ISI America

Medimond - Monduzzi Editore International Proceedings Division
ALLERGY, ASTHMA
& IMMUNOPHYSIOLOGY:
FROM BASIC SCIENCE
TO CLINICAL APPLICATION
Editor
Professor REVAZ SEPIASHVILI
MEDIMOND
International Proceedings
ALLERGY, ASTHMA &

IMMUNOPHYSIOLOGY:
FROM BASIC SCIENCE
TO CLINICAL APPLICATION
Proceedings of the
VI WORLD CONGRESS ON IMMUNOPATHOLOGY

AND RESPIRATORY ALLERGY
Moscow (Russia), September 15-18, 2011
and
V world asthma & copd forum
New York (USA), April 21-24, 2012
Editor
Professor Revaz Sepiashvili
MEDIMOND
International Proceedings
Copyright 2012 by MEDIMOND s.r.l.

Via G. Verdi 15/1, 40065 Pianoro (Bologna), Italy
www.medimond.com info@medimond.com
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form,
or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission,
in writing, from the publisher.
Printed in April 2012 by Editografica Bologna (Italy)
ISBN 978-88-7587-638-8
monduzzi editore
International Proceedings Division

is a registered trademark owned by Medimond s.r.l.
Index
Front page ........................................................................................................................... I
WHO/GARD Strategy for the Prevention and Control of Chronic Respiratory

Diseases
Khaltaev Nikolai ................................................................................................................... 1
How does exhaled nitric oxide measurement fit in asthma assessment?
Bahna SL ............................................................................................................................. 7
Difficult Respiratory Phenotypes in Adults with Asthma
Greenberger Paul A., M.D. .................................................................................................... 11
Diet and Chronic Respiratory Diseases
Khaltaev Nikolai ................................................................................................................... 17
Achieving Control of Fungal Asthma and Allergic Bronchopulmonary Mycosis
Greenberger Paul A., M.D. .................................................................................................... 25
Bacterial immunostimulants in asthma copd and recurrent respiratory infections
Palma-Carlos A.G., MD. PhD, EFAAAAI, HDFACAAI, Palma-Carlos M.L., Pharm, PhD. ........... 31
Bronchial asthma: prevalence, risk factors and severity of disease in the CISRegion
Slavyanskaya T. A., Sepiashvili R.I. ...................................................................................... 39
The role of fungal allergens in respiratory diseases in Bulgaria
Nikolov G., Kandova Y., Hristova R., Nedyalkov M., Petrunov B. ........................................... 47
Pollen sensitization pattern in patients with combined allergic rhinitis and

asthma syndrome from Southern Romania
Popescu F.D., Tudose A.M., Gheonea C. ................................................................................ 55
Effects of Traffic Air Pollution on Hospitalizations for Exacerbations of Chronic

Obstructive Pulmonary Disease in Zagreb, Croatia
Krmpotic D, Luzar-Stiffler V, Hercog P .................................................................................. 59
Influence of allergy-inducing and other triggers to the development and severity

of allergic diseases in the CIS-Region
Slavyanskaya T. A., Sepiashvili R.I. ...................................................................................... 65

2012 by MEDIMOND s.r.l.
VI
Allergy, Asthma & Immunophysiology: From Basic Science to Clinical Application
Muramyl dipeptide has a dual influence on allergic airway inflammation
Guryanova S.V., Shevchenko M.A., Kozlov I.G., Andronova T.M. ........................................... 73
Protease Inhibitors Asthma And Rhinosinusitis
Palma-Carlos A.G., MD.PhD, EFAAAI, HDFACAAI, Palma-Carlos M.L., Pharm D, PhD. ........... 77
Cytokine status as an efficiency criteria of intranasal aerosol therapy in allergic

rhinosinusitis treatment process
Tataurshchikova Natalya, Sepiashvili Yan ............................................................................ 83
The effect of C3 and C4 complement components on allergic rhinitis patients

referred to Amir al-Momenin hospital of Zahedan city
Khazaei H.A, Dashti G.A, Moolaei N., Sharyar M., Dadras M.N, Hejazenia F., Khazaei B
and Noukar A. ...................................................................................................................... 87
The bronchial hyperactivity in children with pollinosis
Saparova L.T., Rozenson R.I. ................................................................................................ 95
Pathogenetic therapeutic decision of immunotherapy in the patients with

infection-dependent bronchial asthma.
Kostina E.M. ......................................................................................................................... 99
Asthma and Chronic Bronchitis Risk Factors in the Scope of INSPIRAR Study
Neuparth Nuno, Martins Pedro, Caires Iolanda, Lopes Claudia, Marques Joo,
Borrego Carlos, Lopes Myriam ............................................................................................ 103
The patternof patients with frequent acute exacerbations of chronic obstructive

pulmonary disease (AECOPD)
Grzetic-Romcevic T., Sonc S., Devcic B. ............................................................................... 109
Immunological characteristics ofcommunity-acquired pneumonia inold patients
Andriesh Lucia, Barba Doina, Berezovskaya Elena, Blaja-Lisnic Natalia, Samotiya Evghenia 115.
Case Studies of Practical, Patient-centered, Parsimonious Initiatives That

Significantly Improve the Care and Quality of Life for Patients with COPD
Lin Samuel, MD, PhD, MBA, MPA, MS, Casanova Danielle, MBA, Jones Joyce, BA,
Sanderson-Austin Julie, RN, Fisher Donald, PhD ................................................................. 123
The influence of fetal neuronal cells on dynamics of anxiety and phobic status
of reanimated in rats of different sex and ages
Kabdualieva N.B, Tazhibaeva D.S, Aitbaeva ZH.B., Beglarova G.E., Ermentaeva L.N. ........... 129
Study of Tobacco sensibilization on the functional state of children engaged

in tobacco growing
Orakbai L.Zh., Omarova M.N., Kalimoldin M.M., Katchibaeva A.S. ....................................... 135
Climate change: impact on hay fever peculiarities
Zhumambayeva Saule, Rozenson Rafail .............................................................................. 139
Antiproliferative effects of licorice root flavonoids and dihydroquercetin in vitro
Tsitsuashvili M.D., Pavlova S.I., Kozlov I.G. .......................................................................... 145
D56+ lymphocytes in demyelinating polyneuropathies
Balmasova I.P., Timchenko O.L., Yuschuk N.D., Sepiashvili R.I. ............................................ 151
115
VII
The humoral response in the autoimmune pemphigus
Makhneva Natalia V., Davidenko Elena B., Potekaev Nikolay N., Beletskaya Ludmila V. ...... 157
Intavenous immunoglobulineGabriglobin use in patients with autoimmune

urticaria.
Orlova E.A., Bolts E.A., Molotilov B.A., Alyoshkin V.A., Novikova L.I. ..................................... 161
Immunologic and immunogenetic indicators in patients with severe forms of

acne
Ryabova V.V., Koshkin S.V., Chermnykh T.V., Zaitseva G.A. ................................................... 167
Immunorehabilitation of children with burh disease
Sakharov Sergey Pavlovich ................................................................................................. 171
Prophylaxis Of Pathological Scarring In Reconstructive Plastic Surgery
Korkunda S., Grigorieva T. .................................................................................................... 175
On the immunomodulate features of the new medical product Lukman-1
Pleskanovskaya S., Kokanov A., Hodjageldiyeva A., Armedowa O. ...................................... 181
Defects in functioning of interferon and immune systems and their correction

in chronic active Epstein-Barr infection
Nesterova Irina V., Kovaleva SvetlanaV., Chudilova Galina A., Lomtatidze Ludmila V. .......... 187
Efficiency Of Simultaneous Hepatites A And B Vaccination In Patients With

Chronic Hepatitis C
Isaeva N., Pavroz K., Arbuzova E., Maltseva S. ..................................................................... 193
The metabolic status of leucocytes at patients with tubulopathy and glomerulopathy
Muravlyova L., Molotov-Luchanskiy V., Kluyev D., Kussainova D. Kolesnikova E.,

Tankibaeva N., Sidenko V., B.., Zholdaspaeva N., Mursalova Zh. ....................................... 199
Dynamics of immune response to kidney and uvea tissues antigens depending

on their species accessory
Nurlyyeva L., Annaberdiyev D., Ezizova G.G., Pleskanovskaya S.A. ...................................... 203
Immunological changes in acute ischemic stroke
Zhyrnova I.G., Komelkova L.V., Maximova M.Ju., Ochtova F.R., Ionova V.G. .......................... 207
Role of immunocytes in human eye structures development.
Reva I.V., Yamamoto T., Reva G.V., Novikov A. S., An E.A., Albrandt K.F., Mogilevskaja E.S. .... 211
Regulatory role of thymus in maintenance of homeostasis
Kiseleva N.M., Novoseletskaya A.V., Zimina I.V., Moskvina S.N., Inozemtsev A.N., Arion V.Ya.,
Kozlov I.G. ............................................................................................................................ 217
Evaluation of bronchial asthma hyperreactivity in children withdifferent allergic diseases
Chikhladze M.V., Khachapuridze D.R., Gamkrelidze S., Sepiashvili R. ................................. 225

Author Index ........................................................................................................................ 229
WHO/GARD Strategy for the Prevention and Control of

Chronic Respiratory Diseases
Khaltaev Nikolai
Global Alliance against Chronic Respiratory Diseases
Geneva, Switzerland
Introduction
Noncommunicable diseases (NCD) such as cardiovascular disease (CVD), certain
types of cancer, chronic respiratory diseases (CRD) and diabetes, are the leading cause
of mortality in the world, representing 60% of all deaths (1).80% NCD deaths occur
in low and middle income countries (LMICs). This invisible epidemic is a cause of
poverty and hinders the economic development of many countries. These diseases
are often associated with common risk factors including tobacco smoking, diet, low
physical activity and alcohol abuse. In order to prevent and control NCD, the 61 st
World Health Assembly endorsed the 2008-2013 Action Plan for the Global Strategy
for the Prevention and Control of Noncommunicable Diseases (NCD Action Plan,
World Health Assembly Resolution 61.14) (1). The NCD Action Plan is intended to
support the coordinated, comprehensive and integrated implementation of strategies
and evidence-based interventions across individual diseases and risk factors, especially
at national and regional levels. Several instruments have been developed at WHO to
support the NCD Action Plan.
The NCDNet (Noncommunicable disease network) (2) is a voluntary collaborative arrangement comprised of United Nations agencies, intergovernmental organizations, academia, research centres, nongovernmental organizations, and the business
community, as identified in objective 5 of the NCD Action Plan (1).
The Package for Essential Noncommunicable (PEN) Diseases Interventions
for Primary Health Care in Low-Resource Settings comprises a core set of interventions and has been developed to be used at country level (3). This document
stresses the importance of providing essential technologies to LMICs. These include
peak flow meters and spacers for inhalers, and when resources permit nebulizers
and pulse oximeters. The core list of medicines required for implementing essential
NCD interventions include salbutamol, prednisolone, beclomethasone, epinephrine
and oxygen.
The WHO Global Alliance against Chronic Respiratory Diseases (GARD) is
P421R9033
a rapidly developing voluntary multidisciplinary partnership that is assisting WHO

in the task of addressing NCD with a special focus on chronic respiratory diseases.
1 Gard
Chronic respiratory diseases are a group of NCD affecting the airways, lungs and
related structures. According to the International Classification of Diseases, ICD-10,
common CRDs include asthma, bronchiectasis, chronic obstructive pulmonary disease (COPD), occupational lung diseases, rhinitis, chronic rhinosinusitis, sleep apnea
syndrome and pulmonary hypertension (4).
Over one billion people suffer from CRDs (Table 1). Many patients experience
considerable adverse impact upon their quality of life, and costs are incurred for the
society (5, 6)
In 2005, WHO has registered 4.057.000 deaths or about 7 % of all causes mortality
due to CRD. Most deaths and burden occur in LMICs. By this indicator; CRD are on
the third place among all NCD after cardiovascular diseases and cancer (7). Asthma
and COPD are responsible for almost 80% of all CRD deaths (8).
Everyone in the world is exposed to risk factors for CRDs.
Table 1 Estimated prevalence of chronic respiratory diseases
1-1- GARD Action Plan

The Global Alliance against Chronic Respiratory Diseases (GARD) is an alliance
of national and international organizations, medical and scientific societies, institutions
and agencies all working with the common goal of reducing the global burden of
CRD(9). WHO provides technical leadership and secretariat support.
The GARD Action Plan 2008-2013 (10) is an instrument of the NCD Action Plan
(1). It was endorsed by the 2008 GARD General Meeting in order to guide its work
between 2008-2013. It is a result-based management document and is being used as
an evolving tool at global and country levels.
The vision of GARD is a world where all people breathe freely. Its goal is to
reduce the global burden of chronic respiratory diseases, and its purpose is to initiate
a comprehensive approach to fight CRDs in countries in line with the NonCommunicable Diseases Action plan (1). GARD pursues to help strengthening capacity building
of the following four main objectives:
1. ADVOCACY. To raise the recognition of the importance of chronic respiratory
diseases at global and country levels, and to advocate integration of the prevention
and control of such diseases into policies across all government departments.
2. PARTNERSHIP. To promote partnering for the prevention and control of

chronic respiratory diseases.
3. NATIONAL PLANS ON PREVENTION AND CONTROL. To support WHO
in assisting countries to establish and strengthen national policies and plans for the
prevention and control of CRDs using WHO endorsed approaches and methods in
collaboration with all
4. SURVEILLANCE. To support WHO in monitoring CRDs and their determinants and to evaluate progress at country, regional and global levels.
GARD does not have a normative function and relies on WHOs technical norms and
standards and ethical evidenced-based options for the prevention and control of NCD.
Existing tools are proposed as examples for CRD control:
In areas with a high burden of communicable diseases and a functioning PHC
service, models like the WHO-PAL (Practical Approach to Lung Health) are promoted
(11,12) In areas with a high prevalence of HIV infection, models like PALSA Plus
(PAL in South Africa) are promoted (13 .
Models of prevention and care for CRDs in middle and high-income countries may use a different model, targeting asthma, rhinitis, COPD, occupational lung
diseases and other CRDs individually. Approaches will be developed from available
management plans and international guidelines according to specific country needs.
In all countries health promotion and prevention are essential
The key aspects of GARD work for the control of CRDs are:

To ensure the availability of drugs for patients with CRDs in each
treatment setting. Drugs for asthma are extremely effective in low income settings
but they are not available or affordable (14). The Asthma Drug Facility (ADF) uses
pooled procurement and other purchasing and supply strategies to obtain affordable
prices for essential asthma medicines. ADFs quality assurance system ensures that
quality is not compromised in the search for low prices (15). Drugs have been sold
using the ADF in different countries including El Salvador, Benin and others.

To assist in knowledge translation strategies for the training of health
care workers in the management of CRDs.
GARD provides a network through which collaborating parties can combine their
strengths, thereby achieving results that no one partner could obtain alone. GARD
improves coordination between existing governmental and nongovernmental programs,
thus avoiding duplication of efforts and wasting of resources.
2- Integration of GARD in the WHO 2008-2013 noncommunicable disease

action plan
2-1- The GARD stepwise approach
GARD has been developed in a stepwise approach with short-term (Step 1),
medium-term (Step 2) and long-term (Step 3) objectives and action plans. Each step
comprises measurable outcomes and deliverables (16). GARD priorities have been
published by WHO (9 ). The adoption of an integrated NCD action plan was proposed
as one of its medium-term goals. GARD action plans have been started in countries
by the Ministries of Health. These include Turkey (17 ) and Italy. (18)
The work of GARD is therefore in line with the 2008-2013 NCD Action Plan
(1). GARD collaborating parties continue to offer their support to WHO to achieve
the agreed objectives according to clear indicators and milestones.
In the GARD stepwise approach, three actions are key and should be carried
out at all levels:
Application of tobacco ban with GARD country representative. As an example, the tobacco ban in Algeria was proposed as the first GARD activity and the law
has been passed.
Training of primary health care professionals to integrate CRDs with other
NCDs.
Strengthening capacity building in LMICs to achieve the goals of the NCD
Action Plan.
2-2- GARD integrated and specific activities

Chronic respiratory diseases include cross-cutting diseases (transversal) with risk
factors common to many NCDs (e.g. primary prevention of COPD by tobacco control)
and diseases which may need a more specific approach (e.g. management of severe
asthma in children). This concept should be considered taking into account prevention
and control of disease as well as national needs, resources and existing health care
plans. In particular, there are many countries where CRD action plans already exist
(e.g. asthma and/or COPD plans in Australia, Brazil, Finland, France, Ireland, Japan,
Poland, Portugal, Tonga or the allergy prevention plan in Finland which was launched
in collaboration with GARD (19). Some of these plans are already embedded in a
national NCD action plan (e.g. 2008-13 China NCD action plan, Turkey, in process).
Flexibility is needed to achieve an optimal GARD action plan integrated in the NCD
action plan in the frame of the country needs and resources.
Two examples may be proposed:
1. Primary prevention of COPD using the WHO FCTC approach against tobacco.
2. Management of severe asthma (in particular in children) using a more targeted
approach. The treatment of asthma is extremely effective. National or regional plans
in both developed and developing countries were shown to be cost-effective (20-22).
Asthma plans are cost-effective even in low resource setting (23). In LMICs, the
control of asthma should be integrated within the NCD action plan.
2-4- Integration of interventions at the primary health care level

Many major NCDs can be prevented and controlled. The direct and indirect
costs of treating complications are enormous and can be reduced. However, despite
existing knowledge, the vast majority of people in the world are not covered by
adequate prevention against NCDs and do not receive appropriate management. This
is particularly the case for primary care in resource-constrained settings. GARD has
clearly indicated that these goals can be achieved using integrated management plans
for major NCD.
Considerable and diverse challenges face health care providers in LMICs and include separate disease-specific interventions fragmenting and duplicating efforts, and
limiting resources across a range of priorities. In many LMICs, chronic communicable
diseases and NCDs may overlap in the same patients and integrated management at
the primary health care level plans need to include all diseases.
The integration of NCDs in management plans is already being accomplished by
several programs such as the Integrated Management of Childhood Illnesses (IMCI)
program and the Integrated Management of Adolescent and Adult Illnesses (IMAI)
(24, 25), the Practical Approach to Lung Health (PAL) (12) or PALSA Plus ( 13) .
However, certain projects more specifically include the management of CRDs within
the frame of the NCD action plan (e.g. the Comprehensive approach to Lung Health
Services (CHLS) (26, 27).
A syndromic approach considering major NCD in primary health care was proposed within the goals of CRD control provided by GARD. This approach should
optimally be integrated with a core set of interventions to accomplish the objectives
of the 2008-2013 NCD Action Plan (1).
References
1. 2008-2013 Action plan for the global strategy for the prevention and control of non communicable diseases. Prevent and control cardiovascular diseases, cancers, chronic respiratory
diseases, diabetes. http://wwwwhoint/nmh/Actionplan-PC-NCD-2008pdf. 2008.
2. http://www.who.int/ncdnet/en/. 2010.
3. Package of Essential Noncommunicable (PEN) disease interventions for primary health
care in low-resource settings. WHO Press. World Health Organization. . 2010.
4. International Statistical Classification of Diseases and Related Health Problems , 10th
Revision Version for 2003 (http://www3.who.int/icd/vol1htm2003/fr-icd.htm). 2003.5.
United Nations General Assembly. Sixty fourth session. Agenda item 114 (A/64/L.52).
Prevention and control of non-communicable diseases. May 13, 2010. http://www0unorg/
depts/dhl/resguide/r64shtml. 2010.
5. Cruz AA, Bousquet PJ. The unbearable cost of severe asthma in underprivileged populations. Allergy. 2009 Mar;64(3):319-21.
6. Franco R, Nascimento HF, Cruz AA, Santos AC, Souza-Machado C, Ponte EV, et al. The
economic impact of severe asthma to low-income families. Allergy. 2009 Mar;64(3):47883.
7. Preventing Chronic Diseases: a Vital Investment: WHO global report World Health Organization; 2005.
8. The World Health Report 2004. Changing history. Annex Table 3, p 130. Geneva, World
Health Organization; 2004.
9. Bousquet J, Khaltaev N. Global surveillance, prevention and control of Chronic Respiratory Diseases. A comprehensive approach. Global Alliance against Chronic Respiratory
Diseases. World Health Organization. ISBN 978 92 4 156346 8. 2007:148 pages.
10. GARD Action Plan 2008-2013,WHO,2008 (www.who.int/gard/publications/GARD_action
plan_FINAL.pdf
11. Camacho M, Nogales M, Manjon R, Del Granado M, Pio A, Ottmani S. Results of PAL
feasibility test in primary health care facilities in four regions of Bolivia. Int J Tuberc
Lung Dis. 2007 Nov;11(11):1246-52.
12. Murray JF, Pio A, Ottmani S. PAL: a new and practical approach to lung health. Int J
Tuberc Lung Dis. 2006 Nov;10(11):1188-91.
13. English RG, Bateman ED, Zwarenstein MF, Fairall LR, Bheekie A, Bachmann MO, et al.
Development of a South African integrated syndromic respiratory disease guideline for
primary care. Prim Care Respir J. 2008 Sep;17(3):156-63.
14. Camargos PA, Cruz AA, Bousquet J. Medications to the North, patients to the South. J
Bras Pneumol. 2009 Jul;35(7):615-7.
15. Ait-Khaled N, Enarson DA, Bissell K, Billo NE. Access to inhaled corticosteroids is key to
improving quality of care for asthma in developing countries. Allergy. 2007 Mar;62(3):2306.
16. Bousquet J, Dahl R, Khaltaev N. Global alliance against chronic respiratory diseases.
Allergy. 2007 Mar;62(3):216-23.
17. Yorgancioglu A, Turktas H, Kalayci O, Yardim N, Buzgan T, Kocabas A, et al. The WHO
global alliance against chronic respiratory diseases in Turkey (GARD Turkey). Tuberk
Toraks. 2009;57(4):439-52.8. Bousquet J, Kiley J, Bateman ED, Viegi G, Khaltaev N,
Cruz AA. Prioritized research agenda for prevention and control of chronic respiratory
diseases. Eur Respir J. 2010 Mar 11.
18. Laurendi G,Centanni S,Donner C et al Global Alliance against Chronic Respiratory Diseases
(GARD-Italy), Strategy and Activities. Resp.Med 2012, Jan 106(1):1-8, E pub 2011, Oct
22
19. Haahtela T, von Hertzen L, Makela M, Hannuksela M. Finnish Allergy Programme 20082018--time to act and change the course. Allergy. 2008 Jun;63(6):634-45.
20. Haahtela T, Tuomisto LE, Pietinalho A, Klaukka T, Erhola M, Kaila M, et al. A 10 year
asthma programme in Finland: major change for the better. Thorax. 2006 Aug;61(8):66370.
21. Kupczyk M, Haahtela T, Cruz AA, Kuna P. Reduction of asthma burden is possible through
National Asthma Plans. Allergy. 2010 Apr;65(4):415-9.
22. Souza-Machado C, Souza-Machado A, Franco R, Ponte EV, Barreto ML, Rodrigues LC,
et al. Rapid reduction in hospitalisations after an intervention to manage severe asthma.
Eur Respir J. 2010 Mar;35(3):515-21.
23. Franco R, Santos AC, do Nascimento HF, Souza-Machado C, Ponte E, Souza-Machado
A, et al. Cost-effectiveness analysis of a state funded programme for control of severe
asthma. BMC Public Health. 2007;7:82.
24. Armstrong Schellenberg JR, Adam T, Mshinda H, Masanja H, Kabadi G, Mukasa O, et
al. Effectiveness and cost of facility-based Integrated Management of Childhood Illness
(IMCI) in Tanzania. Lancet. 2004 Oct 30-Nov 5;364(9445):1583-94.
25. Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A, Senkoro K, et al. Impact of
improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania:
randomised controlled trial. Lancet. 1995 Aug 26;346(8974):530-6.
26. Ait-Khaled N, Enarson DA. Management of asthma: the essentials of good clinical practice.
Int J Tuberc Lung Dis. 2006 Feb;10(2):133-7.
27. Slama K, Chiang CY, Enarson DA. Tobacco cessation and brief advice. Int J Tuberc Lung
Dis. 2007 Jun;11(6):612-6.
How does exhaled nitric oxide measurement fit in

asthma assessment?
Bahna SL
Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
Introduction
Nitric oxide (NO) is an endogenous regulatory molecule widely distributed throughout
the body. It is produced by the enzymes nitric oxide synthases. This presentation
addresses the role of exhaled NO (eNO) measurement in asthma assessment.
Nirtic oxide in asthma

Produced by nitric oxide synthases in airway epithelial cells, particularly
when damaged by eosinophilic inflammation.
Unclear how NO contributes to the pathophysiology of asthma. Is it a good
regulatory agent, a proinflammatory factor, or just a marker of eosinophilic inflammation?
Levels correlate with:

- sputum eosinophils

- broncho-alveolar lavage eosinophils

- basement membrane major basic protein
Procedure of fractional measurement of exhaled nitric oxide (FeNO)

Patient should exhale against a fixed resistance with expiratory pressure of
5-20 cm water (to ensure velum closure), and at an air flow rate of 50 ml/sec until
a plateau for 6-10 seconds.
No nose clip.
Results are expressed as the NO concentration in ppb (equivalent to nanoliters/
Liter) based on the mean of 2-3 values within 10% difference.
Should not be measured following spirometry procedure or exercise.
Factors that increase FeNO

In healthy children levels increase with age
P421R9039
Males have levels 20-30% higher than in females

During menstruation
Intake of nitrate-rich diet
Asthma
Atopic disease, particularly allergic rhinosinusitis
Respiratory infections that promote Th2 (e.g., rhinovirus, tuberculosis)
Ethnicity; Chinese > Blacks > Caucasians
Factors that reduce FeNO

Tobacco smoking. Passive smoking causes transient reduction (for only about
30 min)
Alcohol consumption
Inflammatory lung diseases other than asthma, e.g., COPD, BPD, CF, pulmonary hypertension, pneumonia, influenza.
Ciliary dyskinesia
Inhaled corticosteroid therapy
Exercise or spirometry maneuver
Advantages of FeNO measurement

Reproducible, easy to perform, even by young children
It is a quantitative biomarker of eosinophilic airway inflammation
Can complement other methods of diagnosing or assessing control of asthma
Predicts the response to inhaled corticosteroids
May be useful in certain asthma patients to monitor adherence & adjust
medications
2011 AmericanThoracic Society Clinical Practice Guidelines:

Recommendations for FeNO

Diagnosis of eosinophilic inflammation

Monitoring airway inflammation in asthma
Use in accounting for persistent or high allergen exposure
Use to determine likelihood of steroid responsiveness:
- If FeNO <25 ppb (<20 ppb in children): Unlikely
- If FeNO >50 ppb ( >35 ppb in children): Likely
- If FeNO 25-50 ppb (20-35 ppb children) interpret cautiously
Normal ranges of FeNO levels vary widely

Adults:

2.6 to 28.8 ppb in men

1.6 to 21.5 ppb in women
Children:
Increases with age; upper limit is 15 ppb at age 4 yr and reaches 25 ppb in
adolescents
Limitations of FeNO measurement

Expensive equipment, calibration & supplies
Requires patient cooperation for optimal performance
Many factors influence eNO level; up & down
Limited effect on improving asthma control when added to guidelines approach
Normal and abnormal cut-off values differed from one study to another
Normal ranges are not settled; vary by age, gender, race, habits (diet, alcohol,
smoking)
Conclusion
Optimal application of FeNO measurement in asthma management
The application of FeNO measurement is still not widely accepted
May help in diagnosis of suspected asthma
Identifying eosinophilic asthma phenotype
Good predictor of ICS response
Can be useful for adjusting ICS dose
Check compliance with ICS therapy.
May be useful in anticipating exacerbations in certain patients.
Limited effect on improving asthma control when added to a guidelines
approach.
For appropriate interpretation, multiple factors should be taken into consideration
References
1. Delgado-Corcoran C, Kissoon N, Murphy SP, et al. Exhaled nitric oxide reflects asthma
severity and asthma control. Pediatr Crit Care Med 5:1-10, 2004.
2. Dupont LJ, Demedts MG, Verleden GM. Prospective evaluation of the validity of exhaled
nitric oxide for the diagnosis of asthma. Chest 123:751-6, 2003.
3. Dweik RA, Boggs PB, Erzurum SC, et al. An official ATS clinical practice guideline:
interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir
Crit Care Med 184:602, 2011.
4. Ferrer M, Jarque A, Tosca R, et al. Is it necessary to treat all asthmatic children with
raised levels of exhaled nitric oxide?: treating the patient or the data. Allergol Immunopathol 39:280, 2011.
5. Gelb AF, Flynn Taylor C, Shinar CM, et al. Is it necessary to treat all asthmatic children with
raised levels of exhaled nitric oxide?: treating the patient or the data. Chest 129:1492, 2006.
6. Khalili B, Boggs PB, Shi R, Bahna SL. Discrepancy between clinical asthma control
assessment tools and fractional exhaled nitric oxide. Ann Allergy Asthma Immunol
101:124-9, 2008.
7. Kharitonov SA, Gonio F, Kelly C, et al. Reproducibility of exhaled nitric oxide measurements in healthy and asthmatic adults and children. Eur Respir J. 21:433-438, 2003.
8. Little SA, Chalmers GW, MacLeod KJ, et al. Non-invasive markers of airway inflammation
as predictors of oral steroid responsiveness in asthma. Thorax 55:232-4, 2000.
9. Malmberg LP, Pelkonen AS, Haahtela T, et al. Exhaled nitric oxide rather than lung
function distinguishes preschool children with probable asthma. Thorax 58:494-9, 2003.
10. Meyts I, Proesmans M, De Boeck K. Exhaled nitric oxide corresponds with office evaluation of asthma control. Pediatr Pulmonol 36:283-9, 2003.
10
11. Pijnenburg MW, Hofhuis W, Hop WC, et al. Exhaled nitric oxide predicts asthma relapse
in children with clinical asthma remission. Thorax 60:215-218, 2005.
12. Smith AD, Cowan JO, Filsell S, et al. Diagnosing asthma: comparisons between exhaled
nitric oxide measurements and conventional tests. Am J Respir Crit Care Med 169:473478, 2004
13. Smith AD, Cowan JO, Brassett KP, et al. Use of exhaled nitric oxide measurements to
guide treatment in chronic asthma. N Engl J Med 352:2163-73, 2005
14. Szefler SJ, Mitchell H, Sorkness CA, et al: Management of asthma based on exhaled
nitric oxide in addition to guideline-based treatment for inner-city adolescents and young
adults: a randomised controlled trial. Lancet 372:1065, 2008.
15. van der Valk RJ, Baraldi E, Stern G, et al. Daily exhaled nitric oxide measurements and
asthma exacerbations in children. Allergy 67:265, 2012
16. Zacharasiewicz A, Wilson N, Lex C, et al. Clinical use of noninvasive measurements
of airway inflammation in steroid reduction in children. Am J Respir Crit Care Med
171:1077-82, 2005.
Difficult Respiratory Phenotypes in Adults with Asthma

Greenberger Paul A., M.D.
Division of Allergy-Immunology
Department of Medicine
Northwestern University Feinberg School of Medicine
Chicago, IL
USA
Supported by the Ernest S. Bazley Grant to Northwestern University and Northwestern Memorial
Hospital
Correspondence to
Paul A. Greenberger, M.D.
# 14108
676 N. St. Clair Street
Chicago, IL 60611
USA
Email: p-greenberger@northwestern.edu
Introduction
The notion of difficult respiratory phenotypes in adults refers to patients with
persistent asthma and additional issues that increase the risk of a serious adverse
event, make management difficult or cause excessive loss of FEV1. Patients may
be identified because they are 1) experiencing especially severe attacks of asthma
leading to repeated emergency department visits, hospitalizations or intubations, 2)
achieving insufficient control of asthma, 3) requiring long term oral corticosteroids
despite other practice parameter based recommendations, 4) having co-morbidities
that complicate asthma, or 5) having other conditions and diseases that can challenge
many specialists and health care professionals.
A Differential Diagnosis for Insufficiently Controlled Asthma

The preliminary differential diagnosis for patients with difficult to treat asthma
should include determining if symptoms of dyspnea, shortness of breath and wheeze,
abnormal FEV1 or FVC, and responses to pharmacotherapy are consistent with asthma.
Some of the considerations for difficult to treat asthma in adults are listed in Table 1.
Some patients have combinations of these conditions that limit achieving control of
asthma and do not have undiagnosed rare conditions. For example, pharmacotherapy
P421R9042
11
12
may be inadequate when the home or work environment contributes to severe allergic
asthma from animal, dust mites or fungal exposures. It is important to clarify that
the patient has persistent asthma. For example, patients with obesity and a diagnosis
of asthma may report dyspnea but have little response to beta2 adrenergic agonists
(LABA)/inhaled corticosteroid (ICS) combinations, leukotriene receptor antagonists
(LTRA), long acting anti-cholinergic antagonists (LAMA) and courses of prednisone.
Indeed, some such patients with asthma have little or no objective evidence supporting the diagnosis and can be withdrawn from their medications.1 Patients who fail
to improve with multiple medications may have vocal cord dysfunction either with
or without asthma.2 Undetected vocal cord dysfunction can result in severe dyspnea
and a poor quality flow volume loop or 3 consistently non-reproducible vital capacity
maneuvers (within 5% of each other). When treated with long term oral corticosteroids for their steroid resistant asthma, the patients with unrecognized vocal cord
dysfunction may experience adverse effects such as hypertension, diabetes mellitus,
weight gain or mood change. An additional form of a dynamic upper airway dysfunction has been described which is characterized by contraction of the supraglottal
areas and entire larynx.3
Asthma with Pulmonary or Peripheral Blood Eosinophilia

Patients with asthma may have peripheral blood eosinophilia and sputum eosinophilia defined when the differential in sputum is at least 2% eosinophils. The eosinophilia often clears with ICS or oral and inhaled corticosteroid treatment, although
some patients require injectable corticosteroids. In addition, non-atopic (intrinsic)
asthma patients have evidence of peripheral blood and sputum eosinophilia. Patients
with allergic bronchopulmonary aspergillosis (ABPA) typically have 8-20% peripheral blood eosinophilia when a chest radiographic infiltrate is present in contrast to
a patient experiencing an exacerbation of Churg Srauss Syndrome or parasitism and
presenting with 40-60% peripheral blood eosinophilia.
Churg Strauss Syndrome should be suspected in a patient with asthma who presents with evidence of mononeuritis multiplex or acute onset of of paresthesias, and
peripheral blood eosinophilia. From a clinical perspective, there is wrist drop (radial
nerve palsy), sudden onset difficulty in dorsiflexion of the foot or toes (peroneal nerve
palsy) or sciatica. Alternatively, some patients present with unexplained pulmonary
infiltrates, palpable purpura or peripheral blood eosinophilia. The diagnosis is based
on a classification system of the American College of Rheumatology where there are
at least 4 of 6 criteria present: asthma, peripheral blood eosinophilia, polyneuropathy,
pulmonary infiltrates, paranasal sinus abnormality, and extravascular eosinophils.4 The
peripheral blood count ranges from 20-60%, and the concentration of total serum
IgE is increased. The ANA is detected as perinuclear (myeloperoxidase) in 60% and
as cytoplasmic (proteinase 3) in 10% of cases. Urinary leukotriene E4 (evidence of
leukotriene D4 generation) is elevated. There are detectable CD4+Th2 +(and Th1+)
lymphocytes, and CD4+CD25+ IL-5+ cells are increased in number compared to
patients with asthma. Of note, at the time of diagnosis, the numbers of CD4+CD25+
lymphocytes that produce mRNA for IL-10 is low which is consistent with fewer
protective/modifying Tregulatory cells.4
ABPA or allergic bronchopulmonary mycosis results in recurrent pulmonary in-
13
filtrates and bronchiectasis if the infiltrates persist. Oral corticosteroids remain the
treatment of choice and anti-fungals as adjunctive if they are used at all. Minimal
diagnostic criteria for ABPA include asthma, immediate cutaneous reactivity (or in
vitro IgE) to Aspergillus fumigatus, total serum IgE concentration >417 kU/L (or >
417 IU/L) and bronchiectasis that is compatible with ABPA or cystic fibrosis. A useful
confirmatory test is the demonstration of increased in vitro IgE and or IgG antibodies
to Aspergillus fumigatus compared to sera from patients with asthma without ABPA.5
ABPA can present with symptomatic or asymptomatic pulmonary infiltrates (that may
suggest lymphoma), worsening asthma, tenacious mucus plugs that are difficult or
impossible to remove at bronchoscopy, peripheral blood eosinophilia or in patients
with unexplained bronchiectasis or known cystic fibrosis. The total serum IgE concentration can surge 2-10 fold over the baseline elevated concentrations at the time
of new pulmonary infiltrate. From the laboratory perspective, there is evidence of
CD4+Th2+ activated lymphocytes and many other findings.6 Genetic susceptibility7
and gain of function of IL-4R8 have been described.
Difficult to Control Asthma

Assuming that the difficult phenotype is truly consistent with a patient with
asthma who is adherent to recommendations, the patients treatment response may be
disappointing because of the heterogeneity of responses in asthma.9 The science of
personalized medicine is growing and although there may be a gap in our understanding from the pharmacogenetic perspective, it is important to consider that some
descriptive information is available. Good responders to ICS are those patients who
have a more robust bronchodilator response to albuterol. Alternatively, steroid resistant asthma has been defined as <10%10 or <15%11 improvement in pre-bronchodilator
FEV1 after 1 week of 40mg/day of prednisone. One should review the possibility that
conditions or diagnoses in Table 1 are present in patients with difficult to control
asthma in addition to working to optimize pharmacotherapy.
Summary
The management of asthma can be complicated by difficult phenotypes including
the heterogeneity of pharmacologic responses and relative ease of control. The
death rate in the U. S. has been declining but the per capita rate of hospitalizations
is excessive compared to other countries. Continued progress in research and the
science of implementation of findings to patients and health care systems remain
paramount.
Table 1. Some Conditions and Issues that Complicate the Diagnosis or Treatment of Persistent Asthma in Adults
1. Non-adherence or improper techniques with scheduled medications/delivery

devices
2. Poor self-efficacy (a patients inability to initiate an action plan)
3. Psychiatric/psychologic conditions (depression, schizoaffective disorder, denial
etc)
14
4. Socioeconomic issues interfering with appropriate mangement, office visits,

obtaining medications, etc
5. Obesity
6. Cigarette smoking and/or substance abuse
7. Vocal Cord Dysfunction
8. Chronic rhinosinusitis or severe allergic rhinitis
9. Gastroesophageal reflux disease (GERD) or atypical reflux conditions
10. Obstructive Sleep Apnea
11. Allergen exposure (pets, molds, rodents, roaches etc) at home or work
12. Allergic Bronchopulmonary Aspergillosis or Mycosis
13. Churg Strauss Syndrome (vasculitis)
14. Ineffective pharmacotherapy for the severity of asthma
15. Concurrent primary immunodeficiency leading to repeated infections
16. Bronchomalacia
17. Combinations of the above
Table 2. Asthma and Pulmonary Infiltrates with Eosinophilia
Allergic Bronchopulmonary Aspergillosis or Mycosis

Churg Strauss Syndrome
Drug Allergy
Eosinophilic Pneumonias
Acute
Chronic
Simple
Tropical
Hypereosinophilic Syndrome
Parasitism
References
1. Aaron SD, Vandemheen KL, Boulet L-P, et al. Overdiagnosis of asthma in obese and
nonobese adults. CMAJ 2008;179:1121-31.
2. Ayres JG, Mansur AH. Vocal cord dysfunction and severe asthma: Considering the total
airway. Am J Resp Crit Care Med 2011;184:2-3.
3. Low K, Lau KK, Holmes P, et al. Abnormal vocal cord function in difficult-to-treat asthma.
Am J Respi Crit Care Med 2011;184:50-6.
4. Saito H, Tsurikisawa N, Tsuburai T, Oshikata C, Akiyama K. The proportion of regulatory
T cells in the peripheral blood reflects the relapse or remission status of patients with
Churg-Strauss Syndrome. Int Arch Allergy Immunol 2011;155 (suppl 1):46-52.
5. Greenberger PA, Yucha CB, Janson S, Huss, K. Using rare diseases as models of biobehavioral research : Allergic Bronchopulmonary Aspergillosis. Allergy Asthma Proc
2007;28:489-96.
6. Knutsen AP, Bush RK, Demain JG, et al. Fungi and allergic lower respiratory tract diseases. J Allergy Clin Immunol 2012;129:280-91.
7. Knutsen AP, Slavin RG. Allergic bronchopulmonary aspergillosis in asthma and cystic
fibrosis. Clin Dev Immunol 2011; 843763.
15
8. Knutsen AP, Kariuki B, Consolino JD, Warrier MR. IL-4 alpha chain receptor (IL-4R)
polymorphisms in allergic bronchopulmonary aspergillosis. Clin Molec Allergy 2006;3: 1-6.
9. Greenberger PA. Personalized medicine for patients with asthma. J Allergy Clin Immunol
2010;125:305-6.
10. Li LB, Leung DY, Martin RJ, Goleva E. Inhibition of histone deacetylase 2 expression
by elevated glucocorticoid receptor beta in steroid-resistant asthma. Am J Resp Crit Care
Med 2010;182:877-83.
11. Wang W, Li JJ, Foster PS, Hansbro PM, Yang M. Potential therapeutic targets for steroidresistant asthma. Curr Drug Targets 2010;11:957-70.
Diet and Chronic Respiratory Diseases

Khaltaev Nikolai
World Health Organization/Global Alliance against Chronic Respiratory Diseases,
Geneva, Switzerland
Introduction
During the past decades, rapid expansion in a number of large population - based
epidemiological studies has helped to clarify the role of diet in preventing and controlling morbidity and premature mortality resulting from non-communicable diseases
(NCDs); mainlycardiovascular, certain types of cancer and diabetes mellitus. WHOs
latest assessment of the relationship between diet and the development of chronic
diseases is set out in the report produced by a WHO Expert Committee [1]. Some of
the specific dietary components that increase the probability of occurrence of NCDs
in individuals, and interventions to modify their impact, have also been identified.
(Table 1). Population nutrient intake goals (PNG) have become the background for
the development of the WHO Global Strategy on Diet, Physical Activity and Health,
where specific reference values for nutrients are important in improving the dietary
recommendations for the population and to prevent chronic diseases [2].
Over one billion people suffer from chronic respiratory diseases (CRD) (Table 2).
Despite the enormous burden caused by CRD and an important role of diet in
the prevention of chronic diseases there is less reliable data available on the effect
of diet on CRD.
WHO PNG and CRD

In this article an attempt was made to compare existing PNG for preventing diet
related chronic diseases with the available associations between diet and CRD to consider a dietary approach for the prevention of CRD. Its important from the viewpoint
of the WHO Global Strategy for the Prevention and Control of NCD where reduction
of the major shared modifiable risk factors for NCD tobacco use, unhealthy diet,
physical inactivity and harmful use of alcohol is one of the major objectives [4].
P421R9034
17
18
Table 1, Ranges of population nutrient intake goals. *
Table 2, Estimated prevalence of chronic respiratory diseases.
19
Consumption of individual nutrients or food and CRD

Fat and fatty acids.
There is no data that total fat consumption within WHO PNG of 15-30% (Table
2) has negative effect on CRD as well as reduction of saturated fatty acids (SFA)
intake less than 10%. Polyunsaturated fatty acids (PUFAs) intake 6-10% needs special
discussion. PUFAs consist of n-6 PUFAs and n-3 PUFAs or 6 and 3 PUFAs. The
most important n-6 PUFA is linoleic acid, which is abundant especially in soybean
and sunflower oils. The most important n-3 PUFAs are eicosapentaenoic acid and
docosahexaenoic acid found in fatty fish and sea animals, and -linolenic acid found
in plant foods. N-6 PUFAs can lower plasma total and LDL cholesterol concentrations (5). The biological effects of n-3 PUFAs are wide ranging from beneficial:
powerful lowering of serum triglycerides, lowering of blood pressure, improvement
of cardiac function, arterial compliance, endothelial function, vascular reactivity and
potent anti-platelet and anti-inflammatory effects, to the harmful increase in serum
LDL cholesterol (6). An optimal balance between n-6 and n-3 PUFAs is considered
as 5-8% and 1-2% respectively (Table 2)
From the CRD point of view; n-6 PUFAs (including arachidonic fatty acid) are
considered to be proinflammatory due to higher levels of inflammatory mediators
(prostaglandins PGE2 and leukotrienes LTB4). In a representative sample of more
than 13,000 Dutch adults; high intake of several n-6 fatty acids was associated with
significant reduction in FEV1, particularly in smokers (7). This proinflammatory effect
theoretically should be also balanced by anti-inflammatory effect of n-3 PUFAs (8).
Childhood Asthma Prevention Study (CAPS) initiated as the first randomized controlled trial tested the effectiveness of n-3 fatty acid supplementation in reducing the
incidence of asthma and allergic sensitization in Australian children (9). No beneficial
effect was found in the study. Thus; more studies are needed to find the appropriate
balance between n-6 and n-3 PUFAs to protect against CRD.
Trans-fatty acids appear during the process of partial hydrogenation of PUFAs.
This process creates trans-fatty acids and also removes the critical double bonds in
essential fatty acids necessary for the action. Most trans-fatty acids are contributed
by industrially hardened oils, deep fried fast foods and baked goods (10). There is
only very limited data about the association between consumption of trans-fatty acids
and asthma. In cross sectional studies higher prevalence of asthma is observed in
those countries that have higher levels of trans-fatty acids intake (11). Higher levels
of margarine consumption are also associated with the increased risk of asthma (12).
Two large prospective studies in US demonstrated an increased risk of development
COPD in men and women associated with diet rich in desserts and French fries
(13,14). In view of this the PNG of trans-fatty acids consumption (less than 1% of
total energy) could have a beneficial effect on CRD. Nevertheless more studies and
in particular those where the trans-fatty acids consumption could be validated by fatty
acid composition in adipose tissue are needed.
Monounsaturated fatty acids (MUFAs) are beneficial for cardiovascular diseases
by lowering plasma total and LDL cholesterol (15). There is little evidence on the
effect of MUFAs on CRD. There are some data on the harmful effect of MUFAs
which promote allergic sensitization and hay fever while SFA from dairy products
20
have been associated with reduced asthma risk (16). The only nutritionally important
MUFA is oleic acid, which is abundant in olive and canola oils and also in nuts.
The recommendation to calculate MUFAs by difference: total fat (SFA+ PUFAs +
trans-fatty acids) when applied for CRD should consider adequate consumption of n-3
PUFAs along with the presence of SFA preferably within the recommended amounts.
However more studies in this area are needed.
Carbohydrates and dietary cholesterol

Since fruits and vegetables besides carbohydrates contain other nutrients; its difficult to interpret the role of total carbohydrates in the development of CRD. On the
other hand; the limited consumption of free sugars (less than 10% of total energy)
will allow better controlling obesity and overweight taking into account the role of
sugar in promoting obesity which is associated with higher prevalence of asthma (1,
3). There is no data on the impact of dietary cholesterol on CRD. However within
the western pattern diet linked with the development of CRD dietary cholesterol
should be considered (13,14). The western dietary pattern is heavy loaded by high
consumption of refined grains, cured and red meats, desserts and sweets, French
fries, eggs and high- fat dairy products. Consumption of cholesterol as well as free
sugars within this pattern is of no doubt higher than the recommended WHO range
for these nutrients.
Sodium chloride
More data exists on sodium chloride and fruits and vegetables impact on CRD.
In some population based cross-sectional studies the association between salt intake,
bronchial symptoms and asthma was found in children (17). There where an improvement in pulmonary function with low salt diet and promising results of trials on
reduction of salt in exercise induced asthma (18). Limitation of dietary sodium intake
to less than 5 gram per day should take into account total sodium intake from all
dietary sources, for example additives such as monosodium glutamate and preservatives (Table 1).
Fruits and vegetables

Consumption of fruits and vegetable 400 g per day could be also justified for
prevention of CRD possibly due to antioxidants/vitamins presence in fresh fruits and
vegetables (Table 1). A beneficial effect of fresh fruit consumption on symptoms, lung
function or asthma control has been observed in children and adults by several epidemiological studies (19). The relationships between dietary patterns and lung function
and spirometrically defined COPD were investigated in a cross sectional study of
1,551 males and 1,391 females in UK. It was shown that a prudent dietary pattern
(high consumption of fruit, vegetables, oily fish and whole meal cereals) may protect
against impaired lung function and COPD, especially in male smokers (20). Almost 16
years follow up of 72 043 US women in the Nurses Health Study has demonstrated
a negative association between a diet rich in fruit, vegetables and fish with the risk
of COPD. A positive association with the risk of COPD was found between a diet
rich in refined grains, cured and red meats, desserts, and French fries (13). 12 years
follow up data collected from a large prospective cohort of 42,197 US men (Health
21
Professionals Follow-up Study) have shown a negative association between the risk
of newly diagnosed COPD and diet rich in fruits, vegetables and fish. Diet rich in
refined grains, cured and red meats, desserts and French fries may increase the risk
of COPD (14). Statistical analysis of these long-term prospective studies has adjusted
multiple risk factors, including smoking to demonstrate independent role of dietary
factors in developing of COPD. These results also suggest that dietary antioxidants may
modify the development of CRD in susceptible individuals. Dietary supplementation
with vitamin C also significantly improves asthma control, pulmonary function and
pulmonary inflammatory markers in children with moderate persistent asthma [21].
Non-starch polysaccharides
Whole grain cereals, fruits and vegetables are the preferred sources of non-starch
polysaccharides. Due to lack of data on the effect of dietary fiber on CRD and referring
to the above mentioned studies on fruits, vegetable and whole grain associations with
CRD we can assume that recommended consumption of fruits, vegetables and wholegrain foods is likely to provide >20g per day of non-starch polysaccharides (>25 g
per day of total dietary fiber) (1). This will probably have a protective effect on CRD.
Protein
High consumption of cured and red meat is typical for the western dietary pattern.
This pattern associated with the higher prevalence of COPD assumes a high animal
protein diet (Table 2). On the other hand prudent dietary pattern heavily loaded
by a high consumption of fruits, vegetables, fish, poultry and whole grain products
is associated with the lower prevalence of CRD (13,14). Increasing soy consumption
from the soybean products (tofu, natto, bean sprouts and soy milk drinks) was also
associated with a decreased risk of COPD and breathlessness (22).
Conclusion
Finally, NCD mainly cardiovascular diseases, cancers, diabetes and CRD are the
worlds biggest killers causing an estimated 35 million deaths each year-60% of all
deaths globally [4]. Diet and nutrition are important factors in the prevention and
maintenance of good health throughout the entire life course. Their role as determinants of major chronic NCD is well established and they therefore occupy a prominent
position in the WHO prevention and control activities of the 2008-2013 WHO Action
Plan for the global strategy for the prevention and control of NCDs (4). Despite the
fact that the role of dietary factors in developing of CRD is less convincing than for
other NCDs like cardiovascular diseases, certain types of cancer and diabetes mellitus;
the reported associations in general do not contradict to existing ranges of the WHO
population nutrient intake goals. Limited intake of total fat within the recommended
range, restriction of salt consumption, adequate intake of fresh fruits and vegetables,
weight control and attention to the processed food which can be recommended for
the prevention of CRD are generally compatible with existing dietary guidelines for
the control of major NCDs. Nevertheless more research is needed to better study the
relationships between diet and CRD.
22
References
[1] Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint WHO/FAO
Expert Consultation. WHO Technical Report Series 916, Geneva, 2003. (http://www.who.
int/nutrition/topics/5_population_nutrient/en/index.html cited on the 31st of May; 2010
[2] Global Strategy on Diet, Physical Activity and Health A framework to monitor and evaluate
implementation. Geneva, World Health Organization, 2006.
[3] Bousquet J, Khaltaev N. Global surveillance, prevention and control of Chronic Respiratory Diseases. A comprehensive approach. Global Alliance against Chronic Respiratory
Diseases. Geneva, World Health Organization, 2007.
[4] World Health Organization. 2008-2013 Action Plan of the Global Strategy for the Prevention and Control of Noncommunicable Diseases. World Health Organization, Geneva,
2008.
[5] Wijendran V, Hayes KC. Dietary n-6 and n-3 fatty acids balance and cardiovascular health.
Annu Rev Nutr. 2004; 24: 597-615. Review
[6] Herbault C .Omega-3 et sant (Omega-3 and health). Revu Medical de Bruxelles. 2006;
27(4): 355-60.
[7] McKeever TM, Lewis SA, Cassano PA, et al. The relation between dietary intake of individual fatty acids, FEV1 and respiratory disease in Dutch adults. Thorax. 2008; 63(3):20814.
[8] Oddy WH, de Klerk NH, Kendall GE, Mihrshahi S, Peat J K. Ratio of omega-6 to omega-3 fatty acids and childhood asthma. J. Asthma. 2004; 41 (3): 319-26.
[9] Almquist C, Garden F, Xuan W, et al. for the CAPS Team. Omega-3 and omega-6 fatty
acid exposure from early life does not affect atopy and asthma at age five years. J Allergy
Clin Immunol. 2007; 119 (6): 1438-44.
[10] M B Katan Trans fatty acids and plasma lipoproteins. Nutr Rev 2000; 58: 188-91.
[11] Weiland S K, Vonmutius E, Husing A, Asher M I. Intake of trans fatty acids and prevalence of childhood asthma and allergies in Europe. Lancet 1999; 353 (9169): 2040-2041.
[12] Wijga AH, Houwelingen AC, Smit HA, et al. Fatty acids in breast milk of allergic and
non-allergic mothers: The PIAMA birth cohort study. Pediatr. Allergy Immunol. 2003; 14
(3): 156 62.
[13] Varraso R, Fung TT, Barr RG, Hu FB, Willet W, Camargo CA Jr. Prospective study of
dietary patterns and chronic obstructive pulmonary disease among US women. Am Clin
Nutr 2007; 86(2): 488-95
[14] Varraso R, Fung TT, Hu FB, Willett W, Camargo CA. Prospective study of dietary patterns
and chronic obstructive pulmonary disease among US men. Thorax 2007; 62 (9): 786-91.
[15] KrisEtherton PM. AHA Science Advisory; monounsaturated fatty acids and risk of cardiovascular disease. American Heart Association Nutrition Committee. Circulation 1999;
100: 1253- 58.
[16] Trak-Fellermeier MA, Brasche S, Winkler G, Koletzko B, Heinrich J. Food and fatty acid
intake and atopic disease in adults. Eur Respir J 2004, 23:575-82.
[17] Corbo GM, Forastiere F, De Sario M, et al. SIDRIA-2 Collaborative Group. Wheeze and
asthma in children: association with body mass index, sports, television viewing, and diet.
Epidemiology 2008; 19(5): 747-55.
[18] Gotshall R, Mickleborough T, Cordain L. Dietary salt restriction improves pulmonary
function in exercise induced asthma. Med Sci Sports Exerc. 2000; 32 (1815): 1819.
[19] Barros R, Moreira A, Fonseca J, et al. Adherence to the Mediterranean diet and fresh fruit
intake are associated with improved asthma control. Allergy 2008; 63: 917-23.
[20] Shaheen SO, Jameson KA, Syddall HE, et al. The relation of dietary patterns to adult
lung function and COPD. Eur Respir J 2010 Aug;36(2):277-84.
[21] Biltagi MA, Baset AA,Bassiouny M, Kasrawi MA, Attia M. Omega-3 fatty acids, vitamin
23
C and Zn supplementation in asthmatic children: a randomized self-controlled study. Acta

Paediatr. 2009; 98 (4): 737-42.
[22] Hyrayama F, Lee AH, Binns CW, et al. Soy consumption and risk of COPD and respiratory
symptoms: a case-control study in Japan. Respir Res 2009 Jun 26; 10:56.
Achieving Control of Fungal Asthma and Allergic

Bronchopulmonary Mycosis
Greenberger Paul A., M.D.
Department of Medicine
Northwestern University Feinberg School of Medicine
Chicago, IL
USA
Supported by the Ernest S. Bazley Grant to Northwestern University and Northwestern Memorial
Hospital
Correspondence to
Paul A. Greenberger, M.D.
# 14108
676 N. St. Clair Street
Chicago, IL 60611
USA
Email: p-greenberger@northwestern.edu
Introduction
Sensitization to fungi is associated with a risk of developing asthma, and fungal
asthma can be a cause of increasingly severe asthma.1 The notion of control of fungal
asthma includes identification where fungi contribute meaningfully to ongoing persistent asthma or to episodes of intermittent asthma. (see Figure 1). It is recognized
that dampness in home living spaces is associated with hospitalizations for asthma
especially in children < 5 yrs of age.similar risk to the risk from rodents, second
hand smoke and cockroaches.1 Alternaria and Cladosporium have been associated
with development, persistence and severity of asthma. Aspergillus fumigatus has been
associated with severe persistent asthma (and Allergic Bronchopulmonary AspergillosisABPA). Exposures to Basidiospores and Ascospores in the first 3 years of life are
associated with onset of asthma, and sensitization to Alternaria by age 6 years has
been correlated with persistent asthma at age 22 years.1 Exposure to fungi is a risk
factor for fatalities from asthma and severe adverse events (respiratory arrests and
hospitalizations) as well as persistent severe fungal asthma.
P421R9043
25
26
Figure 1. Asthma with Fungal Sensitization Syndromes
Control of Asthma
According to the National Asthma Education and Prevention Program (2007) Expert Panel report2, in considering assessment and monitoring, there are 3 categories
to consider: severity, control, and responsiveness. Severity is the intrinsic intensity
of the disease process whereas control is the degree to which the manifestations
of asthma (symptoms, functional impairments, and risk of untoward events) are minimized and the goals of therapy are met. Responsiveness is the ease with which
control is achieved by therapy. To make practical use of the categories, the NAEPP
report proposed 2 domains for severity and control: impairment and risk. Impairment
after a patient has received pharmacotherapy assesses the frequency and intensity of
symptoms and functional limitations. Similarly, in the Global Initiative for Asthma
(GINA) 2009 Global Strategy for Asthma Management and Prevention3, a patient with
control of asthma is identified by all 5 of the following criteria (preferably considered over the previous 4 weeks): daytime symptoms (twice or less/week); limitations
of activity (none); nocturnal symptoms and awakenings (none); need for reliever/
rescue treatment (twice or less/week); lung function FEV1 or PEF (normal). Partially
controlled asthma is when any of the 5 criteria are more frequent than controlled
or FEV1 or PEF is < 80% or of the personal best. Thus, a patient who experiences
daytime symptoms of asthma 3 times a week or is symptomatic at night once a week
is at best partially controlled.
Achieving Control of Fungal Asthma

Achieving control of fungal asthma begins with improvement of the environment.
While studies have not reported significant improvement in FEV1 or PEF, they have
reported reduced symptoms and medications. 4,5 Evidence exists that a comprehensive
effort including improving exhaust ventilation in the home, repairing water leaks,
27
stopping entry of rainwater into the home, and remediation (cleaning and removal of
visible mold with a detergent-surfactant product, application of a fungicide, repainting
with a fungicide containing paint) helps reduce symptoms and improve control of
asthma.4,5 Allergen immunotherapy with Alternaria and Cladosporium is recognized
to be effective.6 Pharmacotherapy for asthma is indicated. Evidence suggests that in
addition to treatment for persistent asthma, itraconazole helps to reduce symptoms
and improves control of asthma if a patient has the diagnosis of severe asthma with
fungal sensitization (SAFS), a condition that is not ABPA or mycosis.7 Itraconazole
has been associated with improved outcomes in such patients and discontinuation led
to worsening of control.
Achieving Control of Allergic Bronchopulmonary Mycosis

Achieving control of Allergic Bronchopulmonary Aspergillosis (ABPA) or mycosis
involves controlling asthma and managing current, recognizing future and if possible
preventing future pulmonary infiltrates and complications of bronchiectasis or pulmonary
fibrosis. ABPA can affect the proximal bronchi (identified as dilated bronchi compared
to the adjacent bronchial vessel in the inner 2/3 of the high resolution computerized
tomographic examination of the lungs) or smaller airways (identified as bronchiolitis
obliterans and pulmonary fibrosis). There may be chronic sputum production, colonization of bronchi with gram negative bacteria (Pseudomonas species) or atypical
mycobacteria (Mycobacterium avian-intracellulare complex), increasing dyspnea and
arterial oxygenation desaturation. Approaches to control of ABPA involve environmental
sources at home or work, recognizing, treating and clearing pulmonary infiltrates and
overcoming arterial desaturation if present. Monitoring the concentration of total IgE in
a prospective manner can help identify new pulmonary infiltrates, when the total IgE
concentration doubles (high sensitivity but moderate specificity).8 Identifying sources
of fungi in the home or work can help suggest avoidance measures. For example, if a
patient is an avid gardener, it should be explained that compost piles or moldy compost
may trigger either acute severe asthma (status asthmaticus) or an exacerbation of ABPA
(new pulmonary infiltrates, 100% increase in total IgE concentration, sputum plugs
or peripheral blood eosinophilia). Although there arent controlled studies with oral
corticosteroids, they have been utilized since the 1960s for treatment of pulmonary
infiltrates in ABPA. When the patient with ABPA has pulmonary infiltrates such as
mucus plugging, homogeneous consolidation, pulmonary infiltrate with doubling of the
total IgE over baseline or a presumptive new diagnosis, the author recommends a 1-2
week course of prednisone 0.5mg/kg administered each morning and then for 8 weeks
as alternate morning therapy. The chest radiograph can be repeated at 2-4 weeks, and
the total IgE concentration should be reduced by at least 33% after 6 weeks. After 8
weeks, the high resolution computerized tomographic examination of the lungs should
be obtained to document clearing of the initial findings. At that time, the prednisone
can be tapered over a month and discontinued. Some patients will require continued
inhaled corticosteroid and possibly long acting beta2 agonist therapy or treatment with
a concomitant leukotriene receptor antagonist to achieve control of persistent allergic
asthma. Alternatively, a limited number of patients become prednisone dependent
asthma and require modest doses such as 10-30mg on alternate days despite inhaled
corticosteroid/LABA and leukotriene receptor antagonist therapies. Anti-fungal medi-
28
cations are adjunctive1,9 but it is necessary to consider drug-drug interactions as azoles

inhibit elimination of medications. Itraconazole has been associated with a reduction
of sputum eosinophilia and evidence of activation of eosinophils10 although it isnt
clear if itraconazole as monotherapy will resolve pulmonary infiltrates. Voriconazole
has large variations in absorption and some adverse effects such as changes in vision
(an unwelcome darkening of the visual field or alteration of perception of colors),
decreased renal function and liver function abnormalities.
There are case reports of success11 and failure12 of omalizumab in ABPA. Harm has
not been reported. A trial of 6 months can be considered to determine if a response for
asthma has occurred.13 It is not proved that empiric treatment with omalizumab will
prevent pulmonary infiltrates in ABPA, although that is a worthy goal of treatment.
A small number of patients with ABPA have chronic rhinosinusitis and nasal
polyps with pan-opacification on sinus computerized tomography. Allergic fungal
rhinosinusitis may be present. A larger number of patients with ABPA have allergic
rhinitis (as also occurs in patients with other fungal asthma syndromes). Treatment
of the nose and sinuses is advisable in reaching the level of control. As illustrated
in Figure 1, there are multiple conditions that comprise the patient with asthma who
is sensitized to fungi and if there is not improvement, one should determine if the
diagnosis is correct, if environmental factors are still contributing to morbidity, whether
pharmacotherapy is appropriate and whether allergen immunotherapy or omalizumab
should be initiated.
References
1. Knutsen AP, Bush RK, Demain JG, et al. Fungi and allergic lower respiratory tract diseases. J Allergy Clin Immunol 2012;129:280-91.
2. National Heart, Lung, Blood Institute. National Institutes of Health. National Asthma
Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis
and Management of Asthma. 2007. http://www.nhlbi.nih.gov/guidelines/asthma accessed
9/2/2012.
3. Global Initiative For Asthma. Global strategy for asthma management and prevention.
2011. http://www.ginasthma.org/guidelines-gina-report-global-strategy-for-asthma.html
accessed 9/2/2012.
4. Burr ML, Mathews IP, Arthur RA, Gregory CJ, Dunstan FD, Palmer SR. Effects on
patients with asthma of eradicating visible indoor mould: a randomized controlled trial.
Thorax 2007; 62:767-772.
5. Kercsmar CM, Dearborn DD, Schluchter MD, et al. Reduction in asthma morbidity in
children as a result of home remediation aimed at moisture sources. Environ Health Perspect 2006; 114:1574-1580.
6. Helbling A, Reimers A. Immunotherapy in fungal allergy. Curr Allergy Asthma Rep 2003;
3:447-453.
7. Denning DW, ODriscoll BR, Powell G, et al. Randomized controlled trial of oral antifungal
treatment for severe asthma with fungal sensitization: The Fungal Asthma Sensitization
Trial (FAST) study. Am J Respir Crit Care Med 2009; 179:11-18.
8. Greenberger PA. Allergic Bronchopulmonary Aspergillosis. J Allergy Clin Immunol
2002;110:685-92.
9. Stevens DA, Schwartz HJ, Lee JY, et al. A randomized trial of itraconazole in allergic
bronchopulmonary aspergillosis. N Engl J Med 2000; 11:756-762
10. Wark PA, Hensley MJ, Saltos N, et al. Anti-inflammatory effect of itraconazole in stable
29
allergic bronchopulmonary aspergillosis: a randomized controlled trial. J Allergy Clin

Immunol 2003; 111:952-957.
11. Cornelis K van der Ent, Hans Hoekstra, Ger T Rijkers. Successful treatment of allergic
bronchopulmonary aspergillosis with recombinant anti-IgE antibody. Thorax 2007; 62:276277.
12. Brinkmann F, Schwerk N, Hansen G, Ballmann M. Steroid dependency despite omalizumab
treatment of ABPA in cystic fibrosis. Allergy 2010;65:134-5.
13. Greenberger PA. Persistent severe asthma and aging: step-up therapy with omalizumab to
improve control. Allergy Asthma Proc 2010; 105:408-10.
Bacterial immunostimulants in asthma copd

and recurrent respiratory infections
Palma-Carlos A.G., MD. PhD, EFAAAAI, HDFACAAI,
Palma-Carlos M.L., Pharm, PhD.
Clinical Allergy Immunology Center
Lisbon, Portugal
a.g.palma.carlos@gmail.com
Immunostimulants from bacterial origin have been used in respiratory pathology

from almost 50 years in order to increase response to pathogenic organisms and
induce also a non specific innate immunity. Our first work on immunodulators has
been presented in the European Allergy Congress (Basel 1962) 50 years ago, and
larger series presented in the next few years (table I).
In the respiratory tract innate and adaptive immunity play a role. Innate immunity
is a primary line of defense, cellular and humoral, constitutively present not antigen
specific and without memory response. Adaptive immunity is a second line of defense, cellular and humoral, delayed to react, antigen specific and with immunological
memory. In adaptive immunity dendritic cells prepare the immune response,local or
at distance through activation of memory cells and naive T-cells. Bacteria, fungi lipopolysacharides and also bacterial immunostimulants, called sometimes vaccinoids trigger
a differentiation of circulating monocytes CD14-CD/80, 83-86 to immature dendritic
cells CD14-CD80, 83,86 +/- and finally to mature dendritic cells CD14-CD80,83,
86+. Bacterial immunostimulants are used by sublingual route local application in
nose pharyns or by parenteric route. The targets of this mucosal immunostimulation
are innate defense mechanisms in epithelium and lamina propria mucosa associated
immune cell population, dendritic cells, B-cells, plasma cells, T-cells, NK cells, antigen
specific IgA production through mucosal lymphoid aggregates and finally, Treg cells
through dendritic cells in mucosa.
In current practice only one small part of population has a significant immune
response to respiratory pathogens which is only induced by heavy bacterial load. This
fact justifies the use of immunostimulants to prevent respiratory infections. These
immunostimulants can be employed by different routes, parenteral with a system effect, inhaled either nasal, oropharyngeal or bronchial, with a local effect, sublingual
probably with local and systemic effects and oral with gastrointestinal response and
through lymphatic system also respiratory (table II).
P421R9026
31
32
table I
table II
33
table III
Currently immunostimulants are available in tablets containing bacterial lysates or

ribosomal proteins adjuved by membranal extracts of Klebsiella nasal or sublingual
sprays, sublingual drops, oral drops, lyophilized powder or liquid solution. Some immunostimulants have fixed formulas containing lysates of the more current respiratory
pathogens, other have an open composition depending on the choice of the prescriptor.
Results - From the last seventies many papers have been published on non
specific immunotherapy. In the eighties we have evaluated a group of 274 patients
with recurrent infections, bronchitis or asthma during 2 consecutive years in the first
without immunostimulant, the second year after a 3 month treatment with OM.85 the
all group being used as an internal control using a basic score system (o-absence,
1 presence) for cough, sputum and dyspnea and casting the number of respiratory
infections each year. The score has been improved in 61% of the patients and the
number of respiratory infections/patients decreased from 2,14 the first year to 1,08
p<0,001 (table III).
A recent paper has used a similar methodology evaluating before and after the
use of a sublingual drops formulation (Bac-Tek) not only the number of respiratory
infections but also the number of proliferating memory cells which was clearly increased. Numerous double-blind placebo controlled trials have been published in the
last years namely for standard oral immunostimulants used by oral route and some
meta-analysis published with large number of patients either adults or children confirming the efficacy in respiratory pathology. In a comparative assay we have studied
34
table IV
the clinical and immunologic effect of 2 current brands of oral immunostimulants in

tablets one ribosomal and one bacterial lysate (table IV).
The patients have been studied before and after a 3 months course of immunomodulator 2 consecutive years and the number of respiratory infections by month and
patient, the total number of disease days, the numbers of fever days by month and
patient the consumption of antibiotics by month and patient and the absenteism of
school or work by month and patients have been compared. Results were comparable
with a slight advantage in favour of ribosomal tablets for days of respiratory infections
number of days with fever and absenteism.
In the same group the variation of the response to multitest a poly antigen device
used to evaluate cellular immunity and the intradermal infection of standardized extract of bacteria, the ribosomal preparation and Candida albicans has been compared
after immunostimulation differences were significant in favour of bacterial lysates to
Moraxella and in favour of Ribosomal preparation to Klebsiella. Results for the Ribosomal preparation and Candida are related to negative response for these 2 antigens
in a large number of patients in initial evaluation (tables V, VI).
Discussion - In the last few years an increasing number of papers in immunostimulants has been published. New data have been acquired on the effect on dendritic
cells on Treg. A first quotation has been included in a recent English language text
book. An International Board has been launched in PARIS in 2006 in order to evaluate the use of bacterial immunostimulants in prevention of recurrent respiratory tract
infections: definition of diseases treated and evaluation of criteria.
Bacterial immunostimulants are nowadays registered and commercialized in about
table V
table VI
35
36
65 countries and the number of treatment per year is over 8 million patients. From
the launches in the 1980s between 130 and 200 million patients have been treated in
the world. The clinical experience confirm very good tolerance, few side effects and
less than 10 cases of serious side effects. A first presentation of immunostimulants
has been done is World Allergy Congress 2009 in Buenos Aires. Immunostimulants
are included as a valuable tool in EPOS (European Position Paper on Sinusitis) and
as the last versions of COLD as preventive therapy of COPD,
Razi Harmandi, Abao et al. find that the immunostimulant OM-85 prevents wheezing in pre-school children. Recently HOLLAMS, HOLT/PC et al. have found that
oral vaccins increase immunity to bacteria and the number of asthma crisis. The same
group has shown that after the use of oral immunostimulants up-regulation of CD86
on dendritic cells precedes TH cell activation and bronchial hyperreactivity and that
microbe stimulation of the gut enhances Treg control of CD86.
NAVARRO, COSSALTUR et al. propose that the oral administration of bacterial
extracts prevents asthma via the recruitment of regulating T-cells on airways and
STRICKLAND, JUDD, MORT et al. suggest to boost airways T-regulatory cells by
gastro intestinal stimulation with bacterial products.
Similar evidence is presented by FERLAZZO TOLL like receptors are activated
by bacterial lysates and an interaction through dendritic cells and natural killer (NK)
cells play a role in the activation of CD86. For this effect mixture of bacteria are
superior to single steads. In double blind placebo controlled assays an increase in
naive B-cells and memory cells is triggered by bacterical immunostimulants increasing
also specific antibodies.
Conclusions - In the last 30 years a large sum of clinical and experimental work
has confirmed the efficacy of immunostimulating vaccins in respiratory infections
and asthma.
Recent basic and clinical studies point to an action through dendritic cells and a
balance between Treg, TH1 and TH2 as well as for local immunostimulating factors
as for sublingual, oral and parenteric routes.
References
1 - Alecsandru D, Valor L, Sanchez-Ramon et al. Sublingual therapeutic immunization with a
polyvalent baxterial preparation in patients with recurrent respiratory infections Clin Exp
Immunol 2011, 164, 100-107
2 - Belanti JA, Oliveira D, Serrano E. Ribosomal immunostimulation: a review evaluating its
clinical relevance in prevention of upper and lower respiratory tract infections in children
and adults Bio Drugs 2003, 17, 355-367
3 - Bousquet J, Fiocchi A. Prevention of recurrent respiratory tract infections in children using
a Ribosomal immunotherapeutic agent Pediatric Drugs 2006, 8, 235-243
4 - Bousquet J, Olivieri D. Role of Ribomunyl in the prevention of recurrent respiratory tract
infection in adults Treat Respir Med 2006, 5, 327-324
5 - Bousquet J. Immunostimulation in respiratory diseases 7-27 in Simposio Broncho-Vaxom
OM Pharma, Lisboa 2011
6 - Boyle P, Bellanti JA, Robertson C. Meta analysis of published clinical trials of a ribosomal
vaccine in prevention of respiratory infections Bio Drugs 2000, 14, 389-408
7 - Braido F. Strenght the natural defense DVD 24 - Int Symposium on Rhinosinusitis WAC
2009, Buenos Aires
37
8 - Braido F, Traggiai E, Lanzilli G. et al. Polyvalent mechanical bacterial lysate treatment in

COPD : New Immunological evidence Int J. Immunorehabilit 2011, 13, 56
9 - Bystron J, Hermanova Z, Szotkovska et al. Comparison of the effect of Ribosomol Immunotherapy on Plasma levels of total IgE and citokines in adult atopic and non-atopic
patients during the pollen season Clin Drug Invest 2004, 24, 755-760
10 - Collet JP, Shapiro S, Ernst P et al. Effect of an immunostimulating agent on acute exacerbations and hospitalization in COPD patients Am J Respir Crit Care Med 1997, 156,
1719-1724
11 - Collet JP, Shapiro S, Robinson A. et al. Economic impact of using an immunostimulating
agent to prevent severe acute exacerbation in patients with COPD Am Respir J. 2001,
8, 27-33
12 - Ferlazzo G. Immune system cellular cross - talk in the presence of bacterial components
IV World Asthma and COPD Forum, Paris 2011
13 - Navarro G, Cossalter G, Chiavaroli C. et al. The oral administration of bacterial extracts
prevents asthma via the recruitment of regulatory T cells to the airways Mucosal Immunol
Advance online publication 2010, doi 1038/mi 2010-51
14 - Olivier D, Fiocchi A, Pregliasco F. et al. Safety and tolerability of ribosome componente
imune modulator in adults and children Allergy Asthma Proc 2009, 45, suppl 1, 33-36
15 - Palma-Carlos AG. Die anwendung bakterieler impstoffe in der Betrundlung von Infektiosen
Asthma Therap Umschau 1964, 21, 258-265
16 - Palma-Carlos AG, Palma-Carlos ML. Immunotherapie orale avec lysates bacteriens dans
lasthme et infections respiratoires de repetition Mdecine Hygine 1985, 13, 2718-2721
17- Palma-Carlos AG, Palma-Carlos ML, Incio FF et al. Oral immunotherapy with lyophilized
bacterial lysates in patients with recurrent tract infections Int J Immunotherapy 1987, 3,
123-130
18 - Palma-Carlos AG. Basic aspects of therapy of intrinsic asthma 263-278 in Intrinsic Asthma,
Schmit-Schuman M, Menz G (ed) Birkhusen, Basel, 1989
19 - Palma-Carlos AG, Palma-Carlos ML. Non specific immunomodulation in respiratory
infections Eur Ann Allergy Clin Immnol 1990, 22, 179-183
20 - Palma-Carlos AG, Trindade MF, Condet Oral immunotherapy with bacterial extracts versus
ribosomal extracts adjuved with membrane proteoglycans Clin Exp Allergy 1990, 20, 12-6
21 - Palma-Carlos AG, Palma-Carlos ML. Immunologic basis for the use of Immunomodulators
in RRI and asthma. 1-6 in simposio Broncho-Vaxom, OM Pharma, Lisboa, 2011
22 - Razi CH, Harmanoi K, Abaoi A. et al. The immunostimulant OM-85 BV prevents wheezing attacks in preschool children J Allergy Clin Immunol 2010, 126, 763-769
23 - Strickland D, Judd S, Holt PG et al. Boosting airways T-regulatory cells by gastrointestinal
stimulation as a strategy for asthma control Mucosal Immunol Advance online publications
2010, --- 10, 1038/mi, 2010-43
24- Thomson NC Multicomponent oral bacterial vaccins in Asthma and COPD, Barnes PJ,
Drazen J, N et al. Academic Press, London 2009
25-Trindade FM, Conde TA, Palma-Carlos AG. et al. Oral immunomodulation in asthma with
bacterial extracts vs Ribosoma extracts In vivo evaluation Allergie Immunol 1991, 23, 32
Bronchial asthma: prevalence, risk factors and severity

of disease in the CIS-Region
Slavyanskaya T. A., Sepiashvili R.I.
Russian University, Department of Allergy and Immunology, Moscow, Russia; Institute of
Immunophysiology, Moscow, Russia
Summary
In this study there has been analyzed the data from epidemiological studies on
the prevalence and peculiarities of the course of bronchial asthma (BA) among the
adult (Ad), children (Ch) and teenagers (Tg) in the CIS-region (CIS-R) over the
past 5-10 years. It has been established that BA is dominated in the structure of
allergic diseases (ADs) of the CIS-R. BA, on average, suffer from 7 to 48,3% Ad
and from 4 to 31% Ch. The diagnosis of BA was recorded by the Statistical Reports
in only 2.3% of children and Ad-less than 1%. An analysis of existing data revealed that the mild forms of BA were dominated. The share of severe and moderate
BA according to the age accounted for between 2 and 48%. The structure of BA
recorded by statistical morbidity, dominated the moderate or severe forms of BA.
The true incidence is much higher, as the uptake to the doctor takes place only
in cases of the disease formed, earlier symptoms often go undetected. Often BA
has been diagnosed at later stages with severe disease and complications. Unified
account of the early features of ADs in a particular region will not only develop
a National Prevention Program of ADs in the CIS-R, identify the main ways of
their implementation, but also will allow to plan Allergic service in each region,
important element of which is education and training of primary care physicians to
identify early symptoms of ADs.
Introduction
The development of civilization, scientific and technical progress, the introduction of new technologies in production, urbanization of the population have a huge
impact on the development of various socio-economic formations of states and have
both a positive and a negative value. And this is primarily related to human health.
In this study there has been analyzed the data from epidemiological studies on the
prevalence and peculiarities of the course of bronchial asthma (BA) among the adult
P421R9029
39
40
(Ad), children aged 6-8 years old (Ch) and teens aged 13-15 years old (Tg) in the
CIS-region (CIS-R) over the past 5-10 years.
Materials and Methods

There have been used the results of studies of ISAAC, Statistical Reports (SR) of
the Republic Ministries of Health and Medical facilities in the CIS-R; the literature data.
Results
Prevalence of Bronchial Asthma (BA) in the CIS-Region (CIS-R)
It was established that in the CIS-R is dominated by BA in the structure of allergic
diseases (ADs). The highest incidence of BA among the population, especially Ad is
observed in Armenia, Belarus, Moldova, Ukraine, Kyrgyzstan, Russia and Tajikistan.
In Armenia, according to preliminary estimates, BA, depending on severity, sick 120
thousand Ad and 30-40 thousand Ch/Tg. The prevalence of BA symptoms among Ch of
Armenia - 2%, while Tg was 4,1%. Prevalence of wheezing was 9% in Ch and 8.4%
in Tg. Current wheezing (i.e. wheezing in past 12 months) was observed in 3.7% and
4% first and ninth grade schoolchildren, and self-reported doctor diagnosed BA was
observed in 0.5 and 0.8% respectively. The number of patients with BA in Belarus
in 2009 amounted to 60 thousand people. The prevalence of BA in Belarus over the
past 10 years has increased almost in 1.5 times from 4.47 to 6.32 per 1,000 population. In Ukraine, more than 4 million people (10-15% of the population) suffer from
BA, 20% of whom were patients with severe BA. The highest number of new cases
reported in Ch/Tg. In Georgia, the average incidence of BA among Ch was within
the limits of 3.6 5.6%. The study of the prevalence of BA among schoolchildren in
Tbilisi has shown that a diagnosis of BA was found in 2.4% of Tg and 1.7% of Ch.
The number of diagnosed cases of BA was 10 times higher than official statistics.
In Kazakhstan, according to official statistics from 2000 to 2008, the morbidity of
BA increased depending on the region from 1.22 to 1.97 times. Results of an epidemiological study in the Republic of Tajikistan have shown that BA was diagnosed in
22.2% - 23.1% of the population. The results are higher than official statistics in 4
times. Epidemiological studies conducted in Moldova, have shown that the symptoms
of BA 22.5% complained of Tg, these symptoms are noted, parents of Ch in 26.7%
of cases. In this case the diagnosis of BA in the institutions of practical public health
was recorded only in 2.3% of Tg/Ch (Tg-3.2% and Ch-1.5%). Despite such frequent
manifestations of bronchopulmonary pathology appealability to medical institutions
is low and amounted to - 2.6% in the ambulance, and 4.3% - to a family doctor. In
Moldova, according to official statistics from 2000 to 2009 the situation in the early
detection of patients with ADs has not changed. If the rates of BA morbidity were
found, on average, at 18.5 persons (10.3-Tg/Ch and 21 - Ad) per 10.000 people, the
incidence of BA per 10,000 population according to official data, the average was 1.4
in 2,000 person (2 Tg/Ch and 1.3 - Ad). In 2009 - 20.4 (14.7 Tg/Ch and 22-Ad)
and 1.6 (2 Tg/Ch and 1.5 - Ad) people, respectively. During the analytical period
morbidity of BA among Ad and Tg/Ch was in 13 times higher than the incidence of
BA, established in therapeutic and diagnostic facilities.
Analysis of materials on the prevalence of ADs shows the growth of pathology
41
The Prevalence of Bronchial Asthma in the CIS-Region (%)
both among Ad and among Ch/Tg. The increase of BA among Ch is an alarming

signal. The actual incidence among Ch and Tg was 21-40%,for the Ad - 23-48%.
In this case, the diagnosis of BA in the institutions of practical public health was
recorded only in 2.3% of Ch/Tg (Tg-3.2%, Ch-1.5%), and in Ad - less than 1%. It
has been established that BA is dominated in the structure of ADs of the CIS-R. BA,
on average, suffer from 7 to 48.3% Ad and from 4 to 31% Ch/Tg (Fig.1).
Influence of climatic and geographical conditions and urbanization on

the prevalence of BA
Studies conducted in various countries of the CIS-R (Armenia, Azerbaijan, Georgia,
Tajikistan and others) have shown that the prevalence of BA depends on urbanization
in the region and the climatic and geographical conditions. In industrialized areas,
the prevalence of ADs, including BA, was 2-3 times higher than the incidence in
rural areas. In urban areas the proportion of BA and chronic asthmatic bronchitis
prevailed. The prevalence of BA in environmentally disadvantaged area was almost
2 times higher than in more affluent areas environmentally. BA is more common
in Ch living in ecologically unfavorable conditions in the subtropics. BA in the
highlands was extremely rare. For example, in Azerbaijan revealed that in the same
climate semi-desert, BA develops 2 times more often in Ch living in urban areas
(4.6%) than in rural areas (2.5%). The incidence of BA of Ch in the subtropics of
42
Azerbaijan was 2.8% and 1.8% - in the mountainous region, which confirmed the
importance of climatic and geographical conditions and the factors of urbanization
on the development of BA.
In the low mountains of Armenia (800-1250 m above sea level), BA was diagnosed
in 23.1%, in terms of middle (1500-2000 m elevation above sea level) -15.2%. In the
highlands (3500-4500 m elevation above sea level) BA have been identified in none
of the subject. The results are 4 times higher than official statistics (in Armenia).
Studies in the Imereti region of Georgia have shown that BA symptoms were
found in 2.9% of Ch. Found no difference in the prevalence of BA among Ch and
Tg, living in a humid subtropical and dry subtropical climate of Georgia. BA was set
at 4.6% of first-graders who live in humid subtropical climate of Georgia about the
same number of patients in Telavi, where the dry subtropical climate (5%).
The study of the prevalence of BA in the Republic of Tajikistan from 2003 to
2008 within the framework of a standardized program ISAAC among Ad and Ch/
Tg population showed that the prevalence of BA symptoms among Tg was 4.1%.
Among Ch the BA symptoms were observed in 2%. The prevalence of BA in environmentally disadvantaged area (Dushanbe) was - 1.8% (17.89 per 1,000 Ch), which
is almost 2 times higher than in a more environmentally favorable area (village Ziddi)
- 0.9% (8.68 at 1,000). ADs of Ad meet as often as Ch. In a survey of 4,000 people
(statistics for the Republic of Tajikistan, the form 12) in lowlands (800 - 1250 m
above sea level), ADs, including BA, were found in 16.3% (650 people), in terms of
middle (1500 - 2500 m above sea level) at 9.9% (from 99 in 1,000). In the highlands
of Tajikistan (at an attitude of 3500 - 4500 m above sea level) ADs are extremely
rare. The relationship between the ADs and the different climatic conditions has
been established in the Republic of Tajikistan. The highest incidence was observed
in ecologically unfavorable regions of low mountains.
Age and sex

It is established that the incidence of BA in all CIS-R increases with age. For
example, in Armenia, the analysis showed that BA at the age of 11-15, 16-20, 2130, 31-40, 41-50, 51-60 - recorded respectively in 21.7% -25.7% -32 4% -35.4%
-33.1% - 48.3%.
There is some evidence that at an early age the frequency of complaints of the
respiratory system in preschoolers, particularly wheezing and wheezing in the chest
were more common in boys (33%), than girls (18.4%).
Disease severity and current features of BA

In the epidemiological studies in the CIS-R patients with mild BA have been dominated, whereas in hospitals there have been observed patients with moderate and
severe disease. In the structure of the severity of BA among Ch and Tg, and Ad are
dominated by mild forms of the disease (60-90% and 35-55% respectively) as mild
intermittent or mild persistent BA, which in most cases are not diagnosed and do not
receive adequate, timely assessment. In Azerbaijan, Russia and Ukraine over moderately asthma in Ch reported in 13-15% of cases. The share of severe and moderate
BA according to the age accounted for between 2 and 48%. The highest percentage
of moderate asthma in children was set in Tajikistan (32%). In 60% of patients with
43
The Severity of Bronchial Asthma in the CIS - Region
disease severity was associated with late diagnosis. The structure of BA recorded by
statistical morbidity, dominated the moderate or severe forms of BA (Fig.2).
Severe BA in Azerbaijan more often was found in environmentally adverse conditions
of an industrial city with a semi-desert climate (5%) and in the subtropics (4.5%). In a
mountainous region the disease was rare (1.5%).
BA was often combined with other ADs, especially with AR and atopic dermatitis
(AD) in all CIS-R. Nearly half of Ch with AR later has developed BA. Diagnosis
is very important to identify the ADs and families with atopy, especially if atopy is
inherited through the maternal line. For example, in Azerbaijan, BA in 10.7% of cases,
combined with the AP+AD. Moreover, in rural areas of co-incidence of allergy in
the form of the BA+AR is significantly higher because of the relatively long period
of pollination and grass weeds (Table 1). In the Azerbaijani population a genetic
predisposition has revealed to atopic BA.
Risk factors
Among the risk factors for ADs, and especially BA, should be noted: passive
smoking, poor social conditions, the presence of pets in the apartment, the high frequency of viral respiratory infections in medical history, family history. Tajikistan and
Turkmenistan are characterized by the development of ADs and BA associated with
low uptake, poor social conditions, low family income, inability to timely purchase of
medicines and medical assistance, as well as the large number of children per family.
It is established that BA patients during exacerbation of the disease in 85% of cases
received skilled care in a hospital, outpatient treatment received only 7.9%, indicating
that the deficiencies in the management of BA is in primary care.
44
The Frequency of Combinations of Bronchial Asthma and Other Allergic Diseases in Children in Different Regions
of Azerbaijan
Conclusions
BA is one of the most common ADs in the CIS-R.
Epidemiological studies have important scientific and practical value, allowing an objective assessment and providing accurate information on the prevalence,
structure, and the severity of BA.
In all CIS-R there are the hypodiagnosis of mild BA and inconsistency of the
results of official statistics with the actual incidence in the population. An analysis of
existing data revealed that the mild forms of BA were dominated. The true incidence
is much higher, as the uptake to the doctor takes place only in cases of the disease
formed, earlier symptoms often go undetected.
Often BA has been diagnosed at later stages with severe disease and complications.
The prevalence of BA symptoms exhibited a clear dependence on the climatic
and geographical conditions and urbanization of the region.
It is necessary to consider and monitor risk factors for BA at the population
level in the preparation of preventive programs.
There is both the inadequate training of primary care physicians, which makes
hard to detect early mild ADs, and the lack of clear criteria for diagnosis of ADs.
Unified account of the early features of ADs in a particular region will not
only develop a National Prevention Program of ADs in the CIS-R, identify the main
ways of their implementation, but also will allow to plan Allergic service in each
region, important element of which is education and training of primary care physicians to identify early symptoms of ADs.
45
Major reference
1. Dzhamalyan K.R. Medical social factors of respiratory allergic diseases development and
progression in Armenia // Synopsis of PhD dissertation. Armenia, Erevan. 2010. 26 p.
2. Kabulov G.G. Epidemiological, clinical functional and immunological characteristics of
allergic diseases in children from different climatic geographic areas of Azerbaijan. //
Synopsis of MD dissertation. Azerbaijan, Baku. 2009. 44 p.
3. Nurpesov T.T. Improvement of allergic medical care in Kazakhstan. // Synopsis of MD
dissertation. Almaty, Kazakhstan. 2010. 42 p.
4. Allahverdiyeva L.I. New aspects of pathogenesis and treatment of respiratory allergies in
children and adolescents of the Azerbaijan population. // Synopsis of MD dissertation.
Azerbaijan, Baku. 2005. 36 p.
5. Chuchalin A.G., Tsoi A.N., Arkhipov V.V., Gavrishin E.A. Bronchial asthma in Russia: a
national study of quality medical care to patients with bronchial asthma.// J. Pulmonology. - 2006 . 6. - P. 94-102.
6. Jishkariani I.R., Shanidze M.A., Macharadze D.Sh. Prevalence of asthma and atopic diseases
in Georgia. // J. Allergology and Immunology.- 2007.- vol.8.- 1, P.71.
7. Abramidze T., Gotua M., Rukhadze M., Gamkrelidze V. The prevalence of asthma and
allergies among adolescents in Georgia: a comparison of the two surveys. Georgian Med
News. March 2007. (144). - P. 38-41.
8. Mamedov D.Yu. The influence of regional conditions on the prevalence and incidence of
asthma in Azerbaijan.// International Journal of Medicine.- 2009.- 3.
9. Tusupkaliev B.T., Kalieva A.T., Tulegenova G.A., Gerasimenko N.I., Sundetova R.A. Effect of environmental factors on the course asthma in Kazakhstan. // J. Allergology and
Immunology.-2008. - Vol.9. - 1.- P.15-16.
10. Umarov D. Prevalence and clinical features of the course of allergic diseases in children
in the Republic of Tajikistan, treatment and prevention. // Synopsis of MD dissertation.
Moscow.-2009. - 42 p.
The role of fungal allergens in respiratory diseases in

Bulgaria
Nikolov G., Kandova Y., Hristova R., Nedyalkov M., Petrunov B.
National Center of Infection and Parasitic Diseases, Laboratory of Allergy, Sofia, Bulgaria,
e-mail: labalerg@ncipd.org
Abstract
Fungi have been known to be a major health risk. In Bulgaria fungal spores appear
in late winter. In May and June the spores become more prevalent. Peak counts occur
in June, July, August. Spores of Cladosporium spp. occur more abundantly and are
the dominant airborne spores in Bulgaria.
Our results show that at least 6% of adults and children tested in our department
over the last 5 years are mono-sensitized to fungal allergens.
In clinical practice allergenic extracts are used routinely to diagnose and treat
fungal allergies. Bulgarian fungal extracts are prepared from spores, culture medium
and fresh mycelia mats. We have studied 643 atopic patients with persistent allergic
rhinitis and/or bronchial asthma who underwent 3-year course of Specific Immunotherapy (SIT). 108 of the patients were sensitized to different fungal allergens. About
70 % of the patients with bronchial asthma and fungal sensitization have shown very
good and good clinical results.
We have examined 438 agricultural workers for farmers lung. Two of the examined persons show a coincidence for the all diagnostic indices. 36 (8.25%) could
be accepted as latently sensitized towards the yeast that cause farmers lung.
Fungi are common in the environment and exposure to airborne spores is almost
constant throughout the year. Fungi may colonize the human body and may damage
airways by production of toxins, proteases, enzymes and volatile organic compounds.
Thus, molds have a far greater impact on the patients immune system than pollen
or other allergenic sources.
Keywords: fungal allergens, sensitisation, immunotherapy, farmers lung.
Introduction
For decades fungi have been known to be a major health risk. In contrast to airborne
pollen, fungal spores are not primarily associated with IgE-mediated type I allergies
P421R9003
47
48
Fig. 1. Annual fungal spore counts in the air of Sofia, Bulgaria
but also with a broad panel of other diseases: allergic bronchopulmonary mycosis
(ABPM) and hypersensitivity pneumonitis, fungal sinusitis and toxic pneumonia.
Seasonal and weather patterns of fungal prevalence

Most fungi commonly considered allergenic in Bulgaria, such as Cladosporium
spp, Alternaria spp., et cet. display a seasonal spore release pattern, but this is less
well defined than it is for pollens.
Exposure to fungi (and presumably to fungal allergens) has been traditionally
assessed by microscopically identification and quantitation the number of fungal
spores in air samples or by using semi quantitative cultures obtained from air or
settled dust samples. However many fungal spores derived from different species
are similar morphologically and this limits the completeness of spore identification
in air sampling surveys.
In Bulgaria fungal spores appear in late winter, when the snow cover begins to
dissipate. As the weather warms, especially in the months of May and June, the spores
become more prevalent. Peak spore counts occur in summer (June, July, August), with
numbers falling thereafter. Once snow covers the ground (or the ground is frozen),
airborne spores decrease in number, until the cycle begins again in late winter (Fig. 1.).
Airborne spores are usually present in high numbers and frequently exceed pollen
concentrations by 100- to 1000-fold [1].
Spores of Cladosporium spp. occur more abundantly than any other spore type
and are the dominant airborne spores in Bulgaria (Fig. 2.).
Generally, indoor fungi are a mixture of those that have entered from outdoors and
those from indoor sources. Aspergillus spp. and Penicillium spp. are less common outdoors
and are usually considered the major indoor fungi in Bulgaria [2, 3].
49
Fig. 2.
Fungal Allergy
Airborne spores are present in nearly all environments. Their concentrations are
frequently high enough to present a substantial antigen load to exposed individuals and
are now generally recognized as important causes of respiratory allergies. Allergic reactions associated with fungi involve the lower respiratory tract more frequently than do
pollen allergies.
The immunological mechanisms underlying mold allergies are hypersensitivity reactions
of type I, II, III and IV. The spectrum of allergic symptoms caused by these hypersensitivity reactions is very broad, including rhinitis, asthma, atopic dermatitis (AD) and ABPM.
Fungal allergy is not as well defined as other seasonal allergies and probably causes
problems indoors for fewer people than do major allergens from cats or mites. A significant portion of the atopic population does have underlying sensitivities to fungal spore
allergens, although subjects sensitized to a single fungal species are quite rare. Thus,
fungal allergies are more difficult to diagnose and treat than other allergies since fungi
are far more numerous and antigenically variable than other allergens and are exceedingly
difficult to avoid. So, management of fungal allergy can be a formidable clinical challenge.
The incidence of mold allergy ranges from 6 [4] to 24% [5] in the general population,
up to 44% among atopic persons and 80% among asthmatics [6].
50
Clinical manifestations of fungal allergy

Allergic Rhinitis
Allergic rhinitis is induced by a large number of fungal species, with Alternaria
spp., Aspergillus spp, Cladosporium spp., Curvularia and Penicillium spp. being the
most prominent.
Allergic Asthma
Comparing the size of pollen grains and fungal spores, it is obvious that fungal
spores are smaller in general. Therefore, they may reach the alveolar surface of the
lung inducing chronic inflammation of the lung tissue [7]. In many studies, an apparent link between asthma and fungal sensitization was described. Taken together,
the molds Alternaria spp., Aspergillus spp, Cladosporium spp., Helminthosporium,
Epicoccum, Aureobasidium and Penicillium spp. have frequently been implicated in
allergic asthma.
Atopic Dermatitis
In recent years, Malassezia furfur has been implicated in the pathogenesis of AD
[8]. Saccharomyces cerevisiae is another yeast species showing a significant correlation
between a positive skin prick test (SPT) and AD [9].
Diagnosis of fungal allergy

Diagnosis of any allergic disease is based on the clinical symptoms of the patient,
determination of exposure to the allergen, results of skin and in vitro tests, and sometimes, if necessary, provocative inhalation challenge testing.
Skin testing is the simplest method to detect IgE directed against a specific allergen. Two methods commonly used to diagnose allergies to fungi are prick and
intradermal skin testing.
On the basis of aero biologic surveys conducted in different locations of the world,
skin test studies, and fungal allergen characterization, the consensus is that skin test
panels should include, at the minimum: Alternaria alternata, Aspergillus fumigatus,
Cladosporium herbarum, E. nigrum, Fusarium roseum and Penicillium chrysogenum.
The fungal panel, used in Bulgaria for allergy skin tests includes: Alternaria alternata, Aspergillus fumigatus, Cladosporium herba rum, Penicillium chrysogenum;
Mucor racemosus, Neurospora sitophila, Rhizopus nigricans, Fusarium lini [1].
We have tested 315 atopic patients (161 females, 154 males) for inhalant allergens.
Most subjects sensitive to fungi are also sensitive to other inhalant allergens 61%.
This increases the difficulty of diagnosis. Mono sensitized to fungal allergens were
6.1% of the subjects tested in our department in last 5 years.
The Fluorescence enzyme immunoassay - FEIA (ImmunoCAP) is an in vitro test
designed to measure the circulating allergen-specific IgE antibodies of a patient. It is
generally considered less sensitive than skin testing, although a FEIA conducted with
partially purified fungal allergens can be comparable to skin tests in both sensitivity
and specificity.
Provocative challenge with specific fungal allergens can provide a definitive diagnosis of fungus-induced allergic disease. False-positive results can occur, however,
so experienced investigators must perform and interpret these tests, which include
nasal, conjunctival, or bronchial provocation.
51
Despite the introduction of provocative challenge and the development of sophisticated

in vitro tests, making the diagnosis of mold allergy remains difficult.
Fungal allergen extracts

In clinical practice crude extracts are used routinely to diagnose and treat fungal allergies.
They generally contain proteins, carbohydrates, and proteolytic and glycosidic enzymes
in various amounts. Fungal allergen extracts are usually obtained from cultures. Fungal
growth in culture is affected by temperature, moisture, light, and culture media. Strain
variability within a given species presents an additional complicating factor. Fungi also
mutate readily in culture, contributing additional variables during in vitro cultivation.
Biochemical variability within a given species has been documented for several important
allergenic fungi.
To overcome the problem of variability we cultivate several isolates of the specific
fungus and then pool extracted material from each culture. Our fungal extracts have been
prepared from spores, culture medium, and fresh mycelia mats. This extracted material is
centrifuged, filtered and the supernatant or filtrate undergoes further processing.
The variability of commercial extracts is widely acknowledged, however, and considerable effort has been expended on improving and standardizing extracts.
Standardization of fungal allergen extracts

Skin testing is a sensitive measure of the potency of an extract, but the responses of
different populations to a selected allergen may vary and the reaction observed in a single
individual may not always appear the same. These problems are a significant disadvantage of skin testing. In addition, skin testing reveals nothing about individual allergens in
complex mixtures such as crude fungal extracts.
Although in vitro standardization is more practical, the extracts standardized in this
way must still be demonstrated by their usefulness for skin tests.
The use of monoclonal antibodies (MAbs) can overcome these problems; they can be
exquisitely specific and can be produced in large quantities.
Aspergillus spp. antigens have been studied thoroughly, because Aspergillus spores
were among the first to be recognized as important aeroallergens, and these fungi cause
several other diseases.
The 18-kDa antigen (Asp f 1 [Asp f I]) was isolated from the mycelium of 10 different
strains of Aspergillus fumigatus. Asp f 1 shows extensive sequence homology (95%) to
mitogillin (a cytotoxin) produced by Aspergillus restrictus. On the basis of cDNA and
deduced amino acid sequence homology to hsp 90 from other organisms, this allergen is
apparently a heat shock protein of the hsp 90 family. Asp f1 is expressed only in actively
growing cells [10]. The protein is secreted into the surrounding media only during active
growth of the organism. The standardization of extracts for Asp f1 must therefore take
growth conditions into consideration very carefully.
Using MAb ELISA for detection of Asp f1 (INDOOR Biotechnologies) we determine
the quantities of Asp f1 allergen in different types of Aspergillus fumigatus extract. We
have found that the greatest amount of Asp f1 (1.49 ng/ml) is contained in culture medium of the extract, while the mycelium have considerably less of this major allergen.
52
Fig. 3.
Immunotherapy with fungal allergens

The efficacy of immunotherapy with the currently available partially standardized
extracts has been demonstrated. Candidates for fungal immunotherapy include patients
with (i) documented symptoms (rhinitis or asthma) that occur during periods of elevated airborne spore counts; (ii) IgE to well-characterized fungal allergens, as shown
by skin test, or other in vitro test etc.; and (iii) symptoms that cannot be controlled
by conventional pharmacotherapy or avoidance. We have studied 643 atopic patients
with persistent allergic rhinitis and/or bronchial asthma which carried 3 years course
of Specific Immunotherapy / SIT /. 108 of the patients were sensitized to different
fungal allergens. The clinical outcome after the treatment is shown on following
diagram (Fig. 3).
It is seen that about 70 % of the patients with bronchial asthma and fungal sensitization have received a very good and good clinical results [11].
Other manifestation of fungal hypersensitivity

The farmers lung is a professional allergic disease widely spread among agricultural
workers. In acute stage, clinically, it is displayed as unspecific pneumonia or bronchitis, while in chronical stage - with lasting difficulties in breathing, asthma attacks and
53
general weakness due to the connective tissue in the lung. It is caused by thermophilic
actinomyces mainly Micropolispora faeni, which find suitable conditions for developing
in stored cereals, fodder and other vegetable diet.
We have examined 438 agricultural workers (346 men 79% and 92 women 21%).
The sensitization concerning the cause for farmers lung (Micropolispora faeni
and Thermoactinomyces vulgaris) has been evaluated after 4 basic indices: anamnesis;
skin allergic tests with allergenic extract from corresponding yeast; mycological study
of sputum in order to discover the respective yeast and assessment of precipitating and
haemagglutinating antibodies in the serum of the patients.
98 (22.4 %) out of the agricultural workers studied had history for farmers lung.
The percentage of those, who had positive skin allergic tests to the allergens from Micropolispora faeni and Thermoactinomyces vulgaris, was 13.2% and 7.3% respectively.
In the sera of 25 (5.7 %) of the workers examined was found low titer of haemagglutinating antibodies against Micropolispora faeni. The presence of this yeast was observed
in the sputum of 2 people - 0.45%. However in the sputum of 77 (17.6 %) workers we
identified presence of Thermoactinomyces vulgaris.
Only two of the patients examined showed a coincidence for the four indices which indicate
the diagnosis farmers lung. Three of the four indices were apparent in 36 (8.25%) workers.
They could be accepted as latently sensitized towards the yeast that cause farmers lung.
In the complex criteria, when giving the diagnosis farmers lung, besides the mentioned four indices, a thorough clinical test was made, roentgen and functional examination
of the lung. In 6 of the cases with latent sensitization a correlation between the data of
allergologic and mycological investigations on the one side and the clinical, roentgen and
functional examinations on the other was established.
The investigation performed on a small scale, discovered agricultural workers who
are sensitized towards the cause of farmers lung and registered clinically manifested
forms of the disease.
Conclusion
In contrast to other allergenic sources, fungi are very common in the environment,
and exposure to airborne spores is almost constant throughout the year. A major difference from other sources, e.g. house dust mite or pollen, is that fungi may colonize
the human body, and they may damage airways by the production of toxins, proteases,
enzymes and volatile organic compounds. Thus, molds have a far greater impact on
the patients immune system than pollen or other allergenic sources.
References
[1] Petrunov B., D. Konstantinova, E. Stanoeva. (1974). In: Allergens. (ed. V. Kalajiev),
Medicina i fizcultura, Sofia, pp. 78-84.
[2] Boteva A., Nikolov G., Petrunov B. (1999). Study on the incidence of allergy to fungi
and its relationship to sensitization to some indoor allergens. Infectology, 4: pp. 32-34.
[3] Hristova M., Boteva A., Nikolov G., Petrunov B. (2005). First studies on the indoor bio
aerosol in the dwellings of allergic patients in Sofia. Allergy, Hypersensitivity and Asthma,
1: pp. 16 - 20.
[4] Tariq SM, Matthews SM, Stevens M, Hakim EA. (1996). Sensitization to Alternaria and
Cladosporium by the age of 4 years. Clin Exp Allergy; 26: pp. 794798.
54
[5] Salvaggio J, Aukrust L. (1981). Postgraduate course presentations. Mold-induced asthma.

J Allergy Clin Immunol. 68: pp. 327346.
[6] Lopez M, Salvaggio JE. (1985). Mold-sensitive asthma. Clin Rev Allergy; 3: pp. 183196
[7] Denning DW, ODriscoll BR, Hogaboam , Bowyer P, Niven RM. (2006). The link between
fungi and severe asthma: a summary of the evidence. Eur Respir J. 27: pp. 615626.
[8] R, Trautmann A, Wuthrich B, Blaser K, Scheynius A, Crameri R. (2005). IgE-mediated
andT cell-mediated autoimmunity against manganese superoxide dismutase in atopic
dermatitis. J Allergy Clin Immunol. 115: pp.10681075.
[9] Kortekangas-Savolainen O, Lammintausta K, Kalimo K. (1993). Skin prick test reactions
to brewers yeast (Saccharomyces cerevisiae) in adult atopic dermatitis patients. Allergy;
48: pp. 147150.
[10] Arruda L. K., B. J. Mann, and M. D. Chapman. (1992). Selective expression of a major
allergen and cytotoxin, Asp f I, in Aspergillus fumigatus. J. Immunol. 149: pp. 33543359.
[11] Petrunov B. et al. (2005). Allergen specific immunotherapy 40 years of experience. Int
J Immunorehabilitation. 7: pp. 79-82.
Pollen sensitization pattern in patients with combined

allergic rhinitis and asthma syndrome from Southern
Romania
Popescu F.D.1, Tudose A.M.1, Gheonea C.2
1
2
Allergology Department, University Medicine & Pharmacy Carol Davila, Bucharest;

Paediatrics Department, University Medicine & Pharmacy Craiova, Craiova; Romania
Summary
Southern Romania is a region having temperate-continental climate of a transitional
type, specific to Central Europe, with local differences which affect exposure to aeroallergens, especially pollens. Evaluating 596 enrolled patients with combined allergic
rhinitis and asthma syndrome (CARAS), indoor allergen sensitization was significant
for house dust mites (49.83%) and cat dander (17.79%). The rate of sensitization to
Poaceae pollens was particularly high (47.82%), while skin prick tests with Asteraceae
weed pollen extracts were positive in 14.77% of cases for mugwort and 13.93% for
ragweed. Spring tree pollens involvement was relatively rare (Betulaceae, 11.58%; Fraxinus excelsior, 2.01%). Regarding comorbidities, allergic conjunctivitis was frequently
associated to respiratory allergy, and pollen-food syndrome was an important finding.
Introduction
European prevalence of pollen respiratory allergy increased in the last decades.
Exposure to aeroallergens represents a key environmental factor in the etiopathogenesis
of allergic rhinitis and asthma [1].
Southern Romania (SR) is a region located in the southeastern part of Central
Europe, north of the Balkan Peninsula, on the Lower Danube and bordering the
Black Sea. SR is an interesting region to study pollen exposure and sensitization
due to its climate characteristics, with pollination seasons lasting from early spring
to late autumn, its agricultural sector, one of the largest in Eastern European Union,
with farmland biodiversity, but with decreasing profitability, and also due to land use
change in the last two decades, urban and rural ruderal sites, cropland abandonment
and reforestation, logging and forest fragmentation [2] and recent spread of a new
allergenic weed, ragweed [3].
According to updated Europe map of the Kppen-Geiger climate, SR has a tem2012 by MEDIMOND s.r.l.
P421L5049
55
56
perate continental climate (Dfb), specific for Central Europe, with local differences
caused by altitude and by submediterranean / temperate oceanic (Cfb) (South-Western
Oltenia), semi-arid warm continental (Dfa) (Eastern Muntenia), warm oceanic / humid
subtropical (Cfa) (Dobrogea) influences [4], and local weather events, with winds
from the north-east, cold in the winter and hot-dry in the summer, possible severe
thunderstorms, even small tornadoes [5]. There are few epidemiological studies in
Romania regarding the sensitization to different aeroallergens [3].
Materials and methods

This clinical study, covering three-year consecutive pollen seasons, enrolled patients
from SR (marked by the Southern Carpathian Mountains, the Danube river and the
Black Sea, including three historical provinces: Oltenia, Muntenia and Dobrogea),
with allergist diagnosis of CARAS. Persistence andseverity of respiratory allergy was
evaluated according to current international guidelines, and written informed consent
for allergy skin prick tests was obtained for all patients. We used the European panel of aeroallergens for skin prick testing, suggested by Global Allergy and Asthma
European Network, extended from Central Europe and Balkan centers, including
Pyroglyphidae house dust mites (Dermatophagoides pteronyssinus, Dermatophagoides
farinae), pet animal epithelia (cat, dog, optional: hamster, guinea pig, rabbit), cockroach (Blattella germanica), and Ascomycota fungi: Alternaria alternata, Cladosporium
mix, Aspergillus mix, Penicillium mix, Mucor racemosus. For anemophilous pollen
sensitization evaluation, allergen extracts used were: Betulaceae tree pollen mix (Betula
pubescens / B. alba, Alnus glutinosa, Corylus avellana, Carpinus betulus), Fagaceae
tree pollen mix (Fagus sylvatica, Quercus robur, Castanea vulgaris), Salicaceae tree
pollen mix (Populus alba, Salix caprea), Malvaceae tree pollen (Tilia platyphyllos),
Oleaceae pollens (Olea europea, Ligustrum vulgare and/or Fraxinus excelsior),
Pooideae grasses pollen mix (Phleum pratense, Dactylis glomerata, Poa pratensis,
Lolium perenne, Anthoxanthum odoratum), Asteraceae pollens from weeds (Ambrosia
artemisiifolia var. elatior, Artemisia vulgaris) and Helianthus annuus, Plantaginaceae
and Polygonaceae pollens (Plantago lanceolata, Rumex acetosa), Urticaceae weed
pollens (Urtica dioica, Parietaria sp), Amaranthaceae or Chenopodiaceae weed pollen
mix (Amaranthus retroflexus, Chenopodium album). Positive control was histamine
(10 mg/mL), while negative control, phenolated glycero-saline.
Results
We recruited 596 patients with CARAS, 46.81% males and 53.19% females,
mean age 33.57 14.51 yrs [12-78 yrs]. We found important comorbidities: 42.79%
had concomitant allergic conjunctivitis, and 4.9% presented associated pollen-food
syndrome (3.2% of patients had a personal history of oral allergy syndrome, while
1.7% reported allergic anaphylaxis). Foods involved in pollen-food syndrome or associations were represented (percentage from the total number of patients) by honey
(0.84%), chamomile (0.67%), carrot (0.5%), celery (0.84%), banana (0.34%), and
sunflower seeds (0.34%).
The rate of sensitization to Poaceae pollens in patients with CARAS was particularly
high compared with tree pollens (47.82% versus 12.2%). Dicotyledonae tree pollens
57
involved were those from families Betulaceae (birch family, 11.58%), Fagaceae (oak
family, 0.83%), Salicaceae (willow family, 0.84%), while sensitizations to Fraxinus
excelsior (European ash, 2.01%) and Tilia platyphyllos (large-leaved linden, 0.84%)
pollens were also detected.
Sensitization rates to weed pollens were important for those belonging to Asteraceae (Compositae) family, 14.77% for mugwort (Artemisia vulgaris) and 13.93% for
commonragweed (Ambrosia artemisiifolia var. elatior). More than a third of patients
with positive prick tests to Artemisia pollen extract has positive prick tests also to
Ambrosia pollen, and vice versa. Sunflower (Helianthus annuus) pollen sensitization
appeared in only 3.69% of cases, almost always in patients sensitized to at least
one wind-pollinated Asteroideae weed type of pollen (Artemisia or Ambrosia spp.).
Several cases of sensitization to pollens of weeds from the other plant families were
noted (1.17% to Plantago lanceolata, 0,67% to Urticaceae weeds, 0.34% to Rumex
acetosa; 0.34% to Amaranthaceae or Chenopodiaceae pollens).
Other allergen sensitization was significant for Pyroglyphidae house dust mites
(49.83%) and cat dander (17.79%), less frequent for Dothideomycetes fungi (Alternaria and Cladoporium, 10.4%), german cockroach (8.56%), dog epithelia (9.06%).
Several sensitizations to other pets were found (hamster, 0.84%; guinea pig, 0.67%;
rabbit, 0.5%).
Discussions
Variation in the rates of sensitization in distinct European regions is probably an
important factor for different rates of allergic disease in some European countries.
Weather, climatic and agricultural changes are also influencing sensitization to pollen
aeroallergens. Sensitization rates to tree pollens in SR is lower for Betulaceae compared with Austria or Germany, but similar to Greece, and much lower for Fraxinus
excelsior compared with Austria, and for Salicaceae compared with Belgium. Compared
to other European countries, the sensitization rate for grass pollens in SR is similar to
Greece and Hungary, but higher than in Austria. Sensitization rates for mugwort and
ragweed pollens in SR are lower compared with Hungary, but slightly higher than in
Austria, and similar to Greece [6; 7]. These data suggest the need to implement the
European aeroallergen panel for skin prick testing with regional adjustments.
Conclusions
In SR, a vast region which offers a mosaic of plant habitats, with traditional
farmlands and modern settlements, urbanvegetation with grasses, trees and weeds,
plains dominated by cropland and occasional forest patches, hill areas with forests on
slopes, grassland and cropland on valleys and plateaus, and mountain zones mostly
forested with grassland in the valleys, patients with CARAS are sensitized especially
to Poaceae and Asteraceae pollens, and to a lesser degree to tree pollens.
References
1. DAMATO G, CECCHI L, BONINI S, NUNES C, ANNESI-MAESANO I, BEHRENDT
H, et al. Allergenic pollen and pollen allergy in Europe, Allergy, 62, 976-990, 2007.
58
2. KUEMMERLE T, MULLER D, GRIFFITHS P, RUSU M. Land use change in Southern

Romania after the collapse of socialism, Reg Environ Change, 9, 1-12, 2009.
3. POPESCU FD, GHEONEA C. Aeroallergen sensitisation in allergic rhinitis: a study on
patients from southern Romania, Allergy, S88(63), 429, 2008.
4. PEEL MC, FINLAYSON BL, MCMAHON TA. Updated world map of the Kppen-Geiger
climate classification, Hydrol. Earth Syst. Sci, 11, 1633-1644, 2007.
5. OPREA IC, BEL A. Meteorological environment of a tornado outbreak in Southern Romania, Nat. Hazards Earth Syst Sci, 9, 609-622, 2009.
6. HEINZERLING L, FREW AJ, BINDSLEV-JENSEN C, BONINI S, BOUSQUET J,
BRESCIANI M, et al. Standard skin prick testing and sensitization to inhalant allergens
across Europe - a survey from the GA2LEN network, Allergy, 60(10), 1287-1300, 2005.
7. HEINZERLING LM, BURBACH GJ, EDENHARTER G, BACHERT C, BINDSLEVJENSEN C, BONINI S, et al. GA2LEN skin test study I: GA2LEN harmonization of skin
prick testing: novel sensitization patterns for inhalant allergens in Europe, Allergy, 64(10),
1498-506, 2009.
Effects of Traffic Air Pollution on Hospitalizations

for Exacerbations of Chronic Obstructive Pulmonary
Disease in Zagreb, Croatia
Krmpotic D, Luzar-Stiffler V, Hercog P
University Hospital Centre Zagreb, Clinic for Lung Diseases Jordanovac, University of
Zagreb School of Medicine, Croatia
University of Zagreb, University Computing Centre - SRCE and CAIR Research Center, Zagreb,
Croatia
EKONERG Energy and Environmental Protection Institute, Zagreb, University of Zagreb,
School of Pharmacy and biochemistry, University of Applied Sciences VVG, Velika Gorica,
Croatia
E-mail: krmpotic@vip.hr
Abstract
Background: There are reported associations of sulphur dioxide (SO2) with
hospitalization for COPD, but it is uncertain whether SO2 is responsible for the
observed effects.
Aims and objectives: to investigate the possibility of an association between of
traffic related pollutants NO2, SO2 and PM10 and daily hospitalizations for COPD
in Zagreb.
Methods: Daily COPD hospitalizations were regressed on pollutants and potential
confounding variables using an autoregressive Poisson model.
Results: The risk of hospitalization of COPD was associated with NO2 lag0
(RR=1.09; 95%CI: 1.01-1.17). No significant effects were found of PM10 and SO2.
There was no interaction between SO2 and PM10 particles.
Conclusions: No effects of SO2 neither its interaction with PM10 particles were
detected possibly reflecting decline of concentrations of SO2 as a result of control
on emissions and change in fuel use.
Keywords: chronic obstructive pulmonary disease, hospitalization, traffic air pollution, time-series
Introduction
Epidemiological studies have demonstrated the short-term effects of urban ambient
levels of gaseous pollutants and particles on emergency visits or hospital admissions
P421C0003
59
60
for chronic obstructive pulmonary disease (COPD), although mechanisms of their

action are not completely understood [1]. Some studies have reported the associations
of sulphur dioxide (SO2) with hospital admissions for COPD, but it is uncertain
whether SO2 being highly soluble gas is responsible for the observed effects [2,3]. It
is possible that SO2 exerts its action after biding on particles which could transport
it into the lower respiratory tract; however, it is unclear whether their interaction is
important for exacerbation of COPD at population level.
The aim of this study was to investigate associations between of NO2, SO2 and
PM10 particles and daily hospitalizations for COPD, adjusting for weather and seasonality in Zagreb. The possible interaction between SO2 and PM10 particles was
also explored.
Methodology
Health and Environmental Data
Zagreb with its temperate continental climate, is located in the southern part of
Central Europe, and has a population of over 779,000
Health and environmental data were analyzed according to the APHEA protocol [4]. Data for daily emergency hospital admissions of patients with COPD were
obtained from Clinic for Lung Diseases Jordanovac. Discharge diagnosis was used
according to the ICD-10. Air pollution data obtained from three monitoring stations of
the Ministry of Environmental Protection and one monitoring station of the Institute
of Public Health.
Statistical Analysis
Daily COPD hospitalizations were regressed on pollutants and potential confounding
variables using an autoregressive Poisson model. After the base model was developed, the air pollution exposure variables were evaluated by adding them individually
into each of the single pollutant models. Finally, a multi pollutant model was
constructed with pollutant variables being selected first individually and then jointly,
using the goodness of fit criteria (scaled deviance, Pearson 2). Interaction effects
of any two pollutants on daily COPD hospitalizations were evaluated by introducing
interaction terms for pollutants significant at p<0.05 into the multi pollutant model.
The short-term effect of the selected traffic air pollutant is expressed as relative risk
i.e., percent increase in daily COPD hospitalizations. The statistical analysis was carried out using SAS Version 9.1 statistical software (SAS Institute, Cary, NC, USA)
licensed to the University of Zagreb.
Results
The daily mean number of hospitalizations for COPD was 1.99 (standard deviation
=1.65). Table 1 shows that mean and median concentrations of selected pollutants
did not exceed the current daily European limits [5]. The traffic air pollutants were
positively correlated, especially NO2 with SO2 (r=0.51) and PM10 (r=0.74).
Table 2 summarizes the results of single pollutant and multi-pollutant models for
COPD hospitalizations with selected lags. The significant lag for NO2 and SO2 was
Table 1. Summary of traffic pollutants concentrations and weather parameters, Zagreb 2004-2006
Table 2. Parameter estimates for pollutants from single and multi-pollutant Poisson models
Table 3. Relative risks for COPD hospitalization per 10 g/m increase in pollutant concentrations
61
62
the same day, and for PM10 two days prior the hospital admissions. The Poisson regression coefficient was statistically significant (p<0.05) for NO2 at the same day lag.
As shown in Table 3 the relative risk for COPD hospitalization was statistically
significant only for NO2. In other words, daily hospital admissions for COPD increased on average by 0.9% when NO2 concentration increased for 10g/m. As no
significant interaction between PM10 particles and SO2 were detected, these results
were not shown.
Discussion
This study showed increased risk of hospitalization for COPD to be associated
with increase in ambient levels of NO2. No significant effects of PM10 particles and
SO2 were detected.
As most other studies, the current results suggest that NO2 may be considered
as an indicator for traffic air pollution associated with emergencies for chronic
respiratory diseases such as COPD and asthma [6,7]. Several studies showed significant effects of PM10 particles on COPD exacerbations, while others found no
associations between PM10 and COPD outcomes, as was the case with the present
study [8,9]. For particles, considering their heterogeneous composition, the effects
can be expected inconsistent among cities. The present study like some other studies failed to detect effects of SO2 on COPD [9,10]. By contrast, earlier studies
reported associations between SO2 and COPD admissions [2,11]. As nowadays the
air pollution in cities is characterized by mixture of pollutants derived from traffic
exhaust, it may reflect lower levels of SO2 than in past achieved by reducing the
combustion of fossil fuels.
In conclusion, the present study indicates that traffic air pollution is associated
with increased risk of emergency hospital admissions for COPD in Zagreb. However,
no effects of SO2 neither its interaction with PM10 particles were detected possibly
reflecting decline of concentrations of SO2 as a result of control on emissions and
change in fuel use.
REFERENCES
[1] Viegi, G.,Baldacci, S. (2002). Epidemiological Studies of Chronic Respiratory Conditions
in Relation to Urban Air Pollution in Adults. Eur Respir Mon 21, pp.1-16.
[2] Sunyer, J., Anto, J.M.,Murillo, C.,Saez, M.(1991). Effects of Urban Air Pollution on Emergency Room Admissions for Chronic Obstructive Pulmonary Disease. Am J Epidemiol
134(3), pp.277-28.
[3] Harre, E.S., Price, P.D. Ayrey, R.B., Toop, L.J., Martin, I.R., Town, G.I. (1997). Respiratory Effects of Air Pollution in Chronic Obstructive Pulmonary Disease: a Threee Month
Prospective Study. Thorax 52, pp. 1040-1044.
[4] Katsouyanni, K, Schwartz, J., Spix, C., Zmirou, D., Zanobetti, A., Wojtyniak, B., Vonk,
J.M., Tobias, A., Ponka, A., et al. (1996). Short-term Effects of Air Pollution on Health:
a European Approach using Epidemiological Time-series Data: the APHEA Protocol. J
Epidemiol Commun Health 50, pp.S12-S18.
[5] The European Parliament and the Council of the European Union, Directive 2008/50/EC
of the European Parliament and the Council of 21 May 2008 on Ambient Air Quality and
Cleaner Air for Europe. EUR-Lex 2008 51, pp. 1-44.
63
[6] Anderson, H.R., Spix, C.,Medina, S., Schouten, J.P., Castellsague, J., Rossi, G., et al.
(1997). Air Pollution and Daily Admissions for Chronic Obstructive Pulmonary Disease
in 6 European Cities: Results from APHEA Project. Eur Respir J 10, pp. 1064-1071.
[7] Krmpotic, D., Luzar-Stiffler, V., Rakusic, N., Stipic Markovic, A., Hrga, I., Pavlovic, M.
(2011). Effects of Traffic Air Pollution and Hornbeam Pollen on Adult Asthma Hospitalizations in Zagreb. Int Arch Allergy Immunol 156, pp. 62-68.
[8] Medina-Ramon, M., Zanobetti, A., Schwartz, J. (2006). The Effect of Ozone and PM10
on Hospital Admissions for Pneumonia and Chronic Obtructive Pulmonary Disease: A
National Multicity Study. Am J Epidemiol 163, pp. 579-588.
[9] Tenias, M.J., Ballester, F., Perez-hoyos, S., Rivera, M.L. (2002). Air Pollution and Hospital
Emergency Room Admissions for Chronic Obstructive Pulmonary Disease in Valencia,
Spain. Arch Environ Health 57(1), pp. 41-47.
[10] Fusco, D., Forastiere, F., Michelozzi, P., Spadea, T., Ostro, B., Arca, M., Perucci, C.A.
(2001). Air Pollution and Hospital Admissions for Respiratory Conditions in Rome, Italy.
Eur Respir J 17, pp. 1143-1150.
[11] Dab, W., Medina, S. Quenel, P., Le Moullec, Y., Le Tertre, A., Thelot, B., et al. (1996).
Short Term Respiratory Health Effects of Ambient Air Pollution: Results of the APHEA
Project in Paris. J Epidemiol Commun Health 50, pp.S42-S46.
Influence of allergy-inducing and other triggers to the

development and severity of allergic diseases in the
CIS-Region
Slavyanskaya T. A., Sepiashvili R.I.
Russian University, Department of Allergy and Immunology, Moscow, Russia; Institute of
Immunophysiology, Moscow, Russia
Summary
This paper presents the results of influence of different risk factors (RF) to the
development and severity of allergic diseases (ADs) in the CIS-region (CIS-R). It
has been established that in industrialized areas, ADs is 2-3 times higher than the
incidence in rural areas. The highest incidence is noted in ecologically unfavorable regions of low mountains where suffering from ADs is more often met. In the
medium mountains ADs appear with less intensity, in conditions of high mountains
ADs are extremely rare. The maximum prevalence of ADs has been observed at the
experience of working in hazardous conditions from 5 years and above. A high degree
of contamination airpollutions in the industrial cities correlated with the prevalence
of respiratory allergies and other ADs were observed. Were identified the most frequent and significant allergens that cause ADs in adult and children/teens, as well
as the main triggers which involved in the development or exacerbation of ADs in
the CIS-R. Epidemiologic studies are of great theoretical and practical significance
as they provide impartial evaluation and reliable data on ADs prevalence and the
most important allergens. Climatic and geographical conditions of the environment
and ecological situation in the region are significant RF, requiring consideration in
determining the probability of a genetic predisposition to ADs.
Introduction
On-going growth of allergy all over the world is a consequence of human activity.
Poor ecology, chemization, food genetic determinacy, increasing medication use, informational and emotional stresses are amongst the factors accounting for allergic diseases
(ADs) development. This paper presents the results of influence of risk factors (RF)
on development and severity of allergic diseases (ADs) in the CIS-region (CIS-R).
N915R9005
65
66
Figure 1.

ISAAC and ARIA studies results, data on atopic dermatitis, Republic Ministries
of Health and Statistical Reports from the CIS-R as well as literature data have been
analyzed.
Results
Mean ADs prevalence in CIS countries varies from 15% to 40% while their real
prevalence is significantly different from official data (Fig.1). Amongst ADs in CIS
countries, bronchial asthma (BA), allergic rhinitis (AR), atopic dermatitis (AD), pollen
disease (P) and allergic conjunctivitis (AC) have predominated.
AR was diagnosed in 1721% adults (Ad) from 5.8% to 33.3% and 510% children
(Ch) and teens (Tg) from 2% to 34.7%. AR prevalence is particularly high in Belarus,
Kazakhstan, Russia, Ukraine and Tajikistan. In Armenia, Russia and Ukraine, perennial
AR has prevailed, while in Tajikistan, seasonal AR has predominated.
BA was diagnosed in 748.3% Ad and 431% Ch/Tg. BA prevalence is particularly high in Armenia, Belarus, Moldova, Ukraine, Russia and Tajikistan. Real BA
incidence in Ch/Tg and Ad reached 2140% and 2348%, respectively. Mean AD in
67
Figure 2.
Ad and Ch/Tg was 628.7% and 2.220.3%, respectively. High AD incidence was
registered in Ukraine, Tajikistan, Kazakhstan, Kyrgyzstan and Belarus. In Armenia,
Azerbaijan and Tajikistan AD prevalence in Ch was 2.74.7%.
AC prevalence was the highest in Armenia, Tajikistan, Kazakhstan, Azerbaijan and
Georgia (see Fig.4). Thus, in Armenia AC incidence was high in Ch/Tg (39.162.2%)
as compared with Ad (13.632.9%). In Kazakhstan and Tajikistan Ad frequently revealed as well (17.523.1%). In other CIS countries, this pathology was not regarded
as socially significant.
In Tajikistan, Belarus, Kazakhstan and Armenia there have been revealed a lot of
patients with P, most of them are Ad (15.729.3%) as compared with Ch/Tg - 4.35.2%.
Only in Russia the prevalence of P in urban people was 3.5-times higher as
against country people (38-times depending on area) and consisted 14.526% the
whole of ADs. For the last 5years, the number of Tg with P increased in 4 times. In
Kazakhstan, P has represented 2636% the whole of ADs. In Belarus, prevalence of
allergic reaction to birch, grass and weed pollen was 40.88.4%, 64.65.7% and
24.85.2%, respectively (excepting multiple sensitization). In Armenia, P prevalence
did not almost depend on occupation (excepting social services) and varied from
6.1% to 13.3%. P was revealed more frequently in people who had deal with mowed
grass (17.6%) and chemicals (26.9%). In Georgia, total P prevalence was 3.8%. Its
incidence depended on disease duration (Fig.2).
Studies have shown that ADs prevalence depended on region urbanization and
ecology-geographic conditions (comfort, climatic conditions, the level of air and water pollution) incidence of ADs was dependent on the regions urban ecological and
geographical conditions (comfort, climatic conditions, the level of air and water pol-
68
lution). Great variation in AR incidence was due to regional climatic and geographic
conditions, socio-economic level of development, flora characteristics.
It has been established that in industrialized areas, ADs is 2-3 times higher than
the incidence in rural areas and 3-5 times more than in clean areas. In Russia the
incidence of P among the urban population, on average 3.5 times higher (3 to 8 times
depending on the area) than of agriculture and is 14.5-26% of ADs. In clean areas
with the incidence of allergy Georgia was 1.3%. In polluted areas the prevalence of
ADs was high: 7.3% - 38.4%. Screening examination in Moldova, has shown that
allergic diseases are different in different ecological zones of the Republic from 90.0
1.9 to 202.4 9.7 o/oo. In areas with heavy air pollution was recorded early onset and
more severe development of ADs in Tg and young Ad. Air pollution is a factor in
the growth on the prevalence of ADs: 63% of people with BA lived in areas where
standards are exceeded limits of air pollution.
The main source of Indoor/outdoor pollutants were: motor vehicles and diesel
exhaust (88.6% of the total pollution), thermal and electro central plants (11.4%),
sulfur dioxide, nitrogen dioxide, carbon monoxide, hydrocarbons; new artificial
materials, heavy metals, natural rubber, meteorological conditions and high levels
of natural background radiation (Kazakhstan, Kyrgyzstan; radionuclides in Ukraine
after Chernobyl disaster), chemical substances used at home and at work and other.
The most significant predisposing factor for ADs, especially respiratory allergies
in Ch/Tg in the CIS-R included: atopic constitution, polysensibilization, an early
manifestation of the disease, the presence of co-morbidity. For example, in Uzbekistan
polypathia prevalence increases due to the many children in families (in 19.1 times),
divorce and the increasing of widowed women (in 4 times), hard physical work (in
4.5 times), poor housing and living conditions (in 2 times), mainly consumption of
fatty foods (in 1.1 times), microcirculatory disturbances and combinations of RF.
In Kyrgyzstan almost every second Ch was detected polyvalent pollen sensitization
(48.1%). Environmental factors act as etiological factor and enabler of exacerbation
of diseases.
At the analysis of the social aspects influencing indicators of prevalence of respiratory allergic diseases, dependence both on conditions of life and on professional
work is established. The structure and expressiveness of a sensitization to household
in environment household, pollen, fungi and food allergens differs at children with
the allergic diseases, living in different climato-geographical regions.
The highest incidence is noted in ecologically unfavorable regions of low mountains
where suffering from ADs is more often met. In the medium mountains ADs appear
with less intensity, in conditions of high mountains ADs are extremely rare. The
maximum prevalence of ADs has been observed at the experience of working in
hazardous conditions from 5 years and above. A high degree of contamination air
pollutions in the industrial cities correlated with the prevalence of respiratory allergies
and other ADs were observed.
Prevalent causative factors detected in ADs were domestic (house dust mites),
epidermal (cat and dog dandruff), tree and grass pollen, food and fungous allergens.
The main triggers which involved in the development or exacerbation of ADs in
Azerbaijan, Armenia, Russia and Uzbekistan are: house dust mites, pollen of trees
and plants, insect and pet allergens. In Belarus, Kazakhstan, Turkmenistan, Ukraine,
Moldova, the cause-important allergens are: pollen of trees, grasses and weeds. The
69
Table 1.
main triggers involved in the development and exacerbation of allergic diseases in

Kyrgyzstan are: pollen (mugwort) food, household, epidermal (wool of sheep). In
Georgia, Armenia and Uzbekistan revealed an allergy to drug (Table1).
Allergic analysis in the CIS-R by skin prick-tests, has allowed to allocate the basic
triggers playing a role in the development and exacerbation of ADs. Insect allergy
occurred in Armenia from 2 to 40.8%, in Russia up to 35%. Allergic analysis in
the CIS by skin prick tests, possible to identify key triggers that play a main role
in the development and exacerbation of ADs. The insect allergy met in Armenia
from 2 to 40.8%, in Russia to 35%. In Kirghizia the most significant allergens are
pollen and food, and in Azerbaijan household and food. In such countries as Armenia, Azerbaijan and Belarus is marked a frequent sensitization sick Ads by fungal
antigens. Intensive reproduction and universal distribution of mushrooms puts is a
problem of a fungal sensitization in the category of one of actual at Ch with atopy. It
70
Table 2.
is necessary to notice that with increase of weight of current BA at Ch, irrespective

of region of their residing, also it was found out a tendency to increase of frequency
and expressiveness of a sensitization to fungal allergens. In development of AR by
the main triggers were aeroallergens (like dust mite, plant pollen, moulds), and in
the development of BA was viral infection.
Among the most significant risk F for ADs should be noted: burdened by heredity
(65.5-75.9%), high frequency of SARS in history (16.2-77%), passive smoking (43.162.5%), poor social conditions (17-42%) the presence of pets in the apartment (12.517%). Children (78years) were more susceptible to environmental RF as compared
with teens (1314years). In Tajikistan and Turkmenistan, ADs were closely related
with poor social conditions, low household income and large-family (Table2).
In developments of an allergy in Ch the big role such RF, as an allergic diathesis
play, focal infections and artificial feeding in the first year of life of the Ch. The
great value has studying of features of a current antenatal and intrapartum periods,
and also genetic predisposition as these deviations with confidence can be considered,
as one of RF of development BA.
Conclusions & Recommendations

Epidemiologic studies are of great theoretical and practical significance as
they provide impartial evaluation and reliable data on ADs prevalence and the most
important allergens.
Climatic, geographical conditions of the environment and ecological situation
71
in the region are significant risk factors (RF), requiring consideration in determining
the probability of a genetic predisposition to ADs.
The important thing for the prevention of ADs in different countries is the
creation of a special warning service of ADs including annual aerobiological monitoring and alert system for daily level of pollen and spores in the air.
It is desirable to establish regional preparations for the diagnosis (allergens),
the most relevant in a particular region. This is necessary to carry out palynological
investigations, determination of the cross - reacting antigens of pollen and food.
Major reference
1. Filipushenko I.A., Gulomov Z.S. Diseases of civilization- asthma and main risk factors in
Tadjikistan. // J. Allergology and Immunology.- 2005.-Vol.6.- N3.-p.338.
2. Dzhamalyan K.R. Medical social factors of respiratory allergic diseases development and
progression in Armenia // Synopsis of PhD dissertation.Armenia, Erevan.2010. 26 p.
3. Kabulov G.G. Epidemiological, clinical functional and immunological characteristics of
allergic diseases in children from different climatic geographic areas of Azerbaijan. //
Synopsis of MD dissertation. Azerbaijan, Baku. 2009. 44 p.
4. Macharadze D.Sh., Beridze V.D., Jishkariani I.R. Climate and Allergy.// Russian Journal
of Allergology.- 2006.- N5.- p.23-30.
5. Zharin V.A. Prevalence, features of diagnosis and treatment of allergic diseases in
military personal in the Republic of Belarus. // Synopsis of PhD dissertation. Belarus,
Minsk.-2007.- 23p.
6. Bogova A.V., Ilyina N.I., Luss L.V. Trends in the study of epidemiology of allergic diseases
in Russia for the last 10 years. // Russian J. of Allergology.-2008.-N6.-p.3-14.
7. Zhorzholiani L., Karseladze R., Goderdzishvili L., Tschakaia M. Air Pollution and Prevalence of Allergic Diseases in Georgian Adolescent Population // Materials of RTO HFM
Symposium NATO Medical Surveillance and Response, Research and Technology Opportunities and Options. Budapest, Hungary. 2004.
8. Usovik O.V. Rationale and development of pollen allergens in Belarus.// Synopsis of PhD
dissertation. Belarus, Vitebsk.-2007.-21p.
9. Pukhlik B.M. Allergy and allergens in the Ukraine. Report of the Ukraine Association of
Allergologists.-2008.
10. Modestov A.A., Tepletskaya R.N., Torshkhoeva R.M. etc. Prevalence of allergic diseases
in children living in different ecology-geographic conditions.// Questions of modern
Pediatrics.-2007.-V.6.-N4.-p.12-16.
11. Khakberdyev M.M., Yuldashev I.R., Doniyarov K.Sh. Epidemiology and etiology of allergic
diseases in school children in a large city in Uzbekistan.// J. Allergology and Immunology.- 2002.-Vol.3.- N2.-p.303-304.
Muramyl dipeptide has a dual influence on allergic

airway inflammation
Guryanova S.V., Shevchenko M.A., Kozlov I.G., Andronova T.M.
Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russia;
Russian State Medical University, Moscow, Russia
Summary In the present study the capacity of GMDP in suppression of allergic

airway inflammation was examined. The data showed that intraperitoneal injections
of GMDP to allergen-sensitized mice at the stage of allergen inhalation suppressed
the main features of allergic airway inflammation such as eosinophilia, pro-allergic
cytokines secretion and allergen-specific IgE. The mechanisms of GMDP-mediated
effect should be further investigated.
Introduction N-acetylglucosaminyl-N-acetylmuramyl dipeptide (GMDP) is known
to possess immunomodulatory activity against viral and bacterial infection [1, 2]. As
the derivative of the muramyl dipeptide GMDP is known to possess high affinity
interaction to NOD2 receptor and is able to drive NALP3-inflammasome activation
and Interleykin-1beta production [3, 4]. The last is associated with activation of
neutrophil response, which is known to be impaired in allergic asthma [5, 6]. The
aim of the present study was to evaluate the effect of GMDP treatment on allergic
airway inflammation both on the stage of sensitization and during ongoing of the
inflammation in the airways.
Materials and Methods To induce allergic airway inflammation BALB/c mice
received intraperitoneal (i.p.) injections with 10ug/q OVA/Alum on days 0, 14, 21 and
then were challenged intra-pharyngealy (i.ph.) with 1% OVA on days 27, 28 and 35
(OVA/OVA group). GMDP was administrated to mice 2 days before each i.p. OVA
treatment (GMDP/OVA/OVA group) or between the second and the third challenge
(OVA/GMDP/OVA group). The total GMDP dose comprised 300ug/mouse. The effect
of GMDP treatment was evaluated 48 hours after the last OVA challenge by total
and differential bronchoalveolar lavage (BAL) cell count. BAL fluid cytokine and
immunoglobulin production was detected by ELISA.
Results Immunization of mice with GMDP during allergen challenge did not influence the total number of BAL cells (Figure 1 A). Positive effect was observed in
group of mice that received GMDP at the stage of allergen challenge, BAL eosinophil
number in this group was significantly reduced (Figure 1 B). At the same time the
increased level of infiltrated lungs neutrophils was detected in OVA/GMDP/OVA mice
N915L5018
73
74
Figure 1. Influence of GMDP on the airways infiltration during allergic airway inflammation. Total (A) and
differential (B) cell count of BAL of mice with allergic airway inflammation that received GMDP i.p. injections at the stage of sensitization (GMDP/OVA/OVA) or at the stage of allergen-challenge (OVA/GMDP/OVA).
Representative results from 5 independent experiments (from 3 to 5 mice per group) are presented as
means SEM. Statistic analyses was performed by using Students t test, ns: non significant, ***: P <
0.005 vs OVA/OVA group.
Figure 2. Influence of GMDP on BAL fluid cytokine production. IL-4 (A) and IL-13 (B) levels were measured
in BAL fluid of mice with allergic airway inflammation and mice, which were treated with GMDP at the
stage of sensitization or allergen challenge. Data were collected in three independent experiments from 3
to 5 animals per group. Results are presented as means SEM. Statistic analyses was performed by using
Students t test, **: P < 0.05, ***: P < 0.005 vs OVA/OVA group.
(Figure 1 B). Both schemes of GMDP immunization did not result in BAL macrophages number alteration (Figure 1 B). The levels of pro-allergic cytokines IL-4 and
IL-13 were significantly reduced in BAL fluids of OVA/GMDP/OVA mice compare the
OVA/OVA group (Figure 2 A, B). GMDP immunization on the stage of sensitization
did not alter the IL-13 and IL-4 BALF levels (Figure 2 B). In order to investigate
the mechanisms of protective effect of GMDP on allergic airway inflammation BAL
fluid and serum cytokine levels were measured. The results showed that immunization
with GMDP during allergen challenge significantly decreased BALF IgA level (Figure
75
Figure 3. Alteration of allergen-specific immunoglobulin production by GMDP immunization. BAL fluid IgA
(A), serum IgG (B) and serum IgE (C) were compared fro treated and not treated with GMDP mice with
allergic airway inflammation. Representative results from 5 independent experiments (from 3 to 5 mice per
group) are presented as means SEM. Statistic analyses was performed by using Students t test, ns: non
significant, *: P < 0.05, ** P < 0.01 and ***: P < 0.005 vs OVA/OVA group.
3 A). Together with that the serum IgG2a production in OVA/GMDP/OVA mice was
elevated (Figure 3 A, C). Twofold decrease of serum OVA-specific IgE was detected
in OVA/ GMDP/OVA mice compare to the OVA/OVA group (Figure 3 B).
Conclusions The present study showed that intraperitoneal injections of GMDP to
allergen-sensitized mice at the stage of allergen inhalation suppressed the main features
of allergic airway inflammation such as eosinophilia, pro-allergic cytokines secretion
and allergen-specific IgE. The mechanisms of GMDP-mediated effect presumably
concern with Th2 to Th1 shifting and neutrophil airway recruitment.
References
1. [Comparison of adjuvant activities of glucosaminyl-muramyl dipeptide and of the gene
coding for granulocyte-macrophage colony-stimulating factor in DNA immunization against
herpes simplex virus]. Kozlov AIu, Klimova RR, Shingarova LN, Boldyreva EF, Nekrasova OV, Gurianova SV, Andronova TM, Novikov VV, Kushch AA. Mol Biol (Mosk).
39(3):504-12. 2005.
2. Turnek J, Ledvina M, Kasn A, Vacek A, Hrbalova V, Krejc J, Miller AD. Liposomal
preparations of muramyl glycopeptides as immunomodulators and adjuvants. Vaccine.
12;24 Suppl 2:S2-90-1. 2006.
3. Coulombe F, Divangahi M, Veyrier F, de Leseleuc L, Gleason JL, Yang Y, Kelliher MA,
Pandey AK, Sassetti CM, Reed MB et al: Increased NOD2-mediated recognition of Nglycolyl muramyl dipeptide. J Exp Med, 206(8):1709-1716. 2009.
4. Roberts RL, Topless RK, Phipps-Green AJ, Gearry RB, Barclay ML, Merriman TR. Evidence of interaction of CARD8 rs2043211 with NALP3 rs35829419 in Crohns disease.
Genes Immun. 11(4):351-6. 2010.
5. Martinon F, Gaide O, Ptrilli V, Mayor A, Tschopp J. NALP inflammasomes: a central
role in innate immunity. Semin Immunopathol. 29(3):213-29. 2007.
6. Baines KJ, Simpson JL, Scott RJ, Gibson PG. Immune responses of airway neutrophils
are impaired in asthma. Exp Lung Res. 35(7):554-69. 2009.
Protease Inhibitors Asthma And Rhinosinusitis

Palma-Carlos A.G., MD.PhD, EFAAAI, HDFACAAI,
Palma-Carlos M.L., Pharm D, PhD.
Clinical Allergy Immunology Center, Lisbon, Portugal
a.g.palma.carlos@gmail.com
The serpin family is a group of proteinase inhibitors involved in inflammation

complement activation, coagulation and fibrinolysis. Alpha-1-proteinase inhibitor (A1PI)
Alpha-1-antitrypsin is the archetype of the serpin family and also designed SERPINA-1
(table I). A1PI synthesis is genetically controlled with multiple alleles. Normal pattern
is Pi MM. The more frequent abnormal alleles conditiones more profound deficiency
are Z (Glu 342-Lys) S (Glu 264-val) and non-secretor null Q0. Homozygotes, have a
more profound deficiency than heterozygotes. ZZ, SZ, SS and certain null genotypes
are linked to a marked decrease of A1PI levels and COPD. The association of A1PI
deficiency with asthma and rhinosinusitis has been described as long as 1969/70 by
FAGERHOL and ourselves and confirmed in more recent publications (1,4,5).
A1PI has multiple anti-inflammatory effects aside of the well-known inhibition
of neutrophil elastase which degrades elastin and collagen. It also inhibits proteinase
3 which activates IL-1 and MMP9 (matrix metallo protein).It also blocks mast cell
chymase and caspase 3 and the release of pro-inflammatory cytokines. On the other
hand A1PI is inactivated by collagenases and gelatinases-proteinases released during
macrophages and neutrophils activation by bacteria or endotoxins. A1PI also prevents
angiogenesis, lung endothelial and alveolar cells apoptosis. In presence of lower
levels not only these mechanisms play a role but the remaining A1PI is inactivated
(tables 2,3,4).
The incidence of A1PI deficiency is variable, S and Z alleles being the more
common. Z variant is more frequent in North of Europe and S in the South (4, 5).
Only laboratory confirms A1PI deficiency. Quantification of A1PI can detect all
deficient homozygotes and most heterozygotes but only in absence of acute phase
inflammatory reaction increasing A1PI hepatic synthesis. A marker of inflammation
as C reactive protein (CRP) must be used simultaneously and a cut-off value for
CRP. Following our previous experience 0,2 mg/dl must be the higher level without
simultaneous acute phase increase of A1PI.
Material and methods - 2 400 out-patients suffering from rhinitis, sinusitis, asthma, COPD and urticaria have been studied. A1PI has been evaluated by nephelometry
P421R9027
77
78
table I
table 2
table 3
table 4
79
80
table V
after previous serum electrophoresis. Obstruction of small airways was present in all
the asthmatic patients. 90 patients have been selected and studied for S and Z alleles.
Assay of A1PI by nephelometry have been done in all patients. Increase of CRP has
been used as a marker of acute phase reactions maskerading A1PI deficiency. A cutoff of 0,2 mg/dl has been considered for CRP (table V).
When A1PI concentration was less than 90 mg/dl in absence of inflammatory reactions, a genetic study was done. Genomic DNA was extracted and the research of
mutations Glu 264 - Val (S allele) of Glu 342 -Lys (Z allele) studied by enzymatic
amplification of DNA by PCR with specific oligonucleotides and analysis of melting
curves of amplification products. For 2 or more A1PI values less than 90 mg/dl even
in normal Pi MM genotype the presence of a Q0 non secreting null gene as been
considered. Rhinosinusitis has been confirmed by clinical history, rhinoscopy and
pharingoscopy. CT scan has been done in all the patients suspected of rhinosinusitis.
Lung function has been done in all asthmatic patients. Obstruction of small airways
was present in all the asthmatic patients.
Results - In 84 patients (43M 41F) 10 to 60 years the presence of abnormal variants (S, Z or Q0) of A1P1 was confirmed. S allele was present 55 times Z, 37 and
Q0 8. Genotypes: SS-7, MS-33, MZ-24, ZZ-1, SZ-11, MQ0-8. Clinical presentation
for these patients: Chronic rhinosinusitis 48, Rhinosinusitis/asthma 20, Rhinosinusitis/COPD 1, Rhinosinusitis/urticaria 5, Asthma 1, COPD 1, Chronic urticaria 7.
Rhinosinusitis was present in 75 patients (89,3%) asthma in 22 (26,2%) urticaria in
12 (14,3%) COPD in 2 (2,4%). The incidence of rhinosinusitis was independent of
81
genotype: MS 32/33, MZ 23/24, SS 6/7, MQ0 7/8, SZ 7/11, ZZ 0. CT scan has been
abnormal in all cases of rhinosinusitis, in 3 only as rhinitis. For asthma MS 9/33,
MZ 8/24, SZ 2/11, MQ0 3/8 (table VI).
A1PI GENOTYPES AND CLINICAL PRESENTATION
Discussion - The diagnosis Of A1PI deficiency can only be confirmed by laboratory studies. However, a simple quantitative assay is only sufficient in cases of
marked deficiency (homozygotes ZZ and SS and heterozygotes SZ). In other cases
the increase of the protein during all phases of acute phase of inflammation mark the
basal low levels and induces false normal results. In suspected cases serial assays of
A1PI must be done and a targetted study organized. To identify the increase of A1PI
linked to acute inflammation a simultaneous marker of inflammatory reactions must
be assayed simultaneously. C reactive protein (CRP) is useful for this purpose. On
the basis of our own results a cut-off as low as 0,2 mg/dl for CRP must be used.
Higher values of CRP invalidate A1PI serum levels and in suspicious cases a genetic
study is underdone.
A1PI deficiency is classically considered as a causing factor of COPD but only
for profond deficiencies ZZ, SZ. A link with some cases of asthma as been described
more than 40 years ago by FAGERHOL and ourselves and confirmed by many other
studies. In the present group of 84 patients asthma is present in 26% of the cases for
all genotypes except ZZ either in atopic and non atopic asthmatic patients. Due to the
particular recruitment of our patients in an Allergology Clinic the number of COPD
is limited. The relationship of A1PI deficiency with rhinosinusitis has been already
pointed off in our early paper. In these series the great majority of A1PI deficient
patients, 75 out of 84 (89%) have a chronic rhinosinusitis confirmed by CT scan in all
the cases and with sinusal lesions in all but 3 presenting only an hypertrofic rhinitis.
The anti-inflammatory effects of A1PI are certainly not only present in bronchial
tree but also in upper airways. During the initial phases infection or allergic aggressions the basal level of A1PI is low and an inflammatory process can be triggered.
Proteases and mast cell chymase are not inhibited and the remaining A1PI blocked
82
by matrix-metalloproteins conditioning an evolution to chronic rhinosinusitis. A recent

paper from an ENT group of Montreal confirm these findings (2).
Abnormal variants of A1PI have to be considered as a potential worsening of
triggering factor in upper and lower airways with a probable evolution to chronicity
of rhinosinusitis and asthma.
Even if substitution therapy is very expensive and not generally available for these
cases, preventive measures can be suggested. As LTB4 is the major chemotactic factor
for neutrophils and therefore increases proteases release the inhibition of leucotrienes
in these cases by permanent use of montelucast or zafirlukast can be logically useful.
A decrease in the number of acute respiratory infections would also be a possible
way of diminishing the risks of A1PI deficiency. Bacterial lysates which have recently
been evaluated as an useful preventive immune therapy in airways pathology can also
be indicated for the prevention of respiratory infections and also of asthmatic symptoms.
A1PI deficiencies must be reavaluated. A1PI variants are not only linked to COPD
but also with rhinosinusitis, asthma and some cases of urticaria. Larger multicenter
studies will be useful to clarify this issue.
References
1 - Aboussouan L.S, Stoller JK. Detection of alpha-1 antitrypsin deficiency: A review Resp
Med 2009, 103, 335-341
2 - Fagerhol MK, Hauge H.E. Serum Pi types in patients with pulmonary diseases Acta Allergol 1969, 24, 107-115
3 - Kilty SJ, Boss Y, Carns ER et al. Polymorphism in the serpine 1 (Alpha-1-Antitrypsin)
gene are associated with severe chronic rhinosinusitis unresponsive to medical therapy
Am J Rhinol Allergy 2010, 24, 4-9
4 - Laurel CB, Eriksson S. The electrophoretic alpha-1-globulin pattern serum alpha-1-antitrypsin
deficiency. Scand J Clin Lab Invest 1963, 15, 132-40
5 - Palma-Carlos AG, Palma-Carlos ML. Alpha-1-antitrypsin in chronic obstructive pulmonar
disease and bronchial asthma Pneumologia 1970, 1, 171-178
6 - Palma-Carlos AG, Palma-Carlos ML. Alpha-1-antitrypsin deficiency asthma and allergy
Eur Ann Allergy Clin Immunol 2007, 39, 127-132
7 - Palma-Carlos AG, Palma-Carlos ML. S and Z alfa-1-antitrypsin variants and allergy Allergy 2008, supll 88, 603
8 - Palma-Carlos ML, Palma-Carlos AG. S and Z variants of alfa-1-antitrypsin and allergic
diseases Int Rev Allergol Clin Immunol 2008, 14, 85-91
9 - Palma-Carlos AG, Spnola-Santos A, Palma-Carlos ML. Alpha-1-antitrypsin, Asthma and
Allergy Asthma 2009, 10, 25-27
10 - Palma-Carlos AG, Spnola-Santos A, Palma-Carlos ML. Alpha-1-antitrypsin asthma and
allergy 149-153 in New Horizons in Allergy Asthma and Immunol. Sepiashvili, (ed) Medimond International Proceedings, Bologna 2009
11 - Palma-Carlos AG, Palma-Carlos ML. Alpha-1-antitrypsin variants and rhinosinusitis Allergy 2011, 66, suppl 94, 493-494
12 - Palma-Carlos AG, Palma-Carlos ML. Alfa-1-proteinase inhibitor (A1PI) deficiency in
rhinosinusitis, asthma and urticria Int Rev Allergol Clin Immunolg 2011, 17, 10-15
13 - Racheleesky, Hogarth DK. Issues in the diagnosis of alpha-1-antitrypsin deficiency J Allergy Clin Immunol 2008, 121, 833-838
14 - Stoller JK, Sandhaus RA, Torino et al. Delay in diagnosis of alpha-1-antitrypsin deficiency.
A continuing problem Chest 2005 128, 1989-1994
Cytokine status as an efficiency criteria of intranasal

aerosol therapy in allergic rhinosinusitis treatment
process
Tataurshchikova Natalya, Sepiashvili Yane
Russian University, Moscow, Russia
Instutute of Immunophysiology, Moscow, Russia
E-mail: natalytataur@yandex.ru
The assessment of patients blood serum and nasal secret cytokine concentration
allows to evaluate and forecast the course of sharp and chronic inflammatory process
in mucosal mantle of upper airways. It is known, that the infection activator only acts
aggressive in case of impossibility to go through the first overepithelial defense layer,
which is often represented by non-specific immune system mechanisms. Epithelial
cells can secret proinflammatory cytokines (including IL-8), that attract inflammatory
cells. IL-4 also takes its active part in allergic-based inflammation process, and it
stimulates E-class immunoglobuline synthesis. Thus, cytokine network is major for
endogenic immunoregulation mechanisms activation. Cytokine levels study allows to
get information concerning functional activity of different types of immunocompetent
cells; concerning inflammation process strength, forecasting the process and predicting
the time when it steps to system level; concerning T-helpers of 1 and 2 type activation
process correlation (which is vital to those, trying to maintain differential diagnostics
of a number of infective and immunopathological processes); concerning the current
stage of some allergic and autoimmune diseases[1-4].
One of the most effective and safe methods of immunothropic medicine usage is
intranasal aerosol therapy. Long-term research concerning the usage of Cycloferon
Russian low-molecular interferon inductor (Polisan, Russia) in cases of allergopathology showed the necessity of its usage among immunocompromised patients
with allergy[5-12].
Aim of the research: to assess dynamics informativity concerning profile cytokine
content to determine the efficiency of local immunotherapy among immunocompromised patients suffering from allergic rhinosinusite.
Methodology
Method was as follows: examination of specific cytokine content, pro- (-TNF
P421R9100
83
84
tumor necrosis factor, IL-8 interleikin 8, -INF - gamma-interferon) and contrainflammatory IL-4 (interleikin-4) in blood serum and nasal secret. Cytokine content
was determined using IFA method with the help of diagnostic test-systems, produced
by Vektor-Best (Russia). Research material was blood serum, taken in the morning
fasting from the ulnar vein. Simultaneously to blood sample there were taken nose
mucosal mantle swabs.
Observation group included 43 patients aged 18-40 suffering from allergic rhinosinusopathy, accompanied with opportunistic infection (cytomegalovirus, 1-2 type
herpes virus) and infection syndrom. Control group included 36 patients suffering
from allergic rhinosinusopathy aged 18-43, accompanied with opportunistic infection
(cytomegalovirus, 1-2 type herpes virus) and infection syndrom who were treated
using intramuscular Cycloferon therapy (125 mg\ml intramuscular N 10). Hearths of
chronic infection were preliminarily sanified, and patients having pathogenic flora in
nasal mucosal mantle were also sanified using antiseptic and antibacterial medicine.
At the time of research all patients received basic therapy on antihistaminic medicine
and decongestant if needed. Intranasal glucocorticoid medicine were declined a month
before the research start.
Intranasal immunotherapy was based on Cycloferon 125 mg\ml mixed with saline
solution in proportion 2:1 serum injection in nasal mucosal by means of nebulizer.
Inhalation device NIKO (Inter-Eton, Russia) was used for inhalations.
Clinic-immunological activity assessment was based on following criteria:
Infection syndrome exacerbation frequency
Allergic syndrome clinic markers presence frequency
Cytokine profile level dynamics (IL-4, -INF, -TNF, IL-8)
All the data was assessed in a 3 month before research start period and in a 3
month after period.
The following indicators were calculated: average value (M), importance level
reached (p), average imprecision (m).
Results
Immunocompromised patients suffering from allergic rhinosinusite cytokine status,
stated before treatment, was basically characterized by rather stable serum cytokine
values, excluding lowering y-interferon content on majority of patients in the group
(65,8% both serum and nasal secret) and rising IL-4 level in nasal secret. Results
acquired were accompanied with high herpetic and chlamydial titles on the moment
of research. Rapid increase in -TNF values both in serum and in nasal secret was
stated by 17,7 % of patients and was accompanied with a period on hidden herpetic
infection exacerbation rapid rise of titles absent clinic symptoms. Cytokine content
dynamics (serum and nasal secret) correlated one another. Results of cytokine dynamics in blood serum and nasal secret before and after treatment, acquired during our
research, show, that immunocompromised patients suffering from allergic rhinosinusite tend to restore changed values (representing the activity of virus immunity and
inflammation process activity) after treatment.
85
Discussion
Acquired positive -INF dynamics using both aerosol and parenteral ways
correlates to positive dynamics of infection syndrome manifestation. Thus, after
treatment risk of SARS in both groups lowered from 88% to 32%, episodes of
sharp ENT-organs pathology were absent, opportunistic infection exacerbation
frequency lowered from 44,2% to 4,3%, which means improvement of quality of
life, the need of medicamental therapy lowered. Normalization of -TNF values
was marked in both groups on all patients, who had disturbances before treatment
and was accompanied with herpetic infection titles normalization absent infection
exacerbation and infection syndrome, what can be considered anti-inflammatory
effect of Cycloferon. In case of athopic inflammation, -TNF is a mediator,
that is in charge of the last phase of athopic reaction progress. It is considered,
that -TNF is responsible for chronisation of athopic inflammation. Far less
manifested is the IL-8 values restoration dynamics, what can be explained by
specifics of Cycloferon action mechanism. It is possible, that nasal secret IL-8
changes preservation confirms chronic bacterial process in nasal mucosal mantle. Serious differences between observed groups are in IL-4 dynamics. Nasal
secret value restoration was marked in 79% cases by patients, who received the
treatment intranasal, and the intramuscular injection group showed no dynamics
in nasal secret IL-4 normalization. IL-4 secrecy disregulation is vital factor for
later allergopathology development. Rising of IgE synthesis in response for IL-4
stimulation leads to IgE-stimulated cytokine synthesis acceleration (by means of
cells, that are capable of producing IL-4, IL-5, IL-6). Received data is best to
be considered as a kind of antiallergic effect, acquired as a result of a launch of
series of anti-inflammation effects after using Cycloferon aerosol way.
Cytokine status dynamics fully correlated to clinic infection and allergy syndroms. Strengthening virus defense in both groups correlated to -INF serum and
local value restoration.
Conclusion
Acquired correlation between clinic indicators and cytokine status indicators confirms high informativity of profile cytokine content evaluation (most of all local
fractions), and can be a base for a method of immunotherapy effectiveness evaluation.
Literature
1. Symbirtsev A. Cytokines in allergy treatment and immunopathogenesis//RAJ, 2007, N1,
p.5-20
2. Symbirtsev A. Cytokine defense reaction regulation system// Cytokines and inflammation.
2002. N 1. p. 916.
3. The Cytokine Handbook. / Ed. A.W. Thomson and M.T. Lotze. London, San Diego:
Academic Press, 2003.
4. Demianov A., Kotov A., Symbirtsev A. Diagnostic value of cytokine level research in
clinic practice //Cytokines and inflammation. 2003. N 3. p. 2035.
5. Romantsov M., Kovalenko A. Cycloferon interferone inductor: Summary and prognosis
in clinical usage: Recommendations for doctors. SPB.: Semax,2007.- 24p.
86
6. Tataurshchikova N.. Cycloferone in clinical allergology, SPB, Tactic-Studio, 2009, 48

p.,
7. Romantsov M., Kovalenko A. Cycloferone characteristics: immunomodulator with polifunctional activity. See.: Cycloferone in clinical pulmonology. SPB.: Tactic-Studio: 2005.
9 14.
8. Tataurshchikova N. Allergopathology by patients, subjected to radiation impact (clinicimmunological characteristics and therapy methods): synopsis M., - 40c.
9. Tataurshchikova N., Degtyareva E., Krasnov V., Romantsov M. Immunocompromised
patient , SPB,, Tactic-Studio 2009, 48 p.
10. Romantsov M., Ershov F. Medicine, used to cure infection diseases M.: GEOTARMedia, 2007. 363p.
11. Nesterova I. Malinovskaya V., Tarakanov V., Kovaleva C. Interferone and immunotherapy
in cases of often and long-time ill children and adults., M.,Publ.: Capricorn Publishing
Inc., 2004. 159 p.
12. Appelgans T., Savinkina H., Machov V., Vorojisheva A., Nikonova E., Orlova ., Maslova
E. Children rhinosinusite differential diagnosis //Vektor-Best 2008, N4(50) ,p.2-5
13. Kovaltchuk L., Gankovskaya L. Bogomilsky M., Pchelyonok C., Yudina C.. Snimshikova I., Konovalova M., Galkina T., Shustickaya A. Thopic cytokinotherapy in
othorinolaringology:Methodic recommendations for doctors M.,2007. -39p.
14. Airway diseases aerosol therapy //Recommendations for doctors, prof. M.Romantsov, SPB,
2007, 28p.,
15. Arefyeva N. Usage of cyloferone 12,5% serum in chronic tonsyllite and recidive sinusite
exacerbation cases SPB.: Polysan, 2007. p.242-244
The effect of C3 and C4 complement components on

allergic rhinitis patients referred to Amir al-Momenin
hospital of Zahedan city
Khazaei H.A1, Dashti G.A2, Moolaei N.3, Sharyar M.3, Dadras M.N4,
Hejazenia F.1, Khazaei B1 and Noukar A.4
1- Research center for children and adolescencents health and Dept of Immunology and
hematology, Zahedan Medical Sciences University and health, Zahedan University of Medical
Sciences, Zahedan-Iran
2. Dept. of ENT, Zahedan Medical Sciences University, Zahedan- Iran
3. Dept of Internal medicine, Zahedan Medical Sciences University, Zahedan- Iran
4. Dept. of Immunology, Immunology research center, Mashhad, Iran
Abstracts
Background and Objectives:
Initially the complement system was introduced for destroying microbe or erythrocytes
that were sensitized with antibody. It is now clear that this system with composition
of several serum proteins and cellular receptors, relates to the immunopathologic
reactions to several diseases such as allergic rhinitis. The aim of this study was to
investigate the role of C3 and C4 as inflammatory and anaphylatoxic reaction markers
in patients suffering from allergic rhinitis in Zahedan city to determine serum levels
of these components in relation with their serum specific IgE antibodies.
Material and methods:

This analytic and descriptive study was carried out in 176 allergic rhinitis patients.
Periphery blood sample was taken after completion demographic questioner forms
from each patients sex and age matched with healthy control. Serum was taken and
analysed for measurement of C3 and C4 levels by nephlometry methods. The exact
amount of total IgE component was measured by ELISA method. The results were
analyzed by SPSS,15.0 programme.
Results:
From 176 patients, 21% had increased amount of C3 and 6% had decreased
amount of this component whereas only 28 had increased amount of C4 and 16%
N915L5009
87
88
had decreased amount of this component. In healthy control the C3 level was within
the normal range and C4 level had increased in a %2 of them). The exact amount of
serum IgE concentration had increased in 76% in contrast with normal individuals,
5% of them had increased the exact amount of serum IgE.
Conclusions:
The results of this study indicated that the complement system activation and
concentration of C3 and C4 in allergic rhinitis are involved in the immunopathology
of allergic rhinitis. Further study is required to investigate more the complement
cleavage products of C3 and C4 and other components and the activation of their
corresponding receptors in cells regulate the development of specific immunity such
as Th2 responses of allergic rhinitis patients.
Key words: C3, C4 complement components and allergic rhinitis
Introduction:
Innate and adaptive immunity have physiologic function to protect individuals from
infectious pathogens. One of the innate immunity powers is complement system that
comprises of the most important proteins that have essential role in enhancing humeral
immunity (1). Initially this system was described around hundred years ago and was
responsible for destroying microbe or erythrocytes that were sensitized with antibody
(2). It is now clear that this system with composition of several serum proteins and
cellular receptors produce important mediators of host defense and inflammation.
Among of them C3 and C4 have inflammatory and anaphylaxis functions and have
influence on susceptibility of host to infectious diseases and immunopathologic
reactions to several diseases such as allergic rhinitis (1) that is common chronic
inflammatory disease of the nasal mucus membranes and the upper airways with a
high prevalence in a round of world (3). Based on the results from scientific reports,
complement system have activated locally and systemically in allergic patients and
they were susceptible to infection and anaphylaxis suggesting that the complement
cleavage products complement components such as C3 and C4 (1,4). Although there
are few reports in this regards indicated that activation of the complement system
by an allergen would result in activation of anaphylatoxins products such as C3a,
C4a, that these would increase activation of type I response leading to mast cell
degranulation (5).
The prevalence of allergic rhinitis varies between the sexes, age groups, and by
epidemografic factors (6).The most data were obtained from children. Based on review
report from database of allergic rhinitis patients in Europe and North America, the
prevalence of AR has increased over the last decade especially in some of African
countries, China-Taiwan and several Middle East countries (3). In the Asian-Pacific
population, appears to be extremely common across Asia-Pacific nations (7). Although
there was no well document about overall frequency of allergic rhinitis in Iran but it
seems common. In North of Iran the prevalence of allergic rhinitis, eczema and asthma
in childhood has been reported as moderate in this area and for AR was 14.5% (8).
In order to study innate immune system of allergic rhinitis patients, we measured
serum complement levels of C3 and C4 of patients compared results with the control
group to show whether serum complement levels change in allergic rhinitis patients.
89
Fig 1: The comparison of C3 level in allergic rhinitis patients and healthy control (P value <0.001)

This analytic and descriptive study was carried out in 176 allergic rhinitis referred
to immunodiagnosis of allergic disease at three main hospitals of Zahedan city during
2005-2010. All patients and control subjects sex and age matched, gave informed
voluntary consent to take part in our study according to the protocol approved by
the local Ethics Committee of ZAUMS. 5 ml periphery blood sample was taken
from their after completion demographic questioner forms. Complete blood cell count
(CBC) and red cell indices were measured. Serum was then taken in sterile tubes
and stored frozen at 20 C until used for measurement of complements. C3 and C4
levels for each case and control individuals were measured by nephlometry methods
using the Minineph Human C3 and C4 Kit (Binding Site Limited, Birmingham, UK).
The results were analyzed by SPSS,15.0 programme and for finding significance of
data, Chi square test was used for comparing mean value in two group of case and
control. A P-value under 0.05 (P<0.05) was considered significant.
Results:
From 176 allergic rhinitis patients, 102 were females and 74 males with age range
2 to 76 years old with 32.73 9.50 years. 21% of patients had increased amount
of C3 and 6% had decreased amount of this component. In healthy control, the C3
90
Fig 2: The comparison of C4 level in allergic rhinitis patients and healthy control (P value <0.001).
level was within the normal range and this differences was statistically significant
with Chi square test (P Value <0.001) (Fig 1).
Regarding to the amount of C4, 28% had increased and 16% had decreased
amount of this component. In healthy control the C4 level had increased in 2% of
them and this differences was statistically significant with Chi square test (P Value
<0.001) (Fig 2).
The exact amount of serum IgE concentration had increased in 67% of patients
in contrast with normal individuals, 5% of them had increased the amount of IgE
and this differences was also statistically significant with Chi square test (P Value
<0.001) (Fig 3).
Due to the result of the exact amount of serum IgE level in patients and its relation with C3 and C4 concentration, as a few patients increased the amount of C3 and
C4 levels, therefore there was impossible to demonstrate any statistically significant
relationship between these parameters.
Discussion:
The complement system provides an important protective role against pathogens and contribute to the pathogenesis of Type I allergy. This system is involving
proteolytic cleavage of serum glycoproteins in induction of chemotaxis responses,
91
Fig 3: The comparison of total IgE level in allergic rhinitis patients and healthy control (P value <0.001).
opsonization, inflammatory, anaphylaxis, and finally attacking the cell membrane of

pathogens. Complement cascade comprises of three pathways as classical, alternative
and lectin pathways resulted to produce many components (9). C3 component play
in the activation of complement system. Any changes in amount of this component
lead to susceptibility to bacterial infection (10).
C4 provides protective role against the development of autoimmune diseases (11,
12). Moreover, little is known about the role of these components in induction of
allergic rhinitis that is common chronic inflammatory diseases of the nasal mucus
membranes and the upper airways but it has been suggested that the complement
system is activated by the allergen and the anaphylatoxins, and C3- C4 levels in
serum of patients, contributes to the severity of the disease (12). But an important
consideration in allergic patients is their exposure to allergens can lead to alterations
in humeral immune system secondary to T-cell immune response (13, 14).
In this analytic and descriptive study that was conducted on 176 allergic rhinitis
patients, C3 and C4 serum levels were analysed as well as measuring total IgE by
nephlometry method. The results showed 21% increased amount of C3 that these
patients may prone to bacterial and viral infections. In healthy control the C3 level
was within the normal range and this differences was statistically significant with Chi
square test (P Value <0.001). Little patients demonstrated reduced serum complement
92
of C3. This can be either due to reduced synthesis or increased consumption of this
component (15).
On the other hand, %28 increased amount of C4 whereas in healthy control, the
C4 level increased in 2% of them and thus this differences was also statistically significant with Chi square test (P Value <0.001). The C4 concentrations were reduced
in more patients that can be attributed to multiple factors resulted in an exposure of
patients to various allergens.
This study also revealed that the serum IgE concentrations increased in 76% in
contrast with normal individuals, 5% of them increased the amount of IgE and this
differences was also statistically significant with Chi square test (P Value <0.001).
Due to the result of the exact amount of serum IgE level in patients and its relation
with C3 and C4 concentration, as a few patients increased the amount of C3 and
C4 levels, therefore there was impossible to demonstrate any statistically significant
relationship between these parameters thus this may play role in humeral immune
system activity (16).
The alterations of serum immunoglobulin and complement levels in these patients
may be due to marked heterogeneity of the patients in different concerns environmental factors (17). We did not find in literature review any similar study that worked
on allergic rhinitis patients. Based on results obtained from this study, the precise
role of complement system in induction of AR disease is not fully understood and
need to investigate more to determine the exact role of this system suggesting that
complement may become as a new diagnostic and therapeutic target for this disease.
Conclusion:
This study showed C3 serum complements of RA patients elevated that may be
considered a hallmark of inflammation and revealed the predictive value for response
to environmental factors such as microbial and allergens agents.
It is important to know about effects of C3 and C4 on immune system due to high
prevalence of allergic rhinitis in world population. C3 and C4 were slightly higher and
statistically differences in allergic rhinitis patients in compared to control subject and
this may effect on natural defense in the immune system of allergic rhinitis patients.
Although recent findings is not completely sufficient to indicate the precise effect of
complement on allergic airway diseases suggesting that complement may serve as a
new diagnostic and therapeutic target for this disease. Further study on serum level of
other component of complement patients can be helpful for definite effect of serum
complement level on allergic rhinitis.
References:
1- Laumonnier Y, Schmudde I, Kohl J. The role of complement in the diagnosis and management
of allergic rhinitis and allergic asthma. Curr Allergy Asthma Rep. 2011 Apr;11(2):122-30.
2- Carroll MC. The complement system in B cell regulation. Mol Immunol 2004,41(2-3):1416.
3- Katelaris CH, Lee BW, Potter PC, et al. Prevalence and diversity of allergic rhinitis in
regions of the world beyond Europe and North America. Clin Exp Allergy. 2011 Nov 3.
4- Rondon C, Canto G, Blanca M. Local allergic rhinitis, a new entity, characterization and
further studies. Curr Opin Allergy Clin Immunol. 2010 Feb;10(1):1-7.
93
5- Dervadis M, Hidvegi T, Schmidt B, et al. Ragweed allergy: correlation between skin

reactivity and in vitro complement activation. Immunol Lett 1998, 64(23):119-123.7.
6- Pawankar R, Bunnag C, Chen Y, et al. Allergic rhinitis and its impact on asthma update
(ARIA 2008) western and Asian Pacific perspective. Asian Pac J Allergy Immunol. 2009
Dec;27(4):237-43.
7- Katelaris CH, Lai CK, Rhee CS, et al. Nasal allergies in the Asian-Pacific population:
Results from the Allergies in Asia-Pacific Survey. Am J Rhinol Allergy. 2011 Sep;25 Suppl
1:3-15.
8- Iraj Mohammadzadeh, Javad Ghafari, Rahim Barari Savadkoohi et al. The Prevalence of
Asthma, Allergic Rhinitis and Eczema In North of Iran: the International Study of Asthma
and Allergies in Childhood(ISAAC). Iran J Pediatr, Jun 2008;Vol 18 (2), p117-122.
9- Schiosser RJ, Mulligan RM, Casey SE et al. Alteration of gene expression of complement
in chronic rhinosinusitis. Am J Rhinol Allergy.2010 Jan;24(1):21-5.
10- Lukacs NW, Glovsky MM, and Ward PA: Complement dependent immune complex induced bronchial inflammation and hyperreactivity. Am J Physiol Lung Cell Mol Physiol
2001,280:L512-L518.
11- Einav S, Pozdnyakova OO, Ma M, Carroll MC.). Complement C4 is protective for lupus
disease independent of C3. J Immunol. 2002 Feb 1;168(3):1036-41.
12- Holers VM: The complement system as a therapeutic target in autoimmunity. Clin Immunol
2003, 107(3):140-151.
13- Reijula K, Leino M, Mussalo-Rauhamaa H, et al. IgE mediated allergy to Fungal allergens in Finland special reference to Alternaria alternata and Cladosporium herbarum. Ann
Allergy Asthma Immunol 2003; 91(3):280-7.
14- Chang FY, Lee JH, Yang YH et al. Analysis of the serum levels of fungi-specific immunoglobulin E in patients with allergic diseases. Int Arch Allergy Immunol. 2011;154(1):49-56.
2010 Jul 27.
15- Alexander M Abdelnoor, Firas Kobeissy, et al. Circulating immune complexes and complement C3 and C4 levels in a selected group of patients with rhinitis in Lebanon. Clinical
and Molecular Allergy 2004, 2:6.
16- Mandhane SN, Shah JH and Thennati R. Allergic rhinitis An update on disease, present
treatments and future prospects. Int Immunopharmacol. 2011 Jul 23.
17- Tovey ER, Marks GB. Its time to rethink mite allergen avoidance .J Allergy Clin Immunol.
2011 Aug 18.
The bronchial hyperactivity in children with pollinosis

Saparova L.T., Rozenson R.I.
Astana Medical University
Astana, Kazakhstan Republic
Introduction: Hay fever management in children needs through follow-up, and

among the most important techniques is monitoring of lung function, as these changes
are evident both in asthma and in allergic rhino sinusitis [1-3].
Among the methods available for this purpose most suitable in clinical practice in
developing countries are computer spirography and prolonged peak expiratory flow
(PEF), especially in conditions of artificially induced bronchodilatation. The changes
of lung function are evident not only during the pollinosis exacerbation, but also in
winter months [3-5].
There are many studies in which the peculiarities of bronchial asthma circadian
rhythms were described [6-8]. Knowledge of biological rhythms structure is important in estimation of the lung function and to prognose disease history in pollinosis
patient. Bronchial hyperreactivity is one of the most specific signs in patient with
bronchial asthma. Hyperreactivity itself means that airway react too much in response
to provocation stimulus. Hyperreactivity depends on allergic inflammation and could
be diagnosed during contact with eiologically significant allergens, non-specific chemicals and exercise [9, 12-14].
A lot of other trigger factors was identified as bronchial provocators, including
tobacco smoking, weather changes, stress and other [16]. Tobacco smoking and weather changes are important also in allergic diseases development [15,17]. Pollinosis
patients may have the seasonal exacerbations in spring, summer or autumn and symptom worsening mostly during dry sunny days, especially out of city. In our previous
studies we showed asthma prevalence in 37.2& of our hay fever patients.
Aim of the study was to develop an easy available technique of lung function
monitoring in pollinosis patients to predict the clinical course of disease both in seasonal exacerbation period and during the winter remission.
Material and methods: We studied 98 children with pollinosis aged 6-14 years
(mean age 10.81.4 years) patients were distributed according to following criteria:
treated in allergic center Umit, department of children diseases N1 (n=62) according to disease duration and sensitization spectrum. Peak flow (PF) parameters were
studied 3 times per day, namely in the morning (8am), lunch time (1pm) and in
the evening (9pm), from the first of April to 30th October. Patients history records
P421L5041
95
96
included hay fever symptoms and peak flow data. The curves of PF were drawn for
disease monitoring and prediction.
Results and discussion: Analyzing the daily changes of peak expiratory flow
parameters, we estimated that in children with hay fever sensibilization to Artemisia
species without evident asthma symptoms already at the second season peak expiratory flow decreased by 15-20% and during the third season decreased further by
30% from the best parameters of the first year. These patients in 68.4% of cases
presented with such symptoms as cough, especially during the morning hours and in
34.7% the had breathlessness and in 36,2% - chest tightness attacks. In this group of
patient in 73.3% of cases the so called third type of PF curve was registered. In
this type morning and evening parameters were minimal and lunch time parameter
was maximal. This type was commonly registered in children with late diagnosis and
who didnt receive specific immunotherapy.
In pollinosis patients we also registered the increased histamine sensitivity to histamine
serial dilution test and increased 2-adrenoreactivity.In patients with moderate rhinitis
and conjunctiva changes with disease duration more than 3 years but who received
the specific immunotherapy in 52.4% we registered the second and fourth PF curve
types. (Picture 1.) The second curve was characterized by lowest morning parameters
with lunch time evaluation, then parameter was stable. In the fourth curve type all
parameters were stable during the whole day. This type was most commonly seen in
patients with pollinosis duration less than 5 years and received the 3years specific
immunotherapy. Most striking in our studies was the finding that after the pollination
season especially in children with disease duration more than 3 years and who did not
receive the specific immunotherapy the level of changes decreased, but the type of
PF curve didnt change. In prognosis the most important was the possibility of pollen
asthma appeared in most children already during the second hay fever season and
was easy predictable by bad peak expiratory flow curves second and third type.
So we found that peak expiratory flow monitoring is useful in disease prognosis and
possible to be performed not only in exacerbation period, but also in a remission time.
Literature
1. Aleshina R.M. The clinical and allergological hay fever peculiarities in Voroshilovgrad
region and some problems of medical rehabilitation Candidates thesis, Voroshilovgrad,
1985-24P (in Russian)
2. Astaliyeva N.G. Allergic rhinitis and its influence on asthma // Russian Allergology J.2008.
P37-38 (in Russian)
3. Astaliyeva N.G., Goryachkina L.A. Hay fever pollen allergy // Allergology 1998-Vol2.
P34-40
4. Birman C.V. Shapiro G.G. The clinical signs of bronchial hyperreactivity in children //
Sandos Review 1990. Vol2. P12-19
5. Dobrynina E.Ya. Clinical and functional characterization of exercise bronchoconstriction
in children with bronchial asthma and the liped allergy mediators // Candidates thesis,
Moscow, 1991 P155
6. Zhbankova N.U., Moldavanu I.V. Hyperventilation syndrome in children with bronchial
asthma // VOMD 1989 N5-P14-17.
7. Kolchik P.V. The evidence based allergy and immunology Moscow, Practical medicine,
2010-P528 (in Russian)
97
8. Lopatin A.S. The clinical guidelines in allergic rhinitis diagnosis and treatment Saint
Petersburg, 2004-P76 (in Russian)
9. Mizernitskij Yu.L. The clinical variants of bronchial obstruction in youg children .. Maternity and children 1992-N6-7.P18-22 (in Russian)
10. Mizernitskaya O.N. Clinical recommendations in allergic rhinitis diagnosis and treatment.
Doctorates Thesis-Moscow-1970. (in Russian)
11. Perevezeva N.Yu. Peak flow parameter changes in children with bronchial asthma Candidate thesis Moscow 1990.P183 (in Russian)
12. Shiryayeva I.O. Lukina O.F., Reutova V.S. et al. Functional changes of bronchial system
in children Clinical recommendations Moscow, Ministry of health, 1990 P34
13. Allergic rhinitis and its impact on asthma. Guidelines ARIA 2007.
14. Bousquet J, Lockey R, Malling H. WHO Position Paper. Allergen immunotherapy: Therapentic vaccines for Allergic disease. Allergy.-1998.-Vol. 53.- N44 (Suppl.): P.42.
15. Eid N., Yandell B., Howell L. et al. Can peak expiratory flow predict airflow obstruction
in children with asthma? // Pediatrics.-2000.-Vol.105.-N2.-P.354-358.
16. Lopez-Vienna A., del Castillo-Arrevalo E. Influence of PEF monitoring on an asthma
self-management education program// Resp. Med.-2000.-Vol.94.- N8.-P.760-766
17. Sterk P.J., Bel E.H. Bronchial hyperresponsiveness: the need for a distinction between
Hypersensitivity and excessive airway narrowing.//Eur.Resp.J. 1989.-N2.-P.267-274.
Pathogenetic therapeutic decision of immunotherapy

in the patients with infection-dependent bronchial
asthma.
Kostina E.M.1
1
Government Education Institution of Additional Professional Education of the Federal Agency

of Public Health Service and Social Development Penza Institution of Advanced Medical
Studies, Allergology and Clinical Immunology Department, Penza, RF
Abstract
Efficacy of the methods of immunotherapy in the treatment of infection-dependent
bronchial asthma is discussed up to date. This work is devoted to the study of efficacy of different immunotherapy methods (allergen-specific immunotherapy with
Neisseria Perflava and immunotherapy with Rusam) and its prescription according to
the pathogenesis of disease in the patients with infection-dependent bronchial asthma.
Key words: infection-dependent bronchial asthma, immunotherapy, allergen-specific
immunotherapy, Neisseria Perflava, Rusam.
1. Introduction
Bronchial asthma (BA) is the one of the most widespread diseases of allergic
pathology that lowers quality of life and is the important socio-economic problem of
modern medicine. Up to date there is the discussion about detection of different clinical pathogenetic types of the disease. Infection-dependent bronchial asthma (IDBA)
is not recognized by all medical scientists and doctors in spite of finding of allergic
type of BA in less than 30% of patients. And with it infectious factor acts as disease
inductor and trigger in the most part of patients [1,7,8,9,10].
Allergen-specific immunotherapy (ASIT) remains the most effective pathogenetic treatment mode in the patients with allergic diseases. ASIT efficacy makes up
between 70% and 92% according to the data of different authors [1,2,5,6]. However,
there is the part of patients, who has a little response to ASIT and in the number
of cases there is no response to ASIT. It demands more in-depth study of causes of
unsatisfactory results of therapy and developing the differentiated approaches to the
immunotherapy (IT).
Allergic hypersensitivity develops through the including of immune mechanisms
N915L5020
99
100
which may be immunoglobulin E (IgE)-mediated and non-IgE-mediated. IgE-mediated

mechanisms may be atopic and not atopic [3,4,5]. The presence and intensity of
nonspecific mechanisms affects on the ASIT efficacy [3,4,5].
Many works is devoted to study of ASIT mechanisms and efficacy in the treatment
of allergic diseases conditional on pollen and hosehold sensitization. Questions about
ASIT in the patients with bacterial sensitization are still under discussion. Patients`
selection criteria for ASIT with bacterial allergens are insufficiently developed [1,5].
Taking aforesaid into account, we were interested in study of ASIT efficacy in the
treatment of different clinical pathogenetic types of IDBA.
2. Objectives
To increase the efficacy of the IDBA treatment in view of pathogenetic mechanisms of disease.
3. Materials and methods

168 patients with IDBA have been examined. All patients were provided with the
complex clinical laboratory and allergic immunologic examination both before and
after treatment.
Clinical laboratory examination included clinical disease course analysis, instrumental examination for the purpose of detection of nidi of chronic infection, respiratory
function examination.
Allergic immunologic examination included skin test (what was developed by V.N.
Fedoseeva) with native bacterial allergen Neisseria Perflava (LLP Medall production,
Moscow (State research center Institution of Immunology)). Total IgE level tests
and the tests of the level of specific IgE-antibodies (sIgE-AB) to bacterial allergens
were provided. Parameters of both humoral link and T-cells link of immunity were
studied. Cytokines` level test were provided.
The most patients (92.3%) have the clear connection of BA exacerbation with viral
infection addition, what worsens the patient condition and leads to chronic course of
bacterial inflammation. 98% of patients were detected to have different concomitant
diseases of respiratory and gastrointestinal tract.
Chronic pathology of upper airways preceded development of clinically apparent
asthmatic fits in the 1/3 of cases of the patients with BA. Additionally to the BA
64 patients were detected to have infection-allergic rhinosinusitis which significantly
worsened the BA clinical course.
Long and sluggish inflammation process was characterized by torpidness to the
anti-inflammatory and antibacterial therapy what is indicative of clinical manifestation
of the secondary immunodeficiency.
4. Results and discussion

Patients were divided on 3 groups: group 1 consisting of the 65 patients got ASIT
with Neisseria Perflava; group 2 consisting of 48 patients got the therapy with Rusam and the group 3 (control group) consisting of 55 patients got anti-inflammatory
therapy with the inhaled glucocorticosteroids (IGCS) according to the BA consensus.
101
Skin allergic reactions on the Neisseria Perflava allergen was characterized with
different intensity level (between 1 + and 3-4 +). Total IgE serum level in the
patients was between 25 IU/ml and 300 IU/ml and it averaged 109,30 10,20 IU/
ml. Patients with intensive immediate skin allergic reactions (3-4 +) were odserved
to have increased total IgE level. The values of sIgE-AB to the Neisseria Perflava
were registered within lower and medium levels (class I and II) and a part of patients
had higher levels of sIgE-AB to the Neisseria Perflava (class III). Efficacy of ASIT
in the group 1 were the best (89,5%) in the patients with IgE-mediated mechanism
of BA and were significantly lower (60%) in the patients with nonspecific (non-IgEmediated) mechanisms of BA.
Clinically, there was the significant decrease of BA severity and BA symptomatic
relapses rate, decrease of necessity in the baseline therapy, improvement of indices of
bronchial and nasal breathing, decrease of the rate of relapses of concomitant nidi of
chronic infection. There was recorded the significant decrease of total IgE level from
123.8 21.6 IU/ml to 82.7 3.4 IU/ml (p < 0.05) and the decrease of intensity of
skin allergic reactions on the allergen Neisseria Perflava from positive to the negative one (in 10 patients) what confirmed the hyposensitizing action of ASIT with the
allergen Neisseria Perflava in the patients with BA.
At the background of ASIT the dynamics of the immune indicators were characterized with the following changes: significant increase of blast-transformation reaction
with PHA from 58.1 1.1 to 66.0 1.2 (p < 0.05), NK-cells level increase from 12.0
0.7% to 21.2 0.9% (p < 0.05), CD95+ level increase from 17.4 2.5% to 41.0
1.1 (p < 0.05), CD16+ level increase from 12.0 0.7 to 21.2 0.9% (p<0,05),
CD25+ level decrease from 10.7 1.9 to 6.2 0.4% (p<0,05). There weren`t detected the significant dynamics of IgA, IgM, IgG levels during ASIT. Examination of
serum factors indicated the reliable dynamics of interleukins (IL) levels: IL-2 level
decrease from 123.8 21.6 pg/ml to 82.7 3.4 pg/ml (p < 0.05), IL-4 level decrease
from 570.0 90.6 pg/ml to 360.0 29.4 pg/ml (p < 0.05), g-interferon (g-INF) level
decrease from 56.9 11.7 pg/ml to 32.6 2.7 pg/ml (p < 0.05).
Findings indicate that during ASIT there is the depression of Th2-dependent response with the immediate activation of Th1-limphocytes and g-INF producing what
prevents the development of allergic process in the patients with bacterial sensitization
Efficacy of immunotherapy with Rusam in the group 2 was 74.8%. During the
therapy we indicated the decrease of skin allergic reactivity, the changes in total IgE
level and sIgE-AB level (p < 0.05). Positive clinical effect was accompanied with the
increase of levels of activation markers: CD25+ level increase from 11.7 1.9% to
15.1 1.3% (p < 0.05), IL-2 level increase from 6.5 0.9 pg/ml to 16.5 1.2 pg/
ml (p < 0.05). Rusam doesn`t have hyposensitizing action on specific mechanisms of
allergic inflammation in the patients with bacterial sensitization. Anti-inflammatory
effect of Rusam determines its use in treatment of IDBA.
Patients of the group 3 (who didn`t get immunotherapy) wasn`t detected to have
changes in the levels of the indicators of the humoral and T-cells links of immunity
and dynamics of skin tests during the 1 year of observation.
1/3 of these patients are observed to have the worsening of the disease course,
worsening of respiratory function and increase of IGCS use.
102
5. Conclusion.
The efficacy of ASIT with allergen Neisseria Perflava is defined by clinical pathogenetic mechanisms of IDBA development. The best results were observed in the
patients group with the immune (IgE-mediated) mechanisms. Rusam may be used as
immunotropic anti-inflammatory medication in the patients with the prevalence of
nonspecific BA mechanisms.
References.
[1] Pyckij V.I. (2008). Mechanisms of arising and developing of bronchial asthma and the
baseline principles of its treatment. Pharmarus Print Media, Moscow. p.53.
[2] Johanson S.G.O. (2002). A revised nomenclature for allergy a condensed version of the
EAACI position statement from the EAACI nomenclature task force. Allergy end Clin.
Immunol. Intern. V.14. (6). pp.279-287.
[3] Pyckij V.I. (2000). Atopy and the group of atopic and pseudo-atopic diseases. Therapeutic
archive. N12. pp. 64-67.
[4] Pyckij V.I. (2005). Non-immune mechanisms in the pathogenesis of the atopic diseases`
group. Allergology and immunology. V.6. N1. pp.98-105.
[5] Fedoseeva V.N., Molotilov B.A., Larina O.N., Fedoskova O.U. (2004). Bacterial allergy.
Penza. P. 213.
[6] Fedosova L.B., Pyckij V.I., Filatov O.U. (2003). Efficacy of specific allergovaccination in
the patients with different combination of immune and non-immune mechanisms of atopy
developing. Allergology and immunology. V.4. N3. pp. 104-115.
[7] Oehling A. (1999). Bacterial infection as an impotant triggering factor in bronchial asthma.
J. Invest. Allergol. and Clin. Immunol. V.9. N1. pp.6-13
[8] Oehling A. (1999). Bacterial infection in the aetiology of bronchial athma. Pat. physiol.
N1. pp.6-9
[9] Guilbert T.W., Denlinger L.C. (2010). Role of infection in the development and exacerbation of asthma. Expert Rev Respir Med. 4(1). pp. 71-83
[10] Ikeda K., Yokoi H., Kusunoki T., Saitoh T., Yao T., Kase K., Minekawa A., Inoshita
A., Kawano K. (2011). Bacteriology of recurrent exacerbation of postoperative course
in chronic rhinosinusitis in relation to asthma. Auris Nasus Larynx. 38(4). pp. 469-73.
Asthma and Chronic Bronchitis Risk Factors in the

Scope of INSPIRAR Study
Neuparth Nuno1, Martins Pedro1, Caires Iolanda1, Lopes Claudia1,
Marques Joo2, Borrego Carlos3, Lopes Myriam3
1
CEDOC, Departamento de Fisiopatologia, Faculdade de Cincias Mdicas, Universidade Nova
de Lisboa, Portugal
2
Servio de Imunoalergologia, Hospital de Dona Estefnia, Centro Hospitalar de Lisboa
Central, Portugal
3
GEMAC, Departamento de Ambiente e Ordenamento, Universidade de Aveiro, Portugal
E-mails: nuno.neuparth@fcm.unl.pt, nneuparth@gmail.com
Abstract
Introduction: Chronic respiratory diseases constitute a major public health problem,
existing nowadays several identified risk factors.
Methods: In the INSPIRAR project we performed an observational, case-control
study, involving workers from a group of plants in the city of Estarreja (cases) and
a control group of the same county. In May 2011 both groups were studied through
the application of a medical questionnaire, adapted from the BOLD study. In addition, we performed spirometry with bronchodilation to all participants. The diseases
considered for analysis were: physician-diagnosed asthma and presence of symptoms
of chronic bronchitis.
Results: 360 individuals were evaluated. The mean age was of 43.9 10.6 years
and 67.1% were male. The frequency of reported diagnosis of asthma was 6.4% and
5.3% reported symptoms of chronic bronchitis. In spirometry analysis, 5.0% of the
subjects had an FEV1/FVC ratio <70% after administration of a bronchodilator. From
the several variables considered - age, sex, smoking and dusty work place only
current smoking persisted in the multivariate analysis, as a significant risk factor for
chronic bronchitis (OR: 2.93, 95% CI: 2.09 168,70, p = 0,009). We didnt find any
association between asthma and the variables studied. The concordance between the
existence of a FEV1/FVC <70% and asthma or chronic bronchitis was low.
Conclusion: Like other studies, smoking seems to be the most important risk
factor for chronic bronchitis. The low correlation between spirometry and chronic
bronchitis could suggest an underreport of the diseases.
Project funded by Fundao para a Cincia e Tecnologia INSPIRAR Project
PTDC/AAC-AMB/103895/2008.
P421C0014
103
104
Keywords: Chronic respiratory diseases, Asthma, Air pollution, Bold questionnaire,

Industrial environment.
1 Introduction
Over the last years, scientific community has become increasingly aware of potential
impacts on air quality and human health caused by the presence of harmful substances in
the environment. Studies [1-6] based on complete assessments of air quality and human
exposure in urban areas have been major contributors to the better evaluation of air pollutants impact on human health, especially in sensitive groups such as children, elderly
and asthmatics. With the continuous increase of hardware capabilities, new modelling
tools are being developed worldwide, including in the Universidade de Aveiro. In the
scope of research projects [3; 6; 7] or doctoral programs [1; 7; 8], several models for
different purposes have been developed, tested and validated with a published accuracy
of its modelling results. Among others, the Air Quality Forecasting System [8; 9] the
local scale VADIS model [10], the exposure MEXPO model [1] and the accidental release assessment RISCAV model [7]. Nevertheless, the development of a local/regional
modelling system, for air quality and exposure assessment, in industrialized urban areas is
one of the urgent developments nowadays. The integration of available tools concerning
emission [9], dispersion and exposure [1] in a local/regional scale modelling system is a
valuable decision-support tool for present and future control regulations.
Parallel to air quality impacts, epidemiological studies have shown that, occupational
chronic respiratory diseases represent, in highincome countries, as well as in low- and
middle-income countries, a public health problem with substantial economic implications
[11]. Preventing such diseases is therefore extremely important. The workplace environment
contributes significantly to the general burden of asthma [12] and chronic obstructive
pulmonary disease (COPD) [13] but information on prevalence is difficult to obtain. The
population attributable risk of asthma and COPD arising from work exposure is estimated
to be up to 15% [14]. To have an idea of the magnitude of the problem, the worldwide
mortality and morbidity from asthma, COPD, and pneumoconiosis arising from occupational airborne exposure were estimated for the year 2000 as 386.000 deaths and nearly
6.6 million DALYs (disability adjusted life years) [15].
A combination or air quality and exposure modeling with epidemiological approaches
and/or prospective studies, provides a basis for an integrated assessment of exposure to
industrial air pollutants and human health in industrialized urban areas.
2 methods
INSPIRAR project aims to develop a multidisciplinary methodology for air quality,
exposure and population health impacts assessment, from the emission of industrial
pollutants in an industrialized urban area. The proposed study methodology includes
two main approaches, namely, the application of computational modeling tools that
allow quantifying the contribution of industrial activity on air quality and exposure,
and an epidemiological approach for the individual and populational health characterization, especially for industrial workers. The methodology is being applied to the
Estarreja region, an urban area that has one of the largest chemical complexes in
Portugal, which is currently under expansion.
105
The Epidemiological approach consists in a medical evaluation based on the

analysis of statistical indicators of population health and on the application of the
Portuguese version of the standardized BOLD study questionnaire on chronic diseases,
risk factors and respiratory function tests for two sample groups, a control group of
outpatients recruited in Estarrejas population and a group of industry workers. After
the questionnaire, a spirometry is also performed.
The sample of workers will be monitored throughout the project duration twice a
year. On the other hand, the control outpatients group will be monitored in the first
and the last evaluations. The INSPIRAR project aims to create methods of analysis
and provide information to support decision making, particularly in the of air quality
management and prevention of risks related to exposure and health effects. It may
also contribute to the awareness and public information, especially the most affected
population by the proximity to industrial complexes.
This paper constitutes a report of INSPIRAR project - phase 1. We performed an
observational, case-control study, involving workers from a group of plants in the
city of Estarreja (cases) and a control group of the same county. In May 2011 both
groups were studied through the application of a medical questionnaire, adapted from
the BOLD study. In addition, we performed spirometry with bronchodilation to all
participants. The diseases considered for analysis were: physician-diagnosed asthma
and presence of symptoms of chronic bronchitis. Chronic Obstructive Pulmonary
Disease (COPD) was considered when FEV1/FVC after administration of a bronchodilator was less then 70%.
3 results
360 individuals were evaluated, 184 workers and 176 controls. The mean age
was of 43.9 10.6 years and 67.1% were male. Fig. 1 shows the distribution of the
considered diseases.
Fig. 1 - Frequency of reported diagnosis of asthma, symptoms of chronic bronchitis and COPD.
(*) post-BD after bronchodilation
From the several variables considered age, sex, smoking and dusty work place
only current smoking persisted in the multivariate analysis, as a significant risk factor
for chronic bronchitis (OR: 2.93, 95% CI: 2.09 168,70, p = 0,009) (Tables 1 and 2).
106
We didnt find any association between asthma and the variables studied. The
concordance between the existence of a FEV1/FVC <70% and asthma or chronic
bronchitis was low.
4 discussion
These preliminary results from the INSPIRAR study was obtained in 184 workers
from a group of plants in the city of Estarreja and in 176 controls, living in Estarreja,
using a observational, case-control approach. From the application of a translated
version of the BOLD Questionnaire [16], it was possible to identify those [with a
physician-diagnosed asthma and those with symptoms of chronic bronchitis. All subjects
performed basal spirometry and after bronchodilation. Those with bronchial obstruction (FEV1/FVC<70%) after bronchodilation were considered as COPD patients. The
frequency of the reported diagnosis of asthma [17], symptoms of chronic bronchitis,
and that of COPD [18], were in accordance with published results.
Concerning multivariate analysis looking for risk factors in chronic respiratory
diseases, in this study only smoking was found significant. Taking this into account,
in subsequent analysis, exposure should be be corrected to smoking status. On the
other hand, the low correlation observed between spirometry and chronic bronchitis,
suggests an under-report of this disease as it was found previously in other studies [11].
For the studied variables (age, gender, smoking and dusty work place) we didnt
find any associations with asthma. Finally, there was no concordance between asthma
and airflow limitation as it might be expected.
107
5 Conclusion
Like in other studies, smoking seems to be the most important risk factor for
chronic bronchitis. The low correlation between spirometry and chronic bronchitis
could suggest an under-report of this disease.
References
[1] Costa AM. 2008. Microscale modelling of exposure to atmospheric pollutants in urban
areas. Universidade de Aveiro., Aveiro
[2] Hanninen O, Kruize H, Lebret E, Jantunen M. 2003. EXPOLIS simulation model: PM2.5
application and comparison with measurements in Helsinki. J Expo Anal Environ Epidemiol
13:74-85
[3] Borrego C. MAI, Ferreira J., Costa A.M., Amorim J.H., Valente J., Martins H., Santos J.,
Lopes M., Santos P., Monteiro A.M., Tavares R. 2008. Projecto PAREXPO - Relatrio
Final (POCI/AMB/57393/2004), Universidade de Aveiro, Aveiro
[4] L.-J. Sally Liu IC, Dirk Keidel, Jurg Heldstab, Nino Kunzli, Lucy Bayer-Oglesby, Ursula
Ackermann-Liebrich, Christian Schindler, and the SAPALDIA team. 2007. Characterization
of Source-Specific Air Pollution Exposure for a Large Population-Based Swiss Cohort
(SAPALDIA). Environmental Health Perspectives 115:1638-45
[5] Borrego C. LM, Valente J., Tchepel O., Miranda A.I., Ferreira J. . The role of PM10 in air
quality and exposure in urban areas. Proc. Transactions on Ecology and the Environment,
Skyathos, Greece, 2008, 116:511-20: WIT Press
[6] Borrego C., Neuparth N., Carvalho A.C., Carvalho A., Miranda A.I., et al. 2008. A Sade
e o Ar que Respiramos Um Caso de Estudo em Portugal. pp 125. Lisboa: Fundao
Calouste Gulbenkian
[7] Tavares R, Santos P, Amorim JH, Costa AM, Miranda AIa, Borrego C. Modelling system for
accidental release of atmospheric contaminants in a sea port. . Proc. 2nd International Conference on Harbours, Air Quality and Climate Changes, Rotterdam, the Netherlands., 2008:
[8] Monteiro A, Miranda AI, Borrego C, Vautard R, Ferreira Ja, Perez AT. 2007. Long-term
assessment of particulate matter using CHIMERE model. . Atmospheric Environment
41:7726 - 38
[9] Monteiro A., Vautard R., Lopes M., Miranda A.I., C. B. 2005. Air Pollution Forecast in
Portugal: a demand from the new Air Quality Framework Directive. International Journal
of Environment and Pollution 2:25
[10] Borrego C., Tchepel O., Salmim L., Amorim J.H., Costa A.M., J. J. 2004. Integrated modelling of road traffic emissions: application to Lisbon air quality management. Cybernetics
and Systems. An International Journal 35:535- 48
[11] Martins P, Rosado-Pinto J, do Ceu Teixeira M, Neuparth N, Silva O, et al. 2009. Underreport and underdiagnosis of chronic respiratory diseases in an African country. Allergy
64:1061-7
[12] Vandenplas O, Toren K, & , Blanc PD. 2003. Health and socioeconomic impact of workrelated asthma. Eur Respir J 22:689-97
[13] Trupin L, Earnest G, San Pedro M, Balmes JR, Eisner MD, et al. 2003. The occupational
burden of chronic obstructive pulmonary disease. Eur Respir J 22:462-9
[14] Balmes J, Becklake M, Blanc P, Henneberger P, Kreiss K, et al. 2003. American Thoracic
Society Statement: Occupational contribution to the burden of airway disease. Am J Respir
Crit Care Med 167:787-97
[15] Driscoll T, Nelson DI, Steenland K, Leigh J, Concha-Barrientos M, et al. 2005. The global burden of nonmalignant respiratory disease due to occupational airborne exposures.
American Journal of Industrial Medicine 48:432-45
108
[16] Buist AS, Vollmer WM, Sullivan SD, Weiss KB, Lee TA, et al. 2005. The Burden of
Obstructive Lung Disease Initiative (BOLD): rationale and design. COPD 2:277-83
[17] To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, et al. 2012. Global asthma
prevalence in adults: findings from the cross-sectional world health survey. BMC Public
Health 12:204. [Epub ahead of print]
[18] Pauwels RA, Buist AS, Ma P, Jenkins CR, SS; H, Committee. GS. 2001. Global strategy
for the diagnosis, management, and prevention of chronic obstructive pulmonary disease:
National Heart, Lung, and Blood Institute and World Health Organization Global Initiative
for Chronic Obstructive Lung Disease (GOLD): executive summary. Respir Care 46:798825
The patternof patients with frequent acute

exacerbations of chronic obstructive pulmonary disease
(AECOPD)
Grzetic-Romcevic T.1, Sonc S.1, Devcic B.2
1
2.
Pulmonary Department of the Hospital Sezana, Cankarjeva 3, Sezana, Slovenia

Clinic of Pulmonary Disease and Allergy , University Clinical Centre, Ljubljana , Slovenia
Summary
The aim of this study was to establish the pattern of patients with frequent acute
exacerbation of COPD. The study was carried out from 1 January to 31 December
2011 on 224 consecutive patients with COPD who were attending the out-patient clinic
(Sezana). The diagnosis of COPD and classification of severity was made according to
the GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria. Patients
with two or more exacerbations during the year were considered to have frequent
exacerbations. A total of 86 patients (38.3%) reported 128 AECOPD. Out of these,
60% of them experienced one exacerbation and 40% two or more exacerbations. A
total of 53.8% of the patients with one AECOPD had been hospitalised during the
year for this reason. Of the patients with frequent exacerbations, 82% had undergone
hospitalization. The frequent exacerbators had a AECOPD of 2.11.5 in the past year
while those with one exacerbation had had a 0.41.1 AECOP. The patients with one
exacerbation comprised 85% males and the frequent exacerbators 45% males. Breaking
down the disease into stages of severity, the group of frequent exacerbators consisted
of 41% patients in the moderate stage,12% in the severe stage and 47% patients in
the very severe stage of the disease. The group with one exacerbation comprised 69%
patients in the moderate stage, 12% in the severe stage and 19% in the very severe
stage of the disease.
Introduction
Patients with chronic obstructive pulmonary disease (COPD) often have an acute
exacerbation of COPD (AECOPD). AECOPD is currently defined as a sustained
worsening of the patients condition, from the stable state and beyond normal dayto-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD (1). AECOPD had negative implications on
P421C0017
109
110
Figure1. Number of AECOPD in COPD patients
health related QOL (2), pulmonary function (3), increased risks of hospitalisations
and death (4). Some evidence suggests that more frequent exacerbations accelerate
the progression of COPD (5). There is increasing interest in patients with frequent
exacerbation of COPD. Therefore frequent exacerbators have been proposed as one
of several clinically distinct phenotypic characteristics of this heterogeneous disease
that has prognostic, therapeutic and mechanistic implications for the long term course
of the disease (6).

Between January and December 2011, a total of 224 consecutive patients with
COPD attending the out-patient clinic (Sezana) participated in the study. The average
age of the patients was 73.17.9 years (79% males). A spirometry was performed on
all the participants. The FEV1 and FVC were recorded following the American Thoracic Society guidelines (7) on a spirometer flow screen jaeger (Jaeger, Wuertzburg,
Germany). A bronhodilatatory test was performed with the inhalation of salbutamol
(4 puffs of 100 mcg of salbutamol).We used the Gold definition of reversibility
(FEV1 increase of 200 ml and 12% improvement above baseline FEV1 following
administration of the bronchodilator). The values were expressed as a percentage of
the predicted value. Bronchoconstriction was diagnosed if the FEV1/FVC ratio was
<0.7 (according to GOLD guidelines). Classification of COPD by severity was made
according to GOLD guidelines based on the post-bronchodilator FEV1 (predicted
percentage) as follows: Gold I (mild), >80%, Gold II (moderate), 50-80%, Gold III
(severe), 30 50%, and very severe <50% or <50% plus chronic respiratory failure (8).
Predicted values were those of the European Community for coal and steel approved
by the European Respiratory Society (9). Patients with two or more exacerbations
during the year were considered to have frequent exacerbations.
Results
There were 128 acute exacerbations (mean 1.8: range 1 to 3.) in the 86 patients
over the follow up year. During the 1- year period, 52 patients reported one exa-
111
Table1. Baseline characteristics of COPD patients with frequent and non-frequent exacerbations
Table2. Smoking status among COPD patients with frequent and non- frequent exacerbations
cerbations and 34 patients reported two or more exacerbations. Among the frequent
exacerbators, 26 patients experienced two and 8 patients three.
The baseline characteristics of patients with COPD-related frequent and non-frequent
exacerbators are shown in Table1.
The mean age of the total group was 73.17.9 years with no differences in the
age of patients with frequent and those with non-frequent exacerbations. The majority of the patients were male (79%). Differences between the proportions of males
in the group with frequent exacerbators (45%) and the group of the non-frequent
exacerbators (85%) did however exist. Male were predominantly in the group of
non-frequent exacerbators.
There were no differences in smoking habits between these two groups. The greatest number of patients with frequent and non-frequent readmissions due to COPD
comprised ex-smokers. A few persons of each group were current smokers.
A total of 28 patients (53.8%) with one AECOPD had undergone hospitalization
while the remainder had received treatment at the out-patient clinic. Among the
112
Figure 2. Frequency of hospitalizations for AECOPD
Figure 3. Gender distribution of patients with AECOPD
frequent exacerbators, 28 patients (82%) had been hospitalized while the remainder
also receiving treatment at the out-patient clinic. Fourteen patients had undergone one
hospitalization (50%), 6 two hospitalizations (21%) and 8 patients three hospitalizations
(29%). The frequent exacerbators had a AECOPD of 2.11.5 in the past year and the
patients with one exacerbation 0.4 1.1 AECOPD in the past year.
113
Figure 4. Classification of the severity of COPD according to GOLD
Among the group of the patients with one exacerbation, 85 % were male (44
patients) while the group of frequent exacerbators predominantly comprised females
or 55% (19 patients).
According to the stage of the disease, the frequent exacerbators comprised 41%
patients with the moderate stage of the disease, 12% with the severe stage and 47%
with the very severe stage of the disease. Of the group of patients with one exacerbation, 69% had the moderate stage of the disease, 12% the severe stage and 19%
the very severe stage of the disease.
Conclusions
In this study, frequent exacerbators were compared to non-frequent exacerbators
along with associated factors. These results suggest that the patients with frequent
AECOPD have more exacerbations, regardless of the severity of the disease. Similar
findings were found in the ECLIPSE study, where the authors found that one group
of patients appeared to be susceptible to exacerbations, irrespective of the disease
severity as defined by spirometric assessment of the lung function (10). In our study, the frequent exacerbators underwent more hospitalizations, were predominantly
female and had had a larger quantity of prior exacerbations. The high rate of prior
exacerbations and high rate of hospital readmission were consistent with prior findings
(10). The observation of gender-based differences in exacerbation frequency is intriguing. All these results should be considered with caution for our group of subjects
was not a population sample, but a sample of symptomatic patients known to the
respiratory physician with further confirmation needed from prospective longitudinal
studies. These results also suggest that the phenotype of frequent exacerbations may
best be described as an exacerbation-susceptibility phenotype in which persons with
the phenotype are prone to exacerbations as a result of intrinsic susceptibility and
exacerbations on exposure The frequent exacerbator is a phenotype that is associated
114
with worse clinical outcomes.(3) Therefore, identification of patients with frequent

exacerbations is clinically important since effective therapeutic options which reduce
the frequency of these events are currently available. A better understanding of the
underlying mechanisms that predisposes a patient to exacerbations could lead to the
development of a more effective preventive therapy (11).
References
1. RODRIGUES- ROISIN R. Towards a consensus definition for COPD exacerbations. Chest
2000; 117:398s-401s.
2. SEEMUGAL TA, DONALDSON GC, PAUL EA, BESTALL JC, JEFFRIES DJ, WEDZICHA
JA. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary
disease. American Journal of Respiratory Critical Care Medicine 1998; 157:1418-1422.
3. DONALDSON GC, SEEMUGAL T.A, BHOWMIKA, WEDZICHA JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary
disease Thorax 2002; 57:847-852.
4. SOLER-CATALUNA JJ, MARTINEZ-GARCIA MA, ROMAN SANCHEZ P, SALCEDO
E , NAVARRO M, OCHANDO R. Severe acute exacerbations and mortality in patients
with chronic obstructive pulmonary disease. Thorax 2005; 60: 925-931.
5. DONALDSON GC, SEEMUNGAL TA, BHOWMIK A, WEDZICHA JA. Relationship
between exacerbation frequency and lung function decline in chronic obstructive pulmonary
disease. Thorax 2002; 57:847-852.
6. HANMK, AGUSTI A, CALVERLEY PM ET AL.COPD phenotypes: the future of COPD.
American Journal of Respiratory Critical Care Medicine 2010:182:598-604.
7. AMERICAN THORACIC SOCIETY. Standardization of spirometry 1994 update. American
Journal of Respiratory Critical Care Medicine 1995; 152:1107- 36.
8. Global Initiative for Chronic Obstructive Lung disease available on http://www.goldcopd.
com/
9. QUANJER PH , TAMMELING GJ, COTES JE, PEDERSEN OF, PESLIN R, YERNAULT
JC. Lung volumens and forced ventilatory flows. Standardization of lung function tests.
European Community for Steel and Coal. Official Statement of the European Respiratory
Society. Eur Respir J 16 Suppl: 5 40, 1993.
10. HURST JR, VESTBO J, ANZUETO A ET AL. Susceptibility to exacerbation in chronic
obstructive pulmonary disease. N Engl J Med 2010; 363:1128-1138
11. TASHKIN D.P. Frequent exacerbations of Chronic Obstructive Pulmonary Disease - A
distinct phenotype? N Engl J Med 2010; 363:1183-1184.
Immunological characteristics ofcommunity-acquired

pneumonia inold patients
Andriesh Lucia1, Barba Doina1, Berezovskaya Elena1, Blaja-Lisnic Natalia1,
Samotiya Evghenia2
Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova
National Centre of Geriatrics and Gerontology, Institute of Oncology, Chisinau, Moldova
E-mail: imunlab@mail.ru
1
2
Abstract
The main pathogen in community-acquired pneumonia (CAP) in old people is
Streptococcus pneumoniae. Chlamydia pneumoniae is not observed in the elderly
patients with CAP. The onset of the CAP in the old patients is in most cases uncharacteristic. However, when the Streptococcus pneumoniae is present the symptoms
can be similar to those of CAP in younger people. The objective changes (percussion,
auscultation) do not differ essentially from those in the younger patients. The values
of leucocytes, lymphocytes, erythrocyte sedimentation rate, C reactive protein, and
fibrinogen in most cases do not deviate significantly from the normal data in elderly
patients. At the same time the signs of intoxication can be more expressive in this
age group. The period of recovery from CAP is longer and the normalization of the
clinical symptoms and the paraclinical data takes place slower in the old patients with
CAP. The results of the immune status examination denote the important decrease
of cellular immunity, modifications of the humoral immunity, a decreased regulatory
function and a low capacity of infection control in the presence of the associated
pathologies. Pneumonia has a poor picture and a protracted evolution when the severe
disturbances of the immunity exist. When the immune response is preserved, the old
patient develops a classic pneumonia.
Keywords: Community-acquired pneumonia, old age, immunity status.
1 Introduction
Pneumonia presents a major cause of morbidity for people of different ages all
over the world. For instance, the morbidity index in the USA is equal to 1016
per thousand (1016). In Great Britain, Russia, France, and Ukraine this index
is equal to 1011, 3.9, 1011, 4.7, respectively [1-9]. In the Republic
of Moldova 22,000 persons suffer from pneumonia annually and the death-rate is
N915R9004
115
116
equal to 5.4 [2]. With age increase the risk to contact pneumonia increases, the
number of hospitalizations and the mortality from this disease also increases [6]. In
Moldova, in 2005 the mortality from pneumonia (reported per 100000 of persons)
was the following: 23.95 for persons with the age up to 64 years, 57.29 for patients
over 65 and 75.02 for persons older than 75 years [3]. Ageing leads to the reduction
of regulatory functions and the capacity of adaptation of the body to the medium as
well as to the reduction of the defence functions against different infections. Seniors
with associated pathologies run the risk to fall ill with pneumonia [1]. It is difficult
to diagnose pneumonia for seniors at early stages because the disease may manifest
itself through a poor or atypical symptomatology [5, 7]. Meanwhile, the diagnosis
determined in time and correct therapeutic tactics are of vital importance since for
elderly people pneumonia is accompanied by different complications as well as by
worsening of the primary disease [7, 8]. Starting from said above it can be concluded
that the question of pneumonia for seniors is very pressing.
The objectives of the present work consist in the following:
1. Determination of the aetiologic features of the community-acquired pneumonia
in elderly people.
2. Study and systematization of clinical and evolutional features of the communityacquired pneumonia in elderly people.
3. Examination of the immunity status in patients with the community-acquired
pneumonia.
2 Materials and research methods

238 patients with community-acquired pneumonia (CAP) have been examined.
The patients were divided into two groups (Canadian classification, 2000). The I
group included 149 patients with the age over 65 years (the main group); the II
group included 89 patients with the age up to 65 years (the comparison group).
All patients passed the following examinations: clinical examination, blood and
urine analyses, biochemical analyses, ECG, radiological exam of the lungs. The
phlegm analysis (general, biological, and BK examination) was recommended
to all patients. The anti-Chlamydia pneumoniae IgM and IgG, anti-Mycoplasma
pneumoniae IgM and IgG antibodies were determined with ELISA method. The
CD3+, CD4 +, CD5 +, CD8 +, CD16 +, CD19 +, CDHLA DR+ populations of lymphocytes were estimated with the aid of the immunofluorescent method with
monoclonal antibody activation. The immunoglobulins A, M, G were determined
with immunoturbometric method.
3 Results
The aetiology of CAP was determined in 62.4% patients from the main group and
in 74.2% patients from the comparison group (Fig. 1).
Along with pneumonia all old patients presented associated pathologies. On the
contrary the young patients in 25% cases had only CAP. The cardiovascular associated
pathologies predominated in old patients (67.8% for arterial hypertension, 77.2% for
ischemic heart disease, 80.5% for cardiac failure); the respirator system pathologies
were more typical for young patients (54% cases). Some manifestations in the clinical
117
118
picture of CAP in old patients were different in comparison with those in younger
people (Table 1).
In seniors the paraclinical changes were frequently less expressive in comparison
with those for the younger patients. The values of sedimentation rate of erythrocytes
(SRE) are increased in all examined groups. However, in old patients, moderate increase of these values can be observed (1630 mm/h in 35% and more than 31 mm/h
in 41% of old patients). Another picture can be observed in younger patients with
CAP, who presented in 51% cases the value of SRE higher than 34 mm/h (p<0.05).
The C reactive protein (CRP) in patients with the age over 65 years is often negative
or has normal values (612 un/ml). Being increased (in 35.8% cases) this index does
not take on very high values (the mean value is 30.46.14 UDO). For younger people
with CAP high values of CRP are often characteristic (the mean value is 40.612
UDO). Fibrinogen is increased in old patients in 36.6% cases and in younger patients
in 47.7%. The urea values are increased only in 16.2% cases in younger patients
and in 35% cases in patients of the main group. The changes of immune status can
be also observed in patients with CAP (Table 2, 3). The more expressed changes of
immunity take place in the case of severe pneumonia.
The diagnosis of CAP was confirmed by radiological examination. In all the
119
examined cases the presence of pulmonary infiltration was detected. The radiological
changes do not differ essentially in both groups. The mean period of hospitalisation did
not differ essentially in both groups, being around 810 days. However, at the end of
the treatment along with general status normalisation, some manifestations persisted:
fatigue was observed in 49.7% of the elderly and in 19.1% of the young people,
cough was typical for 43.6% and 31.5% patients of these groups, respectively, there
was practically no difference in percussion and auscultation changes in both groups
of the patients at the end of treatment. However, the differences in the paraclinical
evolution were more evident: leukocyte formula normalisation was seen in 71.7% of
the elderly and in 85% of younger patients; the ESR normalisation presented 31.7%
and 42.1%, respectively, the CRP normalisation was seen in 73.1% of old patients and
in 86.7% of younger patients, the urea values become normal in 53.3 and in 80%,
respectively. As a result of the performed treatment 66.4% of the elderly and 73%
of the younger patients recovered, the remaining patients of these groups, 33.6 and
27%, respectively, presented amelioration. No one had negative outcome.
4 Discussion
The etiological structure of the old people group does not differ essentially from the
young one, in both groups Streptococcus pneumoniae being at the first place between
the pathogens. Chlamydia pneumoniae is uncharacteristic pathogen for pneumonia development in old people. The incidence of Mycoplasma pneumoniae is practically the
same in both groups. The clinical picture of CAP is less expressive in the old people,
dyspnoea, fatigability, nausea, general status alteration, passive position, presence of
peripheral oedema, superficial respiration, and tachypnoea being more typical than
for patients from the comparison group. Percussion and auscultation changes practically are the same in both groups. The mean values of the inflammation markers
are a little higher in the younger patients, but the percentage of CRP and fibrinogen
increase does not differ very much in both groups. The increased plasmatic levels of
the CRP in old patients are more typical for the CAP with Streptococcus pneumoniae
as well as for the cases with severe evolution. The fact that urea was higher in the
old people reflects the expressed intoxication syndrome which is conditioned by the
kidney function worsening in the presence of some infection (like pneumonia in our
case). The detoxication function in the old people is inadequate. The mean value of
leukocytes in studied groups falls to the normal limits. Very seldom leukocytosis can
be seen; leukopenia, practically, was not observed. The values of lymphocytes exhibit
120
a tendency to lymphocytopenia in patients from the main group. A remarkable decrease

of the CD19, CD3, CD4, CD5 lymphocyte population values and the tendency of the
CD16 to increase can be observed. The mean values of IgA and IgM are practically
normal, but the IgG is increased. The old patients with CAP who present increased
values of IgA, IgM and B lymphocytes demonstrate expressive manifestations of the
disease. In the majority of cases these pneumonias are provoked by Streptococcus
pneumoniae. In the younger people the IgM increase manifests the primary reaction to
the pathological process. In old people IgG can serve as the marker of the associated
chronic diseases like hepatitis, diabetes etc. According to our data the old patients
with CAP recover more slowly than the younger patients. After the treatment some
symptoms like cough, fatigability can persist. For older patients the period of normalisation of some paraclinical indices such as leukocytes, SRE, CRP, urea is longer
than in the younger patients with CAP.
5 Conclusions
The main pathogen in CAP in old people is Streptococcus pneumoniae. According
to our results, Chlamydia pneumoniae is not observed in the elderly patients with CAP.
The onset of the CAP in the old patients is in most cases uncharacteristic. However, when the Streptococcus pneumoniae is present the symptoms can be similar to
those of CAP in younger people. The objective changes (percussion, auscultation) do
not differ essentially from those in the younger patients. The values of leucocytes,
lymphocytes, erythrocyte sedimentation rate, C reactive protein, and fibrinogen in
most cases do not deviate significantly from the normal data in elderly patients. At
the same time the signs of intoxication can be more expressive in this age group.
The period of recovery from CAP is longer and the normalization of the clinical
symptoms and the paraclinical data takes place slower in the old patients with CAP.
The results of the immune status examination denote the important decrease of
cellular immunity, modifications of the humoral immunity, a decreased regulatory
function and a low capacity of infection control in the presence of the associated
pathologies. Pneumonia has a poor picture and a protracted evolution when the severe
disturbances of the immunity exist. When the immune response is preserved, the old
patient develops a classic pneumonia.
References
1. Bolibar A.J., Balanzo I., Risk factors for community-acquired pneumonia in adults: A
population-based case-control study. Eur Respir J. 1999; 13: 349.
2. Botnaru V. Pneumoniile. Ghid de practica medicala. FEP Tipografia Centrala, Chisinau,
1999: 100 p.
3. European health for all databases, WHO Regional Office for Europe, Copenhagen, Denmark,
2005. (www.euro.who.int/HFADB).
4. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis,
Assessment of Severity, Antimicrobial Therapy and Prevention. Am Thor Society, Am J
Crit Care Med. 2001; 163: 1730-1754.
5. Lim W-S., Macfarlane J.T. Defining prognostic factors in the elderly with community
cquired pneumonia: a case controlled study of patients aged >75 yrs. Eur Respir J. 2001;
17: 200-205.
121
6. Loeb M. Community-acquired pneumonia in older adults. Geriatrics and Gerontology

International 2005; 5: 75-81.
7. Riquelme R., Torres A., El-Ebiary M., Mensa J., Estruuch R., Ruiz M. Community-acquired
pneumonia in the elderly. Clinical and nutritional aspects. Am J Respir Crit Care Med.
2007; 156: 1908-1914.
8. Zalacain R., Torres A., Celis R., Blanquer J., Aspa J., Esteban L., Menendez R., Blanquer
R., Borderias L. Community-acquired pneumonia in the elderly: Spanish multicentre study.
Eur Respir J. 2003; 21: 294-302.
9. Sinopalnikov A.I. Modern recommendations on maintenance of patients with communityacquired pneumonia. Aktualnye voprosy pulmonologii i kardiologii 2003; 1-7. (in Russian).
Case Studies of Practical, Patient-centered,

Parsimonious Initiatives That Significantly Improve the
Care and Quality of Life for Patients with COPD
Lin Samuel, MD, PhD, MBA, MPA, MS, Casanova Danielle, MBA,
Jones Joyce, BA, Sanderson-Austin Julie, RN, Fisher Donald, PhD
American Medical Group Association, Alexandria, Virginia, U.S.A.
SUMMARY: This paper will provide an overview of a recent pilot collaborative

endeavor among 12 multispecialty medical practice groups that focused on how best
to improve the care of COPD patients. The groups accomplished this by establishing
clinical processes and protocols that incorporated principles of accountable care whose
calculated application resulted in meaningful outcomes in COPD care in the realms
of practicality, patient-centeredness and parsimony. (1)
INTRODUCTION: COPD is the fourth leading cause of death in the United
States and is the only major fatal illness for which there is still an increasing death
rate. U.S. death rates for COPD have doubled since 1970 while death rates for heart
disease and stroke have decreased. The U.S. National Institutes of Health predicts
COPD will be the U.S.s third leading cause of death by 2020. Patients with COPD
account for 20% of total U.S. hospitalizations. Annual U.S. economic costs of COPD
have been estimated to be $24 billion. (2,3)
In spite of these numbers, within health care settings, COPD has not been a high
priority for care-management as exemplified by the haphazard diagnosis and random
treatment of COPD patients in venues of primary care, specialty care, the emergency
department (ED) and inpatient facilities. Moreover, a recent survey indicated only
54% of primary care physicians were aware of recognized evidence-based COPD
guidelines compared to 94% of pulmonologists. It has been proposed that the primary
challenge has been the lack of infrastructure to accurately identify and appropriately
treat patients with a COPD diagnosis, e.g., a lack of routine, quality spirometry testing and electronic tracking of care and progress. Additionally, the lack of public
awareness of the prevalence of COPD has perpetuated a lackadaisical attitude towards
the urgency of its diagnosis and treatment. These reparable failings underscore the
need for targeted, aggressive interventions, particularly in primary care specialties,
to promote the diagnosis and management of COPD patients in synchrony with costeffectiveness and efficiency. (4,5,6)
P421C0028
123
124
The 12 health care organizations, whose work is featured herein, are members of
the American Medical Group Association (AMGA), a U.S.-based, non-profit, 60-year
old trade association whose mission is to improve care for patients by supporting
multi-specialty medical groups and other organized systems of care. AMGA represents
over 425 large medical groups in 49 states, employing 125,000 physicians who care
for 130 million patient lives. American Medical Group Foundation, AMGAs subsidiary
that fosters quality improvement in group practice through grants, educational and
research programs, provided financial support for this project. Anceta, AMGAs data
warehouse subsidiary, mines and analyzes de-identified COPD (and other) clinical and
claims data for comparative analytics of clinical protocols, outcomes, medication use,
efficacy and evaluation of quality care metrics between AMGAs member groups. (7)
AMGA defines accountable care as the practice of fully integrated and totally
coordinated patient-centered care whose principles include: (a) teamwork across
specialties and disciplines; (b) use of evidence-based guidelines; (c) dedicated care
managers; (d) interoperable electronic health records (registries and e-prescribing);
(f) systematic monitoring of quality and efficiency; and (g) reward for meaningful
outcomes. The relativity of these principles to the conduct and success of this COPD
collaborative will be discussed further on. (8)
MATERIALS AND METHODS: Twelve AMGA member organizations volunteered to participate in a pilot collaborative from November 2010 to November 2011
with the intent of improving chronic care management for patients with COPD. The
participants agreed to collect and submit clinical data in order to compare each the
others outcomes in diagnosis and treatment of COPD patients as a consequence of
various interventions for improving the management of COPD.
The working premise of the 12 groups was that soundly managed programs for
clearly identifying high-risk COPD patients and for delivering high-quality, evidencebased, coordinated COPD care services could reduce repetitive ED visits and inpatient
admissions. Several factors were determined by the groups to be common in substantiating this premise: (a) correct identification of patients with COPD; (b) a need
to educate practitioners in the use of evidence-based COPD clinical guidelines; (c)
transference of guidelines and their implementation by an electronic means of tracking
and analyzing (e.g., an electronic health record (EHR) and a COPD registry); (d) a
redesign of workflow and staff roles in order to generate optimal COPD care; and, (e)
coordination of consistent COPD management across the settings of primary, specialty, subspecialty and inpatient care. It was further postulated that implementing these
factors could result in optimal therapeutic regimens, tailored to the patient, that could
maximize COPD care processes and reduce hospitalizations and readmissions. (9,10)
Additionally, effective COPD care management was determined to have three parameters: (1) coordination and continuity of care, (2) patient-centered and self-managed
care and (3) patient adherence with evidence-based COPD guidelines. Identified subsets
of these parameters included: (a) routinely and systematically identifying individuals
with COPD; (b) stratifying those identified by high illness burden; (c) supporting a
patient-centric approach to self-management of COPD; (d) providing practitioners and
patients with COPD-specific education and communications of progress towards goals;
(e) measuring key quality measures to assess progress, satisfaction and outcomes;
and, (f) addressing gaps in patient adherence with quality improvement action plans.
It was postulated that applying these parameters could: (a) improve influenza and
125
pneumococcal immunization rates; (b) identify and provide interventions to smokers;

(c) improve diagnosis through increased use of spirometry; and, (d) improve clarity
in identification of related health problems. Finally, the Collaboratives overall intent in the management of patients with COPD was to: (a) improve their quality of
care; (b) maximize their quality of life; and, (c) reduce their rates of ED visits and
hospitalizations.
Common to the 12 groups, two specific measures were designated for comparative analysis: (1) percentage of patients, older than 18 years of age, with a diagnosis
of COPD who had had a documented evaluation by spirometry and (2) percentage
of patients, also older than 18 years of age, with a diagnosis of COPD who had an
FEV1/FVC <70%, were symptomatic and were prescribed an bronchodilator inhaler.
Also, common to the 12 groups, was the establishment of Clinical COPD Teams
comprised of various combinations of clinical staff including: (a) an overall COPD
program manager, (b) a pulmonologist, (c) a nurse practitioner as COPD clinical
care coordinator, and (d) clinical COPD champions embedded in primary care
departments. Additional comparative metrics, referenced below, were also employed
by different groups to demonstrate outcomes.
Patients with COPD were recruited through EHRs, claims data analysis and direct
clinician referrals (e.g., hospitalists, pulmonologists and adult primary care clinicians). Patients were initially contacted by letter and then by telephone by a care
coordinator to solicit their participation. Patients who enrolled were provided with
introductory educational literature and a self-management plan to review. Subsequently, care coordinators held intake calls and visits with the patients and these were
followed by regular clinical follow-up visits with a designated primary care team,
specialized Advanced Clinical Practitioners and/or pulmonary specialists. The intensity
of the patients management protocols and educational regimen was based upon an
assessment of their clinical or risk stratification of COPD.
Evidence-based, clinical standards for managing the recruited patient populations were
drawn from relevant standards of the Global Initiative for Chronic Lung Obstructive
Disease (GOLD), the National Committee for Quality Assurance and the American
Thoracic Society. Pre-set and expanded measures for monitoring and assessing patient
progress and program success included: (a) percent of patients with spirometry documented, (b) percent of patients not using tobacco products, (c) percent of patients
administered pneumococcal and flu vaccine, (d) percent of patients with advanced
directives and (e) provider satisfaction and patient experience surveys. Quality and
cost metrics also were monitored using standardized parameters including: (a) inpatient
days per thousand enrolled members, (b) skilled nursing facility days per thousand
enrolled members, (c) emergency department visits per through enrolled members and
(d) acute rehabilitation hospital days per thousand enrolled members. Per member
per month costs for enrolled patients were also tracked in areas of specific ancillary
diagnostic costs and total cost per member per month. During preliminary runs of
this initiative, modest adjustments of initial assessment tools were made, at times, in
order to align some of the metrics more closely with quality standards and to facilitate
the data collection and tracking processes. (11)
RESULTS: With regard to the two metrics common to all 12 groups, significant
increases were demonstrated in (1) percentages of patients whose COPD diagnoses
were confirmed by spirometry and (2) percentages of patients with FEV1/FVCs <70%
126
Figure 1
Figure 2
who were treated with bronchodilators (FIGURE 1). Structural changes in the clinical
management of COPD patients included: (a) embedding spirometry evaluation in clinical
guidelines for patients suspected of having COPD; (b) establishing baseline metrics
and performance outcomes for all patients with sub-marginal findings for FEV1/FVC;
and, (c) establishing and analyzing COPD registries. An incidental finding was that
having a diagnosis of COPD in a patients clinical record did not always mean the
patient had COPD when challenged by spirometry and EHR analyses. Preliminary
results included attainment of the core principles of accountable care as demonstrated
by: (a) increased patient satisfaction (e.g., 47%), (b) increased patient involvement in
their care, (c) expansion of the clinical capacity of practitioners with reduced burn-out
and (c) reduction of unnecessary health utilization and costs (FIGURE 2). Compared
127
Figure 3
to prior periods, procedural successes included: (a) increased percentages of patient

with COPD who had spirometry, (b) numbers of clinicians obtaining spirometry when
considering a COPD diagnosis and (c) clinicians having more confidence in support
staff competencies for performing spirometry. Other improvements include decreases
in the number and rate (e.g., 30%) of ED visits and hospital admissions (e.g., 21%)
for COPD care during the study period compared to prior periods (FIGURE 3). Additionally, risk-adjusted costs of care for COPD patients enrolled in the interventions
rose at a significantly lower rate than that for control populations.
DISCUSSION: The most unique de novo theme in the current U.S. debate on
health care reform is that of accountable care, a tenet that is visualized in the conduct
of quality-based care aligned with the application of transparent, data-driven, practical
and evidence-based care principles. As referenced earlier, these principles include teambased care-coordination, patient-centered care and the collection and management of
health data via health information technology. It has been demonstrated previously that
these hallmarks of quality care are best carried out by highperforming health care
organizations that incorporate the unique aspects of multi-specialty medical groups,
integrated health systems and other organized systems of care. We firmly believe
that because the 12 AMGA member groups in this COPD collaborative are highperforming health care organizations, they were able to successfully apply the said
principles resulting in positive outcomes for their COPD patients. Thus, through the
engagement of clinical integration and targeted intervention, what otherwise might have
been disparate, independently practicing physicians struggling to provide fragmented
care for disenfranchised patients were, instead, coordinated practitioners aligned into
a comprehensive COPD management program with a clear set of evidence-based,
quality care objectives and metrics that led to meaningful outcomes in improved
health status and reduced costs of COPD patients. (12)
CONCLUSIONS: A number of clearly defined lessons have been gleaned from
128
this pilot collaborative. Targeted, evidence-based and pre-emptive clinical and social
interventions, coupled with patient-centric care were shown to reduce the intensity or
the re-occurrence of COPD-related events. These diminutions of disease have been
accomplished by accurately identifying patients with COPD, focusing care efforts to
assure adherence to national standards, coordinating care processes across all relevant
clinical staff and actively engaging patients in self-management support. Additionally,
a new dynamic in patient-centered care was established that focused on appropriately
transitioning patients through the COPD care continuum and tailoring the clinical
progress to a patients specific level of involvement and should be further tested.
Employing a health system-wide EHR not only authenticated a COPD registry, but
also facilitated the smooth transition of the patient care processes and settings. Critical
to the conduct of these interventions was the clear, personal support of the groups
executive medical leadership, demonstrated by the accessibility of senior administrators
and their commitment to being the physician champions of the initiative. Lastly, of
broader consequence, the templates of intervention carried out by these 12 AMGA
member groups can be re-adapted in the future to engage meaningful management
of other chronic illnesses and conditions. (13,14)
REFERENCES
1. AMERICAN COLLEGE OF PHYSICIANS. Ethics Manual, 6th Edition. Philadelphia. 2012.
(Accessed on March 19, 2012 at http://www.acponline.org/running_practice/ethics/manual/)
2. D. SIN et al. Contemporary Management of Chronic Obstructive Pulmonary Disease.
JAMA 290(17): 2301-2312. 2003.
3. S. SULLIVAN et al. The Economic Burden of COPD. Chest 117 (2suppl): 5S-9S. 2000.
4. D. BELLAMY et al. Role of Primary Care in Early Diagnosis and Effective Management
of COPD. Int. J. Clin. Pract. 61(8):1380-1389. 2007.
5. J. FOSTER et al. Enhancing COPD Management in Primary Care Settings. MedGenMed
9(3):24-40. 2007.
6. J. BOURBEAU et al. Practice Patterns in the Management of Chronic Obstructive Pulmonary Disease in Primary Practice: the CAGE Study. Can. Respir. J. 15(1): 13-19. 2008.
7. AMERICAN MEDICAL GROUP ASSOCIATION. Organization Website. (Accessed on
March 19, 2012 at http://www.amga.org)
8. AMERICAN MEDICAL GROUP ASSOCIATION. Accountable Care Organizations:
Principles. (Accessed on March 19, 2012 at http://www.amga.org/AboutAMGA/ACO/
principles_aco.asp)
9. S. RENNARD. Looking at the Patient--Approaching the Problem of COPD. NEJM 350
(10):965-966. 2004.
10. D. PRICE et al. Improving the Differential Diagnosis of Chronic Obstructive Pulmonary
Disease in Primary Care. Pharmacoepidemiol. Drug. Saf. 85(12): 1122-1129. 2010.
11. The Global Initiative for Chronic Obstructive Lung Disease (GOLD). Update 2009. (Accessed March 19, 2012 at http://www.goldcopd.com)
12. AMERICAN MEDICAL GROUP ASSOCIATION. CMS Announces PGP Demonstration
Succeeded in Reducing Costs While Improving Quality. (Accessed March 19, 2012 at
http://www.amga.org/AboutAMGA/News/article_news.asp?k=522)
13. D. LINDERMAN et al. Effect of Integrated Care on Advance Chronic Obstructive Pulmonary Disease in High-Mortality Rural Areas. Arch. Int. Med. 171(22):2059-2061. 2011.
14. AMERICAN MEDICAL GROUP ASSOCIATION. COMPENDIUM - AMGA COPD
Collaborative Wrap-up Meeting, November 2-4, 2011. (In Preparation for Print)
The influence of fetal neuronal cells on dynamics of

anxiety and phobic status of reanimated in rats of
different sex and ages
Kabdualieva N.B, Tazhibaeva D.S, Aitbaeva ZH.B., Beglarova G.E.,
Ermentaeva L.N.
JSC Astana Medical University, Astana City
The Republic of Kazakhstan
Summary
Experiments were performed on 135 male rats and females who have reached to
the beginning of studies of age 1,5 and 12 months. All animals were determined baseline APS. Then was simulated 4-minute clinical death and subsequent resuscitation.
At the time of cardiac activity appearance the suspension of fetal neural cells were
injected intraperitoneally. On the 1st, 7th, 14th and 21st days of the study the level
of anxiety was assessed at all rats. Once held neurotransplantation, as compared to
control, did not change the level of anxiety in young males and females. Meanwhile,
at the adult female of IVB group the analyzed integral indicator of anxiety was higher
than in controls, to the 7th days of the PRP. On the basis of age-related differences
the higher level of anxiety was recorded in a group of adult males and young females.
Introduction. The finding out of the most effective ways of post resuscitation
encephalopathy treatment is one of the most actual problems of the resuscitation [1,
2]. Used conservative therapy does not bring the desired effect, and sometimes leads
to various complications, aggravating serious condition of resuscitated patients [3].
It is widely used the cellular biotechnology in experimental and clinical resuscitation
in recent years. Intraperitoneal application of fetal liver cells have been established
effects in early postresuscitation period (PRP) in experiments on animals . The positive
effect of fetal nervous tissue cells has also been shown experimentally in the late PRP
[4]. However, evidence of the fetal nerve cells use in the early PRP were not found
in the available literature. Also observed significant changes in the emotional sphere
in the recovery period [5] also require, in our opinion, correction with modern cell
biotechnology use. However, we did not find the data on the cellular technologies
use for the postresuscitation emotional disorders treatment in the available literature.
In connection with mentioned above, we performed a series of studies that investigated anxiety-and-phobic state (APS) [6] of resuscitated rats of different age
P421L5028
129
130
Table 1 - Dynamics of APS at resuscitated young rats of both sexes
and sex, as well as evaluated also the effect of a single neurotransplantation on the
development of this condition.
Materials and Methods. Experiments were performed on 135 male rats and females
who have reached to the beginning of studies of age 1,5 and 12 months. All animals
were determined baseline APS. Then was simulated 4-minute clinical death [7] and
subsequent resuscitation. At the time of cardiac activity appearance the suspension of
fetal neural cells were injected intraperitoneally. On the 1st, 7th, 14th and 21st days
of the study the level of anxiety was assessed at all rats.
In the first stage we estimated APS in control animals. Animals were divided into
the following groups: I - 1,5-month males, II - 1,5-month females, III - 12-month-old
males, IV - 12-month-old female. Rats of these groups served as controls for groups
of resuscitated animals.
Results. Our study showed not significant differences in baseline anxiety-and-phobic
status in young rats of both sexes. On the 1st, 14th and 21th days of the experiment
the increase of anxiety was showed in group I. In group II also was found an APS
level increase at 1-st, 14-th and 21-st days of the study. In the group of adult males
(III) it was observed an increase of APS level to the 7-th day of experiment, compared with the outcome. In the remaining periods there were no significant differences
comparing with outcome. In the group of adult females (IV group) were detected
more frequently than in males of group III, the total score growth of anxiety (on
the 1st, 7th and 14th day of study). Sexual dimorphism was determined to end of
the experiment, when the anxiety-and-phobic status of adult females was higher than
among individuals of the opposite sex.
In the next step we assessed the level of APS in 36 resuscitated rats, males and
females of various ages: IA - 1.5-month-old males, IIA - 1.5-month-old female,
IIIA - 12-month-old males, IV - 12-month-old female. As can w see from Table 1,
young individuals from IA and IIA groups were not found out differences in APS
131
Table 2 - The dynamics of anxiety-and-phobic status in resuscitated adult rats of both sexes
level in contrast with control (I) group. However, signs of sexual dimorphism were
determined by 21-st day of the PRP, when the severity of situational anxiety in a
group of females was less than in males (p2 <0.02). In groups of resuscitated adult
males (IIIA) differences with control (III) were detected in the 1st and 14th days of
the experiment. In average, the anxiety increase was 3 score (Table 2). It is not established differences with the control in the females group of adult resuscitated rats.
Associated with sexual reactivity differences were observed for 2 terms - to the
1st and 14th days of experiment, when the lively females (IVA) showed lower than
in resuscitated male (IIIA) the level of situational anxiety.
The assessing of the age reactivity factor role possible to establish the following:
in groups of young resuscitated rats it was observed the decrease in compared with
adult rats, the severity of situational anxiety.
On the next stage APS was assessed at the resuscitated rats of different sex and age
with a single neurotransplantation divided into the following groups: IB - 1,5-month
males, IIB - 1,5-month females, IIIB - 12-month-old males, IVB - 12 - monthly
females (Tables 3 and 4).
Comparing with the results of the control animals of young (IA) and old age group
(IIIA) it was found that a single injection of fetal nerve cells suspension to males of
IB group (Table 3) and IIIB group (Table 4) did not cause changes in the APS level.
The animals of IVB group showed an increase of total score of anxiety to the 7
th day of the study compared with IVA group. Sex differences in the severity of APS
were found by the 14th day of observation, when the females of IVB group showed
132
Table 3 - Effect of a single neurotransplantation on the dynamics of APS in young resuscitated rats of
both sexes
Table 4 - Effect of a single neurotransplantation on the dynamics of APS in adults resuscitated rats of
both sexes
133
lower than males IIIB group, level of anxiety. In group IIIB anxiety to the 1st day
of the experiment was higher than in young male (IB group). Adult females of IVB
group to the 14 th day of observation, in contrast, showed decline, compared with
young females of the group IIB, the APS level.
Conclusions. Thus, as compared to control, once held neurotransplantation did
not change the level of anxiety in young males and females. Meanwhile, at the adult
female of IVB group the analyzed integral indicator of anxiety was higher than in
controls, to the 7th days of the PRP. On the basis of age-related differences the higher
level of anxiety was recorded in a group of adult males and young females.
References
1. Safar P. Cerebral resuscitation from temporary complete global brain ischemia //Cerebral
Blood Flow: mechanisms of ischemia, diagnosis, and therapy / Ed. By M.R.Pinsky. Springer, 2002. - P. 106-136.
2. Usenko L.V., Tzarev A.V. Cardial-pulmonary and cerebral reanimation from evidence
medicine position // Pain, diseases and intensive therapy - 2004. - N1. - P. 50-68.
3. Usenko L.V., Tzarev A.V. , Yarovenko V.V. Postreanimation disease: not realized potencial
(Contemporary condition of problem) // Medicine of extremal conditions. - 2008. - N4(17).
- P. 9-16.
4. Semchenko V.V., Makoveckii K.K. Treshold of brain seizure activity and high nervous
activity data in postreanimation period at intracranial allotransplantation of embrional
neocortex tissue // Bull. experim. byol. and med. - 1996. - N 2. - P. 234-237.
5. Safar P. Resuscitation from clinical death: Pathophysiologic limits and theraupetic potentials
//Crit. Care Med. - 1988. - Vol. 16. - N10. - P. 923-941.
6. Rodina V.I., Krupina N.A., Kryzhanovskii G.N., Oknina N.B. Multiparameter method of
complex evaluation of anxiety-phobic conditions at rats // J. high. nerv. activ.- 1993. - T.
43, Ed. 5. - P. 1006-1017.
7. Shim N.V. Experimental model of white rats reanimation after clinical death from asphyxia
and exogenic heparin influence on clinical death duration // Pathogen. and experiment.
therapy of termynal. states. - Omsk, 1979. - P. 57-62.
Study of Tobacco sensibilization on the functional state

of children engaged in tobacco growing
Orakbai L.Zh., Omarova M.N., Kalimoldin M.M., Katchibaeva A.S.
Scientific Center of Hygiene and Epidemiology H. Zhumatov name, city Almaty. Kazakhstan
One of the priorities of the rural economy of Kazakhstan in recent years is the
tobacco industry in a market economy, bringing real and stable income.
Currently, the range of growing culture of tobacco has increased considerably:
Almaty, Taldykorgan, Zhambyl and South Kazakhstan region, where tobacco production deals with small farms, family-based contract, which along with active adults
and children.
In the available medical literature research on the study of hygiene issues of
working conditions and health of persons engaged in tobacco country, not covered.
The few works devoted to this problem [1], the disease is characterized by mostly
individual organs and systems of growers. Virtually no research on the complex
hygienic evaluation of working conditions on tobacco plantations. Meanwhile, researchers attracted much attention the problem of contamination of tobacco plantations
chemicals. According to M.N. Omarova, G.S. Abdrasil (2001) [2], heavy metals, as
a particularly dangerous chemical pollutants found in air, soil, plants in all regions
of tobacco production, which indicates the need for biological monitoring of environmental pollution factor.
In most localities Shelek district of Almaty region practiced method of post-harvest
processing tobacco at home, which is associated with adverse in the sanitary factors.
In residential areas, where tobacco is processed (smoothing of the leaves, sorting,
packaging and so on), the air is polluted with dust, fumes of toxic substances, which
dramatically affects the sanitary conditions of dwellings growers. Thus, according to
the sanitary-epidemiological service of the nicotine concentration in the room, in this
case can reach up to 0.075 mg/m3, of methanol - 0.89 mg/m3, essential oils - 0.77
mg/m3, CO2 - from 0.55 to 1.5%. There is a high dust content of air. The concentration of dust when working in the yard was 1.8-22.0 mg/m3 indoor 4.7-20.9 mg/m3
(maximum kontsentratsiya-3mg/m3). In recent, the farm in the Almaty region farmstead is still stringing tobacco and drying, which also adversely affects the sanitary
conditions of dwellings.
Thus, the marked adverse occupational factors can significantly affect the health
of children - students who participate in this process.
P421L5038
135
136
In this regard, one of the objectives of our study was to investigate the tobacco
sensibilization on functional status of children engaged in tobacco growing.
The results of previously conducted a questionnaire survey of 260 children. Shelek
showed that in the summer and in the transitional time of year for field work or in
the gardens occupied the vast majority of children (97% of students).
To conduct the study students were selected fifth, sixth and seventh grades, taking
part in the growing and harvesting tobacco. All adolescents were born in the village
Shelek Almaty region. Control group consisted of students Zharkent.
Analysis of indicators of physical performance of children in both groups of
students showed that the dynamics of the learning process of the functional state of
the organism in the two compared groups, undergo certain changes. The most significant decline in the late afternoon exercise performance observed in the group of
boys who have contact with tobacco, from 27.2% - Grade 5 to 30.6% - Grade 7. In
the control group these figures to the end of the occupation declined marginally by
8.7% - Grade 5, and 7.4% - Grade 7. Approximately the same changes occur in two
comparable groups with schoolgirls.
Analysis of indicators of mental activity of schoolchildren showed that boys in
the experimental group by the end of the school day more tired. This is evidenced
by the latent period of visual-motor reactions, which is slowed down by the end of
classes for fifth grade students at 30% compared with the initial state, the sixth-graders
at 34%, the seventh-graders - 33%. In the control group also showed a decrease in
mental performance of schoolchildren by the end of the school day. However, the
level of reduction of these indicators they are much lower and amounted to 9.9%,
15%, and 12%. Identical changes in the studied parameters are marked in the group
of girls - schoolgirls.
At the same time more complex training program with an increase in class teaching, the higher the level of reduction by the end of training mental health of schoolchildren. This is particularly clearly manifested in the experimental group students.
Fatigue on the lessons noted by many respondents (87%). Among them, the boys are
(49%) and girls (38%).
According to the district pediatrician, mostly allergic reactions in children occur in
the transitional seasons: fall (73%) and spring (24%). Health care providers serving
the school noted that tobacco dermatitis they occur most often during the break-up
of tobacco. They believe that it is possible the emergence of dermatoses in children
contribute to skin injury, through which, catching the juice from the leaves of tobacco
can easily penetrate into the deeper layers of skin. During this period, many children
complain of itching (71%), and the burning of the skin (73%). Some children (46%),
there are headache, dizziness, until nausea (37%) of the pungent smell of tobacco.
Thus, the results of studies on the health of school children engaged in tobacco
growing suggest that most children have some variations in health. At the same pollen
sensitization causes multiple organ change, accompanied by tissue hypoxia, changes
in excitatory and inhibitory processes in the cerebral cortex. The latter is fraught with
the development of mental fatigue, which manifests itself a violation of the functional
parameters of central nervous system. Therefore, to study the influence of tobacco on
the sensibilization the functional state of central nervous system and the incidence of
school-age children involved in the production of this crop an urgent problem for
the Republic of Kazakhstan and serves as a basis for further research.
137
Literature
1. Shershembaeva N.B. Immune status and its correction by professional pathology residents
tabakoseyuschego region: Avtoref.kand.biol.nauk. Bishkek. 2002. 19 p.
2. Omarova M.N., Kozlovsky V.A., Abdrasil G.S. Evaluation of mental fatigue of school
performance based on the functional parameters of central nervous system // Ecology,
radiation and health. Semipalatinsk. 2001. p. 114-115.
Climate change: impact on hay fever peculiarities

Zhumambayeva Saule, Rozenson Rafail
Astana Medical University JSC, Astana, Kazakhstan
Summary:
We studied the hay fever peculiarities, differences in age and the incidence of
different pollinosis syndromes among children and adolescents in two consecutive
seasons in conditions of different pollen burden at the same territory.
The striking difference in pollinosis incidence in two consequent pollination seasons,
increase of additional pollen-induced atopic dermatitis incidence and pollen-induced
asthma (26.7% vs 42.2%), early onset of pollinosis in children under 3 years of life
were determined.
Introduction:
Still, there is an important gap in scientific understanding of seasonal influence
of the weather changes on pollinosis clinical manifestations and treatment efficacy.
Only in recent years several studies were published in different countries, stated that
hay fever incidence rate is increasing with registered thermal gradient displacement
from the South to the North [1-3].
An important role in hay fever development belongs to climate and geographical
features of the flora in concrete region. In the Republic of Kazakhstan pollinosis
is more often related to weeds pollen such as Artemisia, Atriplex or hemp species,
and less often to meadow grasses like Festuca, Dactylus Glomerata, Phleum or Poa
species [4,5].
The wind and other weather conditions have great impact on pollen concentration
in atmosphere. Big amount of rainfalls during the pollination season promotes stronger blossoming and pollen concentration increase. However, it is not clear, whether
climatic changes can affect increasing of hay fever incidence and its association with
aeroallergens concentration in the air.
Many studies have shown that pollen season by regionally specific species is beginning earlier in the year in various parts of the world [6-8]. These changes have been
described most thoroughly in Europe [9], although evidence of an earlier pollination
has also been documented in the United States and Asia [10].
Allergen exposure in children is an important area of research in understanding
P421L5044
139
140
recent and future trends in disease burden [11]. Climatic anomalies that were frequent
in Kazakhstan last two years, included extremely hot Spring-Summer season of 2011.
The aim of the study:

To investigate the hay fever peculiarities, differences in age and the incidence of
different pollinosis syndromes among children and adolescents in two consecutive
seasons in conditions of different pollen burden at the same territory.
Material and methods:

The study was conducted during pollination seasons (May-October) of 2010 and
2011 at the basis of Department of Children Diseases N1, Astana Medical University
JSC, the Republic of Kazakhstan. Total 273 pollinosis cases were studied. The special
allergological questionnaires with information about feeding type in early age, conditions
of life, food allergy and allergological anamnesis were completed. The presence of
different hay fever syndromes, including pollen asthma, pollen dermatitis and polleninduced urticaria were thoroughly recorded. Clinical data included sex, age, presence
of eye and nasal symptoms like snoring, nasal obstruction, rhinorrhea, sneezing and
nasal itching. Allergic rhinitis was defined as rhinitis symptoms lasting longer than
4 days per week and more than 4 weeks on the basis of ARIA guidelines (Allergic
Rhinitis And its Impact on Asthma) [12]. Correlation between intensity of clinical
manifestations and meteorological factors like average daily temperature, atmospheric
moisture capacity, precipitations, direction and the wind force were determined. Pollen
burden count was assessed by the standard method. Smooth glass, one side of which
is covered with oil, was put in horizontal position on the open air. Then every 24
hours pollen grains that left on the glass were calculated under microscope. Skin prick
tests were performed and total and specific IgE level in blood serum were determined.
Comparison between groups was by Student T test. The 95% confidence interval (CI)
was given for each ratio. Statistical significance is denoted by p value less than 0.05.
Results and discussion:

It is well established, that the pollinosis incidence and pollination duration increases with average temperature gradient from North to South [6-11]. However, it
was not known, if pollination burden in Kazakhstan influence the clinical course and
treatment efficacy.
For evaluation of climate and weather changes influence on hay fever peculiarities
and incidence rate of its different syndromes among children and adolescents at the
same territory, we compared pollen burden in two consequent pollination seasons of
2010 and 2011.
Based on previous studies we assumed that there is growing evidence to support an
association between climate change and aeroallergens as well as hay fever and exposure
to pollen with subsequent later-life allergen sensitization. To our knowledge, this is
the first study to examine an association of climate changes with hay fever definite
peculiarities because previously it was studied mostly the incidence of some allergic
diseases and our data made it possible to highlight some aspects of this problem.
141
Total 273 pollinosis cases were studied. Among these patients 131(47.9%) were
in 2010 and 142(52.0%) - in 2011. Basic demographic data and characteristics of the
study population is shown in table 1.
It was determined extremely high (in 1.6 times) increase of hay fever prevalence in
children of young age group. Our finding is consistent with several studies, including
a cohort study in California that involved 514 Mexican children in an agricultural
community. Authors determined that early life exposure during first 3 month of life
to pollen was associated with early wheeze among children under 24 months [13].
There was no any significant sex predominance in both study years and the female:
male ratio was not different between 2 groups (p > 0.05).
The duration of symptoms (SD) in 2011 was longer than that of 2010 (4.90.3
vs 3.4 0.2, in years, p< 0.01). Enlargement in pollinosis duration among patients in
2011 assume clinical symptoms persistence and may be due to increasing sensibilization level in elder age groups.
The most important finding of our study was striking difference in pollinosis
incidence in two consequent pollination seasons at the same territory, as it is shown
in figure 1.
We determined the peculiarities of pollinosis in children and adolescents, among
them were high incidence of concomitant asthma, atopic dermatitis, and even urticaria
that is shown in table 2.
Obtained and analyzed data showed that the incidence of rhinoconjunctivitis
stayed at the same level and was 99.2% in 2010 and 99.2% in 2011. The incidence
of pollen-induced asthma differed strikingly from 26.7% in 2010 to 42.2% in 2011.
This finding is consistent with recent study from Montreal, Canada showing an association between pediatric emergency department asthma visits and daily grass pollen
concentrations [14].
The incidence of pollen-induced atopic dermatitis exacerbations also increased from
13.7% in 2010 pollen season to 21.1% in 2011. Similar tendency was determined in
the study of urticaria incidence with its increase from 6.1% in 2010 to 14.7% in 2011.
There was need of additional nebulizer treatment in 21.8% of pollen-induced
142
asthma due to inhaled glucocorticosteroids use resistance, which was higher among
infants and young children in the second year study group.
Due to unusually warm April of 2011 with average temperatures more than 17oC
above usual, it was determined a great shift in pollination duration and intensity.
The total pollen burden in August 2010 was from 14 to 37 pollen grains per one
air liter3, whereas at the same period in August 2011 it varied from 31 to 64 pollen
grains per one air liter3.
So, we had clearly established that the clinical course of pollinosis in children
and adolescents among other variables depends also on pollen burden. There is the
statistically significant increase possibility of more severe hay fever course among
the exposed in warmer years.
143
Conclusions:
We determined striking difference in pollinosis incidence in two consequent pollination seasons, increase of additional pollen-induced atopic dermatitis incidence and
pollen-induced asthma (26.7% vs 42.2%), early onset of pollinosis in children under
3 years of life.
References:
1. SCHMIER JK, EBI KL. The impact of climate change and aeroallergens on childrens
health // Allergy Asthma Proc. 30:P.229237.-2009.
2. SETTIPANERA. Complications of allergic rhinitis // Allergy Asthma Proc.20(4):P.209
213.-1999.
3. GUPTA R, SHEIKH A, STRACHAN DP, ANDERSON HR. Burden of allergic disease in
the UK: secondary analyses of national databases // Clin Exp Allergy 34(4):P.520-526.-2004.
4. MORENKO M.A., ROZENSON R.I., AMANKULOVA A.A. et al. Bronchial asthma
features in children, concomitant with allergic rhinitis // Otorhinolaryngology. Head, Neck
Surgery 1(2):P.83-84.-2009.
5. SAPAROVA L.T., ROZENSON R.I. Allergic rhinitis prevalence in children of North
Kazakhstan region // Science and public health 3:P.91-93.-2010.
6. CLOT B. Trends in airborne pollen: An overview of 21 years of data in Neuchatel
(Switzerland) // Aerobiologia. 19:P.227234.-2003.
7. LEVETIN E, VAN DE WATER P. Changing pollen types/concentrations/distribution in the
United States: fact or fiction? // Curr Allergy Asthma Rep. 8:P.41824.-2008.
8. TERANISHI H, KATOH T, KENDA K, HAYASHI S. Global warming and the earlier
start of the Japanesecedar (Cryptomeria japonica) pollen season in Toyama, Japan // Aerobiologia. 22:P.9094.-2006.
9. SPIEKSMA FTM, CORDEN JM, DETANDT M, et al. Quantitative trends in annual totals
of five common airborne pollen types (Betula; Quercus; Poaceae; Urtica; and Artemisia),
at five pollen-monitoring stations in western Europe // Aerobiologia. 19:P.171184.-2003.
10. PATZ, J., ET AL. The Potential Health Impacts of Climate Variability and Change for the
United States: Executive Summary of the Report of the Health Sector of the U.S. National
Assessment Environmental Heath Perspectives, 108(4):P.368-376.-2000.
11. SHEFFIELD PE, WEINBERGER KR, KINNEY PL. Climate change, aeroallergens, and
pediatric allergic disease // Mt Sinai J Med. 78(1):P.78-84.-2011.
12. BOUSQUET J. et al. Development and implementation of guidelines in allergic rhinitis
an ARIA-GA2LEN paper // Allergy. 65(10):P.1212-21.-2010.
13. HARLEY KG, MACHER JM, LIPSETT M, et al. Fungi and pollen exposure in the first
months of life and risk of early childhood wheezing // Thorax. 64:P.353358.-2009.
14. HEGUY L, GARNEAU M, GOLDBERG MS, et al. Associations between grass and weed
pollen and emergency department visits for asthma among children in Montreal // Environ
Res. 106:P.203211.-2008.
Antiproliferative effects of licorice root flavonoids and

dihydroquercetin in vitro
Tsitsuashvili M.D.1, Pavlova S.I.1, 2, Kozlov I.G.1, 2
Russian National Research Medical University named after N.I. Pirogov, 2Federal Research and
Clinical Center for Pediatric Hematology, Oncology and Immunology named after D. Rogachev,
Moscow, Russia
Abstract
Flavonoids are polyphenolic compounds derived from plants which have large biological properties based on their ability to suppress proliferation. There is evidence that the
basis of the mechanism of antiproliferative activity is the inhibition of phosphorylation
of intracellular signaling molecules (kinases, transcription factors). The aim of this study
was to compare antiproliferative effect of dihydroquercetin and licorice root flavonoids
(LRF) against U-937 tumor cell line in vitro. Evaluation of proliferation of tumor cells
was done using a radioisotope method. Proliferation was evaluated by 3H-thymidine DNA
incorporation assay. Radioactivity of 3H-thymidine incorporated into DNA was measured
after 24 h of cell culture incubation with flavonoids and the result was expressed as
a percentage of control. These findings demonstrate that LRF and dihydroquercetin
(0.1-20 mkg/ml) inhibit the proliferation of tumor cells in dose-dependent manner.
However effect of dihydroquercetin was comparatively less pronounced than the effect
of the LRF. Which is why, it can be concluded that LRF is more effective against
growth of U-937 tumor cell line, than dihydroquercetin, and it might be perspective
for the development of new anticancer agents.
Introduction
Flavonoids are among the most ubiquitous groups of polyphenolic compounds in
food of plant origin. As integral constituents of the diet, they may exert a wide range of beneficial effects on human health, including protection against cardiovascular
diseases and different forms of cancer [1, 4]. They likely produce such biological
effects through their free radical-scavenging antioxidant activities and metal ionchelating abilities. In addition, flavonoids, either natural or synthetic, are known to
exhibit various biological activities [2, 3, 4, 5]. In particular, many compounds possess
antitumor or related activities, such as antimitotic activity through the inhibition of
aromatase or topoisomerase. They are also known for their ability to inhibit enzymes
P421R9030
145
146
such as protein-kinase C, several protein-tyrosine kinases, or cyclin-dependent kinase

[4, 5]. Dihydroquercetin is a flavonol of plant origin (citrus, apples, red onions, red
wine, green tea), which has a lot of biological effects. There is evidence that this
flavonoid has antiproliferative effects against tumor cells [3, 5]. In our laboratory we
have obtained and studied antiproliferative effects of licorice root flavonoids (LRF).
The goal of this research was to compare effects of LRF with antiproliferative effects
of dihydroquercetin against U-937 tumor cell line in vitro.

Flavonoids
In this study we have used flavonoid dihydroquercetin (Alfa aesar, UK)
and licorice root flavonoids, isolated from the extract of licorice roots in our
laboratory.
Licorice root flavonoids isolation

Licorice root extract was macerated with 96% ethanol overnight. After filtration,
the alcoholic solution was concentrated to dryness. The residue dissolved in hot 10%
solution of sodium chloride was subjected to a polyamide column chromatography
and eluted with ethanol. Total phenolic contents were assayed using Folin-Ciocalteu
reagent and gallic acid as a standard [6]. The concentrations of phenolic compounds
in preparation were expressed as mg of gallic acid equivalents per milliliter.
Cell-line culturing
In our research we have used human monocytic leukemia U-937 (CRL-1593.2TM,
ATCC) cell line. The cells were cultured in RPMI1640 medium (GIBCO, USA)
supplemented with 10% fetal bovine serum and 2 mM L-glutamine (GIBCO, USA),
100U/ml penicillin and 100g/ml streptomycin and maintained at 37C with 5%
CO2 in a humidified atmosphere.
Evaluation of proliferation
In this study we have used a radioisotope 3H-thymidine DNA incorporation method
to evaluate the proliferation of tumor cells. The U-937 cells were dispensed in 96-well
U-bottom microtiter plates (NUNC, Denmark) at a density of 104-2104 per well. After
24 h of cells pre-incubation, flavonoids and 3H-thymidine were added to the culture of
cells. LRF were added in the concentration range of 0.1-20 mkg/ml, so that the final
ethanol concentration did not exceed 1%. In the control wells were added appropriate
amounts of high-purity ethanol. Alcoholic solution of dihydroquercetin was prepared
at the highly purified ethanol and added into the culture of cells in a concentration
range of 1-20 mkg/ml. At the end of a 24-hour incubation with the agents being studied cells from the wells were collected on an automatic Cell Harvesting System, and
the radioactive material was transferred from the wells on glass fiber filters HA-930
(Whatmann, UK). The dried filters were placed into a quartz glass vials containing 4
ml of scintillation solution. Radioactivity of incorporated 3H-thymidine was counted in
the scintillation counter. The result was expressed as a percentage of control.
147
Statistical data analysis

The statistical analysis was performed using the Students t-test. All values are
expressed as the mean S.E.M. P values < 0.05 were regarded as significant.
Results
Influence of licorice root flavonoids on the proliferation of U-937
tumor cell line in vitro
Cells of monocytic leukemia U-937 were highly sensitive to the flavonoids of
licorice root. Thus, at a concentration of 1 mkg/ml level of proliferation was significantly (p <0.05) different from the controls and was 85.3 4.5%. LRF (5 mkg/
ml) inhibited the proliferation for more than 40% in comparison with control (60.1
4.7%; p <0.05). At the concentration of LRF - 10 mkg/ml the proliferation was
inhibited for more than 56% in comparison to control (44.2 2.3%; p <0.05). And
at a concentration of 20 mkg/ml LRF inhibited the proliferation almost for 80% in
comparison to the control (22.1 3.9%; p<0.05) (figure 1).
148
Influence of dihydroquercetin on the proliferation of U-937 tumor cell

line in vitro
When dihydroquercetin was added to the cell culture at the concentration of 1 mkg/
ml level of proliferation was significantly (p <0.05) different from the controls and was
102.1 8.1%. Dihydroquercetin (5 mkg/ml) inhibited the proliferation only for 10% in
comparison with control (93.5 3.9%; p<0.05) At the concentration of dihydroquercetin 10 mkg/ml the proliferation was inhibited approximately for 20% (78.7 2.5%;
p<0.05). And at the concentration 20 mkg/ml dihydroquercetin inhibited proliferation
only for 50% in comparison to control (46.5 2.9%; p <0.05) (figure 2). IC50 for
LRF was 7.5 mkg/ml, and for dihydroquercetin 19.5 mkg/ml.
Conclusions
Study of the antiproliferative effects of the LRF and dihydroquercetin against U-937
tumor cells in vitro allow us to conclude that LRF and dihydroquercetin in the concentration range 1.0-20.0 mkg/ml inhibit the proliferation of cells in dose-dependent
manner. However, effect of dihydroquercetin, was comparatively less pronounced
than the effect of the LRF. LRF is more effective against growth of U-937 tumor
cell line, than dihydroquercetin, and it might be perspective for the development of
new anticancer agents.
149
References
1. Formica J.V., Regelson W. Review of the biology of Quercetin and related bioflavonoids
// Food Chem. Toxicol. 1995, 33(12), 10611080.
2. Roger C.R. The nutritional incidence of flavonoids: Some physiological and metabolic
considerations // Experientia. 1988, 44(9), 725773
3. Huang Y.T., Hwang J.J., Lee P.P., et al. Effects of luteolin and quercetin, inhibitors of
tyrosine kinase, on cell growth and metastasis-associated properties in A431 cells overexpressing epidermal growth factor receptor // Br. J. Pharmacol. 1999, 128(5), 999-1010.
4. Ramos S. Cancer chemoprevention and chemotherapy: dietary polyphenols and signalling
pathways // Mol. Nutr. Food Res. 2008, 52, 507-526
5. Teillet F., Ahcene B. et al. Flavonoids as RTK inhibitors and potential anticancer agents
// Medicinal Research Reviews. 2007, 10, 715-745.
6. Vermerris W., Nicholson R. Isolation and identification of phenolic compounds. In: Phenolic
Compound Biochemistry. Springer, the Netherlands. 2006, 152-153.
D56+ lymphocytes in demyelinating polyneuropathies

Balmasova I.P., Timchenko O.L., Yuschuk N.D., Sepiashvili R.I.
Moscow University of Medicine & Dentistry, Moscow, Russia
Institute of Immunophysiology, Moscow, Russia
E-mail: immunolab@mail.ru
Abstract
At present acquired autoimmune demyelinating polyneuropathies include GuillainBarr Syndrome (GBS) and Chronic Inflammatory Demyelinating Polyneuropathy
(CIDP), which differ in the etiology (GBS usually develops as a complication of
infectious processes), immunopathogenesis, course duration, methods of treatment
and therefore demand differential diagnostics. The aim of the study is to survey
CD56+ lymphocytes role in the pathogenesis of demyelinating polyneuropathies by
examining the blood of 42 patients with GBS and 26 patients with CIDP by flow
cytometry. It was found that in GBS unlike CIDP the decrease of NKT number is
not observed but NK cell number is reliably reduced. The changes in NK cell in
GBS patients were accompanied by decrease of KIR, NKG2D, NKp46 expression.
It is expected that observed GBS immunopathogenetic peculiarities can be useful to
reveal its difference from CIDP.
Introduction
Among demyelinating diseases of the nervous system special attention is attached
to heterogeneous group of demyelinating polyneuropathies. Their pathogen basis is
autoimmune mechanism of systemic lesion of peripheral nerves. At present GBS and
CIDP are referred to acquired autoimmune demyelinating polyneuropathies. Their
prevalence ranges from 2 to 7.7 for 100.000 population [4].
GBS is one of the most serious diseases of peripheral nervous system with lethality
of 118% (and 533% among patients with severe forms). Molecular mimicry
N is the
basis of GBS, the reasons for its origin are rather different [6, 15]. The G S releasing mechanisms are connected with infectious processes caused by Campylobacter
jejuni, cytomegalovirus, EpsteinBarr virus as well as with other agents [4, 14, 16].
Some authors indicate that GBS develops after vaccination and stress.
As opposed to GBS in CIDP there are usually no indications to previous infection
diseases [5, 18] though clinical CIDP presentation is very similar with that of GBS
P421R9046
151
152
with the exception of rate and time of the development [3, 5]. Moreover if programmed
plasmapheresis and intravenous IgG pulse therapy are considered as basic specific
methods in treatment of GBS patients in CIDP agents of choice are corticosteroids
while their prescription in GBS is a gross error [1, 2]. Differences in pathogenesis and
approaches of treatment in GBS and CIDP patients demand timely differentiation of
these states which causes some difficulties especially at early stages of the diseases
[4] as peculiarities of their immunopathogenesis are not finally identified.
The analysis of the problems described defined the aim of present investigation:
to qualify significant immunologic factors of GBS which could serve as additional
differential-diagnostic criteria for its difference from CIDP.
Patients and Methods

Were observed 68 patients with demyelinating diseases of the peripheral nervous
system aged 1660 unrestricted with sex and severity of the disease. The group was
divided into two subgroups: 42 patients with GBS and 26 with CIDP. The group
of control consisted of 6 healthy persons. Blood analysis was carried out by flow
cytometry with the use of BD FACSCantoII flow cytometer, after automated test
preparation of whole blood in accordance with manufacturers instructions and monoclonal antibodies application regulations.
Results
The results of primary immunologic examination of GBS and CIDP patients as
compared with data of healthy persons are presented in Fig. 1.
As seen in Fig. 1, the development of axonal demyelinating polyneuropathies
leads to rather significant shifts of the cell composition of typical immunograms.
At that the changes of CD56+ cells in blood had quite different character in GBS
153
and CIDP. In particular the number of NKT (CD3+/CD56+) in CIDP patients was 10
times lower than in healthy persons in the absence of reliable deviations in control
of GBS patients. At the same time the number of natural killers reliably decreased
(1.6 times) in GBS patients and in CIDP either didnt change (relative values) or
increased (absolute values).
In connection with noted phenomenon the subpopulation content and functional
state of CD56+ cells was thoroughly examined (Table 1).
Subpopulation of NKT was analyzed by percent estimation of correlation of three
main subpopulations of these cells. CD4+ subpopulation according to literature data
is the least mature and can regulate the correlation of T-helpers of I and II type
[9, 11]. In patients with demyelinating polyneuropathies the content of these cells
among NKT increased 10 and more times both in GBS and CIDP. Other subpopulation NKTCD8+ characterized by suppressor activity [19] on the contrary reliably
quantitatively decreased in blood 1.7 fold in GBS and 1.3 fold in CIDP. As concerns
double negative NKT (CD3+/CD56+/DN) subpopulation able to reveal cytotoxic activity [9, 11] its content in blood in demyelinating polyneuropathies remained stable
as compared with healthy persons. The stability was revealed in the correlation of
natural killers subpopulations CD56bright with secretory properties and CD 56dim
with prevalence of cytotoxic activity [13].
Functional state of CD56+ cells was detected in the first place by their expression
of killing inhibiting and activating receptors of immunoglobin (CD158a,h) and lectin
(CD94, NKG2D) nature. These receptors are placed both on NK and NKT membranes. At the same time was detected the presence on the surface of CD56+ cells
of receptors of natural (NKp46) and antibody dependent (CD16) cytotoxicity. The
last two receptor categories are present on the membrane only of the natural killers
[17]. Results of the expression detection of the named receptors by CD56+ cells are
demonstrated in Fig. 2.
Development of demyelinating polyneuropathies was attended by rather intense
shifts of receptor instrument of the indicated cells. At that rather often these changes
were multidirectional. Especially this is referred to the expression of immunoglobulin
killing inhibiting and activating receptors CD158a,h (KIR).These receptors actively
154
correlate with the cells carrying classic histocompartibility molecules of I type (HLA
A, B, C) with antigen presentation [8, 13]. In the connection the growth or decrease of
expression of the named receptors indirectly reflects the level of antigen presentation
by different microorganisms cells. According to the data A. Lunemann et al. [13] the
lower is the level of immunoglobulin receptor expression the more is expressed the
autoimmune component of the disease. From that point of view the fact of reliable
decrease of the expression of named receptor in GBS patients when in CIDP patients
observed their growth testifies to more expressed autoagression in acute demyelinating
process i.e. in GBS.
As far as lectin (CD94, NKG2D) receptors are concerned regulating NK and
NKC, reliable shift of their expression is noted only in GBS and characterized by
the content decrease of activating receptors (NKG2D) on their membrane. The latter
define interaction of natural killers with molecule analogs of MHC-I (MICA, MICB,
ULBP) on target cells membrane. In excess they are present on the surface of numerous tumor targets, the cells which in stress effect serve as receptors for viruses
[10]. As ligands of NK lectin receptors can also act oligosaccharides of microbe and
endogenous nature [7]. In this connection the fall of expression of lectin activating
receptors in GBS can block effective elimination of infectious agents with CD56+
cells participation and maintain trigger mechanisms of the autoimmune component
of the disease.
Last suggestion is also proved by the decrease of cytotoxic potency of natural
killers which is revealed by low expression of natural cytotoxicity (NKp46) in this
cells and antibody dependent cytotoxicity (CD16). The fall of natural cytotoxicity
of receptor content in 1.8 fold on NK membrane is observed only in GBS while
negative shift in receptor expression of antibody dependent cytotoxicity is observed
in all manifestations of demyelinating polyneuropathies. However in GBS expression
155
of CD16 decreases 1.4 fold and in CIDP 5.3 fold that in a way can characterize
the level of autoimmune component expression.
Conclusion
Thus investigation of subpopulation content and functional state of CD56+ cells
in the blood of patients with demyelinating polyneuropathies allow not only reveal
unknown before aspects of immunopathogenesis of these diseases but helps to assume
potentially important criteria of GBS and CIDP differential diagnostics.
References
[1] Belyakov, K.M. (2007). Peculiarities of morphological picture of blood plasma in polyneuropathies. V.M. Bekhterev Neurologic Reporter 39(1), pp. 115-118.
[2] Gusev, E.I., Shnaider, A.B. (2009.) Neurology and Neurodurgery. Clinical Recommendations Moscow: GEOTAR Publ. pp. 267-280.
[3] Kantemirova, E.A., Shaider, N.A. (2009). Chronic Inflammatory Demyelinating Polyneuropathy: Definition, Epidemiology, Classification and Diagnostics. Herald of Clinical
Hospital #51 3(7), pp.24-27.
[4] Piradov, M.A. (2003). Guillain-Barre Syndrome. Moscow: Intermedica 240 pp.
[5] Podchuvarova, E.V. (2003). Advances in Diagnostics and Treatment of Inflammatory
Demyelinating Polyneuropathy and Other Immunolologically Mediated Neuropathies.
Neurological Journal #4, pp. 59-64.
[6] Arami, M.A., Yazdchi, M., Khandaghi, R. (2006). Epidemiology and Characteristics of
Guillain-Barre Syndrome in the Northwest of Iran. Ann Saudi Med. vol. 26 pp. 22-27.
[7] Feizi, T. (2000). Carbohydrate-mediated Recognition Systems in Innate Immunity. Immunol.
Rev. vol. 173, pp. 79-88.
[8] French, A.R., Yokoyama, W.M. (2004). Natural Killer Cells and Autoimmunity. Arthritis
Res. Ther. 69(1), pp. 8-14.
[9] Golden-Mason, L., Castelblanco, N., OFarrelly, C., Rosen, H.R. (2007). Phenotypic and
Functional Changes of Cytotoxic CD56pos Natural T Cells Determine Outcome of Acute
Hepatitis C Virus Infection J. Virol. 81(17), pp. 9292-9298.
[10] Groh, V., Bahram, S., Bauer ,S. et al. (1996). Cell Stress-regulated Human Major Histocompatibility Complex Class I Gene Expressed in Gastrointestinal Epithelium. Proc. Natl.
Acad. Sci. USA. vol. 93, pp. 12445-12450.
[11] Hammond, K.J., Pelikan, S.B., Crowe, N.Y. et al. (1999). NKT Cells are Phenotypically
and Functionally Diverse. Eur. J. Immunol. 29(11), pp. 3768-3781.
[12] Hartung, H.P., Kieseier, B., Kiefer, R. (2001). Progress in Guillain-Barre Syndrome. Curr.
Opin. Neurol. vol. 14, pp. 597-604.
[13] Lnemann, A., Lnemann, J.D., Mnz, C. (2009). Regulatory NK-Cell Functions in Inflammation and Autoimmunity. Mol. Med. 15(9-10), pp. 352358.
[14] McCarthy, N., Giesecke, J. (2001). Incidence of Guillain-Barre Syndrome Following Infection with Campylobacter Jejuni. Am. J. Epidemiol. vol. 153, pp. 610614.
[15] Radziwill, A.J., Kuntzer, T., Steck A.J. (2002). Immunopathology and Treatments of
Guillain-Barr Syndrome and Chronic Inflammatory Demyelinating Polyneuropathy. Rev.
Neurol. (Paris). vol. 158, pp. 301-310.
[16] Tam, C.C., OBrien, S.J., Petersen, I. et al. (2007). Guillain-Barre Syndrome and Preceding
Infection with Campylobacter, Influenza and Epstein-Barr Virus in the General Practice
Research Database. PLoS ONE. vol. 2, e. 344.
156
[17] Trotta, R., Col, J.D., Yu, J. et al. (2008). TGF-beta Utilizes SMAD3 to Inhibit CD16mediated IFN-gamma Production and Antibody-dependent Cellular Cytotoxicity in Human
NK cells. J. Immunol. 181(6), pp. 3784-3792.
[18] Viala, K. Epidemiological and Clinical Aspects of CIDP. (2007). Rev. Neurol. vol. 163,
pp. 31-35.
[19] Zhou L., Wang H., Zhong X. et al. (2008). The IL-10 and IFN-gamma Pathways are
Essential to the Potent Immunosuppressive Activity of Cultured CD8+ NKT-like Cells.
Genome Biol. 9(7), pp. 119.
The humoral response in the autoimmune pemphigus

Makhneva Natalia V., Davidenko Elena B., Potekaev Nikolay N.,
Beletskaya Ludmila V.
Moscow Research and Practical Center of Dermatovenerology and Cosmetology,
Moscow Regional Research Clinical Institute,
Institute of Transplantation and Artificial Organs, Moscow, Russia
Summary
The autoimmune pemphigus refers to a group of life-thraetening autoimmune bullous dermatosis in which the pathogenic role belongs to circulating immunoglobulins
class G (IgG) autoantibodies, directed against antigens of an epidermis intercellular
substance. As IgG subclasses are associated with different functional and antigenic
properties, the study of the question of their role in the development and course
of pemphigus is still current. Serum samples of 29 patients with different forms of
autoimmune pemphigus were tested by indirect immunofluorescence. The results of
immunological researches show polyclonal humoral response in autoimmune pemphigus. Prevalence of IgG2/IgG4-antibodies testifies to a chronic antigen challenge. The
acquired knowledge in the field of subclass characteristic of IgG-autoantibodies in
this bullous dermatosis slightly opens curtain of the extremely complex mechanism
of its development and promotes working out of new methods of the treatment based
on their specificity.
Introduction
The autoimmune pemphigus refers to a group of life-traetening autoimmune bullous dermatosis in which the pathogenic role belongs to circulating immunoglobulins
class G (IgG) autoantibodies, directed against antigens of an epidermis intercellular
substance. Within last decades there were made a number of the researches devoted
to the analysis of distribution of IgG subclasses at patients with autoimmune pemphigus. Irrespective of clinical forms of autoimmune pemphigus various distribution
of subclasses of antibody G, with primary prevalence of subclasses IgG1 and IgG4 is
revealed [1, 2, 6, 7]. As IgG subclasses are associated with different functional and
antigenic properties [3, 4, 5], the study of the question of their role in the development
and course of pemphigus is still current.
P421L5092
157
158
Figure 1. Immunohistochemistry research of material of autoimmune pemphigus patients. Magnification x400.

a frozen sections of clinically intact skin of patients with pemphigus. The method of direct immunofluorescense. Treatment with serum against human immunoglobulin G. Deposition of IgG in the epidermal
intercellular substance;
b - d treatment with autoimmune pemphigus patients sera. The method of indirect immunofluorescense.
Frozen sections of skin of calf: b - IgG reaction in an intercellular substance of all epidermis layers; c IgG2 reaction in an intercellular substance of granular and fields of corneous layers; d - IgG4 reaction in
an intercellular substance of all epidermis layers.

Serum samples of 29 patients with different forms of autoimmune pemphigus were
tested by indirect immunofluorescence using luminescent sera against human IgG and
calf skin as the substrate. All diagnosis were made according direct immunofluores-
159
cence analysis (fig. 1, a). Unfixed cryosections of a calf skin in the thickness 4-5
microns were carefully washed in the phosphatic buffer (PBS), pH 7,0-7,4, within
10 minutes, then sections were processed with unlabeled patients serum. Patients
serum was applied in maximum number of dilutions. Processing of sections spent in
the damp chamber at room temperature within 45 minutes. Further sections washed
out within 3-5 minutes in PBS (pH 7,0-7,4), then processed labelled serum against
human IgG within 30 minutes, again washed out 3-5 minutes in PBS and concluded
under integumentary glass in 60 % neutral glycerine. Preparations were investigated
by means of luminescent microscope LABORLUX of firm LEIKA with an objective
x 40. The biggest dilution which gave specific positive dynamics was considered.
Further the patients serum containing circulating IgG autoantibodies to an intercellular substance (fig. 1, b), were tested by indirect immunofluorescense using
monoclonal human antibodies to subclasses IgG1, IgG2, IgG3 and IgG4 (SIGMAALDRICH, USA).
Results
Autoantibodies to an intercellular substance are revealed at 22 (75,9 %) from 29
patients. The titer of antibodies varied from 1:5 to 1:2560 regardless of the clinical
form of pemphigus and stage of its development. After testing the serum samples of
22 patients which were containing specific autoantibodies with monoclonal human
antibodies to subclasses IgG1, IgG2, IgG3 and IgG4, it was revealed that specific
antibodies at the same time contain two or more subclasses. So, IgG1 is found in 16
(72,7 %) cases, IgG2 - in all 22 (100 %) cases, IgG3 - in 13 (59 %) cases, IgG4 in 20 (90,1 %) cases (fig. 1, c, d). But the most expressed reaction is noticed with
IgG4 and/or IgG1 that confirms their basic pathogenic role in the development and
course of this bullous dermatosis.
Conclusion
The results of immunological researches show polyclonal humoral response in
autoimmune pemphigus. Prevalence of IgG2/IgG4-antibodies testifies to a chronic
antigen challenge, mainly glycoprotein nature. Besides, the interesting fact in distinction of antigen-specificity of subclasses IgG is elicited. If antibodies-IgG1, -IgG3
and -IgG4 are directed to target antigens basal and spinal layers of epidermis, IgG2
- it is exclusive to antigens of acinose (granular) layer.
Thus, the acquired knowledge in the field of subclass characteristic of IgGautoantibodies in this bullous dermatosis not only slightly opens curtain of the
extremely complex mechanism of its development, but also promotes working out
of new methods of the treatment based on their specificity.
References
1. David M., Katzenelson V., Hazaz B. et al. Determination of IgG subclasses in patients with
pemphigus with active diseases and in remission // Arch.Dermtol., 1989; 125: p.787-790.
2. Kanwar A.J., Thami G.P., Bedi G.K. IgG subclasses in pemphigus vulgaris // Indian
J.Dermatol. Venereol. Leprol., 1997; 63: p. 20-21.
160
3. Maran B., Dueymes M., Le Corre R. et al. IgG subclasses of human autoantibodies //
Ann.Med.Interne (Paris), 1997; 148 (1): p. 29-38.
4. Reznikov Iu.P. The clinical importance of determining immunoglobulin G subclasses //
Ter.Arkh., 1991; 63 (11): p. 144-148.
5. Schroeder H.W. Jr., Cavacini L. Structure and function of immunoglobulins // J.Allergy
Clin.Immunol., 2010; 125 (2 Suppl. 2): p. S41-52.
6. Sitaru C., Mihai S., Zillikens D. The relevance of the IgG subclass of autoantibodies for
blister induction in autoimmune bullous skin diseases // Arch.Dermatol.Res., 2007; 299
(1): p. 1-8.
7. Qaqish B.F., Prisayanh P., Qian Y. et al. Development of an IgG4-based classifier/predictor
of endemic pemphigus foliaceus (Fogo Selvagem) // J.Invest.Dermatol., 2009; 129 (1): p.
110-118.
Intavenous immunoglobulineGabriglobin use in

patients with autoimmune urticaria.
Orlova E.A.1, Bolts E.A.2, Molotilov B.A.3, Alyoshkin V.A.4, Novikova L.I.5
1
2
3
4
G.N.Gabrichevsky Research Institute for Epidemiology and Microbiology, Moscow, RF
5
G.N.Gabrichevsky Research Institute for Epidemiology and Microbiology, Moscow, RF
lisaorl@yandex.ru, elenablc@rambler.ru, borismolotilov@yandex.ru, info@gabrich.com
Abstract
Intavenous immunoglobulines use is perspective line in therapy of autoimmune
urticaria. This work objective was to present the experience of chronic autoimmune
urticariatreatment with Russian inravenous immunoglobuline Gabriglobin.
Key words: autoimmune urticaria, Gabriglobin
1. Introduction
According to the literature data, autoimmune disease course develops in 30-50 %
of all cases among the patients with chronic urticaria [1]. Baseline therapy of autoimmune urticaria is antihistamines and glucocorticosteroids use. Often, standard therapy
is not desired effective because it doesn`t influence on main links of pathogenesis
and in connection with it, pathogenetic-grounded therapy search and prescription
is perspective. There are few works about intravenous immunoglobulins use in the
treatment of chronic urticaria [2,3,4,5]. In our study we have evaluated the efficacy
of medication Gabriglobin in the treatment of patients with autoimmune urticaria.
2. Materials and methods

57 patients aged between 18 and 60 with chronic urticaria have been examined.
N915L5017
161
162
Table 1. Numerical score scheme of urticarial symptoms
Table 2. Numerical score scheme of remission duration
28 patients of them have been diagnosed with autoimmune urticaria. All patients
with chronic urticaria have been provided with autoserum skin prick test, what was
suggested by Hide and joint authors [5]. We have suggested new interpretation of
autoserum skin prick test results in our past works [7,8]. According to our data, the
autoserum skin prick test result sized 7 mm and more has to be decided as reliable
one to diagnose autoimmune urticaria. Additional criteria were thyroid pathology and
complement system disorders. Patients with chronic autoimmune urticaria had been
divided on 2 groups: the group 1 (13 patients) got traditional therapy (antihistamines
of 1 and 2 generation, desensitizing medications and glucocorticosteroids); the group
2 (15 patients) got Gabriglobin additionally to the traditional therapy. Gabriglobin
in the dose 2,5 mg per day was drip-feed injected to the patients for 4 days. All patients got the same doses of medication. Patients groups didn`t differ from each other
in disease duration, severity of the disease, patient`s age. The efficacy of the therapy
was evaluated according to numerical score scheme what was devised by us (Table
1). Evaluation parameters were autoserum skin prick test diameter after treatment,
wheals` quantity dynamics, itching intensity changes.
The remission duration was also evaluated according to numerical score scheme
what was devised by us (Table 2).
During 1 year after treatment completion all patients were check examined every
other 6 months and every other 12 months.
Results had been processed by mathematical statistics methods in the computer
package Statistics 6.0 for Windows.
3. Results and discussion.

28 patients (53,8%) was diagnosed with autoimmune urticaria in the issue of
examination.
Against the background of treatment there are wheals and itching relapses in
163
the patients of the group 1 what had got traditional therapy. Only 1 patient (7,7%)
from this group had clinical remission at the discharging, the others from this group
(92,3%) had insignificant amelioration. Autoserum skin prick test diameters of 12
patients was invariable after treatment. Autoserum skin prick test diameters of 1
female patient of this group enlarged on 1 mm in a prick place. 12 patients (80%)
of group 2 experienced complete regress of wheals. Only 1 patient (6,6%) from this
group had no response to the treatment and 2 patients (13,3%) had been discharged
with insignificant amelioration. Body temperature rise was registered in 2 patients
(13,3%) after first and fourth drip-feed injections of Gabriglobin. Also, these patients experienced pain in loin after the first injection. Other adverse events had not
been registered. Gabriglobin was good tolerable and didn`t provoke the allergic and
general concurrent reactions.
On the fifth observation day (1 day after end of treatment with Gabriglobin)
average decrease of autoserum skin prick test diameters of 13 patients of group 2
was 4,5 mm, including complete negative reaction on autoserum skin prick test of
3 patients. Autoserum skin prick test diameter of 1 patient of the group 2 (6,6%)
with clinical amelioration was not changed. Autoserum skin prick test diameter of 1
patient of the group 2 (6,6%) with lack of efficacy of treatment with Gabriglobin
enlarged on 4 mm what possibly indicated on progression of autoimmune process
and required treatment with higher doses of medication Gabriglobin. 12 patients of
the group 2 had been discharged with complete clinical remission on sixth observation day (2 days after end of treatment with Gabriglobin). Patients of both groups
were observed over the 12 months. During this observation period 12 of 13 patients
(92,3%) of the group 1 had disease recurrences and only 5 of 15 patients (33,3%)
of the group 2 had recurrences. This difference was statistically significant (Fisher`s
exact method, p = 0,0021). Assessment of recurrences-free periods were performed by
Kaplan Meier method. Recurrences-free periods in group 1 and in group 2 differed
(early recurrences were observed in the group 1). This distinction is also statistically
significant (Log-Rank test, p=0,0069; Gehans Wilcoxon test, p=0,034). Median of
the recurrences-free period of the 2nd group was unable to assess because more than
half of patients of the group 2 had no disease recurrences. Disease recurrence median
in the group 1 was 4 months and disease recurrences occurred in 75% of the patients
of the group 1 in 8,75 months after treatment completion.
The efficacy of the therapy was evaluated according to numerical score what was
devised by us (Picture 1).
As it follows from the picture 1, there were excellent and good effect more frequently in the group 2 (Gabriglobin treatment group) and satisfactory and negative
effect in the group 1 (traditional treatment group).
This distinction in the treatment efficacy numerical evaluation is statistically significant (Mann Whitney test, p=0,0037).
One of the main criterion of the treatment efficacy is decrease of autoserum skin
prick test diameter. Changes of autoserum skin prick test diameters was evaluated
before and after treatment. In the group 1 autoserum skin prick test diameters before
and after treatment were invariable. In the group 2 decrease of autoserum skin prick
test diameters after treatment was evident. In the group 2 diameter median before and
after treatment was 9 mm and 6.5 mm accordingly. This distinction is statistically
significant (Wilcoxons test, p=0,0049).
164
It should be noted that after multimodality therapy with intravenous immunoglobulin use, disease recurrences were taking slighter courses with small quantity of
wheals and less intense of skin itching. Thereby, high clinical efficacy and safety of
medication Gabriglobin allow to recommend including medication Gabriglobin
to the multimodality therapy of patients with chronic autoimmune urticaria.
References.
[1] Altrich M.L., Halsey J.F., Altman L.C. (2009). Comparison of the in vivo autologous skin
test with in vitro diagnostic tests for diagnosis of chronic autoimmune urticaria. Allergy
Asthma Proc. N30(1), pp. 28-34.
[2] Lam L., Whitsett C.F., McNicholl J.M., Hodge T.W., Hooper J. (1993). Immunologically
active proteins in intravenous immunoglobulin. Lancet N342(8872), p.678.
[3] ODonnell B.F., Barr R.M., Black A.K., Francis D.M., Kermani F., Niimi N., Barlow R.J.,
Winkelmann R.K., Greaves M.W. (1998). Intravenous immunoglobuline in autoimmune
chronic urticaria. Br. J. Dermatol. N138(1), pp.101-106.
[4] Klote M., Nelson M.P., Engler R.J. (2005). Autoimmune response in urticaria of treatment
with high doses of intravenous immunoglobulin. Ann. Allergy Asthma Immunol. N94,
pp.307-308.
[5] Pereira C., Tavares B., Carrapatoso I., Loureiro G., Faria E., Machado D., Chieira C.
(2007). Low-dose intravenous gammaglobuline in the treatment of severe autoimmune
urticaria. European annals of allergy and clinical immunology. N39(7), pp.237-242.
[6] Hide M., Francis D.M., Grattan C.E., Hakimi J., Kochan J.P., Greaves M.W. (1993).
Autoantibodies against the high-affinity IgE receptor as a cause of histamine release in
chronic urticaria. N. Engl. J. Med. N328, pp.1599-1604.
[7] Molotilov B.A., Bolts E.A., Orlova E.A. (2010). To the analysis of specificity of autoserum
165
skin test in patients with urticaria. Herald of Ural Medical Academic Science. Thematic
issue devoted to the allergology and immunology. N2/1 (29), pp.176-177.
[8] Molotilov B.A., Orlova E.A., Bolts E.A., (2011). Diagnosing of chronic autoimmune
urticaria. Medicine sciences. Clinical medicine. N4 (20), pp.59-64.
Immunologic and immunogenetic indicators in patients

with severe forms of acne
Ryabova V.V., Koshkin S.V., Chermnykh T.V., Zaitseva G.A.
Kirov State Medical Academy of the Health and Social Development Ministry of Russia
Kirov Research Institute of Hematology and Blood Transfusion of the Federal Medical Biological
Agency of Russia, the city of Kirov, Russia
Summary: The current study was to compare immunologic and immunogenetic

indicators in patients with severe forms of acne and regional parameters of healthy
individuals.
Introduction. Acne is one of the most common skin diseases that affects up to
85% of people. 20% of the population suffer from severe forms [1]. The type of acne
depends on the character of immune reaction [2-4]. This is genetically determined. [5-8].
Materials and methods. 21 patients with severe forms of acne were studied. Their
age range was 17 to 28 years (figure 1-3). The duration of the disease was 3 to 5
years. Class I HLA antigens were identified by means of a standard microlymphocytoxic test with a set of typing serums. Specificity of class II HLA (locus DRB1*)
was identified with a set of sequence specific primers. Reliability of differences was
2
determined according to value and criterion of risk RR.
Results. Reliable decrease of absolute and relative contents of HLA-DR+ cells,
amount of CD16+- lymphocytes, percentage of phagocytizing neutrophils as well
as increase of the values of the following indicators: amount of CD3+, CD8+-cells,
NBT-test, level of circulating immune complexes, IgG and IgM in blood serum were
revealed in the group of patients (table 1). Distribution of antigens of class I and II
HLA were evaluated and estimated. Reliable decrease of frequency of HLA-A3, HLAB35 antigens was revealed. Increase of frequency of HLA-B13 was also detected (table
2). Frequency of phenotypic and haplotypic associations of antigens was analyzed. It
was determined that frequency of phenotypic combination of B7/B13 in the patients
and haplotypic combinations A2/B7, A9/B7 significantly exceeded those in healthy
individuals. The current comparative analysis of distribution of alleles HLA-DRB1*
did not reveal reliable differences (table 3). Of interest is a tendency to decrease of
frequency of occurrence of HLA-DRB1*11 specificity and increase of frequency of
HLA-DRB1*13 allele.
Conclusions. Dysfunction of immunity with main activation of T-cell immunity
was revealed. The results of the study suggest associative relations of the degree of
P421L5111
167
168
Table 1 Immunologic indicators in patients with severe forms of acne
Table 2 - Character of distribution of some antigens of class I HLA in patients with severe forms of acne
169
Table 3 Character of distribution of antigens of class II HLA in patients with severe forms of acne
Figure 1. Nodulo-cysticacne
Figure 2. Severeacne
170
Figure 3. Nodulo-cysticacne
severity of acne with antigens of HLA-complex. The results and findings have a
preliminary character because the group of patients was not large. Further studies in
this area will help investigate clinical polymorphism of acne from the point of view
of endogenic determination. They will help determine immunogenetic markers of
predisposition to severe forms of acne.
References
1. Perlamutrov Yu.N., Olkhovskaya K.B., LyaponA.O., Tsarkova Yu.B. Innovative therapy
for acne. Moscow, Journal of dermatology and venerology, # 5, 2011. P. 132-136.
2. Holland D.B, Jeremy A.N, Roberts S.G et al. Inflammation in the acne scarring: a comparrison of the responses in the lesions from patients prone and not prone to scar. Br. J.
Dermatol. 2004; 150 (1): 72- 81
3. Jeremy AH et al. Inflammatory events are involved in acne lesion initiation. Journal of
Investigation Dermatology 2003; 121: 20-27.
4. Kim J Review of the innate immune response in acne vulgaris: activation of Toll- like
reseptor 2 in acne triggers inflfmmatory citokine responses Dermatology 2005; 211 (3):
193- 198
5. Zaitseva G.A. Immunogenetic markers of blood and condition of antiinfectious immunity.
Dissertation of doctor of medical science degree. Kirov, 1989. 42 p.
6. Khaitov R.M., Alexeev L.P. Genomics of HLA: new opportunities of human molecular
genetics in diagnosis and therapy. Molecular medicine, # 1, 2003. P. 17 - 31.
7. Alexeev L.P., Boldyreva M.N. Physiological functions of the HLA system new views.
Journal Allergology and immunology # 5, 2004, P. 27 30.
8. Mayansky N.A., Mayansky A.N. Nomenclature and functions of the main complex of
histocompatibility. Journal of immunology, # 1, 2006. P. 43 46.
Immunorehabilitation of children with burh disease

Sakharov Sergey Pavlovich
Tyumen state medical academy, Tyumen,
Russia
Resume
Treatment of serious combustions continues to remain one of unresolved problems of clinical medicine. At the analysis of indicators of immunity at patients of
lethal group immunodepression presence is accurately shown. At application of an
immunoglobulin normal human at suffered children noted activation of cellular and
humoral links of immunity which reduced number of toxic and is purulent-septic
complications.
Introduction
Treatment of serious combustions continues to remain one of unresolved problems
of clinical medicine [1,2,3,4].
For today there is an insignificant number of the works devoted to complex studying
of a condition of immune system at suffered children and its role in a pathogenesis
of a burn disease. The understanding of sequence and expression of the immune disturbances occurring in an organism of patients, will allow to optimize pathogenetic
therapy, to lower quantity of complications and a lethality during the late periods of
a burn disease [2,4].

Under our observation was 17 children, at the age from 1 year till 3th years, with
the average area of a lesion of a body 36+2,5 %, from these patients at 8 - a lethal
outcome (control group), at 9 recover (the basic group). Children from both groups
are homogeneous for age, sex, depth and combustion severity level, character of the
thermal agent (in 100 % of cases a combustion hot water). The victim from the basic
group, in addition to traditional therapy, from the moment of deducing of the child
from a condition of burn shock (with 2 for 3 days from the moment of a trauma)
started to enter daily intravenously an immunoglobulin normal human in a dose of
3-4 ml on 1 kg of mass of a body, no more 25 ml a day. On course of treatment
P421L5112
171
172
it was used from 3 to 5 injections. Preparation introduction was spent intravenously

slowly to 15 drops in a minute.
Blood sampling carried out in the morning, on 3 - 7 and 10 15 days after trauma
reception that corresponded to an acute burn toxemia and septicotoxemia to a burn
disease stage. Phenotyping of lymphocytes of various populations and subpopulations
was carried out by means of the panel of monoclonal antibodies (firm Beckman
Coulter, the USA) on flowing Epics XL (firms Beckman Coulter, the USA): CD3
(mature T-limfotsity); CD4 (helperno-induktornuju subpopulation T-limfotsitov); CD8
(supressorno-cytotoxic subpopulation T-limfotsitov); CD19 (V-limfotsity).
Level of immunoglobulins of classes A, M, G in blood serum defined on the
immunochemical analyzer of fibers TURBOX plus (firms Orion Corporation Orion
Diagnostica, Finland).
Results
Comparing results of inspection of patients with a burn disease, treated (the basic
group) and not treated (control group) an immune preparation, we have come to the
objective conclusion that level of cellular and humoral immunity in these groups
considerably differed. So, at victims of control group quantity CD3 in a stage of an
acute burn toxemia was in 1,6 times less, than at patients of the basic group, and in
septicotoxemia the period difference observed in 2 times.
At the analysis of results of research of concentration in blood CD4 it is noticed
that at patients with a lethal outcome in septicotoxemia a stage it authentically was
below norm, and in group with application therapies reached norm borders. Especially
visually influence of an immunocorrection on level CD8 is visible. So, at the patients
who have received therapy, quantity CD8 in an acute burn toxemia was in 1,7 times
more than at patients without an immunocorrection, and in septicotoxemia a stage it
was enlarged - in 3,2 times.
At the analysis of results of research of concentration in blood CD19 it is noticed
that at patients with a lethal outcome, both in an acute burn toxemia, and in septicotoxemia a stage it didnt exceed norm, and at application therapies reached norm
borders. In the maintenance of immunoglobulins in the given groups in our researches
we havent taped distinctive features.
Conclusions
Thus, at the analysis of indicators of immunity at patients of lethal group presence
of the immunodepression enlarged in septicotoxemia of a stage of a burn disease is
accurately shown. At application of immune preparations (an immunoglobulin normal
human) at patients of the basic group noted activation of cellular and humoral links
of immunity which reduced number of toxic and is purulent-septic complications at
children with a burn disease in 1,6 times.
References
1. BALSEVEN-ODABAS1 A., TMER A.R., KETEN A., YORGANC K. Burn injuries
among children aged up to seven years. Turk J Pediatr. Vol. 51; P. 328-335; 2009.
173
2. CARVAJAL H.F., PARKS D.H. Burns in Children Pediatric Burn Management. Medical
Year Book Publishers, Chicago, 1988.
3. PEDEN M., OYEGBITE K., OZANNE-SMITH J., Hyder A A.., BRANCHE K [et al].
World report on child injury prevention, World Health Organization, 2008.
4. SHEN N.P. Burns in Children. Triada-X, Moscow, 2011.
Prophylaxis Of Pathological Scarring In Reconstructive

Plastic Surgery
Korkunda S., Grigorieva T.
Kharkiv Medical Academy of Postgraduate Education, Kharkiv, Ukraine
svkorkunda@gmail.com, tamaragrigo@gmail.com
Abstract:
One of the most unfavourable complications in reconstructive plastic surgery is the
formation of pathological scars. It is especially actually when performing surgery on
scar-changed tissues. The traditional protocol of preparation and rehabilitation of such
patients did not influence directly on the mechanisms of pathological scar formation.
The represented authors technology of conducting preparation, surgical intervention
actually and rehabilitation during the postoperative period is based on the principles
of Physiological Regulating Medicine and influence directly on the etiopathogenesis
of pathological scars formation. The comparative results of use of traditional protocol
and the authors technology are represented in this article.
Keywords: Pathological scar, Physiological Regulating Medicine, low dose drug,
MADE, Guna-Collagen, homotoxicology, reconstructive and plastic surgery.
Introduction.
Modern trends in selective surgery, to which reconstructive plastic surgery mainly
refers, are aimed at improvement of the quality and guaranteeing the safety of the
conducting treatment. The problem of pathological scarring is one of the most difficult
problems in surgery in general, and, therefore, the ability to control the formation of
postoperative scar is quite promising [5, 11]. The traditional medicamentous protocol
in reconstructive plastic surgery is hardly oriented to the preparing the organism for
surgery and during the postoperative period antimicrobial and steroid preparations,
NSAIDs, a massive infusion therapy, physiotherapy are normally used, what provokes
various somatic complications [2 4, 6, 16, 17, 19, 20]. Active introduction into
the work of the clinic principles of Physiological Regulating Medicine and Homotoxicology allowed developing of authors technology of medicamentous support for
prophylaxis of pathological scarring and various complications of the internal organs
during reconstructive plastic surgeries [8 10, 14, 15].
P421L5146
175
176
Materials and Methods.

A comparative analysis of traditional methods and the authors methods of scars
surgical treatment was carried out in Kharkiv Burn Center. In the main group of 54
patients surgical treatment was based on the principles of Physiological Regulating
Medicine in 2008-2011. Conventional treatment (in comparison group) was assessed
by retrospective analysis of surgical treatment results of 75 patients in Kharkiv Burn
Center in 1997-2007. To the studied parameters belonged: quality of postoperative
scars, the need of analgesics and antibiotics, recurrence of cicatricial deformities and
cost of surgical treatment.
The main group included 54 adult patients (18 63 y.o.), who underwent surgical treatment of scar and aesthetic indications (scar tissues, scar contracture of the
joints, scars deformities). Treatment protocol of main group consists of three stages.
The first stage is the general and local preparation. The main task is to enhance the
adaptive capacities of the organism as a whole and especially of the skin in the area
of surgical intervention before the operational stress. Implementation of this approach
has an impact on microcirculation vessels and extracellular matrix (ECM) when using
the mesotherapeutic technology based on low dose drugs (LDD). The result of this
exposure is the normalization of ECM condition, optimization of tissues functioning
and possibility to have the required quantity of plastic material to form normotrophical postoperative scar. Changing of quantitative and qualitative characteristics of
ECM can cause these effects [1, 10, 18]. The role of ECM is multidimensional, and
each of these characteristics has a clinical relevance. ECM makes up about 25% of
the human body mass and is a network of glucosaminoglicans (GAGs). ECM is a
transit zone and the molecular sieve between vessels and cells. This zone transmits
control signals (nervous, endocrine, immune). ECM can be in the zole form and this
ensures the effective interaction of cells and systems or it can gain gel form that
fails the transfer and regulation [1,10 ]. While developing acidosis the ECM loses
its ability to dissolve and starts to form the mucin clots, so the prevention or urgent
correction of such condition in surgical wounds is the prevention of pathological scar
formation. GAGs with good quantitative and qualitative characteristics can regulate
the shaping of new collagen fibers (into fibroblasts) in the areas to be treated (in
particular, in surgical wound) blocking synthesis of abnormal collagen and developing pathological scars. GAGs deficiency or accelerated destroying by hyaluronidaze
causes vascular irregularities, such as need for angiogenesis [7, 10]. Any changes of
the environment influence intracellular processes by changing the ECM conditions.
Saving products of metabolism in ECM leads to the blocking income of nutrients
into a cell and, accordingly, to toxins removing. Methods of classic detoxification
(plasmapheresis, IVLI, UVI, hemodialysis) are aimed at neutralizing and removing
specific toxins, but this process occurs in vascular systems. LDD with drainage effect
are able to clean ECM. There are a lot of vegetative neural fibers in ECM. Here
the information transfer of psycho-neural-endocrine-immune nature takes place. The
immune cells develop inflammatory processes. Any process in ECM at a molecular
level is realized by concentrated vital substances which correspond to potency 8DH
and 13DH. So, the normal functioning of cells due to anatomical and functional integrity of the matrix certainly depends on the degree of the purity and the ability to
detoxify the ECM [1, 10, 18]. The great role of the enzyme hyaluronidase is realized
177
in the renewal and purification of ECM. Hyaluronidase is expressed by fibroblasts

and secreted by pathogenic bacteria that are widely used in modern production of
HA. Hyaluronidase is able to dissolve the main substance of ECM and thats why
it is possible to use enzymes to remove toxins from cells in order to burn them
through the fire of inflammation. So, inflammation is a classic mesenchymal reactive phase and the mechanism of antihomotoxical prevention aimed at the purification of ECM from toxic factors. According to Physiological Regulating Medicine
and Homotoxicology, LDD are able to activate immune mechanisms, to support the
defensive reactions [1, 16, 17]. Therefore, in accordance with the modern studies on
the connective tissue, ECM is the zone of most important processes and key factor of
low dose remedies action. If we take account of this fact, it is the obvious advantage
of intradermal (mesotherapeutic) way of using the low dose drugs [8 -10, 12, 15].
Introduction of MADE and Guna-Collagen (an operational intervention zone) makes
possible to optimize the performance of biological functions in the skin due to an
indirect stimulation of fibroblasts activities and angiogenesis. Using low dose drugs
makes possible to realize all the vital processes during surgical treatment by physiological ways without any side effects. Such an approach of patient preparation to
planned surgical intervention ensures adequate reaction of the organism, both generally
and locally in the zone of surgical treatment.
In the preoperative period after the examination and treatment planning the preparation of the organism in whole is conducted (per os: Guna-Basic, Son-Formula, VitFormula, preparations from the series Bach flowers - as a universal Resource Remedy)
and the mesotherapy course with preparations Made and Guna-Collagen in the area
of the forthcoming operation is conducted locally. Before the operation patient has
intracutaneous injection of MADE and Guna-Collagen once a week, 4 - 6 procedure.
Patient takes LDD per os for drainage, and continues to do it in the future after the
operation (Guna-Limpho, Guna-Matrix).
The surgical intervention (the second stage). Careful planning of operational tactic
avoids the problems of microcirculation, the incision should be done according to
vessels and nerves, skin tension lines, movement of the patient after the operation
in various position of the body. Displaced flap of skin must converge without tension. Just after sewing up the surgical wound intracutaneous injections of LDD with
drainage and anti-inflammatory effect should be made (Lymphomyosot, Traumeel,
Omeoformula 5). Always use elastic compression.
In the postoperative period (the third stage) the first and the second wound revision
(the first and the second days after operation) includes the session of intracutaneous
injections of LDD Lymphomyosot, Traumeel, Omeoformula 5. Postoperative period
in 2 weeks after the operation includes the session of mesotherapy by Guna-Collagen
and MADE just to the surgical suture (once a week N 6 - 10), elastic compression
and antiscar ointments. Common purpose: Guna-Limpho, Guna-Matrix, Son-Formula,
Guna-Tonic, Ferro Guna (if it is possible), Resource Remedy.
Results of treatment: All the patients noticed the comfort feeling, the pain syndrome is expressed moderately, they dont need the additional intake of analgesics;
the patients are active direct after the operation; only after the intubation narcosis or
by the fixation of limbs the patients need hospitalization during 1 3 days after the
operation. Formation of pathological scar took place by one patient (1,85%), who
couldnt provide treatment in postoperative period in the whole volume.
178
Table 1. Results of surgical treatment of main and control group.
Table 2. The cost of drugs for surgical treatment
Any cases of contracture recurrence and scar ulceration in postoperative period

(observing period 2 months 3 years). Such drug is a supplement for preparing,
training, and rehabilitation of patients with normal skin and tissue changed into
scar in reconstructive plastic surgery, it improves the results of a surgical treatment;
improves the qualitative characteristics of the organism as a whole, as well as the
zone where operation will be performed; blocks the development of inflammatory
complications and pathological scar formation; eliminates the risk of side effects of
allopathic drugs; reduces pain syndrome (patients need no additional analgesics and
antibacterial remedies); reduces the time for medical and social adaptation, including
hospitalization; improves the emotional condition of patients.
Conventional treatment (control group). 75 adult patients (18 65 y.o.), who
underwent surgical treatment of scars and aesthetic indications (scar tissues, scar contracture of the joints, scars deformities). Common preparation may include vitamins.
Surgical treatment is standard. Indication of postoperative period: wound dressing,
antibiotics, NSAIDs, steroid remedies, elastic compression, physiotherapy, steroid and
Longidasa injections into the scars, antiscar ointments. Quantitative characteristics of
treatment are presented in Table 1.
Resume.
The comparative analysis of the authors treatment technology and the traditional
treatment technology let us make next conclusions:
1. Improvement of aesthetic and functional results of surgical scars treatment.
2. Prevention of pathological scar formation.
3. Reduction of symptoms of pain after operation.
4. Shortening of medical and social rehabilitation.
5. Reducing the patients drug burden.
6. Prevention of various physical complication.
7. Reduction of the cost of treatment.
8. Improving the quality of life of patients.
The introduction of the treatment protocols based on the principles of the Phisio-
179
logical Regulating Medicine will qualitatively change the results of planned reconstructive and plastic surgery. The influence on etiopathogenetic mechanisms of scar
formation is biologically safe and can be recommended for the wide application in
reconstructive plastic surgery.
Reference:
1. Antihomotoxic and detoxification therapy // Method. recommendation. Kiev, 2007. 56 p.
2. Baida V. Use of regional anesthesia techniques in private clinic of plastic surgery // Plastic
surgery and aesthetic medicine: Proceeding of science and practice conference UAPRAS.
Kiev, 2006. P.11-13.
3. Baida V., Kompaniec V., Chigirinec O. Particularly anesthetic management of face plastic surgery // Plastic surgery and aesthetic medicine: Proceeding of science and practice
conference UAPRAS. Kiev, 2006. P.15-17.
4. Bezrucov S., Saenko V. Intra- and postoperativ medicaiton prevention of postoperativ
complications in patients with maxillofacial pofile // Plastic surgery and aesthetic medicine: Proceeding of science and practice conference UAPRAS. Kiev, 2006. P.19-20.
5. Belousov A. Scars as a global problem of plastic surgery // Plastic surgery and
aesthetic medicine: Proceeding of science and practice conference UAPRAS. Kiev,
2006. P.24-26.
6. Berestovoi O. Problem of resistance to antibiotics // Womens health - N 3 (15). - 2003
.- P. 143-147.
7. Ilina S. Antimicrobial activity of hyaluronic acid // Journal of Microbiology, Epidimiology
and Immuobiology. 2001. - N 1. P. 7475.
8. Korkunda S., Grigorieva T. Profilaxis of pathological scarring in reconstructive and plastic
surgery // Les Nouvelles Esthetiques Ukraine. 2010. - N 2 (60). p. 26-29.
9. Korkunda S. Mesotherapy in reconstructive and plastic surgery // Mesotherapy. 2010.
- N 2. P. 18-21.
10. Korkunda S., Grigorieva T. Pathogenic aspects of medication management in reconstructive and plastic surgery // Kharkive Surgical School. 2010. - N 1 (39). P. 37-41.
11. Mishalov V., Hrapach V., Babalan O. The possibility of obtaining an ideal posroperative scar // Plastic surgery and aesthetic medicine: Proceeding of science and practice
conference UAPRAS. Kiev, 2006. P. 109-110.
12. Pavlenko O. Complications of mesotherapy // Aesthetic medicine. 2008. T.VII, N3.
P. 429-431.
13. Pasichnic V. B.B. Clinical and anatomical features of age-related changes in the
soft tissues of the face and neck // Problems of the modern medical science and education. 2009. - N2. P. 83-89.
14. Patent N 54001 dated 25.10.10. Method of preparation of tissues for reconstructive and
plastic surgery. Korkunda S., Grigorieva T.
15. Patent N 54002 dated 25.10.10. Method of profilaxis of pathological scarring in reconstructive and plastic surgery. Korkunda S., Grigorieva T.
16. Pinchuk V., Tkach O. Collaboration of cosmetologist and surgeon // LNE Ukraine. - 2007.
- N 3 (43). P. 32-34.
17. Smirnova L. Ways to improve anesthesia in reconstructive surgery // Plastic and Reconstructive Surgery. 2006. - N1. P. 62-67.
18. Chenomorets P., Nurischenko N. Common pathophisiolgical aspects of degenerativedystrophic processes // Antihomotoxical correction of peripheral circulatory disorders in
therapy of degenerative-dystrophic processes. Abstracts. Kiev. 2008. P. 6-22.
19. Godsey M.H., Zheleznova-Heldwein E.E., Brennan R.G. Structural Biology of Bacterial
180
Multidrug Resistance Gene Regulators // Published, JBC Papers in Press. 2002, August
22. DOI 10.1074/jbc.R200018200.
20. Martin R.G., Rosner J.L. Legal issues associated with antimicrobial drug resistance // Curr.
Opin. Microbiol. 2001. V. 4. P. 132 137.
On the immunomodulate features of the new medical

product Lukman-1
Pleskanovskaya S., Kokanov A., Hodjageldiyeva A., Armedowa O.
State Medical University of Turkmenistan, Institute of Medical plants of Turkmen Academy of
Science, Ashkhabad, Turkmenistan.
The root of licorice is known all over the world as a medicinal plant. In olden
days The licorice root is known all over the world as a medical plant. In days of
old the Tibetan, Indian, Arabian national doctors prepared from licorice medicines
for treatment of various diseases. Licorice, described as the grandfather of grasses,
was used with 500 to b.c. [18] fore treatment of peptic ulcers, cough, tuberculosis
and many other diseases [14]. Avicenna, recommended to use broth of licorice roots
for treatment of skin ulcers, kidneys diseases, gastritis, a fever, lungs diseases - such
as a bronchial asthma and a chronic bronchitis [2]. Licorice - Glycyrrhiza L. consists
approximately of 30 versions, including G. glabra, G. uralensis Fisch and others
[17]. The licorice root, collected at coast Amu Derya (Turkmenistan), is classified as
G. glabra [11,26] and it takes a special place in recipes of ancient doctors [1,3,4,5].
Scientific interest to a licorice root all increases as in it are found triterpenoids and
saponins [6]. Others triterpenes (liquiritic acid, glycyrretol, glabrolide) and chalcones
[27], fatty acids (C2-C16) as are found in a licorice root [15].
Not only the root, the surface part of licorice contains flavonoids, C- glycosides,
such as vitexin and its isomer saponaretin, as well as foleroside were extracted from
licorice herbs. The root and herbs of licorice contains such coumarins as umellipheron
and gernisarin and such oxybrown acids as ferulic and saponic ones [26].
Various properties of licorices continue to be studied in Turkmenistan as it is
our endemic plant. During the last 15 years various medicinal forms of licorice are
created. There are ointments [23, 24, 25] tablets [16], syrups [8].
New medical product, named Lukman -1 (L-1) was elaborated on the base of
Glycyrrhiza glabra and Althaeae officinalis in Institute of Medical plants of Turkmen
Academy of Sciences. It represents the sugar syrup prepared on the basis of specified
plants with addition of some quantity of ethyl alcohol. Now intensively are studying
immunomodulating properties of licorices medical products [19,20,21].
The goal of our work was to study the immunomodulating activity of L-1.
In particular we studied we studied influence of L-1 on the blood leucocytes migration from a glass capillary in vitro. The migration capacity of practically healthy
P421L5137
181
182
Fig.1. Absolute number of WIM and PHD blood leukocytes migrating from a glass capillary, depending on
dissolving liquid kind
donors (PHD) and white inbred mices (WIM) blood leucocytes were determined
by the method of S. Pleskanovskaya [21]. Results were expressed as the leucocytes
migration modulating indexes (LMMI).
L-1 before using was dissolved 1:10 by distilled water (DW) or 0.9% natrium
chloride (NC) and then has been added into the leucocytes incubation medium an
1.0 mkl. Thus, the final concentration of L-1 has reached 3.8 x10-3 - (L-1)1;
1, 7.6 x10-3 - (L-1)2 and 11.4 x 10-3 - (L-1)3 per ml of cultures medium. In experiments has been used the peripheral blood of 20 WIM with mass not more 20.0
g and 50 PHD aged from 18 to 25. Obtained dates were mathematically processed.
It has been shown, that L-1 considerably modulates ability to migration of leukocytes as the HD and WIM. Degree of leukocytes migration modulation depends
on concentration and a kind of solvent. In cases of use of the DW to dissolve L-1
the number of the migrating from glass capillaries leukocytes has increased more
considerably in comparison with NC (a Fig. 1). As you can see on the diagram the
number of leukocytes, migrating from glass capillary that more than above concentration L-1. So the absolute number of migrating leukocytes directly correlates with
concentration L-1 (Fig.1). Basically the effect essentially did not depend on a solvent
kind. But L-1 dissolved with the DW was more active and consequently only it was
used in the further experiments.
At the second step of the leucocytes migration investigation in the L-1 presence
we expressed results of reaction as the LMMI (Fig.2). As you see on diagram the
LMMI was minimal in the presence of minimal L-1 concentration that had made
3,8x10-3 per ml. In the presence of 7,6 x10-3 and 11,4 x10-3 L-1 per ml the numerous
183
Fig.2. Values LMMI depending on a kind of a dissolving liquid
Fig.3. Structure of practically healthy donors LMI values
of migrated cells significantly increased (p <0.05 in all cases). Thus, there is back
correlation between the L-1 concentration and the ability of it to inhibit migration
activity of the leucocytes as well as of PHD as WIM.
The received effect did not depend on a kind of the used solvent. However the analysis of size LMMI has shown that L-1 stimulates migration of leukocytes of the PHD
184
Fig.4. Structure of white inbred mice LMI values
only in 20 % of cases, and WIM - in 35 %. As a whole average size LMMI in group

of healthy donors has made 75,010,0. Value LMMI at 20 % of the PHD has made
181,09,6 (p <0,001 in relation to average size on all group). Size LMMI in 6.7 % of
cases did not differ from average size on group of the PHD and has averaged 72,72,6
(distinction not authentically in relation to average data on group, p> 0,05) (Fig.3).
Practically the same results were obtained in experiments on mice (Fig.4). In 55
% of cases LMMI for leukocytes of WIM blood had low values. In other words,
more, than in more half of cases L-1 suppresses migration of mice leukocytes. It is
well known, that decreasing of the migrated from glass capillary leucocytes number
testifies as the migration inhibition (7, 9,10,12,13, 22).
Thus, the new medical product, elaborated in Turkmenistan, named Lukman -1
(L-1) possesses ability to modulate (mainly to inhibit) migration of leucocytes from
glass capillary. In all cases leucocytes specific accessory has no essential value. The
capacity of L-1 to inhibit the leucocytes migration from glass capillary in vitro, in
our opinion, specifies in possibility of its using as a resolving and immunomodulating
medical product.
References to article
1. Atayev A. Biological and ecological funds of Turkmenistan licorice agrocenosis usage.
Ilim, Ashgabat, Turkmenistan, 287, 2004. (Rssian).
2. Avicenna (Abu Ali ibn Sina) Cod of medical sciense (Kanon vrachebnoy nauki), II, Fan
Uzbekskoy SSR, 832, 1982 (Russian).
3. Berdimuhamedov G.M. Medical plants of Turkmenistan 1, Ashkhabad, Turkmenistan, 2008.
4. Berdimuhamedov G.M. Medical plants of Turkmenistan Vol.II, 2009, Ashkhabad, Turkmenistan.
5. Berdimuhamedov G.M. Medical plants of Turkmenistan Vol.3, 2012, Ashkhabad, Turkmenistan.
6. Blumenthal , M., Goldberg, A., and Brinckmann, J. Herbal medicine: Expanded commission
E monograph, 233-236, Austins. TX: American Botanical Council2000.
185
7. Bowers, William (2006). Immunology Chapter nine: Cells involved in immune responses. Microbiology and Immunology On-Line Textbook. USC School of Medicine. January
2007. Retrived 4http://patmicro.med.sc.edu\bowers\immune%20cells.htm.
8. Cocanov A., Spiridonova N., The new native medicine forms of licorice Astracts of the
International Scientific Conference dedicated to the 10-th anniversary of State Programme
of President of Turkmenistan Health. Askhabad, Turkmenistan, p.575, 2005.(Turkmen)
9. Immune deficiency states (edit. prof. Smirnov V.S. and prof. Freydlin I.S.) . Foliant, StPeterburg, 163-189, 2000. (Russian).
10. Immunology (edit. W.E. Paul) Raven Press Book, Ltd. 1984
11. Kerbabayev B.B., Gladishev A.I. Turkmen licorice root Ilim, Ashkhabad, 94, 1971.
(Russian).
12. Khaitov R.M. Physiology of immune system. M:2001.
13. Khaitov R.M., Gusshin I.G., Pinegin B.V., Zebrev A.I. Eksperimental studying immunoaspiration activity of pharmacological preparations. Methodical instructions. Immunology.
Moscow, 2002.
14. Marjan Nassiri-Asl, Hossein Hosseinzadeh. 2012. Licoice (Glycyrrhiza species) in Genetic
resources, chromosome engineering, and crop improwement. Medical Plants. Vol. 6.
15. Nf, R.and Jaquier, A. 2006. New Lactones in licorice (Glycyrrhiza glabra L.) Flavor and
Fragrance Journal. 21:193-197
16. Nepesov G.A., Sachatov E.S., Kurbanov M.A, The study of the technological properties
of tablettes prepared from the thik licorice extract . Annual 55-th scient. Confer. Turkmen
gos. Med. Inst. Devot, 8-th enniver. Independ. of Turkmenistan, Ashgabat, Turkmenistan,
77, 1995. (Russian
17. Obuchov A.N. Licorice root and its storage, work and sale. Nauka, Moscow, Leningrad,
96, 1934. (Russian).
18. Ody, P. 2000. The complete guide to medicinal herbs, 75. London : Dorling Kindersley.
19. Pleskanovskaya S.A. Phytoimmunmodulation - possibilities and prospects Immunol.&Allergol.
V 6. N3. 2005, ctp323.
20. Pleskanovskaya S.A., Ashyraliyeva M.A., Mammedova B.A. Licorice medical and
biological value. Turkmen science and technology J. . 2006, N5, p.15-27
21. Pleskanovskaya S.A., Ovezova G.K. Immunological method of individual selection of the
phytopreparation used at internal diseases treatment. Patent N274 from 04.07.2002,
Turkmenistan.
22. Roit A., Brostfour J., Mail D. Immunology. Moscow Mir, 2000 (rus. Transl.)
23. Sakhatov E.S., Shukurova G.Ch, Nepesov G.A. Determination of the optimal parameters
of the technological process of the licorice thick extract ointment receiption, Proc. Annual
57-th scient. Confer. Turkmen gos. Med. Inst. Devot, 8-th enniver, Independ. Turkmenistan,
Ashgabat, Turkmenistan, 1997,102. (Russian).
24. Sakhatov E.S., Shukurova G.Ch, Nepesov G.A. Determination of the optimal parameters
of the technological process of the licorice thick extract ointment receiption, Proc. Annual
57-th scient. Confer. Turkmen gos. Med. Inst. Devot, 8-th enniver, Independ. Turkmenistan,
Ashgabat, Turkmenistan, 1997,102. (Russian).
25. SakhatovE.S., Nepesov G.A., Shukurova G.Ch., Kulamova N.A. Investigation of osmotics
properties of the licorice thick extract ointment. Proc. Annual 56-th scient. Confer. Turkmen gos. Med. Inst., Ashgabat, Turkmenistan, 1996, 82 . (Russian).
26. The lower karakumes plants definitor (edit. S.K.Cherepanov). Ilim, Ashkhabad, 192,
1991. (Russian).
27. Williamson, E.M.2003.Licorice. In potters cyclopedia of herbal medicine, 296-271. Soffron Walden, UK: C.W.Daniels.
Defects in functioning of interferon and immune

systems and their correction in chronic active EpsteinBarr infection
Nesterova Irina V.1, Kovaleva SvetlanaV.2, Chudilova Galina A.3,
Lomtatidze Ludmila V.4
University of Friendship of Peoples, Moscow, Russia
Kuban State Medical University, Krasnodar, Russia
3
4
E-mails: inesterova1@yandex.ru
1
2
Abstract
Creating of new methods of treatment of patients with chronic active Epstein-Barr
virus (EBV) infection is a very actual problem. The activation of EBV infection may
occur in connection with major disturbances of interferon (IFN) system and immune
system (IS). The aim of our study was to research the IFN system, main antiviral
mechanisms of IS in patients with atypical chronic active EBV infection and to
create new methods of IFN- and immunotherapy for treatment of this disease. We
had studied 35 patients (both sexes in age of 20 50 years), suffering from atypical chronic active EBV infection associated with chronic fatigue syndrome, prolong
mild pyrexia, nonexudative pharyngitis, tonsillitis, lymphadenopathia. EBV infection
was tested by PCR and serological methods and was found in 100% of cases. Levels of induced production of IFN and IFN were tested for the assessment of the
IFN system. Numbers of CD3+, CD3+CD4+, CD3+CD8+, CD3+CD56+, CD4+CD25+
CD4+HLA-DR+, CD8+HLA-DR+, CD8+CD25+, CD3-CD16+CD56+, CD3-CD16-CD56+,
CD56+HLA-DR+, CD19+ cells , levels of serum IgG, IgM, IgA, numbers of neutrophilic
granulocytes(NG) and activity of theirs reactive oxidative species (ROS) production
by chemoluminescense method were researched before and after treatment. Defects
of IFN system were found in 100.0% of cases: impairments of induced production of
IFN had place in 100.0%, induced production of IFN in 82.8% of cases. Different
defects of T chain (deficiencies of CD3+ and/or CD3+CD4+, and/or CD3+CD8+, and/or
CD3+CD56+, increasing level of CD4+CD25+ lymphocytes) were tested in 80.0% of
patients. Low levels of NKs (CD3-CD16+CD56+ and/or CD3-CD16-CD56+) were tested
in 77.1% of cases. Deficiencies of serum IgG and/or IgM took place in 42,8% of pa-
P421R9047
187
188
tients. Dysfunctions of NG (neutropenia, defects of ROS production) were revealed in

74,3% of cases. In the issue all patients had had different combine disturbances of IFN
and immune systems. We had created program of combine IFN- and immunotherapy
including: a) the base prolonged continuous systemic IFN therapy by recombinant N
H2 Viferon, using differential doses (at the first step in dose 6 Mln.IU during 4
weeks and then the gradual dose reduction every 4 weeks), course of Viferon treatment
was longed 4.5 months; b)restoration of T chain of IS with using of 10 days courses
of Isoprinosine monthly during 4.5 months; c) for reconstruction of NK, NG, humoral
chain Licopid was used (2mg/daily during 10 days, then supporting dose 2mg/daily
3 time a week 1 month, then 2mg/daily 2 time a week 1 month). We had used
the alternation of courses of Isoprinosine and Licopid. At the first step of treatment
synthetic drug Famvir was used for better elimination of EBV: 1000mg daily during
14 days. If it was necessary course of Famvir was repeated in acute period. As result of treatment the regression of chronic fatigue syndrome, prolong mild pyrexia,
nonexudative pharyngitis, lymphadenopathia had observed after 2-3 weeks from the
beginning of IFN and immunotherapy. We could see the preservation of the positive
clinical effects after 1 year from the end of the treatment. Positive dynamic of changes
in IFN and immune systems were observed in 77.7% of patients. Thereby IFN- and
immunotherapy allow to achieve positive clinical and immunological efficiencies in
atypical chronic active Epstein-Barr virus infection.
Keywords: Epstein-Barr virus, chronic infection, interferon, immune system, interferon- and immunotherapy
Introduction.
The Epstein-Barr virus (EBV) has evolved a plethora of strategies to evade immune system recognition and to establish latent infection in memory B cells, where
the virus resides lifelong without any consequence in the majority of individuals.
However, some imbalances in the equilibrium between the inherent virus transforming
properties and the host immune system can lead to the development of different diseases (Merlo A, Turrini R, Dolcetti R, Martorelli D, Muraro E, Comoli P, Rosato A.,
2010). Upon viral infection, the major defense mounted by the host immune system
is activation of the interferon (IFN)-mediated antiviral pathway, which is mediated
by IFN regulatory factors (IRFs) ( Randall R.E., Goodbourn S., 2008). EBV LF2
tegument protein specifically interacts with the central inhibitory association domain
of IRF7, and this interaction leads to inhibition of the dimerization of IRF7, which
suppresses IFN-alpha production and IFN-mediated immunity(.Wu L, Fossum E, Joo
CH, Inn KS, Shin YC, Johannsen E, Hutt-Fletcher LM, Hass J, Jung JU., 2009).
The interaction between the EBV and TLR pathways was investigated. Both UVinactivated and untreated EBV upregulated the expression of TLR7 and downregulated
the expression of TLR9 in naive B cells. Interferon regulatory factor 5 (IRF-5) is a
downstream mediator of TLR7 signaling. IRF-5 has tumor suppressor and antiviral
properties. IRF-5 was induced following EBV infection, and IRF-5 was expressed
in B-cell lines with type III latency. EBV initially uses TLR7 signaling to enhance
B-cell proliferation and subsequently modifies the pathway to regulate IRF-5 activity
(Martin HJ, Lee JM, Walls D, Hayward SD., 2007). EBV can escape from actions of
CD8(+) and CD4(+) T cell immunity via concerted actions of multiple gene products.
189
Viral-IL10 causes a reduction in mRNA levels of TAP1 and bli/LMP2, a subunit of

the immunoproteasome. MHC class I molecules present at the cell surface are downregulated by BILF1. Also the antigen presenting capacity of MHC class II molecules
is severely compromised by multiple EBV lytic gene products, including gp42/gH/gL,
BGLF5, and vIL-10. (Ressing ME, Horst D, Griffin BD, Tellam J, Zuo J, Khanna
R, Rowe M, Wiertz EJ., 2008 ). Furthermore, following In the EBR acute infection,
expression of the receptor for the homeostatic cytokine IL-15 on NK and T cells is
lost (Hislop AD, Taylor GS, Sauce D, Rickinson AB., 2007). Two genes encoded by
the EBV --LMP1 and LMP2A--allow EBV to exploit the normal pathways of B-cell
differentiation so that the EBV-infected B blast can become a resting memory cell.
(Thorley-Lawson DA., 2001). Thus EBV has developed much more elaborate and
sophisticated strategies for subverting host immune system, which may account for
its high prevalence in immune competent hosts. EBV-specific immune dysregulation
is very important for the occurrence of EBV latency (Ning S., 2011).
EBV chronic infection manifest after infectious mononucleosis or after acute respiratory viral infection that is mask EBV infection. The activation of chronic EBV
infection may occur in connection with major disturbances of interferon (IFN) system
and immune system (IS). One of form of chronic EBV infection is atypical chronic
acute EBV infection (Pizzigallo Eligio, Racciatti Delia, and Gorgoretti Valeria, 2010).
In atypical chronic acute EBV infection patients suffer from prolong mild pyrexia,
nonexudative pharyngitis, tonsillitis, lymphadenopathia, chronic fatigue syndrome for
a long time. Diagnostic and treatment of atypical chronic acute EBV infection often is
very difficult. Creating of new methods of treatment of patients with atypical chronic
active Epstein-Barr virus (EBV) infection is a very actual problem.
The aim of our study was to research the IFN system, main antiviral mechanisms
of IS in patients with atypical chronic active EBV infection and to create new methods
of IFN- and immunotherapy for treatment of this disease.
Methods.
We had studied 35 patients (both sexes in age of 20 50 years) suffering from
atypical chronic active EBV infection. EBV was tested by PCR (blood, saliva, tonsils,
urine) and serological methods (IgM to EA, IgG to VCA, IgG to EBNA). Levels of
induced production of IFN and IFN were tested for the assessment of the IFN system.
Numbers of CD3+, CD3+CD4+, CD3+CD8+, CD3+CD56+, CD4+CD25+ CD4+HLA-DR+,
CD8+HLA-DR+, CD8+CD25+, CD3-CD16+CD56+, CD3-CD16-CD56+, CD56+HLA-DR+,
CD19+ cells by flow cytometry on CYTOMICS FC500 (Beckman Coulter, USA)
with a panel of monoclonal antibodies, levels of serum IgG, IgM, IgA, numbers of
neutrophilic granulocytes(NG) and activity of theirs reactive oxidative species (ROS)
production by chemoluminescense method were researched before and after treatment.
Results.
All patients were suffering from chronic fatigue syndrome, prolong mild pyrexia,
nonexudative pharyngitis, chronic tonsillitis, lymphadenopathia (Table 1). EBV infection
was found in 100% of cases. Defects of IFN system had been identified in 100/0%
of cases: impairments of induced production of IFN had place in 100/0%, induced
190
Table 1 Clinical criteria before and after treatment
Table 2 . Interferon system and immune system in patients with atypical chronic active EBV infection
before and after treatment.
production of IFN in 82.8% of cases. Different defects of T chain (deficiencies of

CD3+ and/or CD3+CD4+, and/or CD3+CD8+, and/or CD3+CD56+, increasing level of
CD4+CD25+ lymphocytes) had been found in 80.0% of patients. Low levels of NKs
(CD3-CD16+CD56+ and/or CD3-CD16-CD56+) had been tested in 77.1% of cases. Deficiencies of serum IgG and/or IgM had took place in 42,8% of patients. Dysfunctions
of NG (neutropenia, defects of ROS production) had been revealed in 74,3% of cases.
As a result of investigation it was established that all patients had violations different
variants of combine disorders of IFN and immune systems (Table 2).
191
We had created program of combine IFN- and immunotherapy including:

a) the
N
base prolonged continuous systemic IFN therapy by recombinant H2 Viferon,
using differential doses (at the first step in dose 6 Mln.IU during 4 weeks and then
the gradual dose reduction every 4 weeks), course of Viferon treatment was longed 4.5
months; b)restoration of T chain of IS with using of 10 days courses of Isoprinosine
monthly during 4.5 months; c) for reconstruction of NK, NG, humoral chain Licopid
was used (2mg/daily during 10 days, then supporting dose 2mg/daily 3 time a week
1 month, then 2mg/daily 2 time a week 1 month). We had used the alternation
of courses of Isoprinosine and Licopid. At the first step of treatment synthetic drug
Famvir was used for better elimination of EBV: 1000mg daily during 14 days. If it
was necessary course of Famvir was repeated in acute period. As result of treatment
the regression of chronic fatigue syndrome, prolong mild pyrexia, nonexudative
pharyngitis, lymphadenopathia had occurred after 2-3 weeks from the beginning of
IFN and immunotherapy in all patients. We could see the preservation of the positive
clinical effects after 1 year from the end of the treatment (Table 1). Positive dynamic
of changes in IFN status and immune systems were observed in 77.1% of patients
(Table 2). Thereby IFN- and immunotherapy made it possible to get positive clinical
and immunological efficiencies in atypical chronic active Epstein-Barr virus infection.
References
1. Hislop AD, Taylor GS, Sauce D, Rickinson AB.( 2007) Cellular responses to viral infection in humans: lessons from Epstein-Barr virus. Annu Rev Immunol. 25, pp. 587-617.
2. Martin HJ, Lee JM, Walls D, Hayward SD. ( 2007) Manipulation of the toll-like receptor
7 signaling pathway by Epstein-Barr virus. J Virol. 81(18),pp.9748-9758.
3. Merlo A, Turrini R, Dolcetti R, Martorelli D, Muraro E, Comoli P, Rosato A. (2010) The
interplay between Epstein-Barr virus and the immune system: a rationale for adoptive cell
therapy of EBV-related disorders. Haematologica 95(10), pp.1769-1777.
4. Ning S. Innate immune modulation in EBV infection. (2011) Herpesviridae 2(1), pp.1.
5. Pizzigallo Eligio, Racciatti Delia, and Gorgoretti Valeria (2010) EBV Chronic Infections.
Mediterr J Hematol Infect Dis. 2(1): e2010022;
6. Randall R.E., Goodbourn S. (2008) Interferons and viruses: an interplay between induction, signalling, antiviral responses and virus countermeasures. J. Gen.Virol. 89, pp.1-47.
7. Wu L, Fossum E, Joo CH, Inn KS, Shin YC, Johannsen E, Hutt-Fletcher LM, Hass J,
Jung JU. (2009) Epstein-Barr virus LF2: an antagonist to type I interferon. J Virol. 83(2)
pp.1140-1146.
Efficiency Of Simultaneous Hepatites A And B

Vaccination In Patients With Chronic Hepatitis C
Isaeva N., Pavroz K., Arbuzova E., Maltseva S.
Perm State Academy of Medicine named after Academician E.A. Wagner, Perm, Russia
Summery. The paper contains modern epidemiological characteristics of mixedhepatites among the population of a big industrial center and results of analytical
epidemiological case-control investigations, aimed at efficiency estimation of
combined hepatites A and B vaccinal prevention in patients with chronic hepatitis C.
Introduction. High level of prevalence and unfavorable clinical aftereffects of
hepatites of combined etiology defined the problem of searching safe prophylactic
measures of these infections. The aim of the investigation was to evaluate immunological and preventive efficiency of simultaneous hepatites A and B vaccination in
persons with chronic hepatitis C.
Materials and Methods. Prevalence of mixed-hepatites was studied with the
method of total screening of all the cases of viral hepatites among the population
of a big industrial center according to primary documentation data of Public Health
authorities and institutions as well as Rospotrebnadzor over the period 2002-2010
(n=7093). Immunological efficiency of simultaneous hepatitis A (HA) and hepatitis
B (HB) vaccination was estimated in case-control investigations. The experimental
group as well as the control one included thirty persons identical by sex and age.
The experimental group consisted of patients with chronic hepatitis C (CHC) after
the completed course of therapy with negative result of polymerase reaction. The
control group consisted of healthy persons. The examined contingent was thrice HB
vaccinated intramusculary according to the scheme 0-1-6 months with vaccines Euvax
B (1st vaccination) and Regevac B (2nd and 3rd vaccinations) in the doze of 1 ml
and twice HA vaccinated intramusculary with vaccine HEP-A-in-VAC in the doze
of 1 ml. Antibody concentration equal to 20 ME/l was adopted as protective titer
in case of HA and was equal to 10 ME/l in case of HB. Quantitative definition of
anti-Hbs antibodies and qualitative definition of anti-HAV antibodies in blood serum
were carried out with chemiluminescence method using automatic analyzer Architect
2000 with the test-systems of the same company (n=60). Quantitative definition of
anti-HAV antibodies in blood serum was carried out with electrochemiluminescence
method using automatic analyzer Elexis 2010 (n=60). Five blood analyses were made
during the investigation: before HA and HB immunization (background level), in one
P421L5081
193
194
month after the first HB vaccination, four months after the second HB vaccination ,
in one month after the completed HB immunization course and in a month after the
second HA immunization, performed in 11 months after the beginning of immunization. Statistical treatment was fulfilled according to traditional method.
Results. The percentage of viral hepatites was 65,8% in the structure of all liver
diseases in the population of a big industrial center. The cases of acute co-infection
with different hepatitis- causing viruses among the adult population were extremely
rare 1-2 cases per 1 million of persons annually. The percentage of mixed-hepatites
in patients with chronic viral hepatites was rather high -12,5%. Etiological structure
of mixed-hepatites was presented by 8 combinations of viruses among which, the first
rank position belonged to patients with HB+hepatitis C (HC) (74,6%) (fig.1). Hepatic
cirrhosis was revealed in every tenth patient with mixed-hepatites (9,5%), whereas
it occured 7,5 times (p<0,05) more rare in patients with hepatitis, caused by only 1
virus. Moreover, probability of lethal outcome in patients with hepatitis of combined
etiology was 25 times higher than in patients with isolated types of hepatites.
While analyzing sexual structure, no reliable differences between men and women
in mixed-hepatites morbidity levels were revealed (t=1,5). Among the patients with
combined etiology of hepatitis two thirds of all the cases were young persons aged
20-39.
High prevalence of mixed-hepatites was registered among the persons, taking
narcotics, suffering from chronic alcoholism and medical workers.
To estimate efficiency of vassinal prevention of mixed-hepatites, CHC patients
were included in epidemiological case-control investigations because this contingent
195
made 74,9% of all the patients with chronic viral hepatitis and was perspective for
simultaneous HA and HB vaccinal prevention.
After the first HB vaccination seroconversion was observed in 100% of cases
among both healthy persons and CHC patients (fig.2). At the same time, 57,1% of
the observed persons had protective antibody level in experimental group and 61,5%
- in control group. The difference of compared indices is statistically invalid. In four
months after the second HB vaccination 92,8% and 96,3% of the observed persons
were protected, respectively. In a month after the completed vaccination course, blood
serum anti-Hbs antibodies were revealed in protective concentration in 96,7% of CHC
patients and 96,3% -of healthy persons (p<0,05).
During the dynamic study of the structure of different concentrations of anti-Hbs
antibodies it was established that in a month after single vaccination the percentage
of persons with anti-Hbs antibody titer less than 10 ME/l was 42,9% in experimental
group and 38,5% in control group (p<0,05) (fig.3). In a month after a triple vaccination, this index was 3,3% and 3,7%, respectively. The antibody level higher than
1000 ME/l after the first injection of preparation was observed in 42,3% of the examined persons of control group against 25,0% of CHC patients (p<0,05). In a month
after the completed vaccination course, the protective level of high anti-Hbs antibody
concentration (higher than 101 ME/l) was equal in persons of both experimental and
control groups and was revealed in 90,0% and 92,6% of persons, respectively (p<0,05),
at the same time, 53,3% of control group patients and 70,4% of experimental group
patients had anti-Hbs antibody titer higher than 1000 ME/l (p<0,05). In a month after
the completed HB vaccination course the average geometric of the titer was 1947,1
in experimental group and 1560, 9 in control one (p<0,05).
In a month after a single HA immunization, seroconversion was observed already
196
in 50,0% of cases, whereas, this index in control group was reliably lower (33,3%)
(fig.4). However, in four months after a single immunization, no statistically reliable
difference in seroconversion indices of persons from experimental and control groups
was revealed: 73,3% and 85,2%, respectively. In seven months after a single immunization seroconversion was observed in 100% of cases in both groups. Protective
197
antibody level was detected in 60,0% of persons of experimental group and in 51,9%
- control group. (p<0,05)(fig.5). Anti-HAV antibody content (higher than 100ME/l) was
revealed in 50,0% and 33,3% of the observed persons, respectively (p<0,05). After a
single immunization the average geometric of the anti-HAV antibody titer 3,9 times
exceeded the protective level in experimental group, 2,4 times - in the control (p<0,05).
In a month after the second HA immunization, performed in 11 months after the
first one, seroprotection was fixed in 96,6% of persons in experimental group and in
93,1% - control group (p>0,05). After double immunization the anti-HAV antibody
content (higher than 100 ME/l) occurred in 86,2% and 93,3%, respectively (p>0,05).
At the same time, the average geometric of the titer in experimental group 28,1 times
exceeded the protective level, 38,8 times - in control group. No reliable differences
in weak local reactions were observed in both groups. One year later after usage of
vaccinal prevention; no HA and HB cases in CHC patients were established.
Conclusions. Etiological structure of mixed-hepatites is presented by 8 combinations with prevalence of combination hepatitis B + hepatitis C. Formation of cirrhosis
of the liver in hepatitis with combined etiology occurred 7,5 times more frequently
and probability of lethal outcome was 25 times higher in comparison with monoinfections. Young persons aged 20-39 taking narcotics, persons suffering from chronic
alcoholism and medical workers belonged to risk groups.
Possibility of protecting the patients with chronic hepatitis C from hepatites A and
B viruses co- and superinfection by means of simultaneous vaccinal prevention is
demonstrated. Dynamics of production and concentration of antibodies to hepatites A
and B viruses in patients with chronic hepatitis C didnt statistically significant differ
from the healthy contingent.
The metabolic status of leucocytes at patients with

tubulopathy and glomerulopathy
Muravlyova L1., Molotov-Luchanskiy V1., Kluyev D1., Kussainova D1.
Kolesnikova E1., Tankibaeva N1., Sidenko V.2, B.., Zholdaspaeva N.1,
Mursalova Zh.3
1
State medical university, 2Regional Center of Medical Care of Veterans of World War II, 3 The
Regional hospital, Karaganda, Kazakhstan
Summary
The decomposition of nucleosomalhistonesand augmentation ofcarbonylderivativesof proteinswere observed in leukocytesat patients withglomerulopathyandtubulopathy. The significant alteration of self - organization processes of leukocytes
lyzats were found. Peculiarities of profiles of morphotypes of leukocytes lyzats were
identified in subjects with glomerulopathyandtubulopathy.
Introduction
It is assumed that endothelial disorder is an important contributor to the pathogenesis of chronic kidney diseases. One of the possible mechanisms of endothelial
infringement is based on the disorders of adhesive properties of phagocytes. Phagocytes
secrete different mediators, including cytokines, active oxygen radicals and proteases.
These mediators induce disorders in endothelial cells, contributing to development
of inflammatory process (1,2). The study of metabolic processes in phagocytes may
expand our understanding of the pathogenesis of chronic kidney disease. Our prior
studies (3) demonstrated nucleosomehistonedecompositionin neutrophils of patients
at chronic kidney disease associated with arterial hypertension .
The purpose of research was studying the metabolic status of the leucocytes at
patients with tubulo- and-glomerulopathy.
Materials and Methods.

The purpose of research was studying leucocytes metabolic status in patients with
tubulo- and-glomerulopathy. 62 patients, including 25 males and 37 females in the
age from 19 till 52 years were surveyed. Patients have been allocated in 2 groups. In
N915L5014
199
200
1 group were patients with chronic pyelonephritis (n=43). In second group patients
suffering of chronic glomerulonephritis (n=19) have been included. Diagnostics of
chronic pyelonephritis (CP) and chronic glomerulonephritis (CG) was carried out
on the basis of complex research including studying anamnestic and clinical data,
results of ultrasonic research of kidneys. At CP carried out bacteriological research
of patients urine. The test on bacteriuria was considered positive at detection not less
than 106 microbic organisms. In clinical diagnostics of CG the approaches recommended by recognized nephrological centers of the world were used (4,5). In some
cases the morphological verification of glomerulopathy was carried out (in two cases
nephrobiopsy has allowed to reveal IgA-deposites in basal membrane of glomerula, in
20% patients with nephritic form of CG the mesangioprolipherative glomerulopathy
was revealed).
The group of patients with chronic pyelonephritis was not homogeneous on structure.
These patients had various degrees of activity of the inflammatory process described
by corresponding clinical-laboratory criteria. 25% of patients with CP had I degree
of activity of pyelonephritis, 75 % - II degree.
Prevailing clinical form of CG was nephrotic variant (79% from the general number of patients in the given group). Latent form CG was diagnosed for other patients
with hematuria, and in two patients the IgA-depositary glomerulopathy was found out.
Obligatory methods of laboratory researches were the general analyses of blood and
urine, biochemical tests for activity of transaminases, levels of blood creatinine and
urea. Estimation of glomerula filtrations and tubulo-reabsorbtion were carried out by
Reberg-Tareyev method. Also the approaches offered Cockroft and Gault were used.
Control subjects were healthy volunteers (n = 18) without any medication. All
patients and healthy subjects were informed of any discomforts associated with the
blood sampling before giving their consent to participate.
Blood collected from the brachial vein (6 ml/sample) was drawn into Vacutainer
tubes containing heparin. For neutrophilic leukocytes separation we used the procedure
of previously described (6). Cells were then washed, counted, and resuspended in
buffer. Purity and viability were assessed by trypan blue dye exclusion. The samples
of >85% neutrophilic leukocytes with >90% viability wereobtained.The count of
neutrophilic leukocytes was detected by using Mindray BC-3200 Hematology Analyzer.
The cells used within 2-4 hours of collection. We measured the content of nucleosomal
histones and histone H1 (7), the concentration of protein carbonyl derivates (8) with
a spectrophotometer PD - 303 UV APEL (Japan). Concentration of protein carbonyl
derivates calculated using the extinction coefficient at 370 nm = 22,000 mol -1cm-1 (8).
The dehydration self - organization processes of leukocytes lyzats were investigated. Morphotypes of the solid phase (facia) of leukocytes lyzats were obtained and
described in following the protocol of Shabalin V. & Shatokhina S. (8). Comparisons
between patients and controls were performed using non-parametric Mann-Whitney
U test (for independent variables)
Results.
As compared to control ones the change of the ratio of H1, H2A, H2B, H3 and
H4 histones in leukocytes at patients with CP and CG was obtained. Comparison
between two groups of patients demonstrated similar trend in decomposition of nu-
201
cleosomal histones. At the same time statistically significant multidirectional change

of histone H1 was revealed: decreasing in leukocytes at patients with CP (by 2 times)
and increasing in leukocytes at patients with CG (p <0.05).
In leukocytes at patients with CP and CG the augmentation of protein carbonyl
derivatives concentration in compare to control subjects was observed. Comparison
between two groups of patients demonstrated statistically significant difference only
for aldehydedenitrophenylhydrazones.
It was founded the alterations in morphotypes of the solid phase of leukocytes
lyzats at patients with CP and CG. The distinctive features of morphotypes of
leukocytes lyzats at patients with CP were the appearance of abnormal large scaly
structures. There were two types of patterns of morphotypes of solid phase of
leukocytes lysats at patients with CG. The first type was represented by randomly
distributed small crystalline structures. The second type was represented by dendritic crystal structures preferentially localized in the center of facies. Those data
demonstrated the peculiar properties of the metabolic status of the leukocytes at
patients with CP and CG.
Conclusions
Taken together our date showed interconnection between accumulation of protein
carbonyl derivatives and decomposition of nucleocomal histones in leukocytes at patients with CP and CG. In our opinion it may be connected with incorrect formation
of scaffold for neutrophil extracellular traps. The appearance in blood neutrophil extracellular traps with reduced efficiency induced the disorders of red thrombus formation
and endothelium (10, 11). From other hand significant alteration of self organization
processes of leukocytes lyzats demonstrated disorders of intracellular metabolic
processes. In this study we had no correct explanation of the observed differences
in morphotypes of leukocytes lyzats at patients of both groups. The further research
must be done for understanding the reasons of infringement of self - organization
processes of leukocytes at patients with tubulo- and-glomerulopathy.
References
1. HEINZELMANNM., MERCER - JONESM., PASSMORE J. Neutrophils and renal
failure. American journal of kidney diseases. 34 (2):384-399, 1999
2. TOPCHIY I.I. The interaction of macrophages, platelets and endothelial cells as a mirror
of evolution of our perception of atherogenesis in cardionephrology. Ukrainian therapeutic
Journal. 1: 9-18, 2008
3. MURAVLYOVA L., MOLOTOV-LUCHANSKIY V., KULMAGAMBETOV I. et al. Histone proteins of leukocytes at patients with chronic kidney disease, associated with arterial
hypertension. International Journal on Immunorehabilitation. 12 (2): 178, 2010
4. TAREYEVA I. /Ed. Nephrology: Guide for phisycians Moscow: Medicine. 2000.
5. DAVISON A.M.A., CAMERON J.S. /Ed. et al. Oxford Textbook of Clinical Nephrology.
Oxford University Press. 2005.
6. FEDOROVAM.LEVIN V.The complexmethod ofstudy geometry, surface area,reserve
capacity of the membraneandosmotic regulation of leukocyte .Clinical medicine. 8:
35-38. 2000
7. MARKUSHEVA L., SABINA M., RESHINA V. et al. Nuclear proteins of chromatin in
202
assessing of the effectiveness of treatment of patients with psoriasis. Clinical laboratory

diagnostics. 7: 18-20, 2000
8. LEVINE R., GARLAND D., OLIVER C.N. et al. Determination of carbonyl content in
oxidatively modified proteins. Method Enzymol. 186: 464-478, 1990
9. SHABALINE V, SHATOKHINA S Diagnostic markers in the structures of human biological liquids // Singapore Med J. 48 (5): 440 -446, 2007
10. FUCHS T., ABED U., GOOSMANN Ch. et al. Novel cell death program leads to neutrophil extracellular traps. J Cell Biol. 176: 231241, 2007
11. MURAVLYOVA L., MOLOTOV-LUCHANSKIY V., KLUYEV D., TANKIBAEVA N,
KOLESNIKOVA E., Protein carbonyl products in blood cells at chronic kidney disease.
European Journal of Natural History. 5: 3-5, 2011
Dynamics of immune response to kidney and uvea

tissues antigens depending on their species accessory
Nurlyyeva L., Annaberdiyev D., Ezizova G.G., Pleskanovskaya S.A.
Scientific-research Center of State medical university of Turkmenistan, Askhabad, Turkmenistan
Now the considerable quantity methods are used to estimate specific cellular
immunity [1,4,5]. One of them is reaction of lymphocytes migration inhibition (RLMI).
The reaction has received wide recognition in clinical and experimental practice as one
of the sensitive and informative tests, allowing to judge hypersensitivity lymphocytes
to an antigene [2,3,6 ]. Now considerable methods of quantity are used to estimate
certain cellular inviolability [8,4].
However, in accessible references we have not found information on dynamics of
value LMI in any method of the statement use RLMI. One of last variants of RLMI
statement methods updating of Turkmen scientists [7]. Reaction has been simplified
to a maximum, but essence and a way to express result, that is calculation of an
leukocytes migration index (LMI) remains invariable
The goal of the work was to study dynamics of value of leucocytes migration
index in RLMI with using the soluble allo- and isoantigenes of kidneyss and the uvea
to determine the significance of antigeness specificity and the time of the maximum
expression of lymphocytes immune response to them.
During the experiment the blood samples of 15 white non-linear mice (males)
of the mass equal to not less than 20 g and of 5 healthy donors (voluntiers were
students) were used. RLMI with using of soluble tissue antigenes of the kidneys
and the uvea were conducted by Pleskanovskayas method [7]. The kidneys tissues
antigenes were prepared from the tissues of a human and a mouse, tissue antigenes
of the uvea from tissue of a human only. Antigenes were made by water-saline
extraction method [3]. The values of LMI were determined through the 5,15, 30, 60,
90 and 120 minutes from the moment of the beginning of the reaction every day
during 5 days. The received data were processed mathematically.
Originally we defined number of the leukocytes spontaneously migrating from a glass
capillary (Fig. 1). It has appeared, that in 5 minutes from the beginning of incubation
they appear in cultivating medium. Their number progressively increased till 90 minutes
of incubation. On 120th minute of incubation the number of migrating leukocytes has
decreased. It is necessary to notice, that between number of the leukocytes migrating
with 60 on 120th minutes of incubation there is no essential distinction.
P421L5139
203
204
Fig.1. Dynamics of the spontaneously migrating from a glass capillary leukocytes number
Further we observed, that within 5 minutes from the beginning of incubation in

vitro leukocytes react to presence and allo isoantigenes kidneys (KTAAG, KTIAG)
and uvea (UTAAG, UTIAG), that testifies to leucocytes migration stimulation . The
leukocytes migration index (LMI) was much more low at presence alloantigenss, in
comparison with isoantigenes (p> 0.001) (Fig. 2)
In all cases LMI increased within the first 15 minutes. Further dynamics of its
values (size) was depending on a kind of a fabric and antigene type. So, the respance
of lymphocytes to an kidneys alloantigene within the first 5 minutes of incubation
is expressed much more poorly, than on isoantigene (p <0.05). On 30th minute
of incubation the respance to kidneys isoantigene progressively increases, but on
alloantigene - sharply decreased and remained actually at this level till the end of
supervision term (within 2 hours of incubation). Distinction is expressed as much as
possible on 90th minute of incubation (p <0.001) (Fig. 2).
Immune reaction of lymphocytes on uvea isoantigens differed from reaction on
kidneys isoantigens. It decreased since 30th minute of incubation and remained at the
reached level till the end of supervision - within 2 hours (p> 0.05 in comparison with
30th minute). But, dynamics of immune lymphocytes reaction on uvea alloantigene
corresponded that on an alloantigene of kidneys (Fig. 3).
The analysis of the received results has shown, that the immune answer lymphocytes
on tissues isoantigens of kidneys and uvea in vitro is shown within first 5 minutes
of incubation. However the antigen type influences on immune reaction formations
dynamics. If the response to kidneys isoantigen reaches a maximum by 60th minute, on an uvea antigen - on 15th minute. In both cases stimulation of migration
of leukocytes from a glass capillary in the presence of an antigen originally takes
place. Gradually reaction decreases and replaced by inhibition of migration which is
stabilized with 90th for 120 minutes of incubation.
Fig.2. Dynamics of LMI values at presence of kidneys allo - and isoantigens
Fig.3. Dynamics of LMI values at presence of uvea isoantigens.
205
206
Thus, the obtained data, in our opinion, allow to recommend for use at statement of
reaction of leukocytes migration inhibition in clinical practice only isologus antigenes.
Besides, we consider, that it is possible to reduce time of leucocytes incubation with
antigenes kidneys and uvea tissues antigenes to 30 - 60 minutes.
References to article
1. Bowers William (2006). Immunology Chapter nine: Cells involved in immune responses. Microbiology and Immunology On-Line Textbook. USC School of Medicine.
January 2007. Retrived
2. 4http://patmicro.med.sc.edu\bowers\immune%20cells.htm.
3. Fradkin V.A. (1975). Allergodiagnostics in vitro, Moscow: Medicine.
4. Immunological methods (Edit. Freemel H.) (1987). Moscow: Medicine.
5. Khaitov R.M. Immunology (2008). Moscow: GEOTAR-Media Publishing Group.
6. Khaitov R.M. (2001). Physiology of immune system. Moscow.
7. Khaitov R.M., Gushchin I.S., Pinegin B.V., Zebrev A.I. (2002. Eksperimental studying of
immunotropical activity of pharmacological preparations. Methodical recommendations.
Immunology. Moscow.
8. Pleskanovskaya S.A. (1982). Cellular and humoral immune response at cutaneous leishmaniosis (experimental researches and supervision) Autoreferat dissert. PHD Moscow.
9. Roit A., Brostfor J. Mail D. Immunology. Moscow:Mir. 2000 (transl.)
10. Understanding the Immune System: How it Works (PDF). National Institute of Allergy
and Infectious Diseases (NIAID). Retrieved . January 2007. http://www.niaid.nih.gov\
publications\immune\the immune system.pdf.
Immunological changes in acute ischemic stroke

Zhyrnova I.G., Komelkova L.V., Maximova M.Ju., Ochtova F.R., Ionova V.G.
Research Center of Neurology Russian Academy of Medical Sciences. Moscow. Russia
Summary. The character of changes of cellular and humoral immunity we studied

in 41 patients at 1-3, 7, 21 days of ischemic stroke (IS). Control group consisted of
31 patients with uncomplicated arterial hypertension (AH). Lymhpopenia and deficiency CD3, CD4 and CD8 cells was found at 1-3 days of stroke; the reduction of
IgG was revealed in 33% of patients. Positive dynamics of changes was found at 7
and 21 days of stroke. However, symptoms of immunodeficiency with the decrease
in the number of CD8 cells and index CD4/CD8 still had in 70% of patients. All
revealed findings suggest that immune status of patients in acute stroke is the immune
response on stress. The mechanisms of immune system involvement in pathogenesis
of acute stroke are discussed.
Introduction. The interaction between the brain and immune system has been
intensely studied in patients with stroke. The central nervous system and the immune
system are extensively interconnected through neural pathways hormonal cascades
and cell-to-cell interactions induced primarily by cytokines (1, 2, 3). The aim of
the study was to look for evidence of immune activation and alterations in cellular
and humoral immunity in patients with IS in comparison to age-matched healthy
controls and patients with AH and to determine of the phenotype lymphocytes and
the activated cells.
Materials and Methods. The study involved two groups of patients. The first group
consisted of 41 patients in the acute period of IS (23 male and 18 female; average
age was 59 years old). Immunological studies were conducted at 1-3, 7 and 21 days
of IS. The control group consisted of 31 patients (13 male, 18 female; average age
58 years old) with uncomplicated AH. We determined the phenotype of lymphocytes:
markers of the major subpopulations (CD19, CD3, CD4, CD8, index CD4/CD8, CD16,
56), as well as the expression of markers of cell activation (HLA-DR, CD25, CD95,
CD45RA, and CD45R0). The phenotype of lymphocytes studied by 2 -colour flow
cytometry (Beckman Coulter Epics XL). The state of humoral immunity was tested
according to the generally accepted methods. The content of IgG, IgA, IgM in the
serum measured by Manchini G. and the fraction of immune complexes (IC) detected
by means of their precipitation with solutions of PEG and spectrophotometry. Statistical
processing was performed using the applied package Statistica 6,0.
P421L5088
207
208
Fig. 1. The frequency of changes in the cellular immunity in patients with arterial hypertension.
Fig. 2. The changes of phenotype of lymphocytes at 1-3 days of ischemic stroke compared with arterial
hypertension.
Results. Phenotypic indicators of blood lymphocytes of both groups patients were

compared with data of the average content of these subpopulations of lymphocytes
in the blood of healthy donors (n = 356) presented in the previous reports (4). The
changes of CD4 + and CD8 + subpopulations have been revealed in 35% of patients
with AH (I group). Abnormal values of index CD4 + / CD8 + have been found in
60% of patients. That data could indicate an immune system dysregulation. Decreased
number of NK cells has been revealed in 52% of patients with AH. The analysis of the
phenotypical changes in composition of lymphocytes in patients with AH in compare
with donors are shown in Fig. 1. The obtained data about changes in cell-mediated
innate immunity combined with increased lymphocyte activation marker expression
and IgM may reflect an autoimmune processes. The maximal intensity of changes
in phenotypic composition of lymphocytes observed in patients with acute period of
IS. At 1-3 days of the IS have been found out the decrease of CD3, CD4, CD8 cells
209
Fig. 3. Dynamics of changes in the phenotype of lymphocytes in patients at 1-3, 7 and 21 days of IS.
respectively in 42%, 35% and 50% of patients. Changes in count of NK cells and
the CD4/CD8 index were found in 70% of patients (Fig. 2). Besides increased IgM
levels in patients with acute IS there are also different alterations of IgG levels. Thus,
33% of patients have shown decreased IgG levels that could be estimated like signs
of the immunodeficiency. Thus, the immune status of patients in acute period of IS
presents leukocytosis with lymphopenia and various immune system dysfunction of
cell-mediated and humoral immunity. This alterations predispose to the development
of complications after stroke connected with immune deficiency and with autoimmune
process. The analysis of these immunological parameters in dinamics at 7 and 21 days
of IS (Fig. 3) has shown that at 7th day increase the concentration of lymphocytes
and in part of patients decrease the deficit of CD3 and CD4 cells. However, the
deficiency of CD8 and NK cells revealed in 70% of patients until 21 days of IS.
Evaluation of CD25, CD95, CD45RA, and CD45R0 markers expression proposed a
high level of lymphocyte activation during the acute period of IS.
Conclusions. This study provides a detailed analysis of the temporal dynamics
of cellular and humoral immunity in patients with IS. Changes of phenotype of lymphocytes, content of NK cells and the CD4/CD8 indicate to dysfunction of innate
immunity. At 1-3 days of IS revealed the immune insufficiency, which in part of
patients remained during acute period of IS. Involvement of innate immune system
in the pathogenesis of IS is the response of the organism to activation of neuroimmunoendocrine system. The mechanism of the involvement of the immune system
in the pathogenesis of IS can be associated with the action of DNA components of
the plasma on the Toll-like receptor 9 type.
References.
1. BAIRAKOVA A.L., VOROPAEVA E.A., AFANASIEV S.S. et al. The role and biological
significance of toll-like receptors in the anti-infectious resistance of the organism. Journal
of RA of Med. Sci., N 1, 45-54, 2008. 2.GUSEV Eu. I., SKVORTSOVA V. I. Brain
ischaemia. Moscow, Meditsina Publishers, 2001.
210
3. GUSEV Eu. I. in The brain: theoretical and clinical aspects. Moscow, Meditsina Publishers,
139-157, 2003.
4. KHIADUKOV S. V., ZUROCHKA A.V. In the book. Issues of modern flow cytometry.
Clinical Applications. Chelyabinsk, 6-16, 2008.
5. GANNUSHKINA I.V. In the book. Essays angioneurology, Moscow, Atmosphera Publishers, 17-41, 2005.
Role of immunocytes in human eye structures

development.
Reva I.V.1, Yamamoto T.1, Reva G.V.1, Novikov A. S.2, An E.A.2, Albrandt K.F.2,
Mogilevskaja E.S.2
Vladivostok State Medical University, Vladivostok, Russia
Niigata University, Japan.
Abstract. Disturbance in the development of human eye is an important problem

of contemporary ophthalmology. Patient with different eyes dysplasia are significance
group in clinical ophthalmology. [5, 16] For the successful study of such pathology the
knowledge of general pattern in human visual organ development is necessary [6]. In
sources facts about role of immune phagocytes in morphogenesis in the human eyes are
absent. We have studied 91 samples of human eyes in prenatal ontogenesis. Role of CD68,
CD163, CD204 cells in process of eye development were analyzed. A theory about cornea
separation process is designed. It shows that immunocytes takes part in physiological and
reparative regeneration of structures in the human eye. We think that it is possible that
immunocytes identification in human eyes in embryogenesis is maternal cells, because
human embryo does not have blood system creation.
Introduction. Investigation of morphogenesis, time of separation, growth

and differentiation of the eye structure cells is necessary as for understanding
of normal eye structures so and for more detailed imagination about histological
prerequisites of disturbance in this system [13, 18, 23]. Absence of detailed data
about role of the effector cells responsible for the immunophagocytosis during
reparation processes and changes of the human eye structures during Glaucoma
and other pathological reactions put a solution of this problem on the one of
the first place in ophthalmology [1, 4, 12]. Though, most studied the role of
immunocytes in pathological processes of eye on the animal model [7, 10, 14,
22]. Role of immunocytes in human eye development shows in a not numerous
sources [2, 3, 25]. Existing poor data about the role of immunophagocytosis cells
in reparative regeneration of eye structures [20], become formed our aims and
goal of our research.
Materials and methods. As a material of study we used 91 samples of eyes from
embryo, fetal and infants of human, taken on the Pathology Department of Vladivostok State Medical University. Classic morphological stain methods and immunostain
protocols for the detection of CD 68, CD163 and CD 204 cells were used and carried
P421L5110
211
212
Fig1. Drainage system of human eye in the period of embryogenesis. Immunostaining for CD163 (A, B), CD68
(C, D, E), CD204 (G,F). Photo shows macrophages in development of the anterior chamber angle. Pointer
showed macrophages and mast cells. A, B, C, E, G, F, T, Rx800; D, S x200; Kx400.
out in Niigata University. Visualized data received by the Olympus microscope model
BX-51 and analyzed using equipped it original soft.
Results. Analysis of owned data shows that the process of anterior chamber has
opening between the developing cornea and iris is realizing consequently through
the destruction of the gomogenic colored plate which is appear a split borderline of
choroid and fibrous coat, is undergoing for lysing by cells, in our opinion, macrophages. Our assumption has got additional confirmation by immunostain on detection of
macrophages are CD 68, CD 163 and CD 204 (fig. 1). It was established that in the
primordial moment they are absent, but comes and quantitatively increase from 4-th
until 6,5 month of prenatal period, that corresponding for a period of drainage zone
structures differentiation. Antigen-presenting cells CD 68 are placed in the fibrous coat
mainly in the area of corneal and scleral border. We conceive that antigen-presenting
cells are direct and regulate the development of Schwalbes rings and the drainage
zone through the phagocytes induction. Also, we investigate that lens differentiation
from the surrounded structures issued because of phagocytosis process than apoptosis,
which accepted. Apoptosis is registering only in macrophages lying to the anterior lens
capsule and in cells of inner lay of capsular epithelium, generating during invagination
of the lens capsule (fig.2). In vitreous body of the human eye cells we identified
cells CD 68, CD 163, and CD 204. Parts of them having the antigen-presenting cells
markers are residual, related with collagen-fiber framework of the vitreous (fig.3).
213
Fig2. A-T. Microphoto of anterior capsule in human lens, 16weeks. Method: A, B, D, E, G-hematoxylineosin; F- TUNEL; H-T-Immunostaining. Pointer shows macrophages in isolated lens from surrounding
structures. x 400.
Fig. 3. Microphoto of human vitreous body, fetal eye. (A-10 weeks; B-14 weeks; C-16 weeks; D, E-24
weeks. Immunostain for CD204 (A, B, C), CD68 (E), CD163(D). In addition coloring hematoxylin-eosin A-B;
In addition hematoxylin C-E. Ax800; Bx1000; C, D, E x400.
214
These can be associate with the eye structures are immunodeficient. Thats why the
residual cells take function of the antigen presenting cells. Consider that avascular
structures of human eye are immunodeficient there is especially important role of the
residual cells, having markers CD 68.
Conclusion. Presence of big amount of immunocytes in the developing eye structures and during pathological processes are testify about perceptiveness and effectiveness of the immunomodulating methods of eye treatment development. We think
that in earlier stages of development in embryogenesis during the intensive fiber coat
differentiation, forming of cornea and sclera, rebuilding of the drainage zone [17]
structures and trabecular apparatus, conversion of cellular vitreous in to vascular and
than to tissue fibrillar [21] realizing under control of effector high specialized immunocytes of maternal organism, migrating in to the eye structures before placentas and
hematoophtalmic barriers forming. During this period in human embryo only anlage
hematopoietic and organs of immune defense has occurring. Forming of anterior eye
chamber has completing to beginning of the medullar hemopoiesis of fetal organism.
References
1. Balazs E.A., Toth L.Z., Ozanics V.. Cytological studies on the developing vitreous as
related to the hyaloid vessel system. Albrecht Von Graefes Arch. Klin. Exp. Ophthalmol.
1980;213(2):71-85.
2. Boltz-Nitulescu G., Grabner G., Frster O. Macrophage-like properties of human hyalocytes.
Adv. Exp. Med. Biol. 1979; 121B:223-8.
3. Caspi R. Autoimmunity in the immune privileged eye: pathogenic and regulatory T cells.
Immunol Res. 2008;42(1-3):41-50. Review.
4. Dagkalis A, Wallace C, Xu H, Liebau S, Manivannan A, Stone MA, Mack M, Liversidge
J, Crane IJ. Development of experimental autoimmune uveitis: efficient recruitment of
monocytes is independent of CCR2. Invest Ophthalmol Vis Sci. 2009 Sep;50(9):4288-94.
5. Edn U, Iggman D, Riise R, Tornqvist K. Epidemiology of aniridia in Sweden and Norway.
Acta Ophthalmol. 2008 Nov;86(7):727-9.
6. Els S., Gopferich A., Framme C., Heilman J. Hyalocytes in tissue engineering. Adv. exp.
Med. Biol. 2006.-Fisher J.P.(ed), 585.
7. Fuerst PG, Bruce F, Rounds RP, Erskine L, Burgess RW. Cell autonomy of DSCAM
function in retinal development. Dev Biol. 2012 Jan 15;361(2):326-37.
8. Horai R, Caspi RR. Cytokines in autoimmune uveitis. J Interferon Cytokine Res. 2011
Oct;31(10):733-44. Epub 2011 Jul 25. Review.
9. Lee HJ, Ahn BJ, Shin MW, Jeong JW, Kim JH, Kim KW. Ninjurin1 mediates macrophageinduced programmed cell death during early ocular development. Cell Death Differ. 2009
Oct;16(10):1395-407.
10. Lin ML, Li YP, Li ZR, Lin JX, Zhou XL, Liang D. Macrophages acquire fibroblast characteristics in a rat model of proliferative vitreoretinopathy. Ophthalmic Res. 2011;45(4):180-90.
11. Meghpara B, Li X, Nakamura H, Khan A, Bejjani BA, Lin S, Edward DP. Human anterior chamber angle development without cell death or macrophage involvement. Mol
Vis. 2008;14:2492-8.
12. Niederkorn JY. Immune mechanisms of corneal allograft rejection. Curr Eye Res. 2007
Dec;32(12):1005-16.
13. Petrovski G, Bernyi E, Moe MC, Vajas A, Fss L, Berta A, Facsk A. Clearance of
dying ARPE-19 cells by professional and nonprofessional phagocytes in vitro- implications
for age-related macular degeneration (AMD). Acta Ophthalmol. 2011 Feb;89(1):e30-4.
215
14. Qiao H., Hisatomi T., Sonoda K.N., Kura S., Sassa Y., Kinoshita S., Nacamura T., Sakamoto T., Ihibata T. The characterization of hyalocytes the origin, phenotype and turnover.
Br. J. Ophthalmol. (2005), 89:513-517.
15. Reva G.V. Development of the human eyes. Monograph. 1998. 256 p.
16. Reva G.V., Reva G., Reva I., Yamamoto T. Infectious conception of glaucoma pathogenesis. //Japan-Russia International Workshop 2010. The 54th ISTC Japan Workshop. Current
Life Threatening Infections Medical Exchange and Networks. (May-Tokyo, 2010; JuneNiigata, 2010. See Page 29, S9 - 1).
17. Reva G.V., Filina N.V., Gaponko O.V. Morphology of developing eye drainage system
in conceptions of congenital glaucoma pathogenesis.// Pacific medical journal. -2010,
N1. - p. 27 30.
18. Reva G.V., Reva G., Reva I., Yamamoto T. The structure of human vitreous body eyes.//
Pacific medical journal. 2011, N1. - p. 65 - 69.
19. Reva G.V., Filina N.V. The drainages zone of the human eyes. Monograph. East Far
science.- 2010. - 124 p.
20. Reva G., Reva I. Hyalocytes of the human eyes. // Allergology and immunology. 2009,
21. Reva G.V., Reva G., Reva I., Yamamoto T.. Phenotypes differones of hyalocytes in vitreous body of the human eyes.//Foundamental research.-2011, N11 (part 1), p. 114-121.
22. Santhiago MR, Singh V, Barbosa FL, Agrawal V, Wilson SE. Monocyte development
inhibitor PRM-151 decreases corneal myofibroblast generation in rabbits.//Exp Eye Res.
2011 Nov;93(5):786-9.
23. Stefek M, Karasu C. Eye lens in aging and diabetes: effect of quercetin. Rejuvenation
Res. 2011 Oct;14(5):525-34.
24. Tang J, Zhu W, Silver PB, Su SB, Chan CC, Caspi RR. Autoimmune uveitis elicited
with antigen-pulsed dendritic cells has a distinct clinical signature and is driven by unique effector mechanisms: initial encounter with autoantigen defines disease phenotype. J
Immunol. 2007, May. 1;178(9):5578-87.
25. Wayne J. Streilein Ocular immune privilege: therapeutic opportunities from an experiment of nature. Nature Reviews Immunology, 3, 879-889 (31 October 2003) doi:10.1038/
nri1224 Review.
Regulatory role of thymus in maintenance of

homeostasis
Kiseleva N.M.1,3, Novoseletskaya A.V.2, Zimina I.V.3, Moskvina S.N.3,
Inozemtsev A.N.2, Arion V.Ya.3, Kozlov I.G.1
The Russian National ResearchMedical University named after N.I. Pirogov (RUSSIA);
Lomonosov Moscow State University (RUSSIA);
3
FSI Scientific Research Institute for Physical-Chemical Medicine FMBA (RUSSIA)
kiseleva.67@mail.ru
1
Abstract
Previous researches and our own experiments showed that thymus plays an important
role not only in the immunity regulation, but also acts on other regulatory systems
by means of its regulatory molecules. Stress is associated with impaired homeostasis, therefore we used different models of stress effects on rats and tried to correct
affected parameters by thymic peptide preparation tactivin. Neurochemical analysis of
neurotransmitters in the rat brain after emotional stress showed that tactivin changes
serotonin/noradrenaline ratio in hypothalamus and frontal cortex in favor of serotonin.
We suppose that such hormone ratio alteration could explain positive effect of tactivin
during emotional stress. It is concluded, that thymic peptides, and thymus by itself,
play regulatory role in restoration of homeostasis under various stress conditions.
Key words: stress, thymus, tactivin, homeostasis.
Introduction
Nowadays a great amount of facts confirm the existence of tight interaction between
all systems, participating in the maintenance of homeostasis. For example, there are
highly associated direct and feedback relations between thymus and hypothalamuspituitary system. It is well known that the break of pituitary gland function leads to
thymus aplasia, decrease of thymic hormone secretion by epithelial cells and acceleration
of age-dependent thymus involution [1]. Functional activity of thymus is controlled by
prolactin, adrenocorticotropic hormone (ACTH), somatotropic and thyrotropic hormones
(TTH), which enhance secretion of thymus polypeptides. TTH action on thymus is
mediated by thyroid hormones, whereas ACTH and gonadropic hormones influence is
occurred via glucocorticoid (GC) and gonadal hormones. Direct regulation of thymus
activity by hypothalamus is carried out by sympathetic and parasympathetic branches
P421R9006
217
218
of vegetative nervous system [2]. In its turn thymus influences on hypothalamic

neuroendocrine centers differentiation during embryogenesis [3]. Different thymosin
peptides and opioids, produced by thymus, stimulate synthesis of releasing-factors,
which is followed by gonadotropic hormones and prolactin secretion increase [4].
Generality of the signaling information transfer between cells changed notion about
the work of main regulatory systems neural and endocrine and led to appearance
of a new biomedical field neuroimmunoendocrinology over last ten years [5].
Taking into consideration data from scientific publications and results of our own
experiments, we assumed that thymus plays an important role not only in immune
regulation but also exerts influence on other regulatory systems via its molecules. In
other words it takes active part in maintenance of organism homeostasis. Stress is
accompanied by significant homeostasis disbalance, thereby we tried to correct this
failures with the help of thymic peptides on various models of stress in animals.
Previously tactivin was used in the models of diffuse acute peritonitis, caused by
Gram-negative microflora and burning injury in rats and it was shown that tactivin
not only improved immune system parameters, but induced elimination of signs of
intoxication in these animals as well [6, 7].
In experiments on rats stress caused by benzene intoxication was studied. There
were two models of intoxication - subacute and chronic. In case of chronoc intoxication the activity of cytochrome P450, C-reductase, benzpirenhydroxylase, epoxihydrase
decreased. On the contrary, subacute intoxication led to the abrupt increase of activity
of gluthation-S-transferase and epoxidhydrase, which are known to be enzymes of the
second phase of xenobiotic metabolism. Monotherapy by tactivin resulted in normalization of enzymatic activity. In case of subacute intoxication tactivin decreased raised
enzymatic activity, and in case of chronic intoxication, accompanied by decreased
activity of a number of enzymes, the preparation restored it [8].
However, in the above mentioned cases the influence of immune system was too
great, wherefore it was rather difficult to set forth the difference between immunomodulating and antistress effects of the thymic preparation. In order to verify the
hypothesis about thymus participation in the stress-limiting system functioning it was
necessary to create a specific stress situation, in which participation of immune system
would be less significant. We chose a model of emotional stress, induced by reversible
functional derangements of conditional reactions of active avoidance (CRAA) [9].
Methodology
The process of emotional stress development was studied on male Wistar rats,
weight 180-200 g. During 5 days before the experiment immunotropic thymic preparation tactivin was injected intraperitoneally (0,5 mg/kg of body weight, volume 0,5
ml) to experimental animals (n=50). Animals in the control group (n=55) received
physiologic solution (0,5 ml). Pharmacological activity of tactivin on the experimental
animals was compared with that of anxiolytic drug diazepam (0.5 mg/kg, n=30) and
cognitive enhancer piracetam (300 mg/kg, n=30). After the beginning of training the
animals continued to receive injections of tactivin and physiologic solution once in
every 48 hours. When the number of CRAA reached 80%, breakdown of CRAA was
carried out: reaction of the animals in response to stimuli didnt lead to the irritant
termination and during 5 passages into the other chamber compartment animals re-
219
Fig.1 Reproduction of avoidance response right after breakdown

*- p<0,05 against control; # - p<0,05 against mean value before breakdown
ceived current impulses (0,4-0,9 mA). Then during 20 trials the level of CRAA under
initial conditions was tested.
Emotional stress is also provoked by the spatial alteration of avoidance response
[10]. After attainment of the learning criterion of CRAA, the aperture, through which
the animal passed into another half of the chamber during training period, was closed,
and instead it another aperture was opened in the opposite side of the partition. Then
during 20 trials the level of CRAA under changed conditions was tested.
Phycopharmacological properties of tactivin were studied by means of highperformance liquid chromatography (HPLC) with electrochemical detection. Tactivin
effect on the content of monoamines and their metabolites in brain structures of Wistar
rats after CRAA and emotional stress (breakdown) attainment was studied. This work
was carried out in the Laboratory of Neurochemical Pharmacology, Research Institute
of Pharmacology named after V.V. Zakusov, (the head of the laboratory Ph.D Kudrin
V.S.) on 40 animals, weight 180-200 g. Among them 20 animals (10 experimental and
10 control) were contained in vivarium conditions and served as comparison groups,
while the other 20 (10 experimental and 10 control) were exposed to emotional stress.
Results
After CRAA breakdown abrupt derangements of attained behavioral habits in the
control group of animals were observed, which was expressed in 3-time reduction of
avoidance reaction (p<0,05). Tactivin prevented functional derangement the number of avoidance reactions after CRAA breakdown in the first block of trials didnt
change in all 50 rats (Fig. 1).
Besides the reduction of conditional reactions in comparison with initial level
after breakdown in the control group animals, the augmentation of generalized motional activity, expressed in the increase of intertrial responses (ISR) number, was
220
Fig.2. Intertrial responses before and after breakdown

*- p<0,05 against control; # - p<0,05 against mean value before breakdown
observed. This fact denotes the existence of emotional stress in these animals. In
the experimental group of animals the increase of ISR number was less prominent
in comparison with the control group of animals (p<0,05) and it achieved the initial
level more quickly (Fig. 2). Differences in comparison to the mean value before
functional disruption stopped to be statistically significant after the second block of
trials in the experimental group, whereas in the control group of animals it occurred
only after the third block of trials. Besides, tactivin treatment led to disappearance
of jumping, chaotic running, vocalization and other reaction typical for the higher
nervous activity breakdown.
Change of aperture location also promoted abrupt deregulation of previously formed
acquired habits in control animals, expressed by significant 2,5-time decrease of avoidance reaction numbers as compared to initial level (p<0,05). As it was observed at
breakdown, the most profound reduction of avoidance reactions level was registered
just after functional derangement. Tactivin treatment promoted less expressed level
of this disturbance, in other words, tactivin decreased the negative effect of spatial
alteration, providing the higher level of avoidance reaction reproducing in 1 5 and
subsequent trials (Fig. 3).
Simultaneously with the decrease of the avoidance reactions level, rise of motion
activity in animals was observed, which was expressed in the augmentation of ISR.
Spatial alteration induced more significant elevation of ISR rate as compared with the
effect of CRAA breakdown, which confirms its more expressed influence on emotional
state of the rats. However, the rate of ISR increase in the experimental group (from
18,57% to 33%) was less expressed as compared to control group of animals (from
14% to 56%) (Fig . 4).
Neurochemical properties of tactivin were studied by means of high-performance
221
Fig.3 Reproduction of avoidance response right after change of the aperture location
*- p<0,05 against control; # - p<0,05 against mean value before change of an aperture location
Fig.4. Intertrial responses before and after spatial change of an aperture location
*- p<0,05 against control; # - p<0,05 against mean value before change of an aperture location
liquid chromatography (HPLC) with electrochemical detection. Tactivin effect on the

content of monoamines and its metabolites in Wistar rat brain structures after CRAA
and emotional stress (breakdown) formation was examined. The research was carried
out on 40 animals, weight 180-200 g. Among them 20 animals (10 experimental and
10 control) were contained in vivarium conditions and served as comparison groups,
and the other 20 animals (10 experimental and 10 control) were exposed to emotional
stress. Tactivin treatment resulted in significant increase of serotonin (5-hydroxytryp-
222
Fig.5. Serotonin and Noradrenalin levels in some brain structures after avoidance response breakdown
*- p<0,05 against control
tophan 5-HT) level in hypothalamus, corpus striatum and frontal cortex. As tactivin
didnt induce above mentioned changes in intact rats (animals without training and
breakdown), it was concluded that this increase could be explained by CRAA breakdown. Elevation of 5-HT synthesis in brain structures during stress was observed
by many authors [11] and this fact is usually considered as one of the variants of
adaptation to stress impact. Besides the influence of tactivin on the increase of 5-HT
level, the thymic preparation also promoted the elevation of noradrenalin (NA) level
in hypothalamus and frontal cortex after functional deregulation (Fig. 5).
Decrease of NA level, at least in hypothalamus, is the most typical sign of emotional
stress [12]. Inhibition of serotonergic activity of neurons is mediated via noradrenergic
terminals [13] and therefore the increase of NA level leads to the decrease of serotonergic system activity and stress-protective effect under given model conditions [14].
Conclusions
Tactivin reduces the rate of memory processes imbalance, induced by avoidance
response breakdown and spatial change of behavioral habit. These facts point to the
correction effect of thymic peptides.
Tactivin reduces some negative effects, caused by stress situations and prevents
manifestation of reactions associated with higher nervous activity breakdown, which
confirms the influence of thymus on central nervous system.
Tactivin changes serotonin/noradrenalin ratio in hypothalamus and frontal cortex
for serotonin benefit. This alteration is the basis for positive effect of thymus preparations under given kind of stress.
As far as immunotropic thymus preparation tactivin reproduces all main functions
of thymus [15], and taking into consideration formerly published data [16, 17] and
results presented in this article, we conclude that thymus maintains not only immune
223
homeostasis but along with nervous and endocrine systems plays an important role
in maintenance of the whole organism homeostasis.
References
1. Yarilin A.A., Belyakov I.M. (1996) Thymus as the Endocrine Organ. Immunology (1),
pp. 4-10.
2. Yarilin A.A. (1999) Basis of Immunology. Moscow, Medicine, 608 p.
3. Pierpaoli W., Kopp. H., Miller J. et al.(1977) Interdependence between Neuroendocrine
Programming and Generation of Immune Recognition in Ontogeny. Cell. Immunol. 29
(1), pp.16-21.
4. Healey D., Hodgen G., Schulte et al. (1983) The Thymus-Adrenal Connection: Thymosin
and Corticotrophin Releasing Activity in Primates. Science. 222 (4630), pp. 1353-1355.
5. Tausk F., Elenkov I., Moynihan J. (2008) Psychoneuroimmunology. Dermatol. Ther. 21 (1), pp. 22-31.
6. Bolshakov I.N., Choroshich L.V.,Arion V.Ya.,et al. (1991) Tactivin Influence on Rat Spleen
Antibody-Forming Cells. Bul. Exp. Biol. Med. 111 (6), pp. 644-646.
7. Semochkin S.V., Kargina I.B., Arion V.Ya. et al. (2000) Immunocorrection by Thymus
Preparations in Burning Trauma. Int. J. Immunorehabil. 2 (2), pp. 154-159.
8. Arion V.Ya, Chromenkov Yu.I., Tagirova A.K. et al. (1987) Tactivin Influence on Xenobiotic Metabolic Enzymes. Vopr. Med. Chim. 33 (6), pp. 56-58.
9. Inozemtsev AN, Pragina LL. [A reversible disorder of the avoidance reaction as an experimental model for the study of the action of psychotropic preparations on higher nervous
activity]. Zh Vyssh Nerv Deiat Im I P Pavlova. 1989 Jul-Aug;39(4):764-766.
10. Pragina LL Stress actions as experimental model far investigation of nootropic influence an
avoidance learning. Vestnik Moskovskogo Universiteta. Biologiya, 1999, No. 4, pp. 2331.
11. Gorbunova A.V. (1998) Biogenic Amines of Brain Nuclei of August and Wistar Rats in
Repeated Stress. J. High Nervous Activity 48 (6), pp. 1051-1057.
12. Yumatov E.A. (1982) Systemic Approach as a Conceptual Base for Emotional Stress
Investigation . Vestnik AMN SSSR (2), pp. 63- 69.
13. Baraban J.M., Aghajanian G.K. (1981) Noradrenergic Innervation of Serotonergic Neurons
in the Dorsal Raphe: Demonstration by Electron Microscopic Autoradiography. Brain Res.
204, pp. 1-11.
14. Kalugniy A.L. (1998) Comparative Analysis of Stress-Protective Action of Pyracetam on
Functional Derangement of Conditional Reflectory Activity in Wistar, Fisher-344 and WAG
Rats. Authors Abstract of Ph.D. Thesis. Moscow, 23 p.
15. Arion V.Ya., Zimina I.V., Moskvina S.N. et al. (2007) Tactivin Natural Immunocorrector.
Clinical Application. Immunol. Allergol. Infectol. (4), pp. 14-26.
16. Kiseleva NM, Novoseletskaia AV, Zimina IV et al. (2010) Effect of Tactivin on the Behaviour and Learning in Rats. Vestnik RAMN (1), pp. 23-26.
17. Novoseletskaia AV, Kiseleva NM, Inozemtsev A.N. et al. (2010) Influence of Thymus
Preparation Tactivin on Conditional Food Reflex Formation in Rats. Rus. J. Immunol. 4
(1), pp. 83-87.
Evaluation of bronchial asthma hyperreactivity in

children withdifferent allergic diseases
Chikhladze M.V., Khachapuridze D.R., Gamkrelidze S., Sepiashvili R.
National Institute of Allergology, Asthma and Clinical Immunology,
Georgian Academy of Sciences, Tskhaltubo, Georgia
Institute of Immunophysiology, Moscow, Russia
Abstract
The prevalence of allergy, bronchial asthma and autoimmune diseases among children
increases all over the world. The aim of our investigation is to reveal correlation of
bronchial hyperreactivity phenomenon (BHP) of airways in children with different
allergic diseases. By method of random selection were interrogated and examined 535
children living in Kutaisi aged 614 years. The diagnostics included personal screening
with the use of ISAAC questionnaire and BHP investigation with pickfluorimeter:
evaluation of peak expiratory rate (PER) both in physiologic conditions and exercise
stress against the background of 2-agonist inhalation. Questionnaire screening allowed
select children with allergic nature of the disease of definite nosologic form: I group
children with bronchial asthma (BA) 61 persons (11.4%); II group children
with allergic rhinitis (AR) 42 (7.8%); III group children with atopic dermatitis
(AD) 22 (4.1%). A group of children with primary diagnosed allergic disease (BA,
AR, AD) 57 persons (10.7%) was singled out and 68 (12.7%) cases with already
diagnosed allergic disease. IV group 410 (76.7%) consisted of children with no
deviations according to ISAAC questionnaire. PER in physiological conditions was
decreased in I group by 21%, in II, III groups by 10% whereas in the VI group
of control only in 1.5% cases. PER decreased for more than 15% of initial figures
in 6 min after exercise stress in I group by 18%, in groups II and III 7% and in
group IV only in 2% cases. PER increased for more than 15% in 1520 min after
2-agonist inhalation (Ventolin): in I group in 29%, in II, III groups in 31% whereas
in control group only in 2 cases. Stated above allows assume bronchial obstruction
reversibility and BHP dependence on the state of adrenoreceptors in this contingent.
Thus high correlation between BHP and different allergic disease is revealed. These
children demand monitoring and carrying out of proper treatment if necessary.
P421R9048
225
226
Introduction
The last decade is marked by the increased morbidity with allergic diseases among
children in most countries, including Georgia [6, 7]. Comparative epidemiologic
analysis allows explain the changes in prevalence of BA and other atopic diseases in
children. So the refinement of possible reasons of morbidity growth and identification
of risk factors of asthma and allergy in children of concrete regions is the important
problem of modern medicine [47]. There is no doubt that bronchial obstruction and
bronchial hyperreactivity is patophysiological bases for many diseases of respiratory
system, first of all BA. So it would be reasonable to detect frequency and character
of bronchial function changes in children with atopic diseases. According to literature
data, peakfluorimetry is considered an adequate test for diagnostics of functional lungs
state which allows define the presence of bronchial hyperreactivity and obstruction
of the I stage and its reversibility. Peakfluorimetry is aimed at PER evaluation which
meaning correlates with the degree of bronchial obstruction [13]. Above-stated defined
the aim and tasks of present investigation: to reveal correlation of airways bronchial
hyperreactivity in children with different allergic diseases.

By method of random selection were interrogated and examined 535 children living
in Kutaisi aged 614 years. The diagnostics included personal screening with the use
of ISAAC questionnaire and BHP investigation with pickfluorimeter: evaluation of
PER in physiologic conditions. To diagnose bronchospasm, induced by exercise stress
was used running on the spot for 1015 min. PER was determined in 5 and 10 min
after the load. In persons who showed PER decrease both in physiological conditions
and provocation test inhalation with Ventolin (2-adrenomimetic) was carried out,
afterwards PER was measured once again. The results were considered as reliable if
PER indices were 1020% or lower than age-specific rate. (PER 1012% was considered as borderline, more than 20% as abnormality.) The examined contingent
was selected as the result of solid investigation of three secondary schools of Kutaisi;
parents informed consent was received.
Results and Discussion

The first stage of investigation included questionnaire screening according to ISAAC
questionnaire. The questionnaire for children of 610 was filled in by their parents;
school children of 1114 answered the questions themselves. With the help of adapted
questionnaire 123 children (23.3%) with positive test were selected. Among them 69
children (55%) were 67 years old and 56 (45%) 1314. Questionnaire screening
allowed select the children with allergic nature of the disease of definite nosologic
form. Igroup were the children with bronchial asthma (BA) 61 persons (11.4%);
II group children with allergic rhinitis (AR) 42 (7.8%); III group children with
atopic dermatitis (AD) 22 (4.1%). The screening allowed single out the children
with already diagnosed and primary diagnosed allergic disease (BA, AR, AD). On
the basis of the above mentioned three groups of children were selected: I group 57
(10.7%) children with primary diagnosed allergic disease; II group 68 (12.7%)
227
Table1 Distribution of children with allergic diseases according to localization of process and nosologic form
with already diagnosed allergic disease; III group 410 (77.6) practically healthy
children with no deviations according to ISAAC questionnaire (Table 1).
By peakfluorimetry it was revealed that among children with different allergic
diseases PER in physiogic conditions in group I was decreased by 21%, in group II
by 10% whereas in the III control group only in 1.5% cases. PER decreased more
than by 15% of initial figures in 6 min of exercise stress in I group by 18%, in II
group by 7% and in III group only in 2% cases.
So, among children with different allergic diseases according to investigation data
PER decrease was revealed both in physiologic conditions and against the background
of exercise stress.
To study the reversibility of bronchial obstruction in children of group I, II and III
Ventolin inhalation was carried out. It should be noted that the test was considered
as positive if after inhalation PER returned to normal values. PER increased by more
than 15% in 1520 min after inhalation of 2-agonist (Ventolin) in group I in 29%,
in group II in 31% whereas in the control group only in 2% cases. That allows
assume bronchial obstruction is reversible in this contingent and bronchial reactivity
depends on the state of 2-adrenoreceptors, which is confirmed by literature data [13].
Thus high correlation between bronchial hyperreactivity phenomenon and different
allergic diseases is revealed. PER and bronchoprovocative tests makes it possible to
detect among the children with different allergic diseases patients with changes of
bronchial tree function and unite them in chronic obstructive diseases risk group.
These children demand monitoring and carrying out of proper preventive treatment
if necessary.
References
1. Alferov, V.P., Sidorova, T.A., Lipnogorsky ,S.B., Chugunova, O.V. (2001). Bronchoobstructive Syndrome in Early Age Children (St-Petersburg) (In Russian).
2. Fedoseev, G.B. (1995). Mechanisms of Bronchial Obstruction. Agency of Medical Information. (In Russian).
3. Casale, T.B., Rhodes, B.I., Donelly, A. Weiler I.M. (1998). Airway reactivity to metaxoline
in nonatoria astmatic adult. J. Appl. Physiol. 64(6) pp. 2558-2561.
4. Worldwide Variation in Prevalence of Symptoms of Asthma, Allergic Rhinoconjunctivitis,
and Atopic Eczema (1998). ISAAC. Lancet 351, pp. 1225-1232.
5. Bousquut, J., Kjellman, N. (1986). Predictive Value of Tests in Childhood Allergy. J.
Allergy Clin. Immunology 78, pp. 1019-1022.
228
6. Macharadze, D.Sh., Shanidze, M.A., Dzhishkariani, I.R. et al. (2005). Prevalence of Allergic Diseases in Children According to Literature and ISAAC Data. Asthma 6(1-2), pp.
11-15. (In Russian).
7. Macharadze, D.Sh., Shanidze, M.A., Dzhishkariani, I.R.(2006). Climate and Allergy. Russian J. Allergology #5, pp. 25-29.
Author Index
Aitbaeva ZH.B., 129
Albrandt K.F., 211
Alyoshkin V.A., 161
An E.A., 211
Andriesh Lucia, 115
Andronova T.M., 73
Annaberdiyev D., 203
Arbuzova E., 193
Arion V.Ya., 217
Armedowa O., 181
Bahna SL, 7
Balmasova I.P., 151
Barba Doina, 115
Beglarova G.E., 129
Beletskaya Ludmila V., 157
Berezovskaya Elena, 115
Blaja-Lisnic Natalia, 115
Bolts E.A., 161
Borrego Carlos, 103
Caires Iolanda, 103
Casanova Danielle, 123
Chermnykh T.V., 167
Chikhladze M.V., 225
Chudilova Galina A., 187
Dadras M.N, 87
Dashti G.A, 87
Davidenko Elena B., 157
Devcic B., 109
Ermentaeva L.N., 129
Ezizova G.G., 203
Fisher Donald, 123
Gamkrelidze S., 225
Gheonea C., 55
Greenberger Paul A., 11, 25
Grigorieva T., 175
Grzetic-Romcevic T., 109
Guryanova S.V., 73
Hejazenia F., 87
Hercog P, 59
Hodjageldiyeva A., 181
Hristova R., 47
Inozemtsev A.N., 217
Ionova V.G., 207
Isaeva N., 193
Jones Joyce, 123
Kabdualieva N.B, 129
Kalimoldin M.M., 135
Kandova Y., 47
Katchibaeva A.S., 135
Khachapuridze D.R., 225
Khaltaev Nikolai, 1, 17
Khazaei B, 87
Khazaei H.A, 87
Kiseleva N.M., 217
Kluyev D., 199
Kokanov A., 181
Kolesnikova E., 199
Komelkova L.V., 207
Korkunda S., 175
Koshkin S.V., 167
Kostina E.M., 99
Kovaleva SvetlanaV., 187
Kozlov I.G., 73, 145, 217
Krmpotic D, 59
Kussainova D., 199
Lin Samuel, 123
Lomtatidze Ludmila V., 187
Lopes Claudia, 103
Lopes Myriam, 103
Luzar-Stiffler V, 59
Makhneva Natalia V., 157
Maltseva S., 193
229
230
Marques Joo, 103

Martins Pedro, 103
Maximova M.Ju., 207
Mogilevskaja E.S., 211
Molotilov B.A., 161
Molotov-Luchanskiy V., 199
Moolaei N., 87
Moskvina S.N., 217
Muravlyova L., 199
Mursalova Zh., 199
Nedyalkov M., 47
Nesterova Irina V., 187
Neuparth Nuno, 103
Nikolov G., 47
Noukar A., 87
Novikov A. S., 211
Novikova L.I., 161
Novoseletskaya A.V., 217
Nurlyyeva L., 203
Ochtova F.R., 207
Omarova M.N., 135
Orakbai L.Zh., 135
Orlova E.A., 161
Palma-Carlos A.G., 31, 77
Palma-Carlos M.L., 31, 77
Pavlova S.I., 145
Pavroz K., 193
Petrunov B., 47
Pleskanovskaya S., 181
Pleskanovskaya S.A., 203
Popescu F.D., 55
Potekaev Nikolay N., 157

Reva G.V., 211
Reva I.V., 211
Rozenson R.I., 95
Rozenson Rafail, 139
Ryabova V.V., 167
Sakharov Sergey Pavlovich, 171
Samotiya Evghenia, 115
Sanderson-Austin Julie, 123
Saparova L.T., 95
Sepiashvili R., 225
Sepiashvili R.I., 39, 65, 151
Sepiashvili Yan, 83
Sharyar M., 87
Shevchenko M.A., 73
Sidenko V., B.., 199
Slavyanskaya T. A., 39, 65
Sonc S., 109
Tankibaeva N., 199
Tataurshchikova Natalya, 83
Tazhibaeva D.S, 129
Timchenko O.L., 151
Tsitsuashvili M.D., 145
Tudose A.M., 55
Yamamoto T., 211
Yuschuk N.D., 151
Zaitseva G.A., 167
Zholdaspaeva N., 199
Zhumambayeva Saule, 139
Zhyrnova I.G., 207
Zimina I.V., 217

ISI America

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

ISI America

Hochgeladen von

Copyright:

Verfügbare Formate

Medimond - Monduzzi Editore International Proceedings Division

Professor REVAZ SEPIASHVILI

ALLERGY, ASTHMA &

VI WORLD CONGRESS ON IMMUNOPATHOLOGY

Professor Revaz Sepiashvili

Copyright 2012 by MEDIMOND s.r.l.

International Proceedings Division

Front page ........................................................................................................................... I

WHO/GARD Strategy for the Prevention and Control of Chronic Respiratory

Khaltaev Nikolai ................................................................................................................... 1

How does exhaled nitric oxide measurement fit in asthma assessment?

Difficult Respiratory Phenotypes in Adults with Asthma

Greenberger Paul A., M.D. .................................................................................................... 11

Diet and Chronic Respiratory Diseases

Khaltaev Nikolai ................................................................................................................... 17

Achieving Control of Fungal Asthma and Allergic Bronchopulmonary Mycosis

Greenberger Paul A., M.D. .................................................................................................... 25

Bacterial immunostimulants in asthma copd and recurrent respiratory infections

Slavyanskaya T. A., Sepiashvili R.I. ...................................................................................... 39

The role of fungal allergens in respiratory diseases in Bulgaria

Pollen sensitization pattern in patients with combined allergic rhinitis and

Popescu F.D., Tudose A.M., Gheonea C. ................................................................................ 55

Effects of Traffic Air Pollution on Hospitalizations for Exacerbations of Chronic

Krmpotic D, Luzar-Stiffler V, Hercog P .................................................................................. 59

Influence of allergy-inducing and other triggers to the development and severity

Slavyanskaya T. A., Sepiashvili R.I. ...................................................................................... 65

Allergy, Asthma & Immunophysiology: From Basic Science to Clinical Application

Muramyl dipeptide has a dual influence on allergic airway inflammation

Guryanova S.V., Shevchenko M.A., Kozlov I.G., Andronova T.M. ........................................... 73

Protease Inhibitors Asthma And Rhinosinusitis

Cytokine status as an efficiency criteria of intranasal aerosol therapy in allergic

Tataurshchikova Natalya, Sepiashvili Yan ............................................................................ 83

The effect of C3 and C4 complement components on allergic rhinitis patients

The bronchial hyperactivity in children with pollinosis

Saparova L.T., Rozenson R.I. ................................................................................................ 95

Pathogenetic therapeutic decision of immunotherapy in the patients with

Kostina E.M. ......................................................................................................................... 99

The patternof patients with frequent acute exacerbations of chronic obstructive

Grzetic-Romcevic T., Sonc S., Devcic B. ............................................................................... 109

Immunological characteristics ofcommunity-acquired pneumonia inold patients

Case Studies of Practical, Patient-centered, Parsimonious Initiatives That

Study of Tobacco sensibilization on the functional state of children engaged

Climate change: impact on hay fever peculiarities

Zhumambayeva Saule, Rozenson Rafail .............................................................................. 139

Antiproliferative effects of licorice root flavonoids and dihydroquercetin in vitro

Tsitsuashvili M.D., Pavlova S.I., Kozlov I.G. .......................................................................... 145

D56+ lymphocytes in demyelinating polyneuropathies

Allergy, Asthma & Immunophysiology: From Basic Science to Clinical Application

The humoral response in the autoimmune pemphigus

Intavenous immunoglobulineGabriglobin use in patients with autoimmune

Immunologic and immunogenetic indicators in patients with severe forms of

Immunorehabilitation of children with burh disease

Sakharov Sergey Pavlovich ................................................................................................. 171

Prophylaxis Of Pathological Scarring In Reconstructive Plastic Surgery

Korkunda S., Grigorieva T. .................................................................................................... 175

On the immunomodulate features of the new medical product Lukman-1

Pleskanovskaya S., Kokanov A., Hodjageldiyeva A., Armedowa O. ...................................... 181

Defects in functioning of interferon and immune systems and their correction

Efficiency Of Simultaneous Hepatites A And B Vaccination In Patients With

Isaeva N., Pavroz K., Arbuzova E., Maltseva S. ..................................................................... 193

The metabolic status of leucocytes at patients with tubulopathy and glomerulopathy

Muravlyova L., Molotov-Luchanskiy V., Kluyev D., Kussainova D. Kolesnikova E.,

Dynamics of immune response to kidney and uvea tissues antigens depending

Immunological changes in acute ischemic stroke