Inhaler Steroid Use Changes Oral and Airway Bacterial and Fungal Microbiome Profile in Asthma Patients.

INTRODUCTION: The full spectrum of bacterial and fungal species in adult asthma and the effect of inhaled corticosteroid use is not well described. The aim was to collect mouthwash and induced sputum samples from newly diagnosed asthma patients in the pretreatment period and in chronic asthma patients while undergoing regular maintenance inhaled corticosteroid therapy, in order to demonstrate the bacterial and fungal microbiome profile. METHODS: The study included 28 asthmatic patients on inhaler steroid therapy, 25 steroid-naive asthmatics, and 24 healthy controls. Genomic DNA was isolated from induced sputum and mouthwash samples. Analyses were performed using bacterial primers selected from the 16S rRNA region for the bacterial genome and "panfungal" primers selected from the 5.8S rRNA region for the fungal genome. RESULTS: Dominant genera in mouthwash samples of steroid-naive asthmatics were Neisseria, Haemophilus, and Rothia. The oral microbiota of asthmatic patients on inhaler steroid treatment included Neisseria, Rothia, and Veillonella species. Abundant genera in induced sputum samples of steroid-naive asthma patients were Actinomyces, Granulicatella, Fusobacterium, Peptostreptococcus, and Atopobium. Sputum microbiota of asthma patients taking inhaler steroids were dominated by Prevotella and Porphyromonas. Mucor plumbeus and Malassezia restricta species were abundant in the airways of steroid-naive asthma patients. Choanephora infundibulifera and Malassezia restricta became dominant in asthma patients taking inhaled steroids. CONCLUSION: The oral and airway microbiota consist of different bacterial and fungal communities in healthy and asthmatic patients. Inhaler steroid use may influence the composition of the oral and airway microbiota.

Real-world patient-level cost-effectiveness analysis of omalizumab in patients with severe allergic asthma treated in four major medical centers in Turkey.

AIMS: To evaluate the cost-effectiveness of standard-of-care treatment (SoC) to SoC in combination with omalizumab (OML + Soc) in patients with severe asthma using real-world prospective clinical data from four major medical centers in Turkey. MATERIALS AND METHODS: Between February 2018 and November 2019, a total of 206 patients with severe asthma, including 126 of whom were in the OML + SoC group and 80 in the SoC group, were followed for 12 months to evaluate their asthma status and quality of life. Cost data for this patient-level economic evaluation were sourced from the MEDULA database of the hospitals and expressed in Turkish Lira (₺). Efficacy data were obtained by means of Turkish versions of the Asthma Control Test for asthma status, the 5-level EQ-5D-5L version (EQ-5D-5L), and the Asthma Quality of Life Scale for quality of life. A Markov model with 2-week cycles was specified, comparing costs and treatment effects of SoC vs. OML + SoC over a lifetime from the Turkish payer perspective. RESULTS: Per-patient costs were ₺23,607.08 in the SoC arm and ₺425,329.81 in the OML + Soc arm, for a difference of ₺401,722.74. Life years (LY) and quality-adjusted life years (QALY) were 13.60 and 10.08, respectively, in the SoC group; and 21.26 and 13.35, respectively, in the OML + SoC group, for differences of 7.66 LYs and 3.27 QALYs. This yielded an incremental cost-effectiveness ratio of an additional ₺52,427.04 to gain 1 LY and an incremental cost-utility ratio of an incremental ₺122,675.57 to gain 1 QALY; the latter being below the ₺156,948 willingness-to-pay threshold for Turkey referenced by WHO. One-way and multivariate sensitivity analyses confirmed the base-case results. CONCLUSION: Whereas most economic evaluations are based on aggregate data, this independent cost-effectiveness analysis using prospective real-world patient-level data suggests that omalizumab in combination with standard of care is cost-effective for severe asthma from the Turkish public payer perspective.

What is the context? Severe asthma, a subset of difficult-to-treat asthma, refers to asthma that cannot be controlled despite adherence to optimized maximal therapy and treatment of contributing factors, or asthma that worsens when high-dose therapy is reduced.Omalizumab is the first biologic therapy approved for the treatment of allergic asthma. Its main role is to prevent the release of various inflammation factors that cause severe asthma episodes.Cost-effectiveness analysis is an economic method of determining how much more a new and better treatment costs relative to the current treatment in terms of how many life years (LY) and how many quality-adjusted life years (QALY) are gained with the new treatment. Cost-effectiveness results tell us how much more money is needed over the cost of the current treatment to achieve one additional LY, regardless of the quality of life, or one additional LY with good quality of life.No cost-effectiveness data obtained from actual clinical patient data are available for Turkey. What is new? Our study found that the addition of omalizumab to the current standard of care for severe asthma increases costs but also increases life years and quality-adjusted life years. The additional cost was less than what the World Health Organization assumes is reasonable for Turkey.This study used actual clinical patient data and noted that asthma patients in the omalizumab group used fewer health services, had a better clinical course, had a better quality of life, and lived longer with their disease under control.What is the impact? In severe asthmatic patients, adding omalizumab to standard-of-care, while more costly, yields better outcomes and is therefore cost-effective.The cost-effectiveness estimates fall within the margins of being cost-responsible. The Turkish public payer should strongly consider making omalizumab available to all eligible patients. This will enable working-age patients to work, and contribute to their families, while also strengthening the Turkish economy.

A new classification option for NSAID hypersensitivity: Kalyoncu classification.

BACKGROUND: The European Network for Drug Allergy (ENDA) proposed a consensus document for hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs) in 2011. A subgroup of patients with NSAIDs-exacerbated respiratory disease (NERD) develop urticaria/angioedema type reactions in response to NSAIDs. The Kalyoncu classification might be a novel option to classify patients with NSAID hypersensitivity (NH). In this study, we compare the ENDA and the Kalyoncu classifications. METHODS: This study enrolled a total of 196 patients. NH reaction types were categorized as asthma, rhinitis, urticaria/angioedema and anaphylaxis. Based on the reaction history and oral provocation test findings, patients were grouped according to ENDA and Kalyoncu classifications. RESULTS: The mean age of the 196 patients was 40.32±13.28 years, and 130 (66.3%) of them were female. Under the ENDA and Kalyoncu classifications, the most common NH subgroups were NERD (32%), and isolated NH (34.2%), the least prevalent NH subgroups were single NSAID-induced delayed reactions (SNIDR) (1.5%), and pseudo Samter's syndrome (11.7%). CONCLUSIONS: Our research revealed that the Kalyoncu classification is more descriptive of patients with NERD exhibiting urticaria/angioedema-type reactions. It also provides future risk assessment for development of NERD. For controversial cases, the Kalyoncu classification can be utilized as a new complimentary option alone or in conjunction with ENDA classification.

Is the Perioperative Period No Longer a Problem for Adult Asthmatics under Control?-OPERA Study.

OBJECTIVES: Asthma is a global problem and chronic condition that persists through patient's entire life, during which the possibility of a surgical procedure is common. An accurate clinical and functional evaluation of respiratory functions and asthma control is needed in patients undergoing surgical procedures and requiring general anesthesia. The aim of this study was to disclose any possible relation between postoperative complications and some pre- and postoperative factors. MATERIALS AND METHODS: In this prospective cross-sectional study, randomly selected 111 asthmatic patients who presented to 10 different tertiary centers were included. The patients were evaluated at three different periods; any day between 1-7 days before surgery, and postoperative third and seventh to tenth days. RESULTS: Among the patients included in the study, 86 (77.5%) were women and mean age was 52.2±13.8 years. General anesthesia was the most common anesthesia type (89.2%), and 33.3% of patients had had a thoracoabdominal surgery. There was a statistically significant difference between pre- and postoperative third-day values, including ACT scores (22.2±3.16 and 21.59±3.84, respectively; p<0.001); forced expiratory volume during the first second (84.92±19.12 and 78.26±18.47, respectively; p<0.001); peak flow rate (79.51±21.12 and 70.01±19.72, respectively; p<0.001); and SaO2 (96.95±1.82 and 95.8±3.32, respectively; p<0.001). Bronchospasm and pain were the most common complications during the postoperative period. CONCLUSION: Controlled asthma under treatment steps 1-2-3 does not cause any serious postoperative pulmonary complications (PPCs). Therefore, achieving an optimal control level of asthma during the preoperative period must be considered the "gold standard" to reduce the risk of PPCs in asthmatic patients.

The Frequency and Risk Factors for Oropharyngeal Candidiasis in Adult Asthma Patients Using Inhaled Corticosteroids.

OBJECTIVES: Worldwide, asthma is a major health problem and inhaled corticosteroids (ICS) are the mainstay of asthma treatment. High-dose and long-term use of ICS can result in some side effects. The present study aimed to determine the frequency of oral and systemic candidiasis infections in adult asthma patients using ICS, and to identify possible risk factors. MATERIAL AND METHODS: This study included 186 randomly selected adult asthma patients that presented to allergy clinic between May 2011 and September 2012. RESULTS: Among the patients, 147 (79%) were female. The lifelong incidence of oral candidiasis was 19.4% (n=36), whereas 5.38% (n=10) of the patients already had it by the time of the study. The lifelong incidence of any fungal infection was 59.7% (n=111). There weren't any significant differences in gender, age, age at onset of asthma, oral hygiene, atopy, or comorbid diseases between the oropharyngeal candidiasis (OPC)-positive and -negative groups. A history of persistent rhinitis, use of a leukotriene receptor antagonist together with ICS, and use of ciclesonide as an ICS were associated with a higher incidence of OPC. CONCLUSION: In the present study the incidence of OPC in adult asthma patients was quite high, but no definitive risk factors were identified. Further studies are needed to distinguish these individual differences.

Asthma phenotypes in Turkey: a multicenter cross-sectional study in adult asthmatics; PHENOTURK study.

BACKGROUND AND AIMS: To evaluate asthma phenotypes in patients with asthma from different regions of Turkey. METHODS: A total of 1400 adult asthmatic patients (mean (SD) age: 44.0 (13.9) years, 75% females) from 14 centers across Turkey were included in this study and a standard questionnaire was applied between the time period of February 2011-January 2012. RESULTS: The disease onset ≥ 40 years of age was higher percentage in obese vs. normal/overweight patients and nonallergic vs. allergic patients (P < 0.01). The percentage of patients who had FEV1 values over 80% was higher in allergic than nonallergic and normal/overweight than obese patients (P < 0.01). Uncontrolled asthmatics have more severe disease (P < 0.01). There were more frequent hospital admissions in nonallergic and uncontrolled asthmatics (P < 0.01). Chronic rhino-sinusitis was the leading comorbid disorder in normal/overweight and allergic asthma, while gastroesophageal reflux disorder was more frequent in nonallergic and uncontrolled asthma (P < 0.01). Asthma control rate was the highest (39.0%) in patients from Marmara region among all geographical regions (P < 0.05). CONCLUSION: In conclusion, our findings revealed existence of clinical/trigger related phenotypes based on BMI, allergic status, control level and geographical region with more frequent respiratory dysfunction and/or adverse health outcomes in uncontrolled, obese and nonallergic phenotypes.

Minimum prick test panel for adult patients with asthma and rhinitis in Ankara, Turkey.

OBJECTIVE: Determination of the number and type of allergens needed to be tested in epidemiological studies is important in order to identify most of the sensitized subjects with a cost-effective approach. This study aimed to investigate the minimum skin prick test panel for the identification of at least 95% of the sensitized subjects with symptoms of asthma and/or allergic rhinitis (AR) in Ankara, Turkey. METHODS: Skin prick test results of 7492 patients who were referred to our outpatient clinic with clinical symptoms of asthma and/or AR between 1991 and 2005 were evaluated retrospectively. Seven allergens were tested in all and 13 allergens in 4202 patients. The allergen group needed for detection of 95% of the sensitized subjects was determined for both the 7 and 13 allergen panels. The study protocol was approved by the local ethics committee of Hacettepe University. RESULTS: The atopy prevalences in the whole study population and in 4202 patients tested with the 13 allergen panel were calculated as 32.2% and 42.6%, respectively. Three allergens (Phleum pratense, Dermatophagoides pteronyssinus and Artemisia vulgaris) within the 7 allergen panel were adequate for the identification of at least 95% of the sensitized subjects. Olea europae was added to the previous three allergens when the 13 allergen panel was applied. CONCLUSION: Three to four allergens are sufficient for identification at least 95% of sensitized subjects with asthma and/or AR in Ankara, Turkey.

Protective efficacy of sunglasses on the conjunctival symptoms of seasonal rhinitis.

BACKGROUND: Although allergen avoidance can lead to significant improvements in symptoms of allergic rhinitis, there are very few studies in this area. Sunglasses could be effective for protection of eyes from pollen as a cheap, comfortable, and simple avoidance option for allergens. The aim of this study is to determine if wearing sunglasses can decrease ocular symptoms. METHODS: Ocular symptomatic patients (39 total) who had a confirmed history of seasonal rhinitis by skin prick tests and negative skin prick tests for perennial allergens were included in the study. The duration of the study was 4 weeks with 3 required visits. At the onset of the 1-week run-in period, patients were randomized and divided into 2 groups. Group I (n = 18) received topical aqueous nasal budesonide regularly and loratadine once daily as a rescue medication. Group II (n = 21) wore sunglasses during daytime as an addition to this medication. Subjective data included a daily diary recording nasal and ocular symptom scores and antihistamine need during the study period. RESULTS: Sunglasses significantly reduced ocular symptoms (p = 0.002) and use of antihistamines (p = 0.009). CONCLUSION: Sunglasses are an inexpensive and simple treatment for patients with allergic conjunctivitis.

Non-steroidal anti-inflammatory drug hypersensitivity in adults and the factors associated with asthma.

BACKGROUND: Characteristics of non-steroidal anti-inflammatory drug (NSAID)-hypersensitivity (NH) associated with underlying/accompanying diseases has not been studied in Turkey. In addition, the factors associated with asthma in NH patients are not well known. The present study aimed to investigate the relationship between NH and chronic urticaria, rhinitis/rhinosinusitis, and asthma in an effort to identify NH phenotypes. The study's secondary aim was to identify the factors associated with asthma in NH patients and the NSAID reaction pattern in asthmatics. METHODS: Data for 1137 NH patients in our hospital's allergy clinic database were retrospectively analyzed. Patients were divided into 5 groups based on their accompanying diseases (chronic urticaria, asthma, rhinitis/rhinosinusitis). Asthmatic patients were compared to non-asthmatic patients to identify the factors associated with asthma. RESULTS: Reaction patterns and patient characteristics in each group differed from those in the reference group (NH only group). Asthma in patients with NH was associated with female gender, sinonasal polyposis/polyp surgery, rhinitis/rhinosinusitis, NSAID-induced rhinitis/asthma or a blended reaction pattern, immediate reaction following NSAID intake, self-reported history of food allergy, and family history of asthma; the odds ratios and 95% CIs were 1.35 (1.02-1.78), 13.52 (8.74-20.9)/10.94 (6.73-17.77), 12.06 (9-16.17), 15.28 (10.45-22.36)/2.43 (1.70-3.45), 1.76 (1.31-2.35), 1.49 (1.04-2.14), and 3.1 (2.35-4.08), respectively. The characteristics of the asthmatic patients that had urticaria/angioedema-type reactions to NSAID intake (pseudo Samter's syndrome) differed from those in the asthmatics with rhinitis/asthma-type reactions. CONCLUSIONS: Chronic urticaria, rhinitis, and asthma commonly accompany NH. NSAID response patterns in NH patients may help differentiate groups of patients. The present study identified factors associated with asthma in NH patients and observed that there seems to be different phenotypes of Samter's syndrome, for which a new classification scheme was proposed.

The analysis of Hymenoptera hypersensitive patients in Ankara, Turkey

Background Although there are some published data about the prevalence of honeybee and vespid venom allergy from Turkey, there has been no report about Hymenoptera venom immunotherapy practice. Our aim was to determine the characteristics of Hymenoptera venom hypersensitivity and venom immunotherapy practice in Ankara, Turkey. Methods Demographic and clinical data, intradermal test, and serum specific IgE results of 65 Hymenoptera venom allergic patients who were followed up in our department from February 2005 to August 2009 were analysed. Results Serum Vespula specific IgE class (p:0.02) and Apis specific IgE class were high (p<0.0001) and Apis intradermal test results were positive (p<0.001) in accordance with the patients’ history. However, intradermal test results with Vespula were not consistent with self-reported Hymenoptera type (p:0.15). While Apis specific IgE and intradermal test results were correlated with each other (rho: 0.59, p<0.0001), Vespula specific IgE and intradermal test results were not (rho: 0.2, p:0.17). Intradermal test against Vespula did not discriminate between Apis and Vespula hypersensitive patients. There were no significant differences when the grade of reaction and specific IgE and intradermal test results were compared between Apis and Vespula. Conclusions Vespula venom hypersensitivity was more common among our patients. However, intradermal tests with Vespula had limited diagnostic sensitivity and were not correlated with serum specific IgE. Based on our results and previous reports, we recommend that negative skin test responses, especially with Vespula, need further investigation(AU)

The analysis of Hymenoptera hypersensitive patients in Ankara, Turkey.

BACKGROUND: Although there are some published data about the prevalence of honeybee and vespid venom allergy from Turkey, there has been no report about Hymenoptera venom immunotherapy practice. Our aim was to determine the characteristics of Hymenoptera venom hypersensitivity and venom immunotherapy practice in Ankara, Turkey. METHODS: Demographic and clinical data, intradermal test, and serum specific IgE results of 65 Hymenoptera venom allergic patients who were followed up in our department from February 2005 to August 2009 were analysed. RESULTS: Serum Vespula specific IgE class (p:0.02) and Apis specific IgE class were high (p<0.0001) and Apis intradermal test results were positive (p<0.001) in accordance with the patients' history. However, intradermal test results with Vespula were not consistent with self-reported Hymenoptera type (p:0.15). While Apis specific IgE and intradermal test results were correlated with each other (rho: 0.59, p<0.0001), Vespula specific IgE and intradermal test results were not (rho: 0.2, p:0.17). Intradermal test against Vespula did not discriminate between Apis and Vespula hypersensitive patients. There were no significant differences when the grade of reaction and specific IgE and intradermal test results were compared between Apis and Vespula. CONCLUSIONS: Vespula venom hypersensitivity was more common among our patients. However, intradermal tests with Vespula had limited diagnostic sensitivity and were not correlated with serum specific IgE. Based on our results and previous reports, we recommend that negative skin test responses, especially with Vespula, need further investigation.

Smooth muscle hyperplasia in an asthmatic patient: do we know it all?

Bronchial smooth muscle hyperplasia is a well-known structural change in asthma. The degree of hyperplasia is related to asthma severity. We report a case of extreme smooth muscle hyperplasia in an asthmatic patient. A 54-year-old female with a diagnosis of analgesic-induced asthma was admitted to our center for nasal polyposis surgery. During her preoperative evaluation, atelectasis of the right middle lobe was detected on chest X-ray. Bronchoscopy revealed the presence of a vegetating polypoid mass obliterating the entrance of the right middle lobe. Histopathological examination of the surgically excised polypoid mass showed benign smooth muscle proliferation with diffuse eosinophilic infiltration. This is a rare case representing an extreme example of benign smooth muscle hyperplasia forming an endobronchial mass in an asthmatic patient.

The effects of antidepressants on the results of skin prick tests used in the diagnosis of allergic diseases.

BACKGROUND: Some drugs may cause false negative results by suppressing the reactivity of the skin prick tests (SPTs). The aim of this survey was to show whether escitalopram, fluoxetine and sertraline had any effect on the reactivity of SPT. METHODS: Twenty-four patients who were admitted to the outpatient clinic of the Psychiatry Department at the Hacettepe University Hospital and planned to be treated by these antidepressants were included in the study between May and October 2008. SPTs with positive control (histamine), negative control and 3 common aeroallergens were performed in the beginning, at the first and fourth weeks. A questionnaire including 26 questions about respiratory symptoms and allergic diseases was filled in face to face by the fellow-in-training. The Visual Analog Scale (VAS) of current respiratory and nasal symptoms was recorded at all 3 visits. RESULTS: There were no statistically significant differences between the 3 mean diameters measured at 3 time points in addition to the mean diameters of the wheals between groups using escitalopram, sertraline and fluoxetine (p > 0.05). There was a statistically significant decrease between the VAS of nasal symptoms at the 3 visits (p < 0.05). CONCLUSIONS: Escitalopram, fluoxetine and sertraline do not seem to affect the reactivity of SPTs. Nasal symptoms might have been decreased due to both the allergic treatment suggested and the end of the pollen season.

Asthma and allergic diseases in school children from 1992 to 2007 with incidence data.

BACKGROUND: Information about change in the prevalence of asthma and allergic diseases and factors related with these diseases would be beneficial in decreasing the burden of these diseases. OBJECTIVE: To assess (i) change in prevalence of asthma and allergic diseases; (ii) factors associated with asthma and wheeze; and (iii) incidence of asthma and wheeze. METHODS: A questionnaire was administered to children aged 7-12 years in first five grades in the same primary school in 1992 (n: 1036), 1997 (n: 738), 2002 (n: 621), and 2007 (n: 422) and filled by the parents. A second survey in 2007 (n: 474, in eight grades) was conducted in the same schoolchildren, 6 months apart, to assess the incidence of asthma and wheeze and the associated factors. RESULTS: Comparison of 1992, 1997, 2002, and 2007 surveys revealed that prevalence of asthma (8.3%, 9.8%, 6.4%, 3.3%, respectively), wheeze (11.9%, 13.3%, 6.4%, 3.1%, respectively), hay fever (15.4%, 14.1%, 7.2%, 3.1%, respectively), and eczema (4.0%, 4.3%, 1.8%, 1.2%, respectively) were significantly lower in 2002 and 2007 compared with that in 1992. Percentage of passive smoking decreased after 1992 (74.0%, 64.0%, 64.1%, and 65.5%, respectively). Incidence of asthma and wheeze in 2007 surveys were 0.9/100 and 1.1/100, respectively. After the adjustment for age and gender, infection in the past, family atopy, and presence of atopic disease (eczema or hay fever) were associated with asthma and wheeze. Maternal smoking and lack of breast feeding were associated with asthma. Male gender, pet ownership in the past, lack of health insurance coverage, snoring, and wood or coal used as fuel were associated with wheeze. CONCLUSIONS: Decreased prevalence of asthma and allergic diseases in the last 10 years could be related to decreased rate of passive smoking. Lower socioeconomic status and lack of breast feeding could increase the risk of asthma in children.

Association between asthma, rhinitis and NSAID hypersensitivity in chronic urticaria patients and prevalence rates.

BACKGROUND: The coexistence of allergic diseases and chronic urticaria (CU) is not uncommon. Our aim was to show the prevalence of allergic diseases in chronic urticaria patients and whether possible risk factors precipitate the development of these conditions. METHODS: The data of 953 patients diagnosed with CU in our adult allergy clinic between January 1991 and June 2006 were retrospectively evaluated. RESULTS: The mean ages of the CU patients with and without non-steroidal anti-inflammatory drug hypersensitivity (NSAIDH) were 39.0 +/- 11.8 and 36.7+/- 12.3, respectively (p = 0.014). There was a female predominance in both groups (74.6 and 68.2%, respectively, p = 0.06). Apparently, some conditions occurred significantly more often in CU patients with NSAIDH compared to those without NSAIDH: 16.4 and 8.4% for asthma (p < 0.001), 4.2 and 0.8% for nasal polyps (p < 0.01), 20.8 and 7.3% for antibiotic hypersensitivity (p < 0.001), 21.6 and 12.3% for metal sensitization (p < 0.01), and 8 and 0.6% for familial NSAIDH (p < 0.001), respectively. Dermographism was more common in CU patients without NSAIDH compared to those with NSAIDH (29.4 and 21.2%, respectively; p < 0.05). NSAIDH increased the risk of asthma and rhinitis development [odds ratios: 52.9 (18.1-154.6) and 5.2 (2.0-13.4)]. CONCLUSION: Based on our data, the incidence rates of asthma, nasal polyps, antibiotic hypersensitivity, metal sensitization and familial NSAIDH are increased in patients with CU with NSAIDH compared to those with CU only. Coexistence of NSAIDH and CU increases the risk of developing asthma and rhinitis.

Successful heparin desensitization after anaphylactic shock due to heparin.

A successful desensitization protocol in a patient with low molecular weight heparin induced anaphylactic reaction is being presented. A 72-years-old patient who was known to have multiple drug allergies and asthma was admitted with acute renal insufficiency. She had an anaphylactic reaction with a low molecular weight heparin during a hemodialysis session. Peritoneal dialysis was not feasible. Anticoagulation with warfarin was not considered appropriate; alternative anticoagulants were not available. Therefore a desensitization protocol was planned and applied, comprising of IV administration of diluted heparin by gradually increasing doses (0.1 to 5000 units), at 15 minute intervals, completing 8 hours before the procedure. By this way, IV heparin could be administered during the subsequent hemodialysis sessions with no reactions. The Naranjo probability scale revealed a probable adverse reaction associated with nadroparin for this patient. Anaphylactic reaction to low molecular weight heparins is reported rarely in the literature. To the best of our knowledge, this is the third case of successful heparin desensitization. When other anticoagulants are not available and anticoagulation is indispensible, heparin desensitization can be an option.

[Allergic rhinitis and its impact on asthma update (ARIA 2008). The Turkish perspective]. / Allerjik rinit ve astim üzerine etkisi güncelleme (ARIA 2008). Türkiye deneyimi.

In this article, it is aimed to summarize the newly updated and published version of "Allergic Rhinitis and its Impact on Asthma (ARIA) 2008" and add the recent Turkish epidemiological data on it.

[Respiratory symptoms and functions in tea workers]. / Cay isçilerinde solunum semptomlari ve fonksiyonlari

Respiratory symptoms and function tests were studied in tea workers and in a control group. The prevalance of acute and chronic respiratory symptoms were not different in two groups except for an acute burning sensation of eye-nose-throat and a chronic cough. Also the comparison of the respiratory function tests between tea workers (both smokers and nonsmokers) and the controls were not different at preshift and postshift 30th minute and 8th hour. When preshift and postshift results were compared in tea workers (both in smokers and nonsmokers); statistically significant reductions of FEV1, FEV1/FVC, FEF25-75 and FEF25 were seen at the postshift values. However statistically significant reductions were not observed in controls. Thus we conclude acute tea dust exposure may cause bronchial obstruction particularly in small airways.