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Background Many United Kingdom patients with asthma and rhinitis are allergic, but in primary care few diagnostic and management decisions are made with formal allergy assessment. Arguably, knowing a patient's atopic status might be helpful in distinguishing the cause of disease and in selecting appropriate treatments. Objectives Our objective was to estimate the extent to which a formal allergy assessment (a structured allergy history and skin prick tests to 5 common aeroallergens) would improve the precision of allergy diagnosis compared with a patient's self-report or the structured allergy history alone. Methods One hundred twenty-seven patients with asthma, rhinitis, or both were recruited from 4 general practices in Wessex, United Kingdom. Allergy status based on the patient's opinion and on structured allergy history alone was compared with formal allergy assessment. Assessments were validated by an independent allergy specialist reviewing the files. Patients were given written advice specific to their allergies and followed up 3 months later to assess satisfaction, recall, and effect on health and behavior. Results Self-reporting misclassified allergic status in many patients. A structured allergy history alone was little better and resulted in false-positive rates for cat allergy of 32%, grass pollen of 48%, house dust mite of 75%, tree pollen of 54%, and dog of 27% compared with formal allergy assessment. Skin prick testing combined with a structured history was essential to reach a correct causative diagnosis. Three months later, 41% patients had made changes to lifestyle, medications, or both, and 18% reported clinical improvement. Conclusions Skin prick testing improves the accuracy of an assessment of allergic status based on patient opinion or a structured allergy history alone.

Specific immunotherapy is widely used to treat allergic rhinitis, but few large-scale clinical trials have been performed.We sought to assess the efficacy and safety of specific immunotherapy with 2 doses of Alutard grass pollen in patients with moderately severe seasonal allergic rhinitis inadequately controlled with standard drug therapy.We performed a double-blind, randomized, placebo-controlled study of 410 subjects (203 randomized to 100,000 standardized quality units [SQ-U] maintenance, 104 to 10,000 SQ-U, and 103 to placebo). Three hundred forty-seven (85%) completed treatment. Groups were well matched for demographics and symptoms.Across the whole pollen season, mean symptom and medication scores were 29% and 32% lower, respectively, in the 100,000-SQ-U group compared with those in the placebo group (both P.001). Over the peak pollen season, mean symptom and medication scores were 32% and 41% lower, respectively, than those in the placebo group. The 10,000-SQ-U group had 22% less symptoms than the placebo group over the whole season (P.01), but medication scores reduced by only 16% (P = .16). Quality-of-life measures confirmed the superiority of both doses to placebo. Local and delayed side effects were common but generally mild. Clinically significant early and delayed systemic side effects were confined to the 100,000-SQ-U group, but no life-threatening reactions occurred.One season of immunotherapy with Alutard grass pollen reduced symptoms and medication use and improved the quality of life of subjects with moderately severe hay fever. The 100,000-SQ-U regimen was more effective, but the 10,000-SQ-U regimen caused fewer side effects.

The past year has seen a welcome increase in the number of articles published in the Journal on environmental and occupational disorders. Some of the major themes have been risk factors for allergic sensitization, the measurement and containment of domestic allergens (especially cockroach but also house dust mite), and risk factors for occupational allergy and asthma. Some important articles were also presented on mechanisms of occupational and environmental asthma.

The environment plays a crucial role in determining the development and expression of allergic disorders. Epidemiologic studies allow us to understand risk factors for allergic disease, which may lead to interventional studies to provide the evidence base for our clinical advice. Articles published in The Journal of Allergy and Clinical Immunology last year highlighted the relevance of mold exposure and environmental tobacco smoke as risk factors for the development of asthma and the expression of symptoms. The role of fitted carpets as a reservoir for house dust allergens was also challenged by data arising from this work. Occupational allergy is an important clinical and socioeconomic problem. A large body of work on latex allergy has been reported in the past year, demonstrating the impact of containment strategies on exposure to latex and the incidence of sensitization to latex. Other articles have explored the range of latex allergens to which patients are sensitized and the HLA associations of latex allergy. Two models of isocyanate sensitization were reported, providing some insight into possible mechanisms of isocyanate asthma and some clues for understanding nonallergic asthma. Environmental and occupational disorders are highly relevant to our readership, and the new Editorial Board hopes to encourage submission and publication of relevant articles in this area.

Glucocorticosteroids are the backbone of asthma therapy and are administered mainly by the inhaled route. Patients with "difficult" asthma are not a single homogeneous group. Some are stable on high-dose steroid therapy but experience unacceptable side effects; others remain unstable despite receiving high doses of inhaled or oral steroids. Several different steroid-sparing and alternative agents have been tried, with varying degrees of success. Some success has been achieved with conventional immunosuppressants such as methotrexate, gold, and cyclosporin A, but these agents can be justified only in a limited range of cases. Leukotriene receptor antagonists have proved a useful addition to asthma therapy and have been shown to have a modest steroid-sparing effect. Although the existing range of alternative agents has not proved to be particularly effective, several new therapeutic agents have been developed to target specific components of the inflammatory process in asthma. These include IgE antibodies, cytokines, chemokines, and vascular adhesion molecules. Future developments might include better forms of immunotherapy and strategies targeting the remodeling of structural elements of the airways.

Airway remodeling in asthma refers to a collection of chronic structural changes including subepithelial fibrosis, airway smooth muscle hypertrophy/hyperplasia, and possibly angiogenesis. The mechanisms leading to remodeling are not well defined. One molecule of possible relevance is basic fibroblast growth factor (bFGF), which is a potent mitogen for fibro-blasts, airway smooth muscle cells, and endothelial cells. To test the hypothesis that bFGF expression is increased in asthma, we measured levels of the growth factor in bronchoalveolar lavage (BAL) fluid. Basally, BAL fluid bFGF concentrations were significantly higher in subjects with atopic asthma than in control subjects without asthma (median 0.22 vs 0.06 pg/mL, P = .003). The effect of acute allergen exposure was examined with a segmental bronchoprovocation model in a separate group of subjects with atopic asthma. Ten minutes after segmental bronchoprovocation there was a 5-fold increase in bFGF levels in BAL fluid recovered from allergen-challenged sites compared with control saline-challenged sites (1.52 vs 0.30 pg/mL, P < .002). We conclude that basal levels of BAL fluid bFGF are increased in atopic asthma and that a further increase occurs in response to acute allergen exposure. These findings lend support to the hypothesis that bFGF is implicated in airway remodeling in asthma.

Background: Occupational asthma caused by western red cedar (Thuja plicata) is a common problem in sawmill industries. The objective of this study was to examine the cellular and immunologic mechanisms of western red cedar asthma (WRCA) more closely. Methods: Bronchial biopsy specimens, bronchoalveolar lavage (BAL) mast cells and peripheral blood basophils from patients with WRCA, patients with atopic asthma, and nonatopic control subjects were challenged in vitro with plicatic acid (PA), PA-human serum albumin conjugate (PA-HSA), grass pollen, or calcium ionophore. Results: PA (100 μg/ml) released histamine from the basophils of 9 of 11 patients with WRCA, 1 of 7 patients with atopic asthma, and 2 of 7 normal subjects. PA triggered histamine release from 10 of 11 bronchial biopsy specimens and 8 of 8 BAL samples from patients with WRCA. Interestingly, PA released histamine from BAL cells and bronchial biopsy specimens from 3 of 7 normal subjects but in none of the patients with atopic asthma. PA-HSA-induced histamine release from basophils and biopsy specimens was confined to patients with WRCA. PA-specific IgE was not detectable in serum from most patients with WRCA, and their serum did not transfer PA sensitivity to human lung fragments or lactate-stripped basophils. After pretreatment with anti-IgE in the absence of calcium, basophils from 14 subjects with WRCA still responded to PA (mean 64% to 67% of pretreatment response), whereas responses to grass pollen or anti-IgE were abolished. Conclusions: This study confirms that PA releases histamine from bronchial mast cells of most patients with WRCA but not from those of patients with atopic asthma. The PA response of some normal subjects suggests that PA may have both specific and nonspecific actions on mast cells and basophils, whereas the serologic studies indicate histamine release in WRCA cannot simply be attributed to PA-specific IgE.

Rationale: as stress is known to exacerbate asthma symptoms, we examined whether written emotional disclosure (writing about traumatic experiences) could improve lung function in adults with asthma. Writing may facilitate cognitive and emotional processing of stressful events and help to reduce the physiological stress associated with inhibition of emotions. Methods: 138 adults aged between 18 and 45 with a diagnosis of asthma, requiring regular inhaled corticosteroids and able to read and understand English were invited to participate in this double blind randomised controlled trial. Participants were randomly allocated to receive either the written emotional disclosure or non-emotional writing instructions. Participants were asked to write for 20 minutes over 3 consecutive days. Spirometry readings and questionnaires measuring quality of life, asthma symptoms, subjective asthma control and medication use were conducted at baseline, 1 and 3-month follow up. Results: baseline analysis showed no significant differences between the two conditions. Controlling for baseline scores, no significant findings for lung function, quality of life or asthma symptoms were found. At 3-month follow up, participants in the intervention condition reported significantly better subjective control of their asthma (as defined by the Asthma Control Test): OR = 3.01, 95%CL (1.30, 6.94) and reported significantly better objective control of their asthma (defined as using their ?-agonist less than once a day): OR = 2.96, 95%CL (1.38, 6.33). Conclusions: written emotional disclosure may be useful in the management of asthma, improving perceived control of asthma in addition to reducing patients' use of their reliever medication

Rationale Valuation of the clinical efficacy and safety of Specific Allergy Vaccination (SAV) with Alutard SQ Grass in the doses 100,000 SQ-U and 10,000 SQ-U. Methods Subjects aged 18 to 60 years with grass pollen-induced allergic rhinoconjunctivitis not adequately controlled by symptomatic treatment were included. In all, 203 subjects were randomized to 100,000 SQ-U, 104 to 10,000 SQ-U and 103 to placebo. Up-dosing was performed over 8 weeks. Maintenance treatment was given every 6 weeks +/− 2. Subjects completed a daily diary card on symptoms and use of allergy medication. Allergic symptoms were assessed weekly by Visual Analogue Scale (VAS) and Quality of Life (QoL) was measured. Subjects were given free symptomatic medication during the study. Results In the 100,000 SQ-U group reductions were obtained in symptom and medication score and VAS compared to placebo (p Conclusions SAV with Alutard SQ Grass 100,000 SQ-U is clinically effective, superior to 10,000 SQ-U and well tolerated.