ppharmПедиатрическая фармакологияPediatric pharmacology1727-57762500-3089Издательство «ПедиатрЪ»10.15690/pf.v11i1.889ppharm-133Research ArticleКЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИCLINICAL RECOMMENDATIONSСОВРЕМЕННЫЕ ПРИНЦИПЫ ТЕРАПИИ АЛЛЕРГИЧЕСКОГО РИНИТА У ДЕТЕЙMODERN PRINCIPLES OF ALLERGIC RHINITIS THERAPY IN CHILDRENВишнёваЕ. А.VishnevaE. A.

кандидат медицинских наук, ведущий научный сотрудник отдела стандартизации и клинической фармакологии, врач аллерголог-иммунолог отделения восстановительного лечения детей с аллергическими болезнями и заболеваниями органов дыхания НИИ профилактической педиатрии и восстановительного лечения ФГБУ «НЦЗД» РАМН

MD, leading research scientist of the Department of Standardization and Clinical Pharmacology, allergist-immunologist at the Department of Medical Rehabilitation for Children with Allergic and Respiratory Diseases of the Research Institute of Preventive Pediatrics and Medical Rehabilitation of SCCH

vishneva@nczd.ruНамазова-БарановаЛ. С.Namazova-BaranovaL. S.АлексееваА. А.AlexeyevaA. A.ЭфендиеваК. Е.EphendiyevaK. E.ЛевинаЮ. Г.LevinaY. G.ВознесенскаяН. И.VoznesenskayaN. I.ТомиловаА. Ю.TomilovaA. Y.МурадоваО. И.MuradovaO. I.СелимзяноваЛ. Р.SelimzyanovaL. R.ПромысловаЕ. А.PromyslovaE. A.Научный центр здоровья детей, МоскваРоссияScientific Center of Children’s HealthRussian FederationНаучный центр здоровья детей, Москва, Российская Федерация Первый Московский государственный медицинский университет им. И.М. Сеченова, Российская Федерация Российский национальный исследовательский медицинский университет им. Н.И. Пирогова, МоскваРоссияScientific Center of Children’s Health First Sechenov Moscow State Medical University Pirogov Russian National Medical Research UniversityRussian FederationНаучный центр здоровья детей, Москва, Российская ФедерацияРоссияScientific Center of Children’s HealthRussian FederationНаучный центр здоровья детей, Москва, Российская ФедерацияПервый Московский государственный медицинский университет им. И.М. Сеченова, Российская ФедерацияРоссияScientific Center of Children’s Health First Sechenov Moscow State Medical UniversityRussian FederationНаучный центр здоровья детей, Москва, Российская ФедерациПервый Московский государственный медицинский университет им. И.М. Сеченова, Российская ФедерацияРоссияScientific Center of Children’s Health First Sechenov Moscow State Medical UniversityRussian Federation201415022014111Педиатрическая фармакология614Copyright © Вишнёва Е.А., Намазова-Баранова Л.С., Алексеева А.А., Эфендиева К.Е., Левина Ю.Г., Вознесенская Н.И., Томилова А.Ю., Мурадова О.И., Селимзянова Л.Р., Промыслова Е.А., 20142014Вишнёва Е.А., Намазова-Баранова Л.С., Алексеева А.А., Эфендиева К.Е., Левина Ю.Г., Вознесенская Н.И., Томилова А.Ю., Мурадова О.И., Селимзянова Л.Р., Промыслова Е.А.Vishneva E.A., Namazova-Baranova L.S., Alexeyeva A.A., Ephendiyeva K.E., Levina Y.G., Voznesenskaya N.I., Tomilova A.Y., Muradova O.I., Selimzyanova L.R., Promyslova E.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.pedpharma.ru/jour/article/view/133

Статья посвящена проблеме аллергического ринита (АР) у детей. АР широко распространен среди детей и подростков, отрицательно влияет на физическое и психологическое состояние, социальную жизнь, школьную успеваемость снижает качество жизни как самих пациентов, так и членов их семей. Авторами рассмотрены самые современные подходы к диагностике и контролю над заболеванием и даны доказательно обоснованные рекомендации. Представлена актуальная классификация, описаны классические и дополнительные симптомы болезни, указаны ключевые нозологические формы дифференциального диагностического поиска. Комплекс терапевтических мероприятий при АР имеет цель облегчить изнуряющие симптомы болезни и включает ограничение контакта с патогенетически значимыми аллергенами, лекарственную терапию, специфическую иммунотерапию и обучение. Мероприятия профилактического характера направлены на предотвращение развития сенсибилизации/манифестации/утяжеления течения АР. Представленная в статье информация имеет цель содействия распространению основных принципов терапии АР, призвана повысить доступность современных методов контроля над аллергическими болезнями.

 

The article is dedicated to allergic rhinitis (AR) in children. AR is widespread among children and adolescents; it negatively affects physical and psychological condition, social life and school performance and reduces life quality of both patients and members of their families. The authors consider the most modern approaches to diagnostics and control over the disease and present evidence-based recommendations. The authors offer the relevant classification; describe classic and additional disease symptoms and list the key nosological forms of differential diagnostic search. The complex of therapeutic measures to be taken at AR is aimed at relieving devastating symptoms of the disease and involves limitation of contacts with pathogenetically significant allergens, drug therapy, specific immunotherapy and education. Preventive measures are aimed at preventing development of sensitization/manifestation/aggravation of the AR course. The information given in the article is aimed at spreading the main principles of AR therapy and increasing accessibility of the modern methods of control over allergic diseases.

Key words: allergic rhinitis; children; control; therapy

аллергический ринитдетиконтрольтерапияallergic rhinitischildrencontroltherapyReferencesBousquet J., Khaltaev N., Cruz A. A., Denburg J., Fokkens W. J., Togias A. et al. Aller-gic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organiza tion, GA (2)LEN and AllerGen). Allergy. 2008; 63 (Suppl. 86): 8–160.Bousquet J., Khaltaev N., Cruz A. A., Denburg J., Fokkens W. J., Togias A. et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA (2) LEN and AllerGen). Allergy. 2008; 63 (Suppl. 86): 8–160.Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. Brozek J. L., Bousquet J., Baena-Cagnani C. E., Bonini S., Canonica G. W., Casale T. B., van Wijk R. G., Ohta K., Zuberbier T., Schunemann H. J. Global Allergy and Asthma European Network, Grading of Recommendations Assessment, Development and Evaluation Working Group SOJ. Allergy Clin Immunol. 2010; 126 (3): 466.Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. Brozek J. L., Bousquet J., Baena-Cagnani C. E., Bonini S., Canonica G. W., Casale T. B., van Wijk R. G., Ohta K., Zuberbier T., Schunemann H. J. Global Allergy and Asthma European Network, Grading of Recommendations Assessment, Development and Evaluation Working Group SOJ. Allergy Clin. Immunol. 2010; 126 (3): 466.Аллергия у детей: от теории — к практике. Под ред. Л. С. Намазовой-Барановой. М.: Союз педиатров России. 2010–2011. 668 с.Allergiya u detei: ot teorii — k praktike. Pod red. L.S. Namazovoi-Baranovoi [Allergy in Children: from Theory to Practice. Edited by L.S. Namazova-Baranova]. Мoscow, Union of Pediatricians of Russia, 2010–2011. 668 p.Намазова-Баранова Л. С., Огородова Л. М., Томилова А. Ю., Деев И. А., Алексеева А. А., Вишнева Е. А., Громов И. А., Евдокимова Т. А., Камалтынова Е. М., Коломеец И. Л., Торшхоева Р. М. Распространенность астмаподобных симтомов и диагностированной астмы в популяции подростков. Педиатрическая фармакология. 2009; 6 (3): 59–65.Namazova-Baranova L.S., Ogorodova L.M., Tomilova A.Yu., Deev I.A., Alekseeva A.A., Vishneva E.A., Gromov I.A., Evdokimova T.A., Kamaltynova E.M., Kolomeets I.L., Torshkhoeva R.M. Prevalence astmapodobnyh simtomov and diagnosed asthma in the adolescent population. Pediatricheskaya farmakologiya = Pediatric pharmacology. 2009; 6 (3): 59–65.Roberts G., Xatzipsalti M., Borrego L. M., Custovic A., Halken S., Hellings P. W., Papadopoulos N. G., Rotiroti G., Scadding G., Timmermans F., Valovirta E. Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology. Allergy. 2013; 68: 1102–1116.Roberts G., Xatzipsalti M., Borrego L. M., Custovic A., Halken S., Hellings P. W., Papadopoulos N. G., Rotiroti G., Scadding G., Timmermans F., Valovirta E. Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology. Allergy. 2013; 68: 1102–1116.Silva C. H. M., Silva T., Morales N., Fernandes K., Pinto R. Quality of life in children and adolescents with allergic rhinitis. Braz J Otorhinolaryngol. 2009;75: 642–649.Silva C. H. M., Silva T., Morales N., Fernandes K., Pinto R. Quality of life in children and adolescents with allergic rhinitis. Braz. J. Otorhinolaryngol. 2009;75: 642–649.Ant K., Pearce N., Anderson H. R., Ellwood P., Montefort S., Shah J. Global map of the prevalence of symptoms of rhinoconjunctivitis in children: The International Study of Asthma and Allergies in Childhood ISAAC Phase Three. Allergy. 2009; 64: 123–148.Ant K., Pearce N., Anderson H. R., Ellwood P., Montefort S., Shah J. Global map of the prevalence of symptoms of rhinoconjunctivitis in children: The International Study of Asthma and Allergies in Childhood ISAAC Phase Three. Allergy. 2009; 64: 123–148.Durham S. R., Smurthwaite L., Gould H. J. Local IgE production. Am J Rhinol. 2000; 14: 305–307.Durham S. R., Smurthwaite L., Gould H. J. Local IgE production. Am. J. Rhinol. 2000; 14: 305–307.Shin S., Choi S., Hur G., Lee K., Kim S., Cho J. et al. Local production of total IgE and specific antibodies to the house dust mite in adenoid tissue. Pediatr Allergy Immunol. 2009; 20: 134–141.Shin S., Choi S., Hur G., Lee K., Kim S., Cho J. et al. Local production of total IgE and specific antibodies to the house dust mite in adenoid tissue. Pediatr. Allergy Immunol. 2009; 20: 134–141.Bertelsen R., Lodrup C., Carlsen K. Rhinitis in children: co-morbidities and phenotypes. Pediatr Allergy Immunol. 2010; 21: 612–622.Bertelsen R., Lodrup C., Carlsen K. Rhinitis in children: co-morbidities and phenotypes. Pediatr. Allergy Immunol. 2010; 21: 612–622.Modrzynski M., Zawisza E. The influence of birch pollination on the adenoid size in children with intermittent allergic rhinitis. Int J Pediatr Otorhinolaryngol. 2007; 71: 1017–1023.Modrzynski M., Zawisza E. The influence of birch pollination on the adenoid size in children with intermittent allergic rhinitis. Int. J. Pediatr. Otorhinolaryngol. 2007; 71: 1017–1023.Shin S., Choi G., Lee K., Kim S., Cho J., Park H. IgE response to staphylococcal enterotoxins in adenoid tissues from atopic children. Laryngoscope. 2009; 119: 171–175.Shin S., Choi G., Lee K., Kim S., Cho J., Park H. IgE response to staphylococcal enterotoxins in adenoid tissues from atopic children. Laryngoscope. 2009; 119: 171–175.Webber C. M., England R. W. Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge. Ann Allergy Asthma Immunol. 2010; 104: 101–108.Webber C. M., England R. W. Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge. Ann. Allergy Asthma Immunol. 2010; 104: 101–108.Hellings P. W., Fokkens W. J., Akdis C., Bachert C., Cingi C., Dietz de Loos D. et al. Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today? Allergy. 2013; 68: 1–7.Hellings P. W., Fokkens W. J., Akdis C., Bachert C., Cingi C., Dietz de Loos D. et al. Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today? Allergy. 2013; 68: 1–7.Vogl T. J., Stemmler J., Heye B., Schopohl J., Danek A., Bergman C. et al. Kallman syndrome versus idiopathic hypogonadotropic hypogonadism at MR imaging. Radiology. 1994; 191: 53–57.Vogl T. J., Stemmler J., Heye B., Schopohl J., Danek A., Bergman C. et al. Kallman syndrome versus idiopathic hypogonadotropic hypogonadism at MR imaging. Radiology. 1994; 191: 53–57.Астафьева Н. Г., Удовиченко Е. Н., Гамова И. В., Перфило ва И. А., Наумова О. С., Кенесариева Ж. М., Вачугова Л. К., Гапон М. С. Аллергические и неаллергические риниты: сравнительная характеристика. Лечащий врач. 2013; 4: 10–12.Astaf'eva N.G., Udovichenko E.N., Gamova I.V., Perfilova I.A., Naumova O.S., Kenesarieva Zh.M., Vachugova L.K., Gapon M.S. Allergic and non-allergic rhinitis: comparative characteristics. Lechashchii vrach = Practicing Doctor. 2013; 4: 10–12.Simons F. E., Simons K. J. Histamine and H1-antihistamines: celebrating a century of progress. J Allergy Clin Immunol. 2011; 128: 1139–1150.Simons F. E., Simons K. J. Histamine and H1-antihistamines: celebrating a century of progress. J. Allergy Clin. Immunol. 2011; 128: 1139–1150.Ng K. H., Chong D., Wong C. K., Ong H. T., Lee C. Y., Lee B. W. et al. Central nervous system side effects of first- and second-generation antihistamines in school children with perennial allergic rhinitis: a randomized, doubleblind, placebo-controlled comparative study. Pediatrics. 2004; 113: e116–e121.Ng K. H., Chong D., Wong C. K., Ong H. T., Lee C. Y., Lee B. W. et al. Central nervous system side effects of first- and second-generation antihistamines in school children with perennial allergic rhinitis: a randomized, doubleblind, placebo-controlled comparative study. Pediatrics. 2004; 113: e116–e121.Wandalsen G., Mendes A. I., Sole D. Objective improvement in nasal congestion and nasal hyperreactivity with use of nasal steroids in persistent allergic rhinitis. Am J Rhinol Allergy. 2010; 24: e32–e36.Wandalsen G., Mendes A. I., Sole D. Objective improvement in nasal congestion and nasal hyperreactivity with use of nasal steroids in persistent allergic rhinitis. Am. J. Rhinol. Allergy. 2010; 24: e32–e36.Meltzer E., Tripathy I., Maspero J., Wu W., Philpot E. Safety and tolerability of fluticasone furoate nasal spray once daily in paediatric patients aged 6–11 years with allergic rhinitis: subanalysis of three randomized, double-blind, placebo-controlled, multicentre studies. Clin Drug Invest. 2009; 29: 79–86.Meltzer E., Tripathy I., Maspero J., Wu W., Philpot E. Safety and tolerability of fluticasone furoate nasal spray once daily in paediatric patients aged 6–11 years with allergic rhinitis: subanalysis of three randomized, double-blind, placebo-controlled, multicentre studies. Clin. Drug. Invest. 2009; 29: 79–86.Lohia S., Schlosser R. J., Soler Z. M. Impact of intranasal corticosteroids on asthma outcomes in allergic rhinitis: a meta-analysis. Allergy. 2013; 68: 569–579.Lohia S., Schlosser R. J., Soler Z. M. Impact of intranasal corticosteroids on asthma outcomes in allergic rhinitis: a metaanalysis. Allergy. 2013; 68: 569–579.Bielory L. Ocular symptom reduction in patients with seasonal allergic rhinitis treated with the intranasal corticosteroid mometa-sone furoate. Ann Allergy Asthma Immunol. 2008; 100: 272–279.Bielory L. Ocular symptom reduction in patients with seasonal allergic rhinitis treated with the intranasal corticosteroid mometasone furoate. Ann. Allergy Asthma Immunol. 2008; 100: 272–279.Garavello W., Di B., Romagnoli M., Sambataro G., Gaini R. Nasal rinsing with hypertonic solution: an adjunctive treatment for pediatric seasonal allergic rhinoconjunctivitis. Int Arch Allergy Immunol. 2005; 137: 310–314.Garavello W., Di B., Romagnoli M., Sambataro G., Gaini R. Nasal rinsing with hypertonic solution: an adjunctive treatment for pediatric seasonal allergic rhinoconjunctivitis. Int. Arch. Allergy Immunol. 2005; 137: 310–314.Li H., Sha Q., Zuo K., Jiang H., Cheng L., Shi J. et al. Nasal saline irrigation facilitates control of allergic rhinitis by topical steroid in children. ORL J Otorhinolaryngol Relat Spec. 2009; 71: 50–55.Li H., Sha Q., Zuo K., Jiang H., Cheng L., Shi J. et al. Nasal saline irrigation facilitates control of allergic rhinitis by topical steroid in children. ORL J. Otorhinolaryngol Relat. Spec. 2009; 71: 50–55.Куличенко Т. В., Намазова-Баранова Л. С., Торшхоева Р. М., Лукина О. Ф., Вишнева Е. А. Анти-IgE-терапия тяжелой бронхиальной астмы у детей: двухлетний опыт. Педиатрическая фармакология. 2010; 7 (3): 57–65.Kulichenko T.V., Namazova-Baranova L.S., Torshkhoeva R.M., Lukina O.F., Vishneva E.A. Anti-IgE-treatment of severe asthma in children: two-year experience. Pediatricheskaya farmakologiya = Pediatric pharmacology. 2010; 7 (3): 57–65.Куличенко Т. В., Баранов А. А., Абелевич М. М., Балашова Е. В., Вишнева Е. А. и др. Обобщенный анализ применения моноклональных антител к IgE в лечении бронхиальной астмы у детей в РФ. Педиатрическая фармакология. 2011; 8 (2): 50–56.Kulichenko T.V., Baranov A.A., Abelevich M.M., Balashova E.V., Vishneva E.A. et al. Generalized analysis using monoclonal antibodies to IgE in the treatment of asthma in children in Russian. Pediatricheskaya farmakologiya = Pediatric pharmacology. 2011; 8 (2): 50–56.Man L. X. Complementary and alternative medicine for allergic rhinitis. Current Opinion in Otolaryngology & Head & Neck Surgery. 2009; 17: 226–231.Man L. X. Complementary and alternative medicine for allergic rhinitis. Current Opinion in Otolaryngology & Head & Neck Surgery. 2009; 17: 226–231.Benninger M., Farrar J., Blaiss M., Chipps B., Ferguson B., Krouse J. et al. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class. Ann Allergy Asthma Immunol. 2010; 104: 13–29.Benninger M., Farrar J., Blaiss M., Chipps B., Ferguson B., Krouse J. et al. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class. Ann. Allergy Asthma Immunol. 2010;104: 13–29.Di L. G., Pacor M. L., Pellitteri M. E., Morici G., Di G. A., Lo B. C. et al. Randomized placebocontrolled trial comparing fluticasone aqueous nasal spray in mono-therapy, fluticasone plus cetirizine, fluticasone plus montelukast and cetirizine plus montelukast for seasonal allergic rhinitis. Clin Exp Allergy. 2004; 34: 259–267.Di L. G., Pacor M. L., Pellitteri M. E., Morici G., Di G. A., Lo B. C. et al. Randomized placebocontrolled trial comparing fluticasone aqueous nasal spray in mono-therapy, fluticasone plus cetirizine, fluticasone plus montelukast and cetirizine plus montelukast for seasonal allergic rhinitis. Clin. Exp. Allergy. 2004; 34: 259–267.Anolik R. Mometasone Furoate Nasal Spray With Loratadine Study Group. Clinical benefits of combination treatment with mometasone furoate nasal spray and loratadine vs monotherapy with mometasone furoate in the treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2008; 100: 264–271.Anolik R. Mometasone Furoate Nasal Spray With Loratadine Study Group. Clinical benefits of combination treatment with mometasone furoate nasal spray and loratadine vs monotherapy with mometasone furoate in the treatment of seasonal allergic rhinitis. Ann. Allergy Asthma Immunol. 2008; 100: 264–271.Van Cauwenberge P., Bachert C., Passalacqua G., Bousquet J., Canonica G. W., Durham S. R. et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy. 2000; 55: 116–134.Van Cauwenberge P., Bachert C., Passalacqua G., Bousquet J., Canonica G. W., Durham S. R. et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy. 2000; 55: 116–134.Calderon M. A., Gerth van Wijk R., Eichler I., Matricardi P. M., Varga E. M., Kopp M. V. et al. Perspectives on allergen-specific immunotherapy in childhood: an EAACI position statement. Pediatr Allergy Immunol. 2012; 23: 300–306.Calderon M. A., Gerth van Wijk R., Eichler I., Matricardi P. M., Varga E. M., Kopp M. V. et al. Perspectives on allergen-specific immunotherapy in childhood: an EAACI position statement. Pediatr. Allergy Immunol. 2012; 23: 300–306.Hankin C., Cox L., Lang D., Levin A., Gross G., Eavy G. et al. Allergy immunotherapy among Medicaid-enrolled children with allergic rhinitis: patterns of care, resource use, and costs. J Allergy Clin Immunol. 2008; 121: 227–232.Hankin C., Cox L., Lang D., Levin A., Gross G., Eavy G. et al. Allergy immunotherapy among Medicaid-enrolled children with allergic rhinitis: patterns of care, resource use, and costs. J. Allergy Clin. Immunol. 2008; 121: 227–232.Hankin C., Cox L., Lang D., Bronstone A., Fass P., Leatherman B. et al. Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study. Ann Allergy Asthma Immunol. 2010; 104: 79–85.Hankin C., Cox L., Lang D., Bronstone A., Fass P., Leatherman B. et al. Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study. Ann. Allergy Asthma Immunol. 2010; 104: 79–85.Wong I. Y., Soh S. E., Chng S. Y., Shek L. P., Goh D. Y., van Bever H. P. et al. Compliance with topical nasal medication — an evaluation in children with rhinitis. Pediatr Allergy Immunol. 2010; 21: 1146–1150.Wong I. Y., Soh S. E., Chng S. Y., Shek L. P., Goh D. Y., van Bever H. P. et al. Compliance with topical nasal medication — an evaluation in children with rhinitis. Pediatr. Allergy Immunol. 2010; 21: 1146–1150.Баранов А. А., Вишнева Е. А., Намазова-Баранова Л. С. Теле-медицина — перспективы и трудности перед новым этапом развития. Педиатрическая фармакология. 2013; 10 (3): 6–11.Baranov A.A., Vishneva E.A., Namazova-Baranova L.S. Telemedicine – prospects and challenges at the new stage of development. Pediatricheskaya farmakologiya = Pediatric pharmacology. 2013; 10 (3): 6–11.Аллергология и иммунология. Под ред. А. А. Баранова и Р. М. Хаитова. Союз педиатров России. 3-е изд., испр. и доп. М.: Союз педиатров России. 2011. 256 с.Allergologiya i immunologiya. Pod red. A.A. Baranova i R.M. Khaitova. Soyuz pediatrov Rossii. 3-e izd., ispr. i dop. [Allergology and Immunology. Edited by А.А. Baranov and R.М. Khaitov. Union of Pediatricians of Russia. 3rd edition, revised and updated]. Moscow, Union of Pediatricians of Russia, 2011. 256 p.

The authors declare that there are no conflicts of interest present.