Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.

In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.

This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.

The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.

Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.

The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

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Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Authors Jan L. Brozek, MD, PhD – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada Jean Bousquet, MD, PhD – Service des Maladies Respiratoires, Hopital Arnaud de Villeneuve, Montpellier, France, INSERM, CESP U1018, Respiratory and Environmental Epidemiology Team, France, and WHO Collaborating Center for Rhinitis and Asthma Carlos E. Baena-Cagnani, MD – Faculty of Medicine, Catholic University of Cordoba, Cordoba, Argentina Sergio Bonini, MD – Institute of Neurobiology and Molecular Medicine – CNR, Rome, Italy and Department of Medicine, Second University of Naples, Naples, Italy G. Walter Canonica, MD – Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy Thomas B. Casale, MD – Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, Nebraska, USA Roy Gerth van Wijk, MD, PhD – Section of Allergology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands Ken Ohta, MD, PhD – Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan Torsten Zuberbier, MD – Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany Holger J. Schunemann, MD, PhD, MSc – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada

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Allergic Rhinitis and Its Impact on Asthma

Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 “combative” to −5 “unarousable”) scale, the Richmond Agitation–Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; κ = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922–0.983) (κ = 0.64–0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93)...

https://www.atsjournals.org/doi/pdf/10.1164/rccm.2107138

The Richmond Agitation-Sedation Scale Validity and Reliability in Adult Intensive Care Unit Patients

I. Purpose and Scope II. Methacholine Challenge Testing A. Indications B. Contraindications C. Technician Training/Qualifications D. Safety E. Patient Preparation F. Choice and Preparation of Methacholine G. Dosing Protocols 1. Two-Minute Tidal Breathing Dosing Protocol 2. Five-Breath Dosimeter Protocol H. Nebulizers and Dosimeters I. Spirometry and Other End-point Measures J. Data Presentation K. Interpretation III. Exercise Challenge A. Indications B. Contraindications and Patient Preparation C. Exercise Challenge Testing D. Assessing the Response References Appendix A: Sample Methacholine Challenge Test Consent Form Appendix B: Sample Methacholine Challenge Pretest Questionnaire Appendix C: Sample Report Format Appendix D: Equipment Sources

Guidelines for methacholine and exercise challenge testing-1999. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999.

Mechanisms involved in the side effects of glucocorticoids

Exposure to chlorine gas (Cl2) causes occupational asthma that we hypothesized occurs through the induction of airway inflammation and airway hyperresponsiveness by oxidative damage Respiratory mechanics and airway responsiveness to methacholine were assessed in A/J mice 24 hours after a 5-minute exposure to 100, 200, 400, or 800 ppm Cl2 and 2 and 7 days after inhalation of 400 ppm Cl2 Airway responsiveness was higher 24 hours after 400 and 800 ppm Cl2 Responsiveness after inhalation of 400 ppm Cl2 returned to normal by 2 days but was again elevated at 7 days Airway epithelial loss, patchy alveolar damage, proteinaceous exudates, and inflammatory cells within alveolar walls were observed in animals exposed to 800 ppm Cl2 Macrophages, granulocytes, epithelial cells, and nitrate/nitrite levels increased in lung lavage fluid Increased inducible nitric oxide synthase expression and oxidation of lung proteins were observed Epithelial cells and alveolar macrophages from mice exposed to 800 ppm Cl2 stained for 3-nitrotyrosine residues Inhibition of inducible nitric oxide synthase with 1400W (1 mg/kg) abrogated the Cl2-induced changes in responsiveness We conclude that chlorine exposure causes functional and pathological changes in the airways associated with oxidative stress Inducible nitric oxide synthase is involved in the induction of changes in responsiveness to methacholine

https://www.atsjournals.org/doi/pdf/10.1164/rccm.200201-021OC

Chlorine-induced Injury to the Airways in Mice

The role of maternal smoking as a causal factor for the incidence of childhood asthma is still not clearly established. It was investigated among 3- and 4-year-old-child incident cases confirmed by a 6-year follow-up (n = 294) and cases who no longer had symptoms after diagnosis (n = 110). The study took place in Montreal, Canada, between 1988 and 1997. Persistent and transient cases were compared with their respective controls from the original case-control study of incidence. The odds ratio for heavy maternal smoking adjusted for known risk factors for asthma was 3.84 (95% confidence interval: 1.68, 8.76) among persistent cases and close to one among transient cases.

Maternal Smoking and Childhood Asthma

We investigated prospectively the incidence and determinants of work-related specific skin sensitization in a cohort of 769 apprentices, including 417 in animal health technology, 230 in pastry-making, and 122 in dental-hygiene technology Subjects were recruited when starting exposure to laboratory animals, flour, or latex A questionnaire and skin-prick tests with common and work-related allergens were administered on entry and at follow-up visits from 8 to 44 mo; information on number of hours of exposure to specific allergens was obtained Among 769 apprentices, 698 attended ⩾ 1 follow-up visit A total of 111 subjects developed specific sensitization over the study period The incidence of work-related sensitization (per person-year) was 89% (95% CI 73 to 110%) in the animal-health program, 42% (95% CI 18 to 82%) in the pastry-making program, and 25% (95% CI = 07 to 43%) in the dental-hygiene program In the animal health group, Cox regression analyses showed that atopy, nasal, and respirato

https://www.atsjournals.org/doi/pdf/10.1164/ajrccm.162.4.2001023

Incidence and determinants of IgE-mediated sensitization in apprentices. A prospective study.

Laboratory animal (LA) workers are frequently affected with allergic sensitization and occupational asthma (OA). The role of preexposure host factors, in particular airway responsiveness, on the incidence of OA has not been satisfactorily studied. A prospective cohort study of 417 apprentices in animal-health technology was conducted to investigate the incidence and determinants of probable OA. Questionnaire and skin-prick tests with common and work-specific allergens were administered on entry and at follow-up visits (up to three) from 8 to 44 mo after starting apprenticeship. Responsiveness to inhaled methacholine was assessed at baseline and at follow-up in apprentices who developed a new specific skin sensitization and in control subjects. Preexposure host characteristics and the school attended were compared between cases and all cohort subjects not meeting the criteria for probable OA. Twenty-eight apprentices satisfied the definition for probable OA, i.e., onset of immediate skin reactivity to > 1 occupational inhalant and > 3.2-fold decrease in the provocative concentration causing a 20% reduction in FEV(1) (PC(20)). The incidence of probable OA was 2.7% (28/1,043 person-years). Baseline immediate skin reactivity to pets (rate ratio [RR] 4.1, 95% confidence interval [CI] = 1.6 to 10.8), and bronchial responsiveness (PC(20) 32 mg/ ml) (RR = 2.5, 95% CI = 1.0 to 5.8) were associated with an increased risk of probable OA; a lower FEV(1) had an apparent, protective effect (RR = 0.58, 95% CI = 0.43 to 0.78). It is concluded that apprentices in animal health show a high incidence of probable OA, and that preexposure airway caliber and responsiveness as well as sensitization to pets are associated with an increased risk.

https://www.atsjournals.org/doi/pdf/10.1164/ajrccm.163.4.2008011

Denyse Gautrin

Papers

Chlorine-induced Injury to the Airways in Mice

Maternal Smoking and Childhood Asthma

Incidence and determinants of IgE-mediated sensitization in apprentices. A prospective study.

Incidence and host determinants of probable occupational asthma in apprentices exposed to laboratory animals

Occupational rhinitis