Research Array. Four major breast cancer subtypes were identified based on immunohistochemical markers (luminal A, luminal B, triple-negative, and human epidermal growth factor receptor 2 (HER2) overexpressing). Quality control of the genotyped data was performed in PLINK. Genetic ancestry was determined for each individual using ADMIXTURE. ANOVAs were performed on the proportion of genetic ancestry and disease subtype. PLINK was used to perform a binary logistic regression on the rs140068132 variant and ER status (ER-negative versus-ER positive), with age and genetic ancestry as covariates.

Results: The breast cancer patients analyzed have the following average ancestry proportions: 77.3% Indigenous American, 17.4% European, 3.8% African and 1.5% East Asian. The frequency of the G allele in the Peruvian breast cancer patients is 14% (compared to 23% in healthy individuals from the 1000 Genomes Project). We found that the G allele of rs140068132 was associated with ER-negative status among cases (OR = 0.6443, P = 0.086) for both HER2 overexpressing and triple-negative. We also examined the proportions of ancestry in relation to subtypes of disease. The proportion of Indigenous American ancestry was associated with the HER2 overexpressing subtype (P = 0.06), with an average Indigenous American ancestry among these patients of 83.1% compared to 77.3% among all patients. The proportion of African ancestry was higher in women with the triple-negative subtype, with an average African ancestry of 4.8% among patients with the triple-negative subtype compared to a 3.8% average among all patients, but this trend was not statistically significant (P = 0.21).

Conclusions: The lower frequency of the variant in Peruvian breast cancer cases is consistent with a protective effect in this population. We have confirmed that the protective effect of the rs140068132 variant is stronger for ER-negative subtypes. Additional analyses are under way in a larger sample of Peruvian breast cancer patients.

This abstract is also being presented as Poster C051.

Citation Format: K.M. Marker, T. Vidaurre, L.I. Tamayo, J.N. Vásquez, R. Meza Florez, S. Casavilca, M. Calderon, J.E. Abugattas, H.L. Gómez, H.A. Fuentes, C.L. Monge Pimentel, S. Song, D. Cherry, S. Huntsman, D. Hu, E. Ziv, L. Fejerman. A genetic variant at 6q25 associated with estrogen receptor-negative breast cancer subtypes in Peruvian breast cancer patients [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR05.

Abstract B080: Assessment of the molecular mechanisms of a protective variant for breast cancer in Latinas

The incidence of breast cancer is lower in women of Latin American origin in the U.S. compared to European American and African American women. Among Latinas, the rs140068132A>G variant, which is common in women with IAA, has been associated to a lower risk of breast cancer. The frequency of the G allele is 0% for non-Latinos while 12% in Latinos, being highest in the Peruvian population (23%). This variant is located on chromosome 6 near the Estrogen Receptor 1 gene (ESR1) and even though experimental evidence suggests that this variant might be functional, the molecular mechanisms that explain its protective effect are unknown. We hypothesize that the rs140068132-G variant decreases ESR1 expression, which affects the expression or function of genes involved in associated pathways. We aim to test the association of the rs140068132 variant and gene expression in breast cancer tumors from patients with high IAA. We collected 47 breast tumors and blood samples from the Instituto Nacional de Enfermedades Neoplásicas in Lima, Peru. These patients were genotyped for IAA estimation and determination of the rs140068132 genotype. Total RNA was extracted from tumor samples and used for a paired-end sequencing (2 × 75bp paired-end,100 million reads per sample) in the Illumina NextSeq500. Differential gene expression between genotypes was performed by DEseq2 R package and statistical significance was determined using FDR<0.05 for samples with at least log2 1.5-fold change. Differentially expressed isoforms were detected by EBseq R package using FDR<0.05. Tumor intrinsic subtypes were obtained using PAM50 as implemented in the genefu R package. The average IAA for the 47 Peruvian patients was 77% (SD=0.17). Twenty-seven patients were homozygous AA, 19 heterozygous AG and 1 GG for the rs140068132 variant. According to PAM50 classification, 10 tumors were Luminal A, 12 Luminal B, 15 HER2+ and 10 Basal. Among luminal tumors there was a suggestive trend towards lower expression of the ESR1 gene in patients carrying the protective allele (p=0.16). Including all subtypes, 27 genes were differentially expressed according to the rs140068132 genotype. Four of these genes are ER dependent or associated with ER status. The expression of the top gene, which is a transcriptional target of ER, is lost in patients with the protective allele. This association is mainly driven by its expression in luminal tumors and remained significant after adjusting for IAA. ESR1 isoforms were not differentially expressed by genotype, however significant differences were detected in the expression of isoforms for 115 genes, of which 18% have been reported to be transcriptional targets of ER or functionally related. Our preliminary results suggest that the rs140068132 variant decreases ER expression and affects the expression of functionally associated genes in luminal tumors. Further allele-specific expression analysis will elucidate if this variant is part of a cis-regulatory module.

Note: This abstract was not presented at the conference.

Citation Format: Valentina A. Zavala, Tatiana Vidaurre, Katie Marker, Sandro Casavilca, Lizeth Tamayo, Carlos Castañeda, Jeannie Vásquez, Fernando Valencia, Zaida Morante, M. Calderon, J. Abugattas, H. Gomez, H. Fuentes, C. Monge-Pimentel, Silvia Neciosup, Jovanny Zabaleta, Laura Fejerman. Assessment of the molecular mechanisms of a protective variant for breast cancer in Latinas [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B080.

Abstract 1589: Breast cancer subtype GWAS in Peruvian breast cancer patients

Background: We previously investigated genetic ancestry associations with breast cancer subtypes in Peruvian women. We found that women with human epidermal growth factor receptor 2 (HER2) over-expressing tumors had higher Indigenous American ancestry than women with other subtypes. We found a suggestive association between African ancestry and triple negative breast cancer (TNBC). We hypothesized that these associations could be due to the presence of germline variants in the Indigenous American genome or the African genome predisposing women to HER2 over-expression or TNBC respectively. We conducted genome wide association analyses to explore this hypothesis.

Methods: Blood samples and clinical data were collected from 1195 women with breast cancer at the Instituto Nacional de Enfermedades Neoplasicas in Lima, Peru. Genotypic profiles for 821 women were generated using the Affymetrix Precision Medicine Research Array. Four major breast cancer subtypes were identified using immunohistochemical markers (luminal A, luminal B, triple negative, and HER2 over-expressing). Genetic ancestry was determined using ADMIXTURE. Genome wide association analyses were conducted in PLINK.

Results: Three polymorphisms with the lowest p values in the TNBC GWAS are of interest. A variant, rs16910137, at 10q26, is located in an intron of the Glutaredoxin 3 gene (GLRX3 or TXNL2, OR = 2.45, P = 8.60*10-07). The protein encoded by this gene may inhibit apoptosis and play a role in cellular growth. It has also been described as a biomarker for TNBC. Our own RNA-seq data for TXNL2 in 52 Colombian women with breast cancer showed that the expression level of this gene is higher in women with triple negative (N=9) compared to luminal tumors (N=43) (P=0.06). The other two variants, rs12327440 and rs13381183, are located in an intron of the Mitogen-Activated Protein Kinase 4 (MAPK4) gene at 18q21 (OR = 0.44 and 1.94 respectively, P = 4.92*10-07 and 7.230*10-06). RNA-seq data for MAPK4 suggestively showed that the expression level is higher in women with TNBC compared to luminal tumors (P=0.18). The variant in the HER2 over-expressing GWAS with the lowest p value, rs11594103, at 10p11 is located upstream of the Enhancer Of Polycomb Homolog 1 (EPC1) gene (OR = 2.38, P = 8.03*10-07). The encoded protein has been linked to apoptosis and DNA repair among other functions and suggested as involved in the activation of metastasis.

Conclusions: Our data suggests that a germline variant within the GLRX3/TXNL2 gene might be associated with the risk of developing TNBC compared to other subtypes. This is particularly interesting in the light that previous work suggested that TXNL2 autoantibodies could be biomarker of TNBC. The MAPK4 and EPC1 genes have been previously implicated in multiple types of cancer and our results indicate that they may play a role in the etiology of specific breast cancer subtypes. This supports the importance of conducting genetic association studies in diverse samples.

Citation Format: Katie M. Marker, Tatiana Vidaurre, Jeannie Navarro Vasquez, Valentina Zavala, Silvia Serrano Gomez, Lizeth Tamayo, Renzo Meza Florez, S Casavilca, M Calderon, JE Abugattas, Henry Gómez, Hugo Fuentes, CL Monge Pimentel, Sikai Song, Daniel Cherry, Scott Huntsman, Donglei Hu, Elad Ziv, Laura Fejerman. Breast cancer subtype GWAS in Peruvian breast cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1589.

Abstract 4184: Tumor and risk factor characteristics among breast cancer patients from different geographic regions in Peru

There are few Latin American cohorts with available biospecimens that include women of high Indigenous American ancestry. The Peruvian population is characterized by a high degree of Native American (NA) ancestry, with this ancestral component varying between 56 to 100% on average, depending on the region. We have collected 1199 Peruvian samples from the Instituto Nacional de Enfermedades Neoplasicas in Lima. This cohort of patients represents a unique opportunity to study the molecular characteristics of breast cancer in the NA genetic and genomic background. Here we present a basic description of the women in the study and a comparison of tumor subtypes distribution and risk factor information of the patients by place of birth and residence.

We explored differences in tumor subtype distribution and risk factors in relation to place of birth or residence in the three main geographical region of Peru. To test differences in proportions we used Chi2 or Fisher-exact tests. To test differences in means for continuous variables we used ANOVA or t-tests. Genetic ancestry was estimated using genome wide genotypes and the program ADMIXTURE. Tumor subtypes were defined using the following criteria: ER+/PR+/HER2- as luminal A, ER+/PR+/HER2+ as luminal B, ER-/PR-/HER2+ as HER2+ and ER-/PR-/HER2- as triple negative.

Overall, the patients included in the study were relatively young (50 yrs, SD=11.0). The average number of full-term pregnancies was 3 (SD=1.8), the average age at first pregnancy 22 (SD=5.7) and age at menarche was 13 (SD=1.8). The tumor subtype distribution was 31% of Luminal B tumors, 24% luminal A, 12% HER2 and 12% triple negative and did not differ by place of birth or residence. We found that patients from the Coastal region were heavier and taller than those born in the Andean region (p<0.005). Women born in the Coastal region had the lowest age at menarche and a lower number of full-term pregnancies (p<0.0001). Similar trends were observed when we compared women by place of residence. Patients born in Lima, the Capital of Peru, smoke more (p<0.05), were heavier, had lower age at menarche, lower number of full term pregnancies and were diagnosed at a younger age, compared to women born outside the city (p<0.05). The distribution of NA genetic ancestry also varied by place of birth: patients born outside Lima had higher proportion of NA ancestry (78% SD=0.15 vs. 74%, SD=0.18, p<0.05).

The distribution of tumor subtypes among women in the Peruvian breast cancer cohort did not differ by place of birth or residence. However, we found that for some breast cancer risk factors, exposures differed between women from different regions. Finally, given the relatively low observed values for reproductive and lifestyle related exposures and the high proportion of Indigenous American ancestry of Peruvian women, this cohort is likely to be particularly informative to study genetic predisposition to breast cancer.

Citation Format: Valentina Zavala, Tatiana Vidaurre, Katie Marker, Jeannie Vásquez, L Tamayo, Renzo Florez, Sandro Casavilca, M Calderon, J Abugattas, H Gómez, H Fuentes, C Monge-Pimentel, S Song, D Cherry, Laura Fejerman. Tumor and risk factor characteristics among breast cancer patients from different geographic regions in Peru [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4184.

Allergen immunotherapy for allergic rhinoconjunctivitis: A systematic review and meta-analysis

BACKGROUND

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. To inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost-effectiveness, and safety of AIT in the management of allergic rhinoconjunctivitis.

METHODS

We searched nine international biomedical databases for published, in-progress, and unpublished evidence. Studies were independently screened by two reviewers against predefined eligibility criteria and critically appraised using established instruments. Our primary outcomes of interest were symptom, medication, and combined symptom and medication scores. Secondary outcomes of interest included cost-effectiveness and safety. Data were descriptively summarized and then quantitatively synthesized using random-effects meta-analyses.

RESULTS

We identified 5960 studies of which 160 studies satisfied our eligibility criteria. There was a substantial body of evidence demonstrating significant reductions in standardized mean differences (SMD) of symptom (SMD -0.53, 95% CI -0.63, -0.42), medication (SMD -0.37, 95% CI -0.49, -0.26), and combined symptom and medication (SMD -0.49, 95% CI -0.69, -0.30) scores while on treatment that were robust to prespecified sensitivity analyses. There was in comparison a more modest body of evidence on effectiveness post-discontinuation of AIT, suggesting a benefit in relation to symptom scores.

CONCLUSIONS

AIT is effective in improving symptom, medication, and combined symptom and medication scores in patients with allergic rhinoconjunctivitis while on treatment, and there is some evidence suggesting that these benefits are maintained in relation to symptom scores after discontinuation of therapy.

Are allergic multimorbidities and IgE polysensitization associated with the persistence or re-occurrence of foetal type 2 signalling? The MeDALL hypothesis

Allergic diseases [asthma, rhinitis and atopic dermatitis (AD)] are complex. They are associated with allergen-specific IgE and nonallergic mechanisms that may coexist in the same patient. In addition, these diseases tend to cluster and patients present concomitant or consecutive diseases (multimorbidity). IgE sensitization should be considered as a quantitative trait. Important clinical and immunological differences exist between mono- and polysensitized subjects. Multimorbidities of allergic diseases share common causal mechanisms that are only partly IgE-mediated. Persistence of allergic diseases over time is associated with multimorbidity and/or IgE polysensitization. The importance of the family history of allergy may decrease with age. This review puts forward the hypothesis that allergic multimorbidities and IgE polysensitization are associated and related to the persistence or re-occurrence of foetal type 2 signalling. Asthma, rhinitis and AD are manifestations of a common systemic immune imbalance (mesodermal origin) with specific patterns of remodelling (ectodermal or endodermal origin). This study proposes a new classification of IgE-mediated allergic diseases that allows the definition of novel phenotypes to (i) better understand genetic and epigenetic mechanisms, (ii) better stratify allergic preschool children for prognosis and (iii) propose novel strategies of treatment and prevention.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Systematic reviews of sublingual immunotherapy (SLIT)

Allergic rhinitis is common worldwide, with significant morbidity and impact on quality of life. In patients who don't respond adequately to anti-allergic drugs. Subcutaneous allergen immunotherapy is effective although requires specialist administration. Sublingual immunotherapy may represent an effective and safer alternative. This Cochrane systematic review is an update of one published in 2003. We searched Cochrane ENT Group Trials Register, Central, PubMed, EMBASE, CINAHL, Web of Science, Biosis Previews, Cambridge Scientific Abstarcts, mRCT and additional sources. We included randomised, double-blind, placebo- controlled trials of sublingual immunotherapy in adults and children. Two authors selected studies and assessed them for quality. Data were put into RevMan 5.0 for a statistical analysis. We used standardised mean difference (SMD), with a random effect model to combine data. Sixty studies were included, with 49 suitable for meta-analysis. We found significant reductions in symptoms (SMD -0.49; 95%CI (-0.64 to -0.34, P < 0.00001)) and medication requirements (SMD -0.32; 95%CI (-0.43 to -0.21, P < 0.00001)) compared with placebo. None of the trials reported severe systemic reactions, anaphylaxis or use of Adrenaline. This updated review reinforces the conclusion of the original 2003 Cochrane Review that sublingual immunotherapy is effective for allergic rhinitis and appears a safe route of administration.

Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Sustained effect of SQ-standardized grass allergy immunotherapy tablet on rhinoconjunctivitis quality of life

BACKGROUND

The prevalence of allergic rhinoconjunctivitis has increased significantly over the past decades with grass pollen being a common trigger. The impact of allergy on patient's quality of life is substantial.

AIM

To investigate the sustained effect on quality of life during the grass pollen season 1 year after 3 years of treatment with the SQ-standardized grass allergy immunotherapy tablet (AIT), Graza (Phleum pratense 75,000 SQ-T/2800 BAU; ALK, Denmark).

METHODS

The trial was a randomized, parallel-group, double-blind, placebo-controlled trial in adult subjects with a history of moderate-severe grass pollen induced rhinoconjunctivitis inadequately controlled by symptomatic medications. Subjects received 3 years of grass AIT (n = 157) or placebo (n = 126), followed by 1 year of follow-up. Quality of life assessments were based on the standardized rhinoconjunctivitis quality of life questionnaire (RQLQ(S)); completed weekly during the entire grass pollen season.

RESULTS

During follow-up, the overall RQLQ(S) score for the entire grass pollen season was significantly improved in the active group (relative difference to placebo: 23%, P = 0.004). The improvement was higher during the peak pollen season (28%, P = 0.001). The treatment effect of grass AIT during the follow-up year and the previous three treatment years was similar. Improvements were found in all seven RQLQ(S) domains. The RQLQ(S) as a function of the weekly average pollen counts showed a clear separation between the treatment groups (P < 0.001).

CONCLUSION

In subjects inadequately controlled by symptomatic medications, grass AIT provided sustained and clinically relevant improvements in rhinoconjunctivitis quality of life compared to placebo. The effect increased with increasing grass pollen exposure.

Towards evidence-based medicine in specific grass pollen immunotherapy

When initiating grass pollen immunotherapy for seasonal allergic rhinoconjunctivitis, specialist physicians in many European countries must choose between modalities of differing pharmaceutical and regulatory status. We applied an evidence-based medicine (EBM) approach to commercially available subcutaneous and sublingual Gramineae grass pollen immunotherapies (SCIT and SLIT) by evaluating study design, populations, pollen seasons, treatment doses and durations, efficacy, quality of life, safety and compliance. After searching MEDLINE, Embase and the Cochrane Library up until January 2009, we identified 33 randomized, double-blind, placebo-controlled trials (including seven paediatric trials) with a total of 440 specific immunotherapy (SIT)-treated subjects in seven trials (0 paediatric) for SCIT with natural pollen extracts, 168 in three trials (0 paediatric) for SCIT with allergoids, 906 in 16 trials (five paediatric) for natural extract SLIT drops, 41 in two trials (one paediatric) for allergoid SLIT tablets and 1605 in five trials (two paediatric) for natural extract SLIT tablets. Trial design and quality varied significantly within and between SIT modalities. The multinational, rigorous trials of natural extract SLIT tablets correspond to a high level of evidence in adult and paediatric populations. The limited amount of published data on allergoids prevented us from judging the level of evidence for this modality.

The CONSORT statement checklist in allergen-specific immunotherapy: a GA2LEN paper

The methodology of randomized clinical trials is essential for the critical assessment and registration of therapeutic interventions. The CONSORT (Consolidated Standards of Reporting Trials) statement was developed to alleviate the problems arising from the inadequate reporting of randomized controlled trials. The present article reflects on the items that we believe should be included in the CONSORT checklist in the context of conducting and reporting trials in allergen-specific immunotherapy. Only randomized, blinded (in particular blinding of patients, health care providers, and outcome assessors), placebo-controlled Phase III studies in this article. Our analysis focuses on the definition of patients' inclusion and exclusion criteria, allergen standardization, primary, secondary and exploratory outcomes, reporting of adverse events and analysis.

Hemodynamic performance in-vivo of a new ventricular assist device

Nowadays, circulatory support has become a common practice in medicine and a standard in the treatments of Cardio Vascular Disease (CVD). A new Pneumatic Ventricular Assist Device (VAD) has been developed in México City. This paper shows the first results of acute in-vivo trials, intended to verify the new system for providing physiological flows and pressures. Two VADs were implanted to as right (RVAD), left (LVAD) support in a 65 kg pig. The support time was 20 minutes with RVAD, 20 minutes with LVAD and 20 minutes with Biventricular (BiVAD). The VAD proved its capability to maintain physiological parameters during the support time. We are satisfied with the results of this trial, and we believe this study will ascertain the first step on the next phase of invivo trials.

Use of a reliable PCR assay for the detection of Neisseria gonorrhoeae in Peruvian patients

Neisseria gonorrhoeae is the most common sexually transmitted disease-causing bacterium worldwide. An in-house PCR assay targeting the carbamoyl-phosphate synthase subunit A (carA) gene was developed for the specific detection of N. gonorrhoeae in clinical specimens. Samples from 605 patients were cultured on selective medium and assayed by PCR in a double-blind fashion. Of 605 urethral/cervical samples analysed, 13 were PCR-positive, of which 11 were culture-positive. The PCR showed a sensitivity and specificity of 100% and 99.7% with these samples. PCR targeting the carA gene appears to be a reliable method for the detection of N. gonorrhoeae in clinical specimens.

Fermentation by Lactobacillus fermentum Ogi E1 of different combinations of carbohydrates occurring naturally in cereals: consequences on growth energetics and alpha-amylase production

Glucose, fructose, sucrose and starch are naturally present in cereals. Fermentation of different combinations of these carbohydrates by Lactobacillus fermentum Ogi E1, a sourdough heterofermentative lactobacillus, was investigated to determine effects on fermentation kinetics, growth energetics and alpha-amylase production. Irrespective of the substrate combination, the strain was able to simultaneously produce alpha-amylase and consume starch, glucose, fructose and sucrose. In mixtures of starch with either sucrose or fructose or with both fructose and glucose, yields of alpha-amylase from biomass (Y(amy/x)) were similar to those observed for starch. However, for starch and glucose or starch, glucose, fructose and sucrose mixtures, both Y(amy/x) and the specific rate of alpha-amylase production decreased markedly. In fructose- or sucrose-containing mixtures, mannitol was formed stoichiometrically indicating that fructose served as electron acceptor, and acetate was produced at constant yield from biomass (Y(ac/x)) (1 g acetate g biomass(-1)). Acetate production was expected to confer to the strain a competitive advantage during natural fermentation by improving biomass formation and growth through an increase in the ATP gain. Y(ATP) varied depending on the carbohydrate mixture, indicating different effects of substrate mixtures on the efficiency in ATP coupling to biomass formation. Compared to starch fermentation, the highest value of Y(ATP) (29 g biomass mol ATP(-1)) was estimated for the starch/fructose mixture but no increase in mu(max) was observed. The lowest value (16 g biomass mol ATP(-1)) was obtained for the starch, glucose and fructose mixture, whereas for the mixture of all carbohydrates, Y(ATP) was similar to that obtained with starch alone (20 g biomass mol ATP(-1)) and it was intermediary for the starch and sucrose mixture (17 g biomass mol ATP(-1)). It is concluded that competitiveness of the strain cannot be based on expected energy gain in mixed substrate fermentation involving fructose and sucrose with glucose and starch, but rather on its ability to simultaneously use carbohydrates while producing alpha-amylase and to produce acetic acid. Acetic acid production could enhance the strain capacity to inhibit nonacid-tolerant, competitive microflora at the earlier stage of natural fermentation.

Nutritional requirements and simplified cultivation medium to study growth and energetics of a sourdough lactic acid bacterium Lactobacillus fermentum Ogi E1 during heterolactic fermentation of starch

AIMS

Nutritional requirements of Lactobacillus fermentum Ogi E1 were studied in order to define a simplified fermentation medium.

METHODS AND RESULTS

When grown with MRS-medium in 2l bioreactors, a biphasic pattern of growth and metabolite production was observed. Study of nutritional requirements resulted in a simplified medium (SYAM) that allowed, under anaerobiosis, similar results to be obtained as in MRS medium, but without biphasic fermentation kinetics. The best substrates for both growth and amylase production were starch and maltose. Although melibiose, raffinose, fructose, sucrose and glucose also supported growth, lower amylase activity was observed.

CONCLUSION

The physiology of the strain can be investigated with SYAM medium, using either starch or maltose as substrate. The strain also presented potential for alpha-galactoside fermentation.

SIGNIFICANCE AND IMPACT OF THE STUDY

Lactobacillus fermentum was one of the dominant bacteria of African maize dough fermentations. Amylolytic strains with activity against other compounds (i.e. raffinose) suggested a potential to be used as starter for cereal fermentation.

Screening for sexually transmitted diseases in human immunodeficiency virus-positive patients in Peru reveals an absence of Chlamydia trachomatis and identifies Trichomonas vaginalis in pharyngeal specimens

To determine the prevalence of sexually transmitted diseases (STDs), we screened 107 human immunodeficiency virus-positive patients in Peru, where the virus is predominantly sexually transmitted. Patients had multiple risk factors for STDs, and 38% of women and 50% of men had at least 1 STD (gonorrhea, trichomoniasis, herpes simplex, anogenital warts, or syphilis seropositivity). No chlamydial infection was detected, even though infection rates in the general population are 5%-12%. Patients receiving trimethoprim-sulfamethoxazole(TMP-SMZ) for prophylaxis or treatment of respiratory infections were least likely to have cervicitis and/or urethritis (odds ratio, 0.37; 95% confidence interval, 0.15-0.89). Although not optimal treatment, administration of TMP-SMZ is effective against chlamydial infection. We speculate that the use of concomitant medications, such as TMP-SMZ, may be inadvertently preventing chlamydial infection in this population. Another finding was the presence of Trichomonas vaginalis in pharyngeal specimens of 3 men with histories of orogenital activity. This has not been previously reported and requires further study.

Sexually transmitted diseases in a family planning and an antenatal clinic in Peru: limitations of current practices and analysis of the use of potential markers, pH testing, and Whiff testing

BACKGROUND

Little data exist on sexually transmitted diseases (STDs), including HIV, in family planning and antenatal clinics in Peru.

GOAL

To evaluate (1) the prevalence of infection, (2) associated factors, (3) current clinical practices, and (4) the sensitivity of whiff and pH testing for STDs.

STUDY DESIGN

A study of 363 women from an antenatal (n = 259) and a family planning (n = 104) clinic in central Lima, Peru that included oral histories and physical examinations. Samples were collected for laboratory diagnosis of common STDs, including HIV.

RESULTS

Overall, 10.8% of antenatal clinic patients and 15.4% of family planning clinic patients had an STD, but no HIV infection was found. The diagnostic sensitivity of health providers was low, especially for cervical infections (sensitivity, 0%). In addition, few factors were associated with cervical infections or trichomoniasis. In the family planning clinic, pH testing was 100% sensitive for trichomoniasis and bacterial vaginosis. In both clinics, whiff testing was 84% sensitive and 47% specific for trichomoniasis and 88% sensitive and 53% specific for bacterial vaginosis.

CONCLUSION

The burden of STDs was high and the sensitivity of current diagnostic practices was low. These results point to the need for simple diagnostic tools. Whiff and pH testing was found potentially useful for the diagnosis of vaginal infections. These simple tests should be implemented as screening tools.

Effect of pH control on lactic acid fermentation of starch by Lactobacillus manihotivorans LMG 18010T

Lactic acid fermentation of starch by Lactobacillus manihotivorans LMG 18010T, a new amylolytic L(+) lactic acid producer, was investigated and compared with starch fermentation by Lact. plantarum A6. At non-controlled pH, growth and lactic acid production from starch by Lact. manihotivorans LMG 18010T lasted 25 h. Specific growth and lactic acid production rates continuously decreased from the onset of the fermentation, unlike Lact. plantarum A6 which was able to grow and convert starch product hydrolysis into lactic acid more rapidly and efficiently at a constant rate up to pH 4.5. In spite of complete and rapid starch hydrolysis by Lact. manihotivorans LMG 18010T during the first 6 h, only 45% of starch hydrolysis products were converted to lactic acid. When pH was maintained at 6.0, lactic acid, amylase and final biomass production by Lact. manihotivorans LMG 18010T increased markedly and the fermentation time was reduced by half. Under the same conditions, an increase only in amylase production was observed with Lact. plantarum A6. When grown on glucose or starch at pH 6.0, Lact. manihotivorans LMG 18010T had an identical maximum specific growth rate (0.35 h(-1)), whereas the maximum rate of specific lactic acid production was three times higher with glucose as substrate. Lactobacillus manihotivorans LMG 18010T did not produce amylase when grown on glucose. Based on the differences in the physiology between the two species and other amylolytic lactic acid bacteria, different applications may be expected.

Group B streptococcal colonization in a developing country: its association with sexually transmitted disease and socioeconomic factors

Group B Streptococcus (GBS) is an important infectious organism in pregnant women and their neonates. Although excellent data are available from the developing world, little epidemiologic information is available from Latin America. To evaluate the prevalence of GBS colonization in a developing country, a prospective study was performed in Lima, Peru. We found a relatively low prevalence of GBS colonization of 6.0% in parturient women and 10.6% in nonpregnant women. No association of GBS colonization was made with previously identified risk factors such as age, parity, or birth control practices. We did find a positive association between GBS colonization and chlamydial carriage (P < 0.05). We also report an even distribution of GBS serotypes: Ia/c = 35%, IIc = 18%, III = 29%, and V = 18%. Our study provides evidence for a low prevalence of GBS maternal carriage in this urban Latin American population.

The effect of nedocromil sodium on human airway epithelial cell-induced eosinophil chemotaxis and adherence to human endothelial cell in vitro

Although some studies have shown that long-term treatment of asthmatics with nedocromil sodium can reduce airway hyperresponsiveness and improve symptoms and lung function, the mechanisms underlying its effects are not well understood. We have investigated the effect of nedocromil sodium on eosinophil chemotaxis, eosinophil adherence to human endothelial cells and release of soluble intercellular adhesion molecule-1 (sICAM-1) from endothelial cells, induced by conditioned medium collected from cultured human bronchial epithelial cells. Conditioned medium significantly increased eosinophil chemotaxis from a baseline median value of 2.1 (range 1.9-4.5) cells-high power field(-1) (HPF) to 10.5 (range 7.8-12.3) cells-HPF(-1) (p<0.05). Similarly, conditioned medium significantly increased eosinophil adherence to endothelial cells from a baseline value of 9 (range 8-12)% to 23 (range 21-30)% (p<0.05). Nedocromil sodium, at 10(-5) M concentration, significantly attenuated the eosinophil chemotaxis and adherence induced by conditioned medium. Conditioned medium also significantly increased the release of sICAM-1 from endothelial cells, from a baseline value of 11.5 (range 8.1-15.4) pg x microg(-1) protein to 67.6 (range 55.6-73.5) pg x microg(-1) protein (p<0.05). This was significantly attenuated by anti-tumour necrosis factor-alpha (TNF-alpha), anti-interleukin-1beta (IL-1beta) and 10(-5) M nedocromil sodium. These findings suggest that human bronchial epithelial cell-derived mediators may potentiate eosinophil activity, and that this can be modulated by nedocromil sodium, suggesting a possible mechanism underlying its anti-inflammatory effect.

The effect of nedocromil sodium on human airway epithelial cell-induced eosinophil chemotaxis and adherence to human endothelial cell in vitro

Although some studies have shown that long-term treatment of asthmatics with nedocromil sodium can reduce airway hyperresponsiveness and improve symptoms and lung function, the mechanisms underlying its effects are not well understood. We have investigated the effect of nedocromil sodium on eosinophil chemotaxis, eosinophil adherence to human endothelial cells and release of soluble intercellular adhesion molecule-1 (sICAM-1) from endothelial cells, induced by conditioned medium collected from cultured human bronchial epithelial cells. Conditioned medium significantly increased eosinophil chemotaxis from a baseline median value of 2.1 (range 1.9-4.5) cells-high power field(-1) (HPF) to 10.5 (range 7.8-12.3) cells-HPF(-1) (p<0.05). Similarly, conditioned medium significantly increased eosinophil adherence to endothelial cells from a baseline value of 9 (range 8-12)% to 23 (range 21-30)% (p<0.05). Nedocromil sodium, at 10(-5) M concentration, significantly attenuated the eosinophil chemotaxis and adherence induced by conditioned medium. Conditioned medium also significantly increased the release of sICAM-1 from endothelial cells, from a baseline value of 11.5 (range 8.1-15.4) pg x microg(-1) protein to 67.6 (range 55.6-73.5) pg x microg(-1) protein (p<0.05). This was significantly attenuated by anti-tumour necrosis factor-alpha (TNF-alpha), anti-interleukin-1beta (IL-1beta) and 10(-5) M nedocromil sodium. These findings suggest that human bronchial epithelial cell-derived mediators may potentiate eosinophil activity, and that this can be modulated by nedocromil sodium, suggesting a possible mechanism underlying its anti-inflammatory effect.

Active surveillance for Vibrio cholerae O1 and vibriophages in sewage water as a potential tool to predict cholera outbreaks

The 1991 Peruvian cholera epidemic has thus far been responsible for 600,000 cholera cases in Peru. In an attempt to design a cholera surveillance program in the capital city of Lima, weekly sewage samples were collected between August 1993 and May 1996 and examined for the presence of Vibrio cholerae O1 bacteria and V. cholerae O1 bacteriophages (i.e., vibriophages). During the 144 weeks of surveillance, 6,323 cases of clinically defined cholera were recorded in Lima. We arbitrarily defined an outbreak as five or more reported cases of cholera in a week. The odds of having an outbreak were 7.6 times greater when V. cholerae O1 was present in sewage water during the four previous weeks compared with when it was not (P < 0.001). Furthermore, the odds of having an outbreak increased as the number of V. cholerae O1 isolations during the previous 4 weeks increased (P < 0.001). The odds of having an outbreak were 2.4 times greater when vibriophages were present in sewage water during the four previous weeks compared with when they were not, but this increase was not statistically significant (P = 0.15). The odds of having an outbreak increased as the number of vibriophage isolations during the previous 4 weeks increased (P < 0.05). The signaling of a potential cholera outbreak 1 month in advance may be a valuable tool for implementation of preventive measures. In Peru, active surveillance for V. cholerae O1 and possibly vibriophages in sewage water appears to be a feasible and effective means of predicting and outbreak of cholera.

Colchicine decreases the infection by Toxoplasma gondii in cultured glial cells

Addition of colchicine (2.5 x 10(-8)-1.25 x 10(-6) M) to cultures of glial cells infected with Toxoplasma gondii decreased the number of parasites up to 80% (P < 0.05) in comparison with controls. Our results indicate that colchicine could interfere with the infectious, or replicative mechanisms, or both, of Toxoplasma and place it as a candidate in the search for additional antitoxoplasmic therapy for those cases where the parasitic load is massive. Further studies in vivo must be made to confirm this finding and provide support for therapeutic trials.

Increased proliferation in keloid fibroblasts wounded in vitro

A keloid is a pathological overgrowth of scar expanding beyond the boundaries of the initiating skin wound. Ultimately, this expansive scar is a result of excess collagen synthesized by fibroblasts within the wound. The processes that lead to this collagen excess remain unknown. An in vitro wound model was developed to test the hypothesis that fibroblasts isolated from keloid tissue and wounded in vitro might proliferate more rapidly that similarly wounded normal dermal fibroblasts. Keloid fibroblasts (KF) and normal human dermal fibroblasts (NDF) were grown to confluence and quiescence in flexible-bottomed culture plates. Wounds were created in a standardized fashion using a specially designed jig. The jig utilized a 25 gauge needle to reproducibly ablate 16-20% of cells from confluent cell sheets. Wounded and nonwounded cells were labeled with 3H-thymidine at 24, 48, 72 and 96 hr postwounding to measure DNA synthesis. Wounded KF and NDF demonstrated increased 3H-thymidine incorporation compared to nonwounded control cultures, and wounded KF demonstrated significantly higher levels of 3H-thymidine incorporation than wounded NDF both 24 and 48 hr after wounding. A similar trend was seen in cell counts. The wounded KF also showed a statistically greater labeling index quantitated by autoradiography than did wounded NDF. The increased commitment to DNA synthesis in response to wounding in vitro in keloid fibroblasts correlates with pathology seen in vivo. Keloid fibroblasts may have a lower inherent threshold for S phase entry than do normal fibroblasts contributing to the increased proliferation of keloid fibroblasts in response to wounding in vitro.

The effect of conditioned medium from cultured human bronchial epithelial cells on eosinophil and neutrophil chemotaxis and adherence in vitro

Several studies have demonstrated that bronchial epithelial cells are capable of synthesizing proinflammatory cytokines that may influence eosinophil and neutrophil activity. We have cultured human bronchial epithelial cells to confluence, as explant cultures, and investigated the effect of conditioned medium from these cells on (1) the chemotaxis of eosinophils and neutrophils and (2) the adherence of these cells to cultured human endothelial cells. Analysis of cytokines, namely interleukin-1 beta (IL-1 beta), interleukin-8 (IL-8), tumor necrosis factor alpha (TNF alpha), granulocyte/macrophage colony-stimulating factor (GM-CSF), and RANTES, which are thought to be involved in these processes, demonstrated that all these cytokines were synthesized and released constitutively from the bronchial epithelial cell cultures. Conditioned medium obtained after 24 h of incubation significantly increased the chemotaxis of eosinophils and neutrophils, from median values of 4.0 cells/per high power field (hpf) (range, 3.0 to 7.0) and 17 cells/hpf (range, 13.0 to 25.0), respectively, for medium 199, to median values of 11.0 cells/hpf (range, 9 to 12; P = 0.005) and 30 cells/hpf (range, 19 to 33; p = 0.01). Whereas anti-GM-CSF and anti-IL-8 neutralizing monoclonal antibodies significantly attenuated the conditioned medium-induced chemotaxis of eosinophils and neutrophils, anti-RANTES neutralizing antibody significantly attenuated the chemotaxis of only eosinophils. Conditioned medium also significantly increased the percentage of eosinophils and neutrophils adhering to endothelial cells in a dose-dependent manner. Both anti-human TNF alpha and anti-human IL-1 beta neutralizing antibodies significantly attenuated the conditioned medium-induced adherence of eosinophils and neutrophils to the endothelial cells and were found to have an additive effect when studied together. Similarly, treatment of endothelial cells with either anti-ICAM-1 or anti-E-selectin, for 1 h before co-culture with eosinophils and neutrophils, significantly attenuated the conditioned medium-induced adherence of both eosinophils and neutrophils to endothelial cells. Treatment of endothelial cells with anti-VCAM-1 attenuated the adherence of eosinophils but not neutrophils. These results suggest that human bronchial epithelial cells, through their ability to generate proinflammatory mediators, are likely to play a role in the pathogenesis of airway disease by influencing chemotaxis and adherence of eosinophils and neutrophils.

Long-term results of the surgical management of symptomatic chronic intestinal ischemia

We analyzed our surgical experience in 20 patients who underwent revascularization procedures for symptomatic chronic intestinal ischemia caused by atherosclerosis. The group comprised 17 women and 3 men, with an age range of 25 to 71 years (mean 58.6 years). Sixteen patients had postprandial abdominal pain, and 4 had pain not related to eating. The average weight loss was 23.8 lb. Malabsorption and diarrhea were present in 8 patients. The duration of the symptoms was from 4 to 46 months (mean 13.4 months). One patient presented with acute intestinal ischemia following balloon angioplasty reocclusion of a stenotic celiac artery, and 3 underwent surgery for stenosis of a previously placed graft. Five patients had single mesenteric artery involvement, 10 had double-artery involvement, and 5 had significant occlusion in all 3 mesenteric arteries. The major arteries were revascularized whenever technically possible; therefore, 36 arteries were revascularized in 20 patients. Bypass grafts were done in 27 vessels, reimplantation in 7, and endarterectomy with patch angioplasty in 2. The saphenous vein was used in 12 vessels, polytetrafluoroethylene grafts in 8, dacron in 6, and inferior mesenteric vein in 1. The type of revascularization or graft utilized did not affect long-term patency. Two patients had early graft thrombosis and required intestinal resection. All patients survived the operation. At a mean follow-up of 36 months, all 20 patients were alive and asymptomatic with regard to their abdominal complaint. Ten patients (50%) underwent postoperative abdominal angiography; all the grafts were patent.(ABSTRACT TRUNCATED AT 250 WORDS)

Coarctation repair in neonates with subclavian-sparing advancement flap

A modification of the technique of using the subclavian-sparing advancement flap for severe coarctation of the aorta was successfully used in 7 neonates ranging in age from 3 to 30 days (mean age, 12 days). Four of the 7 patients had associated cardiac defects with congestive heart failure. The procedure was performed through a left thoracotomy incision, and the coarctation repair was performed by advancing the origin of the left subclavian artery as a flap while preserving flow to the left arm. No deaths occurred, and there was patency of the repair in all patients at follow-up ranging from 1 1/2 to 2 1/4 years (mean, 2 years). In 7 of the 8 patients there was no clinically significant gradient either by examination or Doppler echocardiography at follow-up. One patient underwent balloon angioplasty at the time of catheterization to evaluate other cardiac defects 1 year postoperatively, at which time he was noted to have a peak systolic gradient of 30 mm Hg across the repair site. The technique of subclavian-sparing advancement is a reasonable addition to the surgical armamentarium for coarctation repair in neonates. It provides the advantages of subclavian flap aortoplasty without sacrificing the blood supply to the left arm. Because of the unique anatomic variations associated with coarctation of the aorta, we suggest that the choice of repair be individualized for patients with this condition.

Innominate artery occlusive disease: surgical approach and long-term results

We reviewed our experience with 54 patients who underwent innominate artery revascularization during a 10-year period. Their age range was from 16 to 75 years (mean, 49.8 years). The innominate artery alone was involved in 21 patients (39%); the remaining patients had additional arch vessel obstructions. Before operation, neurologic symptoms occurred in 25 patients (46%), arm ischemia related to claudication and microembolization occurred in 8 patients (14%), a combination of symptoms occurred in 17 patients (32%), and no symptoms were noted in 4 patients (8%). The extrathoracic approach to surgery was used in 16 patients (30%). Eleven of the 38 patients in whom the intrathoracic approach was used had endarterectomy of the innominate artery; in three of those, the procedure was combined with left common carotid endarterectomy. Bypass grafts were used in the other 27 patients undergoing procedures with an intrathoracic approach; in six of those, bypass was combined with carotid endarterectomy. No operative deaths occurred. Perioperative revascularization failure occurred in four cases; all of those patients underwent a second revascularization procedure, with a secondary patency rate of 100%. In four patients, late occlusion was noted at 6 months and at 1, 1.5, and 10 years. One patient had a permanent perioperative neurologic deficit in the distribution of the left carotid artery after a combined common carotid endarterectomy/innominate endarterectomy procedure. No neurologic deficits were directly related to the innominate artery territory. Long-term actuarial survival was 83% at 10 years. Early and late graft failures were related to inadequate inflow in bypass grafts, progression of distal disease in arteritis, and primary closure in endarterectomy.