An internet survey on self-reported food allergy in Greece: clinical aspects and lack of appropriate medical consultation.

BACKGROUND: Food allergy (FA) represents a common and worldwide disorder but in publications referring to FA the reported diagnosis is rarely confirmed. Consequently, the subjectively assessed FA may negatively affect the quality of life of patients and their families. OBJECTIVE: We have conducted this internet survey in order to estimate the self-reported perception of FA in Greece. METHODS: A standard anonymous questionnaire was posted for a 3-month period on http://www.in.gr, a Greek popular Internet portal. Each individual could participate only once. Participants were screened for the presence or history of FA by a key question and were then asked to provide information on symptoms, course and management. RESULTS: A total of 3673 adult subjects (mean age 34.2 years, range 18-74, females 61.3%), reporting FA were included in analysis. Most reported reactions were related to fruits (14.9%), seafood (10.7%) and nuts (9.2%). The first episode occurred principally during the second (29.2%) and third (30.9%) decade within 3 h from consumption (82.2%). Predominant symptoms were urticaria and oral allergy syndrome (almost 25% each one). Nearly half of the participants sought no medical advice, while 31.4% asked for an allergist's consultation. Almost 21% of reactors were hospitalized; nuts, severity of symptoms (lower respiratory and/or cardiovascular), onset in lower age, previous exercise and concomitant alcohol and/or aspirin intake were positively associated with hospitalization. CONCLUSION: Although FA causes severe anaphylactic episodes, almost 50% of individuals who experience symptoms perceived as FA do not seek medical advice. Awareness programmes must be carried out in order to increase consciousness about this potentially fatal medical condition.

Serum neurotensin (NT) is increased in psoriasis and NT induces vascular endothelial growth factor release from human mast cells.

BACKGROUND: Psoriasis involves skin inflammation that often worsens with stress, but the mechanism of this effect remains obscure. We have shown that corticotropin-releasing hormone (CRH) is increased in the serum of patients with psoriasis. A peptide, neurotensin (NT), can trigger skin histamine release and augment the ability of CRH to increase skin vascular permeability. OBJECTIVES: To investigate the serum level of NT, and the expression of genes for NT and NT receptor-1 (NTR-1) in lesional and nonlesional skin of patients with psoriasis, compared with normal controls. Also, to study the effect of NT on human mast cell release of vascular endothelial growth factor (VEGF), which is increased in psoriatic skin. METHODS: Serum was obtained from patients with psoriasis (n = 56) and controls (n = 33); NT levels were measured with the Milliplex microbead assay. Biopsies were obtained from the lesional and nonlesional skin of patients with chronic plaque psoriasis (n = 40), who had not received any treatment for at least 15 days and were free of any systemic inflammatory diseases. Control skin samples were obtained from healthy subjects (n = 30). Expression of genes for NT and NTR-1 in the skin was evaluated by quantitative reverse transcriptase-polymerase chain reaction. LAD2 human mast cells were stimulated by NT (1 µmol L(-1)) for 24 h and VEGF was measured by enzyme-linked immunosorbent assay. RESULTS: Serum NT was increased in patients with psoriasis, while expression of genes for NT and NTR-1 in lesional skin was decreased compared with controls. NT induced VEGF release from mast cells and was augmented by interleukin-33. CONCLUSION: NT may play a role in psoriasis pathogenesis and its worsening by stress, at least in part through activation of skin mast cells.

Recommendations for assessing patient-reported outcomes and health-related quality of life in patients with urticaria: a GA(2) LEN taskforce position paper.

The aim of this Global Allergy and Asthma European Network (GA(2)LEN) consensus report is to provide recommendations and suggestions for assessing patient-reported outcomes (PROs) including health-related quality of life in patients with urticaria. We recommend that PROs should be used both in clinical trials and routine practice for the evaluation of urticaria patients. We suggest that PROs should be considered as the primary outcome of future clinical trials. Two validated and disease-specific instruments for assessing PROs are available, the urticaria activity score (for symptoms) and the chronic urticaria questionnaire on quality of life CU-Q(2)oL. This latter tool, CU-Q(2)oL, is available in many languages and should be preferred, where available, over more generic instruments for assessing urticaria-specific effects on quality of life. CU-Q(2)oL is only suited for the investigation of patients with chronic spontaneous urticaria. Similar instruments for other forms of urticaria have yet to be developed and validated. Also, tools for assessing other chronic spontaneous urticaria PROs besides quality of life and symptoms are needed.

Adaptation and initial results of the Polish version of the GA(2)LEN chronic urticaria quality of life questionnaire (CU-Q(2)oL).

BACKGROUND: Strong negative influence upon the quality of life in chronic urticaria is well proved. Before the GA(2)LEN Chronic Urticaria Quality of Life Questionnaire (CU-Q(2)oL) was introduced, the quality of life in chronic urticaria had been measured with general or dermatology specific questionnaires. CU-Q(2)oL was initially developed in Italy and consisted of 23 items divided into 6 quality of life dimensions. OBJECTIVE: The aim of our study was to adapt the Polish version of CU-Q(2)oL and to provide initial results from the Polish sample. METHODS: To prepare the Polish version forward and back translation was prepared. After cognitive debriefing, we collected a group of 126 chronic urticaria patients who completed Polish CU-Q(2)oL, Dermatology Life Quality Index (DLQI) and Skindex-29 questionnaire. Disease severity was assessed with Urticaria Activity Score (UAS). We performed the factorial analysis to identify CU-Q(2)oL subscales in our study, internal consistency and convergent validity assessment as well as factors driving the results. Moreover, we analysed tool's reproducibility and responsiveness. RESULTS: The factor analysis resulted in six subscales of Polish CU-Q(2)oL version with satisfying face validity: Itching, Swelling/Mental status, Functioning, Sleep, Eating/Limits, Embarrassment. All subscales presented recommended internal consistency and convergent validity. Disease severity was the only factor predicting results of all the subscales. Polish CU-Q(2)oL version was reproducible and sensitive to change. We noticed the highest quality of life impairment in Itching and Embarrassment subscales whereas Eating/Limits was the least affected. CONCLUSIONS: Our study supports reliability, responsiveness and validity of the Polish version of CU-Q(2)oL - easy in use, non time-consuming instrument to be used in research, clinical management and treatment outcome assessment and is one more step to confirm quality of life impairment in chronic urticaria.

Can Internet surveys help us understanding allergic disorders? - results from a large survey in urticaria in Greece.

BACKGROUND: Urticaria is often underdiagnosed and/or undertreated. We have conducted an Internet-based study to record epidemiological and clinical features as well as therapeutic interventions for urticaria in a large sample of patients in Greece. METHODS: A standard anonymous questionnaire was posted for a 3-month period on 'http://www.in.gr', a Greek popular Internet portal. Each individual participated only once. Participants were screened for the presence or history of urticaria by two key questions and were then asked to provide information on symptomatology and management. RESULTS: A total of 12 396 subjects voluntarily responded to the survey, of which 8440 (5136 females) who reported to have or had urticaria, were finally analysed. A total of 4780 (56.6%) had experienced weals only, 507 (6.0%) angio-oedema only and 3018 (35.8%) both. Weals and angio-oedema were found to be more common in women; 2761(57.8%) and 277(54.6%), respectively. Age of onset significantly correlated with disease duration; a 1% higher possibility of longer duration of urticaria exists (more than 6 weeks compared with less than 6 weeks) for each additional year of age of onset after controlling for gender. Patients with chronic urticaria had increased mean age compared with those reporting the acute form (35.04 vs. 33.88 years, P < 0.001). Dermatologists were the most frequently visited specialists and the most common treatments were antihistamines and topical preparations. The self-reported eliciting factors of urticaria were as follows: physical stimuli (approximately 25%), psychological distress (17.2%), direct contact to metals or chemicals (14.5%), foods and drugs (10%), whereas a third of the participants could not identify any trigger. CONCLUSIONS: Internet surveys can be a useful tool for screening the general population for common allergic disorders, such as urticaria.

Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report.

Chronic spontaneous urticaria, formerly also known as chronic idiopathic urticaria and chronic urticaria (CU), is more common than previously thought. At any time, 0.5-1% of the population suffers from the disease (point prevalence). Although all age groups can be affected, the peak incidence is seen between 20 and 40 years of age. The duration of the disease is generally 1-5 years but is likely to be longer in more severe cases, cases with concurrent angioedema, in combination with physical urticaria or with a positive autologous serum skin test (autoreactivity). Chronic spontaneous urticaria has major detrimental effects on quality of life, with sleep deprivation and psychiatric comorbidity being frequent. It also has a large impact on society in terms of direct and indirect health care costs as well as reduced performance at work and in private life. In the majority of patients, an underlying cause cannot be identified making a causal and/or curative treatment difficult. Nonsedating H1-antihistamines are the mainstay of symptomatic therapy, but treatment with licensed doses relieves symptoms effectively in < 50% of patients. Although guideline-recommended updosing up to fourfold increases symptom control in many patients, a substantial number of patients have only little benefit from H1 -antihistamines. Consequently, there is a great need for new therapeutic strategies.

Temporal relationship of allergic rhinitis with asthma and other co-morbidities in a Mediterranean country: A retrospective study in a tertiary reference allergy clinic

Background: Allergic rhinitis is a global health problem which causes major illness and represents a risk factor for asthma. The primary aim of the study was to record the clinical pattern of allergic rhinitis and its temporal relation with asthma in a Greek population. Methods: Three-hundred and sixteen subjects with documented diagnosis of allergic rhinitis in a two-year period were included in this study. All participants completed a standardised questionnaire with full retrospective epidemiological data for rhinitis; in addition, serum IgE measurement and skin prick tests with 22 common inhalant allergens were carried out, while spirometry was performed in subjects with self-reported or doctor-diagnosed asthma. All subjects with at least one positive skin test were included in study analysis. Results: One-hundred and sixty five out of 316 patients (49.1%) stated self reported-asthma while in 63/316 (19.9%) asthma was documented with spirometry. One hundred out of 165 (60.6%) had rhinitis as first clinical manifestation while in 24/165 (14.5%) asthma symptoms appeared first; the remaining 31/165 (24.9%) reported simultaneous onset of upper and lower airways' symptoms. About 68.5% were sensitised to seasonal allergens exclusively, while 50% were sensitised to ≥1 of Parietaria, grasses sp., Olea eur. The duration of rhinitis in the subpopulation of patients with self-reported asthma (n=165) was significantly higher compared with non-asthmatics (mean=3.22 years, p<0.001). Survival analysis for the estimation of asthma onset showed that the mean time interval with rhinitis only is 16.6 years (median 12 years, incidence 0.0596). Conclusions: The unique environmental conditions and the aerobiology of each area clearly affect the clinical features of respiratory allergy

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[Cold-induced urticaria and angioedema. Classification, diagnosis and therapy]. / Kälteinduzierte Quaddeln und Angioödeme. Klassifikation, Diagnostik und Therapie.

The onset of wheals and/or angioedema following the exposure to cold may be associated with a number of different diseases. Most frequently this occurs in cold contact urticaria, a type of physical urticaria, which is characterized by a positive cold stimulation test. The clinical symptoms are based on cold-dependent mast cell activation with subsequent release of proinflammatory mediators. In cases of negative or atypical reaction to cold stimulation testing rare acquired atypical or familiar cold urticaria forms may be suspected. Strict avoidance of cold should be recommended as far as possible. As the underlying causes of cold contact urticaria are widely unknown, the symptomatic use of non-sedating antihistamines is the treatment of first choice. The very rare familiar cold auto-inflammatory syndrome (FCAS) is based on CIAS1/NLRP3 mutations and may be treated effectively by neutralization of pathogenic interleukin 1beta.

Temporal relationship of allergic rhinitis with asthma and other co-morbidities in a Mediterranean country: a retrospective study in a tertiary reference allergy clinic.

BACKGROUND: Allergic rhinitis is a global health problem which causes major illness and represents a risk factor for asthma. The primary aim of the study was to record the clinical pattern of allergic rhinitis and its temporal relation with asthma in a Greek population. METHODS: Three-hundred and sixteen subjects with documented diagnosis of allergic rhinitis in a two-year period were included in this study. All participants completed a standardised questionnaire with full retrospective epidemiological data for rhinitis; in addition, serum IgE measurement and skin prick tests with 22 common inhalant allergens were carried out, while spirometry was performed in subjects with self-reported or doctor-diagnosed asthma. All subjects with at least one positive skin test were included in study analysis. RESULTS: One-hundred and sixty five out of 316 patients (49.1%) stated self reported-asthma while in 63/316 (19.9%) asthma was documented with spirometry. One hundred out of 165 (60.6%) had rhinitis as first clinical manifestation while in 24/165 (14.5%) asthma symptoms appeared first; the remaining 31/165 (24.9%) reported simultaneous onset of upper and lower airways' symptoms. About 68.5% were sensitised to seasonal allergens exclusively, while 50% were sensitised to ≥ 1 of Parietaria, grasses sp., Olea eur. The duration of rhinitis in the subpopulation of patients with self-reported asthma (n=165) was significantly higher compared with non-asthmatics (mean=3.22 years, p<0.001). Survival analysis for the estimation of asthma onset showed that the mean time interval with rhinitis only is 16.6 years (median 12 years, incidence 0.0596). CONCLUSIONS: The unique environmental conditions and the aerobiology of each area clearly affect the clinical features of respiratory allergy.

A simple 3-day "rush" venom immunotherapy protocol: documentation of safety

Background: Venom immunotherapy (VIT) is the only effective treatment for hymenoptera hypersensitivity, but conventional protocols require a few weeks. Objective: We present the safety of a 3-day "rush" protocol that requires only 7 injections and 255mgr cumulative dose before the 100 µg maintenance dose. Methods: Forty-nine patients (33 males, 16 females) of mean age 43.57 ± 12.9yrs received "rush" VIT. Only 7 injections were required until the maintenance dose of 100mgr was reached on Day 5. On Day 1, four injections were administered with initial dose of 5mgr and total dose of 75 µg. On Day 3 a cumulative dose of 180mgr was administered in three injections (40mgr, 60mgr and 80mgr). A dose of 100mgr was administered on Day 5. Twenty-nine individuals were treated with Honey-Bee venom; 18 with Common wasp; 5 with Paper Wasp; while 13 patients received Mixed Vespid preparation. Inclusion criteria were documented IgE-mediated allergy with intradermal sensitivity to ≤0.1mgr/ml venom concentration and concomitant detection of specific venom IgE ≥ 35kU/l. Results: All patients reached the maintenance dose. Forty-nine patients received 65 immunotherapy courses, resulting in 1520 injections. Thirty-three systemic reactions: 7 during building phase (1.5%); and 26 in the maintenance dose (2.4%) were observed in 9 patients. The percentage of reactions/total injection number was 2.2%; all reactions were mild-to-moderate. Fourteen patients reported documented field stings at least two months after VIT onset with only one reported mild systemic reaction. Conclusion: We propose a simple "rush" VIT protocol in an outpatient setting as an easy-to-perform alternative option for VIT induction phase

A simple 3-day "rush" venom immunotherapy protocol: documentation of safety.

BACKGROUND: Venom immunotherapy (VIT) is the only effective treatment for hymenoptera hypersensitivity, but conventional protocols require a few weeks. OBJECTIVE: We present the safety of a 3-day "rush" protocol that requires only 7 injections and 255 mgr cumulative dose before the 100 microg maintenance dose. METHODS: Forty-nine patients (33 males, 16 females) of mean age 43.57+/-12.9 yrs received "rush" VIT. Only 7 injections were required until the maintenance dose of 100 mgr was reached on Day 5. On Day 1, four injections were administered with initial dose of 5 mgr and total dose of 75 microg. On Day 3 a cumulative dose of 180 mgr was administered in three injections (40 mgr, 60 mgr and 80 mgr). A dose of 100 mgr was administered on Day 5. Twenty-nine individuals were treated with Honey-Bee venom; 18 with Common wasp; 5 with Paper Wasp; while 13 patients received Mixed Vespid preparation. Inclusion criteria were documented IgE-mediated allergy with intradermal sensitivity to < or =0.1 mgr/ml venom concentration and concomitant detection of specific venom IgE > or =0.35 kU/l. RESULTS: All patients reached the maintenance dose. Forty-nine patients received 65 immunotherapy courses, resulting in 1520 injections. Thirty-three systemic reactions: 7 during building phase (1.5%); and 26 in the maintenance dose (2.4%) were observed in 9 patients. The percentage of reactions/total injection number was 2.2%; all reactions were mild-to-moderate. Fourteen patients reported documented field stings at least two months after VIT onset with only one reported mild systemic reaction. CONCLUSION: We propose a simple "rush" VIT protocol in an outpatient setting as an easy-to-perform alternative option for VIT induction phase.

Tacrolimus ointment 0.1% in the treatment of allergic contact eyelid dermatitis.

BACKGROUND: Tacrolimus inhibits T-lymphocyte activation and dermal Langerhans' cells, without the side-effects of corticosteroids. The safety profile of tacrolimus makes it a promising therapeutic option for dermatitis affecting the delicate periorbital skin. OBJECTIVE: To access the efficacy and tolerability of tacrolimus ointment 0.1% in the treatment of allergic contact eyelid dermatitis. PATIENTS AND METHODS: Twenty adults (16 women, 4 men) with eyelid dermatitis and with at least one positive patch test reaction to relevant contact allergens were treated with topical tacrolimus in a prospective, open-label, non-comparative clinical study. Dermatitis was graded at baseline, at day 30 and day 60, using a 4-point grading system for the following parameters: erythema, oedema, scaling, lichenification, fissuring (investigator assessment) and burning/stinging and pruritus (patient assessment). RESULTS: All patients completed the study. Erythema, oedema, scaling and lichenification showed improvement from baseline to 30 days of treatment ( P < 0.001), but fissuring was not significantly affected. At 60 days, no further improvement of these investigator parameters was observed. Patient parameters improved significantly by day 30 ( P < 0.004) and there was a trend for further improvement at the end of 60 days (for burning, P = 0.046; for pruritus, P = 0.059). Ten per cent of patients mentioned burning and itching, at the application site, during the first days of treatment. No other adverse events were observed. CONCLUSION: Topical tacrolimus is a promising alternative in patients with allergic contact eyelid dermatitis. Therapy was effective by 1 month and was well tolerated. These preliminary results merit a larger, controlled, study.

Urticaria pigmentosa associated with acute stress and lesional skin mast-cell expression of CRF-R1.

A 38-year-old woman presented with a pronounced increase in symptoms and proliferation of urticaria pigmentosa (UP) after acute psychological stress, which was quantified using the Spielberger's State-Trait Anxiety Inventory. Immunohistochemical examination of a skin biopsy from a new UP lesion showed a large number of activated mast cells expressing corticotrophin-releasing factor receptor-1 (CRF-R1) and there was high serum CRF. This is the first documented report to our knowledge of UP worsening associated with acute stress, possibly through activation of skin mast-cell CRF-R1.

A quercetin containing supplement reduces niacin-induced flush in humans.

Coronary artery disease is associated with increased serum levels of cholesterol, triglycerides and LDL, but low levels of HDL. The most potent agent capable of reversing this trend is the vitamin nicotinic acid (niacin). However, compliance even with extended-release preparations and addition of acetylsalicylic acid (ASA) is hampered by the development of a feeling of erythema and burning ("flush"), especially on the face. We recently showed that the natural flavonoids quercetin and luteolin can eliminate "flush", as well as inhibit both niacin-induced plasma prostaglandin D2 (PGD2) and serotonin increase in an animal model. We conducted a pilot clinical study in humans. Four normal male subjects received (a) 1 g immediate release niacin either alone or after (b) the dietary formulation (Algonot-plus) containing 150 mg quercetin per capsule. Subjects completed a visual scale (1 = no, 5 = worst response) symptom assessment. Erythema and burning sensation scores were both 4.75+/-0.50 and lasted for 3.63+/-1.11 hours. After Algonot-plus administration, both scores were reduced to 2.5+/-0.58 and lasted only for 1.68+/-0.70 hours. Quercetin also inhibited methylnicotinate-induced human mast cell PGD2 release. These preliminary results suggest that quercetin could reduce niacin-induced "flush" in humans.