Spread of Jacobaea vulgaris and Occurrence of Pyrrolizidine Alkaloids in Regionally Produced Honeys from Northern Germany: Inter- and Intra-Site Variations and Risk Assessment for Special Consumer Groups.

Pyrrolizidine alkaloids (PA) and PA N-oxides (PANO) are secondary plant metabolites exhibiting genotoxic and carcinogenic properties. Apart from the roots and leaves, PA/PANO are particularly present in pollen and nectar. Therefore, the spread of Jacobaea vulgaris in certain regions of northern Germany has an impact on the safety of honey produced in that region. In this study, raw honey samples (n = 437) were collected from usually three individual beehives per site (n = 73) in the district of Ostholstein and analyzed for 25 PA/PANO. The results reveal mean levels of 8.4, 1.5, and 72.6 µg/kg and maximum levels of 111, 59.4, and 3313 µg/kg, depending on the season (summer 2015 and spring/summer 2016, respectively). As far as individual data are concerned, sites near areas with J. vulgaris growth did not necessarily result in high PA/PANO values. Furthermore, intra-site investigations revealed remarkable differences in PA/PANO levels of raw honey collected by different bee colonies at the same site. Consumption of these regionally produced honeys entails an increased exposure to PA/PANO, especially in children and high consumers. Margin of exposure values of <10,000 and an exceedance of the health-based guidance value highlight that regionally produced and marketed honey must be considered with care for a proper risk assessment and risk management.

Assessment of the health impact of paper mulberry (Broussonetia papyrifera L.), an invasive plant species in Islamabad, Pakistan.

This study focuses on the risk of pollen allergy due to paper mulberry (Broussonetia papyrifera L.), an Asian invasive plant species now common in large parts of the world. Pollen plays a key role in the pathogenesis of respiratory allergic diseases, particularly rhinitis and asthma, and Islamabad, a major metropolitan city, is severely affected by allergy owing to B. papyrifera pollen. Due to its seasonality and other relationships with climatic variables, we used remote sensing to monitor the trend of pollen count. We also mapped the localisation of patients affected by pollen allergy using geographic information systems. The maximum likelihood algorithm was applied to SPOT-5 satellite imagery for land use/land cover classification. Temporal analysis of remotely sensed data revealed an increasing trend of paper mulberry density towards the southern and south-western part of Islamabad. Although not evident during rainfall, a clear positive correlation was found between patient count and pollen count. Field survey data and hotspot spatial analysis of allergy patients revealed that residents of Shakerperiyan and Lok Virsa areas (Sectors H-8, I-8, I-9, G-8, G-7 and G-6 in Islamabad) had more pronounced symptoms compared to residents of other sectors. The methodology adopted used in this study can be used to map the distribution of similar invasive species in other parts of the country.

Uncovering a New Moral Dilemma of Economic Optimization in Biotechnological Processing.

The trend of emerging biorefineries is to process the harvest as efficiently as possible and without any waste. From the most valuable phytomass, refined medicines, enzymes, dyes and other special reactants are created. Functional foods, food ingredients, oils, alcohol, solvents, plastics, fillers and a wide variety of other chemical products follow. After being treated with nutrient recovery techniques (for fertilizer production), biofuels or soil improvers are produced from the leftovers. Economic optimization algorithms have confirmed that such complex biorefineries can be financially viable only when a high degree of feedstock concentration is included. Because the plant material is extremely voluminous before processing, the farming intensity of special plants increases in the nearest vicinity of agglomerations where the biorefineries are built for logistical reasons. Interdisciplinary analyses revealed that these optimization measures lead to significantly increased pollen levels in neighbouring urban areas and subsequently an increased risk of allergies, respectively costs to the national health system. A new moral dilemma between the shareholder's profit and public interest was uncovered and subjected to disputation.

Static and elevated pollen traps do not provide an accurate assessment of personal pollen exposure.

SUMMARY: Background. Volumetric pollen traps are commonly used to assess pollen exposure. These traps are well suited for estimating the regional mean airborne pollen concentration but are likely not to provide an accurate index of personal exposure. In this study, we tested the hypothesis that hair sampling may provide different pollen counts from those from pollen traps, especially when the pollen exposure is diverse. Methods. We compared pollen counts in hair washes to counts provided by stationary volumetric and gravimetric pollen traps in 2 different settings: urban with volunteers living in short distance from one another and from the static trap and suburban in which volunteers live in a scattered environment, quite far from the static trap. Results. Pollen counts in hair washes are in full agreement with trap counts for uniform pollen exposure. In contrast, for diverse pollen exposure, .individual pollen counts in hair washes vary strongly in quantity and taxa composition between individuals and dates. These results demonstrate that the pollen counts method (hair washes vs. stationary pollen traps) may lead to different absolute and relative contributions of taxa to the total pollen count. Conclusions. In a geographic area with a high diversity of environmental exposure to pollen, static pollen traps, in contrast to hair washes, do not provide a reliable estimate of this higher diversity.

Health Impact Assessment of Asian Dust/Cross-border Air Pollutant and Necessary Preventive Measure.

The health effects of Asian dust (mineral dust) originating from dry lands such as the Gobi Desert and Taklamakan Desert have recently been a concern. In addition to Asian dust, transboundary airborne microparticles that reach Japan include various types of aerosol, such as artificial air pollutants and smoke from combustion. They originate from densely populated areas and are transported along the same route as Asian dust. We analyzed environmental factors and subjective symptoms involving the respiratory organ, nose, eyes, and skin using a conventional equation for estimation, and found that symptoms with a significant risk of worsening varied according to the type of pollutants reaching Japan. We also analyzed the synergistic effects of Asian dust and pollens on nasal symptoms using a two-pollutant model. The odds ratio for symptoms at the time of arrival of a high concentration of Asian dust was 1.37 (95% confidence interval: 1.19-1.58), but the odds ratio adjusted for pollens was 1.18 (95% confidence interval: 1.04-1.34). Although the influence on nasal symptoms overlapped somewhat between Asian dust and pollens, that of Asian dust remained significant. Regarding preventive measures against symptoms, we examined the rate of particle leakage into masks. We found that it is important to wear a mask that fits an individual's facial features and has no gap between the face and the mask. In addition, we report our attempt to construct models for predicting aerosol arrival and forecasting health to establish preventive measures against aerosols.

The associations between daily spring pollen counts, over-the-counter allergy medication sales, and asthma syndrome emergency department visits in New York City, 2002-2012.

BACKGROUND: Many types of tree pollen trigger seasonal allergic illness, but their population-level impacts on allergy and asthma morbidity are not well established, likely due to the paucity of long records of daily pollen data that allow analysis of multi-day effects. Our objective in this study was therefore to determine the impacts of individual spring tree pollen types on over-the-counter allergy medication sales and asthma emergency department (ED) visits. METHODS: Nine clinically-relevant spring tree pollen genera (elm, poplar, maple, birch, beech, ash, sycamore/London planetree, oak, and hickory) measured in Armonk, NY, were analyzed for their associations with over-the-counter allergy medication sales and daily asthma syndrome ED visits from patients' chief complaints or diagnosis codes in New York City during March 1st through June 10th, 2002-2012. Multi-day impacts of pollen on the outcomes (0-3 days and 0-7 days for the medication sales and ED visits, respectively) were estimated using a distributed lag Poisson time-series model adjusting for temporal trends, day-of-week, weather, and air pollution. For asthma syndrome ED visits, age groups were also analyzed. Year-to-year variation in the average peak dates and the 10th-to-90th percentile duration between pollen and the outcomes were also examined with Spearman's rank correlation. RESULTS: Mid-spring pollen types (maple, birch, beech, ash, oak, and sycamore/London planetree) showed the strongest significant associations with both outcomes, with cumulative rate ratios up to 2.0 per 0-to-98th percentile pollen increase (e.g., 1.9 [95% CI: 1.7, 2.1] and 1.7 [95% CI: 1.5, 1.9] for the medication sales and ED visits, respectively, for ash). Lagged associations were longer for asthma syndrome ED visits than for the medication sales. Associations were strongest in children (ages 5-17; e.g., a cumulative rate ratio of 2.6 [95% CI: 2.1, 3.1] per 0-to-98th percentile increase in ash). The average peak dates and durations of some of these mid-spring pollen types were also associated with those of the outcomes. CONCLUSIONS: Tree pollen peaking in mid-spring exhibit substantive impacts on allergy, and asthma exacerbations, particularly in children. Given the narrow time window of these pollen peak occurrences, public health and clinical approaches to anticipate and reduce allergy/asthma exacerbation should be developed.

Climate change. A global threat to cardiopulmonary health.

Recent changes in the global climate system have resulted in excess mortality and morbidity, particularly among susceptible individuals with preexisting cardiopulmonary disease. These weather patterns are projected to continue and intensify as a result of rising CO2 levels, according to the most recent projections by climate scientists. In this Pulmonary Perspective, motivated by the American Thoracic Society Committees on Environmental Health Policy and International Health, we review the global human health consequences of projected changes in climate for which there is a high level of confidence and scientific evidence of health effects, with a focus on cardiopulmonary health. We discuss how many of the climate-related health effects will disproportionally affect people from economically disadvantaged parts of the world, who contribute relatively little to CO2 emissions. Last, we discuss the financial implications of climate change solutions from a public health perspective and argue for a harmonized approach to clean air and climate change policies.

Importance of clinical epidemiology research in studies on respiratory diseases.

Evidence-based medicine (EBM) has generated great interest since the 1990s and many physicians worldwide have based their clinical practice on this idea. Its underlying concepts include a diverse array of findings from clinical epidemiological research. In western countries, many clinical databases of clinical epidemiology are in circulation. Clinical epidemiological research using these data in western countries constitutes the majority worldwide. However, because race, lifestyle, culture, etc., differ among western countries and Japan, it is difficult to apply the results of clinical epidemiological research obtained in Japan to western countries. Unfortunately, there is no large-scale database for respiratory diseases prevalent in Japan. Many specialists agree with the opinion that it is necessary to collect medical information specific to the Japanese population and analyze the clinical data. KiHAC (Kinki Hokuriku Airway Disease Conference) was established in September 2001 with the aim of generating evidence through clinical epidemiological research for airway diseases by targeting physicians practicing respiratory medicine, pediatrics, and otorhinolaryngology, primarily in the Kinki and Hokuriku regions located in the central to western parts of Japan. As a part of the KiHAC, clinical research societies will attempt to cooperate with each other to make joint research possible and to share and utilize information, in addition to further promoting clinical research in the field of respiratory medicine.

Severity assessment of Japanese cedar pollinosis using the practical guideline for the management of allergic rhinitis in Japan and the allergic rhinitis and its impact on asthma guideline.

BACKGROUND: This study intended to assess the severity of Japanese cedar pollinosis using the Practical Guideline for the Management of Allergic Rhinitis in Japan (PG-MARJ) and the Allergic Rhinitis and its Impact on Asthma (ARIA) Guideline. METHODS: An Internet questionnaire survey of patients with pollinosis was conducted in mid-May 2011 and responses were obtained from 3382 individuals who had potential symptoms of Japanese cedar pollinosis from February to early May 2011 and who had experienced such symptoms for at least two pollen seasons. RESULTS: According to PG-MARJ, 23.5% of the respondents had severest rhinitis, 29.4% severe rhinitis, 31.3% moderate rhinitis, 13.8% mild rhinitis and 2.0% asymptomatic rhinitis. According to ARIA, 67.2% of them had moderate/severe persistent rhinitis, 23.8% moderate/severe intermittent rhinitis, 4.4% mild persistent rhinitis and 4.6% mild intermittent rhinitis. CONCLUSIONS: Moderate to severe rhinitis was diagnosed in more than 80% of the respondents according to PG-MARJ, while moderate/severe rhinitis was diagnosed in more than 90% of the respondents according to ARIA. Most of the respondents suffered relatively severe pollinosis. More than 80% of the respondents had all the three major symptoms (i.e., sneezing, rhinorrhea and nasal blockage). Disagreement in the severity assessment between the two guidelines was noted in approximately 20% of the respondents.

Assessment of specific immunotherapy efficacy using a novel placebo score-based method.

BACKGROUND: In trials of allergen immunotherapy, allergen exposure is typically assessed by pollen counts, but these may misrepresent exposure if performed remotely from multiple study centers. OBJECTIVE: To assess whether symptomatology in placebo-treated patients is a better measure of local allergen burden at individual centers in such trials. METHODS: Data from a multicenter, placebo-controlled trial of preseasonal grass pollen immunotherapy were reanalyzed to identify the 4 weeks at each center in which the placebo-treated subjects had the highest combined symptom/medication scores (CSMS). The difference in CSMS between active and placebo groups was compared during the 4 peak placebo score weeks (PlSW) and the 4 peak pollen count weeks (PoCW). RESULTS: The benefit of immunotherapy over placebo in the PlSW analysis (18.5%) was greater than in the PoCW analysis (13.6%), with increased statistical significance (P = .0001, .0038, respectively). Similar improved discrimination was observed when analyzing benefits in subgroups of patients with severe symptoms, a high disease burden, and in different geographical locations. CONCLUSION: This novel PlSW analysis results in better discrimination of the effects of allergen immunotherapy compared with placebo and may be widely applicable in similar studies, both prospectively and retrospectively.

Climate change and allergic disease.

Allergies are prevalent throughout the United States and impose a substantial quality of life and economic burden. The potential effect of climate change has an impact on allergic disorders through variability of aeroallergens, food allergens and insect-based allergic venoms. Data suggest allergies (ocular and nasal allergies, allergic asthma and sinusitis) have increased in the United States and that there are changes in allergies to stinging insect populations (vespids, apids and fire ants). The cause of this upward trend is unknown, but any climate change may induce augmentation of this trend; the subspecialty of allergy and immunology needs to be keenly aware of potential issues that are projected for the near and not so distant future.

Cost effectiveness analysis of immunotherapy in patients with grass pollen allergic rhinoconjunctivitis in Germany.

OBJECTIVES: An economic evaluation was conducted to assess the outcomes and costs as well as cost-effectiveness of the following grass-pollen immunotherapies: OA (Oralair; Stallergenes S.A., Antony, France) vs GRZ (Grazax; ALK-Abelló, Hørsholm, Denmark), and ALD (Alk Depot SQ; ALK-Abelló) (immunotherapy agents alongside symptomatic medication) and symptomatic treatment alone for grass pollen allergic rhinoconjunctivitis. METHODS: The costs and outcomes of 3-year treatment were assessed for a period of 9 years using a Markov model. Treatment efficacy was estimated using an indirect comparison of available clinical trials with placebo as a common comparator. Estimates for immunotherapy discontinuation, occurrence of asthma, health state utilities, drug costs, resource use, and healthcare costs were derived from published sources. The analysis was conducted from the insurant's perspective including public and private health insurance payments and co-payments by insurants. Outcomes were reported as quality-adjusted life years (QALYs) and symptom-free days. The uncertainty around incremental model results was tested by means of extensive deterministic univariate and probabilistic multivariate sensitivity analyses. RESULTS: In the base case analysis the model predicted a cost-utility ratio of OA vs symptomatic treatment of €14,728 per QALY; incremental costs were €1356 (95%CI: €1230; €1484) and incremental QALYs 0.092 (95%CI: 0.052; 0.140). OA was the dominant strategy compared to GRZ and ALD, with estimated incremental costs of -€1142 (95%CI: -€1255; -€1038) and -€54 (95%CI: -€188; €85) and incremental QALYs of 0.015 (95%CI: -0.025; 0.056) and 0.027 (95%CI: -0.022; 0.075), respectively. At a willingness-to-pay threshold of €20,000, the probability of OA being the most cost-effective treatment was predicted to be 79%. Univariate sensitivity analyses show that incremental outcomes were moderately sensitive to changes in efficacy estimates. The main study limitation was the requirement of an indirect comparison involving several steps to assess relative treatment effects. CONCLUSION: The analysis suggests OA to be cost-effective compared to GRZ and ALD, and a symptomatic treatment. Sensitivity analyses showed that uncertainty surrounding treatment efficacy estimates affected the model outcomes.

Pollen counts and suicide rates. Association not replicated.

OBJECTIVE: To replicate a previously reported association between pollen counts and county suicide rates in the continental United States, across space and time. METHOD: The authors evaluated the relationship between airborne pollen counts and suicide rates in 42 counties of the continental United States, containing a pollen-counting station participating in the Aeroallergen Monitoring Network in the United States (N = 120,076 suicides), considering years' quarter, age group, sex, race, rural/urban location, number of local psychiatrists, and median household income, from 1999 to 2002. The county-level effects were broken into between-county and within-county. RESULTS: No within-county effects were found. Between-county effects for grass and ragweed pollen on suicide rates lost statistical significance after adjustment for median income, number of psychiatrists, and urban vs. rural location. CONCLUSION: Future research is necessary to reappraise the previously reported relationship between pollen levels and suicide rates that may have been driven by socioeconomic confounders.

Assessment of allergen sensitization in a general population-based survey (European Community Respiratory Health Survey I).

PURPOSE: Exposed to a common environment, the IgE-mediated immune response differs, for instance, among sensitized subjects, some of them reacting toward one allergen (monosensitized) whereas others are sensitized to a wide array of allergens (polysensitized). However, a better phenotypic characterization is needed for epidemiologic studies. Using the data collected during the ECRHS I (European Community Respiratory Health Survey), several assessments of skin prick tests and serum-specific IgE to identify mono- and polysensitized patients were compared. METHODS: Subjects took part in the ECRHS-I. The CAP-System was used for serum allergen-specific IgE, and allergen-coated Phazet was used for prick tests. Four allergens (Dermatophagoides pteronyssinus, cat, timothy grass, and Cladosporium) were measured using IgE and nine (the same ones plus olive pollen, birch, Alternaria, Parietaria, and ragweed) were skin tested. One to two local allergens were also tested, depending on countries. RESULTS: Prevalence of sensitization in 11,355 subjects (34.0 [27.9-40.1] years, 49.9% men) ranged from 32.3% (four specific IgE, 19.3% mono- and 13.0% polysensitized) to 41.8% (four specific IgE combined to nine prick tests, 19.6% mono- and 22.2% polysensitized). Concordance between four specific IgE and four prick tests was weak (weighted κ 0.65 [0.64-0.66]). Concordance between seven and nine prick tests was high (weighted κ 0.99 [0.98-1.00]). Local allergens induced small changes in the prevalence of sensitization, and reclassified some subjects from mono- to polysensitized. CONCLUSIONS: Skin tests or serum-specific IgE may be chosen to identify allergenic sensitivity, mono- and polysensitized subjects without being strictly interchangeable.

An assessment of the onset and duration of action of olopatadine nasal spray.

OBJECTIVE: Seasonal allergic rhinitis (SAR) is a highly prevalent disease. This study was conducted to evaluate the onset and duration of action of three concentrations of olopatadine nasal spray. METHODS: This was a randomized, double-blind, single-dose, placebo-controlled study, conducted in an environmental exposure chamber in patients with SAR. A total of 320 patients were exposed to ragweed allergen in the chamber and randomized to olopatadine nasal spray 0.2%, 0.4%, 0.6%, or placebo nasal spray. Symptoms (sneezing, runny, itchy, and stuffy nose) were self-assessed during a 12-hour study period. RESULTS: All concentrations of olopatadine nasal spray provided clinically meaningful reductions in total nasal symptom scores at 30 minutes compared to the placebo. Olopatadine nasal spray 0.6% was significantly more effective (P < 0.05) than placebo nasal spray at all time-points starting at 90 minutes post-dose and continuing over 12 hours. CONCLUSIONS: Olopatadine nasal spray 0.6% demonstrated a fast onset of action and maintained an effect for at least 12 hours after dosing.

Assessment of combined symptom and medication scores for rhinoconjunctivitis immunotherapy clinical trials.

BACKGROUND: In randomized, double-blind, placebo-controlled clinical trials the efficacy of immunotherapy for allergic rhinoconjunctivitis is evaluated using the Average Rhinoconjunctivitis Total Symptom Score (ARTSS). Effective treatment is associated with lower ARTSS relative to placebo. For ethical reasons patients are provided with registered rescue medication, which may alleviate symptoms and thus reduce symptom scores. This effect biases the mean difference in ARTSS between effective treatment and placebo towards zero. Therefore, when rescue medication is taken by a patient, the ARTSS needs to be adjusted appropriately. METHODS: We considered five outcome measures: ARTSS, Average Rescue Medication Score (ARMS), and three combined symptom and RMSs. To assess the different outcome measures regarding their power to discriminate between effective treatment and placebo, we calculated their effect size when applied to data from a clinical trial of immunotherapy for allergic rhinoconjunctivitis. RESULTS: Of the five outcome measures considered, the average of the ARTSS and ARMS was associated with the largest effect size, and thus with the highest power to show treatment efficacy. Discriminant and multivariate analyses suggest that this average is approximately optimal among all weighted sums of ARTSS and ARMS. CONCLUSION: Our findings support recommendations made in a World Allergy Organisation document on methodological aspects of immunotherapy trials. The average of the ARTSS and ARMS should be considered as a primary efficacy variable in clinical trials of immunotherapy for allergic rhinoconjunctivitis.

Evaluation of visual analog scales for the assessment of symptom severity in allergic rhinoconjunctivitis.

BACKGROUND: The severity of rhinoconjunctivitis is typically monitored by means of nasal provocation tests (NPTs), where the nasally applied allergens trigger symptoms that are recorded using a scoring system. However, NPTs are time-consuming and stressful for patients; therefore, recording of symptoms during natural allergen exposure on visual analog scales (VASs) is increasingly being used in clinical trials. OBJECTIVES: To evaluate (1) the correlation between VAS symptom recording by patients during natural allergen exposure and symptom scoring by the physician during the NPT and (2) the possibility of replacing the more laborious and distressing allergen provocation tests with the more patient-friendly VAS. METHODS: A total of 119 patients with allergic rhinitis due to grass pollen were enrolled in the study between June 20, 2001, and January 31, 2002. Patients reported the severity of different seasonal symptoms on a VAS and underwent a NPT. RESULTS: No significant correlations between VAS and NPT scores were found. However, all the correlation coefficients between the symptom scores from the NPT and the corresponding symptom scores from the VAS were much higher for the female than the male subgroup. CONCLUSIONS: The VAS does not correlate with the NPT and, therefore, cannot replace the NPT. However, the result may suggest it worthwhile to explore the role of sex in the perception of allergy symptoms.

Health-economic analyses of subcutaneous specific immunotherapy for grass pollen and mite allergy.

OBJECTIVE: To investigate the health and monetary consequences of treating allergy with specific immunotherapy (SIT) compared with symptomatic treatment/standard care among patients with grass pollen or mite allergy. METHODS: We performed an economic analysis based on 253 grass- and/or mite allergic patients who started SIT from 1.1.1996 to 1.1.2002 at the Allergy Unit, Aarhus University Hospital and at a specialist practice in Aarhus. Relevant data were collected before, during and after SIT treatment from the national health service based on each patient's personal identification number and medical records and from a specifically designed questionnaire. A cost-benefit analysis including direct and indirect costs before, during and after SIT was performed. In addition direct costs were related to the clinical effect (improvement in well-being) in the form of a cost-effectiveness analysis. RESULTS: The direct cost per patient/year before SIT (equivalent to standard care) was DKK 2,580. The investment in SIT was DKK 27,545 (in present values) per patient over a 4-year period. After SIT the cost was reduced to DKK 1,072 per patient/year. In the long term, prospective introduction of SIT incurred additional present-value direct costs of DKK 13,676 per patient treated and DKK 2,784 per patient/year of improved well-being. However, when indirect costs were included in the economic evaluation SIT was shown to be net beneficial. CONCLUSION: This study reveals that SIT is associated with initial resource investments and subsequent resource savings in the long term compared with standard care. When all consequences are measured in monetary terms, and assuming that sick days are associated with a loss of productivity, this analysis suggests that SIT increases societal welfare. This conclusion also holds if there is no loss of productivity.

[Impact of allergic rhinitis on work productivity: a pilot study].

BACKGROUND: Allergic rhinitis can interfere with cognitive function, can impair work productivity, and may cause work absences. In this study, we evaluated the impact of Japanese cedar pollinosis (JCP) on work productivity. METHODS: The study was conducted between February 24 and March 8, 2003 (peak pollen season), and 512 workers with JCP were enrolled. Study outcomes included self-reported work productivity (absenteeism and presenteeism) and quality of life (the Medical Outcomes Study Short Form-36). RESULTS: Most patients (91%) did not lose their work time due to JCP during the past 7 days. Approximately half of patients reported a 25% reduction in productivity compared with non pollination season. In multiple logistic regression analysis, the following factors were selected as independent risk factors for lost work time: duration of disease (adjusted odds ratio (aOR) = 0.658) and itching eyes (aOR = 1.552). Likewise, SF-36 PCS (aOR = 0.946), MCS (aOR = 0.927) and using pollinosis relief products (aOR = 2.020) were predictors of lost productivity. CONCLUSION: This study shows that we should pay more attention to ocular symptoms as well as nasal symptoms and improve patients' quality of life as soon as possible in order to reduce productivity losses.