Allergome-wide peptide microarrays enable epitope deconvolution in allergen-specific immunotherapy.

BACKGROUND: The interaction of allergens and allergen-specific IgE initiates the allergic cascade after crosslinking of receptors on effector cells. Antibodies of other isotypes may modulate such a reaction. Receptor crosslinking requires binding of antibodies to multiple epitopes on the allergen. Limited information is available on the complexity of the epitope structure of most allergens. OBJECTIVES: We sought to allow description of the complexity of IgE, IgG4, and IgG epitope recognition at a global, allergome-wide level during allergen-specific immunotherapy (AIT). METHODS: We generated an allergome-wide microarray comprising 731 allergens in the form of more than 172,000 overlapping 16-mer peptides. Allergen recognition by IgE, IgG4, and IgG was examined in serum samples collected from subjects undergoing AIT against pollen allergy. RESULTS: Extensive induction of linear peptide-specific Phl p 1- and Bet v 1-specific humoral immunity was demonstrated in subjects undergoing a 3-year-long AIT against grass and birch pollen allergy, respectively. Epitope profiles differed between subjects but were largely established already after 1 year of AIT, suggesting that dominant allergen-specific antibody clones remained as important contributors to humoral immunity following their initial establishment during the early phase of AIT. Complex, subject-specific patterns of allergen isoform and group cross-reactivities in the repertoires were observed, patterns that may indicate different levels of protection against different allergen sources. CONCLUSIONS: The study highlights the complexity and subject-specific nature of allergen epitopes recognized following AIT. We envisage that epitope deconvolution will be an important aspect of future efforts to describe and analyze the outcomes of AIT in a personalized manner.

PAP treatment in patients with OSA does not induce long-term nasal obstruction.

We hypothesized that positive airway pressure treatment would induce nasal obstruction and decrease nasal cavity due to mucosal swelling. We further hypothesized that subjective and objective nasal obstruction at baseline would negatively affect positive airway pressure adherence. A total of 728 patients with sleep apnea were investigated in the Icelandic Sleep Apnea Cohort at baseline and 2 years after starting positive airway pressure. Patients underwent home sleep apnea testing at baseline. Questionnaires were answered and acoustic rhinometry was completed at baseline and follow-up. The proportion of patients reporting subjective nocturnal nasal obstruction was reduced (baseline: 35% versus follow-up: 24%; p < 0.001). Small interior nasal dimensions increased (p < 0.001) independent of adherence to treatment. Small nasal volume at baseline was a determinant for becoming a non-user of positive airway pressure treatment (odds ratio 2.22, confidence interval 95% 1.35-3.67, p = 0.002). Subjective nasal obstruction decreased 2 years after initiating positive airway treatment in sleep apnea, and objectively small nasal dimensions increased. Small nasal volume at baseline was a negative predictor for positive airway pressure treatment adherence. Maybe most importantly, positive airway pressure treatment did not cause long-term objective or subjective nasal obstruction.

Biological effects and clinical efficacy of a topical Toll-like receptor 7 agonist in seasonal allergic rhinitis: a parallel group controlled phase IIa study.

OBJECTIVE AND DESIGN: The purpose of the study was to examine effects of pre-treatment with a Toll-like receptor 7 (TLR7) agonist (AZD8848) in allergic rhinitis and to evaluate clinical effects of two dosing regimens. SUBJECTS: The study involved 83 patients with allergic rhinitis. Data on effects of AZD8848 on symptoms were analysed with data from a previous study (n = 68) of identical double blind, parallel group design (NCT00770003). TREATMENT: The treatment involved intranasal AZD8848 20 µg three times weekly, 60 µg once weekly, or placebo for 5 weeks. METHODS: Nasal lavage and plasma were analysed for proof-of-mechanism markers. Daily nasal allergen challenges were given for 7 days, starting 24 h after the final AZD8848 dose. Symptoms were monitored after each challenge and every morning and evening. RESULTS: Markers of TLR-activation increased following AZD8848 administration (CXCL10, TNFα, IL-6, IFNγ). Symptoms recorded soon after allergen challenge were reduced up to eight days after the final dose of AZD8848. Morning and evening symptoms were also reduced, and these changes reached statistical significance for morning observations. Adverse effects were more frequent in the 20 µg three times weekly group. CONCLUSIONS: Repeated administration of AZD8848 activated TLR7 and produced IFN-induced effects. This was associated with a sustained reduction in allergen responsiveness.

Selective inhibition by simvastatin of IRF3 phosphorylation and TSLP production in dsRNA-challenged bronchial epithelial cells from COPD donors.

BACKGROUND AND PURPOSE: Statin treatment may ameliorate viral infection-induced exacerbations of chronic obstructive pulmonary disease (COPD), which exhibit Th2-type bronchial inflammation. Thymic stromal lymphopoietin (TSLP), a hub cytokine switching on Th2 inflammation, is overproduced in viral and dsRNA-stimulated bronchial epithelial cells from COPD donors. Hence, TSLP may be causally involved in exacerbations. This study tests the hypothesis that simvastatin inhibits dsRNA-induced TSLP. EXPERIMENTAL APPROACH: Epithelial cells, obtained by bronchoscopy from COPD (n = 7) and smoker control (n = 8) donors, were grown and stimulated with a viral infection and danger signal surrogate, dsRNA (10 µg·mL(-1) ). Cells were treated with simvastatin (0.2-5 µg·mL(-1) ), with or without mevalonate (13-26 µg·mL(-1) ), or dexamethasone (1 µg·mL(-1) ) before dsRNA. Cytokine expression and production, and transcription factor (IRF3 and NF-κB) activation were determined. KEY RESULTS: dsRNA induced TSLP, TNF-α, CXCL8 and IFN-ß. TSLP was overproduced in dsRNA-exposed COPD cells compared with control. Simvastatin, but not dexamethasone, concentration-dependently inhibited dsRNA-induced TSLP. Unexpectedly, simvastatin acted independently of mevalonate and did not affect dsRNA-induced NF-κB activation nor did it reduce production of TNF-α and CXCL8. Instead, simvastatin inhibited dsRNA-induced IRF3 phosphorylation and generation of IFN-ß. CONCLUSIONS AND IMPLICATIONS: Independent of mevalonate and NF-κB, previously acknowledged anti-inflammatory mechanisms of pleiotropic statins, simvastatin selectively inhibited dsRNA-induced IRF3 activation and production of TSLP and IFN-ß in COPD epithelium. These data provide novel insight into epithelial generation of TSLP and suggest paths to be exploited in drug discovery aimed at inhibiting TSLP-induced pulmonary immunopathology.

Long-term follow-up of patients operated with Uvulopalatopharyngoplasty from 1985 to 1991.

OBJECTIVES: Short-term outcome and side effects after Uvulopalatopharyngoplasty (UPPP) are well recognized. However, there is a lack of knowledge of the long-term outcome and side effects after this surgery. This study was completed to investigate the outcome and side effects 20 years after UPPP for snoring and obstructive sleep apnoea. METHODS: Medical records of patients who underwent UPPP surgery for sleep apnoea and snoring between 1985 and 1991 were investigated retrospectively. A specific questionnaire focusing on the present health profile, side effects of previous UPPP surgery and present sleeping patterns of patients was mailed out. RESULTS: UPPP patients, 186 (including 11 females) were identified. Of these, 35 (19%) had passed away and 7 (4%) were not located. 129 patients (mean: age 68 years, range 43-83) of the possible 144 patients answered the questionnaire (response rate 90%). At follow-up, 41 patients (32%) used continuous positive airway pressure (CPAP). 66 of the patients (52%) were satisfied with the result of the operation, but 61 (47%) were not satisfied. 49 patients (38%) reported persistent side effects (problems with nasal regurgitation 18 (14%), swallowing 26 (20%), changed voice 15 (12%), and pain in the oral cavity 15 (12%). CONCLUSION: Almost 50% of patients operated with UPPP were not satisfied with the result of the operation after about 20 years, and one third used CPAP at follow-up. A large proportion of patients still experienced side effects, which, after this time, are likely to be permanent.

Inhalation of LPS induces inflammatory airway responses mimicking characteristics of chronic obstructive pulmonary disease.

AIM: Inhalation of lipopolysaccharide (LPS) produces both systemic and pulmonary inflammatory responses. The aim of this study was to further characterize the response to LPS in order to develop a human model suitable for early testing of drug candidates developed for the treatment for chronic obstructive pulmonary disease (COPD). MATERIALS: Blood and induced sputum were obtained 4, 24 and 48 h following inhalation of saline and LPS (5 and 50 µg). Blood was analysed for C-reactive protein (CRP), α(1)-antitrypsin and neutrophils/leucocytes, and sputum was analysed for biomarkers of neutrophil inflammation and remodelling activities, i.e. neutrophil elastase (NE) protein/activity and α(1)-antitrypsin. Levels of tumour necrosis factor-α (TNFα) were measured in both blood and sputum. Urine was collected 0-24 and 24-48 h postchallenge, and desmosine, a biomarker of elastin degradation, was measured. RESULTS: Lipopolysaccharide inhalation induced dose-dependent flu-like symptoms and increases in plasma CRP and α(1)-antitrypsin as well as increases in blood neutrophil/leucocyte numbers. Furthermore, LPS produced increases in sputum TNFα and sputum NE activity. Urine levels of desmosine were unaffected by the LPS challenge. All subjects recovered 48 h postchallenge, and indices of inflammatory activity were significantly lower at this observation point cf 24 h postchallenge. CONCLUSION: Inhalation of LPS in healthy volunteers can be used as a safe and stable model of neutrophil inflammation. Blood/plasma and sputum indices can be employed to monitor the response to LPS. We suggest that this model may be used for initial human studies of novel COPD-active drugs.

dsRNA-induced expression of thymic stromal lymphopoietin (TSLP) in asthmatic epithelial cells is inhibited by a small airway relaxant.

RATIONALE: Thymic Stromal Lymphopoietin (TSLP) is considered a hub cytokine that activates dendritic cells and T-cells producing asthma-like Th2-inflammation. Viral stimuli, a major cause of asthma exacerbations, have been shown to induce overexpression of TSLP in asthmatic epithelium. Capsazepine has multiple effects and is of interest because it relaxes human small airways. Here we have explored effects of capsazepine on viral surrogate (dsRNA)-induced TSLP and other cytokines (TNF-alpha, IL-8) in human bronchial epithelial cells (HBEC) from healthy and asthmatic donors. METHODS: HBEC obtained from healthy and asthmatic subjects were grown and stimulated with dsRNA. Cells pre-treated with capsazepine (3-30 µM), dexamethasone (0.1-10 µM) or an IkappaB-kinase inhibitor (PS1145, 30 µM) were also exposed to dsRNA (10 µg/ml). Cells and supernatants were harvested for analyses of gene expression (RT-qPCR) and protein production (ELISA,Western blot). RESULTS: dsRNA-induced TSLP, TNF-alpha, and IL-8 in asthmatic and non-asthmatic HBEC. Dexamethasone attenuated gene expression and protein release whereas capsazepine dose-dependently, and similar to a non-relaxant NFkB inhibitor (PS1145), completely inhibited dsRNA-induced TSLP and TNF-alpha in both healthy and asthmatic HBEC. Capsazepine reduced dsRNA-induced IL-8 and it prevented dsRNA-induced loss of the NF-κB repressor protein IkBα. CONCLUSION: Additional to its human small airway relaxant effects we now demonstrate that capsazepine has potent anti-inflammatory effects on viral stimulus-induced cytokines in HBEC from healthy as well as asthmatic donors. Based on these data we suggest that exploration of structure-activity amongst the multifaceted capsazepinoids is warranted in search for compounds of therapeutic value in viral-induced, steroid-resistant asthma.

Early phase resolution of mucosal eosinophilic inflammation in allergic rhinitis.

BACKGROUND: It is widely assumed that apoptosis of eosinophils is a central component of resolution of allergic airway disease. However, this has not been demonstrated in human allergic airways in vivo. Based on animal in vivo observations we hypothesised that steroid-induced resolution of human airway eosinophilic inflammation involves inhibition of CCL5 (RANTES), a CC-chemokine regulating eosinophil and lymphocyte traffic, and elimination of eosinophils without evident occurrence of apoptotic eosinophils in the diseased tissue. OBJECTIVE: To determine mucosal eosinophilia, apoptotic eosinophils, general cell apoptosis and cell proliferation, and expression of CCL5 and CCL11 (eotaxin) in human allergic airway tissues in vivo at resolution of established symptomatic eosinophilic inflammation. METHODS: Twenty-one patients with intermittent (birch and/or grass) allergic rhinitis received daily nasal allergen challenges for two seven days' periods separated by more than two weeks washout. Five days into these "artificial pollen seasons", nasal treatment with budesonide was instituted and continued for six days in a double blinded, randomized, placebo-controlled, and crossover design. This report is a parallel group comparison of nasal biopsy histochemistry data obtained on the final day of the second treatment period. RESULTS: Treatments were instituted when clinical rhinitis symptoms had been established. Compared to placebo, budesonide reduced tissue eosinophilia, and subepithelial more than epithelial eosinophilia. Steroid treatment also attenuated tissue expression of CCL5, but CCL11 was not reduced. General tissue cell apoptosis and epithelial cell proliferation were reduced by budesonide. However, apoptotic eosinophils were not detected in any biopsies, irrespective of treatment. CONCLUSIONS: Inhibition of CCL5-dependent recruitment of cells to diseased airway tissue, and reduced cell proliferation, reduced general cell apoptosis, but not increased eosinophil apoptosis, are involved in early phase steroid-induced resolution of human allergic rhinitis.

Specific nasal symptoms and symptom-provoking factors may predict increased risk of developing COPD.

In a 1992 questionnaire study, we found that certain nasal symptoms and symptom-provoking factors were associated with prevalence of self-reported chronic bronchitis/emphysema (CBE). In this follow-up study, we examined whether any nasal features could predict an increased incidence of self-reported physician's diagnosis of CBE/chronic obstructive pulmonary disease (COPD). In 2000, a survey was performed similar to the one in 1992. Of a paired follow-up group of 4933 participants aged 28-67 years, 4280 (86.8%) returned the questionnaire. Odds ratios (ORs) for cumulative incidence (between 1992 and 2000) of self-reported physician-diagnosed CBE/COPD and asthma, respectively, were calculated by logistic regression with adjustment for age, gender and smoking habits. Reports of thick, yellow nasal discharge and nasal blockage in 1992 predicted incidence of CBE/COPD: OR 2.3 (1.2-4.2) and 1.8 (1.1-2.8) respectively. Moreover, nasal symptoms provoked by exposure to damp/cold air and tobacco smoke predicted CBE/COPD: OR 3.4 (1.9-6.0) and 2.5 (1.4-4.2). Nasal itching and nasal symptoms provoked by exposure to grass pollen and furred animals predicted incidence of asthma. These results suggest that certain nasal symptoms and nasal symptom-provoking exposures, different from those commonly associated with asthma, may predict increased risk of developing CBE/COPD. This supports the possibility of nasal co-morbidity in COPD.

Effects of intranasal TNFalpha on granulocyte recruitment and activity in healthy subjects and patients with allergic rhinitis.

BACKGROUND: TNFalpha may contribute to the pathophysiology of airway inflammation. For example, we have recently shown that nasal administration of TNFalpha produces late phase co-appearance of granulocyte and plasma exudation markers on the mucosal surface. The objective of the present study was to examine indices of granulocyte presence and activity in response to intranasal TNFalpha challenge. METHODS: Healthy subjects and patients with allergic rhinitis (examined out of season) were subjected to nasal challenge with TNFalpha (10 microg) in a sham-controlled and crossover design. Nasal lavages were carried out prior to and 24 hours post challenge. Nasal biopsies were obtained post challenge. Nasal lavage fluid levels of myeloperoxidase (MPO) and eosinophil cationic protein (ECP) were analyzed as indices of neutrophil and eosinophil activity. Moreover, IL-8 and alpha2-macroglobulin were analyzed as markers of pro-inflammatory cytokine production and plasma exudation. Nasal biopsy numbers of neutrophils and eosinophils were monitored. RESULTS: Nasal lavage fluid levels of MPO recorded 24 hours post TNFalpha challenge were increased in healthy subjects (p = 0.0081) and in patients with allergic rhinitis (p = 0.0081) (c.f. sham challenge). Similarly, alpha2-macroglobulin was increased in healthy subjects (p = 0.014) and in patients with allergic rhinitis (p = 0.0034). Lavage fluid levels of ECP and IL-8 were not affected by TNFalpha challenge. TNFalpha increased the numbers of subepithelial neutrophils (p = 0.0021), but not the numbers of eosinophils. CONCLUSION: TNFalpha produces a nasal inflammatory response in humans that is characterised by late phase (i.e., 24 hours post challenge) neutrophil activity and plasma exudation.

Effects of TNFalpha on the human nasal mucosa in vivo.

BACKGROUND: TNFalpha is a cytokine that may contribute to the pathophysiology of airway inflammation. Inhalation of TNFalpha produces granulocyte recruitment and airway hyperresponsiveness in man. Anti-TNFalpha treatment may inhibit allergen-induced plasma exudation in guinea-pig airways. Increased nasal mucosal output of TNFalpha has been demonstrated in allergic rhinitis, but the effect of TNFalpha on the human nasal mucosa has not been examined in vivo. OBJECTIVE: To examine effects of topical TNFalpha on the human nasal mucosa in vivo. METHODS: In a dose-finding study, healthy subjects received intranasal TNFalpha (0-7.5 microg). Nasal lavages were carried out before as well as 10 min and 24 h post challenge and alpha(2)-macroglobulin was measured as an index of plasma exudation. In a second study, involving patients with allergic rhinitis examined out of season, a sham-controlled nasal challenge with TNFalpha (10 microg) was performed and followed 24 h later by an allergen challenge. Lavages were performed before the TNFalpha challenge, 24 h thereafter, and 10 min post allergen challenge. alpha(2)-Macroglobulin, eosinophil cationic protein (ECP), myeloperoxidase (MPO), and IL-8 were analyzed as indices of plasma exudation, eosinophil activity, neutrophil activity, and pro-inflammatory cytokine production, respectively. RESULTS: In the dose-finding study, TNFalpha produced significant increases in alpha(2)-macroglobulin 24h post challenge (p<0.01). In allergic rhinitis, 10 microg of TNFalpha also produced this effect (p<0.01) as well as increases in ECP and IL-8 (p<0.01). MPO was increased 24 h post challenge, but this change did not reach statistical significance. TNFalpha did not produce any acute effects and did not affect the responsiveness to allergen. CONCLUSION: The present study demonstrates that topical TNFalpha produces a human nasal inflammatory response. These data suggest a role of TNFalpha in nasal conditions characterized by mucosal inflammation.

Topical glucocorticosteroids in rhinitis: clinical aspects.

The introduction of nasal glucocorticosteroids, 30 years ago, has been the most important therapeutic progress in rhinitis management since the introduction of the first generation of antihistamines. Our knowledge of the mode of action of glucocorticosteroids in the nose has improved as the airway mucous membrane of the nose is easily accessible for investigation. However, the exact mechanism behind the marked clinical effect remains unclear. Topical glucocorticosteroids are highly effective in diseases characterized by eosinophil-dominated inflammation (allergic rhinitis, nasal polyposis), but not in diseases characterized by neutrophil-dominated inflammation (common cold, infectious rhinosinusitis). Experience for 30 years and a long series of controlled studies have shown that the treatment is highly effective and that the side effects are few and benign. Intranasal glucocorticosteroids can therefore be considered as first-line treatment for allergic and non-allergic, non-infectious rhinitis and nasal polyps.

Clinical trial design, nasal allergen challenge models, and considerations of relevance to pediatrics, nasal polyposis, and different classes of medication.

Clinical trials in allergic rhinitis present several specific difficulties. In seasonal pollen-related disease, there are variations between subjects in the extent of pollen sensitization, individual variations in exposure to pollen even within a set area because of lifestyle differences, and variations between different areas in pollen counts and weather patterns. Thus, large patient numbers are needed in multicenter trials to account for such variations when the standard endpoint is symptom reporting. Furthermore, a pollen season may be relatively short (eg, lasting 6-8 weeks), and the pollen count is inconsistent during this period. Crossover study designs are thus inappropriate, and trials are usually conducted with a parallel-group design. This further increases the trial sample size as it reduces statistical power. These large patient numbers must be recruited over a very short period. Perennial house dust mite-sensitive allergic rhinitis presents other problems. Although there is less disease variation, it is appreciated that symptoms may be induced by nonallergic as well as allergic mechanisms because of the nasal hyperresponsiveness. The nonallergic symptoms may not be modified by treatments based on allergic disease mechanisms. Thus, symptom outcomes--although relevant to the patient--may not adequately reflect the pharmacologic efficacy of the specific intervention. To control variability and focus on allergic disease mechanisms, nasal allergen challenge has been used in drug development. Single-dose challenges in the laboratory or in a pollen chamber, which allow many volunteers to be studied at the same time, have proven useful in the evaluation of drugs that afford acute symptom relief. However, such challenges incompletely model naturally occurring disease, in which the repeated daily exposure to allergen modifies the mucosal inflammatory cell profile and in particular promotes the epithelial accumulation of effector cells. This alters the response to allergen exposure. To model this, repeated low-dose daily allergen exposure has been used to generate these mucosal changes artificially, and early studies suggest that this may be a more valid model for the evaluation of anti-inflammatory therapy. However, little has been published with this model. Different disease groups are associated with their own specific issues in clinical trials. The pediatric population, in which allergic rhinitis is common, has different requirements for education, quality of life evaluation, and adverse-event monitoring; nasal polyposis, because of the nature of the disease, requires additional means of assessment, such as nasal endoscopy and imaging (eg, computerized tomography scanning), as well as attention to additional outcome measures (eg, the measurement of sense of smell). Within clinical trial design, there are important questions to be considered in relationship to the therapeutic intervention. Should this be given topically or systemically? What are the appropriate timing and frequency of medication? Does the disease itself modify the treatment efficacy, and does combination therapy afford better clinical outcome than single-modality therapy? These issues are discussed, and the influences of current therapies on objective outcome measures in allergic rhinitis are reviewed.

Occurrence of apoptosis, secondary necrosis, and cytolysis in eosinophilic nasal polyps.

The paradigm states that inflammatory cells disappear from airway tissues through apoptosis and phagocytosis. However, cells may also be cleared through primary cytolysis, necrosis secondary to apoptosis, or transepithelial migration. This study examines the occurrence of apoptosis, secondary necrosis, and cytolysis of eosinophils in human nasal polyps in vivo and blood eosinophils in vitro. Eosinophils abounded in subepithelium and in paracellular epithelial pathways. Macrophages commonly occurred but without engulfed eosinophils. Scattered cells, including epithelial cells, were stained by antibody to the caspase cleavage product of poly(ADP-ribose) polymerase. Few cells were apoptotic (stained by terminal deoxy RNase nick end labeling). Of more than 3,000 examined tissue eosinophils, 110 were caspase cleavage positive, but only one was apoptotic. Transmission electron microscopy analysis of more than 500 eosinophils revealed viable and cytolytic eosinophils but not apoptosis, secondary necrosis, or engulfment of eosinophils. Plasma cells but neither epithelial cells nor eosinophils exhibited apoptotic ultrastructural morphology. Eosinophils in vitro exhibited different stages of apoptosis, ending with secondary necrosis distinct from in vivo eosinophil cytolysis. Our results show that the clearance of eosinophils from nasal polyps largely occurs through nonapoptosis pathways, including cytolysis and paraepithelial migration, and they challenge the belief that apoptosis is important for clearance of eosinophils from respiratory tissues.

Nasal neutrophil activity and mucinous secretory responsiveness in COPD.

Patients with chronic obstructive pulmonary disease (COPD) frequently report nasal symptoms. In the present study, we have examined whether or not COPD is associated with any nasal inflammation. Plasma exudation evoked by histamine challenges has been employed to improve the recovery of inflammatory indices in nasal lavage fluids. In 23 COPD-patients and 26 healthy subjects, all without history or signs of allergic rhinitis, nasal polyposis, or chronic rhinosinusitis, nasal saline-lavages were performed with and without histamine. alpha2-Macroglobulin, fucose, eosinophil cationic protein (ECP) and myeloperoxidase (MPO) were determined as indices of plasma exudation, mucinous secretion, eosinophil activity and neutrophil activity, respectively. The difference in MPO-levels between the histamine and the saline lavage was greater in COPD patients compared with healthy subjects (P<0.05). Also, COPD patients reporting nasal symptoms presented an increase in MPO at histamine challenge (P<0.05, cf. saline) and greater differences in MPO and fucose, respectively, between the histamine and the saline lavage (P<0.05, cf. patients without symptoms). We conclude that COPD is not associated with any marked nasal inflammation. However, our observation on increased MPO-levels at histamine challenge suggests some degree of increased neutrophil activity in this condition. Furthermore, when associated with nasal symptoms, COPD may be associated with an increased nasal secretory responsiveness.