Enhanced Clinical Efficacy of Sublingual Immunotherapy for Japanese Cedar Pollinosis in the Second Year of Treatment.

Sublingual immunotherapy (SLIT) is thought to have enhanced efficacy in the second year of treatment. We studied treatment efficacy in both the first and the second years of treatment (2015 and 2016, respectively) in patients who began SLIT in 2014. Methods: We compared 132 patients who underwent SLIT (age, 41.8 ± 17.5 years; male-to-female ratio, 75: 57) and a control group of 56 patients who underwent primary pharmacotherapy (age, 44.9 ± 13.5 years; male-to-female ratio, 25: 31). The study was performed during the peak pollen seasons of 2015 and 2016. Pollen dispersal was similar in 2015 and 2016 (2,509 grains/cm2 and 3,505 grains/cm2, respectively). The clinical efficacy of SLIT was evaluated by assessing nasal and eye symptoms and total symptoms with symptom scores and combined symptom-medication scores, visual analog scale scores, and quality of life (QOL) scores according to the Japanese rhino-conjunctivitis QOL questionnaire (JRQLQ No. 1). QOL was also evaluated with JRQLQ No. 1. The first endpoint was enhanced efficacy of SLIT in the second year compared with that in the first year. Results: With respect to nasal and eye symptoms, the assessments in the primary pharmacotherapy group were unchanged in the second year; however, most of these assessments in the SLIT group demonstrated significantly enhanced efficacy of SLIT in the second year. In QOL of SLIT, only 2 of 17 showed significantly enhanced efficacy of SLIT in the second year. Conclusion: SLIT shows enhanced efficacy in the second year.

Group 2 innate lymphoid cells are increased in nasal polyps in patients with eosinophilic chronic rhinosinusitis.

ILC2s represent a critical innate cellular source of type 2 cytokines and may play important roles in various diseases. We examined the role of ILC2s in the pathogenesis of two subgroups of CRSwNP: ECRS and non-ECRS. We analyzed the prevalence of ILC2s in sinonasal tissues and in blood from patients with ECRS, non-ECRS, CRSsNP, and control. The prevalence of ILC2s in nasal tissues was higher in patients with ECRS as compared to those with non-ECRS or CRSsNP. The prevalence of blood ILC2s was not different between patients with ECRS and non-ECRS. The prevalence of blood ILC2s was higher in patients with allergic rhinitis and elevated serum IgE levels. Alternaria-induced IL-33 secretion was increased in nasal epithelial cells derived from patients with ECRS as compared to those from patients with non-ECRS or CRSsNP. ILC2s may be involved in the pathogenesis of CRSwNP, in particular in patients with tissue eosinophilia (i.e., ECRS).

Protective efficacy of passive immunization with monoclonal antibodies in animal models of H5N1 highly pathogenic avian influenza virus infection.

Highly pathogenic avian influenza (HPAI) viruses of the H5N1 subtype often cause severe pneumonia and multiple organ failure in humans, with reported case fatality rates of more than 60%. To develop a clinical antibody therapy, we generated a human-mouse chimeric monoclonal antibody (MAb) ch61 that showed strong neutralizing activity against H5N1 HPAI viruses isolated from humans and evaluated its protective potential in mouse and nonhuman primate models of H5N1 HPAI virus infections. Passive immunization with MAb ch61 one day before or after challenge with a lethal dose of the virus completely protected mice, and partial protection was achieved when mice were treated 3 days after the challenge. In a cynomolgus macaque model, reduced viral loads and partial protection against lethal infection were observed in macaques treated with MAb ch61 intravenously one and three days after challenge. Protective effects were also noted in macaques under immunosuppression. Though mutant viruses escaping from neutralization by MAb ch61 were recovered from macaques treated with this MAb alone, combined treatment with MAb ch61 and peramivir reduced the emergence of escape mutants. Our results indicate that antibody therapy might be beneficial in reducing viral loads and delaying disease progression during H5N1 HPAI virus infection in clinical cases and combined treatment with other antiviral compounds should improve the protective effects of antibody therapy against H5N1 HPAI virus infection.

CLINICAL EFFICACY OF SUBLINGUAL IMMUNOTHERAPY IN THE SECOND TREATED YEAR FOR 133 PATIENTS WITH JAPANESE CEDAR POLLINOSIS IN 2016.

It past 2 years in 2016 after the first purchase of the drug for sublingual immunotherapy (SLIT) for Japanese Cedar pollinosis (JCP). PURPOSE: The purpose of this study is to clear the clinical efficacy of SLIT in the second treated year by comparing with other therapies, such as subcutaneous immunotherapy (SCIT), or other pharmacotherapy. METHODS: We started SLIT at our clinic in October-December, 2014. We compared the clinical efficacy in 2016, of 133 SLIT with 46 SCIT, 351 primary pharmacotherapy that started therapies before pollen dispersal, 221 pharmacotherapy that started therapies after pollen disposal, or 337 non-treatment. The clinical efficacy was evaluated with symptom scores and combined symptom-medication scores (SMS), symptoms of nose and eye by visual analog scale (VAS), quality of life (QOL) scores by Japanese rhino-conjunctivitis QOL questionnaire (JRQLQ No1). RESULTS: Fourteen cases by unknown reasons and 3 cases by inevitable reasons were dropped out for 2 years. Both SCIT and SLIT showed good clinical efficacy without significant difference in every assessment. Both SCIT and SLIT were significantly better than other pharmacotherapy in most assessment. Patients, whose symptom scores of nose and eye were 0 or 1 point without any rescue drugs, accounted for 26.3% of total SLIT. CONCLUSION: SLIT in the second treated year showed good clinical efficacy in reducing symptoms and SMS of JCP, and in improving QOL. SLIT was significantly effective compaired with other pharmacotherapies.

Adherence and Clinical Outcome of Sublingual Immunotherapy for Japanese Cedar Pollinosis.

Sublingual immunotherapy (SLIT) for Japanese cedar pollinosis is known to be effective. However, better SLIT adherence is needed to improve its safety and efficacy. 　Purpose: The purpose of this study was to evaluate SLIT adherence and its influence on clinical outcome. 　Methods: We conducted a detailed survey of 132 patients who have been receiving SLIT for 2 years on adherence at each visit using both questionnaires and direct calculation from prescription. Questionnaires on total symptoms using the visual analog scale (VAS), face scale, and total nasal symptom medication score (TNSMS) were obtained at the peak season for Japanese cedar pollinosis. 　Results: Good adherence by prescription for 2 years was observed in 83.1% ± 11.7% of patients. The adherence in the second year (80.8% ± 13.6%) was lower than that in the first year (88.5% ± 9.8%). However, adherence by questionnaire was 13.5% higher than that by prescription. VAS of total symptoms and adherence did not correlate; however, evaluations by VAS, face scale, and TNSMS were significantly improved if the adherence cut-off value was set to 70% or 75%. 　Conclusion: Our results suggest that SLIT adherence for Japanese cedar pollinosis is high and adequate adherence is required for better efficacy.

[CLINICAL EFFICACY OF SUBLINGUAL IMMUNOTHERAPY FOR JAPANESE CEDAR POLLINOSIS IN THE FIRST FOLLOW-UP YEAR].

UNLABELLED: The first drug of sublingual immunotherapy (SLIT) for Japanese Cedar pollinosis (JCP) was purchased in 2014.   PURPOSE: The purpose of this study is to clear the clinical efficacy of SLIT by comparing with other therapies, such as subcutaneous immunotherapy (SCIT), or other pharmacotherapy.   METHODS: We started SLIT at our clinic in October-December, 2014. We compared the clinical efficacy of 191 SLIT with 48 SCIT, 191 primary pharmacotherapy that started therapies before pollen dispersal, 141 pharmacotherapy that started therapies after pollen disposal, or 169 non-treatment in the first follow-up year. The clinical efficacy was evaluated with quality of life (QOL) scores by Japanese rhino-conjunctivitis QOL questionnaire (JRQLQ No1), symptoms of nose and eye by visual analog scale (VAS), symptom scores and combined symptom-medication scores (SMS).   RESULTS: Mild adverse events (AEs) were observed in many cases, but no patient was discontinued by AEs in SLIT patients. Five cases by unknown reasons and 3 cases by inevitable reasons were dropped out before pollen. Adherence of SLIT was 89±12%. SCIT was better than SLIT in most assessments, but not significant. Both SCIT and SLIT were significantly better than other pharmacotherapy. Patients, whose symptom scores of nose and eye were 0 or 1 point without any rescue drugs, accounted for 16.8% of total SLIT in the first follow-up year.   CONCLUSION: SCIT was slightly better than SLIT in reducing symptoms and SMS of JCP, and in improving QOL. However, the differences were not significant. SLIT was significantly effective than other pharmacotherapies.

[Adverse Events of Sublingual Immunotherapy in 207 Patients with Japanese Cedar Pollinosis].

UNLABELLED: Sublingual immunotherapy (SLIT) for Japanese cedar pollinosis is effective, however, caution must be exercised against allergen-specific adverse events (AEs) during SLIT. PURPOSE: The purpose of this study was to clarify the AEs of SLIT in a large cohort of patients with Japanese cedar pollinosis. METHODS: We conducted a detailed survey, by both questionnaires and direct interviews, of 207 patients receiving SLIT at our clinic. RESULTS: Eighty-four of the 207 patients (40.5%) developed AEs, with AEs involving the oral cavity and throat being the most common (56 patients; 27.1%). Sixteen patients (7.9%) had local mucosal swelling, but the swelling resolved in all the cases. Other allergen-induced symptoms such as nasal symptoms (29 events, 14.0%), eye symptoms (14 events, 6.8%) and ear symptoms (20 events, 9.7%) were also recognized. All the AEs were minor, and discontinuation of SLIT was not necessitated in any of the patients because of AEs. There were 52 AEs (25.0%) in the up-dose phase and 61 AEs (29.3%) in the maintenance phase. However, only 4 of the 161 patients (2.5%) developed AEs during the pollen season. Most AEs developing during the maintenance phase occurred in the first few weeks. In 60% of the cases, the AEs disappeared within 2 weeks, and in 6.0% (5 events), they persisted for longer than 2 months. There were no age-or sex-related differences in the prevalence of cedar pollen-specific IgE, or in the adherence to the treatment. CONCLUSION: AEs in SLIT were shown in many patients, however, the severity of AEs was mild and no events interfered SLIT.

Efficacy of repeated intravenous administration of peramivir against highly pathogenic avian influenza A (H5N1) virus in cynomolgus macaques.

Highly pathogenic avian influenza A (H5N1) viruses cause severe and often fatal disease in humans. We evaluated the efficacy of repeated intravenous dosing of the neuraminidase inhibitor peramivir against highly pathogenic avian influenza virus A/Vietnam/UT3040/2004 (H5N1) infection in cynomolgus macaques. Repeated dosing of peramivir (30 mg/kg/day once a day for 5 days) starting immediately after infection significantly reduced viral titers in the upper respiratory tract, body weight loss, and cytokine production and resulted in a significant body temperature reduction in infected macaques compared with that of macaques administered a vehicle (P < 0.05). Repeated administration of peramivir starting at 24 h after infection also resulted in a reduction in viral titers and a reduction in the period of virus detection in the upper respiratory tract, although the body temperature change was not statistically significant. The macaque model used in the present study demonstrated that inhibition of viral replication at an early time point after infection by repeated intravenous treatment with peramivir is critical for reduction of the production of cytokines, i.e., interleukin-6 (IL-6), tumor necrosis factor α, gamma interferon, monocyte chemotactic protein 1, and IL-12p40, resulting in amelioration of symptoms caused by highly pathogenic avian influenza virus infection.

Efficacy of clarithromycin against H5N1 and H7N9 avian influenza a virus infection in cynomolgus monkeys.

Clarithromycin (CAM), a 14-membered ring macrolide, has anti-inflammatory and immunomodulatory actions and antiviral effects in seasonal influenza virus infection. We examined the prophylactic and therapeutic efficacy of CAM against H5N1 highly pathogenic and H7N9 low pathogenic avian influenza virus infections in cynomolgus monkeys. CAM suppressed H5N1 virus-induced severe signs of disease in the treated monkeys and inhibited virus propagation in tracheal samples and the production of inflammatory cytokines in the lungs of monkeys infected with H5N1 and H7N9 viruses. The prophylactic administration of CAM showed more suppressive effects on clinical signs of disease and viral titers than did therapeutic administration. Thus, since administration of CAM alone showed a tendency to ameliorate clinical sings and to reduce levels of inflammatory cytokines, the macrolides are expected to have effects in combination with the other antiviral drugs on the prophylactic and treatment of patients with severe avian influenza virus infection, which should be further investigated.

[Endoscopic ligation of maxillary and sphenopalatine artery for intractable epistaxis].

We report the endoscopic ligation of the maxillary and sphenopalatine arteries for the treatment of intractable epistaxis. From March 2003 to February 2005, 17 patients (12 men, 5 women) with epistaxis were hospitalized in our department. Patient age ranged from 25 to 83 years, with an average age of 62 years. 8 patients were successfully treated using the conventional packing method, 2 patients were treated using electrocauterization, and 1 patient with macroglobulinemia was treated using plasma exchange therapy. 6 patients underwent endoscopic ligation of the maxillary and sphenopalatine arteries while under general anesthesia. The post operative courses were uneventful, and no recurrent bleeding has been noted. Endscopic ligation of the maxillary and sphenopalatine arteries is safer than intraarterial embolization and less invasive than conventional surgical approach for the ligation of maxillary artery. This technique appears to be a safe and effective surgical treatment for patients with intractable epistaxis.

[Endoscopic resection of benign and malignant tumors in the nasal cavity and paranasal sinus].

Endoscopic resection of nasal and paranasal sinus tumors is more aesthetic and less invasive than conventional resection, such as Luc's operation and lateral rhinotomy. We clarified the effect of radical endoscopic tumor excision and the control of local bleeding hazardous in endoscopic surgery. Subjects were patients with benign lesions in the nasal cavity, medial wall of the maxillary sinus, ethmoid sinus, and/or sphenoid sinus without concurrent malignant lesions. Although patients selection for malignant tumor excision was based on (1) possible en bloc resection, (2) low-grade malignant tumors, and (3) tumors in the nasal cavity and adjoining paranasal sinus, the final decision was made individual. Subjects were 23 patients with benign tumor (10 inverted papilloma, 9 hemangioma, 2 juvenile angiofibroma, and 2 other tumors) and 4 with malignant tumor (olfactory neuroblastoma, acinic cell carcinoma, squamous cell carcinoma, and chondroid chordoma) in the nasal and paranasal sinus. The tumor was resected en bloc except for patients with inverted papilloma (2 cases) and chondroid chordoma. Recurrence in benign tumors was zero during a mean observation of 21 months. One with chondroid chordoma, however, suffered a recurrent lesion 7 months after the initial operation. The lesion was successfully salvaged by a similar endoscopic procedure and subsequently treated with electron beam irradiation. Preoperative arterial embolization, laser coagulation, and ligation of the sphenopalatine artery were very useful in reducing blood loss during surgery and maintaining a clear endoscopic view. In intraoperative bleeding volume, less than 100 ml of bleeding occurred during surgery in 23 of 27 patients. The endoscopic excision of benign lesions in the nasal and paranasal sinus is thus as effective as conventional radical surgery. Endoscopic removal of malignant lesions remains controversial because of the small number of patients and short postoperative observation.

Primary ductal adenocarcinoma of the lacrimal sac: the first reported case.

Primary lacrimal sac tumor is extremely rare, and moreover, glandular tumor is exceptional. Herein, we described the first documented case of primary ductal adenocarcinoma of the lacrimal sac. A 79-year-old Japanese female presented with persistent swelling of her left lower eyelid. Computed tomography demonstrated an irregular-shaped tumor involving the left lacrimal sac, lower eyelid, sinonasal tract, and internal side of the left orbit. Biopsy from the eyelid revealed a poorly differentiated adenocarcinoma. Histopathological study of the resected lacrimal sac tumor revealed an infiltrative neoplastic growth that was composed of cribriform structures with comedonecrosis. The neoplastic cells had relatively rich granular eosinophilic cytoplasm and large round to oval nuclei containing conspicuous nucleoli. The left cervical lymph nodes had metastatic carcinoma. Immunohistochemically, the neoplastic cells were diffusely positive for gross cystic disease fluid protein-15 and androgen receptor. Moreover, mammalian target of rapamycin (mTOR), 4E-BP1, and p4E-BP1 were expressed. According to these results, an ultimate diagnosis of primary ductal adenocarcinoma of the lacrimal sac was made. Only 9 cases of primary lacrimal sac adenocarcinoma have been reported, and this is the first reported case of ductal adenocarcinoma of the lacrimal sac. Ductal adenocarcinoma of the salivary gland shows an aggressive clinical course, and the present case had multiple cervical lymph node metastases. This report is the first to demonstrate that mTOR pathway proteins, which are central proteins involved in carcinogenesis, are activated in ductal adenocarcinoma. Therefore, mTOR inhibitor may be a potential candidate for treatment of this highly aggressive carcinoma.

Pathogenicity of pandemic H1N1 influenza A virus in immunocompromised cynomolgus macaques.

Pandemic (H1N1) 2009 influenza virus spread throughout the world since most people did not have immunity against the virus. In the post pandemic phase when many humans might possess immunity against the pandemic virus, one of the concerns is infection in immunocompromised people. Therefore, we used an immunosuppressed macaque model to examine pathogenicity of the pandemic (H1N1) 2009 virus under an immunocompromised condition. The virus in nasal samples of immunosuppressed macaques infected with the pandemic (H1N1) 2009 virus was detected longer after infection than was the virus in nasal samples of immunocompetent macaques. As expected, not only virus amounts but also virus propagation sites in the immunosuppressed macaques were larger than those in lungs of the immunocompetent macaques when they were infected with the pandemic virus. Immunosuppressed macaques possessed low levels of immune cells producing cytokines and chemokines, but levels of inflammatory cytokines/chemokine interleukin (IL)-6, IL-18, and monocyte chemotactic protein (MCP)-1 in lungs of the immunosuppressed macaques were higher than those in lungs of the immunocompetent macaques, though the differences were not statistically significant. Therefore, under an immunosuppressive condition, the pandemic influenza (H1N1) 2009 virus might cause more severe morbidity with high cytokine/chemokine production by the host innate immune system than that seen in macaques under the immunocompetent condition.

Protection against H5N1 highly pathogenic avian and pandemic (H1N1) 2009 influenza virus infection in cynomolgus monkeys by an inactivated H5N1 whole particle vaccine.

H5N1 highly pathogenic avian influenza virus (HPAIV) infection has been reported in poultry and humans with expanding clade designations. Therefore, a vaccine that induces immunity against a broad spectrum of H5N1 viruses is preferable for pandemic preparedness. We established a second H5N1 vaccine candidate, A/duck/Hokkaido/Vac-3/2007 (Vac-3), in our virus library and examined the efficacy of inactivated whole particles of this strain against two clades of H5N1 HPAIV strains that caused severe morbidity in cynomolgus macaques. Virus propagation in vaccinated macaques infected with either of the H5N1 HPAIV strains was prevented compared with that in unvaccinated macaques. This vaccine also prevented propagation of a pandemic (H1N1) 2009 virus in macaques. In the vaccinated macaques, neutralization activity, which was mainly shown by anti-hemagglutinin antibody, against H5N1 HPAIVs in plasma was detected, but that against H1N1 virus was not detected. However, neuraminidase inhibition activity in plasma and T-lymphocyte responses in lymph nodes against H1N1 virus were detected. Therefore, cross-clade and heterosubtypic protective immunity in macaques consisted of humoral and cellular immunity induced by vaccination with Vac-3.

Memory immune responses against pandemic (H1N1) 2009 influenza virus induced by a whole particle vaccine in cynomolgus monkeys carrying Mafa-A1*052:02.

We made an H1N1 vaccine candidate from a virus library consisting of 144 ( = 16 HA×9 NA) non-pathogenic influenza A viruses and examined its protective effects against a pandemic (2009) H1N1 strain using immunologically naïve cynomolgus macaques to exclude preexisting immunity and to employ a preclinical study since preexisting immunity in humans previously vaccinated or infected with influenza virus might make comparison of vaccine efficacy difficult. Furthermore, macaques carrying a major histocompatibility complex class I molecule, Mafa-A1*052:02, were used to analyze peptide-specific CD8(+) T cell responses. Sera of macaques immunized with an inactivated whole particle formulation without addition of an adjuvant showed higher neutralization titers against the vaccine strain A/Hokkaido/2/1981 (H1N1) than did sera of macaques immunized with a split formulation. Neutralization activities against the pandemic strain A/Narita/1/2009 (H1N1) in sera of macaques immunized twice with the split vaccine reached levels similar to those in sera of macaques immunized once with the whole particle vaccine. After inoculation with the pandemic virus, the virus was detected in nasal samples of unvaccinated macaques for 6 days after infection and for 2.67 days and 5.33 days on average in macaques vaccinated with the whole particle vaccine and the split vaccine, respectively. After the challenge infection, recall neutralizing antibody responses against the pandemic virus and CD8(+) T cell responses specific for nucleoprotein peptide NP262-270 bound to Mafa-A1*052:02 in macaques vaccinated with the whole particle vaccine were observed more promptly or more vigorously than those in macaques vaccinated with the split vaccine. These findings demonstrated that the vaccine derived from our virus library was effective for pandemic virus infection in macaques and that the whole particle vaccine conferred more effective memory and broader cross-reactive immune responses to macaques against pandemic influenza virus infection than did the split vaccine.

Endoscopic ligation of the sphenopalatine artery and the maxillary artery for the treatment of intractable posterior epistaxis.

BACKGROUND: Intractable posterior epistaxis sometimes requires intensive treatment, such as surgery or embolization. Maxillary artery ligation has been widely used for the treatment of intractable posterior epistaxis. It is highly effective, but significant complications may occur, including an oroantral fistula and damage to the infraorbital nerve. Embolization is less invasive and can be performed in poor surgical candidates. However, it has more serious complications, such as facial nerve paralysis and hemiplegia. This investigation evaluates the effectiveness and complications of endoscopic ligation of the sphenopalatine or maxillary artery for the treatment of intractable posterior epistaxis. METHODS: Between April 2003 and March 2007, 46 patients were hospitalized for the treatment of severe posterior epistaxis in our University Hospital. Thirty patients were successfully treated by anterior and/or posterior nasal packing, and five patients were treated by electrocoagulation. Endoscopic ligation was performed under general anesthesia in 11 patients (6 men and 5 women; age range, 50-80 years). RESULTS: Eight patients underwent endoscopic ligation of the sphenopalatine artery, and three patients underwent endoscopic ligation of the maxillary artery through the middle meatus and posterior antral wall opening. There were no complications, and the patients' postoperative courses were uneventful. Recurrent epistaxis occurred in one patient on oral anticoagulants 15 months after ligation of the sphenopalatine artery, and it was successfully treated by anterior nasal packing. CONCLUSION: Endoscopic ligation of the sphenopalatine or maxillary artery is safer than arterial embolization and is less invasive than transantral ligation of the maxillary artery. This technique appears to be a simple and highly effective surgical treatment for patients with intractable posterior epistaxis.