Uncontrolled Allergic Rhinitis Research Articles

An Observational Study to Determine the Real-Life Effectiveness of MP-AzeFlu® in Austrian Patients with Persistent Allergic Rhinitis.

Many patients with allergic rhinitis (AR) have moderate-to-severe persistent AR. Meda Pharma's AzeFlu (MP-AzeFlu®) is an intranasal AR treatment comprising a novel formulation of azelastine hydrochloride and fluticasone propionate in a single device. This prospective observational study of 214 adults and adolescents in Austria with moderate-to-severe persistent AR assessed the effectiveness of MP-AzeFlu (one spray/nostril twice daily; daily doses: azelastine hydrochloride 548μg; and fluticasone propionate 200μg) for AR control in clinical practice using the visual analog scale. Symptom severity was reported on days 0, 1, 3, 7, 14, 21, 28, 35, and 42. Patient demographics, AR phenotype, allergen sensitization, symptomatology, AR treatments in the previous year, and the reason for the MP-AzeFlu prescription were recorded. MP-AzeFlu treatment was associated with a rapid and statistically significant reduction in the visual analog scale score from baseline to each timepoint measured, including day 1 (all p < 0.0001). Mean (standard deviation) visual analog scale score was 53.5mm (26.3) at baseline, 25.3mm (21.0) on day 28, and 19.6mm (17.4) on day 42, a mean overall reduction from baseline of 41.4 (23.9) mm for completers. Results were consistent irrespective of patient age, gender, severity, or traditional AR phenotype. Prior to MP-AzeFlu prescription, congestion was considered the most bothersome symptom. The majority of patients reported using at least two AR therapies in the past year, including oral antihistamines, intranasal corticosteroids, and intranasal antihistamines. Many patients in Austria live with uncontrolled persistent AR despite treatment. MP-AzeFlu provides effective and rapid control of persistent AR in a real-world Austrian setting.

SQ HDM sublingual immunotherapy tablet for the treatment of HDM allergic rhinitis and asthma improves subjective sleepiness and insomnia: an exploratory analysis of the real-life CARIOCA study.

There are still gaps in the knowledge regarding the effectiveness of house dust mite (HDM) sublingual immunotherapy (SLIT) on allergic rhinitis (AR) and asthma (AA)-associated sleep disorders. A non-interventional study was conducted to assess the effect of the Standardized quality (SQ) HDM SLIT-tablet on safety and symptoms in adults with HDM respiratory allergies. The aim was to describe the status of insomnia and daytime sleepiness in AR and/or AA patients treated with the SQ HDM SLIT-tablet. This was a 12-month multicenter, longitudinal and prospective study. Participants started the SQ HDM SLIT-tablet for moderate-to-severe HDM AR, persistent despite the use of symptom-relieving medication; or HDM AA not well controlled by inhaled corticosteroids and associated with mild-to-severe HDM AR. Sleep symptoms were measured using the Insomnia Severity Index (ISI) questionnaire and the Epworth Sleepiness Scale (ESS). A total of 1,526 adult patients were enrolled and 1,483 were included in the analysis. At baseline, 41.5% of patients reported sleep disorders: 77.0% of them had insomnia and 28.9% suffered from excessive daytime sleepiness. Insomnia was significantly more frequent among patients with uncontrolled AR (83.1%) than those with controlled AR (52.6%) (p<0.0001). Over time, 48.3% and 59.7% of patients reported an improvement greater than the minimal clinically important difference on the ISI and ESS scales respectively. In patients with HDM AR and/or asthma associated sleep disorders, an improvement in subjective insomnia and sleepiness was observed after one year of treatment with the SQ HDM SLIT-tablet in a real-life setting.

Determinants of uncontrolled allergic rhinitis in Kinshasa hospitals.

To identify the determinants of uncontrolled allergic rhinitis (UCAR) in a hospital setting in Kinshasa, Democratic Republic of Congo. Hospital-based cross-sectional study of 153 patients with allergic rhinitis (AR). The diagnosis of AR was based on clinical grounds according to the Allergic Rhinitis and its Impact on Asthma (ARIA) criteria. Categorization into controlled AR (CAR) and UCAR was based on the visual analog scale (VAS with cut off point of 5). Binary logistic regression was used to identify factors associated with UCAR. Patients with UCAR (60.1%) proportionally outnumbered those with CAR (39.9%). There were significantly more patients younger than 30 years of age among patients with UCAR. Factors significantly associated with UCAR were age below 30 years (OR = 3.31; 95% CI: 1.49-7.36; p = 0.003), low serum vitamin D level (OR = 3.86; 95% CI: 1.72-8.68; p = 0.001), persistent form (OR = 3.11; 95% CI: 1.39-6.98; p = 0.006) and moderate to severe form of AR (OR = 4.31; 95% CI: 1.77-10.49; p = 0.001). Factors associated with UCAR in this study population were younger age less than 30 years, low vitamin D level, and persistent as well as moderate to severe AR. Further studies are needed to elucidate the underlying mechanisms favoring the occurrence of these factors.

Reassessment of the Need for Asthmatic Patients for Biologic Treatment in a Tertiary Care Hospital.

Asthma is a common chronic inflammatory airway condition. In difficult-to-treat asthma, poor control can be linked to multiple factors like the presence of uncontrolled comorbidities (e.g. gastroesophageal reflux and allergic rhinitis), as well as to poor inhaler use techniques and adherence.In this study we wanted to evaluate our severe asthma patients already on a biologic treatment with regard to presence of any of these factors. Method:A questionnaire-based study, filled by investigators through direct interview with patients. We included all asthma patients on biologic treatment at King Abdul Aziz Medical City, Riyadh, KSA. Started in October 2020 and ended in December 2020. The questionnaire had a demographic section and sections for asthma symptoms, compliance, inhaler techniques, and comorbidities. Case series of N=38 severe asthma patients showed that majority had partially controlled or uncontrolled asthma (66%). Some 42% had intermediate/high risk for obstructive sleep apnea (OSA) based on the common screening tool "STOPBANG" score. Some 47% of our patients had uncontrolled gastro-esophageal reflux disease (GERD), and majority (80%) had uncontrolled allergic rhinitis. Only half of them demonstrated appropriate inhaler technique. And none of them was found exposed to asthma triggers at the time of interview. Significant number of severe uncontrolled asthmatic patients were shown to be associated with at least one comorbid condition that might be interfering with patients' improvement in asthmatic symptoms. By taking appropriate measures toward management and controlling of those comorbid conditions and also educating patients about technique to use inhalers might show notable improvement in asthmatic patients' condition.

A multicenter real‐life study on the multiple reasons for uncontrolled allergic rhinitis

Recent data show uncontrolled disease in 35% of allergic rhinitis (AR) patients on medical treatment. The reasons for uncontrolled disease can arbitrarily be divided into disease-related, diagnosis-related, treatment-related, and patient-related factors. However, the relative importance of these factors in uncontrolled disease remains speculative. This explorative study aimed at determining the factors causing uncontrolled AR on four different continents worldwide, identifying the most common reasons for uncontrolled disease in AR. Patients with uncontrolled AR (n = 430) were asked to fill out a questionnaire and underwent a clinical examination at the outpatient clinic in five university outpatient clinics (Leuven [Belgium], Beijing [China], Kinshasa [Congo], Bangalore [India], and Philadelphia [US]). Two independent physicians evaluated the reason or multiple reasons for uncontrolled disease. The study was coordinated from the University Hospital of Leuven. In uncontrolled AR patients, 76% of patients showed two or more reasons for uncontrolled disease according to the physicians' evaluation. Disease-related factors (64%) were considered most often the reason for uncontrolled disease, followed by treatment- (56%), patient- (54%), and diagnosis-related (47%) factors. There is limited variability in observations across different centers worldwide. We here define the multiple reasons for uncontrolled AR across different continents, with disease-related factors being most frequently associated with uncontrolled disease. A better understanding of uncontrolled disease will guide us in defining strategies to improve AR care.

The Role of Nasal Endoscopy in Allergic Rhinitis and House Dust Mite Sublingual Immunotherapy

Introduction: While there exists considerable evidence for efficacy of sublingual immunotherapy (SLIT), its impact on the improvement of nasal signs in allergic rhinitis (AR) patients remains quite unclear. In this study, the endoscopic examination and the modified Lund-Kennedy (MLK) scoring system were performed to describe and evaluate the therapeutic effect of SLIT. Methods: A total of 105 patients with AR induced by house dust mites were enrolled and treated with standardized Dermatophagoides farinae (D. farinae) drops for 1 year. The total nasal symptoms score (TNSS), total medication score (TMS), visual analog scale (VAS), and MLK scores were assessed at baseline and 6 and 12 months. The MLK score was also compared for its correlation with TNSS, TMS, and VAS. Results: The TNSS, TMS, and VAS scores statistically decreased after SLIT compared to baseline (all p < 0.05). After 12 months of treatment, the rates of well-controlled, partial controlled, and uncontrolled AR patients were 42, 49.5, and 8.5%, respectively. The nasal endoscopy findings showed significant improvement in nasal signs, which mainly included color change of turbinate mucosa, reduction of nasal secretions, and improvement of nasal edema. A significant decrease was observed in MLK scores, and there was a positive correlation between MLK and VAS scores. Conclusions: In addition to commonly utilized subjective assessments (TMS, TNSS, and VAS), our results of endoscopic examination and the MLK scores consistently confirmed that SLIT is an effective therapeutic modality for AR patients. The MLK scores might be considered as an auxiliary tool to evaluate efficacy of SLIT in clinical practice and outcomes research.

Electron microscope of the nasal septal body versus the inferior turbinate

Objective Allergic rhinitis (AR) has increased in prevalence recently, and traditional treatment strategies sometimes show limited effectiveness for patients with intractable AR. Botulinum toxin type A (BTX‑A) is among the increasingly used alternative treatment options. This study was carried out with the aim of performing a clinical assessment of the effect of combined septal and turbinate injection of BTX‑A for the management of uncontrolled AR. Materials and methods A single‑arm pilot study enrolled 40 patients with moderate to severe uncontrolled AR recruited between October 2018 and August 2019. Each patient received 45 units of BTX‑A injected into three fixed points of each side of the nose: inferior turbinate (15 IU), middle turbinate (15 IU), and nasal septum (15 IU). All patients were evaluated in terms of nasal hypersecretions, congestion, and sneezing with a visual analog scale before treatment and at weeks 1, 2, 4, 8, and 12 during the follow‑up period. Results Throughout the 12‑week follow‑up period, a significant difference in the degree of nasal hypersecretions could be identified before and after BTX‑A injection. Sneezing differed significantly only in the first 4 weeks, while nasal congestion did not differ significantly before and after BTX‑A injection. BTX‑A was well tolerated by the patients, with no serious adverse or systemic effects. Conclusion Combined septal and turbinate injection of BTX‑A, in patients with uncontrolled AR, may be a long‑lasting therapeutic option for the treatment of nasal hypersecretions, but not as effective as for sneezing and nasal congestion. Keywords: allergic rhinitis, botulinum toxin, intranasal injection, nasal congestion, nasal hypersecretions, sneezing.

A Prospective Study to Compare Clinical Outcomes of Allergic Rhinitis Between Older and Younger Adults: A Potential Effect of Depression in Older Patients.

Although younger patients with allergic rhinitis (AR) have been successfully treated with pharmacotherapy, there are no definitive data on treatment outcomes in older patients with AR. We performed a prospective study of 51 older adults with AR (aged over 65 years) and 101 younger AR patients (aged from 19 to 40 years) to compare clinical outcomes between the 2 groups and to evaluate the impact of depressed mood on treatment outcomes in older AR patients. Changes in total symptom scores (TSS), rhinitis-specific quality of life questionnaire (RQLQ) results, rhinitis control assessment test (RCAT) results and visual analog scale (VAS) scores were evaluated after 4-week treatment according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guideline, and the severity of depressed mood was assessed by using the geriatric depression scale. After 4-week treatment, younger AR patients had greater improvements in clinical scores compared with older adults; differences in least squares mean changes from baseline in older patients vs. younger patients were 1.71 (P = 0.004) for TSS, 10.84 (P < 0.001) for RQLQ, 0.80 (P = 0.275) for RCAT, and 8.60 for VAS score (P = 0.061). Multiple logistic regression analysis showed that the severity of depressed mood was independently associated with severe chronic upper airway disease (adjusted odds ratio, 1.385; P = 0.004). Our results suggest that older AR patients are less responsive to standard treatment compared with younger AR patients and that depressed mood is strongly associated with the increased risk of uncontrolled AR in older AR patients.

CircARRDC3 contributes to interleukin‑13‑induced inflammatory cytokine and mucus production in nasal epithelial cells via the miR‑375/KLF4 axis.

Allergic rhinitis (AR) is a common inflammatory disorder of the nasal mucosa. It is a major risk factor for asthma development, and uncontrolled AR can lead to the worsening of asthma symptoms, which affects the quality of life and productivity of patients. Circular RNAs (circRNA) were reported to be involved in the pathogenesis of AR. The aim of the present study was to investigate the functional role of circRNA arrestin domain-containing 3 (circARRDC3) in AR progression. circARRDC3 knockdown suppressed the levels of granulocyte-macrophage colony-stimulating factor (GM-CSF) and eotaxin and mucin 5AC (MUC5AC) in IL-13-induced nasal epithelial cells. Moreover, circARRDC3 silencing promoted viability and suppressed apoptosis in IL-13-induced NECs. circARRDC3 targeted microRNA (miR)-375 and negatively regulated its expression. miR-375 inhibition reversed the effects of circARRDC3 knockdown on GM-CSF, eotaxin and MUC5AC expression levels, cell viability and cell apoptosis. In addition, miR-375 inhibited krueppel-like factor 4 (KLF4) expression through direct interaction, and miR-375 overexpression inhibited GM-CSF, eotaxin and MUC5AC expression levels, and cell apoptosis, which was abolished following KLF4 overexpression. In addition, circARRDC3, miR-375 and KLF4 were all dysregulated in the nasal mucosa of patients with AR. miR-375 expression was negatively correlated with circARRDC3 and KLF4 expression, and circARRDC3 expression was positively correlated with KLF4 expression. In conclusion, circARRDC3 contributed to the development of AR by regulating the miR-375/KLF4 axis. These findings may provide novel insights into the pathogenesis of AR.

Allergic rhinitis characterization in community pharmacy customers: a cross-sectional study.

Background Allergic rhinitis represents a public health problem that is significantly prevalent in the global population and has been associated with asthma, a strong desire to sleep and a low quality of life. Objective This study aims to evaluate the prevalence, symptoms, control strategies and treatment, as well as the control of this condition and its impact on the quality of life of customers of community pharmacies with allergic rhinitis. Setting A questionnaire survey was carried out in nine community pharmacies in the city of Guarda, Portugal. Method In this cross-sectional study, data was collected by an interview between May 2014 and December 2014. The control of the illness and the impact of allergic rhinitis on the quality of life were assessed through a CARAT10 test and a WHOQOL-BREF instrument, respectively. Main outcome measure The impact of allergic rhinitis on the patient's quality of life. Results The estimated prevalence of allergic rhinitis was between 10.8% and 15.4%, from which 63 and 42 individuals were medically and symptomatically diagnosed, respectively, from a study population of 804 respondents. The majority of participants (57.1%) suffered from the symptoms more than twice a year. The symptoms, such as difficulty in falling asleep, repeated and continuous sneezing and bilateral nasal obstruction, were severe. There were patients with uncontrolled allergic rhinitis symptoms after the CARAT10 test, even when the individual's perception of the quality of life was good according to the WHOQOL-BREF score, with gender differences in the psychological domain. It should also be emphasized that there was a significant association between higher education levels with better control of the illness/quality of life. Additionally, most participants used pharmacological treatment (not alternative therapies) and the adoption of self-management measures to relieve their symptoms. Conclusions The findings of this study showed that the estimated prevalence of allergic rhinitis seems to be apparently lower in Guarda than that found in the general Portuguese population. From the data, some patients showed uncontrolled allergic rhinitis symptoms, strengthening the importance of the role of intervention by a health professional.

Perception and control of allergic rhinitis in primary care

Perception of a chronic illness is a driver of patient behaviour that may impact treatment outcomes. The cross-sectional PETRA study was designed to describe the links between disease perception, patient behaviour and treatment outcomes in adults with allergic rhinitis (AR). Overall, 687 French general practitioners (GPs) included 1929 analysable patients (mean age: 39 years; intermittent/persistent symptoms: 46.2/52.3%). Of the patients, 14.1% had also been diagnosed with asthma; 71.7% had uncontrolled AR (ARCT score < 20), and 53.6% had a good perception of their illness (BIPQ score < 5). Factors significantly associated with poor perception of AR were ENT (ear/nose/throat) complications, nasal pruritus, uncontrolled AR and asthma. A strong negative correlation was observed between the BIPQ and ARCT scores: the poorer the patient’s perception, the less the AR was controlled. Although no causal relationship could be drawn, GP-driven improvement of AR perception could lead to better control of symptoms.

The Association Between Serum 25-Hydroxyvitamin D Levels and Patients With Allergic Rhinitis

IntroductionMany studies have suggested a link between vitamin D deficiency and the development of other atopic diseases like allergic rhinitis (AR). AR can lead to sleep disturbance, fatigue, depressed mood, and compromised cognitive function, which can impair the quality of life and productivity in many people.ObjectiveWe aimed to determine the association between vitamin D levels and AR and the effect of vitamin D on atopy markers.MethodsAll patients with AR who were diagnosed, treated, and followed up at the King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia from January 2012 to January 2020 were included in the study. Our exclusion criteria were as follows: pediatric patients, patients with insufficient follow-up data, patients with no atopy markers, patients with comorbid conditions affecting their serum vitamin D levels, and patients with a history of taking medications that affect serum vitamin D levels.ResultsFifty-five adult patients with AR were included in the study. Patients with vitamin D deficiency were more likely to have uncontrolled AR. Regarding the effect of vitamin D deficiency on atopy markers, there was no statistically significant relationship between vitamin D deficiency and serum immunoglobulin E (IgE) levels. However, serum eosinophil levels were significantly higher in patients with vitamin D deficiency.ConclusionOur results showed that vitamin D deficiency is strongly associated with uncontrolled AR; there was a statistically significant relationship between vitamin D deficiency and eosinophil levels, but no significant relationship between vitamin D deficiency and serum IgE was found.

Paranasal sinus disease could be a reason for unsuccessful immunotherapy of inhalant allergy in children.

The aim of this study was to evaluate the role of paranasal sinuses condition assessed in computed tomography on inhalant allergen desensitization effects. Retrospective analysis of medical records of children undergoing allergen immunotherapy in outpatient otolaryngology clinic of University Children Hospital in Lublin was performed. Control group consisted of children who underwent allergen immunotherapy and obtained satisfying effects; study group consisted of children who did not experience significant improvement after desensitization therapy. Computed tomography of nose cavity and paranasal sinuses exposed numerous pathologic changes affecting both, control and study group. Blockage of ostiomeatal complex was twice more common in children who did not respond adequately to desensitization therapy. In our study group, radiological findings suggesting rhinosinusitis were found in 73% of patients, while retention cysts in maxillary sinuses were discovered in 27% of patients. Pathological findings in paranasal sinuses in computed tomography may arise from uncontrolled allergic rhinitis. If chirurgical management is indicated, allergen immunotherapy should be postponed until total recovery from operational procedure and repeated.

A cross sectional observational study of severity of allergic rhinitis and its impact on asthma

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Allergic rhinitis (AR) and asthma are chronic diseases that often coexist and whose prevalence is increasing day by day. Uncontrolled allergic rhinitis may be associated with worsening of asthma and hence optimal treatment of AR may improve the coexisting asthma. The objective of the study was to study the severity of allergic rhinitis and its impact on asthma.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A cross sectional study was conducted on 60 patients, at our Institute from November 2017 to June 2019 who were clinically diagnosed to have AR and asthma. Patients were evaluated by proper history taking, in detailed clinical examination and diagnostic nasal endoscopy and spirometry. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In our study out of 60 patients, majority fell in 20 to 40 age group. According to allergic rhinitis and its impact on asthma (ARIA) classification 10 (17%) had mild intermittent AR, 12 (20%) had mild persistent AR, 5 (8%) had moderate/severe intermittent AR and 33 (55%) had moderate or severe persistent AR. In case of moderate/severe persistent AR: 4 had intermittent, 9 had mild persistent, 10 had moderate persistent and 10 severe persistent asthma. Spearman’s rank correlation was done between severity of AR and severity of asthma, spearman’s rho: 0.365, p&amp;lt;0.004 was significant.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; We noted that as the severity of allergic rhinitis increased, severity of asthma also increased, which was a linear correlation.&lt;/p&gt;

Interactions Between Air Pollution and Pollen Season for Rhinitis Using Mobile Technology: A MASK-POLLAR Study

Several studies have suggested an interaction between air pollution and pollen exposure with an impact on allergy symptoms. However, large studies with real-life data are not available. To investigate associations between major air pollutants (ozone and particulate matter with a diameter of <2.5 μm) and allergic rhinitis (AR) control during grass and birch pollen seasons as well as outside the pollen season. The daily impact of allergic symptoms was recorded by the Allergy Diary (Mobile Airways Sentinel NetworK [MASK-air]) app (a validated mHealth tool for rhinitis management) using visual analog scales (VASs) in Northern and Central Europe users in 2017 and 2018. Uncontrolled AR was defined using symptoms and medications. Pollutant levels were assessed using the System for Integrated modeLing of Atmospheric coMposition database. Pollen seasons were assessed by regions using Google Trends. Generalized estimating equation models were used to account for repeated measures per user, adjusting for sex, age, treatment, and country. Analyses were stratified by pollen seasons to investigate interactions between air pollutants and pollen exposure. A total of 3323 geolocated individuals (36,440 VAS-days) were studied. Associations between uncontrolled rhinitis and pollutants were stronger during the grass pollen season. Days with uncontrolled AR increased by 25% for an interquartile range increase in ozone levels during the grass pollen season (odds ratio of 1.25 [95% CI, 1.11-1.41] in 2017 and of 1.14 [95% CI, 1.04-1.25] in 2018). A similar trend was found for particulate matter with a diameter of less than 2.5 μm, especially in2017. These results suggest that the relationship between uncontrolled AR and air pollution is modified by the presence of grass pollens. This study confirms the impact of pollutants in the grass pollen season but not in the birch pollen season.

Interaction between air pollution and pollen seasons on allergic rhinitis control

A few studies have suggested an interaction between air pollution and pollen exposure on allergy symptoms but more research is needed. As part of the POLLAR (Impact of Air Pollution in Asthma and Rhinitis) project, we investigated the associations between major air pollutants (ozone and PM2.5) and allergic rhinitis control, during grass and birch pollen seasons, using the Allergy Diary app (a validated mHealth tool for allergic rhinitis management). The daily impact of allergic symptoms was recorded, using visual analogue scale (VAS), by 3,328 geolocated app users in 2017 and 2018 in Northern Europe, representing 36,523 VAS days. Uncontrolled allergic rhinitis was defined either as 1) VAS≥50, 2) VAS≥35 with intra-nasal corticosteroids or azelastine-fluticasone propionate use or 3) VAS≥20 and use of ≥3 allergic rhinitis medications. For each VAS recorded with geolocation, pollutants levels were assessed using the SILAM (System for integrated modelling of atmospheric composition) database, and pollen seasons were assessed by regions using Google Trends. Generalized estimating equation models were used to account for repeated measures per user, adjusting for gender, age, treatment and country. Positive associations were found between ozone and uncontrolled allergic rhinitis during the grass pollen season only (ORs=1.25 [1.11-1.41] and 1.14 [1.04-1.25], per interquartile range increase in ozone, for 2017 and 2018 respectively). A similar trend was found for PM2.5 levels in 2017 while results for 2018 did not suggest any effect modification by pollen seasons. These results show the importance of air pollution and allergen concentrations, and their interaction, as predictors of allergic rhinitis control.

A delayed diagnosis of eosinophilic granulomatosis with polyangiitis complicated with extensive artery occlusion of lower extremities in children: case report and literature review

BackgroundEosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitis in children. A delayed or missed diagnosis of pediatric EGPA is common, owing to the atypical clinical manifestation and limited recognition of this disorder. The vasculitis in EGPA typically involves small to medium size vessels. Extensive occlusion of arteries in the extremities was being extremely rare and has never been reported in children.Case presentationA 10-year and 10-month-old girl with recurrent wheezing and breathlessness during exercise, was initially diagnosed with asthma at the age of five years. Despite unexplained manifestations, including intermittent remarkably increased eosinophilia, uncontrolled allergic rhinitis, and recurrent petechia, from the onset of asthma through to its remission, the consideration of EGPA was completely ignored until the patient presented with aggravated petechia and severe ulceration of the lower extremities, associated with extensive stenosis and/or occlusion of the arteries of the shank and foot. Given her history of asthma, eosinophilia, allergic rhinitis, mononeuropathy, pulmonary infiltrates, and vasculitis confirmed by the skin biopsy, the diagnosis of EGPA was ultimately confirmed. Regrettably, the initial inappropriate and irrational use of corticosteroid failed to relieve the symptoms until more aggressive treatment with intravenous methylprednisolone was started. This was followed by methotrexate treatment, with tapering of prednisone, without relapse over a six-month follow-up.ConclusionsPediatric rheumatologists should be alert to the possibility of EGPA in children with refractory asthma associated with unexplained manifestations, and should be aware of the thromboembolic complications as vascular sequelae of EGPA.

Rhinology future trends: 2017 EUFOREA debate on allergic rhinitis.

The 2nd Rhinology Future Debate, organized by EUFOREA (European Forum for Research and Education in Allergy and Airways diseases) was held in Brussels in December 2017. One of these debates addressed the position of MP-AzeFlu in allergic rhinitis (AR) treatment. The current article summarizes this debate; reviewing recent data, and exploring how this has been interpreted by experts and incorporated into AR management guidelines and a clinical decision support system (CDSS). The Allergic Rhinitis & its Impact on Asthma (ARIA) guideline position MP-AzeFlu firstline for the treatment of AR, and in preference to intranasal corticosteroids (INSs) during the first 2 weeks of treatment. The AR CDSS recommends MP-AzeFlu as one of the firstline treatments for patients with a visual analogue scale (VAS) score lower than 5/10 cm, and in preference (along with INS) for those with a VAS score equal or higher than5/10 cm. Panellists agreed that AR management should be kept as simple as possible, with some preferring a one treatment fits all approach, while others preferred a step-up approach. The need to change the AR management mentality was acknowledged, accepting that most patients use their medication as needed and use multiple treatments; AR medications are needed which have a very fast onset of action and which target breakthrough symptoms. Panellists agreed that MP-AzeFlu has a role to play here, since it has a 5 minute onset-of-action, provides clinically-relevant symptom relief in 15 mins and AR control in less than 3 days, targets nasal hyper-reactivity (NHR) which likely contributes to uncontrolled AR and breakthrough symptoms, and provides more effective AR symptom relief than INS monotherapy or INS + oral antihistamine. Finally, experts considered it likely that MP-AzeFlu should have a greater impact on asthma control than INS in co-morbid patients, but clinical data is required to back up existing pharmacoeconomic evidence. The next Rhinology Future Debate will be in held in Brussels in Dec 2019.

The Characteristics of Severe Chronic Upper-Airway Disease (SCUAD) in Patients with Allergic Rhinitis: A Real-Life Multicenter Cross-Sectional Italian Study

Background: There are few studies regarding severe chronic upper-airway disease (SCUAD) that represents an important socioeconomic problem for the treatment of rhinitis and associated comorbidities, particularly asthma. Objectives: The aim of our study is to evaluate the prevalence of this pathology in patients with allergic rhinitis (AR) in real life, to phenotype allergic patients with SCUAD, and to identify which factors are related to the severity of the disease. Methods: We studied 113 patients with uncontrolled AR despite optimal adherence to therapy according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines in a multicenter Italian study, analyzing comorbidity, use of additional drugs, not scheduled visits, and the number of emergency room admissions. Results: Our data suggest that polysensitization is the only statistically significant factor correlating with SCUAD. Asthma does not seem to represent a correlating factor. An important finding is the poor use (20%) of allergy immunotherapy (AIT), although patients were suffering from AR and the ARIA guidelines recommend the use of AIT in moderate/severe AR. Conclusions: The SCUAD population seems not to have a specific phenotype; there is a greater presence of SCUAD in polysensibilized patients, perhaps a sign of greater inflammation.

Visual analogue scale - a tool for assessing the control of allergic rhinitis

Allergic rhinitis (AR) is the most common form of rhinitis and the most common allergic disease in children and adults. Numerous clinical studies and daily practice indicate a pronounced negative effect of symptoms of AR on patients’ quality of life, their usual daily activity, cognitive functions, mood and sleep. The type and severity of individual symptoms can vary from patient to patient, and therapy should be directed to the overall control of the symptoms of AR. It is important to obtain reliable and comparable information regarding the severity of AR symptoms before, during and after the treatment, which can be assessed using a simple and accessible tool - a visual analogue scale (VAS). VAS validated for patients with AR allows to define a controlled, partially controlled and uncontrolled AR. The article proposes an algorithm for the treatment of AR, depending on the severity of the symptoms, assessed using VAS.