EPOS2020/EUFOREA expert opinion on defining disease states and therapeutic goals in CRSwNP.

Severe chronic rhinosinusitis with nasal polyps (CRSwNP), a form of diffuse bilateral (usually type 2) CRS, is a debilitating disease with a significant impact on quality of life (QoL). With novel knowledge and treatment options becoming available, there is a growing need to update or revise key definitions to enable communication across different specialties dealing with CRS, and to agree on novel goals of care in CRSwNP. The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) and EPOS expert members discussed how to measure treatment responses and set new treatment goals for CRSwNP. In this paper a consensus on a list of definitions related to CRSwNP is provided: control, remission, cure, recurrence/exacerbation, treatable traits, remodeling, progression, and disease modification. By providing these definitions, the involved experts hope to improve communication between all stakeholders involved in CRSwNP treatment for use in routine care, basic and clinical research and international guidelines aimed to harmonize and optimize standard of care of patients with CRSwNP in the future.

EPOS/EUFOREA update on indication and evaluation of Biologics in Chronic Rhinosinusitis with Nasal Polyps 2023.

Severe chronic rhinosinusitis with nasal polyps (CRSwNP) is a debilitating disease with a significant impact on the quality of life (QoL). It is typically characterized by a type 2 inflammatory reaction and by comorbidities such as asthma, allergies and NSAID-Exacerbated Respiratory Disease (N-ERD). Here, the European Forum for Research and Education in Allergy and Airway diseases discusses practical guidelines for patients on biologic treatment. Criteria for the selection of patients who would benefit from biologics were updated. Guidelines are proposed concerning the monitoring of the drug effects that provide recognition of responders to the therapy and, subsequently, the decision about continuation, switching or discontinuation of a biologic. Furthermore, gaps in the current knowledge and unmet needs were discussed.

A UK community-based survey on the prevalence of rhinosinusitis.

OBJECTIVES: There is limited information about the prevalence of rhinosinusitis in the UK community. This study aimed to identify its prevalence and investigate any association with demographic variables. The secondary aims were to determine the degree of impairment, impact on quality of life and any costs incurred by patients. DESIGN: We used a modified version (MSNOT-20) of a quality-of-life instrument, the sinonasal outcome test-20 (SNOT-20), in a small and successful pilot project. It was then used in a community-based survey and a second phase 6 months later to test repeatability. Nasal examination and comparison of its quality-of-life section with other health-related quality-of-life tools occurred in the second phase. SETTING AND PARTICIPANTS: The questionnaire was administered by post to 2000 Farnborough (UK) residents, selected through stratified randomisation. The relation of an abnormal MSNOT-20 score with hay fever, asthma, smoking, food allergy, work productivity and social limitation was also analysed. MAIN OUTCOME AND RESULTS: The response rate was 79.8%; over thirty per cent of the community suffer from upper respiratory tract symptoms with impact on multiple domains of quality of life including emotional, financial costs and loss of days at work. The MSNOT-20 provided a more sensitive assessment of health-related quality of life than the Short Form 36 questionnaire. CONCLUSION: Rhinosinusitis is prevalent in the Farnborough community and associated with significant morbidity and impairment on quality of life. The MSNOT-20 is a useful disease-specific quality-of-life tool in rhinosinusitis.

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007).

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

Rhinitis in children: common clinical presentations and differential diagnoses.

Rhinitis is a common presentation in childhood. Acute virally induced rhinitis is generally self-limiting and usually does not require medical attention. Whilst allergic rhinitis is the focus of the paediatric allergist, the presentation of other diseases or comorbidities that can complicate or mimic allergic rhinitis needs to be considered. Effects on the child's quality of life also need to be addressed. Rhinitis can be associated with asthma and other significant comorbidities: importantly, non-allergic rhinitis can sometimes be a consequence of systemic immune impairment. The diagnosis of rhinitis is based on clinical findings with directed investigations. Nasal nitric oxide measurement is an emerging diagnostic tool and helpful particularly in relation to evaluating the differential diagnosis in more difficult rhinitis. Successfully identifying the cause of rhinitis in childhood and associated comorbidities can ensure that the patient is successfully treated as described in the recently published EAACI Pediatric Rhinitis Position Paper.

Rhinosinusitis in secondary school children-part 1: pilot study of the MSNOT-20 Young Person Questionnaire (MSYPQ).

BACKGROUND: The SNOT-20 questionnaire, a valid disease related quality of life instrument for rhinosinusitis, was modified for use in secondary school children and became the Modified Sino Nasal Outcome Test -20 Young Person Questionnaire, MSYPQ. METHODODOLOGY: MSYPQ was evaluated in a pilot study of disease (rhinosinusitis) and non-disease according to criteria in the European Position Paper on Rhinosinusitis and Nasal polyposis (EPOS). RESULTS: Those children who were suffering from rhinosinusitis according to the EPOS criteria showed significantly high scores on MSYPQ, whereas those who did not have rhinosinusitis had very low to zero scores on the MSYPQ. CONCLUSION: This pilot study confirmed that the MSYPQ recognises rhinosinusitis symptoms in the 11-16 year age group with its effect on quality of life and is a suitable instrument to investigate the prevalence and impact of this problem in young people.

Rhinosinusitis in secondary school children-part 2: main project analysis of MSNOT-20 Young Persons Questionnaire (MSYPQ).

BACKGROUND: There is little data on rhinosinusitis in adolescent schoolchildren. We have employed a validated, disease specific quality of life questionnaire to determine the extent of this problem and its effects on their lives. METHODOLOGY: The MSYPQ, a disease specific quality of life questionnaire, previously evaluated in a pilot study of adolescent sino-nasal disease, was used in secondary school children in East London to identify the prevalence of rhinosinusitis plus its effects on quality of life. One group of the secondary school children completed ARIA based questions for comparison with MSYPQ rhinitis sub-scores. RESULTS: 71% scored an abnormal value on the MSYPQ for at least one symptom, 32% of those assessed suffered from symptoms compatible with rhinitis, similar to the prevalence of 30% previously found in adults. Unlike adults cough was one of the most significant symptoms. Over 21% of secondary school students had their quality of life affected and 11% took time off school due to their symptoms. The ARIA assessment group showed that symptoms were intermittent in 44% and confirmed significant impairment of sleep and daily activities. CONCLUSION: The MSYPQ demonstrates a high prevalence and impact on quality of life of rhinitis and rhinosinusitis symptoms in the 11-16 age group, with levels comparable to the results from an adult population. The MSYPQ rhinitis sub group of questions was concordant with ARIA based questions.

Nasal polyp syndrome: a patient-centred term for CRSwNP by EUFOREA.

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a chronic inflammatory disease of the nose and paranasal sinus cavities that significantly affects well-being and social function, particularly in young adults and middle-aged populations. CRSwNP is a common health condition in the Western world, with an estimated prevalence of 3%. Despite worldwide evidence-based treatment guidelines such as the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 and the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) chronic rhinosinusitis (CRS) pocket guide, a significant number of patients remain undiagnosed and/or uncontrolled with repeated oral corticosteroids (OCS) treatments and/or (multiple) endoscopic sinus surgeries (ESS).

Local allergic rhinitis - a narrative review.

This narrative review aims to provide an up-to-date definition of local allergic rhinitis (LAR), its classification, mechanisms, comorbidities, recommendations for diagnosis and treatment, and define needs in this area. Both 'PubMed' and 'Science Direct' literature was reviewed systematically, and a manual search for studies not previously encountered in the databases was also carried out. Published studies were identified in PubMed covering the period from 1947 to 2022. The following keyword search strategy was used: (local allergic rhinitis* OR entopy* OR local Immunoglobulin E * OR nasal specific Immunoglobulin E). LAR involves Type 2 nasal inflammation with local IgE and cannot be diagnosed by systemic methods, such as skin prick or blood IgE tests. A nasal allergen challenge is necessary for diagnosis. LAR can respond to usual AR treatments, including allergen specific immunotherapy (AIT). LAR is a novel entity that requires additional investigation in terms of prevalence, proper diagnosis, treatment, and prognosis. The target outcomes and possible benefits of this review are to achieve a consensus for the study and diagnosis of LAR and increase interest in this area.

Pre-asthma: a useful concept? A EUFOREA paper. Part 2-late onset eosinophilic asthma.

The concept of pre-diabetes has led to provision of measures to reduce disease progression through identification of subjects at risk of diabetes. We previously considered the idea of pre-asthma in relation to allergic asthma and considered that, in addition to the need to improve population health via multiple measures, including reduction of exposure to allergens and pollutants and avoidance of obesity, there are several possible specific means to reduce asthma development in those most at risk (pre- asthma). The most obvious is allergen immunotherapy (AIT), which when given for allergic rhinitis (AR) has reasonable evidence to support asthma prevention in children (2) but also needs further study as primary prevention. In this second paper we explore the possibilities for similar actions in late onset eosinophilic asthma.

Pre-asthma: a useful concept for prevention and disease-modification? A EUFOREA paper. Part 1-allergic asthma.

Asthma, which affects some 300 million people worldwide and caused 455,000 deaths in 2019, is a significant burden to suffers and to society. It is the most common chronic disease in children and represents one of the major causes for years lived with disability. Significant efforts are made by organizations such as WHO in improving the diagnosis, treatment and monitoring of asthma. However asthma prevention has been less studied. Currently there is a concept of pre- diabetes which allows a reduction in full blown diabetes if diet and exercise are undertaken. Similar predictive states are found in Alzheimer's and Parkinson's diseases. In this paper we explore the possibilities for asthma prevention, both at population level and also investigate the possibility of defining a state of pre-asthma, in which intensive treatment could reduce progression to asthma. Since asthma is a heterogeneous condition, this paper is concerned with allergic asthma. A subsequent one will deal with late onset eosinophilic asthma.

EUFOREA summit in Brussels 2023: inspiring the future of allergy & respiratory care.

In March 2023, the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) organized its bi-annual Summit in Brussels with expert panel members of EUFOREA, representatives of the EUFOREA patient advisory board, and the EUFOREA board and management teams. Its aim was to define the research, educational and advocacy initiatives to be developed by EUFOREA over the next 2 years until the 10th anniversary in 2025. EUFOREA is an international non-for-profit organization forming an alliance of all stakeholders dedicated to reducing the prevalence and burden of chronic allergic and respiratory diseases via research, education, and advocacy. Based on its medical scientific core competency, EUFOREA offers an evidence-supported platform to introduce innovation and education in healthcare leading to optimal patient care, bridging the gap between latest scientific evidence and daily practice. Aligned with the mission of improving health care, the expert panels of asthma, allergic rhinitis (AR), chronic rhinosinusitis (CRS) & European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), allergen immunotherapy (AIT) and paediatrics have proposed and elaborated a variety of activities that correspond to major unmet needs in the allergy and respiratory field. The current report provides a concise overview of the achievements, ambitions, and action plan of EUFOREA for the future, allowing all stakeholders in the allergy and respiratory field to be up-dated and inspired to join forces in Europe and beyond.

The intranasal trigeminal system: roles in rhinitis (allergic and non-allergic).

The aim of this paper is to review intranasal trigeminal system and associated reflexes. The literature survey was performed on PubMed, ProQuest Central database of Kirikkale University and Google Scholar. The intranasal trigeminal system and associated reflexes play an important role in humans in both health and disease, including in rhinitis of non-allergic and mixed type. The intranasal trigeminal nerve provides sensory perception to the lining of the nose, supplying information on how patent the nasal airway is and responding to various chemical signals. The reflexes known to exist within the intranasal trigeminal system are nasobronchial reflex, trigemino-cardiac reflex, nasogastric reflex, and nasal cycle. The intranasal trigeminal system and its reflexes play a vital role in normal human physiology. Alterations in how this system operates may underlie multiple forms of rhinitis and more research is needed to fully understand the mechanisms involved.

Diseases mimicking allergic rhinitis.

Although allergic rhinitis is the commonest diagnosis in the child with nasal obstruction and rhinorrhoea, the differential must include other, much rarer, conditions. We present three case histories and discussion of several other diagnoses which should be considered.

Developments in the field of allergy in 2008 through the eyes of Clinical & Experimental Allergy.

In 2008, many thousands of articles were published on the subject of allergic disease with over 200 reviews, editorials and original papers in Clinical & Experimental Allergy alone. These represent a considerable amount of data and even the most avid reader could only hope to assimilate a small fraction of this knowledge. There is therefore a pressing need for the key messages that emerge from a journal such as Clinical & Experimental Allergy to be summarized by experts in the field in a form that highlights the significance of the developments and sets them in the context of important findings in the field published in other journals. This also has the advantage of making connections between new data in conditions such as asthma, where articles often appear in different sections of the journal. As can be seen from this review, the body of work is diverse both in terms of the disease of interest and the discipline that has been used to investigate it. However, taken as a whole, we hope that the reader will gain a flavour of where the field is mature, where there remain controversies and where the cutting edge is leading.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis.

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

BSACI guidelines for the management of allergic and non-allergic rhinitis.

This guidance for the management of patients with allergic and non-allergic rhinitis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practicing in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are clinical classification of rhinitis, aetiology, diagnosis, investigations and management including subcutaneous and sublingual immunotherapy. There are also special sections for children, co-morbid associations and pregnancy. Finally, we have made recommendations for potential areas of future research.

Acetylcholine receptor antibody synthesis by thymic lymphocytes: correlation with thymic histology.

Antiacetylcholine receptor antibody (anti-AChR) was spontaneously synthesized by cultured thymic tissue from 19 of 35 patients with myasthenia gravis. Two other thymus cultures produced antibody after stimulation by pokeweed mitogen. Antibody production correlated with histologic evidence of thymitis, long duration of symptoms, or high serum anti-AChR values. None of seven thymomas synthesized antibody in culture, but evidence suggested that there had been in vivo synthesis or trapping of anti-AChR. Clinical improvement after thymectomy, during the short period of study, did not correlate with synthesis rates of anti-AChR production by the removed thymus. The rates of anti-AChR production in culture were too low to suggest that the thymus is the major source of this antibody. Although we did not find a clear relationship between anti-AChR antibody and clinical state within 3 months of thymectomy, in a study of 25 nonimmunosuppressed, nonthymoma patients followed for 1 to 4 years, we found a significant correlation (p less than 0.05, Spearman Rank correlation) between fall in anti-AChR antibody and clinical improvement after thymectomy (unpublished observations).

Humoral immunity before and after thymectomy in myasthenia gravis.

Humoral immunity was studied in 10 patients with myasthenia gravis before thymectomy, in 15 different patients over 10 years after thymectomy, and in normal controls. Antibody titers to acetylcholine receptor were significantly (p less than 0.01) lower in the post-thymectomy group. However, other antibody titers to common viruses, and to Escherichia coli, and isohemagglutinins showed no significant change. Levels of IgM and IgE (with atopic subjects excluded) decreased following thymectomy (p less than 0.05). Autoantibodies persisted, apart from those directed against the acetylcholine receptor. The absence of any significant changes in humoral immunity after thymectomy for myasthenia gravis suggests that there is no generalized loss of helper T-cell function.