WHAT YOU SHOULD HAVE READ BUT….2010 <ul><li>rhinitis </li></ul>University of Verona, Italy Attilio Boner
<ul><li>Rhinitis general considerations </li></ul>
<ul><li>Rhinitis  prevalence </li></ul><ul><li>and risk factors </li></ul>
5.1  μ g Foods 1.4  μ g  Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhini...
1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vita...
1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vita...
1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vita...
1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vita...
Asthma-free survival among 5-year-old children according to maternal vitamin D intake from food (Kaplan–Meier estimates). ...
Asthma-free survival among 5-year-old children according to maternal vitamin D intake from food (Kaplan–Meier estimates). ...
1.11 HR in children  1.04 Maternal asthma during  pregnancy Maternal Asthma, its Control and Severity in Pregnancy and the...
1.11 HR in children  1.04 Maternal asthma during  pregnancy Maternal Asthma, its Control and Severity in Pregnancy and the...
1.11 HR in children  1.04 Maternal asthma during  pregnancy Maternal Asthma, its Control and Severity in Pregnancy and the...
<ul><li>Rhinitis  etiopathogenesis </li></ul>
Caveolar transport through nasal epithelium of birch pollen allergen Bet v 1 in allergic patients Joenv ää r ä   JACI 2009...
Caveolar transport through nasal epithelium of birch pollen allergen Bet v 1 in allergic patients Joenv ää r ä   JACI 2009...
Caveolar transport through nasal epithelium of birch pollen allergen Bet v 1 in allergic patients Joenv ää r ä   JACI 2009...
+85 +18 +18 Parietaria Olive   Cypress Possible role of climate changes in variations in pollen seasons and allergic sensi...
<ul><li>Pollen counts </li></ul><ul><li>Season duration </li></ul><ul><li>Prevalences of sensitizations for  5 major polle...
<ul><li>Pollen counts </li></ul><ul><li>Season duration </li></ul><ul><li>Prevalences of sensitizations for  5 major polle...
+85 +18 +18 Parietaria Olive   Cypress Possible role of climate changes in variations in pollen seasons and allergic sensi...
Start date (day of the year from January 1) of the pollen seasons of the 5 plants throughout the study years. Possible rol...
Possible role of climate changes in variations in pollen seasons and allergic sensitizations during 27 years  Ariano  Ann ...
<ul><li>6726 children with a mean age of 10 years </li></ul>% children sensitized Alternaria sensitization and allergic rh...
40 – 30 – 20 – 10 – 0 In sensitized children % with past-year rhinoconjunctivitis ever hay fever 27.7% OR=2.34 27.0% OR=2....
Alternaria sensitization and allergic rhinitis with or without asthma in the French Six Cities study Z. A. Randriamanantan...
<ul><li>Rhinitis  diagnosis </li></ul><ul><li>Differential diagnosis </li></ul>
Objective assessments of allergic and nonallergic rhinitis in young children .  Chawes   Allergy 2009:64:1547  Acoustic rh...
Objective assessments of allergic and nonallergic rhinitis in young children .  Chawes   Allergy 2009:64:1547  Decongested...
Objective assessments of allergic and nonallergic rhinitis in young children .  Chawes   Allergy 2009:64:1547  Decongested...
Objective assessments of allergic and nonallergic rhinitis in young children .  Chawes   Allergy 2009:64:1547  <ul><li>255...
Objective assessments of allergic and nonallergic rhinitis in young children .  Chawes   Allergy 2009:64:1547  <ul><li>Nas...
Objective assessments of allergic and nonallergic rhinitis in young children .  Chawes   Allergy 2009:64:1547  Nasal eosin...
<ul><li>Rhinitis burden </li></ul>
Sleep disturbance in persistent allergic rhinitis measured using actigraphy  Rimmer   Ann Allergy Asthma Immunol  2009;103...
Sleep disturbance in persistent allergic rhinitis measured using actigraphy  Rimmer   Ann Allergy Asthma Immunol  2009;103...
Sleep disturbance in persistent allergic rhinitis measured using actigraphy  Rimmer   Ann Allergy Asthma Immunol  2009;103...
Sleep actigraphy evidence of improved sleep  after treatment of allergic rhinitis  Yuksel  Ann Allergy Asthma Immunol  200...
Sleep actigraphy evidence of improved sleep  after treatment of allergic rhinitis  Yuksel  Ann Allergy Asthma Immunol  200...
Sleep actigraphy evidence of improved sleep  after treatment of allergic rhinitis  Yuksel  Ann Allergy Asthma Immunol  200...
Background:  Although allergic rhinitis (AR) is accepted as a risk factor for obstructive sleep  apnea syndrome (OSAS), th...
<ul><li>48 adults with AR and NAR. </li></ul><ul><li>Epworth Sleepiness Scale and 36-Item Short Form Health Survey.  </li>...
Allergic and nonallergic rhinitis:  the threat for obstructive sleep apnea   Kalpaklıoglu   Ann Allergy Asthma Immunol  20...
Allergic and nonallergic rhinitis:  the threat for obstructive sleep apnea   Kalpaklıoglu   Ann Allergy Asthma Immunol  20...
Allergic and nonallergic rhinitis:  the threat for obstructive sleep apnea   Kalpaklıoglu   Ann Allergy Asthma Immunol  20...
Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer   JACI 2009;124:S43  COMMON TR...
Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer   JACI 2009;124:S43  <ul><li>A...
Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer   JACI 2009;124:S43  Parent's ...
Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer   JACI 2009;124:S43  EFFECT OF...
Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer   JACI 2009;124:S43  B A REASO...
Rhinitis and asthma
<ul><li>The ‘‘united airway disease hypothesis’’ proposes that upper and lower airway diseases are both manifestations of ...
<ul><li>A managed care study that included children with asthma and co-morbid rhinitis, showed that treatment directed at ...
<ul><li>The nasal and bronchial mucosa have some evident similarities such as a pseudostratified epithelium and the presen...
<ul><li>Epithelial cells are crucially situated at the external–internal milieu interface and will perform most of the act...
( a ) Nasal and ( b ) bronchial biopsies obtained from the same patient with mild asthma showing CD8 T lymphocyte immunore...
Association of childhood perennial allergic rhinitis with subclinical airflow limitation   Ciprandi,   CEA 2010;40:398 <ul...
Association of childhood perennial allergic rhinitis with subclinical airflow limitation   Ciprandi,   CEA 2010;40:398 <ul...
Association of childhood perennial allergic rhinitis with subclinical airflow limitation   Ciprandi,   CEA 2010;40:398 <ul...
Association of childhood perennial allergic rhinitis with subclinical airflow limitation   Ciprandi,   CEA 2010;40:398
Impact of allergic rhinitis on asthma in children: effects on bronchodilation test  Capasso  Allergy 2010:65:264   <ul><li...
Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso  Allergy 2010:65:264   <ul><li>...
Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso  Allergy 2010:65:264   <ul><li>...
Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso  Allergy 2010:65:264   <ul><li>...
Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso  Allergy 2010:65:264   <ul><li>...
<ul><li>Sinusite </li></ul><ul><li>Otite </li></ul>
Effectiveness of Amoxicillin/Clavulanate Potassium in the Treatment of Acute Bacterial Sinusitis in Children  Wald  Pediat...
<ul><li>POLIPOSI NASALE </li></ul>
<ul><li>Rhinitis  treatment general considerations </li></ul>
Background:   Allergic rhinitis is common, but a validated tool for comprehensive assessment of disease control is not ava...
<ul><li>410 patients with allergic rhinitis. </li></ul><ul><li>Total Nasal Symptom Score (TNSS) assessment and the 26-item...
<ul><li>410 patients with allergic rhinitis. </li></ul><ul><li>Total Nasal Symptom Score (TNSS) assessment and the 26-item...
<ul><li>410 patients with allergic rhinitis. </li></ul><ul><li>Total Nasal Symptom Score (TNSS) assessment and the 26-item...
Median % changes from baseline for total nasal symptom score for  SAR 0  -10 – -20 – -30 – -40 – -22.2% -23.5% -40.7% -15%...
Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for ...
Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for ...
<ul><li>Rhinitis  treatment  anti-histamines </li></ul>
<ul><li>First-generation H1-antihistamines , all of which are sedating, are generally regarded as safe by laypersons and h...
<ul><li>First-generation H1-antihistamines , all of which are sedating, are generally regarded as safe by laypersons and h...
<ul><li>First-generation H1-antihistamines , all of which are sedating, are generally regarded as safe by laypersons and h...
Risk of first-generation H1-antihistamines: a GA2LEN position paper   M. K. Church,   Allergy 2010;65;459 The penetration ...
Risk of first-generation H1-antihistamines: a GA2LEN position paper   M. K. Church,   Allergy 2010;65;459 Sleep/wake cycle...
Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines  d...
Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines  d...
Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines  d...
Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines  d...
Evaluation of desloratadine on conjunctival allergen challenge-induced ocular symptoms   Torkildsen  CEA  2010;39:1052  <u...
Mean change from baseline  in eyelid swelling.  Mean change from baseline  in tearing score.  Evaluation of desloratadine ...
Desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis   Holmberg   Allergy ...
Mean weekly changes vs placebo in  nasal congestion (A), total nasal symptoms (B) and rhinorrhea (C).  Desloratadine relie...
Mean improvement from baseline in total  Rhinoconjunctivitis Quality of Life Questionnaire   scores  and individual domain...
Efficacy of desloratadine in intermittent allergic rhinitis: a GA 2 LEN study  Bousquet  Allergy 2009:64:1516  Evolution o...
Evolution symptom severity by VAS (B)  *P ≤ 0.018  Efficacy of desloratadine in intermittent allergic rhinitis: a GA 2 LEN...
Evolution symptom severity by VAS (B)  *P ≤ 0.018  Efficacy of desloratadine in intermittent allergic rhinitis: a GA 2 LEN...
<ul><li>Rhinitis  treatment nasal corticosteroids </li></ul>
<ul><li>Double-blind, placebo-controlled, crossover experiment in  20 subjects with seasonal allergic rhinitis.  </li></ul...
Fluticasone furoate nasal spray reduces the nasal-ocular reflex: A mechanism for the efficacy of topical steroids in contr...
Fluticasone furoate nasal spray reduces the nasal-ocular reflex: A mechanism for the efficacy of topical steroids in contr...
<ul><li>25 patients with asthma and persistent allergic rhinitis  </li></ul><ul><li>2 weeks treatment </li></ul>Steroid sp...
Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis  A. Nair,   Allergy 2010;65;355 Comp...
Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis  A. Nair,   Allergy 2010;65;355 Comp...
Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis  A. Nair,   Allergy 2010;65;355 Comp...
Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis  A. Nair,   Allergy 2010;65;355 Comp...
Dissolution in nasal fluid, retention and anti-inflammatory activity of fluticasone furoate in human nasal tissue ex vivo ...
The highest retention in nasal tissue  was observed for FF,  followed by FP>MF>Bud>TCA 183 1 p<0.0005 P=0.001 Relationship...
The highest retention in nasal tissue  was observed for FF,  followed by FP>MF>Bud>TCA 183 1 p<0.0005 P=0.001 Relationship...
HPA axis safety of fluticasone furoate nasal spray once daily in children with perennial allergic rhinitis Tripathy   Pedi...
HPA axis safety of fluticasone furoate nasal spray once daily in children with perennial allergic rhinitis Tripathy   Pedi...
<ul><li>Rhinitis  treatment montelukast </li></ul>
Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma  Fagnano  Pediatrics 2009;124:218 <ul><li>194 ...
Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma  Fagnano  Pediatrics 2009;124:218 <ul><li>194 ...
Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma  Fagnano  Pediatrics 2009;124:218 <ul><li>194 ...
Frequent nocturnal awakening in early life is associated with nonatopic asthma in children   Kozyrskyj   ERJ 2009:34:1288 ...
Frequent nocturnal awakening in early life is associated with nonatopic asthma in children   Kozyrskyj   ERJ 2009:34:1288 ...
<ul><li>While shorter duration of sleep has been linked to hyperactivity disorders and obesity in children, to the best of...
Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood   Kaditis   Pediatric Pulmonology ...
Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood   Kaditis   Pediatric Pulmonology ...
Prevalence of obstructive sleep apnea–hypopnea in severe versus moderate asthma Julien   JACI 2009;124:371  <ul><li>Overni...
Prevalence of obstructive sleep apnea–hypopnea in severe versus moderate asthma Julien   JACI 2009;124:371  <ul><li>Overni...
Urine Concentrations of Cysteinyl Leukotrienes in Children With Obstructive Sleep-Disordered  Breathing (SDB)  Kaditis Che...
Urine Concentrations of Cysteinyl Leukotrienes in Children With Obstructive Sleep-Disordered  Breathing (SDB)  Kaditis Che...
Urine Concentrations of Cysteinyl Leukotrienes in Children With Obstructive Sleep-Disordered  Breathing (SDB)  Kaditis Che...
Increased urinary leukotriene E 4  excretion in obstructive sleep apnea: Effects of obesity and hypoxia Stanke-Labesque   ...
Increased urinary leukotriene E 4  excretion in obstructive sleep apnea: Effects of obesity and hypoxia Stanke-Labesque   ...
<ul><li>Rhinitis  other  </li></ul><ul><li>Treatments </li></ul><ul><li>ITS  </li></ul>
<ul><li>conjunctivitis </li></ul><ul><li>vernal conjunctivitis </li></ul>
sinusite
Criteria To Screen for Chronic Sinonasal Disease   Dixon CHEST 2009; 136:1324 Background:  Sinusitis  and  rhinitis  are a...
<ul><li>59 participants were evaluated  </li></ul><ul><li>(42 participants with chronic sinonasal disease,  </li></ul><ul>...
OVER THE LAST 3 MONTHS HOW OFTEN, ON AVERAGE,  DID YOU HAVE THE FOLLOWING SYMPTOMS? Scoring: Never (0), 1-4 times per mont...
OVER THE LAST 3 MONTHS HOW OFTEN, ON AVERAGE,  DID YOU HAVE THE FOLLOWING SYMPTOMS? Scoring: Never (0), 1-4 times per mont...
OVER THE LAST 3 MONTHS HOW OFTEN, ON AVERAGE,  DID YOU HAVE THE FOLLOWING SYMPTOMS? Scoring: Never (0), 1-4 times per mont...
Take home <ul><li>Il difetto di vitamina D durante la gravidanza è un fattore di rischio per lo sviluppo di rinite allergi...
TAKE HOME INFORMATIONS
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Rhinitis

  1. 1. WHAT YOU SHOULD HAVE READ BUT….2010 <ul><li>rhinitis </li></ul>University of Verona, Italy Attilio Boner
  2. 2. <ul><li>Rhinitis general considerations </li></ul>
  3. 3. <ul><li>Rhinitis prevalence </li></ul><ul><li>and risk factors </li></ul>
  4. 4. 5.1 μ g Foods 1.4 μ g Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Erkkola CEA 2010;39:875 Mean maternal daily intake of vitamin D ( μ g) Supplements 6.0 – 5.0 – 4.0 – 3.0 – 2.0 – 1.0 – 0 <ul><li>Population-based birth cohort (n=1669). </li></ul><ul><li>Followed at 5 years. </li></ul><ul><li>Food-frequency questionnaire. </li></ul>From
  5. 5. 1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Erkkola CEA 2010;39:875 <ul><li>Population-based birth cohort (n=1669). </li></ul><ul><li>Followed at 5 years. </li></ul><ul><li>Food-frequency questionnaire. </li></ul>
  6. 6. 1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Erkkola CEA 2010;39:875 <ul><li>Population-based birth cohort (n=1669). </li></ul><ul><li>Followed at 5 years. </li></ul><ul><li>Food-frequency questionnaire. </li></ul>Only 32% of the women were taking vitamin D supplements.
  7. 7. 1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Erkkola CEA 2010;39:875 <ul><li>Population-based birth cohort (n=1669). </li></ul><ul><li>Followed at 5 years. </li></ul><ul><li>Food-frequency questionnaire. </li></ul>Vitamin D supplements alone were not associated with any outcome.
  8. 8. 1.0 – 0.5 – 0 0.80 asthma 0.85 allergic rhinitis In mother with higher intake of vitamin D from foods OR for Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Erkkola CEA 2010;39:875 <ul><li>Population-based birth cohort (n=1669). </li></ul><ul><li>Followed at 5 years. </li></ul><ul><li>Food-frequency questionnaire. </li></ul>Maternal vitamin D intake from foods during pregnancy may be negatively associated with risk of asthma and AR in childhood.
  9. 9. Asthma-free survival among 5-year-old children according to maternal vitamin D intake from food (Kaplan–Meier estimates). Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Erkkola CEA 2010;39:875 <ul><li>Population-based birth cohort (n=1669). </li></ul><ul><li>Followed at 5 years. </li></ul><ul><li>Food-frequency questionnaire. </li></ul>The recommended dietary allowance of vitamin D during pregnancy is 10 μg (400 IU) per day.
  10. 10. Asthma-free survival among 5-year-old children according to maternal vitamin D intake from food (Kaplan–Meier estimates). Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Erkkola CEA 2010;39:875 <ul><li>Population-based birth cohort (n=1669). </li></ul><ul><li>Followed at 5 years. </li></ul><ul><li>Food-frequency questionnaire. </li></ul>Several studies have indicated that doses exceeding 25 μg (1000 IU) per day during pregnancy and lactation are required to achieve a robust normal concentration of circulating 25 (OH)D.
  11. 11. 1.11 HR in children 1.04 Maternal asthma during pregnancy Maternal Asthma, its Control and Severity in Pregnancy and the Incidence of Atopic Dermatitis and Allergic Rhinitis in the Offspring M Martel, J Ped 2009;155:707 <ul><li>26.265 singletons born to mothers with and without asthma </li></ul>2 – 1 – 0 atopic dermatitis allergic rhinitis
  12. 12. 1.11 HR in children 1.04 Maternal asthma during pregnancy Maternal Asthma, its Control and Severity in Pregnancy and the Incidence of Atopic Dermatitis and Allergic Rhinitis in the Offspring M Martel, J Ped 2009;155:707 <ul><li>26.265 singletons born to mothers with and without asthma </li></ul>2 – 1 – 0 atopic dermatitis allergic rhinitis Maternal AR and intranasal corticosteroid use during pregnancy increased the risk of childhood AR by 70% and 45%
  13. 13. 1.11 HR in children 1.04 Maternal asthma during pregnancy Maternal Asthma, its Control and Severity in Pregnancy and the Incidence of Atopic Dermatitis and Allergic Rhinitis in the Offspring M Martel, J Ped 2009;155:707 <ul><li>26.265 singletons born to mothers with and without asthma </li></ul>2 – 1 – 0 atopic dermatitis allergic rhinitis Children of mothers with asthma or AR during pregnancy should be closely monitored to diagnose and treat AD and AR as early as possible
  14. 14. <ul><li>Rhinitis etiopathogenesis </li></ul>
  15. 15. Caveolar transport through nasal epithelium of birch pollen allergen Bet v 1 in allergic patients Joenv ää r ä JACI 2009;124:135 <ul><li>Nasal epithelial cells and biopsy specimens from patients with birch allergy and healthy control subjects in the resting state and after intranasal in vivo birch pollen challenges. </li></ul><ul><li>Immunohistochemistry, immunotransmission electron microscopy, mass spectrometry, transcriptomics. </li></ul>Bet v 1 allergen bound to epithelium immediately after in vivo birch pollen challenge during winter only in allergic individuals. It also travelled through epithelium with caveolae to mast cells.
  16. 16. Caveolar transport through nasal epithelium of birch pollen allergen Bet v 1 in allergic patients Joenv ää r ä JACI 2009;124:135 Often the clusters of Bet v 1 were located in the vicinity of desmosomes. After 1 minute of nasal birch pollen challenge, most of the gold label in immuno-EM was on the epithelial surface.
  17. 17. Caveolar transport through nasal epithelium of birch pollen allergen Bet v 1 in allergic patients Joenv ää r ä JACI 2009;124:135 More than 500 individual photograph frames to show the cross-section of the entire pseudostratified epithelium with underlying mast cells.
  18. 18. +85 +18 +18 Parietaria Olive Cypress Possible role of climate changes in variations in pollen seasons and allergic sensitizations during 27 years Ariano Ann Allergy Asthma Immunol. 2010;104:215–222. <ul><li>Pollen counts </li></ul><ul><li>Season duration </li></ul><ul><li>Prevalences of sensitizations for 5 major pollens (birch, cypress, olive, grass, Parietaria ) </li></ul>90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 There was a progressive increase in the duration of the pollen seasons (days) for
  19. 19. <ul><li>Pollen counts </li></ul><ul><li>Season duration </li></ul><ul><li>Prevalences of sensitizations for 5 major pollens (birch, cypress, olive, grass, Parietaria ) </li></ul>+85 +18 +18 Parietaria Olive Cypress Possible role of climate changes in variations in pollen seasons and allergic sensitizations during 27 years Ariano Ann Allergy Asthma Immunol. 2010;104:215–222. 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 There was a progressive increase in the duration of the pollen seasons (days) for With an overall advance of their start dates.
  20. 20. <ul><li>Pollen counts </li></ul><ul><li>Season duration </li></ul><ul><li>Prevalences of sensitizations for 5 major pollens (birch, cypress, olive, grass, Parietaria ) </li></ul>+85 +18 +18 Parietaria Olive Cypress Possible role of climate changes in variations in pollen seasons and allergic sensitizations during 27 years Ariano Ann Allergy Asthma Immunol. 2010;104:215–222. 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 There was a progressive increase in the duration of the pollen seasons (days) for The total pollen load progressively increased (approximately 25% on average)
  21. 21. +85 +18 +18 Parietaria Olive Cypress Possible role of climate changes in variations in pollen seasons and allergic sensitizations during 27 years Ariano Ann Allergy Asthma Immunol. 2010;104:215–222. <ul><li>Pollen counts </li></ul><ul><li>Season duration </li></ul><ul><li>Prevalences of sensitizations for 5 major pollens (birch, cypress, olive, grass, Parietaria ) </li></ul>90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 There was a progressive increase in the duration of the pollen seasons (days) for These behaviors paralleled the constant increase in direct radiation, temperature, and number of days with a temperature greater than 30°C.
  22. 22. Start date (day of the year from January 1) of the pollen seasons of the 5 plants throughout the study years. Possible role of climate changes in variations in pollen seasons and allergic sensitizations during 27 years Ariano Ann Allergy Asthma Immunol. 2010;104:215–222. <ul><li>Pollen counts </li></ul><ul><li>Season duration </li></ul><ul><li>Prevalences of sensitizations for 5 major pollens (birch, cypress, olive, grass, Parietaria ) </li></ul>
  23. 23. Possible role of climate changes in variations in pollen seasons and allergic sensitizations during 27 years Ariano Ann Allergy Asthma Immunol. 2010;104:215–222. Parietaria Linear trend lines are shown in red. % of sensitized patients Total pollen count Duration of the pollen season
  24. 24. <ul><li>6726 children with a mean age of 10 years </li></ul>% children sensitized Alternaria sensitization and allergic rhinitis with or without asthma in the French Six Cities study Z. A. Randriamanantany, Allergy 2010;65;368 ALTERNARIA 3 – 2 – 1 – 0 2.8% 0.8% also to only to
  25. 25. 40 – 30 – 20 – 10 – 0 In sensitized children % with past-year rhinoconjunctivitis ever hay fever 27.7% OR=2.34 27.0% OR=2.40 30.4% OR=2.95 ever allergic rhinitis caused by allergens other than pollens Alternaria sensitization and allergic rhinitis with or without asthma in the French Six Cities study Z. A. Randriamanantany, Allergy 2010;65;368
  26. 26. Alternaria sensitization and allergic rhinitis with or without asthma in the French Six Cities study Z. A. Randriamanantany, Allergy 2010;65;368 40 – 30 – 20 – 10 – 0 Insensitized children % with past-year rhinoconjunctivitis ever hay fever 27.7% OR=2.34 27.0% OR=2.40 30.4% OR=2.95 ever allergic rhinitis caused by allergens other than pollens we found a link between Alternaria sensitization and allergic rhinitis , independently of asthma, which is compatible with the mechanisms of deposition of Alternaria in the upper airways
  27. 27. <ul><li>Rhinitis diagnosis </li></ul><ul><li>Differential diagnosis </li></ul>
  28. 28. Objective assessments of allergic and nonallergic rhinitis in young children . Chawes Allergy 2009:64:1547 Acoustic rhinometry before and after decongestion with local α-agonist. <ul><li>255 children at 6 years of age. </li></ul><ul><li>Nasal airway patency by acoustic rhinometry before and after decongestion . </li></ul>
  29. 29. Objective assessments of allergic and nonallergic rhinitis in young children . Chawes Allergy 2009:64:1547 Decongested nasal airway patency (cm 3 ) in the study groups. <ul><li>255 children at 6 years of age. </li></ul><ul><li>Nasal airway patency by acoustic rhinometry before and after decongestion . </li></ul>
  30. 30. Objective assessments of allergic and nonallergic rhinitis in young children . Chawes Allergy 2009:64:1547 Decongested nasal airway patency (cm 3 ) in the study groups. <ul><li>255 children at 6 years of age. </li></ul><ul><li>Nasal airway patency by acoustic rhinometry before and after decongestion . </li></ul>Children with allergic rhinitis by age 6 are characterized by nasal mucosal eosinophilia and irreversible nasal airway obstruction suggesting chronic inflammation and structural remodeling of the nasal mucosa , contrasting nonallergic rhinitis with less indication of chronic inflammation.
  31. 31. Objective assessments of allergic and nonallergic rhinitis in young children . Chawes Allergy 2009:64:1547 <ul><li>255 children at 6 years of age. </li></ul><ul><li>Nasal airway patency by acoustic rhinometry before and after decongestion . </li></ul>NONALLERGIC RHINITIS ALLERGIC RHINITIS CONTROLS 26% 12% 4% % Children with Nasal Eosinophila 30 – 25 – 20 – 15 – 10 – 0 5 – 0
  32. 32. Objective assessments of allergic and nonallergic rhinitis in young children . Chawes Allergy 2009:64:1547 <ul><li>Nasal airway patency end-points: </li></ul><ul><li>Baseline nasal airway patency: absolute nasal volume 1–4 cm into the nasal cavity. </li></ul><ul><li>Decongested nasal airway patency: absolute decongested nasal volume 1–4 cm into the nasal cavity. </li></ul><ul><li>Nasal responsiveness from topical α-agonist: </li></ul>decongested nasal airway patency baseline nasal airway patency _ baseline nasal airway patency X 100%
  33. 33. Objective assessments of allergic and nonallergic rhinitis in young children . Chawes Allergy 2009:64:1547 Nasal eosinophilia Eosinophils were counted by light microscopy at high-power (oil immersion, ×1000). Rating was done according to Meltzer's semi-quantitative scale evaluating the mean number of eosinophils per 10 high-power field: (0) 0 cells, (½+) 0.1–1.0 cells, (1+) 1.1–5.0 cells, (2+) 5.1–15.0 cells, (3+) 15.1–20.0 cells, (4+) >20.0 cells. (Howarth PH, J Allergy Clin Immunol 2005;115(3 Suppl. 1):S414–S441) Nasal eosinophilia was defined as ≥1+ and analysed as a dichotomized variable.
  34. 34. <ul><li>Rhinitis burden </li></ul>
  35. 35. Sleep disturbance in persistent allergic rhinitis measured using actigraphy Rimmer Ann Allergy Asthma Immunol 2009;103:190 <ul><li>10 house dust mite-allergic rhinitic patients </li></ul><ul><li>10 nonallergic nonrhinitic control subjects </li></ul><ul><li>5 consecutive days and night of continuous activity monitoring using actigraphy </li></ul>The Actiwatch actigraphy device is worn on the nondominant hand during sleep. The watch face contains the accelerometer, which records movement.
  36. 36. Sleep disturbance in persistent allergic rhinitis measured using actigraphy Rimmer Ann Allergy Asthma Immunol 2009;103:190 Allergic Rhinitis Index of sleep fragmentation Controls 29.5 21.2 p=0.007 30 – 25 – 20 – 15 – 10 – 0 5 – 0 <ul><li>10 house dust mite-allergic rhinitic patients </li></ul><ul><li>10 nonallergic nonrhinitic control subjects </li></ul><ul><li>5 consecutive days and night of continuous activity monitoring using actigraphy </li></ul>
  37. 37. Sleep disturbance in persistent allergic rhinitis measured using actigraphy Rimmer Ann Allergy Asthma Immunol 2009;103:190 <ul><li>10 house dust mite-allergic rhinitic patients and 10 nonallergic nonrhinitic control subjects were studied for 5 consecutive days and night. </li></ul><ul><li>Continuous activity monitoring during the study period using actigraphy </li></ul>Allergic Rhinitis Index of sleep fragmentation Controls 29.5 21.2 p=0.007 30 – 25 – 20 – 15 – 10 – 0 5 – 0 An increased fragmentation index value, is indicative of reduced sleep quality and increased sleep disturbance that may result in the increased tiredness, fatigue, and impaired quality of life typically experienced in such patients.
  38. 38. Sleep actigraphy evidence of improved sleep after treatment of allergic rhinitis Yuksel Ann Allergy Asthma Immunol 2009;103:290 <ul><li>14 children aged 7 to 16 years with grass pollen-sensitized seasonal. </li></ul><ul><li>Questionnaire for sleep quality. </li></ul><ul><li>Actigraphy for 3 days in the pretreatment period. </li></ul><ul><li>After topical corticosteroid and antihistaminic treatment for 8 weeks, actigraphy, the T4SS, and the PSQI were repeated. </li></ul><ul><li>14 healthy children as controls. </li></ul>Sleep can be evaluated using subjective questionnaires, actigraphy, and the gold standard technique, polysomnography. Questionnaires about sleep, one of which is the Pittsburgh Sleep Quality Index (PSQI), are subjective methods of sleep evaluation that depend on self-reported results. Actigraphy investigates sleep pattern variations across time, the effects of different behavioral or medical interferences on sleep-wake patterns, and differences between clinical groups.
  39. 39. Sleep actigraphy evidence of improved sleep after treatment of allergic rhinitis Yuksel Ann Allergy Asthma Immunol 2009;103:290 Pre Post 1.5 – 1.0 – 0.5 – 0 0.57 Results from the Pittsburgh Sleep Quality Index ( PSQI) Controls 1.5 – 1.0 – 0.5 – 0 Pre Post Controls 1.29 0.50 1.29 0.36 0.43 ns ns p=0.004 p<0.001 Treatment Sleep Latency Sleep Disturbation Treatment
  40. 40. Sleep actigraphy evidence of improved sleep after treatment of allergic rhinitis Yuksel Ann Allergy Asthma Immunol 2009;103:290 87% Results from Actigraphy 64% 89% 28 13 11 p<0.01 p<0.001 (Nocturnal sleep time divided by time in bed) 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 100 – 30 – 25 – 20 – 15 – 10 – 0 5 – 0 Pre Post Controls Pre Post Controls Sleep Efficiency Fragmentation Index (No/d) Treatment Treatment
  41. 41. Background: Although allergic rhinitis (AR) is accepted as a risk factor for obstructive sleep apnea syndrome (OSAS), the role of nonallergic rhinitis (NAR) is unknown. Objective: To compare OSAS in patients with AR vs NAR. Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea Kalpaklıoglu Ann Allergy Asthma Immunol 2009;103:20
  42. 42. <ul><li>48 adults with AR and NAR. </li></ul><ul><li>Epworth Sleepiness Scale and 36-Item Short Form Health Survey. </li></ul><ul><li>all-night polysomnography. </li></ul>Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea Kalpaklıoglu Ann Allergy Asthma Immunol 2009;103:20 Patients with AR had a significantly longer sleep duration and better sleep efficiency than did those with NAR. Both groups had frequent arousals.
  43. 43. Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea Kalpaklıoglu Ann Allergy Asthma Immunol 2009;103:20 AR % Patients with OSAS NAR 36% 83% p=0.001 <ul><li>48 adults with AR and NAR. </li></ul><ul><li>Epworth Sleepiness Scale and 36-Item Short Form Health Survey. </li></ul><ul><li>all-night polysomnography. </li></ul>90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 100 –
  44. 44. Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea Kalpaklıoglu Ann Allergy Asthma Immunol 2009;103:20 AR % Patients with OSAS NAR 36% 83% p=0.001 <ul><li>48 adults with AR and NAR. </li></ul><ul><li>Epworth Sleepiness Scale and 36-Item Short Form Health Survey. </li></ul><ul><li>all-night polysomnography. </li></ul>Both AR and NAR are risk factors for a high apnea-hypopnea index, and both can predispose to sleep apnea. However, NAR seems to have a greater risk. 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 100 –
  45. 45. Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea Kalpaklıoglu Ann Allergy Asthma Immunol 2009;103:20 AR % Patients with OSAS NAR 36% 83% p=0.001 <ul><li>48 adults with AR and NAR. </li></ul><ul><li>Epworth Sleepiness Scale and 36-Item Short Form Health Survey. </li></ul><ul><li>all-night polysomnography. </li></ul>Patients with rhinitis should be treated not only for nasal symptoms but also for a better quality of sleep. 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 100 –
  46. 46. Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer JACI 2009;124:S43 COMMON TRIGGERS OF NASAL ALLERGY SYMPTOMS <ul><li>500 children with diagnosed nasal allergies and 504 children without nasal allergies. </li></ul><ul><li>Between the ages of 4 and 17 years. </li></ul>
  47. 47. Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer JACI 2009;124:S43 <ul><li>Absenteeism. </li></ul><ul><li>Presenteeism (or diminished performance while at school). </li></ul><ul><li>Avoided daily activities because of their symptoms. </li></ul>p<0.001 p<0.001 % CHILDREN
  48. 48. Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer JACI 2009;124:S43 Parent's Perceptions on the Effect of Nasal Allergy Symptoms on Type and Amount of Work Performed by Children. <ul><li>500 children with diagnosed nasal allergies and 504 children without nasal allergies. </li></ul><ul><li>Between the ages of 4 and 17 years. </li></ul>
  49. 49. Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer JACI 2009;124:S43 EFFECT OF AR ON THE SOCIAL HEALTH OF CHILDREN Parent's perceptions on the effect of nasal allergy symptoms on children's sleep*. Parent's perceptions on the effect of nasal allergy symptoms on children's activities. B A *p<0.001 *p<0.001 † † allergens affect sleep “a lot or some”
  50. 50. Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey Meltzer JACI 2009;124:S43 B A REASONS FOR DISSATISFACTION WITH MEDICATION AND REDUCED ADHERENCE TO TREATMENT Reasons for requesting a change in prescription nasal allergy medications. Reasons for dissatisfaction with prescription nasal allergy medication.
  51. 51. Rhinitis and asthma
  52. 52. <ul><li>The ‘‘united airway disease hypothesis’’ proposes that upper and lower airway diseases are both manifestations of a single inflammatory process. </li></ul><ul><li>Asthma and rhinitis frequently coexist in the same patients, with asthma present in 20–50% of patients with allergic rhinitis and rhinitis present in up to 80% of patients with asthma. </li></ul>Upper airway · 1: Allergic rhinitis and asthma: united disease through epithelial cells Bourdin Thorax 2009; 64: 999
  53. 53. <ul><li>A managed care study that included children with asthma and co-morbid rhinitis, showed that treatment directed at the upper airways was associated with a 30% reduction in asthma-related visits to the emergency department. </li></ul><ul><li>Treatment to control rhinosinusitis symptoms may lead to a better control of asthma and a subsequent reduction in exacerbations. </li></ul>Upper airway · 1: Allergic rhinitis and asthma: united disease through epithelial cells Bourdin Thorax 2009; 64: 999
  54. 54. <ul><li>The nasal and bronchial mucosa have some evident similarities such as a pseudostratified epithelium and the presence of both ciliated and columnar cells resting on a basement membrane, differences are mainly seen at the submucosal level. The large highly developed vasculature of the nose contrasts with the smooth muscle bundles that surround the bronchial airways. </li></ul><ul><li>Inflammatory changes seen in the nasal mucosa are closely related to those observed at the bronchial level. </li></ul>Upper airway · 1: Allergic rhinitis and asthma: united disease through epithelial cells Bourdin Thorax 2009; 64: 999
  55. 55. <ul><li>Epithelial cells are crucially situated at the external–internal milieu interface and will perform most of the actions cited above—plasticity, regulation, regeneration, orchestration of the inflammatory process and structural changes—by the production of cytokines, chemokines and other molecules balancing the inflammatory process. </li></ul>Upper airway · 1: Allergic rhinitis and asthma: united disease through epithelial cells Bourdin Thorax 2009; 64: 999
  56. 56. ( a ) Nasal and ( b ) bronchial biopsies obtained from the same patient with mild asthma showing CD8 T lymphocyte immunoreactivity of nasal and bronchial biopsies, epithelial columnar cells, epithelial shedding and basement membrane. Upper airway · 1: Allergic rhinitis and asthma: united disease through epithelial cells Bourdin Thorax 2009; 64: 999
  57. 57. Association of childhood perennial allergic rhinitis with subclinical airflow limitation Ciprandi, CEA 2010;40:398 <ul><li>200 children with moderate-severe AR. </li></ul><ul><li>Spirometry. </li></ul>40 – 30 – 20 – 10 – 0 31% % children with FEF 25–75% <80% predicted
  58. 58. Association of childhood perennial allergic rhinitis with subclinical airflow limitation Ciprandi, CEA 2010;40:398 <ul><li>200 children with moderate-severe AR. </li></ul><ul><li>Spirometry. </li></ul>20 – 10 – 0 11% % children with FEV 1 <80% predicted
  59. 59. Association of childhood perennial allergic rhinitis with subclinical airflow limitation Ciprandi, CEA 2010;40:398 <ul><li>200 children with moderate-severe AR. </li></ul><ul><li>Spirometry. </li></ul>20 – 10 – 0 11% % children with FEV 1 <80% predicted Rhinitis duration and sensitization to house dust mites were significantly associated with impaired values of these spirometric parameters.
  60. 60. Association of childhood perennial allergic rhinitis with subclinical airflow limitation Ciprandi, CEA 2010;40:398
  61. 61. Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso Allergy 2010:65:264 <ul><li>200 children with allergic rhinitis. </li></ul><ul><li>150 normal subjects. </li></ul><ul><li>Spirometry and bronchodilation </li></ul>Baseline FEV 1 % predicted
  62. 62. Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso Allergy 2010:65:264 <ul><li>200 children with allergic rhinitis. </li></ul><ul><li>150 normal subjects. </li></ul><ul><li>Spirometry and bronchodilation </li></ul>% Change in FEV 1 post Salbutamol
  63. 63. Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso Allergy 2010:65:264 <ul><li>200 children with allergic rhinitis. </li></ul><ul><li>150 normal subjects. </li></ul><ul><li>Spirometry and bronchodilation </li></ul>% Change in FEV 1 post Salbutamol More than 20% of rhinitics had reversibility (≥12% basal levels).
  64. 64. Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso Allergy 2010:65:264 <ul><li>200 children with allergic rhinitis. </li></ul><ul><li>150 normal subjects. </li></ul>Rhinitis Duration and FEV 1 Reversibility
  65. 65. Impact of allergic rhinitis on asthma in children: effects on bronchodilation test Capasso Allergy 2010:65:264 <ul><li>200 children with allergic rhinitis. </li></ul><ul><li>150 normal subjects. </li></ul>Rhinitis Duration and FEV 1 Reversibility Patients with reversibility had lower FEV 1 levels, longer rhinitis duration, and perennial allergy.
  66. 66. <ul><li>Sinusite </li></ul><ul><li>Otite </li></ul>
  67. 67. Effectiveness of Amoxicillin/Clavulanate Potassium in the Treatment of Acute Bacterial Sinusitis in Children Wald Pediatrics 2009;124;9-15 <ul><li>56 children 1 to 10 years of age with acute bacterial sinusitis. </li></ul><ul><li>Either amoxicillin (90 mg/kg) with potassium clavulanate (6.4 mg/kg) or placebo. </li></ul>% patients cured 50% 60 - 50 – 40 – 30 – 20 – 10 – 0 14% AM/CL PLACEBO P<0.05
  68. 68. <ul><li>POLIPOSI NASALE </li></ul>
  69. 69. <ul><li>Rhinitis treatment general considerations </li></ul>
  70. 70. Background: Allergic rhinitis is common, but a validated tool for comprehensive assessment of disease control is not available. Objective: To develop a simple patient-completed instrument (the Rhinitis Control Assessment Test [RCAT]) to help detect problems with control of rhinitis symptoms. Psychometric validation of the Rhinitis Control Assessment Test: a brief patient-completed instrument for evaluating rhinitis symptom control Schatz Ann Allergy Asthma Immunol 2010;104:118
  71. 71. <ul><li>410 patients with allergic rhinitis. </li></ul><ul><li>Total Nasal Symptom Score (TNSS) assessment and the 26-item developmental RCAT. </li></ul>RCAT items and constructs: developmental questionnaire. Psychometric validation of the Rhinitis Control Assessment Test: a brief patient-completed instrument for evaluating rhinitis symptom control Schatz Ann Allergy Asthma Immunol 2010;104:118
  72. 72. <ul><li>410 patients with allergic rhinitis. </li></ul><ul><li>Total Nasal Symptom Score (TNSS) assessment and the 26-item developmental RCAT. </li></ul>RCAT items and constructs: developmental questionnaire. Psychometric validation of the Rhinitis Control Assessment Test: a brief patient-completed instrument for evaluating rhinitis symptom control Schatz Ann Allergy Asthma Immunol 2010;104:118
  73. 73. <ul><li>410 patients with allergic rhinitis. </li></ul><ul><li>Total Nasal Symptom Score (TNSS) assessment and the 26-item developmental RCAT. </li></ul>Psychometric validation of the Rhinitis Control Assessment Test: a brief patient-completed instrument for evaluating rhinitis symptom control Schatz Ann Allergy Asthma Immunol 2010;104:118 <ul><li>Stepwise regression methods identified 6 items from the developmental RCAT: </li></ul><ul><li>frequency of nasal congestion , </li></ul><ul><li>sneezing, </li></ul><ul><li>watery eyes, </li></ul><ul><li>sleep interference, </li></ul><ul><li>activity avoidance, </li></ul><ul><li>self-assessed control that were most predictive of the </li></ul><ul><li>allergist’s global rating of </li></ul><ul><li>rhinitis symptom control. </li></ul>
  74. 74. Median % changes from baseline for total nasal symptom score for SAR 0 -10 – -20 – -30 – -40 – -22.2% -23.5% -40.7% -15% NAI OAI INS Placebo <ul><li>54 studies </li></ul><ul><li>More than 14,000 adults and 1,580 children with AR </li></ul><ul><li>Nasal antihistamine = NAI </li></ul><ul><li>Oral antihistamine = OAI </li></ul><ul><li>Intranasal steroids = INS </li></ul>Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class Benninger Ann Allergy Asthma Immunol 2010;104:13
  75. 75. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class Benninger Ann Allergy Asthma Immunol 2010;104:13 <ul><li>54 studies </li></ul><ul><li>More than 14,000 adults and 1,580 children with AR </li></ul><ul><li>Nasal antihistamine = NAI </li></ul><ul><li>Oral antihistamine = OAI </li></ul><ul><li>Intranasal steroids = INS </li></ul>Median % changes from baseline for total nasal symptom score for PAR 0 -10 – -20 – -30 – -40 – -50 – -51.4% OAI INS Placebo -37.3% -24.8%
  76. 76. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class Benninger Ann Allergy Asthma Immunol 2010;104:13 <ul><li>54 studies </li></ul><ul><li>More than 14,000 adults and 1,580 children with AR </li></ul><ul><li>Nasal antihistamine = NAI </li></ul><ul><li>Oral antihistamine = OAI </li></ul><ul><li>Intranasal steroids = INS </li></ul>Median % changes from baseline for total nasal symptom score for PAR 0 -10 – -20 – -30 – -40 – -50 – -51.4% OAI INS Placebo -37.3% -24.8% The data, confirm that INSs produce the greatest improvements in nasal symptoms in patients with SAR. In addition, INSs are effective for PAR, but the data were of variable quality, and oral antihistamines may be equally effective for some patients.
  77. 77. <ul><li>Rhinitis treatment anti-histamines </li></ul>
  78. 78. <ul><li>First-generation H1-antihistamines , all of which are sedating, are generally regarded as safe by laypersons and healthcare professionals because of their long-standing use </li></ul><ul><li>They reduce rapid eye movement (REM)-sleep , impair learning and reduce work efficiency </li></ul><ul><li>They are implicated in civil aviation, motor vehicle and boating accidents , deaths as a result of accidental or intentional overdosing in infants and young children and suicide in teenagers and adults </li></ul><ul><li>Some exhibit cardiotoxicity in overdose </li></ul>Risk of first-generation H1-antihistamines: a GA2LEN position paper M. K. Church, Allergy 2010;65;459
  79. 79. <ul><li>First-generation H1-antihistamines , all of which are sedating, are generally regarded as safe by laypersons and healthcare professionals because of their long-standing use </li></ul><ul><li>They reduce rapid eye movement (REM)-sleep , impair learning and reduce work efficiency </li></ul><ul><li>They are implicated in civil aviation, motor vehicle and boating accidents , deaths as a result of accidental or intentional overdosing in infants and young children and suicide in teenagers and adults </li></ul><ul><li>Some exhibit cardiotoxicity in overdose </li></ul>Risk of first-generation H1-antihistamines: a GA2LEN position paper M. K. Church, Allergy 2010;65;459 Legata all’apprendimento
  80. 80. <ul><li>First-generation H1-antihistamines , all of which are sedating, are generally regarded as safe by laypersons and healthcare professionals because of their long-standing use </li></ul><ul><li>They reduce rapid eye movement (REM)-sleep , impair learning and reduce work efficiency </li></ul><ul><li>They are implicated in civil aviation, motor vehicle and boating accidents , deaths as a result of accidental or intentional overdosing in infants and young children and suicide in teenagers and adults </li></ul><ul><li>Some exhibit cardiotoxicity in overdose </li></ul>Risk of first-generation H1-antihistamines: a GA2LEN position paper M. K. Church, Allergy 2010;65;459 First-generation H1-antihistamines should no longer be available over-the-counter as prescription-free drugs for self-medication of allergic and other diseases
  81. 81. Risk of first-generation H1-antihistamines: a GA2LEN position paper M. K. Church, Allergy 2010;65;459 The penetration (red colouring) of (A) diphenhydramine, a first-generation H1-antihistamine, and (B) bepotastine, a second-generation H1-antihistamine, into human brain shown by positron emission tomography A map of histaminergic neurons emanating from the tuberomamillary nucleus in the brain
  82. 82. Risk of first-generation H1-antihistamines: a GA2LEN position paper M. K. Church, Allergy 2010;65;459 Sleep/wake cycle and the effects of a first-generation H1-antihistamine leading to somnolence during the day and abnormal sleep at night reduce and delayed rapid eye movement (REM)-sleep The effect of allergic rhinitis on learning in children and the influence of a first-generation (diphenhydramine) and second-generation (loratadine) H1-antihistamine
  83. 83. Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines dos Santos Ann Allergy Asthma Immunol 2009;102:495 Abstract: Background: Nonsedating antihistamines (nsAHs) are recommended as first-line therapeutics for the treatment of mast cell-driven disorders, including allergic rhinitis and urticaria. However, their superiority over first-generation AHs (fgAHs) has recently been called into question, mainly because of the lack of supporting head-to-head therapeutic studies. Objective: To compare the effects of 3 modern nsAHs with those of the fgAH hydroxyzine on histamine- and allergen-induced skin reactions in a controlled, double-blind, clinical trial.
  84. 84. Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines dos Santos Ann Allergy Asthma Immunol 2009;102:495 <ul><li>SPTs with histamine and Dermatophagoides pteronyssinus extract </li></ul><ul><li>Before and 4 hours after treatment with hydroxyzine, 25 mg; desloratadine, 5 mg; epinastine, 20 mg; fexofenadine, 120 mg; or placebo. </li></ul>60 – 50 – 40 – 30 – 20 – 10 – 0 HYDROXYZIME NON-SEDATING AI % Patients not Developing a Positive Reactions to Histamine > 50% 10% 20%   
  85. 85. Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines dos Santos Ann Allergy Asthma Immunol 2009;102:495 <ul><li>SPTs with histamine and Dermatophagoides pteronyssinus extract were. </li></ul><ul><li>Before and 4 hours after treatment with hydroxyzine, 25 mg; desloratadine, 5 mg; epinastine, 20 mg; fexofenadine, 120 mg; or placebo. </li></ul>60 – 50 – 40 – 30 – 20 – 10 – 0 HYDROXYZIME NON-SEDATING AI % Patients not Developing a Positive Reactions to Histamine > 50% 10% 20%    Similar differences, were detected when comparing the effects of nsAHs with hydroxyzine on D pteronyssinus prick testing.
  86. 86. Suppression of histamine-and allergen-induced skin reactions: comparison of first- and second-generation antihistamines dos Santos Ann Allergy Asthma Immunol 2009;102:495 <ul><li>SPTs with histamine and Dermatophagoides pteronyssinus extract were. </li></ul><ul><li>Before and 4 hours after treatment with hydroxyzine, 25 mg; desloratadine, 5 mg; epinastine, 20 mg; fexofenadine, 120 mg; or placebo. </li></ul>60 – 50 – 40 – 30 – 20 – 10 – 0 HYDROXYZIME NON-SEDATING AI % Patients not Developing a Positive Reactions to Histamine > 50% 10% 20%    Higher doses of nsAHs than those currently recommended are required for the treatment of skin responses to obtain antihistaminic and antiallergic effects that are equivalent to those of first generation AHs.
  87. 87. Evaluation of desloratadine on conjunctival allergen challenge-induced ocular symptoms Torkildsen CEA 2010;39:1052 <ul><li>Adults with a history of seasonal AC and a minimal threshold response to allergen challenge. </li></ul><ul><li>Randomized to receive desloratadine 5 mg daily (n=20) or placebo (n=21) for 7 days after which they underwent a second ocular allergen challenge. </li></ul>  Mean change from baseline in pruritus score. * P <0.001
  88. 88. Mean change from baseline in eyelid swelling. Mean change from baseline in tearing score. Evaluation of desloratadine on conjunctival allergen challenge-induced ocular symptoms Torkildsen CEA 2010;39:1052 * P <0.03 * P <0.003
  89. 89. Desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis Holmberg Allergy 2009:64:1663 <ul><li>Subjects with a ≥2-year history of moderate-to-severe AR to dust mite or cat dander. </li></ul><ul><li>Desloratadine 5 mg/day (n = 293) or placebo/day (n = 291) for 28 days. </li></ul>Nasal congestion mean daily percent change from baseline to study end (day 28) with desloratadine vs placebo in morning.
  90. 90. Mean weekly changes vs placebo in nasal congestion (A), total nasal symptoms (B) and rhinorrhea (C). Desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis Holmberg Allergy 2009:64:1663 *P < 0.05; †P < 0.53
  91. 91. Mean improvement from baseline in total Rhinoconjunctivitis Quality of Life Questionnaire scores and individual domains after administration of desloratadine 5 mg or placebo QD, at day 7 (A) and day 28 (B) . Desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis Holmberg Allergy 2009:64:1663 A day 7 QoL B day 28 QoL
  92. 92. Efficacy of desloratadine in intermittent allergic rhinitis: a GA 2 LEN study Bousquet Allergy 2009:64:1516 Evolution of reflective T5SS total 5 symptom scores *P ≤ 0.018 <ul><li>Patients > 12 years of age with IAR. </li></ul><ul><li>15 days of treatment with DL 5 mg once daily (n = 276) or placebo (n = 271). </li></ul><ul><li>Total 5 Symptom Score ( T5SS ) </li></ul><ul><li>Visual Analogue Scale </li></ul>
  93. 93. Evolution symptom severity by VAS (B) *P ≤ 0.018 Efficacy of desloratadine in intermittent allergic rhinitis: a GA 2 LEN study Bousquet Allergy 2009:64:1516 <ul><li>Patients > 12 years of age with IAR. </li></ul><ul><li>15 days of treatment with DL 5 mg once daily (n = 276) or placebo (n = 271). </li></ul><ul><li>Total 5 Symptom Score ( T5SS ) </li></ul><ul><li>Visual Analogue Scale </li></ul>
  94. 94. Evolution symptom severity by VAS (B) *P ≤ 0.018 Efficacy of desloratadine in intermittent allergic rhinitis: a GA 2 LEN study Bousquet Allergy 2009:64:1516 The criteria for IAR according to the ARIA classification (symptoms of allergic rhinitis present <4 days/week or for <4 consecutive weeks/year). <ul><li>Patients > 12 years of age with IAR. </li></ul><ul><li>15 days of treatment with DL 5 mg once daily (n = 276) or placebo (n = 271). </li></ul><ul><li>Total 5 Symptom Score ( T5SS ) </li></ul><ul><li>Visual Analogue Scale </li></ul>
  95. 95. <ul><li>Rhinitis treatment nasal corticosteroids </li></ul>
  96. 96. <ul><li>Double-blind, placebo-controlled, crossover experiment in 20 subjects with seasonal allergic rhinitis. </li></ul><ul><li>Nasal antigen challenge was performed consecutively for 3 days after 1 week of treatment with either placebo or fluticasone furoate nasal spray (FFNS). </li></ul>Fluticasone furoate nasal spray reduces the nasal-ocular reflex: A mechanism for the efficacy of topical steroids in controlling allergic eye symptoms Baroody JACI 2009;123:1342 The solid bars represent median levels. The dashed line represents the priming response. † P ≤.03 vs day 1, illustrating priming, and ∗∗ P <.01 and ∗ P <.03 vs placebo, demonstrating the inhibitory effect of active treatment. The effect of FFNS on the sneezing response after allergen challenge.
  97. 97. Fluticasone furoate nasal spray reduces the nasal-ocular reflex: A mechanism for the efficacy of topical steroids in controlling allergic eye symptoms Baroody JACI 2009;123:1342 The solid bars represent median levels. The dashed line represents the priming response. † P ≤.04 vs day 1 and ∗∗ P ≤.01 vs placebo, demonstrating the inhibitory effect of active treatment. The effect of FFNS on the total eye symptom score after allergen challenge. <ul><li>Double-blind, placebo-controlled, crossover experiment in 20 subjects with seasonal allergic rhinitis. </li></ul><ul><li>Nasal antigen challenge was performed consecutively for 3 days after 1 week of treatment with either placebo or fluticasone furoate nasal spray (FFNS). </li></ul>
  98. 98. Fluticasone furoate nasal spray reduces the nasal-ocular reflex: A mechanism for the efficacy of topical steroids in controlling allergic eye symptoms Baroody JACI 2009;123:1342 The solid bars represent median levels. The dashed line represents the priming response. † P ≤.04 vs day 1 and ∗∗ P ≤.01 vs placebo, demonstrating the inhibitory effect of active treatment. The effect of FFNS on the total eye symptom score after allergen challenge. <ul><li>Double-blind, placebo-controlled, crossover experiment in 20 subjects with seasonal allergic rhinitis. </li></ul><ul><li>Nasal antigen challenge was performed consecutively for 3 days after 1 week of treatment with either placebo or fluticasone furoate nasal spray (FFNS). </li></ul>Control of eye symptoms can be achieved during nasal administration of an intranasal steroid in patients with seasonal allergic rhinitis.
  99. 99. <ul><li>25 patients with asthma and persistent allergic rhinitis </li></ul><ul><li>2 weeks treatment </li></ul>Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis A. Nair, Allergy 2010;65;355 STUDY DESIGN
  100. 100. Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis A. Nair, Allergy 2010;65;355 Comparison of treatment effects on lower airway outcomes: Methacholine PC20 exhaled tidal NO asthma quality of life
  101. 101. Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis A. Nair, Allergy 2010;65;355 Comparison of treatment effects on lower airway outcomes: Methacholine PC20 exhaled tidal NO asthma quality of life Combined treatment was not significantly different from low dose fluticasone and we could not demonstrate a steroid sparing effect on methacholine PC20
  102. 102. Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis A. Nair, Allergy 2010;65;355 Comparison of treatment effects on upper airway outcomes: Peak nasal inspiratory flow Nasal NO rhinitis QoL
  103. 103. Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis A. Nair, Allergy 2010;65;355 Comparison of treatment effects on upper airway outcomes: Peak nasal inspiratory flow Nasal NO rhinitis QoL Combined treatment alone produced improvements in upper airway outcomes and suppressed systemic inflammation but not adrenal function
  104. 104. Dissolution in nasal fluid, retention and anti-inflammatory activity of fluticasone furoate in human nasal tissue ex vivo Baumann Clinical & Experimental Allergy 2009;39:1540 <ul><li>Solubility of the compounds in artificial human nasal fluid and the retention in human nasal tissue as well as typical spray volumes of commercially available drug preparations. </li></ul>183 1 p<0.0005 P=0.001 <ul><li>FF is delivered in the smallest application volume per spray. </li></ul><ul><li>The dissolution of FP, MF and FF was significantly enhanced in artificial nasal fluid and FF displayed the most pronounced enhancement of solubility in the presence of proteins . </li></ul>
  105. 105. The highest retention in nasal tissue was observed for FF, followed by FP>MF>Bud>TCA 183 1 p<0.0005 P=0.001 Relationship between the binding of the analysed glucocorticoids to human nasal tissue and relative affinities to the human glucocorticoid receptor. The coefficient of correlation was r = 0.971 (P  0.01) Dissolution in nasal fluid, retention and anti-inflammatory activity of fluticasone furoate in human nasal tissue ex vivo Baumann Clinical & Experimental Allergy 2009;39:1540
  106. 106. The highest retention in nasal tissue was observed for FF, followed by FP>MF>Bud>TCA 183 1 p<0.0005 P=0.001 Relationship between the binding of the analysed glucocorticoids to human nasal tissue and relative affinities to the human glucocorticoid receptor. The coefficient of correlation was r = 0.971 (P  0.01) Dissolution in nasal fluid, retention and anti-inflammatory activity of fluticasone furoate in human nasal tissue ex vivo Baumann Clinical & Experimental Allergy 2009;39:1540 Low application volume per spray is a prerequisite for effective drug utilization by avoiding immediate loss by nose runoff or drip down the throat.
  107. 107. HPA axis safety of fluticasone furoate nasal spray once daily in children with perennial allergic rhinitis Tripathy Pediatr Allergy Immunol 2009:20:287 <ul><li>6 wk of treatment with FFNS 110 μg once daily compared with placebo in pediatric patients (n = 112). </li></ul><ul><li>Serum cortisol (SC) concentrations and urinary cortisol (UC) excretion. </li></ul>Change from baseline in 24-h UC excretion (μg/dl/day) after 6 wk of treatment
  108. 108. HPA axis safety of fluticasone furoate nasal spray once daily in children with perennial allergic rhinitis Tripathy Pediatr Allergy Immunol 2009:20:287 <ul><li>6 wk of treatment with FFNS 110 μg once daily compared with placebo in pediatric patients (n = 112). </li></ul><ul><li>Serum cortisol (SC) concentrations and urinary cortisol (UC) excretion. </li></ul>Change from baseline in 24-h UC excretion (μg/dl/day) after 6 wk of treatment FFNS 110 μg QD has no significant effect on HPA axis function in 2- to 11-yr-old pediatric patients with PAR.
  109. 109. <ul><li>Rhinitis treatment montelukast </li></ul>
  110. 110. Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma Fagnano Pediatrics 2009;124:218 <ul><li>194 asthmatic children </li></ul><ul><li>(aged 4 –10 years) </li></ul><ul><li>Sleep-Related Breathing Disorder Questionnaire that contains 3 subscales: snoring, sleepiness , and attention/hyperactivity </li></ul><ul><li>A sleep score of > 0.33 was considered indicative of SDB </li></ul>33% % CHILDREN WITH SDB 50 – 40 – 30 – 20 – 10 – 0
  111. 111. Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma Fagnano Pediatrics 2009;124:218 <ul><li>194 asthmatic children </li></ul><ul><li>(aged 4 –10 years) </li></ul><ul><li>Sleep-Related Breathing Disorder Questionnaire that contains 3 subscales: snoring, sleepiness , and attention/hyperactivity </li></ul><ul><li>A sleep score of > 0.33 was considered indicative of SDB </li></ul>33% % CHILDREN WITH SDB 50 – 40 – 30 – 20 – 10 – 0 Children with SDB had significantly worse behavior scores anxious/depressed, hyperactive (3.0 vs 1.8), peer conflict (0.74 vs 0.43), and immature
  112. 112. Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma Fagnano Pediatrics 2009;124:218 <ul><li>194 asthmatic children </li></ul><ul><li>(aged 4 –10 years) </li></ul><ul><li>Sleep-Related Breathing Disorder Questionnaire that contains 3 subscales: snoring, sleepiness , and attention/hyperactivity </li></ul><ul><li>A sleep score of > 0.33 was considered indicative of SDB </li></ul>33% % CHILDREN WITH SDB 50 – 40 – 30 – 20 – 10 – 0 Poor sleep was independently associated with behavior problems in a large proportion of urban children with asthma
  113. 113. Frequent nocturnal awakening in early life is associated with nonatopic asthma in children Kozyrskyj ERJ 2009:34:1288 <ul><li>A community-based birth cohort. </li></ul><ul><li>Followed up at years 1, 2, 3, 6, 8, 10 and 14. </li></ul><ul><li>Parent-completed questionnaires. </li></ul>In Children with Frequent Nocturnal Awakening During the First 3 Yrs OR for Non-Atopic Asthma at Age 6 and 14 Yrs 2.18 2.5 – 2.0 – 1.5 – 1.0 – 0.5 – 0
  114. 114. Frequent nocturnal awakening in early life is associated with nonatopic asthma in children Kozyrskyj ERJ 2009:34:1288 <ul><li>A community-based birth cohort. </li></ul><ul><li>Followed up at years 1, 2, 3, 6, 8, 10 and 14. </li></ul><ul><li>Parent-completed questionnaires. </li></ul>In Children with Frequent Nocturnal Awakening During the First 3 Yrs OR for Non-Atopic Asthma at Age 6 and 14 Yrs 2.18 2.5 – 2.0 – 1.5 – 1.0 – 0.5 – 0 There was no effect on atopic asthma.
  115. 115. <ul><li>While shorter duration of sleep has been linked to hyperactivity disorders and obesity in children, to the best of our knowledge, this is the first report of frequent nocturnal awakening in early life and asthma development. </li></ul><ul><li>Several pro-inflammatory cytokines, such as IL-6 , IL-1 and TNF- α , participate in sleep control. Two of these cytokines, IL-6 and TNF- α , are elevated in sleep-deprived adults. </li></ul><ul><li>TNF- α has been implicated in neutrophilic inflammation in neutrophilic airway inflammation has been observed in children with sleep apnoea. </li></ul>Frequent nocturnal awakening in early life is associated with nonatopic asthma in children Kozyrskyj ERJ 2009:34:1288
  116. 116. Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood Kaditis Pediatric Pulmonology 2009;45:255 Tonsillar Hypertrophy In Children with a History of Wheezing OR for Snoring 2.34 1.73 2.5 – 2.0 – 1.5 – 1.0 – 0.5 – 0 p=0.001 p=0.013 <ul><li>Wheezing requiring treatment. </li></ul><ul><li>Snoring ≥ 1 night/week. </li></ul><ul><li>Tonsillar hypertrophy. </li></ul><ul><li>442 children mean age: 7.6 years </li></ul>
  117. 117. Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood Kaditis Pediatric Pulmonology 2009;45:255 Tonsillar Hypertrophy In Children with a History of Wheezing OR for Snoring 2.34 1.73 2.5 – 2.0 – 1.5 – 1.0 – 0.5 – 0 p=0.001 p=0.013 <ul><li>Wheezing requiring treatment. </li></ul><ul><li>Snoring ≥ 1 night/week. </li></ul><ul><li>Tonsillar hypertrophy. </li></ul><ul><li>442 children mean age: 7.6 years </li></ul>Children with history of wheezing have more frequently tonsillar hypertrophy than those without wheezing. Tonsillar hypertrophy may mediate at least in part the reported association between asthma and obstructive sleep-disordered breathing in childhood.
  118. 118. Prevalence of obstructive sleep apnea–hypopnea in severe versus moderate asthma Julien JACI 2009;124:371 <ul><li>Overnight home polysomnography. </li></ul><ul><li>26 patients with severe asthma. </li></ul><ul><li>26 patients with moderate asthma. </li></ul><ul><li>26 controls without asthma. </li></ul>SEVERE % Subjects with Apnea–Hypopnea Index ≥15 Events/h of Sleep MODERATE CONTROLS 31% 58% 88% 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 P< 0.001 for trend ASTHMA
  119. 119. Prevalence of obstructive sleep apnea–hypopnea in severe versus moderate asthma Julien JACI 2009;124:371 <ul><li>Overnight home polysomnography. </li></ul><ul><li>26 patients with severe asthma. </li></ul><ul><li>26 patients with moderate asthma. </li></ul><ul><li>26 controls without asthma. </li></ul>SEVERE % Subjects with Apnea–Hypopnea Index ≥15 Events/h of Sleep MODERATE CONTROLS 31% 58% 88% 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 P< 0.001 for trend These observations suggest potential pathophysiologic interactions between obstructive sleep apnea–hypopnea and asthma severity and control. ASTHMA
  120. 120. Urine Concentrations of Cysteinyl Leukotrienes in Children With Obstructive Sleep-Disordered Breathing (SDB) Kaditis Chest 2009;135:1496 <ul><li>19 children with moderate-to-severe SDB </li></ul><ul><li>(OAHI: 14.4±9.6 episodes/h) </li></ul><ul><li>29 subjects with mild SDB (OAHI: 2.9±0.8 episodes/h) </li></ul><ul><li>26 children with primary snoring (PS) (OAHI: 1.1 ± 0.3episodes/h) </li></ul><ul><li>18 control subjects (OAHI: 0.7±0.3 episodes/h) </li></ul>r =0.40; p <0.01
  121. 121. Urine Concentrations of Cysteinyl Leukotrienes in Children With Obstructive Sleep-Disordered Breathing (SDB) Kaditis Chest 2009;135:1496 <ul><li>19 children with moderate-to-severe SDB </li></ul><ul><li>(OAHI: 14.4±9.6 episodes/h) </li></ul><ul><li>29 subjects with mild SDB (OAHI: 2.9±0.8 episodes/h) </li></ul><ul><li>26 children with primary snoring (PS) (OAHI: 1.1 ± 0.3episodes/h) </li></ul><ul><li>18 control subjects (OAHI: 0.7±0.3 episodes/h) </li></ul>InCysLTs correlated significantly with log-transformed obstructive apnea hypopnea index (OAHI) in 92 children with obstructive SDB ( r =0.40; p <0.01). r =0.40; p <0.01
  122. 122. Urine Concentrations of Cysteinyl Leukotrienes in Children With Obstructive Sleep-Disordered Breathing (SDB) Kaditis Chest 2009;135:1496 <ul><li>19 children with moderate-to-severe SDB </li></ul><ul><li>(OAHI: 14.4±9.6 episodes/h) </li></ul><ul><li>29 subjects with mild SDB (OAHI: 2.9±0.8 episodes/h) </li></ul><ul><li>26 children with primary snoring (PS) (OAHI: 1.1 ± 0.3episodes/h) </li></ul><ul><li>18 control subjects (OAHI: 0.7±0.3 episodes/h) </li></ul>This finding indicates that 5-lipoxygenase pathway products participate in the pathogenesis of obstructive sleep apnea in childhood or alternatively that SDB promotes CysLTs biosynthesis. r =0.40; p <0.01
  123. 123. Increased urinary leukotriene E 4 excretion in obstructive sleep apnea: Effects of obesity and hypoxia Stanke-Labesque JACI 2009;124:364 <ul><li>Urinary leukotriene E 4 (U-LTE 4 ) in OSA </li></ul><ul><li>72 patients with OSA </li></ul>
  124. 124. Increased urinary leukotriene E 4 excretion in obstructive sleep apnea: Effects of obesity and hypoxia Stanke-Labesque JACI 2009;124:364 <ul><li>Urinary leukotriene E 4 (U-LTE 4 ) in OSA </li></ul>Compared with patients with normal weight, LTE 4 urinary concentrations are significantly higher in overweight and obese patients with OSA.
  125. 125. <ul><li>Rhinitis other </li></ul><ul><li>Treatments </li></ul><ul><li>ITS </li></ul>
  126. 126. <ul><li>conjunctivitis </li></ul><ul><li>vernal conjunctivitis </li></ul>
  127. 127. sinusite
  128. 128. Criteria To Screen for Chronic Sinonasal Disease Dixon CHEST 2009; 136:1324 Background: Sinusitis and rhinitis are associated with uncontrolled asthma. There are no simple, validated tools to screen for these diseases. The objective of this study was to assess instruments to assist in the diagnosis of chronic sinonasal disease. Methods: Participants without acute sinonasal symptoms underwent an extensive evaluation. The results were submitted to an expert panel that used the Delphi method to achieve consensus. Using the consensus diagnosis of the panel, we determined the sensitivity and specificity of test procedures to diagnose chronic sinonasal disease. We determined the reproducibility of the most sensitive and specific instrument in a separate cohort.
  129. 129. <ul><li>59 participants were evaluated </li></ul><ul><li>(42 participants with chronic sinonasal disease, </li></ul><ul><li>17 participants without chronic sinonasal disease). </li></ul><ul><li>A five-item questionnaire based on the frequency of nasal symptoms had a sensitivity of 0.90 and a specificity of 0.94 for the diagnisis of sinonasal disease </li></ul>Criteria To Screen for Chronic Sinonasal Disease Dixon CHEST 2009; 136:1324
  130. 130. OVER THE LAST 3 MONTHS HOW OFTEN, ON AVERAGE, DID YOU HAVE THE FOLLOWING SYMPTOMS? Scoring: Never (0), 1-4 times per month (1), 2- 6 times per week (2), and daily (3). Score reported as average of 5 items: range of possible scores 0 - 3. Criteria To Screen for Chronic Sinonasal Disease Dixon CHEST 2009; 136:1324 Never 1-4 times per month 2-6 times per week Daily Runny nose Post nasal drip Need to blow your nose Facial pain/pressure Nasal obstruction
  131. 131. OVER THE LAST 3 MONTHS HOW OFTEN, ON AVERAGE, DID YOU HAVE THE FOLLOWING SYMPTOMS? Scoring: Never (0), 1-4 times per month (1), 2- 6 times per week (2), and daily (3). Score reported as average of 5 items: range of possible scores 0 - 3. A cutpoint of 1 (experiencing each symptom an average of one to four times per month) was highly sensitive and specific for diagnosing chronic sinonasal disease. Criteria To Screen for Chronic Sinonasal Disease Dixon CHEST 2009; 136:1324 Never 1-4 times per month 2-6 times per week Daily Runny nose Post nasal drip Need to blow your nose Facial pain/pressure Nasal obstruction
  132. 132. OVER THE LAST 3 MONTHS HOW OFTEN, ON AVERAGE, DID YOU HAVE THE FOLLOWING SYMPTOMS? Scoring: Never (0), 1-4 times per month (1), 2- 6 times per week (2), and daily (3). Score reported as average of 5 items: range of possible scores 0 - 3. In these circumstances, the Sino Nasal Questionnaire was superior to endoscopy and CT scan assessment using standard scoring systems Criteria To Screen for Chronic Sinonasal Disease Dixon CHEST 2009; 136:1324 Never 1-4 times per month 2-6 times per week Daily Runny nose Post nasal drip Need to blow your nose Facial pain/pressure Nasal obstruction
  133. 133. Take home <ul><li>Il difetto di vitamina D durante la gravidanza è un fattore di rischio per lo sviluppo di rinite allergica (RA) nel bambino, </li></ul><ul><li>L’effetto serra ha anticipato e prolungato la stagione pollinica, </li></ul><ul><li>I decongestionanti nasali sono meno efficaci nella RA, </li></ul><ul><li>I soggetti con RA hanno un sonno frammentato e conseguente sonnolenza diurna, fenomeni che si attenuano dopo trattamento combinato con steroidi nasali e anti-H1 di seconda generazione, </li></ul><ul><li>C’è una correlazione tra RA ed asma specialmente nei pazienti allergici agli acari e con lunga durata della malattia, </li></ul><ul><li>Un buon controllo della RA si ottiene con l’uso combinato di steroidi nasali e anti-H1 di seconda generazione (la desloratadina decongestiona ed il fluticasone ha effetto anche sulla congiuntivite), </li></ul><ul><li>Attenzione agli effetti collaterali degli anti-H1 di prima generazione, </li></ul><ul><li>Si può aumentare il dosaggio degli anti-H1 di seconda generazione. </li></ul>
  134. 134. TAKE HOME INFORMATIONS

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