REVI EW ARTICLES

t The usefulness of biomarkers of airway inflammation in managing asthma Patil and Long

ORIGINAL ARTICLES

t Efficacy and safety of mometasone furoate/formoterol 200/10 mcg combination treatment in patients with persistent asthrna previously on mediurn-dose ICSs Nathan el al

t Efficacy and safety of mometasone furoate/formoterol 200/10 mcg and 400/10 mcg combination treatments in patients with persistent asthma previously on high-dose ICSs Weinstein et al

t Levocetirizine dihydrochloride in pedía trie allergic rhinitis or chronic urticaria Hampel et al

t Oral olopatadine hydrochloride for the treatment of SAR Yamamoto et al

t Epinephrine auto-injector use in a V.A. population Amirzadeh et al

t Repeat epinephrine treatment for food-related allergic reactions Banerji et al

t Reduced clinic, ER and hospital utilization after home environmental assessment Barnes et al

t Immunotherapy for treatment of allergic asthma in children Alzakar nnd Alsamarai

t Acetaminophen for preventing rnood and rnemory effects of prednisone Brown et al

t Irnportant Florida botanical aeroallergens Pl1illips et al

, t Atmospheric pollen count in Monterrey, Mexico Gonzalez-Diaz et al

t DNA repair gene XRCCl polymorphisms and the risk of asthma Batar et nl

t POPS Case: A 41-year-old male with cough, wheeze, and dyspnea poorly responsive to asthma therapy Ricketti et al ALLERGY and ASTHMA PROCEEDINGS

Editor-in-Chief: Joseph A. Bellanti, MD Associate Editor: Russell A. Settipane, MD Executive Editorial Board

American Board Members: Sami L. Bahna, MD Lawrence D. Frenkel, MD Kevin McGrath, MD Shreveport, LA Rockford, IL Fairfield, CT William Berger, MD Marianne Frieri, MD Christopher C. Randolph, MD Mission Viejo, CA East Meadow, NY Waterbury, CT Michael Blaiss, MD Sandra Gawchik, DO Diane E. Schuller, MD Memphis, TN Chester, PA Hershey, PA Malcolm Blumenthal, MD StanJey Goldstein, MD Robert J. Settipane, MD Minneapolis, MN Rockville Centre, NY Providence, RI Wamer W. Carr, MD Daniel Hamilos, MD Charles J. Siegel, MD Glenwood, MD Boston, MA Kansas City, MO Bradley Chipps, MD Bettina C. Bilman, MD Ronald Simon, MD Sacramento, CA Tyler, TX LaJolla, CA Linda S. Cox, MD Richard Honsinger, MD Raymond G. Slavin, MD Fort Lauderdale, FL Los Alamos, NM St. Louis, MO Timothy Craig, DO Donald E. Klein, MD Ricardo U. Sorenson, MD Hershey, PA Providence, RI New Orleans, LA Andrew Davidson, MD David M. Lang, MD Clifford Tepper, MD 1 SummervilJe, SC Cleveland, OH Albany, NY Lawrence M. DuBuske, MD Bobby Q. Lanier, MD John M. Weiler, MD Gardner, MA Fort Worth, TX Iowa City, lA Chitra Dinakar, MD D. Betty Lew, MD David Weldon, MD Kansas City, MO Memphis, TN College Station, TX Mark S. Dykewicz, MD Eric Macy, MD Peter Weller, MD St. Louis, MO San Diego, CA Boston, MA Stanley Fineman, MD Lyndon E. Mansfield l lugh Windom, MD Marietta, GA El Paso, TX Sarasota, FL

Intemational Board Members Attilio Boner, PhD Kamal Maurice Hanna, MD Hugo Neffen, MD Verona, Italy Cairo, Egypt Sante Fe, Argentina Jean Bousquet, MD PhD S.T. Holgate, PhD Elio Novembre, MD PhD France Southampton, UK Florence, Italy Helen Chan, MD Patrick Holt, PhD Antero G. Palma-Carlos, MD Hong Kong W. Australia Lisbon, Portugal Tse Wen Chang, PhD José G. Huerta López, MD Giorgio Piacentini, PhD Taiwan Mexico City, Mexico Verona, Italy Felicidad Cua-Lim, MD S. Gunnar O. Johannson, PhD P. Pohunek, MD PhD San Juan, Philipines Sweden Czech Republic Ale¡andro Escobar, PhD Matti Korppi, MD PhD Kostas Priftis, MD PhD Mexico City, Mexico Koupio, Finland Alhens, Greece Alessandro Fiocchi, MD PhD Marek L. Kowalski, MD Johannes Ring, MD PhD Milano, Italy Lodz, Poland Germany S.rndra N. Gonzalez Diaz, MD Mario LaRosa, PhD J. Rosado-Pinto PhD Monterrey, Mexico Catania, Italy Lisbon, Portugal

Scction Editors Cli11ical Pearls and Pitfalls "POPS" Case Reports W.1m1:r W Carr, MD )o<:eph A. Bellantí, MO

Editorial/Publishing Staff: Sus.rn Colucci, Ginny Loiselle, and Diane Zerba. Advertising Rep: Jim Brady, James T. Brady, lnc. (516-742-7960), [email protected]. Comrnercial Reprints: Contact Mrnna Burgess, Sales Director, Cadmus Communications, 443-527-3855 or email [email protected]. Participating Societies Arizona Allergy and Asthma Massachusetts Allergy & Asthma Oregon Society of Allergy, Asthma, Society Society and Immunology President: Miriam Anand, MD President: James A. Maclean, MD President: Jason Friesen, MD

Allen Cazort Allergy Society of Pennsylvania Allergy and Asthma Arkansas Michigan Allergy and Asthma Society President: Gail Cookingham, MD Association President: Blake G. Scheer, MD President: Janet L. Beausoleil, MD Buffalo Allergy Society President: Mark Sands, MD Mid-South Allergy Forum Rhode Island Society of Allergy President: Joseph S. Fahhoum, MD President: Russell A. Settipane, MD Eastem Allergy Conference Director: Russell A. Settipane, MD Missouri State Allergy Association South Carolina Allergy, Florida Allergy, Asthma, & President: Mark L. Vandewalker, MD Asthma, and Imrnunology Society Immunology Society President: Emmanuel D. Sarmiento, M President: Frank J. Eidelman, MD Nebraska Allergy, Asthma and Immunology Society South Dakota Allergy Society Allergy / Asthma/Immunology Society President: Againdra Bewtra, MD President: Mark Bubak, MD of Georgia President: Caro! A. Wiggins, MD Southwest Allergy Forum New England Society of Allergy Director: Agile Redmon, MD Greater Washington Asthma Allergy President: Mitchell R. Lester, MD and Immunology Society President: Richard R. Rosenthal, MD Tennessee Allergy, Asthma, and New Hampshire Allergy Society lmmunology Society Illinois Society of Allergy, Asthma and President: Ashok Shah, MD President: John P. Overholt, MD Immunology President: Giselle Mosnairn, MD New Jersey Society of Allergy, Texas Allergy, Asthma, & Asthma, and Immunology Immunology Society lowa Society of Allergy and President: Stuart L. Abramson, MD Immunology President: Michael B. Sherman, MD President: Francisco G. Peralta, MD Asthma and Allergy Society of Kentucky Society of Allergy, Asthma New Mexico Allergy Society Virginia and Clinical Immunology President: James H. Sussman, 00 President: Craig Koenig, MD President: Tao Le, MD New York State Society of Allergy, Washington State Society of Allergy. Long Island Allergy and Asthma Asthma & Immunology Asthma, and Immunology Society President: Robert N. Corriel, MD President: Mary Farrington, MD President: Muataz Jaber, MD Oklahoma Allergy Society Western Society of Allergy, Asthma, Louisiana Allergy, Asthma, and President: Suzanne Olive, MD Immunology Society and Immunology President: Laurianne G. Wild, MD President: William E. Berger, MD Orange County (CA) Allergy, Asthma & Maine Society of Allergy Immunology Society Wisconsin Allergy Society President: Matthew Aresery, MD President: Geeta Venkat, MD President: Susan Higgins-Larkey, M Copyright Disclosure & onlin~) NDICA Allergy Asthma Proceedings (ISSN 1088-5412 Erint, ISSN 1539-§3__94 is owned and published bi-monthly by OceanSide Publications, Inc., 95 Pitman Street, Prov1aeñee,ltr 02906. Single copies: $25 (add $5 shipping within the USA, S 'ATANfl for outside USA address); 2010 Subscriptions: $189 per year domestic, see complete price options in reader services. Email MPOR [email protected]. Copyright© 2010, OceanSide Publications, Inc. (401-331-2510; Fax 401-331-0223). Printed in the USA. All rights reserved. t­ Vamir 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 prior written permission from the publisher. Statements and opinions expressed in articles and communications herein are those of the author(s) and not necessarily those of the Editor(s), publisher, the American Association of Certified Allergists (AACA), or the affiliated regional, state, and local allergy societies. The Editor(s), publisher, the American Association of Certified Allergists (AACA), and the affiliated regional, state, and local allergy societies disclaim any responsibility or liability for such material and do not losing guarantee, warrant, or endorse any productor service in this publication, nor do they guarantee any claim made by the manufacturer of such productor service. Allergy and Asthma Proceedings is registered with Copyright Clearance Center, Inc 222 Rosewood Drive, Danvers, MA 01923. To get permission to use copyrighted material from this publication, go to www .copyright.coro. tdvers 1fectic Al TABLE OF CONTENTS Vol. 31, No. 4 July-August 2010

Review Article 259 The usefulness of biomarkers of airway inflammation in managing asthma S. U. Patil ~d A. A. Long Original Articles 269 Twenty-six-week efficacy and safety study of mometasone furoate/formoterol 200/10 µg combination treatment in persistent asthmatic patients previously receiving medium-dose inhaled corticosteroids R. A. Nathan, H. Nolte, and D. S. Pearlman, on Behalf of the P04334 Study Investigators 280 Twelve-week efficacy and safety study of mometasone furoate/formoterol 200/100 µg and 400/10 µg combination treatments in patients with persistent asthma previously receiving high-dose inhaled corticosteroids S. F. Weinstein, J. Corren, K. Murphy, H. Nolte, and M. White, on Behalf of the Study Investigators of P04431 290 Safety and tolerability of levocetirizine dihydrochloride in infants and children with allergic rhinitis or chronic urticaria F. Hampel, P. Ratner, and J.-M. C. Haeusler 296 Efficacy of oral olopatadine hydrochloride for the treatment of seasonal allergic rhinitis: A randomized, double-blind, placebo-controlled study H. Yamamoto, T. Yamada, S. Kubo, Y. Osawa, Y. Kimura, M. Oh, D. Susuki, T. Takabayashi, M. Okamoto, and S. Fujieda 304 EpiPen use and demographics in a Veterans Administration population A. Amirzadeh, P. Yerma, S. Lee, and W. Klaustermeyer 308 Repeat epinephrine treatments for food-related allergic reactions that present to the emergency department A. Banerji, S. A. Rudders, B. Corel, A. M. Garth, S. Clark, and C. A. Camargo, Jr. 317 Reduced clinic, emergency room, and hospital utilization after home environmental assessment and case management C. S. Bames, M. Amado, and J. M. Portnoy 324 Efficacy of immunotherapy for treatment of allergic asthma in children R. H. Alzakar and A. M. Alsamarai 331 Randomized, double-blind, placebo-controlled trial of acetaminophen for preventing mood and memory effects of prednisone bursts E. S. Brown, D. Deruúston, B. Gabrielson, D. A. Khan, S. Khanani, and S. Desai 337 Important Florida botanical aeroallergens ]. F. Phillips, M. L. Jelks, and R. F. Lockey tmospheric pollen count in Monterrey, Mexico S. N. González-Díaz, P. G. Rodríguez-Ortiz, A. Arias-Cruz, A. Macías-Weinmann, D. Cid-Guerrero, and e G. A. Sedo-Mejia 349 DNA repair gene XRCCl polymorphisms and the risk of asthma in a Turkish population B. Batar, M. Guven, l. Onaran, B. TutluogJu, and G. Kanigur-Sultuybek Patient Oriented Problem Solving (POPS) Case Report 355 A 41-year-old male with cough, wheeze, and dyspnea poorly responsive to asthma therapy P. A. Ricketti, A.]. Ricketti, D. J. Cleri, M. Seelagy, D. W. Unkle, and J. R. Vemaleo Online Articles-www.allergyandasthmaproceedings.com 359 Clinical characteristics of oral tolerance induction of IgE-mediated and non- IgE-mediated food allergy (e39) using interferon gamma J. H. Lee, G. Noh, J. Noh, S. J. Lee, W. S. Choi, H. S. Kim, K. Lee, S. Choi, H. Jin, S. Cho, and S. Lee 359 Impact of delay in asthma diagnosis on health care service use (e48) B. A. Lynch, C. A. Van Norman, R. M. Jacobson, A. L. Weaver, and Y. J. Juhn Table 1 Pollen types found in the study area and their monthly concentration (grains/m3 per mo) during 2004 Taxa Month Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Jan. Total Acacia farnesiana o 2 43 20 2 o 5 o o o 3 o o 76 Acalypha spp 9 2 21 65 28 4 2 32 30 1 o o o 192 Agave spp o 2 15 o o o o o o o o o o 17 Alnus glutinosa 8 17 15 8 o o o o 12 o o o 24 83 Alternatera spp o o o o 8 o o o o o o o o 8 J\rnaranthaceae/ 3 17 28 47 212 95 48 122 72 108 33 447 25 1256 Chenopodiaceae Ambrosía spp 5 15 52 17 108 9 49 97 75 127 30 248 77 909 Apiaceae spp o o o 1 6 o o o o o o o o 6 Argemone mexicana o 1 5 26 1 o o o o o o o o 32 \..... Artemisia spp o o 1 o 9 o o 19 o 38 3 o o 71 Aster spp o o 6 4 1 o o o 4 o o 1 o 16 Bauhinia spp o o 3 3 10 o o o o o o o o 16 Bouganvillae spp o o o 9 o o o o o o o o o 9 Caesalpinia mexicana o o 5 o o o o o o o o o o 5 Callistemon speciosus o o o o 66 7 o o o 1 o o o 75 Carya spp o 1 46 66 47 9 1 o o 29 2 o o 201 Casuarina equisetifolia o o 1 o o 2 o o o 20 9 1 11 43 Celtis spp 3 39 215 70 109 420 49 203 185 127 19 107 o 1548 Citrus spp o o o o 1 o o o o o o o o 1 Compositae o o o 1 24 o 1 2 o o o o o 27 Cupressus spp 266 273 82 43 2 6 o o 32 101 42 40 331 1218 Cyperus rotundifolia o 1 22 21 14 5 2 o o 2 o o o 66 Ehretia anacua o o 51 8 5 2 o o o o o o o 65 Ephedra spp 1 1 o o 3 o o o o o o o o 4 Erythrina spp o o o o 1 o o o o o o 294 o 295 Eucalyptus spp 1 1 4 o o o 2 o o 37 2 o o 46 Fouquieria splendens o o 7 1 8 17 o o o o o o o 33 Fraxinus spp 430 5837 512 237 10 o 2 o 11 37 1 1 35 7112 Grainineae/Paoceae 22 29 52 67 120 158 86 116 251 191 64 826 71 2051 Helianthus annus 1 1 4 20 44 4 5 1 2 59 28 4 o 172 Hippeastrum equestre o o o o o o 1 o o o o o o 1 Jacaranda mimosifolia o o 371 137 31 9 2 1 o o o o o 550 Junglans spp o 2 22 81 29 1 o o o o o o o 135 Langerstroemia indica o o o o o 3 7 o o o o o o 10 Lantana cámara o o o o o o o o o o o o o o Leucaena leucocephala o o 42 15 1 9 14 115 o 4 o o o 200 Leucophyllum frutescens o o 2 16 o o o o o o o o o 18 Ligustrum lucidum 2 9 187 150 33 66 18 5 o 18 1 o 1 491 Magnofolia grandiflora o o o o 31 o o o o o o o o 31 Malvaceace o o o o 7 8 o 15 o o o o o 29 Mimosa malacophylla o o 178 68 44 37 37 63 6 o 11 o o 445 Morus spp 5 1417 418 155 76 23 23 o 1 o o o o 2118 Palma e 1 5 8 o 3 o o o o o o o 1 17 Parietaria spp 25 131 645 126 120 59 97 63 100 53 12 1 6 1439 Parkinsonia aculeata o o 8 3 3 16 2 5 o o o o o 37

342 July- August 201 O, Vol. 31, No. 4 Table 1 Continued Taxa Month Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Jan. Total Parthenium 5 16 80 161 103 187 37 32 o o o o 2 624 hysteophorus Persea americana o o 2 o o o o 1 o o o o o 3 Phitecellobium o o o o o 1 1 o o o o o o 2 Pinus spp 2 45 592 182 117 57 43 31 o 10 18 1 3 1103 Platanus occidentalis o 211 87 11 o o o o o o o o o 308 Populus spp • o 3 18 3 o o o o o o o o o 24 Prosopis spp o 3 138 89 96 22 2 25 o o o o o 374 runus pérsica o 4 o o o o o o o o o o o 4 teris longifolia o o o o o 2 o o o o o o o 2 uercus spp 1 222 108 69 38 10 1 o o 1 o o o 449 ododendron o 2 2 5 o o 1 1 o o o o o 11

icinus communis 14 39 148 119 103 36 23 46 49 87 so 4 67 785 Rosaceae o o o 1 o o o o o o o o o 1 alix spp o 16 145 226 20 36 29 15 3 3 o 8 o 500 apium sebiferum o o o o o o o o 11 28 o o o 39 chrankia uncinata o o o o o o 1 o o o o o o 1 elaginella spp o o 2 o o o o o o o o o o 2 olanum spp o o 1 31 o o o 2 4 o o o o 37 amarix gálica o o o 2 o 21 24 88 28 52 2 o o 215 radescantia o o o o 1 o o o 1 12 o o o 14 virginiana inca rosea o o 8 2 o o o o o o o o o 10 ashingtonia filifera o o 2 37 44 51 14 o o o o 2 o 148 ucca spp o o o o 11 o 1 o o o o o o 11 ea mays o o o o o o 1 o o o o o o 1

rain collection was done according to the recom­ mounted in layers of glycerin and safranine on a endations of the Pan-American Aerobiology Asso­ slide. The works by Kremp,19 Erdman,2º·21 Faegri e iation using a Hirst 7-day recording air sampler Iversen,22 and Kapp23 were used to identify pollen. Burkard Manufacturing Co., Hertfordshire, U.K.), Trained personnel from the School of Biologic Sci­ ith an airflow volume of 10 L/minute, installed on ences of the Universidad Autónoma de Nuevo Leon e roof of a four-story building of the "Dr. Jose counted and identified with a light microscope leuterio Gonzalez" University Hospital, 12 m off (40X), with four longitudinal sweeps. A correction e ground, and located in the western part of the factor was applied by multiplying the number of ity of Monterrey, Nuevo Leon (altitude, 540 m grains observed by 0.54 to obtain the real number of hove sea level; coordinates, north 27°49' and south grains per cubic meter of air. 3°11' north latitude; east 98°26' and west 101 º14' A daily count of the pollen identified was made daily est longitude). for the 365 days that the study !asted. The average The particles were trapped on Melinex (Du Pont, daily count of pollen was obtained by adding the daily SA) transparent polyester film (345 mm with a pollen count of each month and dividing it by the total ilicon solution asan adhesive) mounted on a clock­ number of days corresponding to that month. In this ork-driven drum, which contains a sampling plate way, the average count of pollen particles per cubic at moves at 2 mm/hour; this allows hourly calcu­ meter per day of sampled air was reported. We also tions of air particles. The collection drum rotates determined the total monthly count of each pollen ompletely during 1 week of sampling. The tape was identified and the pollination period (PP). The begin­ emoved weekly and cut into seven pieces with each ning of the PP was established when 5% of the total piece representing a day of sampling (48 mm of count was reached and lasted until it reached 95% of aampling). Afterward, the strips of tape were the total.24

Allergy and Asthma Proceedings 343 Table 1 Pallen types found in the study area and their monthly concentration (grains/m3 per mo) during 2004 Taxa Month Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Jan. Total Acacia farnesiana o 2 43 20 2 o 5 o o o 3 o o 76 Acalypha spp 9 2 21 65 28 4 2 32 30 1 o o o 192 Agave spp o 2 15 o o o o o o o o o o 17 Alnus glutinosa 8 17 15 8 o o o o 12 o o o 24 83 Alternatera spp o o o o 8 o o o o o o o o 8 Amaranthaceae/ 3 17 28 47 212 95 48 122 72 108 33 447 25 1256 Chenopodiaceae Ambrosía spp 5 15 52 17 108 9 49 97 75 127 30 248 77 909 Apiaceae spp o o o 1 6 o o o o o o o o 6 Argemone mexicana o 1 5 26 1 o o o o o o o o 32 \..._ Artemisia spp o o 1 o 9 o o 19 o 38 3 o o 71 Aster spp o o 6 4 1 o o o 4 o o 1 o 16 Bauhinia spp o o 3 3 10 o o o o o o o o 16 Bouganvillae spp o o o 9 o o o o o o o o o 9 Caesalpinia mexicana o o 5 o o o o o o o o o o 5 Callistemon speciosus o o o o 66 7 o o o 1 o o o 75 Carya spp o 1 46 66 47 9 1 o o 29 2 o o 201 Casuarina equisetifolia o o 1 o o 2 o o o 20 9 1 11 43 Celtis spp 3 39 215 70 109 420 49 203 185 127 19 107 o 1548 Citrus spp o o o o 1 o o o o o o o o 1 Compositae o o o 1 24 o 1 2 o o o o o 27 Cupressus spp 266 273 82 43 2 6 o o 32 101 42 40 331 1218 Cyperus rotundifolia o 1 22 21 14 5 2 o o 2 o o o 66 Ehretia anacua o o 51 8 5 2 o o o o o o o 65 Ephedra spp 1 1 o o 3 o o o o o o o o 4 Erythrina spp o o o o 1 o o o o o o 294 o 295 Eucalyptus spp 1 1 4 o o o 2 o o 37 2 o o 46 Fouquieria splendens o o 7 1 8 17 o o o o o o o 33 Fraxinus spp 430 5837 512 237 10 o 2 o 11 37 1 1 35 7112 Granúneae/Paoceae 22 29 52 67 120 158 86 116 251 191 64 826 71 2051 Helianthus annus 1 1 4 20 44 4 5 1 2 59 28 4 o 172 Hippeastrum equestre o o o o o o 1 o o o o o o 1 f acaranda mimosifolia o o 371 137 31 9 2 1 o o o o o 550 f unglans spp o 2 22 81 29 1 o o o o o o o 135 Langerstroemia indica o o o o o 3 7 o o o o o o 10 Lantana cámara o o o o o o o o o o o o o o Leucaena leucocephala o o 42 15 1 9 14 115 o 4 o o o 200 Leucophyllum Jrutescens o o 2 16 o o o o o o o o o 18 Ligustrum lucidum 2 9 187 150 33 66 18 5 o 18 1 o 1 491 Magnofolia grandiflora o o o o 31 o o o o o o o o 31 Malvaceace o o o o 7 8 o 15 o o o o o 29 Mimosa malacophylla o o 178 68 44 37 37 63 6 o 11 o o 445 Morus spp 5 1417 418 155 76 23 23 o 1 o o o o 2118 Palmae 1 5 8 o 3 o o o o o o o 1 17 Parietaria spp 25 131 645 126 120 59 97 63 100 53 12 1 6 1439 Parkinsonia aculeata o o 8 3 3 16 2 5 o o o o o 37

342 July-August 201 O, Vol. 31, No. 4 Table 2 Average pollen count for trees, weeds, and grasses per month, reported in grains/m3 per day from January 2004 to January 2005 Month Trees Weeds Grasses Total % January 2004 49.5 2.5 1.4 53.4 5.82 February 2004 281 6.5 1.0 288.5 31.39 March 2004 106.2 34.1 1.6 141.9 15.45 April 2004 59.8 18.9 2.2 80.9 8.81 May 2004 28.2 23.3 3.8 55.3 6.15 June 2004 26.1 14.7 5.2 46 5.02 July 2004 7.4 9.7 2.7 19.8 2.19 August 2004 15.4 16.2 3.7 35.3 3.85 September 2004 11.1 9.7 8.3 29.1 3.16 October 2004 16.2 14.6 6.2 37 4.02 November 2004 4.8 3.9 2.1 10.8 1.18 \...... December 2004 14.7 22.S 26.6 63.8 6.95 January 2005 29.4 6.9 4.4 40.7 4.73 Year average (grains/m3 per day)• 54 15 6 75 Percentage corresponding to the total pollen count 72% 20.3% 7.7% 100 •Average number of grains per cubic meter per day.

2SO

l!GO ,,t --ltees -'E 1SO l ---Weecls I! l:J 100 .....Gral&

!IO

o Figure 1. Pallen count average of trees, weeds, ami grasses during study.

RESULTS half of the year; the months with the highest concen­ During the period of study we identified 70 different tration were February and March. Weed pollen was types of ~ollen . The total pollen studied was 25,918 higher in March, May, and December. The highest grains/m . In Table 1 the pollen types found are de­ concentration of grass pollen was reported in Decem­ scribed, as well as the total monthly concentration of ber (Table 2 and Fig. 1). pollen per truca. Of ali the collected pollen in the year, Fraxinus spp. The months with the highest pollen concentration was the most important in quantity with a total of 7112 3 were February, with an average of 289 grains/ m3 per grains/m . A peak occurred in February with a daily 3 day, and March with 142 grains/m3 per day. The average of 201 grains/m . This pollen corresponded to months of July and November had the lowest concen­ 27.5% of the total count of pollen in the year. tration with a total of 20 and 11 grains/ m3 per day, The most frequently identified tree pollen was Fraxinus respectively (Table 2). spp, with high concentrations in January and April; Most of the pollen corresponded to trees (72% of the Moms spp, present from February to May, reaching its total), followed by weeds (20.3%), and last, by grass highest concentration in February; Celtis spp, present pollen (7.7%). Tree pollen count was higher in the first most of the year (March to December), presented its

344 July-August 201 O, Vol. 31, No. 4 highest concentration in June; Cupressus spp, a1so present tion for this relationship.34 Extremely sensitive patient most of the time, mainly from October to April, had its will experience symptoms with levels of pollen be highest concentration in January; and Pinus spp, which tween 1 and 15 grains/m3 for trees, 1 and 5 grains/m was present from February to August, had the highest in grasses, and 1and10 grains/m3 in weeds. However concentration in March. Table 1 corresponds to the aver­ most individuals will present sym¡ toms with variablE age pollen count of grains per cubic meter per month of pollen counts (16-90 grains/m from trees, 6-2( the main trees identi.fied during the study. grains/m3 from grasses, and 11-50 grains/m3 from The predom.inant weed pollen was Parietaria spp, weeds).34 For example, Negriti et al. reported symp­ present at ali times during the year with an average of toms in aliergic patients to Parietaria spp with 10-15 4 grains/m3 per day. It predom.inated from February to grains/m3 per day at ~80 grains/m3 per da:/' almost May. The highest concentration was reported at 21 90% of the patients presented symptoms.3 Among grains/m3 per day in March. The pollen of Amaran­ weeds, Parietaria spp. was common with counts of at thaceae/Chenopodiaceae was present ali year; mostly least 10 grains/m3 per day for 30 days during the year, in the months of May, June, August, October, and but reached counts of 99 grains/m3 per day (March 16, December, its highest concentration was reported in 2004) with a wide PP. Other weeds that had important December. The pollen of Ambrosía spp. was also levels and considerable amounts were Amaranthaceae/ present ali year, mainly from August to October, De­ Chenopodiaceae (22 days) as well as Ambrosía spp. (20 cember, and January, December being the month with days). Parietaria spp. is special in this group because the highest concentration reported at 8 grains/m3 per although it is frequent, it is not included in the aeroal­ day. Other weeds identified in smalier quantities were lergen panel that we use in our center. Helianthus annus, Parthenium hysteophorus, and Tamarix Table 3 shows the taxa that had pollen counts equal galica {Table 1). The PP for grasses was from the middle or higher than those that cause symptoms according to of April to January; the months with the highest daily the Burge categorization system, number of days with average corresponded to December, with 27 grains/m3 high levels, and the PP. Tree pollen corresponded to per day; September, with 8 grains/m3 per day; and 72% of the total count during the year, Fraxinus spp. October, with 6 grains/m3 per day with a predomi­ reported the highest counts, its importance seems lim­ ance of the Gram.ineae/Poaceae families {Table 2). ited to the lst months of the year, mainly February and March, even though the PP was relatively well defined to the first half of the year, there were exceptions, such as Celtis spp, which was present almost ali year and Aeroallergens are complex molecules that contain an­ Cupressus spp started in September and persisted until ·genic proteins, which actívate and degranulate mast March-April. This causes approaching challenges in lls by specific IgE mechanisms with the subsequent polysensitized patients because, even in the same ease of inflammatory mediators that generate a char­ group of plants PPs can overlap, causing clinical sym~ cteristic allergic response.25.26 Most pollen with aller­ toms with exacerbations at different times of the year. enic potential is transported by the wind and is named Pinus spp corresponded to 4.25% of the total count and 15 emophilous. ,27 The species that disperse pollen into was observed mainly from February to July, regardless e atmosphere usually correlate with the flora of each of the fact that it is found in important quantity, the 5 7 ·on but this is nota rule. ,6,28 Although an increase in days with high pollen counts were few and its alier­ ollen levels can cause an increase in allergic sensitiza­ genic importance is not as relevant as other species, ·on, the level of pollination does not always coincide such as Fraxinus ~p, Morus spp, Cupressus spp, and ·th the sensitiz.ation pattem of certain plants in the same Ricinus communis. 4 7 ason. • This is an important consideration when pre­ The interpretation of the results of Gram.ineae/ 29 1 'bing allergen-specific immunotherapy. --1 Poaceae shows a similar risk of causing symptoms Not ali pollen has the capacity to produce an aliergic such as Fraxinus spp. (SO days versus 49 days, respec­ action. This capacity depends on factors such as pro­ tively). This is not simple in clinical terms because in components that constitute th:i;ollen grain, plant grasses cause symptoms at smalier grain counts and it · tribution, pollen flotation, etc.32 is easier to find patients with symptoms induced by Sorne authors believe that the maximum concentra­ grasses than trees, with a ratio of 4:1.39 The largest 'on of pollen and its duration is more important than amount was 420 grains/m3 (December 21, 2004); the e correlation of symptoms-pollen counts for pa­ PP lasted almost ali year (10 months). Patients sensitive 'ents with pollinosis.36 Because of the characteristics of to grasses would have more variability in their symp­ ollen types, it is not always possible to linearly cor­ toms during December, because the average was hiJíh elate allergy symptoms (rhinorrhea, sncezing, itching, enough to cause pollinosis (26 grains/m3 per day). etc.) and atmospheric pollen counts. The Burge catego­ Despite the advantages offered by the Hirst sampler, rization system is an attempt at a clinical approxirna- a defect in our study is the lack of data on the hourly

Allergy and Asthma Proceedings 345 Table 3 Relevant plants from an allergenic perspective Taxa Concentration with Risk of Main Pollination Period Pollinosis• (days) Trees Cupressus spp 19 January-April Fraxinus spp 49 January-April f unglans spp 3 March-May Ligustrum spp 4 March-June Morus spp 30 February-May Prosopls spp 7 March-June Quercus spp 7 February-May Platanus spp 10 February-March Pinus spp 7 February-August Weeds \..... Amaranthaceae/Chenopodiaceae 22 April-December Ambrosia spp 20 May-December Helianthus spp 7 May-November Parietaria spp 30 February-September Ricinnus spp 18 January-October Artemisa spp 3 August-October Grasses Gramineae/Poaceae 50 April-January First column describes relevant taxa, second column describes the number of days with concentrations > 15 grains/m 3 per day for trees, > 10 grains/m3 per day for weeds, and >5 grains/m3 per day for grasses, and the third column describes main pollination period. •clinically relevant according to the Burge categorization system.

variation of pollen for each taxa, especially those with ever, even in urbanized areas there is an overlapping allergenic importance. Sorne studies have reported the about native species and plants that have been adopted release of pollen from 8 A.M. to 2 P.M. with a maxi­ because of gradual urbanization. A report developed mum peak between 10 A.M. and 12 P.M.39 in parallel with this study was done in a different Factors such as climate change, relative humidity, location of Monterrey (north area), by the same per­ wind, pollution level, and altitude1·40 can influence the sonnel of the School of Biologic Sciences, and there presence of pollen, i.e., pollen production for Ambrosia were sorne differences in pollen count, i.e., higher lev­ spp occurs after sunrise (Bianchi 1951 and Ogden 1969) els of Cupressus spp. and Amaranthaceae/Chenopodi­ and levels decrease during rainy seasons.39 Other au­ aceae pollen, than in our study with the other pollen 43 thors have observed that rain hinders the abnospheric levels almost the same ; this correlates that differences pollen count and the symptomology of affected indi­ in the concentration of pollen in the air depend on the viduals usually decreases, if patients really have polli­ vegetation features in each region and even in different nosis.41 areas of the same city.13•44 This is important to predict This study identifies the rnain pollens in the city of the type of sensitivity that we can expect to find in Monterrey and their variation during the year; a better allergic patients. Also, we can estímate the risk of estimate may be obtained averaging pollen data ob­ exacerbation of symptorns in the allergic population if tained over severa! years, but, unfortunately, we have we know the behavior of pollen in each region; e.g., only completed 1 year. There is a similar behavior Schmier performed a review summarizing existing among tree, weed, and grass pollen during the year asthma-related impact of aeroallergen exposure litera­ according to Cueva-Velazquez14 and Corona,12 but it is ture, and despite that little is known about this rela­ important to point out that these studies were reported tionship, there appears to be evidence that weed pollen >40 years ago. A common phenornenon in our setting is associated with asthma exacerbations.45 is that PPs overlap, and sorne types of pollen are Pollen sampling with different devices is used only present practically all year. This behavior of pollen as a guide. Sorne studies with personal sampling de­ explains why the patient with perennial disease has vices have shown variability depending on the level seasonal exacerbations, because many allergy .gatients where the device is placed (patient level or severa! are sensitive to more than one aeroallergen. How- meters above the ground).34 A fact well known is that

346 July-August 2010, Vol. 31, No. 4 ery sensitive patients can present an allergic response 9. Vignola PL, Cueva VJ, and y Ortiz L. Pólenes atmosféricos de b ith small doses of pollen,46 which makes the atmo­ ciudad de Veracruz. Rev Alerg Mex 9:57-61, 1961. pheric counts and aeroallergen sensitization patterns 10. Castillo VFJ, Cueva VJ, Cortés VM, and Jiménez X. Pólene atmosféricos de la ciudad de Orizaba Veracruz. Rev Alerg Me> several or single allergens) important for the clinician; 9:102-108, 1962. owever, it should always be considered that the pa- 11. Zamacona G, Ortiz OL, González BJ, and Cueva VJ. Pólenes d1 ·ent can be more sensitive !han the pollen detector la ciudad de Puebla. Rev Alerg Mex 8:276-281, 1961. device.39 12. Corona Domínguez A. Pólenes atmosféricos en Torreór Coahuila. Rev Alerg Mex 10:1998-2002, 1962. 13. Ramírez Oviedo A, and Roclr{guez B. Estudio ilustrado de l<>l pólenes del aire de México más comunes. Polinosis. Rev Aler~ ONCLUSIONS Mex 8:187-218, 1961. Tree pollen represented most of the pollen collected, 14. Cueva-Velázquez J. Flora y pólenes alergénicos en la repúblia ainly from lhe months of January-March, with Fraxi- mexicana. Alergia 17:99-110, 1970. us spp having the highest concentration. Weed and 15. Espinosa-Larraf\aga F, and Pérez-Martín J. Guía diagnóstica tera péutica de la rinitis alérgica. Rev Alerg Mex l(suppl):37-54, 2000 ass pollen were perennial presenting sorne peaks 16. Hibush B, Homung H, Heinrich J, et al. Quantification of grou¡ uring the year. 5 grass pollen allergens in house dust. Clin Exp Allergy 30 PP for trees and grass is similar in other cities, such 1645--1652, 2000. s Mexico City, Zacatecas, Tamaulipas, Tepic, Vera­ 17. Becerril Ángeles M, Pérez López A, and Azana Pliego E. Prueb¡ ' Toluca, and Guadalajara, from November to May de provocación alérgica nasal. Rev Alerg Mex 5:166-168, 2000 18. Información geográfica de Monterrey, Nuevo León. Availabl1 ·th each geographical area having its own features. online at www.inegi.gob.mx/geo/default; last accessed No or weeds the PP was mainly from June to October, vember 29, 2009. with the higher atmospheric concentration reported at 19. Kremp GOW. (Ed.) Compostae and helcantheae. In Morphol the end of the summer and beginning of autumn. In ogy Encyclopedia of Palinology. Tucson, AZ: The University o Monterrey, no well-defined period was observed, be­ Arizona Press, 131-134, 1965. 20. Erdtman G. Pollen and spore morphology/plant taxonomy cause several peaks occurred during the year. Plants Gymnospermae, Pteridophyta, Bryophyta (An introcluction t< such as Parietaria spp, Morus spp, Cupressus spp, and palinology II) Alquimist and Wirksell/Stockholm, New York Ricinus communis represent recently found allergens in The Ronald Press Co., 5-44, 1957. this region relevant for diagnosis and treatment, be­ 21. Erdtman G. Pollen morphology and plant taxonomy. (An intro cause allergy to these has been observed. In polysen­ duction to palinology 1, Angiosperms). New York and London Hafner Publishing Company. 1966. sitized patients a perennial pattem of symptoms is 22. Faegri K, and !versen J. Text Book of Pollen Analysis. Denmark more common with several exacerbations during the The Blackbum Press, 1-328, 1989. year. December, January, February, March, and April 23. Kapp OR, Davis OK, and King JE. Pollen and Spores. Th1 were the months with the highest concentration of American Association of Stratigraphics Palynologists Founda pallen count. lt is important to be aware of this for an tion Publication, 1-279, 2000. 24. Clot B. Trends in airbome pollen: An overview of 21 years o appropriate clinical approach of allergic patients. data in Neuch8tel. Aerobiologia 19:227-234, 2003. 25. Aalberse RC. Structural biology of allergens. J Allergy CliI Immunol 106:228-238, 2000. REFERENCES 26. Emel K, Sevim B, Ozhan A, et al. The effect of natural pollei l. Newhouse CP, and Levetin E. Correlation of environmental exposure on eosinophil apoptosis and its relationship to bron factors with asthrna and rhinitis symptoms in Tulsa, OK. Ann chia! hyperresponsiveness in patients with seasonal allergi• Allergy Asthrna Immunol 92:356-366, 2004. rhinitis. Ann Allergy Asthma lmmunol 95:72-78, 2005. 2. Demoly P, Michel F-B, and Bousquet J. In vivo methocls for 27. Weber R Pollen identification. Ann Allergy Asthma Immuno study of allergy skin test, techniques, and interpretation. In 80:141-147, 1998. Allergy Principies and Practice. Middleton E, Reed CH, Ellis E, 28. Dvorin D. Lee J, Belecanech F. et al. A comparative, volumetri1 et al. (Eds.). 5th edition. St Louis, MO: Mosby 430-439, 1998. surveyor airbone pollen in Philadelphia, Pennsylvania (1991· 3. Kaplan A. Predominant aeroallergen pollen grains in the atmo­ 1997), and Cherry Hill, New Jersey (1995-1997). Ann Allergi sphere of Ankara, Turkey. Allergy 59:670-672, 2004. Asthma Immunol 87:394- 4004, 2001. 4. Subiza J, Jerez M, Jiménez JA, et al. Allergenic pollen and 29. White JF, and Bernstein DI. Key pollen allergens in Nortl pollinosis in Madrid. J Allergy Clin Immunol 96:15--23, 1995. America. Ann Allergy Asthma lmmunol 91:425--435, 2003. 5. Katelaris CH, Burke TV, and Byth K. Spatial variability in the 30. Leigh AS, David WG, Bonnie AW, and Michael JR Cross reac pollen count in Sidney, Australia: Can one sampling site accu­ tivity among conifer pollens. Ann Allergy Asthrna Immuno rately reflect the pollen count for a region? Ann Allergy Asthma 84:87-93, 2000. Immunol 93:131-136, 2004. 31. White JF, Levin L, Villarreal M, et al. Lack of correlation be 6. Cecchi L, Morabito M, Dome Neghetti MP, et al. Long distance tween regional pollen counts and percutaneous reactivity h transport of ragweed pollen as a potential cause of allergy in tree pollen extracts in patients with seasonal allergic rhinitis central Italy. Ann Allergy Asthrna Immunol 96:86-91, 2006. Ann Allergy Asthma Immunol 94:240-246, 2005. 7. Gioulekas D, Papakasta D, Damialis A, et al. Allergenic pollen 32. Ritzick DR, and Lamberth JO. Spring brings breezes, wheeze records (15 years) and sensitization in patients with respiratory and pollen oxidasas. J Clin lnvest 115:2067-2069, 2005. allergy in Thessaloniki, Greece. Allergy 59:174-184, 2004. 33. Suphioglu C. What are the important allergens in grass pollei 8. Canseco C. Polinosis en la vertiente del Golfo. Rev Mex Alergol that are linked to human allergic disease? Clin Exp Allerg: 1:5, 1945. 10:1335-1341, 2000.

Allergy and Asthma Proceedings 34i 34. Frenz D. Interpreting atmospheric pollen COWlts for use in 40. Armentia A, Asensio T, Subiza J, et al. Living in towers as risk clinical allergy: Allergic symptomology. Ann Allergy Asthma factor of pollen allergy. Allergy 59:302-305, 2004. lmmWlol 86:150-158, 2001. 41. Rivera M, Cerda M, and Martin J. A correlation study between 35. Port A, Hein J, Wolff A, and Bielory L. Aeroallergen prevalence airbome pollen and cases of polinosis in humans. Aerobiologia in the northem New Jersey- New York City metropolitan area: 18:169-173, 2002. A 15-year surnmary. Ann Allergy Asthma lmmWlol 96:687-691, 42. Ramos-Morln C, and Canseco-González C. Estudio de hiper­ 2006. sensibilidad a alérgenos frecuentes en la región centro de 36. Perez C, Gardiol J, and 'J>aez M. Comparison of intradiumal Coahuila. Rev Alerg Mex 5:150- 154, 1993. variation of airbome pollen in Mar del plata (argentina) Part I. 43. Rocha-Estrada A, Alvarado-Vázquez M, Torres-Cepeda T, and Non arboreal pollen. Aerobiologia 17:151- 163, 2001. Foroughbakhch R. Principales tipos polínicos presentes en el 37. Negrini A, Voltolini S, Troisse C, and Arobba D. Comparison aire de la zona norte del área metropolitana de Monterrey, between urticaceae (Parietaria) pollen coWlt and hay fever Nuevo León. Ciencia-UANL, 69-76, 2008. symptoms: Assessment of a threshold-value. Aerobiologia 44. Mejia Ortega J. Flora de la República Mexicana. Rev Alerg Mex 8:3~329, 1992. 4:98- 105, 1998. 38. Wu F, Steidle G, Meador M, et al. Effect of tree and grass pollens 45. Schmier J, and Ebi K. The impact of climate change and aeroal­ and fungal spores on spring allergic rhinitis: A comparative lergens on children's health. Allergy Asthma Proc 30:229-237, study. Ann Allergy Asthma lmmWlol 83:137-143, 1999. 2009. 39. Bames C, Pacheco F, Landyut J, et al. The effect of temperature, 46. Liu LY , Swenson CA, Kelly EA, et al. Comparison of the effects of relative humidity and rainfall on airbome ragweed pollen con­ repetitive low-dose and sing1e-dose antigen challenge on airway centrations. Aerobiologia 17:61- 68, 2001. inflammation. J Allergy Clin lmmWlol 111:818- 825, 2003. O

348 July-August 201 O, Vol. 31, No. 4