Luís Delgado

Sub-Lingual Immunotherapy: World Allergy Organization Position Paper 2009

Chair: G. Walter Canonica Co-Chairs Jean Bousquet, Thomas Casale, Richard F. Lockey, Carlos E. Baena-Cagnani, Ruby Pawankar, Paul C. Potter Authors Philippe J. Bousquet, Linda S. Cox, Stephen R. Durham, Harold S. Nelson, Giovanni Passalacqua, Dermot P. Ryan, Jan L. Brozek, Enrico Compalati, Ronald Dahl, Luis Delgado, Roy Gerth van Wijk, Richard G. Gower, Dennis K. Ledford, Nelson Rosario Filho, Erkka J. Valovirta, Osman M. Yusuf, Torsten Zuberbier Co-Authors Wahiduzzaman Akhanda, Raul Castro Almarales, Ignacio Ansotegui, Floriano Bonifazi, Jan Ceuppens, Tomás Chivato, Darina Dimova, Diana Dumitrascu, Luigi Fontana, Constance H. Katelaris, Ranbir Kaulsay, Piotr Kuna, Désirée Larenas-Linnemann, Manolis Manoussakis, Kristof Nekam, Carlos Nunes, Robyn O’Hehir, José M. Olaguibel, Nerin Bahceciler Onder, Jung Won Park, Alfred Priftanji, Robert Puy, Luis Sarmiento, Glenis Scadding, Peter Schmid-Grendelmeier, Ester Seberova, Revaz Sepiashvili, Dírceu Solé, Alkis Togias, Carlo Tomino, Elina Toskala, Hugo Van Beever, Stefan Vieths

Sub-lingual immunotherapy: World allergy organization position paper 2009

Co-Authors: Wahiduzzaman Akhanda, Raul Castro Almarales, Ignacio Ansotegui, Floriano Bonifazi, Jan Ceuppens, Tomás Chivato, Darina Dimova, Diana Dumitrascu, Luigi Fontana, Constance HKatelaris, Ranbir Kaulsay, Piotr Kuna, Dèsirée Larenas-Linnemann, Manolis Manoussakis, Kristof Nekam, Carlos Nunes, Robyn O’Hehir, José M Olaguibel, Nerin Bahceciler Onder, JungWon Park, Alfred Priftanji, Robert Puy, Luis Sarmiento, Glenis Scadding, Peter Schmid-Grendelmeier, Ester Seberova, Revaz Sepiashvili, Dirceu Solé, Alkis Togias, Carlo Tomino, Elina Toskala, Hugo Van Beever, Stefan Vieths*

Rhinitis and asthma in athletes: an ARIA document in collaboration with GA2LEN

This consensus document is aimed at reviewing evidence that the rhinits‐asthma links have peculiar features in athletes. Beside a review of epidemological data on the high prevalence of rhinitis and asthma in athletes, the effects on intense physical exercise on the immune system and repiratory functions are discussed, with special reference to the role of allergens and pollutants. In extending the Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations to athletes, the issue is addressed of adapting diagnosis and management to criteria set by the International Olympic Committee (IOC) and regulations adopted by the World Anti‐Doping Agency (WADA).

Adherence to the Mediterranean diet and fresh fruit intake are associated with improved asthma control.

Background:  The traditional Mediterranean diet is claimed to possess antioxidant and immune‐regulatory properties in several chronic diseases. Typical Mediterranean foods have recently been associated with improvement of symptoms of asthma and rhinitis in children. However the effect of adherence to Mediterranean diet on adult asthma outcomes is unknown. We aimed to investigate the association between adherence to Mediterranean diet and asthma control.

Physical training does not increase allergic inflammation in asthmatic children

The effects of a 3-month physical training programme on airway inflammation and clinical outcomes were studied in school-aged children with asthma. Subjects with persistent allergic asthma (aged 12.7±3.4 yrs; n = 34) were randomly allocated into training and control groups. Exercise consisted of twice-weekly 50-min sessions for 12 weeks. Inflammation was assessed by levels of exhaled nitric oxide, blood eosinophils, eosinophil cationic protein, C-reactive protein, and total and mite-specific immunoglobulin (Ig)E. Lung volumes and bronchial responsiveness to methacholine were determined. The Paediatric Asthma Quality of Life Questionnaire and Paediatric Asthma Caregivers Quality of Life Questionnaire were used to evaluate activity restrictions, symptoms and emotional stress. The efficacy of the training was assessed by accelerometry. Following the programme, the exercise group spent twice as much time as the controls undertaking moderate-to-vigorous activities. No differences in changes were seen between groups for asthma outcomes. However, total IgE decreased more in the exercise group, as did mite-specific IgE. Training did not increase inflammation in children with persistent asthma, and may have decreased both total and allergen-specific immunoglobulin E levels. It is concluded that there is no reason to discourage asthmatic children with controlled disease to exercise.

Exercise‐induced hypersensitivity syndromes in recreational and competitive athletes: a PRACTALL consensus report (what the general practitioner should know about sports and allergy)

Exercise‐induced (EI) hypersensitivity disorders are significant problems for both recreational and competitive athletes. These include EI‐asthma, EI‐bronchoconstriction, EI‐rhinitis, EI‐anaphylaxis and EI–urticaria. A group of experts from the European Academy of Allergology and Clinical Immunology and the American Academy of Allergy Asthma and Immunology met to discuss the pathogenesis of these disorders and how to diagnose and treat them, and then to develop a consensus report. Key words (exercise with asthma, bronchoconstriction, rhinitis, urticaria or anaphylaxis) were used to search Medline, the Cochrane database and related websites through February 2008 to obtain pertinent information which, along with personal reference databases and institutional experience with these disorders, were used to develop this report. The goal is to provide physicians with guidance in the diagnosis, understanding and management of EI‐hypersensitivity disorders to enable their patients to safely return to exercise‐related activities.

Ocular allergy: recognizing and diagnosing hypersensitivity disorders of the ocular surface

Ocular allergy includes several clinically different conditions that can be considered as hypersensitivity disorders of the ocular surface. The classification of these conditions is complex, and their epidemiology has not been adequately studied because of the lack of unequivocal nomenclature. Ocular allergy symptoms are often, but not always, associated with other allergic manifestations, mostly rhinitis. However, specific ocular allergic diseases need to be recognized and managed by a team that includes both an ophthalmologist and an allergist. The diagnosis of ocular allergy is usually based on clinical history and signs and symptoms, with the support of in vivo and in vitro tests when the identification of the specific allergic sensitization is required for patient management. The aims of this Task Force Report are (i) to unify the nomenclature and classification of ocular allergy, by combining the ophthalmology and allergy Allergic Rhinitis and its Impact on Asthma criteria; (ii) to describe current methods of diagnosis; (iii) to summarize the therapeutic options for the management of ocular allergic inflammation.

Nutritional modulation of exercise-induced immunodepression in athletes: a systematic review and meta-analysis

Background:Heavy exercise induces marked immunodepression that is multifactorial in origin. Nutrition can modulate normal immune function.Objective:To assess the efficacy of nutritional supplements in exercise-induced immunodepression in athletes.Design:Systematic review.Review methods:Randomised and/or controlled trials of athletes undertaking nutritional supplements to minimise the immunodepression after exercise were retrieved. The primary outcome measure was incidence of upper respiratory tract (URT) illness symptoms after exercise, and secondary outcomes included cortisol, cell counts, plasma cytokine concentration, cell proliferative response, oxidative burst, natural killer cell activity and immunoglobulins. When data were available for a pooled estimate of the effect of intervention, meta-analyses were conducted for direct comparisons.Results:Forty-five studies were included (1603 subjects). The studies were heterogeneous in terms of exercise interventions, selection of athletes, settings and outcomes. The overall methodological quality of most of the trials was poor. Twenty studies addressed carbohydrate supplementation, eight glutamine, 13 vitamin C and four others interventions. Three trials assessed the effect of intervention on prevention of URT infections. The pooled rate ratio for URT infections after vitamin C supplementation against placebo was 0.49 (0.34–0.71). Carbohydrate supplementation attenuated the increase in cortisol and neutrophils after exercise; vitamin C attenuated the decrease in lymphocytes after exercise. No other interventions had significant or consistent effect on any of the studied outcomes.Conclusions:Although the prevention of URT infections by vitamin C was supported by two trials, further studies are needed. The available evidence failed to support a role for other nutritional supplements in preventing exercise-induced immune suppression. Larger trials with clinically relevant and uniform end points are necessary to clarify the role of these nutritional interventions.

Pulmonary Function Electronic Monitoring Devices: A Randomized Agreement Study

STUDY OBJECTIVES To compare in a clinical setting the within-session reproducibility of two pulmonary function electronic monitoring devices (PiKo-1; Ferraris Respiratory Europe; Hereford, UK; and Spirotel; MIR; Rome, Italy) with one mechanical device (Mini-Wright Peak-Flow Meter; Clement-Clarke International; Harlow, Essex, UK), and to evaluate the accuracy of these devices using as reference an office pneumotachograph. DESIGN, SETTING, AND PARTICIPANTS After detailed instructions, adults without airways diseases and patients with stable asthma attending an outpatient clinic performed four sets of expiratory maneuvers, one set for each device, in a strictly random order. Each set comprised three maneuvers with 2 to 3 min of rest between them. MEASUREMENTS Reproducibility of FEV1 and peak expiratory flow (PEF) was assessed by a coefficient of variation (CV) and intraclass correlation coefficient (ICC), and accuracy was assessed by ICC and limits of agreement. RESULTS Of the 38 participants evaluated, 71% were women and 61% had asthma. Ages ranged from 18 to 58 years, and FEV1 ranged from 1.2 to 4.8 L. In all monitoring devices, CV was < 6% and ICC was > 0.94 for the reproducibility of both FEV1 and PEF measurements. The accuracy of the PiKo-1 device was better for FEV1 (ICC = 0.98) than for PEF (ICC = 0.90). The Spirotel device had similar results for FEV1 and PEF (ICC = 0.95). The Mini-Wright device had the lowest accuracy (ICC = 0.87), particularly for PEF values < 500 L/min. CONCLUSIONS These low-cost and easy-to-use electronic monitoring devices showed a very good reproducibility and were in agreement with the pneumotachograph. Therefore, the PiKo-1 and Spirotel devices seem adequate for both screening and monitoring. However, prospective studies are still needed to assess their long-term reproducibility and usability and, particularly, the effects on the improvement of respiratory care.

Dietary intake of α-linolenic acid and low ratio of n-6:n-3 PUFA are associated with decreased exhaled NO and improved asthma control.

As recently described, adherence to the Mediterranean diet is associated with improved asthma control. However, evidence of how specific nutrients such as fatty acids and antioxidants may affect this relationship remains largely unknown. We aimed to examine the association between dietary intake of fatty acids and antioxidants and asthma control. A cross-sectional study was developed in 174 asthmatics, mean age of 40 (SD 15) years. Dietary intake was obtained by a FFQ, and nutritional content was calculated using Food Processor Plus™ software (ESHA Research, Inc., Salem, OR, USA). Good asthma control was defined by the combination of forced expiratory volume during the first second, exhaled NO (eNO) and Asthma Control Questionnaire (ACQ) score (control: forced expiratory volume in the first second ≥80 %; eNO ≤35 ppb; ACQ <1·0, scale 0-6 score). Multiple linear and logistic regression models were performed to analyse the associations between nutrients and asthma outcomes, adjusting for confounders. A high n-6:n-3 PUFA ratio predicted high eNO, whereas high intakes of n-3 PUFA, a-linolenic acid (ALA) and SFA were associated with low eNO. Odds for controlled asthma improved along with an increased intake of n-3 PUFA (OR 0·14, 95% CI 0·04, 0·45; P for trend=0·001), SFA (OR 0·36, 95% CI 0·13, 0·97; P for trend=0·047) and ALA (OR 0·18, 95% CI 0·06, 0·58; P for trend=0·005). A high n-6:n-3 PUFA ratio increased the odds for uncontrolled asthma (OR 3·69, 95% CI 1·37, 9·94; P for trend=0·009), after adjusting for energy intake, sex, age, education and use of inhaled corticosteroids. Higher intakes of n-3 PUFA, ALA and SFA were associated with good asthma control, while the risk for uncontrolled asthma increased with a higher n-6:n-3 PUFA ratio. The present results introduce a protective effect of ALA in asthma control, independent of marine n-3 fatty acids, and provide a rationale to dietary intervention studies in asthma.