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2011 | update

27

. " .

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) ( - 5

Schnemann H, Brozek J, Bousquet J, et al. ARIA 2009 Revision. 1. Allergy 2009 (In press).

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Bousquet J, Reid J, van Weel C, et al. Allergic rhinitis management 3. pocket reference 2008. Allergy 2008;63(8):990-6.

Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for 4. the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008;38(1):19-42.

Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines 5. for the management of rhinosinusitis and nasal polyps. Clin Exp Allergy 2008;38(1):260-75.

Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and 6. management of rhinitis: an updated practice parameter. J Allergy Clin Immunol 2008;122(2 Suppl):S1-84.

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Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice 9. guiedline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137 (suppl):S1-S31.

Price D, Bond C, Bouchard J, et al. International Primary Care 10. Respiratory Group (IPCRG) Guidelines: management of allergic rhinitis. Prim Care Resp J. 2006;15(1):58-70.

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Levy ML, Fletcher M, Price DB, Hausen T, Halbert RJ, Yawn 12. BP. International Primary Care Respiratory Group (IPCRG) Guidelines: diagnosis of respiratory diseases in primary care. Prim Care Resp J 2006;15(1):20-34.

ARIA in the pharmacy: management of allergic rhinitis symptoms 13. in the pharmacy. Allergic rhinitis and its impact on asthma. Allergy 2004;59(4):373-87.

Meltzer EO, Hamilos DL, Hadley JA. Rhinosinusitis: establishing 14. definitions for clinical research and patient care. J Allergy Clin Immunol 2004;114:s155-s212.

Van-Cauwenberge P, Bachert C, Passalacqua G, et al. Consensus 15. statement on the treatment of allergic rhinitis. EAACI Position paper. Allergy 2000;55:116-34.

- Costa DJ, Bousquet PJ, Ryan D et al. Guidelines for allergic rhinitis 1. need to be used in primary care. Prim Care Resp J 2009;18(4):250-7.

Bousquet J, Fokkens W, Burney P, et al. Important research 2. questions in allergy and related diseases: nonallergic rhinitis: a GA2LEN paper. Allergy 2008;63(7):842-53.

Ryan D, van Weel C, Bousquet J, et al. Primary care:the cornerstone 3. of diagnosis of allergic rhinitis. Allergy 2008;63(8):981-9.

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Demoly P, Concas V, Urbinelli R, Allaert FA. Spreading and 5. impact of the World Health Organization's Allergic Rhinitis and its Impact on Asthma guidelines in everyday medical practice in France. Ernani survey. Clin Exp Allergy 2008;38(11):1803-7.

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Green RJ, Davis G, Price D. Concerns of patients with allergic 7. rhinitis: the Allergic Rhinitis Care Programme in South Africa. Prim Care Resp J 2007;16(5):299-303.

Helling PW, Fokkens WJ. Allergic rhinitis and its impact on 8. otolaryngology. Allergy 2006;61:656-64.

- Bousquet J, Bodez T, Gehano P, et al. Implementation of guidelines 1. for allergic rhinitis (ARIA) in specialist practices. A randomised pragmatic controlled trial. Int Arch Allergy Immunol 2009 (in press).

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2011 | update

a metasynthesis of GPs' attitudes to clinical practice guidelines. Br J Gen Pract 2007;57(545):971-8.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=S4. earch&Term=%22Sheikh%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus, Durham S, Calderon MA ,et al. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database Syst Rev. 2007;CD001936.

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2011 | update

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:

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allergy symptoms was therefore utilized to create a model in order to predict when and how to treat hay-fever patients [24]. In the recent years, many allergenic plants that pollinate concomitantly the issues of true correlation between each plants pollen relevance for clinical symptoms [25] and aeroallergens thresholds [26] have become a focus of attention. Another aspect of pollen allergy that kept us busy in recent years is the population genetics factor and its interaction with the pollenic environment. It came up when we observed that in the Israeli Druse population there is very low incidence of sensitivity to olive pollen, even though the Druse have lived in the midst of olive groves for a thousand years; they most probably developed spontaneous desensitization, or tolerance, or both [27]. Other aeroallergens such as molds [28] and Israeli house dust mites were less studied.

Last but not least, we tried to put together a preliminary list of pol-lens and pollination in Israel (tables 1-3). We hope that with the help of our Israeli colleagues in the field of allergy and botanic research we can come up with an updated map of pollination in Israel.

Do you have any comments?If you have any comments on the accuracy of the data, or any data/publications that were missed, we will be happy to incorporate it into our final summary. Please contact: Dr. Carmi Geller-Bernstein: carmigb@zahav.net.il orDr. Nancy Agmon-Levin: nancy.agmon-levin@sheba.health.gov.il

References Kessler, A. Survey of airborne pollen and fungus spores in Israel, 1951-1952. Ann 1. Allergy. 1953;11(3):322-8.Zohary, M. A monographical study of the genus Pistacia Palestine. J. of Botany 2. 1952;5:187-228.Gutmann MJ. Pollen allergic disease (Hay fever) in Israel. Acta Med. Orient. 3. 1958:17:73-79.

Kessler, A. Olive pollen as causing factor for allergy diseases. Dapim Refuim 4. 1958;17: 155-141.Feinbrun, N, Rahat, A and Tass, J. Further studies in atmospheric pollen in 5. Jerusalem. Bull. Res. Council of Israel 1959;8-D:31-40. Tass, J and Rahat, A. Assessment of pollen in the atmosphere of En Bokek. Harefuah 6. 1963;8: 253-254.Weinstein, M. Airborne pollen in the quaternary of Israel. In Horowitz A. ed 7. Academic Press, London 1979:180-186.Glazer, I. Causing factors of pollenosis in Israel. Harefuah 1986;110:378-389.8. Tamir, R, Pick, A, Topilsky, M and Kivity, S. Early and late asthmatic reaction to 9. olive pollen extract in patients with hay fever and allergic asthma. J Allergy Clin Immunol 1987;79:186-19.Tamir, R, Pick, AI, Topilsky, M and Kivity, S. Olive pollen induces asthmatic 10. response. Clinical and Eperimental Allergy 1991;21:329-332.Keynan, N, Geller-Bernstein, C, Waisel, Y, Bejerano, A, Shomer-Ilan, A, Tamir, R. 11. Positive skin tests to pollen extracts of Pistacia in Israel. Clin Allerg 1987;17: 243-249.Waisel, Y, Geller-Bernstein, C, Keynan, N and Arad, G. Antigenicity of the pollen 12. proteins of various cultivars of Olea Europaea. Allergy 1996;51:819-25.Geller-Bernstein, C, Keynan, N, Bejerano, A, Shomer-Ilan, A and Waisel, Y. Positive 13. skin tests to fern spores in atopic patients. Ann of Allergy 1987;58:125-127.Bar-Dayan, Y, Keinan, N, Waisel, Y, Pick, AI and Tamir, R. Podocarpus gracilior and 14. Callitris verucosa: Newly identified aeroallergens. Allerg Immunol 1992;24:65-67.Goldberg, A, Confino-Cohen, R and Waisel, Y. Allergic responses to pollen of 15. ornamental plants: High incidence in the general atopic population and especially among flower growers. J Allergy Clin Immunol 1998;102:210-214.Keynan, N, Waisel, Y, Shomer-Ilan, A and Finalt, M. Artemisia monosperma 16. plants of the costal plain of Israel, as a source of allergens in Jerusalem. Harefuah 1991;20:716-718.Rahmiel M, Verleger, H, Waisel, Y, Keinan, N, Kiviti, S and Katz, Y. The importance of 17. the pecan tree pollen in allergic manifestations. Clin Exp Allergy 1996;26:323-329.Geller Bernstein, C, Arad, G, Keynan, N, Lahoz, C, Cardaba, B and Waisel, Y. 18. Hypersensitivity to Pollen of Olea europea in Israel. Allergy 1996;51: 356-359.Geller-Bernstein, C, Waisel, Y and Lahoz, C. Environment and sensitization to 19. cypress in Israel. Allerg Immunol 2000;32(3):92-3.Waisel, Y and Geller-Bernstein, C. How "dead" is the Dead Sea? The 8th International 20. Congress on Aerobiology 2006; Neuchatel. Abstracts: 23-24.Mekori, Y. Allergic reactions: mechanism and diagnosis. Family Physician 1992; 21. 30:56-51.Waisel, Y, Keynan, N, Geller-Bernstein, C and Dolev, Z. Urban pollution with 22. allergenic pollen: sources and consequences. In: Urban Ecology Ege University Press, Izmir, 1991, Turkey. 24-38.Garty, BZ, Kosman, E, Ganot, E, Berger, V, Garti, L, Weitzen, T, Waisman, Y, 23. Mimouni, M and Waisel, Y. Emergency room visits of asthmatic children: relation to air pollution, weather and airborne allergens. Ann Allergy 1998;81:563-570.Geller-Bernstein, C, Keynan, N, Kennet, R, Shomer-Ilan, A and Waisel, Y. 24. Aerobiology as a tool for prevention of hay fever. Grana, 1991;30:76-78.Waisel, Y, Meinis, Z and Geller-Bernstein, C. The partial contribution of specific 25. airborne pollen to pollen induced allergy. Aerobiologia 2004;20:197-208.Galan, C, Waisel, Y, Geller-Bernstein, C. Factors affecting risk thresholds for pollen 26. allergy, i.e olive pollen. 2010; Abstract in the 17th International Symposium APLE Ourense. Geller-Bernstein, C, Lahoz, C, Cardaba, B, Hassoun, G, Yancovici-Kidon, M, 27. Kenett, R and Waisel, Y. Is it "bad hygiene" to inhale pollen in early life? Allergy Suppl. 2002;75:37-40.Katz, Y, Verleger, H, Barr, J, Rahmiel, M, Kiviti, S and Kuttin, E S. Indoor Survey 28. of Moulds and Prevalence of Mould Atopy in Israel. Clinical and Experimental Allergy 1999;29:186-192.

Geographic distribution

Main flowering seasonNameFamily

Central (near buildings)

February- November

Parietaria judaica

Urticaceae

All partsJanuary-MayUrticaUrticaceae

All partsJune-NovemberAmaranthusAmaranthaceae

South - DesertApril-OctoberArtiplexChenopodiaceae

July-OctoberSalsolaChenopodiaceae

Central (Emek-Hefer)

May-OctoberAmbrosiaAsteraceae

Coast line and South

September- November

ArtemisiaAsteraceae

All partsMarch-AprilPlantagoPlantaginaceae

Table 3 . Weeds of allergenic significance in Israel

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A llergic rhinitis and asthma affect 20%-30% of the population. Sensitization to aeroallergens, the main cause of these allergic diseases, has increased in prevalence and severity in Israel as well as in many western countries. Aeroallergens, both indoor and outdoor ones, are airborne particles, ranging from sub-micron particles to relatively large pollen grains. Indoor allergens such as the house dust mites and molds may cause allergies through-out the year, whereas outdoor aeroallergens, which are consisted mainly of pollens and outdoor molds, usually cause seasonal allergic symptoms.

Pollens are traditionally grouped as trees, grasses and weeds. Tree pollination heralds the beginning of the allergy season in most climates, beginning as early as December or January. Grass pollen season overlaps tree pollination and may run through July-August, however some grasses cause allergic sensitization throughout the year and may cause perennial symptoms. Weed pollination typically occurs during late summer through mid-autumn (October).

To be of clinical significance, an aeroallergen must be allergenic as well as present in significant concentration (allergy threshold). Outdoor aeroallergens vary in concentration between different geographic regions and climates, even within a certain country. Thus, even in a small country such as Israel, sensitization to pol-len might differ between geographical areas as well as between different populations.

In this short review we present our preliminary summary regarding the distribution of "allergenic pollens" in Israel, as well as some examples of Israeli allergists interested in autochthonous pollen and spores during the last 60 years.

The first studies on Israeli pollens appeared in the fifties and the sixties [1-7], in which mostly grasses and olive pollens were described. In 1986, Glazer, I, [8] published a more detailed and precise overview of pollination in Israel and specific pollen-related symptoms. Later on, in the eighties and the nineties, more sophis-ticated studies appeared, dealing with accurate measurements of asthmatic reactions as produced by meticulously measured number of olive pollen grains [9-10]. In addition, Israeli allergists defined new allergenic plants in Israel, such as the different species of Pistacia [11], different cultivars of Olive [12-13], Podocarpus gracilior, Callitris verucosa [14] and ornamental plants [15]. In collaboration with the late Prof. Yoav Waisel and his team, our knowledge of allergenic plants in Israel, such as the Artemisia monosperma, pecan tree and others, has been developed and increased in more details and depth [16-20].

As the interest and development of allergenic plants science grew, so did the need to understand the mechanisms of allergies induced by them [21] and the relationship between pollen and air pollution [22-23]. Corroborating aerobiologic and clinical

Pollen and molds in the Israeli ambient airNancy Agmon-Levin1 and Carmi Geller-Bernstein2

The Zabludowicz Center for Autoimmune Diseases, 1Sheba Medical Center, 2Kaplan Medical Center

Geographic distribution

Main flowering seasonnameFamily

All partsJan-AprilCupressusCupressaceae

Central & northApril-JuneOlea europaeaOleaceae

CentralMayCarya illinoensis

Juglandaceae

All partsApril-OctoberEucalyptusMyrtaceae

North, mountains area (Jerusalem)

March-AprilOakFagaceae

Central NegevLower Galilee

March-AprilPistachiaAnacardiaceae

-

Jerusalem, Zefat, Jaffa

April-JuneAilantusSimaroubaceae

All partsMarch-MayAcaciaMimosaceae

All partsOctober- November

CasuarinaCasuarinaceae

All partsFebruar-MarchThujaCupressaceae

Jordan river, dead sea and south Israel

Februar-AprilPhoenixArecaceae

All partsSeptember- october

CreatoniaCaesalpiniaceae

All partsApril-MaySchinusAnacardiaceae

All parts MayCedarPinaceae

Table 1. Trees of allergenic significance in Israel

Geographic distribution

Main flowering seasonNameFamily

All partsMay-SeptemberCynodon dactylon(Bermuda)

Poaceae

)( All partsJuly-SeptemberPaspalum (Bahia)Poaceae

All partsMay-SeptemberSorghum (Johnson)poaceae

All partsFebruary-AprilPoaPoaceae

All parts February-MayLoliumPoaceae

All partsApril-JunepenisetumPoaceae

All partsApril-JuneDactylis glomerata Paspalum

Poaceaae

Table 2. Grasses of allergenic significance in Israel

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the device corresponded to membranal damage of the bacteria. Their study revealed changes in the bacterial surface protein composition induced by the device. In contrast, neither DNA nor cytoplasm protein damage was detected electrophoretically. The antimicrobial action of the device seems to occur because of chemical modification of the surface proteins of bacteria. In situ hydroxyl-radical formation on the surface of bacteria was pro-posed as the leading mechanism of the protein damage caused by the device. At the same time, DNA damage seems not to be involved in the antibacterial action of the device.

Our findings should encourage further research to confirm the benefits of the Plasma Cluster ion device under natural condi-tions in domestic environments. The data obtained from such studies would broaden the knowledge on the effects of airborne plasma-generated cluster ions and help to produce more efficient air-cleaning devices.

AcknowledgmentsEsther Eshkol is thanked for editorial assistance.

Correspondence:Dr. S. KivityAsthma and Allergy Center, Sourasky Tel Aviv Medical Center, 6 Weizmann Street, Tel Aviv 64239, Israel Phone: (972-3) 697-3734Fax: (972-3) 697-4601email: Allergy@tasmc.health.gov.il

ReferencesStorm van Leeuven W. Allergic Diseases: Diagnosis and Treatment of Bronchial 1. Asthma, Hayfever and Other Allergic Diseases. Philadelphia:JB Lippincott, 1925.Custovic A, Murray CS, Gore RB, Woodcock A. Controlling indoor allergens. 2. Ann Allergy Asthma Immunol 2002; 88: 43241.O'Connor GT. Allergen avoidance in asthma: what do we do now?3. J Allergy Clin Immunol 2005; 116: 2630. Tovey ER, Kemp AS. Allergens and allergy prevention: where to next?4. J Allergy Clin Immunol 2005; 116: 11921. Eggleston PA. Improving indoor environments: reducing allergen exposures. 5. J Allergy Clin Immunol 2005; 116: 1226. Woodcock A, Forster L, Matthews E, et al., Medical Research Council General 6. Practice Research Framework: Control of exposure to mite allergen and allergen-impermeable bed covers for adults with asthma.N Engl J Med 2003; 349: 22536.McDonald E, Cook D, Newman T, Griffith L, Cox G, Guyatt G. Effect of air 7.

filtration system on asthma: a systemic review of randomized trials.Chest 2002; 122: 153542.Juniper EF, Guyatt GH. Development and testing of a new measure of health status 8. for clinical trials in rhinoconjunctivitis. Clin Exp Allergy 1991;21: 7783.Platts-Mills TA, Thomas WR, Alberse RC, Vervloet D, Chapman MD. Dust mite 9. allergens and asthma: report of a second international workshop.J Allergy Clin Immunol 1992; 89: 104660.Gotzsche PC, Johansen HK, Schmidt LM, Burr ML. House dust mite control 10. measures for asthma. Cochrane Database Syst Rev 2004; 4: C001187.Nishikawa K, Nojima H, Aoki M, Kuroda Y. Development of novel air purification 11. technology using ions generated by discharge plasma. ii: Inactivation of influenza virus in air. Healthy Buildings 2003 7th International Conference, Singapore, 2003, pp 6605. Nishikawa K, Nojima H. Air purification effect of positively and negatively charged 12. ions generated by discharge plasma at atmospheric pressure.Jpn J Appl Phys 2001; 40: L8357. Nojima H, Nishikawa K. Air purification technology using ions generated by 13. discharge plasma at atmospheric pressure. J Inst Electrostatics Jpn 2002; 26: 1537.Yagi H, Nishikawa K, Nojima H. Japan Kokai Tokkyo Koho, patent 2003-201722.14. Robertson WH, Johnson MA. Molecular aspects of halide ion hydration: the 15. cluster approach. Ann Rev Phys Chem 2003; 54: 173213.Sharp CO. Reduction of suspended germs in air by plasma generated cluster ions 16. at atmospheric pressure. Society for Antibacterial and Antifungal Agents Japan, Osaka, 2001; 55: 20317. Kawamoto S, Oshita M, Fukuoka N, et al. Decrease in the allergenicity of Japanese 17. cedar pollen allergen by treatment with positive and negative cluster ions. Int Arch Allergy Immunol 2006; 141: 31321.Nogrady SG, Furnass SB. Ionisers in the management of bronchial asthma. 18. Thorax 1983; 38: 91922. Warner JA, Marchant JL, Warner JO. Double-blind trial of ionizers in children with 19. asthma sensitive to the house dust mite. Thorax 1993; 48: 3303. Liccardi G, Custovic A, Cazzola M, Russo M, D'Amato M, D'Amato G. Avoidance 20. of allergens and air pollutants in respiratory allergy.Allergy 2001; 56: 70522. OMeara TJ, Sercombe JK, Morgan G, Reddel HK, Xuan W, Tovey ER. The reduction 21. of rhinitis symptoms by nasal filters during natural exposure to ragweed and grass pollen. Allergy 2005; 60: 52932.Custovic A, van Wijk RG. The effectiveness of measures to change the indoor 22. environment in the treatment of allergic rhinitis and asthma: ARIA update (in collaboration with GALEN). Allergy 2005; 50: 111215.Woodfolk JA, Hayden ML, Couture N, Platts-Mills TA. Chemical treatment 23. of carpets to reduce allergen: comparison of the effects of tannic acid and other treatments on proteins derived from dust mites and cats.J Allergy Clin Immunol 1995; 96: 32533. Lau S, Wahn J, Schulz G, Sommerfeld C, Wahn U. Placebo-controlled study of the 24. mite allergen-reducing effect of tannic acid plus benzyl benzoate on carpets in homes of children with house dust mite sensitization and asthma. Pediatr Allergy Immunol 2002; 13: 316.Digel I, Temiz AA, Nishikawa K, Cook M, Kurulgan E, Arthman GM. Bactericidal 25. effects of plasma-generated cluster ions. Med Biol Eng Comput 2005; 43: 8007.

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No significant change was noted in the spirometric measure-ments obtained during visits to the physician's office. There was good agreement between patients symptoms, diary entries and the physicians report of asthma status.

DISCuSSIoN

Mite allergy is responsible for the majority of respiratory allergies in western societies [3-6,8-10]. Many devices and suggestions are offered to affected individuals in an attempt to reduce or inacti-vate the widespread indoor allergen. Most of the relevant studies evaluated the effect of environmental control on asthma, but only a few investigated nasal symptoms.

The Plasma Cluster ion device was recently introduced as a tool capable of improving the quality of life of individuals sensitive to indoor allergens [11-16]. The molecular structures of the device were identified as H3O+(H2Om) and O2-(H2On) (m, n 0) as the major ions [13,14], while ozone and the other ions were negligible [11-13]. Kawamoto et al. [17] recently demonstrated that the use of the Plasma Cluster ion device significantly reduced the allergenic activity of Japanese cedar pollens in the lab. The rate of decrease in in vitro antigenic activities and in vivo allergenic activities was proportional to the densities of the device caused by changing the input voltage [17].

Previous research on the use of negative ion generators that electrostatically precipitated airborne dust and allergens has shown little or no evidence of any clinical benefits [18]. Warner and co-authors [19] reported that ionizers could not be recommended for use in homes of asthmatic subjects with the intent to alleviate their symptoms, but that a significant abatement of airborne allergen con-centrations may be useful as part of an allergen avoidance regimen. Ionizers and/or air filtration units did not reduce the levels of mite allergens in indoor environments, since the largest amounts of these allergens remained in settled dust [20].

Our data demonstrated an improvement in symptom scores as reported by the patients as well as in the physicians evaluations of

patients who suffer from mite-sensitive respiratory allergies. This is shown for both nasal and airway disease. Importantly, some of the nasal symptoms also continued to improve after removal of the device. The same outcome was seen in the PEFR results, although the difference did not reach statistical significance. We assume that this benefit could be due to the suppression of mucosal inflamma-tion occurring as the result of inactivating dust mite.

Although this is an observational and not a blinded study, it has the advantage of having included a phase of observation prior to the application of the device and another phase 2 weeks following the cessation. Using the device for a longer period might have had a stronger and more long-lasting effect, and a larger group of patients in the asthmatic arm could probably strengthen the results.

More than a dozen clinical trials of allergen-proof encasings [6-8] have been published; they were at least 3 months in duration and they measured mite allergen levels in bedding. All of these trials reported reduced allergen concentrations, varying in efficacy from 39 to 99.9% reduction in mite allergen levels.

HEPA filters and HEPA filter vacuum cleaners can effectively reduce environmental levels of pet-derived allergens in indoor environments, but there are no convincing data [21,22] that environmental control measures can reduce asthma morbidity to acceptable levels in patients with pet-allergic asthma who continue to live with a pet to which they are allergic. The use of chemicals in removing dust mite was shown in a few studies to be effective [23,24] a method hard to apply in daily life. Fewer studies have looked at allergen avoidance for other indoor allergens. Avoidance of cockroach allergen was the focus of several interventional studies, but reductions in allergen levels were not obtained, and no clinical benefits were seen in the trials that reported clinical outcomes. A recent study of an intensive 6 month extermination and cleaning intervention showed that substantial reductions in cockroach allergen levels in infested apartments can be obtained, but clinical outcomes were not assessed. Exposure to mold can aggravate the asthma of sensitized persons, and case reports have described the clinical benefits of eliminating indoor exposure for such individuals. The potential clinical effect of interventions to reduce indoor residential exposure to fungi, however, has not been evaluated in clinical trials.

The use of Plasma Cluster ion devices holds much promise to inactivate the antigenicity and allergenicity of a variety of airborne allergens without elevation of ozone concentrations in domestic surroundings. This device deactivates the immunoglobulin E anti-body binding sites of the allergen on the molecular level and thus prevents the allergen from combining with the IgE antibody.

According to the time/dose-dependent experiments by Digel et al. [25], the inhibiting effects of this device on the multiplication of different bacteria (Staphylococcus, Enterococcus, Micrococcus and Bacillus) became apparent within the first few minutes and led to an irreversible 99.9% destruction of these bacteria within the following 28 hours of exposure. The destructive effect of

IgE = immunoglobulin E

Figure 1. Effect of the Plasma Cluster device on peak expiratory flow rate before, during and after removal of the Plasma Cluster device

Before

P = 0.0137 P = NS

L/m

in

490

470

450

430

410

390

370

350

During After

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PATIeNTS AND MeThoDS

This multicenter study involved 11 allergy treatment facilities in Israel. The study patients had been treated in these centers for at least 1 year prior to their participation in the study. None of the patients was receiving immunotherapy and there was no change in their medications during the entire study and follow-up period. All of the AA patients were considered to have mild-to-moderate degree asthma as defined by the GINA (Global Initiative for Asthma) guidelines and none was taking oral corticosteroids.

Informed consent was obtained from each patient following the studys approval by the ethics committee of each institution. Each center recruited four patients with AR and between one and four patients with AA. Some of the patients had both AR and AA. The centers were located throughout the country and included patients in the central, northern and southern parts of Israel. The study was conducted during different seasons so that the results could be con-sidered not to have been influenced by seasonal changes.

The study cohort consisted of 19 males and 14 females with AR whose ages ranged between 22 and 63 years (mean 35 12) and 5 males and 7 females with AA whose ages ranged between 22 and 45 years (mean 28 9). Six patients had both AR and AA. None of the patients had any other chronic illness. Skin tests were done by prick and included mites, grasses, weeds, epidermals and molds. Each patient had at least one positive prick-skin test to a mixture of mites (Dermatophagoides pteronyssinus and D. farinae).

The DevICe

The Plasma Cluster ions device was donated by Sharp, Osaka, Japan. As described by Nishikawas group and others [11-14], this technology consists of a multi-electrode array that produces positive and negative ions surrounded by a water shell [15]. The ion density is 10,000 pcs/cm. The respective hydrated ions are deposited on microparticles such as bacteria or odor-causing molecules, which they decompose and deactivate chemically [16]. The amount of ozone generated by the device is less than 0.01 ppm, which is significantly less than the standard (0.05 ppm) for industrial operations and consumer electronics.

STuDy DeSIGN

Each patient was seen at least four times during the 8 week study. On the first visit, he/she was interviewed by the investigator, followed by a history intake, physical examination, spirometry (in cases of AA) and initial peak expiratory flow measurement. Each measurement was repeated three times and the best of the three was selected for data analysis. The patient filled in a questionnaire, which included 30 different symptoms (adapted from Juniper and Guyatt [8]). AA patients were given a symptoms diary and instructed to complete it twice daily, using a severity score of 03, recording the amount of puffs of albuterol taken to relieve symptoms, and recording PEFR as measured at home twice a day and throughout the study period.

PEFR = peak expiratory flow rate

Symptoms were recorded for a total period of 8 weeks: 2 weeks as a run-in period without the device, 4 weeks with the device placed in the bedroom and close to the patients bed, and an additional 2 weeks following removal of the device. The patients performed spirometry and filled in a symptoms score at each clinic visit.

STATISTICAL ANALySIS

The data were analyzed by a statistician who recorded the informa-tion of each patient and statistically compared the results by the t-test for the comparison of two periods and ANOVA for changes through-out whole periods. Significance was established at P < 0.05.

ReSuLTS

Thirty of the original 33 AR patients completed the AR protocol, while 10 of the original 12 AA patients completed the AA proto-col. The data on these 43 patients were included in the statistical analysis.

As seen in Table 1, there was a significant improvement at the end of the fourth week with the device compared to baseline, but there was no significant difference for the same parameters between baseline scores and those recorded at the end of the first phase (i.e., 2 weeks of observation). There was good agree-ment between the patients reports and the physicians' assess-ments in terms of improved symptoms (P < 0.05). Improvement was also seen during the 2 weeks after removing the device, although to a lesser degree than during the period of its active use. The mean score of improvement was 5.1 3.2 (on a scale of 010). Almost two-thirds of the patients (19/30, 63%) scored an improvement > 5.

The AA patients reported a significant reduction (P < 0.05) in dyspnea, wheezing, and the need to avoid dust mite. They also had a significant improvement (P = 0.0137) in mean PEFR at the end of the treatment period compared to the observational phase. There was a significant difference between the average daily PEFR measurements for each period (P < 0.005 ANOVA)[Figure 1].

Parameters P

Nasal discharge 0.002

Postnasal drip 0.06

Nasal congestion 0.002

Nasal tching 0.01

Watery eyes 0.04

Itchy eyes 0.05

Headache 0.05

Itchy ears 0.08

Night disturbances 0.05

General feeling (last 2 days of study) 0.02

Table 1. Parameters reported to have significantly improved with the use of the Plasma Cluster device

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Background: Mite allergy is an indoor allergen responsible for most respiratory allergies in the western world. Environmental control can modify disease activity in these patients.objectives: To examine the benefit of the Plasma Cluster device (Sharp, Japan) for inactivating and removing mites from the environment of patients diagnosed with either mite-sensitive perennial allergic rhinitis or mite-sensitive allergic asthma.Methods: Patients with AR (n=30) or AA (n=10) were enrolled into a prospective open observational 8 week study. The first 2 weeks involved initial evaluation, the following 4 weeks consisted of active usage of the device, and the last 2 weeks were designated for follow-up. Symptom scores (recorded daily by patients and during visits by physicians) were recorded and analyzed.Results: Patients with AR experienced a significant (P < 0.05) reduction in nasal discharge, post-nasal drip, nasal congestion, nasal itching, watery eyes, itchy eyes, headache, itchy ears, night disturbances and an improvement in general well-being during the last 2 days of the study compared to baseline. Patients with AA reported significant (P < 0.05) reduction in dyspnea, wheezing and the need to avoid dust mites. There was a significant (P < 0.05) improvement in mean peak expiratory flow rate at study closure compared to baseline.