A comparative analysis of symptom and medication scoring methods used in clinical trials of sublingual immunotherapy for seasonal allergic rhinitis.

Symptom and medication use are the key outcomes for assessing the efficacy of subcutaneous (SCIT) and sublingual allergen immunotherapy (SLIT). Our objective was to explore the similarities and differences between existing scoring mechanisms used in clinical trials of SLIT for seasonal allergens and characterize the impact that such differences may have on efficacy reporting. Randomized, double-blind, placebo-controlled clinical trials investigating the efficacy of SLIT for seasonal allergic rhinitis (2009-2013) were selected for review. Simulated and published data were used to demonstrate differences in scoring methods. Symptom and medication scoring methods across trials, although all designed to achieve the same objective, included important differences. The maximum daily symptom score (DSS) can vary widely depending on the number of symptoms assessed, and terminology of symptoms is not consistent. Similarly, daily medication scoring (DMS) methods differ greatly among studies and are dependent on medications allowed and weighting of scores assigned to each medication. When published DSS and DMS scores were used to calculate simulated daily combined scores (DCSs) based on various published methods, changes from placebo ranged from 19% to 29% when assuming all variables other than the DSS and DMS methods were equal. Variations in trial design, analysis, and seasonal characteristics also have effects on symptom and medication scoring outcomes. We identified multiple differences in trial scoring methods and design that make comparison among trials difficult. Symptom, medication, or combined scores cannot be indirectly compared among trials without taking the methods of scoring and other trial differences into account.

Magnitude of efficacy measurements in grass allergy immunotherapy trials is highly dependent on pollen exposure.

BACKGROUND: The objective was to evaluate the association between grass pollen exposure, allergy symptoms and impact on measured treatment effect after grass sublingual immunotherapy (SLIT)-tablet treatment. METHODS: The association between grass pollen counts and total combined rhinoconjunctivitis symptom and medication score (TCS) was based on a post hoc analysis of data collected over six trials and seven grass pollen seasons across North America and Europe, including 2363 subjects treated with grass SLIT-tablet or placebo. Daily pollen counts were obtained from centralized pollen databases. The effect of treatment on the relationship between the TCS and pollen counts was investigated, and the relative difference between grass SLIT-tablet and placebo as a function of average grass pollen counts was modelled by linear regression. RESULTS: The magnitude of treatment effect based on TCS was greater with higher pollen exposure (P < 0.001). The relative treatment effect in terms of TCS for each trial was correlated with the average grass pollen exposure during the first period of the season, with predicted reduction in TCS = 12% + 0.35% × pollen count (slope significantly different from 0, P = 0.003; R(2)  = 0.66). Corresponding correlations to the entire grass pollen season and to the peak season were equally good, whereas there was a poor correlation between difference in measured efficacy and pollen exposure during the last part of the season. CONCLUSIONS: In seasonal allergy trials with grass SLIT-tablet, the observed treatment effect is highly dependent on pollen exposure with the magnitude being greater with higher pollen exposure. This is an important relationship to consider when interpreting individual clinical trial results.

Efficacy and safety of the SQ-standardized grass allergy immunotherapy tablet in mono- and polysensitized subjects.

The efficacy of single-allergen-specific immunotherapy in polysensitized subjects is a matter of debate. We therefore performed a post hoc analysis of pooled data from six randomized, double-blind, placebo-controlled trials (N = 1871) comparing the efficacy and safety of the SQ-standardized grass allergy immunotherapy tablet (AIT), Grazax (Phleum pratense 75 000 SQ-T/2800 BAU, ALK, Denmark), in mono- and polysensitized subjects. A statistically significant reduction in the mean total combined symptom/medication score (TCS) of 27% was demonstrated in actively treated subjects compared with placebo (P < 0.0001). This was not dependent on sensitization status (P = 0.5772), suggesting a similar treatment effect in mono- and polysensitized subjects (i.e. reductions of the TCSs of 28% and 26%, respectively, both P < 0.0001). Finally, a comparable and favourable safety profile of grass AIT was demonstrated in the two subgroups. Thus, no difference in efficacy and safety of single-allergen grass AIT was observed between mono- and polysensitized subjects.

Days with severe symptoms: an additional efficacy endpoint in immunotherapy trials.

BACKGROUND: In immunotherapy trials, primary and secondary endpoints often focus on average symptom and medication scores during the pollen season or on days with low symptoms and low medication use. Thus, there is a need for endpoints describing the treatment effect on the most troublesome days in the pollen season. AIMS OF THE STUDY: A possible additional efficacy endpoint, days with severe symptoms during the pollen season, was investigated using data from a multicentre, double-blind, randomized, placebo-controlled trial of the SQ-standardized grass allergy immunotherapy tablet (AIT) (Grazax, Phleum pratense, 75,000 SQ-T/2,800 BAU, ALK, Hørsholm, Denmark). METHODS: The trial included 634 subjects (N(Grass AIT) = 316; N(Placebo) = 318) with grass pollen-induced rhinoconjunctivitis. Six different definitions of a day with severe symptoms were suggested. The number of days with severe symptoms was analysed and odds ratios were calculated. RESULTS: The number and percentage of days with severe symptoms differed between definitions, but overall the analysis of days with severe symptoms showed consistent results (odds ratios: 2.0-3.4) for the different definitions. All definitions showed a reduced risk of having days with severe symptoms in the grass AIT group when compared to the placebo group. CONCLUSIONS: Days with severe symptoms during the pollen season is a relevant additional efficacy endpoint, which can be used in immunotherapy trials to support the clinical interpretation of commonly used efficacy endpoints.

Sustained effect of SQ-standardized grass allergy immunotherapy tablet on rhinoconjunctivitis quality of life.

BACKGROUND: The prevalence of allergic rhinoconjunctivitis has increased significantly over the past decades with grass pollen being a common trigger. The impact of allergy on patient's quality of life is substantial. AIM: To investigate the sustained effect on quality of life during the grass pollen season 1 year after 3 years of treatment with the SQ-standardized grass allergy immunotherapy tablet (AIT), Graza (Phleum pratense 75,000 SQ-T/2800 BAU; ALK, Denmark). METHODS: The trial was a randomized, parallel-group, double-blind, placebo-controlled trial in adult subjects with a history of moderate-severe grass pollen induced rhinoconjunctivitis inadequately controlled by symptomatic medications. Subjects received 3 years of grass AIT (n = 157) or placebo (n = 126), followed by 1 year of follow-up. Quality of life assessments were based on the standardized rhinoconjunctivitis quality of life questionnaire (RQLQ(S)); completed weekly during the entire grass pollen season. RESULTS: During follow-up, the overall RQLQ(S) score for the entire grass pollen season was significantly improved in the active group (relative difference to placebo: 23%, P = 0.004). The improvement was higher during the peak pollen season (28%, P = 0.001). The treatment effect of grass AIT during the follow-up year and the previous three treatment years was similar. Improvements were found in all seven RQLQ(S) domains. The RQLQ(S) as a function of the weekly average pollen counts showed a clear separation between the treatment groups (P < 0.001). CONCLUSION: In subjects inadequately controlled by symptomatic medications, grass AIT provided sustained and clinically relevant improvements in rhinoconjunctivitis quality of life compared to placebo. The effect increased with increasing grass pollen exposure.

Occurrence and spread of multiresistant Salmonella Typhimurium DT104 in Danish animal herds investigated by the use of DNA typing and spatio-temporal analysis.

In the investigation we report the occurrence and spread of multiresistant Salmonella Typhimurium phage type (DT) 104 in 174 known Danish animal herds infected between 1996 and 2003. We applied PFGE, plasmid analysis and spatio-temporal analysis for a description of the development and spread of infection among herds. The results showed that in Denmark DT104 are mainly spread by trade of animals; however, horizontal spread of DT104 is also important and the risk of an animal herd becoming infected increased with the proximity in time and space to a DT104-infected herd. Based on these results, it is recommended that specific actions are taken to limit the risk of horizontal spread of DT104 from newly infected herds.

Prolonged preseasonal treatment phase with Grazax sublingual immunotherapy increases clinical efficacy.

BACKGROUND: Sublingual immunotherapy treatment with grass allergen tablets (Grazax) is initiated preseasonally without up-dosing and treatment is continued throughout the entire grass pollen season. AIMS OF THE STUDY: The influence of the duration of preseasonal treatment on clinical efficacy obtained within the grass pollen season was investigated. METHODS: Data from three randomized, double-blind, placebo-controlled, multi-centre trials with varying preseasonal treatment periods were analysed. In the grass pollen season, symptom and medication score reductions relative to placebo were calculated and correlated with the duration of the preseasonal treatment period. RESULTS: The analysis was based on data from 934 patients. A significant reduction in seasonal daily rhinoconjunctivitis symptom and medication scores (17%, CI: 1-33% and 23%, CI: 1-47%, P < 0.05) was observed for patients treated with Grazax compared with placebo after approximately 8 weeks of pretreatment. The magnitude of the reductions in rhinoconjunctivitis symptom and medication scores increased with longer duration of preseasonal treatment (P < 0.0001). CONCLUSIONS: Sublingual immunotherapy with Grazax) must be initiated at least 8 weeks prior to the grass pollen season to provide a significant clinical efficacy. A longer preseasonal treatment period (>8 weeks) improves the clinical efficacy (relative to placebo) during the grass pollen season.

Cryptosporidium and cryptosporidiosis in Denmark--current status.

The genus Cryptosporidium comprises a group of protozoan parasites that infect a broad variety of vertebrates causing severe diarrhoeal illness in immunocompromised as well as immunocompetent hosts. Although molecular heterogeneity of the genus is being increasingly recognised, traditional diagnostic methods do not discriminate all species/subtypes, and population genetic studies of these parasites, using discriminatory molecular markers, have only been published recently. In Denmark, Cryptosporidium research has focussed mainly on detection methods, pathogenicity and veterinary aspects. The present paper gives an overview of recent and ongoing Cryptosporidium research in Denmark with an emphasis on molecular approaches to study epidemiology and transmission.

Relations between the consumption of antimicrobial growth promoters and the occurrence of resistance among Enterococcus faecium isolated from broilers.

The present study investigates, at farm level, the effect of the time-span between sampling and the last time a particular antimicrobial growth promoter (AGP) was included in the feed on the probability of selecting an AGP-resistant Enterococcus faecium isolate from a broiler flock. The probability that a randomly selected E. faecium isolate was resistant to avilamycin, erythromycin or virginiamycin was 0.91, 0.92 and 0.84, respectively if the isolate originated from a broiler flock fed either avilamycin- or virginiamycin-supplemented feed. As the time-span between sampling and the last AGP consumption increased, the probability of isolating an E. faecium isolate resistant to a particular AGP decreased (probability <0.2 within 3-5 years after last exposure to AGPs). The decrease in probability over time showed little farm-to-farm variation. The number of times a particular AGP was given to previous flocks reared in the same house had no effect on the probability of isolating a resistant isolate.

Monitoring the efficacy of steam and formaldehyde treatment of naturally Salmonella-infected layer houses.

AIMS: To monitor if a temperature-humidity-time treatment found to be effective in eliminating Salmonella in laboratory trials (Gradel et al. 2003) was efficient against Salmonella in naturally infected layer houses. METHODS AND RESULTS: Six layer houses with natural Salmonella infections were steam treated in a download period, aiming at >or=60 degrees C and 100% relative humidity (RH) during a 24-h period, with or without the addition of 30 ppm formaldehyde. In addition, two control layer houses were disinfected chemically. Salmonella samples taken from predetermined sites before and after treatment were tested qualitatively for Salmonella and coliforms. Samples with indicator bacteria (feed inoculated with Escherichia coli or Enterococcus faecalis and faeces with naturally occurring E. coli and enterococci) were placed during steam-treatment at 12 sites in each house (where the temperature was logged at 5-min intervals) and tested for surviving bacteria. Generally, the field test results confirmed the results of laboratory tests, especially when 30 ppm formaldehyde was added to the steam. In well-sealed houses, the recommended temperature-humidity-time scheme was accomplished at a minimum of 10 cm above floor level within 1 h. CONCLUSIONS: A steam treatment of >or=60 degrees C and 100% RH during a 24-h period with the addition of 30 ppm formaldehyde at the beginning of the process is recommended for eliminating Salmonella from naturally infected poultry layer houses. SIGNIFICANCE AND IMPACT OF THE STUDY: A specific recommendation for the elimination of Salmonella in poultry houses can be given.

Identification of campylobacteria isolated from Danish broilers by phenotypic tests and species-specific PCR assays.

AIMS: To validate a phenotypic Campylobacter species identification method employed to identify campylobacters in broilers by comparison with campylobacterial species identification using various species-specific PCR analyses. METHODS AND RESULTS: From a collection of 2733 phenotypically identified campylobacterial cultures, 108 Campylobacter jejuni cultures and 351 campylobacterial cultures other than Camp. jejuni were subjected to various species-specific PCR assays. On the basis of the genotypic tests, it was demonstrated that Camp. jejuni and Camp. coli constituted approx. 99% of all cultures, while other species identified were Helicobacter pullorum, Camp. lari and Camp. upsaliensis. However, 29% of the 309 Camp. coli cultures identified by phenotypic tests were hippurate-variable or negative Camp. jejuni cultures, whereas some Camp. lari cultures and unspeciated campylobacter cultures belonged to H. pullorum. It was also notable that 2-6% of the cultures were, in fact, mixed cultures. CONCLUSIONS: The phenotypic identification scheme employed failed to appropriately differentiate Campylobacter species and particularly to identify the closely related species, H. pullorum. SIGNIFICANCE AND IMPACT OF THE STUDY: Future phenotypic test schemes should be designed to allow a more accurate differentiation of Campylobacter and related species. Preferably, the phenotypic tests should be supplemented with a genotypic strategy to disclose the true campylobacterial species diversity in broilers.

Relations between the occurrence of resistance to antimicrobial growth promoters among Enterococcus faecium isolated from broilers and broiler meat.

From 1995 to 2001, Enterococcus faecium isolates were collected from broiler flocks at slaughter and broiler meat products at retail outlets and were tested for susceptibility to classes of antimicrobials used for growth promotion in broilers in Denmark, namely: evernimicin, glycopeptide, macrolide and streptogramin. By February 1998, all antimicrobial growth promoters (AGPs) were withdrawn from the Danish broiler production. The present study investigates, by logistic regression analyses, the (1) changes in the occurrence of AGP resistance among E. faecium from broilers and broiler meat from the fourth quarter of 1995 to the fourth quarter of 2001 and (2) relations between the occurrence of AGP resistance among E. faecium isolates from Danish broilers and AGP resistance among E. faecium isolates from the broiler meat of Danish and unknown origin collected in the same quarter within the year. In the present study, we showed that after the AGP withdrawal, a significant decline in resistance to avilamycin, erythromycin, vancomycin and virginiamycin was observed among E. faecium from broilers and broiler meat. In addition, a decline in the occurrence of AGP resistance among E. faecium from Danish broilers was associated with a decrease in the predicted probability of isolating an AGP-resistant E. faecium isolate from a randomly selected broiler meat product. In the analyses "relations between the occurrence of AGP resistance among E. faecium isolated from broilers and broiler meat collected in the same quarter" errors in the explanatory variable were expected. Therefore, a simulation study was performed to validate the results from logistic regression analyses. The results obtained by the two methods were similar.

Laboratory heating studies with Salmonella spp. and Escherichia coli in organic matter, with a view to decontamination of poultry houses.

AIMS: To determine a temperature-humidity-time treatment that eliminates Salmonella and Escherichia coli in substrates representing organic matter in poorly cleaned poultry houses, i.e. worst case scenario laboratory tests. METHODS AND RESULTS: Organic matter (poultry faeces and feed) in a 2.5-cm layer was inoculated with 2 x 10(5)-3 x 10(6) Salmonella g(-1), left undried or dried at ca. 30% relative humidity (RH) during a 10-day period, and temperature increased at 1 degrees C h(-)1 to the final heating temperature of 50, 55, 60, 65 or 70 degrees C and held at 16-30 or 100% RH. All samples were tested for Salmonella according to predetermined sampling time schedules and faecal samples were also tested for naturally occurring E. coli. Overall, humidity was an important factor in the elimination of Salmonella and E. coli. Results for recovery of Salmonella and E. coli were highly associated. CONCLUSIONS: The application of >/=60 degrees C and 100% RH during a 24-h period eliminated Salmonella and E. coli in all samples. Escherichia coli could be used as an indicator bacterium for the elimination of Salmonella. SIGNIFICANCE AND IMPACT OF THE STUDY: The results from worst case scenario laboratory tests could be applied in steam heating of persistently Salmonella-infected poultry houses. The use of E. coli as an indicator bacterium for the validation of Salmonella results should be considered.

Molecular characterization of Danish Cryptosporidium parvum isolates.

The genetic polymorphism among 271 Danish Cryptosporidium isolates of human and animal origin was studied by partial amplification and sequencing of the Cryptosporidium oocyst wall protein (COWP) gene, the 1 8S rDNA, and a microsatellite locus. Furthermore, the microsatellite locus was studied directly using fragment analysis. A comparative analysis of DNA sequences showed the presence of 3 different subgenotypes (Cl, C2 and C3) in C. parvum isolates from Danish cattle, with prevalences of 16.7, 17.2 and 73.1% including 13 (7.0%) mixed infections. Subgenotype Cl was significantly more prevalent (P < 0.001) in the southern part of Denmark. In Cryptosporidium isolates of human origin the anthroponotic subgenotype H1 was identified, in addition to the zoonotic subgenotypes C1, C2, and C3. Of 44 human samples, 56.8% were anthroponotic, whereas 40.9% were zoonotic genotypes. One human isolate was characterized as C. meleagridis. The porcine Cryptosporidium isolates (N = 4) revealed a pattern which was genetically distinct from human and bovine isolates. Cryptosporidium in a hedgehog (Erinaceus europaeus L.) was identified for the first time. By microsatellite sequencing the hedgehog isolate showed a subgenotype distinct from the previously detected types. The assignment to subgenotype by microsatellite sequencing and fragment typing was 100% identical in samples where results were achieved by both methods. In addition, the fragment analysis proved more sensitive, easier, faster, and less expensive compared to sequencing.

Vancomycin-resistant enterococci (VRE) in broiler flocks 5 years after the avoparcin ban.

The glycopeptide growth promoter avoparcin was banned from animal production in Denmark in 1995. In this study, we investigated the occurrence of vancomycin-resistant enterococci (VRE) in broiler flocks in the absence of the selective pressure exerted by the use of avoparcin. One hundred sixty-two broiler flocks from rearing systems with different histories of avoparcin exposure were investigated for the presence of VRE. Using a direct selective plating procedure, VRE were isolated from 104 of 140 (74.3%) broiler flocks reared in broiler houses previously exposed to avoparcin on conventional and extensive indoor broiler farms. In contrast, only 2 of 22 (9.1%) organic broiler flocks reared on free-range farms with no history of previous exposure to avoparcin were VRE-positive. Furthermore, the occurrence of VRE over time in flocks reared in broiler houses previously exposed to avoparcin was investigated. Results obtained by direct selective plating showed no significant decrease in the proportion of VRE-positive flocks during the study period (1998-2001). This study demonstrated the extensive occurrence of VRE in broiler flocks more than 5 years after the avoparcin ban in Denmark, and indicates that VRE may persist in the absence of the selective pressure exerted by avoparcin. The results differ markedly from previously published Danish surveillance data on VRE in broilers. This may reflect differences in isolation procedures.

Mass spectrometry allows direct identification of proteins in large genomes.

Proteome projects seek to provide systematic functional analysis of the genes uncovered by genome sequencing initiatives. Mass spectrometric protein identification is a key requirement in these studies but to date, database searching tools rely on the availability of protein sequences derived from full length cDNA, expressed sequence tags or predicted open reading frames (ORFs) from genomic sequences. We demonstrate here that proteins can be identified directly in large genomic databases using peptide sequence tags obtained by tandem mass spectrometry. On the background of vast amounts of noncoding DNA sequence, identified peptides localize coding sequences (exons) in a confined region of the genome, which contains the cognate gene. The approach does not require prior information about putative ORFs as predicted by computerized gene finding algorithms. The method scales to the complete human genome and allows identification, mapping, cloning and assistance in gene prediction of any protein for which minimal mass spectrometric information can be obtained. Several novel proteins from Arabidopsis thaliana and human have been discovered in this way.

Trends and seasonal variations in the occurrence of Salmonella in pigs, pork and humans in Denmark, 1995-2000.

A mandatory programme monitoring the occurrence of Salmonella in pork at slaughterhouses and a serological monitoring of slaughter-pig herds has been implemented in Denmark since 1993 and 1995, respectively. All results are stored in a central database. From this, aggregated weekly results of serological and bacteriological samples collected in the period between January 1995 and July 2000 were extracted. In addition, the reported weekly incidence of human infections with S. Typhimurium covering the same time period was obtained. The times series were analysed for trends and cyclic variations by seasonal decomposition. The association between the incidence in humans and the prevalence of Salmonella in pigs and pork, and prevailing weather conditions, were analysed by using a general linear (glm) and a general additive model (gam). Explanatory variables were lagged to account for time elapsed between sampling, consumption, incubation period and case registration. The results of the seasonal decomposition showed an overall declining trend in all three time series. All time series exhibited a double peaked annual cycle. The seasonal variation of the prevalence in pork and the human incidence had a very similar course. The variables that were both biologically meaningful and statistically significant in both regression models were the prevalence in pork sampled 4 to 5 weeks before case registration, the seroprevalence, measured as the average prevalence of week 15 to 35 before case registration, and the air temperature lagged at 2 and 3 weeks. Limitations on inferences from overall surveillance data are discussed.

Prevalence and antimicrobial susceptibility of thermophilic Campylobacter in organic and conventional broiler flocks.

AIMS: To determine the flock prevalence and to estimate the within flock prevalence of Campylobacter in broiler flocks from different rearing systems, and to determine the antimicrobial susceptibility of Campylobacter isolates to selected antimicrobial substances. METHODS AND RESULTS: One hundred and sixty broiler flocks originating from organic, conventional and extensive indoor production farms were investigated for the presence of Campylobacter at the time of slaughter. Campylobacter isolates from a subsample of positive flocks were subjected to susceptibility testing. Campylobacter spp. were isolated from 100% of organic broiler flocks, from 36.7% of conventional broiler flocks and from 49.2% of extensive indoor broiler flocks. Six of 62 Campylobacter isolates were resistant to one or more of the antimicrobials tested. CONCLUSION: These results indicate that the special characteristics of organic broiler production provide a high prevalence of Campylobacter-positive flocks. Antimicrobial resistance was scarce among Campylobacter isolates from all rearing systems. SIGNIFICANCE AND IMPACT OF THE STUDY: Organic broiler flocks constitute a strong potential for introduction of Campylobacter to the processing line upon arrival at slaughter.